Pearls and Irritations

The Australian Public Service Commission released the second capability review of the Department of Health and Aged Care on 18 August. While the review is not as scathing as the first review in 2014, it still sets out a challenging internal reform agenda for new Secretary Blair Comley.

The 2014 capability review was highly critical of many aspects of the Department of Health’s capacity and performance. It ranked the department as being a “serious concern” in relation to people motivation (“leadership behaviours cultivate self-censorship and passive compliance, rather than energising employees and ideas”) and outcome-focussed strategy (“the department does not have a high-level strategic policy framework to help it ascertain upcoming demand, model environmental factors and shape policy decisions and work programs into a strategic roadmap”).

The only bright side was a “well placed” rating for evidence-based choices, where the review noted that “overwhelmingly, external stakeholders have highlighted that the department is leading and influencing the international sport agenda through a period of increasing complexity”. Many health sector workers probably wished the department was as successful with the domestic health agenda.

Measured against this very low bar, the 2023 review is much more positive. There are no red flag ratings, and the department’s capability in relation to a number of aspects of “leadership and culture” and “people” is rated as “embedded” – essentially a credit mark.

However, against all aspects of “collaboration”, “delivery”, and “resourcing and risk” the department is rated as “developing” – a bare pass. There is a lot of scope for improvement.

Every reader of the report will have their own ideas about which areas are most important. In my view – as a health policy wonk – the findings about strategic policy capability are particularly interesting, especially given the damning findings of the 2014 review.

The current review identifies “Integrated strategic policy development capabilities” as the first of nine priority areas for improvement. It observes that

“Nearly everyone this review spoke to expect the department to take a lead in providing a ‘direction of travel’ on major system reform of the health and aged care sectors, and to lead discussions about the detail of that reform… [D]espite strong policy capabilities in particular areas, there is lack of capability in integrated policy development addressing the interactions between the various parts of the health and aged care systems”.

Following the 2014 review, incoming Secretary Martin Bowles established a Strategic Policy Committee with the aim of supporting integrated policy-making across the department. After Bowles’ departure in 2017, the committee was effectively abolished.

It now appears to have been resurrected in 2022 as the Strategic Policy Forum, intended to “allow leaders to tap into the expertise of their peers to inform policy design and implementation; provide ongoing monitoring and evaluation of critical initiatives; integrate policy development; and iterate the longer-term strategic direction of the portfolio”.

The review notes that the forum “is still in its early days”, and that success will depend on executive support and a sustained commitment to the idea of integrated policy making.

However, I believe the review does not give enough weight to the pernicious influence a Minister unwilling to listen to strategic policy advice can have. It is all very well for the review to argue that “the department should maintain system reform policy capabilities regardless of the needs of the minister of the day”, but when departmental resources are tightly stretched it is understandable a secretary might withdraw resources from a function the Minister doesn’t value.

While I am sure that the broader health sector would like the department to take the lead in major health system reform, the department cannot do this without support from the Minister and the government, as the Commonwealth hospital benefit imbroglio in 2017 demonstrated.

The other finding of the review which struck me was the need for the department to improve its use of data to inform policy. It concluded that “the department needs to empower policy makers at various levels to improve their understanding of the availability, flaws and possibilities of data sources plus an ability to pose answerable questions, and then to use the answers to frame policy proposals and options”.

I was fortunate as a newly-minted assistant secretary in the department to spend time in charge of the branches looking after hospital casemix, MBS, and PBS data, and gained a good understanding of the strengths and weaknesses of these data sources. Over time it became clear that many of my colleagues had no idea about these data holdings, and there was no formal process to inform them. A lot of time and effort were spent in developing policies in ignorance of the data that may have pointed to a better solution, or indeed data that showed the problem to be solved by the policy did not exist.

The review’s recommendation is long overdue.

The other major weakness in the department’s data capability is the lack of data to inform policy consideration. While the review gives as an example the lack of data-driven metrics to support PHN performance monitoring, there are numerous other more important gaps.

For example, a recent Croakey article by health policy analyst Jennifer Doggett examines the low COVID-19 vaccination rates for aged care residents, and concludes that “there is no single source of data on the vaccine status of residents, which means it is difficult to know whether the Government’s figures are accurate”.

Due to space limitations this article cannot discuss the other priority areas for capability improvement identified by the review, including the need for a systemic consideration of the health and aged care workforce; increasing knowledge about the providers the department funds and regulates; readiness for future healthcare delivery; learning the lessons from COVID-19; developing collaborative and enduring relationships with the states and territories; improving communication and engagement with the community; and building and empowering the mid-level of the department.

These are all important, and they will not come as a surprise to anyone who has observed, dealt with, or worked in the department over the last decade.

New departmental secretary Blair Comley will be busy as he tries to bring the department with him to address the issue identified by the review. Let’s hope he gets the support he needs from Minister Mark Butler and other portfolio ministers.

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