25 January 2017

One step forward then two back for digital health?

TheHill

 

Spare a thought for Tim Kelsey and his new, and, so far, tightly knit, team at the Australian Digital Health Agency (ADHA).

Faced with an almost impossible task of re-igniting a spark under our digital health agenda, his group had, by year’s end, done an amazing job of re-enlisting large numbers of a mostly disenfranchised and cynical healthcare community into a rebooted crusade for digital change.

Since assuming the top job at the ADHA in mid-August, Kelsey travelled much of Australia, listening to patients, clinicians and regulators at the coalface, and quickly decided on a new team. This team included selected ex NEHTA staff who could provide valuable corporate memory and experience, and had done much of the key initial work required to deliver a cohesive, workable and believable new digital healthcare strategy.

At the same time Kelsey initiated, or restarted, some crucial practical  projects – such as sorting out the mess that is secure messaging – and managed to achieve tangible progress as proof to the many non-believers of what is possible.

Kelsey soon learned that the vacuum of failure had sapped energy and corroded morale in the sector. He had faced it first-hand in multiple community forums and many one-on-one meetings with staff working on the frontline.

And in the face of frustration, anger, and even some outright rude interventions, he focused on listening and encouraged constructive venting of issues at hand. It must have been exhausting.

The Medical Republic asked Kelsey if he felt he could distill all that listening and complexity into key themes. He offered up three:

• That despite all the frustration and despair of the past, he hadn’t met one person who didn’t believe that correctly organised and executed digital health couldn’t bring massive change for the better to the sector in the mid term, nor anyone who wasn’t committed to that change in some way, deep down at least.

• That, in fact, there had been some huge advances and successes in the past, but the circumstances of those successes had made them very hard to recognise, celebrate and, most importantly, share. Those circumstances included that these successes were usually to be found at  the very outer reaches of frontline healthcare delivery, often tightly executed within a well-defined or small community, and usually involving a group that had empowered themselves to organise a locally tailored solution.

• The key for the ADHA and other centralised government, and even non-government bodies, likely lies in empowering the “outer edges of healthcare delivery” by providing access to winning ideas and processes and helping co-ordinate better sharing of ideas, talent and resources. In other words, provide the tools, resources  and communication for those at the coalface to implement effective local solutions, and try to get out of their way.

Kelsey believes that Australia is uniquely placed to develop into a global leader in digital health implementation, particularly given its unique legislation around privacy and the electronic health record.

“No other country in the world has managed to get this sort of legislation in place. It provides the basis for a coordinated and inclusive approach to digital health that is not available anywhere else in the world,” he told The Medical Republic.

But for all the good work by Kelsey and his team, the first week of the New Year brought two foreboding events that threatened to unravel all the groundwork.

Firstly, it emerged that the federal government body co-ordinating digital transformation – The Digital Transformation Office (DTO) – was in crisis mode, following the exit of its founding chief executive Paul Shetler, late last year. Shetler had first been pushed sideways into a chief digital officer role by Assistant Minister for Digital Transformation, Angus Taylor, and replaced by long-time public servant Nerida O’Loughin.

Following further disagreement with Assistant Minister Taylor, Shetler resigned and then launched a stinging attack on the government’s digital transformation agenda and ambitions. Speaking on ABC Radio, Shetler said the Commonwealth lacked the political will to do digital transformation.

Shetler, who like Kelsey, comes from significant experience and success in government-based digital transformation in the UK, was originally appointed to the role of CEO of the Digital Transformation Office by Malcom Turnbull, 18 months ago when the latter was  Minister for Communications. Like Kelsey, Shetler started with a lot of energy and a huge agenda for change.

“When I [joined the government] I thought they were quite ambitious,” Shetler told the  ABC.

“There is a lot to do … but I think there has to be the ambition to do so,” he said.

Shetler accused Assistant Minister Taylor of reorganising the office so it had “the same approach that didn’t work several times before”.

He looks to have been to a victim of going too fast in a public-service culture that was not prepared for criticism and transparency.

Shetler was cut off at the knees, probably for being too outspoken about the government’s “dragnet” approach to debt recovery using Centrelink and Australian Tax Office data-matching, which has resulted in a slew of high-profile errors in the welfare sector.

Commenting on Shetler’s departure, Steve Harrison, chief advisor to the chief executive of the City of Adelaide, said: “It’s a general law of sociology that every large bureaucracy seeks to maintain itself in its current form. And that means the institutional inertia against transformation is enormous. Changing government to operate at internet speed and quality also requires strong will and expenditure of political capital from the nation’s leadership.” Leadership Shetler obviously felt was lacking.

The only saving grace of this very public disavowing of the Commonwealth’s appetite for hard and fast digital transformation is that, despite being a supposed umbrella group for federal government digital transformation and reporting ultimately to the prime minister, it’s very hard to find any connection between the Digital Transformation Office and the Australian Digital Health Agency – something which probably elucidates just how complex bringing about digital change is in government.

The ADHA reports materially to the state and territory health ministers through the COAG Health Council, but effectively it reports to Martin Bowles, who is the secretary of the Department of Health. It’s board shares one member, Paul Madden, with the Department of Health board.

So it is more or less an island of change directed ultimately by the department of health and the health minister. Which brings us to the second of  two steps backwards for digital health this New Year, Sussan Ley.

The only way to drive real change in a bureaucratic organisation and  culture is for our key change agents to be supported in their mission by those at the top. Without cover, they will quickly get mired by a public-service culture which is naturally resistant change.

The ignoble demise of Ley can’t have helped Tim Kelsey’s cause as an agent of change. Or can it?  Word is that Martin Bowles is the key powerbroker in health and is an ardent supporter of the ADHA and Kelsey. And many analysts believe Ley was an ineffective lapdog of the prime minister’s office.

Might a new, stronger minister in the health portfolio be a good thing for digital transformation in the sector?

Unfortunately, the answer to this seems to be that gaining the support of new ministers can be a lottery for talent and change agents such as Tim Kelsey, the ADHA, and possibly even accomplished department secretaries, such as Bowles.

Look at what happened to Shetler soon after Taylor took over the Digital Transformation portfolio on behalf of Malcom Turnbull. Taylor, an ex-McKinsey consultant, appears to have brought his consulting hat to the party and Shetler quickly butted heads with Taylor over how  the office was to be managed.

Time will tell, but if changes at the ministerial level were to hamper the efforts of the ADHA, Kelsey, Madden and Bowles et al, Australian healthcare would be significantly worse off for it.