Healthcare policy change: by design or disaster
Policy change in health often seems to be a reactive process with high profile failures in the delivery of healthcare prompting significant changes. Alison Brown, PhD candidate, University of Melbourne, considers why major reforms in health care policy are driven largely by disaster rather than design.
Hospitals in crisis
Around the world major reforms in health care policy have occurred in response to hospital disasters. The fallout from the discovery of elevated mortality rates along with ‘appalling care’ (Francis, 2013) at the Mid Staffordshire Trust in the UK led to the regulator being given the ability to initiate criminal charges if fundamental standards of patient care were breached. On our own soil, the Victorian state government’s response to delayed identification of preventable perinatal deaths at Djerriwarrh health service saw in 2016 the creation of organisations including Safer Care Victoria and the Victorian Agency for Health Information to inform and lead patient quality and safety. The Victorian response echoes the creation of similar agencies in NSW arising from recommendations in the 2008 Garling report investigating concerns with quality of care in the state’s acute hospitals and changes in Queensland from the 2005 Davies report examining patient harm at Bundaberg hospital. While disasters such as these are significant drivers of policy change, what is limiting proactive policy change by design?
The framing of a problem is seen by Jackson (2007) as a key determinant in policy response. Early responses to patient harm saw the problem being framed as one of problem clinicians. Consequently quality and safety issues were addressed by managing negligent practitioners through professional bodies or through legal means rather than by policy reform.
The scale of patient harm made evident in the findings of the 1995 Quality in Australian health care study (Wilson et al, 1995), along with the evolution of system thinking in understanding healthcare quality, saw a shift in the problem definition to one of financing and structure. Reforms introduced by Rudd via the 2011 National health reform agreement involved funding reforms and structural changes, including the devolution of hospital governance from a predominantly centralist model in most states to create local hospital networks with boards to drive local accountability for financial and quality performance.
Despite these policy responses, problems with the safety of healthcare persist. Following Jackson’s line of reasoning, a further refinement of the problem is needed to drive appropriate policy development. Causes of healthcare failures, while multifactorial, share common feature in that they are generally long term problems that are known by some and often exposed by chance, rather than the systems that were designed to expose them (Walshe and Shortell, 2004).
What is becoming clearer from reviews of high profile hospital failures are fragmented reporting lines and barriers to data availability, sharing and interpretation. At Djerriwarrh health service failures of local governance systems to review serious incidents were compounded by barriers to communication between the professional regulator of clinicians, AHPRA and the hospital and department. Alongside this were slow isolated departmental systems for review and communication of statewide mortality data.
Ask a clinician on the ward and they will tell you that communication failures are a significant contributor to individual cases of patient harm. Similarly recent reviews of hospital disasters highlight that communication and information sharing are significant sector issues. Government departments and hospitals need objective and comparative data to avoid the ‘Lake Wobegon’ effect (Bismark et al, 2013),
The ‘Lake Wobegon effects’ (named after Garrison Keillor’s ﬁctional community, in which ‘all the women are strong, all the men are good looking, all the children are above average’) is unavailability or underuse of reliable information on peer performance.
Disasters provide the impetus for policy reform through intensive resourcing of forensic investigations which, while costly and timely, bring greater clarity and understanding of the problem. Key to enabling future appropriate planned responses to healthcare harm are strategies that enable timely sharing and communication of key clinical data of underperformance and also best practice. In this way continuous problem identification and definition can occur at all governance levels of the health care system. This may bring us closer to healthcare policy by design.
Bismark, M. M., Walter, S. J., & Studdert, D. M. (2013). The role of boards in clinical governance: activities and attitudes among members of public health service boards in Victoria. Australian Health Review, 37(5), 682-687.
Francis, R. (2013). Report of the Mid Staffordshire NHS Foundation Trust public inquiry: executive summary (Vol. 947). The Stationery Office.
Jackson, M. (2007). Government, medical error, and problem definition. Analysing Health Policy: A Problem-Oriented Approach, 188.
Walshe, K., & Shortell, S. M. (2004). When things go wrong: how health care organizations deal with major failures. Health Affairs, 23(3), 103-111
Wilson, R. M., Runciman, W. B., Gibberd, R. W., Harrison, B. T., Newby, L., & Hamilton, J. D. (1995). The quality in Australian health care study. Medical journal of Australia, 163(9), 458-471.