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Fortune favours the bold

Unfortunately, our healthcare system in advance of reforms suffers from many issues that prevents us from being bold. The promise, even with reforms in place, may be vastly different from the reality.

A high-quality cost-effective health system that gives every kiwi the ability to live well is achievable. A big challenge to overcome though lies in the DNA of the organisations that make up the system.

A battleground

Today I operate in the primary care end of health, having a commercial career path and not coming from a clinical background I see stark contrasts of those who have a clinical background leading and running organisations vs those who have a more traditional corporate based mindset. The former is often risk averse and as the latter we are type cast as being too risky, looking to win at the expense of others and non-co-operative.

It often feels like at times a battle of good vs evil with all the actors professing to be good. As for the enlightened in the system, it becomes a matter of perception of who are the good guys in a world of anti-heroes and flawed individuals; and a hope that we can ‘all’ win.

Contributing to this dynamic are the power imbalances arising from those that commission and those that provide services, as well as the structurally diverse organisations that make up the system - crown enterprises, NGO’s and ‘for profit’ entities.

Somehow today the system appears to work, although it does so with a wide range of frustrating mechanisms whenever changes are needed.  In our health tech space this often leads to cumbersome procurement processes or provider organisations trying to build their own systems.

Both often leading to budget blowouts, early write-off’s (e.g., SmartHealth) or underwhelming project outcomes.  On the other-hand innovation is stifled or cost savings are not realised due to prohibitive contracts in place.

A better way

The beneficiaries of the system, that is ‘all of us’ who are living through the system are nearly always unaware of whether things are good or bad. I lived first-hand through this when I broke my ankle recently and spent a week in hospital and subsequently discharged without surgery to much frustration of things that I thought could’ve and should have performed better.

And we can do a lot better. There are some projects that I have been fortunate to have been part of that balance opportunity and risk and are delivering better health.

Today’s risk mitigation model of care with endless RFP’s, on-boarding and off-boarding vendors has in some way delivered the opposite of what we desire. At ProCare (NZ’s largest Primary Healthcare Organisation) I would contend that we have been guilty of this approach and have been slowly adopting a different principled approach with all actors in the system.

So how does one move then to a new paradigm, especially for vendors working with government, DHB’s and PHO’s. I have been taking a lot of cues around game theory and behavioural economics as of late.

Professor Des Gorman as someone who speaks of this often, reminds us of this Nash equilibrium position we find ourselves in where we can never achieve the optimal outcome due to our own organisational self- interest leading to a position where nobody wins.

A focus on trust

So how do we flip the script? Well, we need to change it and the outcomes currently being delivered by including elements that build and maintain Trust.  

So, what do we mean by Trust?

“… generally, there is agreement on the idea that to trust a person is to expect that the other will refrain from opportunistic behaviour, even if the opportunity arises.”

Mechanisms which reduce the conditions that opportunistic behaviour occurs, but also foster the good to thrive such as innovation and lower costs. This needs to be matched with clear consequences of opportunistic unacceptable behaviour against all organisational participants.

A recent article I read posits that: “private and public partnerships work better when you marry trust with good management to incentivise trust or the promotion of trustworthiness. That trust and management are important for both the perceived PPP performance and the cooperation between actors in those projects.” There are several ideas in it on practically incentivising trust.

One other thing that is missing is the trust needed by the very service users of the system that flow through it. Democratising the system needs to include ‘us’ all in there as well.

Trust is so intertwined in our everyday lives that it is often unacknowledged, and it is only when trust erodes, that we can appreciate its significance.

I imagine there will be further answers and experimentations over and above health reforms to try to deliver a health system where everyone has the right to live well. But it must be a trusted way forward.

NZHIT is about to launch its Health Tech sector opportunities report that gives a range of solutions that could enable this.  Watch out when it lands.

Tony Wai is interim chief executive at ProCare Health and Director NZ Health IT

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