View from Oz: comparing the NHS and Australian health system

Matthew Taylor

Hello and welcome to the latest edition of Health on the Line produced by Health Comms Plus on behalf of the NHS Confederation. 

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So whether you've been leading improvement for years or curious about its relevance to your role, this podcast is for you. Go to our website and listen to previous episodes or look out for our next one on co-production, which is about to drop. 

Now this is a first for Health on the Line as we welcome for the first time, one of today's guests who's joining us from Australia.

We are really pleased to welcome Frances Diver, who's chief executive officer at Barwin Health, a major regional health service in Victoria, Australia. That includes the tertiary hospital and a wide range of community-based services. With Frances, we're going to explore a bit about how the Australian model of care works. How it's decentralised, how Frances works as part of the Health Roundtable. 

Let me tell you about the Health Roundtable. It's a membership organisation founded in 1995, 30 years ago, that brings together more than 200 hospitals across Australia and New Zealand to collect, analyse, and publish extensive measures, dashboards, and ports on comparative performance.

And we have an interest here at the Confed because we're seeking to replicate that here in England. 

And my other guest today, a fellow Australian, is therefore also very familiar with the Australian health system, having been chief executive of Central Adelaide Local Health Network, the biggest health authority in South Australia. But she's also very aware of the UK context. 

So, delighted to welcome Lesley Dwyer, who's chosen to work for the NHS and is back again as group chief executive for Norfolk and Waveney University Hospitals Group. Lesley's incredibly well placed, having seen both systems, to reflect on the differences, the similarities, the possibilities, for learning.

So Frances, welcome to Health on the Line, and I'll start with you. Thank you so much for joining us, I think it's 7:30 in the evening where you are. Can you just tell us a bit about yourself and about Barwon Health?

Frances Diver

Sure. Look, thank you very much for the invitation to have a chat. Can I just start by acknowledging the traditional owners of the land where I'm today - the Wadawurrung people of the Kulin nation and pay my respects to their elders past and present. It’s very customary for people in Australia to acknowledge the traditional owners when we do any formal events.

So, yes, it is 7:30 in the evening. It's a balmy 21 degrees. I'm in regional Victoria. In the last month we've had bush fires, we've had floods. The region's coming off, well actually, still in a drought. Welcome to rural and regional Australia. 

I work in a regional setting. We have a region of about 500,000 people. Most of that population is in the main city of Geelong, where Barwon Health is located. And we have a modest, relative to the NHS, organisation of around 9,000 people - staff that is. But we do have what I think is the broadest range of services of most health services, at least in Victoria, if not in Australia.

So, I guess what I'd say is we have the benefit of running what we call an integrated health service, where we run everything from childhood immunisation to aged care, to mental health, to ICU, ECU, cardiac surgery, emergency departments, the kind of whole kit and caboodle. And so that's the thing I love about the job I have, is that I feel like I have a responsibility, alongside a very capable team, to think about and care about the 500,000 people in our region. We sort of work backwards from there to think what can we do to improve the health and wellbeing of our region? 

We have a different system to the NHS and, in fact, we have a different system to South Australia where Lesley's from, and New South Wales. Perhaps some people in the NHS will identify with this, we don't have one system. We've got a number of states that all have different systems and even within each state, the construction of our health system is, partially historic really, built up over time. Not as much restructuring perhaps, certainly in Victoria, than perhaps what I've observed from afar in the NHS. We could probably do with a bit more restructuring. You could probably do with a bit less maybe, I don't know, but we have very, in Victoria, very devolved governance arrangements, decentralised - I think there's a trend towards centralisation happening at the moment, but we really have a responsibility, well I do in my regional area, responsibility for a big geographic patch. Of course, working alongside a whole lot of other partners, including Commonwealth-funded services because of our split system of funding. 

So I hope that gives you a bit of a sense of where I'm from and what I'm running.

Matthew Taylor

It does, Frances. And Lesley, feel free to jump in any time in terms of your thoughts about kind of similarities and differences.

I guess the reflection I would have Frances, is that I've come to the conclusion, and I'm sure I'm not first person to come to this conclusion, that almost every round of NHS reform and there has been, exhaustingly many, has been an attempt to address two birth defects of the NHS and those two birth defects are that it's too nationally centralised and too locally fragmented.

Do you feel that, certainly the system that you've got or the system in other parts of Australia, it suffers less from those characteristics that we have to deal with that national centralisation, local fragmentation. It sounds like you.

Frances Diver 

We certainly don't have the national centralisation that you have in the NHS, but we have a split in our system in a different way. I think because Commonwealth's government funds certain aspects of healthcare and state government’s fund other aspects. 

So the Commonwealth funds primary care GPs fee for service specialists and the pharmaceutical benefits scheme and a few other things, but essentially the Commonwealth funding, not managing, but funding general practice, primary care. They're also subsidising private health insurance, which supports a very large private sector and a very well developed private sector in Australia with maybe 40 per cent of Australians having private health insurance. 

So we've got a split in the system between the Commonwealth-funded primary care and a big private health, private hospital system really. And then the states fund the public hospital system and also public mental health care, some primary care. So our split’s in a different place. 

The centralisation/decentralisation, I think Victoria, the state of Victoria, is a bit unique in the Australian context because we've always had sort of devolved governance or local area management. To be honest, I think there's a bit of a trend towards centralisation at the moment, so everyone's always somewhere in the centralisation/decentralisation pathway. We are probably heading into a bit more centralisation, but health systems are hard to change and that's taking a lot of effort and maybe not always getting to where some people would like it to get to.

Matthew Taylor

So Frances, in terms of that funding, what does that mean for the primary-secondary interface? That primary is funded from a different source to secondary. Does that make it more challenging to work across that? 

And then in particular, we talk a lot, we're not doing very much about it to be honest, but we talk a lot about the left shift, shifting resources out of acute and into community and primary. Is that made more difficult by the different funding systems, so primary and secondary?

Frances Diver

Definitely. So, general practice, a series of, you know, I mean they're grouping up to some corporate practices, but general practice is funded on a fee for service basis from the Commonwealth government.

They're independent practitioners. They do their own thing. We try very hard to connect with them, but I am connecting with 300 general practitioners across the region. I don't manage them, I don't employ them, I don't organise them. I don't plan for them, but I, as much as possible, obviously need to work with them.

So that split between secondary and tertiary care and general practice primary care is, is pretty tricky I think. 

But the other thing to say that I think Australia or, you know, some services better than others have done, and Lesley will have views on this, is that we will then just run our own community-based care, not general practice, but everything other than general practice, we run very strong community-based services. 

So, you know, I'm running community nursing, I'm running hospital in the home, home-based programmes all over the place. So, I might run, probably 150 home-based beds every day for acute and subacute home-based programmes. So if I want to run community-based healthcare, or home-based healthcare, palliative care, then we'll just get on and work out how to do it.

If we want to run an eating disorders hospital in the home programme, we'll just go and run an eating disorders program or mental health, acute mental health care in the home. So I guess we have the sense of there's a community, there's a need. Sure, we've got to run the acute hospital, but if there's things that we can do in the community, our funding models allow us to substitute hospital-based, bed-based care for community-based care, and I think that's something that we've been able to achieve reasonably well in our regional area. That's harder to do in a metropolitan area, to be honest. Much easier for us to do in a regional setting.

Matthew Taylor

So, Lesley, chance to bring you in here.

This question of the kind of integration, the challenges of integration in Australia and England and the way that funding works in that, tell us what you see as being the kind of differences and which system makes integration more possible.

Lesley Dwyer

So, as you said in the introduction, Matthew, this is my second time here and I in some ways see exactly the same NHS, and yet a vastly different one in the intervening years. I was only back in Australia for five and a half years before I came back. 

I think that I really did come back because I wanted to see integration absolutely work, and I felt that the NHS was giving all signs that it was going to do that. And some of that was almost for the opposite of what Frances has said, which is the agility that within particularly a devolved state such as Victoria, you can do to try and overcome the fragmented funding because in some ways we should be able to do that.

Now that was the aspiration. And of course it's just as hard. I think that there is an agility in Australia by being able to have certainty around your funding systems and to have that ability, as Frances says, to make decisions, to move that around. I think it is harder in those centralised states.

Frances and I were talking just before this started. We have worked together, so I say I built my career in Victoria. I describe myself as a Victorian, and then I went to South Australia, quite centralised, where, in fact, they had been known for their integrated approach. And then over time that had been dissipated to non-government authorities, setting up other not-for-profits, et cetera, and they've really lost their community.

Following there, I went to Queensland, which, after I think almost forever, we're reinstating statutory authorities in 16 health services across that state with a board. Up until that point, there had not been a board, and in some states there isn't. So that's how centralised it is. 

So I still think that the NHS has got a great opportunity to do this, but it is going to take a really strong partnership model. And I'm not too sure that that has been a core capability. It has been whose responsibility is that? 

But I'm sure, Frances, you live this every day. You actually do have to make sure you partner well, you achieve what you need to do by influence. It's a little bit harder, and particularly as we're starting to move a little bit more centralist, but the fact is we have to be able to do this because none of us can afford to keep going in the way that we are. We do not have enough money to, I think, reform in a minimalist way and to take so long during that reform that in fact, you've reformed nothing.

Matthew Taylor

So Lesley, I absolutely relate to that and I come to you on this, Frances.

If you look at the literature around public service reform over the last kind of 15 years, a lot of it has focused on the question of how do we respond to more complex challenges? How do we respond to the fact that more and more of our money is spent on people with complex needs? And the answer to that question is very often, well, we've got to be much better at building services around people.

I sometimes say in the NHS we have this wonderful phrase, we talk about patient flow. And when we talk about patient flow, we're saying something which is, it's the responsibility of the patient to flow around us, when actually it ought to be the responsibility of us to flow around the patient.

And a lot of that literature points to the fact that you need to invest money, effort, you need to change processes because actually getting different bits of the state to collaborate effectively in the service of people is really very hard to do. And we tend to invest in bricks not in cement.

We tend to have accountability that's about organisations rather than about places and systems. 

Do you recognise that challenge, Frances? And do you feel that you've been able to overcome that kind of challenge of how we build services around people so that, for example, we stopped over medicalising people because when we see their need, we can refer them to, if it's a housing need or a debt need or some other need, we can refer them to that rather than saying, okay, well you're talking to a doctor, so it's got to be a medical solution.

Frances Diver

So definitely. Health people love institutions. We're good at, we in public service are good at institutions. We quite like institutions, I think.

 One of the things that I think that is a benefit to me, where I sit in the system at the moment - I should say, I have previously worked in the Department of Health as well as a sort of system manager role, but now I'm in the region. 

The single biggest difference that I feel I've got is that I wake up every day to think about 500,000 people and how I can improve their health and wellbeing.

And  I know my catchment. I know it's three and a half hours to drive to one end of the region. I know where the populations are, I understand my populations, and then I'm doing what I can to respond to their needs. 

University Hospital Geelong is a fine institution and we need to grow it and do fancy things that we do in hospitals. But only to the extent that they are providing a benefit to my 500,000 people in my region. So there's a mindset shift for me, which is, I have a catchment, I have 500,000 people, what am I going to do? And I think that's the benefit in Victoria, and I'm sure there's areas in England in a similar way, where they've got their own patch.

And when you have your own patch then my incentive is to work with… if I need to work with the private hospital because that works for that area, then I'll contract out to that private hospital, if it helps. If I need to redirect funds into community-based care, because that's going help me, I will. 

Now, of course there's, you know, of course I've still got to run...still got to deliver babies and run the birth suite and you know, do stuff. But, you know, I can actually also establish a home birth programme because there was a really big demand for it in our region, and we can get one up and running. 

So we've got this ability to respond to the community and the way the funding works, you know, I’m not quite as flexible as I'd like, but I can stretch it. I stretch it to the edges of possibility where I will, okay, if I wanna run a home birth programme, then I'll run a home birth programme. I'll use my inpatient maternity funding. I don't have to ask anyone to do that. I just go and do it because I can substitute my funding for inpatient care for community care.

If I want to shut some of my palliative care beds and run palliative care at home, I can do that, certainly. You know, there's politicians and there's community sentiment and there's all those things I've got to pay attention to, but so long as I'm responding to the community's needs and can demonstrate that, I think I have that flexibility mostly within the funding model. 

But what I'd say is it's a mindset that it's a group of people I'm responding to rather than I'm trying to grow the institution.

Matthew Taylor

Yeah. So Frances, I really want to come back to that in a moment because I think there's another reason why people listening to that in England would kind of go, well, that's really hard for us, which is around the kind of level of kind of regulation and targets that people have to deal with. 

But I just want to go to you first, Lesley, obviously you inherited some big challenges in Norfolk and Waveney, which I know you're tackling really effectively, but ultimately every kind of major trust has got this possibility of thinking about whether it wants to be an integrated health organisation.

Do you see the IHO [integrated health organisations] model as getting some of the benefits that Frances has described?

Lesley Dwyer 

I think an IHO model will get those benefits. I'm not too sure that we are quite there in the NHS. In some ways, that was what drove us to become a group. We have two district general hospitals, so two smaller hospitals plus a larger one, which is a good configuration to have.

Plus we have a pretty bound geographical situation. In fact, we almost mirror Barwon in so many ways because they will also fall into the sea if they start to go over to the borders. And it's that coastal rural populations with a fairly large regional center as well. 

So it's certainly our aspiration, but I just want to come back to something you said, which is that we want to spend a lot of time investing in bricks.

I want them to, because I have two hospitals that need to be replaced. But that has actually meant though, that we've done exactly what Frances has said. Up until now, all of our planning has been about services. When even you talk about a strategy and it has the word ‘acute’ into it rather than it is a health strategy rather than a bounded by a hospital, we never landed it. 

So we went back to do exactly what Frances described, which is let's learn about our population. Not what we have made value judgements about or observed over years, but to really deeply try and understand the health needs of that population. It is really liberating because it starts to change the mindset and it makes that partnering much easier when we're going in about what is going to be a value to this population, what are their needs, rather than I have services A, B and C. And I run them over three. Should I run them over one. It actually just starts the conversation in a place that you can move much more quickly towards, even if we never name it as an IHO, but we talk about a system. Even our campuses now, we are calling them health campuses, not a hospital site. And it's really just trying to start to change our mindset so that we can design in partnership something that is going to be impactful, meaningful to our population and add value.

Matthew Taylor

Thanks for that, Lesley. 

And, and Frances, I want to go back to this point of the kind of relative freedom that you've got. And I think that many leaders, even clinicians, in England would say, well, we don't have that kind of flexibility because we are so hide bound by national performance targets by a very complex regulatory regime.

Standards are really, really important and transparency is really important, but I have felt for a long time that we put too little emphasis in the NHS on creating environments where people can learn from each other as equals rather than the kind of way the center looks at it, which is we found some best practice and we're gonna make everyone do it regardless of whether or not that best practice would work anywhere else.

And we've been around that cycle so many times. So tell us a little bit about the Health Roundtable, because one of the reasons we're trying to replicate that in England is because that kind of data rich, challenging but genuinely peer-to-peer approach to learning and improvement is what excites us.

Frances Diver

So, don't get me wrong, just, I just need to clarify something. There's plenty of regulation and oversight in Victoria and my colleagues would be surprised to hear me say, you know, we've got this freedom because I do have the tendency to complain about oversight. So we have plenty of oversight. We have targets and you know, the whole deal, but I think what Victoria has had is the activity based funding model, and we've had that for a very long time. So, case-mix funding, activity-based funding, because we've had that for, you know, 30 years or more. That has meant that we are quite data oriented in Victoria because we are funded on an activity basis, weighted activity.

And so we sort of live and breathe activity. We don't talk in beds and we don't talk in dollars. We talk in nationally-weighted activity units and how we can exchange those units. So I think that the tradition in Victoria, because of the early implementation of case-mix funding, meant that we, and because we were funded on the basis of that, it was important and so you counted. So we're quite good at counting and because of that we've got well developed patient-level costing systems. We've got well developed monitoring systems for our activity, and that environment I think helps us with our flexibility because we can move funding streams, you know, a bit more easily.

But also that means that we're quite data rich and people recognise that 30 years ago and got together and formed a club essentially of peers. So health people, not department people, as in ministry people, but it was peers getting together and sharing their data. 

And look back in the day it was PDFs and I don't know, maybe the data was like maybe not the greatest quality of data, but it was a start. And over time the maturity of that data set has grown enormously and it really was a sort of self-help home baked benchmarking club. And then it's really evolved over time now into actually a very sophisticated product. And a few years ago, the Health Roundtable board made a decision to move to a professional services firm to support us.

And so we now run a health round. There's a board, I'm on the board, and that's health sector people. And we have a contract with Beamtree who are the professional services firm who run the benchmarking product and what they have done is made a huge difference to, and you know, what they've done, but also life's moved on, hasn't it?

We've moved on from PDF documents, but now we have a much more sophisticated platform, a better data ingestion process, a much more sophisticated ability to benchmark with who you want to over quality, access, finance. And really what we've got now is a very mature data set and a trusted data set that people use to compare their performance across Australia and New Zealand.

And so for me, how do I use it? So, every board meeting every month, there would be something out of Health Roundtable at my board meeting that would be demonstrating either hospital acquired complication data sets, or costing data. So we use it, our finance business partners use it. Our clinicians use it to compare our performance so that I can work out how do I compare to a peer hospital in another state. But also maybe, I don't know, cardiac surgery. I need to compare myself with tertiaries, not other regionals. So I can pick and choose my group. 

Matthew Taylor

And do you find Frances that your managers, your clinicians are open to that? One of the problems about a kind of national systems where people feel they're gonna get punished if they at near the bottom of the lead table is that it can lead to a kind of defensiveness where people's first mode is not to understand the data, but to kind of say, well, you know, there, there's a reason why we're at the bottom. It's a kind of, how do I avoid blame? Does the kind of Roundtable methodology help us avoid that? And do they get clinicians, managers to actually lean into comparisons and really want to learn?

Frances Diver

I think because it's had the tradition of being peers and no health departments or no performance regulators looking, so that helps because no one's, you know, I haven't got big brother looking over saying, look at you, you are number 21 of 26 on the league table. And so it creates an environment of curiosity.

Not everyone can be in the top five, right? Someone's got to be down the bottom. The most important thing is why am I down the bottom? And if I'm down the bottom on that, I'm probably up the top somewhere else. So let's understand the context. And I think that's the curiosity and Health Roundtable is the pond that you can go and swim around in with your curiosity to go, well, I'm pretty good at this, but I'm not very good at that. What's the deal? And then understanding what the issues are. 

And so what Health Roundtable has done over the years is bring groups of people together around particular topics. So cancer services or maternity or, you know, patient flow or whatever it is.

And so I think what I'd say is that. It's a trusted and mature data set. Health departments are now trying to do the benchmarking themselves and nobody trusts it. Nobody believes it. They're not quite getting the right things. It's sort of a bit awkward because you go, oh yeah, well that's interesting, but now tell me what Health Roundtable says and we'll just go to Health Roundtable.

So I think it’s created a safe space and a trusted brand.

Matthew Taylor

I can go to you, Lesley now. So you know, we are working with Beamtree to replicate this in England. Tell us about your experience and the power of this combination of reliable, up-to-date, even predictive data on the one hand, but also this peer learning, the scope of peer learning, rather than the kind of blame game.

Lesley Dwyer

So, probably start by saying, I grew up with the Health Roundtable, as Frances did. You know, growing up professionally because that's what we've been used to. And in fact it's more than 30 years, which is why I feel really quite old. It started quite small, but with really important organisations who were prepared to share their data, particularly with others who potentially could not be able to produce that data in the way that the Health Roundtable could. They just would not have had the resource or the capability with internally to get that. So it was almost gave you the opportunity to say, who do we want to be when we grow up? And you were able to look at some of these larger organisations and then we were put into peer groups.

It started off with anonymised data. Everybody had a gladiator name, which as a baby executive, I was thinking, oh my gosh, I'll never be these highbrow people that have got into, you know, Greek mythology and this, that and the other. It was nothing more than that television show, The Gladiators. And then that's now stopped because of, as Frances says, the trust in the data that in fact people are quite comfortable to share.

But I think for me, what I observe now, and Frances, just so that you know, I do have a health service that is ranked the worst in the country. So I do know what that spectrum looks like. And what this has the potential to do is to stop us, because we compare ourselves, we are in peer groups already, but what it gives you is static data.

You are 134 out of 134 against these things. And this one's better than you. My experience with being able to create peer learning groups and to be looking at data, and Matthew, you started to go here, that is not just retrospective, but it is starting to give you that perspective. Look, what could you do? It gives you the insights. 

Nothing annoys somebody like a chief executive more than when I get an integrated performance report and it gives me two point data analysis, it's gone from this to this. Well, thank you. I can see that. I really am interested in what people see in that. Bringing people together in a learning environment. You're able to actually do that.

Now, I'm not saying this doesn't happen in the NHS. But I think it happens because of some of the constructs that have been put together, such as GIRFT, but in fact it requires motivation. Whereas this is actually trying to feed you insights to take action. And I think it is that lack of action and that continually just prosecuting that has really stopped pace in the NHS and I came to the NHS because of its size. I'd done what I wanted to do at that time in Australia. I thought, what would a single system, not a fragmented system, what would it be able to do because of its largesse. I still maintain it's an absolute strength of the NHS, but it is also its greatest weakness because it has to use that strength to do something, to be something else, to learn and to really have the impact and the scale of that impact that it needs to.

But you know, obviously I'm used to this and I look for it. And so you will find many of us in trusts, now are trying to find partners to do that for us. So this is coming at a really good time.

Matthew Taylor

Great. Well, Lesley, we'll be in touch to get more advice for you on how we can learn from the Australian and New Zealand experience in developing Roundtable with Beamtree here.

Lesley's a bit of a hero here because on the day that the league tables were published and she was bottomed, the advice I'm sure she was given by her communication people was, for goodness sake, don't do media. And she went on our top media program and talked about being at the bottom of the league table and talked about what she was going to do in terms of the future, and It was wonderful to see that, by the way, Lesley, that transparency, it meant a lot to people. 

Now look, we've almost run that. I could talk to both of you for hours, but I'm going to ask you both a last question, but ask you to be really kind of short and sharp in your answer to it. 

The one thing  that is common between Australia and the UK is technology and techno and massive pace of technological change. I just wanted to ask you both, what is the single thing that most excites you about the kind of technological possibilities that are opening up in front of you as health leaders? Frances, can I start with you?

Frances Diver

That's a big question and I want to come up with a pithy answer.

The thing that I find exciting is that I hope the next ten years is going to be very different to the last ten years because I think that health technology has failed us in the last ten years or 20 years. I hope that technology, and it is going so fast that we will come up with different solutions to what we've had in the past because the massive EPRs and those huge systems have not served us well.

Matthew Taylor

Yeah, I absolutely agree with that. Lesley, what do you hope that technology might enable us to do given exactly as, as Frances said, that so often it has not lived up to its promise in recent years.

Lesley Dwyer

It certainly hasn't, and I think some of that's our own risk aversion of being able to say, let's go bigger, faster. We start with so many pilots. 

So what would I like to see? I actually want to see it as the fulcrum to change. We have to be able to change the way the people work, the insights they get, because otherwise we are condemning all of our staff, and therefore our population, to having at this health service they've got today with just a little bit of technology at the edges, a little bit of connectivity.

I need it to be impactful enough to totally make us think about the way we change. And I know you want us to be pithy, but when I look at all systems and their virtual care models that they put in place, particularly during Covid, the way that elastic band went back really quickly, but not in all systems. 

You know, one of the things we're not good at is comparing ourselves. I think Australia does this much better, mainly because we all feel we are isolated and therefore we've got to keep looking to see what is somebody doing better than what we are. That's a typical Australian way. But in fact, we have to use it as the big lever to be able to deliver on the design of a health system that will actually take us into the next century.

Matthew Taylor

Well, Lesley, Frances, it's been an absolutely fascinating conversation. Thank you for joining me from the rather remote Norfolk and Waveney and from the other side of the world. Thank you both.

Matthew Taylor

Well, with a final thank you to my wonderful guests, Frances and Lesley, it's time for me to say goodbye, but I should just say this.

If you have an exciting or innovative programme of work you'd like to tell the world about, well, please contact me. Contact us at Health on the Line. You can do that through HealthCommsPlus@nhsconed.org. That's HealthCommsPlus@nhsconed.org It’d be great to hear from you. Goodbye.