Kym Peake: leading reform in the health and human services sector

SPEECH: What will it take for government to meet the needs of a much higher population? A consensus on outcomes, partnerships across sectors, and co-design with clients. Bureaucrats will need to give up control.

The transformation Melbournians have seen in just 25 years has been remarkable. For example, here in the city there was no Southbank as we know it, no Docklands, no great sporting precinct, no Eureka Tower. The city centre has changed drastically to become a place where businesses and people thrive and where people want to work and live.

By 2031 about a quarter of Australia’s projected population — that’s around 7.7 million people — will live in Victoria. That means our state will be home to an additional 1.8 million in 15 years time. And by 2051 our population will be close to 10 million. That is just 35 years away.

This throws up some big challenges for government — and, in particular, for my department.

How do we sustain timely access to services? How do we ensure our infrastructure keeps up with the growing population? How do we ensure people who live in regional communities and growth corridors have the same access to services as those in metropolitan Melbourne? And how do we ensure that the benefits of economic growth are shared by all — that we don’t inadvertently widen disparities in health and wellbeing?

Part of the reason our population will grow so much is because Australians of all ages are living longer, surviving illnesses that would have previously taken their lives. This is good news.

However, demand for health care is being driven by increasing rates of chronic disease, which are now responsible for 85% of Australia’s burden of disease and nine in every 10 deaths. They are startling figures.

The social determinants of ill health

Importantly, we know that risk factors for chronic disease and preventable hospitalisations are not shared evenly among the community. They are correlated with poor education, unemployment, poverty and social isolation — what eminent public health researcher Michael Marmot refers to as “the causes of the causes”.

These social determinants of ill health concentrate in geographical areas associated with patterns of employment and industry restructuring, poorer transport links, low access to social, education or health services and intergenerational transmission of disadvantage.

They also hit some population cohorts much harder. For example, people living with a disability or mental illness, Aboriginal Victorians, or those from some CALD communities.

We know that people who are socially isolated are between two and five times more likely than those who have strong links to their community to die prematurely.

The fact is social networks, jobs, income, having a purpose in life all matter in helping people to avoid chronic disease, keep them well and help them live longer, healthier lives.

Demand for social services

It is not only health that faces demand increases.

Social services like child protection, social housing, specialist family violence and family support services are also facing this pressure. And in both health and human services care, there are familiar patterns in which those people most in need present for help late — or not at all.

There is a growing body of knowledge about the factors that prompt these kind of attitudes and behaviours. Governments around the world are starting to apply this knowledge to the design of health and human services systems, programs and community initiatives.

This includes recognising that even people experiencing longer-term conditions or needs are likely to spend only a small proportion of their time in contact with health and human service professionals. The rest of the time they, their carers and families manage on their own, which is why systems need to be designed to equip them to manage their own care.

Once, both our health and welfare systems conditioned people to be passive recipients of care — but now people want to be more informed and involved. Our clients increasingly expect that they will get services and products that are tailored to their needs and that they will be offered a choice about what, where, when and how they are served.

But the reality is that many of our services do not connect in ways that allow them to deal with overlapping problems faced by vulnerable people. And at the moment, many of our services rely on people making and keeping appointments that suit us. They have to navigate between different agencies and tell multiple professionals their stories. And too often they have to wait until a service can be made available.

We’re not really set up to fit in with how people’s lives actually work, and the places they regularly visit and use.

Prevention and integration

And so we need to change.

We know that if we keep doing what we’re doing today our system will become more and more misaligned. In the face of rapid population growth, intergenerational disadvantage, increasing rates of chronic disease and long term ill health, and changing client expectations, we simply can’t afford to indulge in incremental change.

We need to challenge ourselves to find a better way.

And that will involve a focus on prevention and integration and empowering people to make changes that stick. In other words, we want to create health and human service systems that prioritise prevention and accommodate the complex needs of many of our patients and clients.

To achieve this we need to be clear about two things: where we are heading, and how we will get there.

The key reform priorities

In all of our work, my department is being guided by four key strategic priorities:

• Person centred services and care — designing services and funding models around people and improving how we measure the experience and impact of our services, programs and investments for the people we serve
• Local solutions — involving people and communities in the design and planning of services and aligning our efforts with community activities
• Earlier and more connected support — getting in early to prevent or address problems before they become too big, and tailoring service responses so that they meet people’s needs; and
• Advancing quality, safety and innovation — keeping our eye on the quality and safety of health and community services and working with our partners to build evidence, share knowledge, scale effective practice and support clinical and practice development and change.

So what does this look like in practice?

Our reform priority of earlier and more connected support goes to familiar concepts like primary prevention, earlier intervention and better coordinated or joined up services.

Victoria prides itself on strong universal services. Our health care system, our education system, our maternal and child health system — all of these deliver great services that are essential to healthy development and wellbeing.

However, our great universal services are not really universally available to everyone, and they aren’t always able to meet the needs of everyone that needs them. As I’ve already discussed, there are vulnerable populations who miss out, and these include Aboriginal people, people with a disability, children in out of home care, and sometimes whole rural communities.

There is another problem — when people do come into these services, they might get a great “core business” response such as treatment for their injury, or great teaching or evidence based screening for health conditions. But sometimes our services don’t look beyond the core business to ask: who else needs to get involved to prevent that injury happening again?

Is there an underlying problem here that we can’t help with but needs to be addressed right now?

And so we are looking at transforming our universal services, to ensure that they become more accessible, more flexible, and more responsive to risk and vulnerability.
And this means mapping and creating more common ‘journeys’ throughout our system — journey’s that allow our clients and their families to define the goals that matter to them.

This engagement with the people using our services will provide us with a more consistent and reliable sequence, mix and intensity of services, all based on the best evidence of what works.

The La Trobe Valley

A good example of earlier and more connected support is the work we are doing with communities in the La Trobe Valley.

You may remember the brown coal mine fire that blanketed Morwell in ash and thick smoke in 2014, sparking health concerns in the communities of the Latrobe Valley. An inquiry was held into the cause and management of the fire, but was reopened after community pressure to investigate the health effects of the fire.

Anyone can register their interest in the govt’s #MorwellAshProject. Visit https://t.co/qtEwiOkEni for info pic.twitter.com/oCsgLLASHS

— VicGovDHHS (@VicGovDHHS) July 14, 2016

A second inquiry also looked at the broader health of the La Trobe Valley community, and it painted a picture of poorer health outcomes and high levels of chronic disease, smoking, and family violence.

Health Minister Jill Hennessy said at the time — and I quote:

“We’ve got to make sure that people that are struggling with current illnesses are better supported, but we’ve also really got to try to break the back of some of the ongoing health challenges.”

This work has started already.

For example, we know more needs to be done to prevent diabetes, heart disease and other chronic diseases. That’s why we are designing and implementing programs to ensure we intervene early. So that when people visit a GP, pharmacist or other health professional, they will also be offered risk assessments for type 2 diabetes, cardiovascular disease, kidney disease and stroke.

We are also investing in programs that target early detection of cancer, the prevention of skin cancers, that support more physical activity and reduce smoking. As part of this, we will be engaging with local businesses, clubs, recreation centres and community centres to promote and provide healthy food and drinks to their members and customers.

In other words, our aim is to develop a culture of inclusion, participation and healthy living in the La Trobe Valley.

This kind of proactive, community based approach to the health and wellbeing of Victorians is the way of the future.

How we get there

The focus on prevention and integration that I’ve talked about will require real transformation of big and complex systems. And to achieve it, we have to change the way we do things — how we plan where we’re going, and how we get there.

Both tasks, planning and execution, need a much greater emphasis on three things:

• Clear objectives
• Broad partnerships and
• Close cooperation with services, workers, patients and clients.

A focus on outcomes
We have to start with absolute clarity about the outcomes we want to achieve — a clear picture of where we are heading. These outcomes have to be the things that matter.

• Can people access healthcare, and is it making them healthier?
• Do people have safe and secure housing?
• Are children in our care getting the education, health care and other support they need?
• When people use our services, are they treated with respect and given as much choice and control as possible?

Clearly-defined and measurable outcomes like this must be at the heart of everything we do. As well as clarifying where we’re going, they will help us work out the right way to get there.

They can show us what is working and what isn’t — for all Victorians, for specific groups, and in different parts of the State. We can adjust interventions accordingly, based on analytics, not chance, precedent or the latest fad.

Using outcomes, we can continually ask each other how can we do better?

The Department will be releasing its new outcomes framework shortly. It will name the key results we are aiming for, so we will know when we’re making progress and when we need to work harder, or take a new approach.

Of course, our measurement systems will be a work in progress. We will need to work with experts and our sector partners to refine data collections and make them more purposeful over time (hopefully reducing the collection of dross in the process!).

I am determined that we do not let perfection be the enemy of the good.

Public purpose sector

When I say “we”, I mean the whole of government. Because we need to work together with schools, the justice system, planning and infrastructure, and beyond, to do a lot of the things I’ve talked about — particularly when it comes to prevention.

From the outside, government can look like a gigantic, monolithic beast. In reality, like any large organisation, government consists of many actors and agents in various roles. But even the whole of government is too narrow a view. We operate within a wider network — our partners and stakeholders — who we work with to deliver services and public value.

The concept of a public purpose sector embraces all these actors engaged in the delivery of public value — whether they are not-for-profits, businesses, charities, associations, communities of interest, or government departments.

All these actors have important roles to play — working together — to create public value. We therefore have to foster partnerships and networks, within government and across the community.

The work underway to advance the recommendations of the Royal Commission into Family Violence is perhaps the most substantial example of government’s attempt to break down the barriers that prevent the kind of cultural change required to design and deliver the services that victims, survivors and perpetrators need.

The five big ideas that come through the Commission’s recommendations relate to better ways to prevent family violence, to get in early before violence escalates, to make perpetrators accountable, and to provide stronger support for safety and recovery.

The recommendations ask us:

• To shift attitudes to women and prevent violence-supportive attitudes
• To make better use of the services victims connect with — so that services like maternity services, emergency departments, early childhood services and schools get better at picking up the cues that someone is at risk and connect them to support earlier.
• To make it easier to get help — by creating more visible points in local communities, better connecting social and legal supports, and ensuring victims and survivors are equal partners in planning, developing and monitoring those supports to make sure they meet their needs.
• To build a closer connection between policies and services focused on children and families and those focused on specialist family violence services
• And to strengthen safety and recovery — by improving information sharing, risk assessments and responses by the legal system, police, corrections, child protection agencies, housing and homelessness services, family violence support services and broader health and social services.
• The Commission paints a picture of fragmented, hard to navigate services which are under significant pressure to meet demand. This experience is not unique to victims and survivors of family violence. And the prescriptions of better ways of working have application to other Victorians who feel shut out from the good life.

Co-design

The ambitious reform agenda across health and human services requires my department to change the way we work across government and with sector partners. It also requires us to shift the dynamic with the people we serve — to view them as genuine partners and collaborators.

At the Police Chief Commissioner’s Youth Justice Forum on Thursday, the Premier emphasised that we will only make a real difference in tackling complex social problems if we act on the best information and engage openly.

The third ingredient to successful reform is often called co-design — working with service providers and service users to tailor systems and services to their needs.

This already happens in some cases, but it isn’t yet the norm, either in how we develop policy or how we deliver services. We are making a concerted effort to change that.

The government’s response to the family violence royal commission and the health assembly in the La Trobe Valley are two of the largest co-design processes we have attempted in this state. Effective co-design brings together data, the best evidence and values the experience of those accessing and delivering services.

If we return to the five big ideas contained in the Royal Commission’s report.

We won’t make inroads into reducing negative stereotypes and promote positive attitudes about women if we don’t involve communities in designing prevention initiatives and programs.

We won’t enhance the capability and role of universal services if we don’t involve the people who work in those services in conversations about how they could make a difference.

And we can’t improve our social services, policing and justice systems if we don’t understand the experiences, social and cultural context and aspirations of the people involved.

We need to combine our data to better segment clients based on their context, needs, preferences and capabilities. And we need to map the service journeys of victims, survivors, children and perpetrators now — and what an improved journey should look like.

We need to build a culture and practice within government of exposing and testing our ideas out in the community early. We need to be open to listening and reflecting on the personal stories, ideas, experiences and perspectives of others. We need to get better at developing ideas together.

Of course not every activity needs to be designed. Sometimes the evidence is already clear and the focus should be on collaborating to implement.

I do want to emphasise that co-design is not a talkfest. The essence of design methodologies is about involving people in a hands-on manner by making and building with them. The focus must be on concrete actions and outcomes — not abstract conversations.

The success of our reforms will depend on all of us shifting mindset from a notion that we design, implement, complete. To a mindset where we learn, adapt and progress. Co-design is all about testing and refining new approaches.

Somethings won’t work. We will need to re-evaluate quickly, so that government and community can have confidence that the inevitable errors and missteps will be identified quickly and remedied.

Just as public servants will have to adjust — there are implications of this way of working for sector partners too. Non-government partners will need to share responsibility for reform processes. To work with officials on joint problems, to consider where compromise is necessary and acknowledge that government will ultimately make decisions and trade-offs between competing interests.

Putting into action

It is clear that these three approaches fit together: outcomes people can agree on, working across sectors, and working with patients and clients.

They won’t just mean services that work better. Together, they will help create a shared agenda — support for ongoing improvement and long-term change.

We need that breadth of support because the work I’ve talked about will take time, spanning well beyond one term of government. The broader the support we can create, the stronger the foundation for transformation.

Another link between outcomes, partnership and co-design is that they all involve giving up some form of control.

An outcomes-based approach means less micro-management — setting the right conditions and incentives, building the capacity of the workforce, providing the right information and support, but being less prescriptive as long as risks are managed and outcomes are on track.

Really collaborating on how our service models work and on the direction of change also means giving up some control — that is what it takes to build consensus.

This new way of working is a big change for government agencies. The public service needs to get better at building consensus and sharing control.

Putting forward a persuasive, long-term view and working across traditional boundaries can be uncomfortable in a traditionally hierarchical culture — a world which can sometimes feel distant from the community.

The end game is not just more efficient public administration. It is about supporting government toward better decisions, sustainable solutions and, most importantly, delivering more value to the people we collectively serve.

The need for integration and prevention involves the business community too. Whether or not you’re part of the public purpose sector as I’ve defined it, I welcome your input into the directions I’ve discussed. Now is the time to be curious of mind, and generous of spirit.

Ultimately, getting integration and prevention right will benefit all of us, including through its impact on the workforce and economic growth.

This is an edited version of a speech given by Kym Peake to a Trans Tasman Business Circle event on July 22 in Melbourne.