Health system pressures are not new, but this time it's different. Something does not feel right. Pre-Covid, the writing was on the wall that the health system pressure during winter continued well into the summer months. What’s different in 2022 is northern hemisphere countries are facing almost identical pressure during their summer as their southern hemisphere colleagues who are in the middle of winter pressures. That is a scary position to be in because any respite from the warmer weather is not forthcoming.
In both hemispheres, signs of overwhelmed health system make daily headlines in Ireland1, England2, Germany3, France4, Canada5, the USA, Australia, and New Zealand.
For an increasing number of ordinary people, even those with means, 2022 is not a good time to be sick. Hospitals have long wait times (and not only in A&E), too many surgeries being canceled, an unprecedented backlog of essential healthcare services, and delays in routine screening and immunization programs. In primary and community care, ambulance callout delays are becoming the norm, getting prompt GP appointments is increasingly difficult, and expecting mothers face challenges in getting midwives. Due to staffing shortages, the elderly at home and in aged care facilities struggle to get the support and care they need.
More investment in health systems
Most commentators blame policy failure, lack of planning, and funding of workforce, hospital beds, ICU, and A&E capacity for the current crisis.
The workforce factor is of particular concern. After more than two years of relentless Covid pandemic pressure and government response policies, health systems globally face unprecedented workforce shortages. Burnout, disenfranchised and frustrated workforce have either quit their profession, looked for greener pasture in another country (often for more pay), or taken industrial actions. The ongoing uncertainty fuelled by the recent resurgence of significant Covid outbreaks is the final straw for many in the frontline to join the "great resignation" trend.
The call for greater urgency by governments to “fix” health systems is deafening. Most healthcare champions'solution to "fix" the problem is for more investments, funding, and better planning.
Pressure on government spending
It’s not a good time to be in government at the moment. Apart from the health sector pressure, governments also face pressures in:
- other social services (education, housing, welfare),
- infrastructures (roads, ports, rails, public transport, utility networks),
- economy (business, jobs, productivity, wages),
- law & order,
- national security and
- last but not least is climate change.
Most of these are broader determinants of any country’s health and well-being and cannot and should not be ignored.
The current global high cost of living fuelled by high inflation is forcing many governments to revisit, curtail and cut back on plans for increasing public spending. This fiscal restraint will not sit well with those calling for higher levels of investments in health systems. It begs the question: <u>what is plan B if the required level of additional funding is not forthcoming?</u>
Plan B
Ernest Rutherford, renowned New Zealand-born Noble prize-winning physicist, credited as the father of nuclear physics, has some worthy advice for those contemplating plan B. “Gentlemen, we have run out of money. It’s time to start thinking. If you don't do the best with what you have, you could never have done better with what you could have had”.
Plan B cannot be more of the same but rather is grounded in three core principles: 1. circuit breaker 2. dual transformation 3. leadership
The circuit breaker principle requires the breaking of “more of the same” mindset, ideas, policies, and practices from politicians, policymakers, funders, providers, board members, academia, professional bodies, and those at the coalface of daily patient care. Too many current reform and transformation agenda is more of the same. Any circuit breaker initiatives will challenge and disrupt the status quo vested interest. But without a break from “more of the same” ideas, practices, policies, and mindset, it is not possible to pursue the next principle – dual transformation.
The dual transformation principle recognizes there are two essential parts of plan B:
The first part is stabilizing the status quo with the primary purpose of transitioning to a "new system."
The second is to create the “new normal” that disrupts the status quo.
Both parts must be implemented concurrently and require a separate operating model, including criteria for success, governance, and leadership talent.
Part 1 is not about preserving the status quo but improving what works and disinvesting what doesn't. Part 2 is all about implementing disruptive innovations to disrupt the status quo. Not all Part 1 and Part 2 initiatives will necessarily work. Still, the discipline of learning, changing, and adapting fast and early stand between "lip service" and "real world" execution of the dual transformation approach.
Concepts such as system thinking, broader determinants of well-being, patient/consumer first, integration, quality, prevention, AI-empowered personalized, and precision medicine are essential elements of both Part 1 and 2. Similarly, innovations in operating and funding models are integral elements, especially in Part 2. However, none of these concepts should be implemented in silos or seen as the silver bullet.
A fundamental pre-requisite for a dual transformation understands the complex starting point of any change. Often the "due diligence" of the starting point focus on fact and data on the demand and supply pressure. The emotional, qualitative, and intangible frustrations of disenfranchised frontline staff, patients, and their families are neglected too often.
Leadership
A circuit breaker mindset and implementing dual transformation require a higher level of leadership on two fronts:
1. strategic thought leadership and
2. last mile implementationStrategic thought leadership requires, amongst other things, a working understanding of the nuances and intricacy of complexity, system, and social behavior theory, concepts, and tools. Equally important is keeping abreast with the 4th (rapidly moving towards 5th) industrial revolution concepts and tools.
The last mile implementation leadership is a non-negotiable twin of strategic thought leadership. Ideas, visions, policies, strategies, and plans, no matter how relevant and well articulated, remain unfulfilled if they are not successfully and skilfully implemented. Implementation failure has long been the Achilles heel of too many aspirational health reforms. Plan B can only succeed once this blatant gap in leadership is uncompromisingly addressed.
Plan B requires both types of leaders. Many health reforms result in the appointment of too many familiar faces appointed with a new title and organization. There is nothing wrong with that, provided their appointment process can robustly establish that they can think and act differently. After all, these same individuals have been managing previous health system that now requires urgent reforms.
Final word
The Covid pandemic and government responses have opened up their health system pandoro's box. Governments
globally are realizing (some faster than others) that once the genie is out of the box, no amount of pushing and shoving can put the genie back. Closing borders, restricting and locking down social and community movements may have been the right things to do in 2020 and 2021. But trying to re-open borders and re-start economic, social, and cultural connections in 2022 is proving much harder. What's dismantled cannot be put back or replaced easily by a "new normal." In any event, too many of the so-called "new normal" look very much like new wine in old wineskins.
The new wine requires a new wineskin rather than trying to patch up the old. The new wineskin should be made from new materials or designed differently. And finally, it is time to change the winemakers.
CHUAH Jin Chai 蔡 仁材 Wellington, NEW ZEALAND 2nd August 2022
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