Challenges arising in archipelago of islands of excellence

4 minute read

No healthcare system is an island. It is perhaps an archipelago however, says Professor Michael Fasher


At its very best, the Australian Health System might be described as an archipelago of islands of excellent care.

Providers on each island are aware of what is working well and what needs improvement … at least on their island. They know how to get things working better if only their island attracted a greater share of the health budget. They raise their eyes when you ask them about the work done on other islands.

Serial episodes of excellent care may be enough to make the providers feel proud of their work but not be enough to improve a patient’s health. The more disadvantaged the patient, the less likely it is that disconnected episodes of care, no matter how excellent, will improve their health.

Fragmented care also has implications for provider well being. It can increase stress and frustration and so fan the flames that lead to burnout. One defence against burnout in such a system is to give up the aspiration for excellence and drift unwittingly into thinking that “good enough care” is good enough.

A further consequence of working in this archipelago is that there has developed, as Sidney Sax describes it, a “strife of interests (which) masquerade as a conflict of principles”.1

Surveying this scene the Federal Minister for Health said on Lateline (ABC TV 20 July 2015), “I don’t support raising taxes to fund the health system until we have made the health system as efficient as possible”. At first glance this seems fair enough but only at first glance.

Steps towards reform.

  1. Find goals that all can share.

The team from WentWest who went east to the US earlier this year found that when division threatens discussion (the strife of interests masquerading as a conflict of principle) the Americans remind all present of what they have in common. The common ground is variously called “The Triple Aim” or “The Triple Aim plus one” or “the Quadruple Aim.”

One version of the Quadruple Aim is:

  • Optimise the patient experience
  • Optimise the health of the population
  • Achieve both of the above cost effectively
  • Optimise provider joy and satisfaction in their work


The George Institute has recently published a report suggesting an Australian version of “The Quadruple Aim.”2

  1. Understand the ambiguity in “efficiency”.

When Treasury cuts a Departmental budget by a certain percentage they believe they have achieved an improvement in “efficiency”. Their idea, indeed their demand, is that current delivery of service must not diminish as a result of the budget cut. As there is often inadequate measure of the impact of departmental activity, the treasury is satisfied that it has achieved a gain in efficiency if there is no politically effective public outcry against the cut.

On the other hand, “cost effectiveness” or “efficiency” in the Quadruple Aim demands that both cost and health gain is effectively measured.

Jane Hall, Professor of Health Economics at Sydney’s University of Technology, argues that, “If reducing commonwealth expenditure remains the primary objective for the health portfolio, it could lead to further fragmentation of care and missed opportunities for developing a coherent and efficient health system.”3 

  1. Move towards better measurement of outcomes in health.

This move is imperative. There is a need to move beyond present day measurements of the care offered on islands, valuable as these measurements are, to measuring the impact of the sum total of all care on the health outcomes of individual patients and on populations of patients. Until we have that capacity Ministers for Health, however splendid their intentions, can only promise changes to the system, they do not have the tools to effect reform.

The very best American health systems have tools that enable the patient’s electronic management plan to be accessed by all providers at every point of care. This joins up islands of care and allows a sophisticated display of metrics4 that demonstrate in real time the impact of care on the patient’s health and wellbeing. Let us be clear about where we want to go and refuse any new investment in IT that does not inch us toward that goal.


  1. Quoted by Jane Hall in #3 below.
  2. A Health Policy Report, The George Institute Australia. 6 August 2015.
  3. Jane Hall, Australian Health Care – The Challenge of reform in a Fragmented System. Perspective. The New England Journal of Medicine. August 6, 2015.

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