Buried in the evidence presented to the hotel quarantine inquiry last week was an important document that described in one complex diagram why Victoria’s Health Department needs a total restructure. Not only did it definitively show that Brett Sutton, Victoria’s Chief Health Officer, did not have “absolute control” over COVID-19 responses (as claimed by some bureaucrats at the inquiry), it also showed how completely ridiculous and unmanageable the Department of Health and Human Services (DHHS) has become.
Contact tracing work under way at the Barwon Health University Hospital in Geelong. Credit:Jason South
Given this, now is a good time to start planning a revitalised post-COVID-19 structure that could better serve Victoria. We don’t need an expensive review by KPMG or PWC – we simply need to look at what aspects of the current Victorian structure are worth saving, then assess the health structures of other states that have managed COVID better than Victoria, to identify those elements that could be emulated.
First, the good bits that should be retained. Clearly, the integration of public health with the world-class Doherty Institute reference lab, which can undertake genomics in a manner that massively guides COVID-19 investigations and contact tracing, has proven to be critical in understanding how best to control COVID-19 spread.
Second, the recent and begrudging call for help by DHHS in which a number of senior infectious diseases clinicians have volunteered to be seconded from their hospitals into Lonsdale Street has shown the value of medical knowledge and expertise in a structure dominated by non-medical career bureaucrats.
Pre-COVID-19, Victoria had only seven doctors working at DHHS – for a population of 6.7 million – roughly one doctor per million. Compare this to our neighbour South Australia, which has 11 health department doctors for 1.7 million (roughly one per 150,000 population). Thus, increasing senior medical expertise seems to have value in a health department, with recent improved outcomes proving this point.
The key change, however, needs to be in structure. The current DHHS is simply too big and unwieldy – it is dealing with everything from at-risk children and family violence, right through to the accuracy of COVID testing kits and the supply of adequate-grade face masks.
At a minimum, it needs to be divided into two – health and, separately, human services. The health structure should look to NSW for a robust, well-funded, hub-and-spoke model where regional public health units can rapidly respond to local outbreaks, recognising they have enhanced local “on-the-ground” knowledge (especially important in areas with large immigrant populations where English may not be their first language), but where they are guided by standardised statewide (and preferably, national) policies and procedures.
For medical leadership structure, Victoria should copy Queensland, where their Chief Medical Officer is a senior medico of key authority and competence, who is also a deputy director-general of health. In this structure the CMO has much greater authority (and responsibility), as well as enhanced direct access to the director-general (or secretary) of health and the health minister and cabinet at times of crisis.
In this model the CMO commands over an integrated health team that includes the chief health officer (responsible for public health), plus separate experts in key areas such as hospital-based healthcare, quality and safety activities, HIV, vaccination policy and insect vector control. By incorporating these two structural changes, Victoria would have a system far better able to respond to outbreaks in a coordinated, effective manner than has been evident with COVID-19.
Finally, there needs to be a total change in health mindset. For decades, Victoria has had an obsession with outsourcing everything it possibly can, rather than developing in-house expertise. As an example, only a few years ago, the DHHS tried to outsource all management and follow-up of active tuberculosis patients – something that totally horrified infectious diseases specialists like me.
Similarly, the perpetual hymn of how cheaply Victoria’s health system is run and how it leads Australia in cost-effectiveness has now been shown to be the mistruth it has always been for those of us who have worked in the system.
In the coming weeks, there should be a parliamentary commitment to sensibly restructure the Victorian Health Department. I don’t think any Victorian could tolerate a re-run of the current COVID-19 response when the next disease outbreak occurs – which it will.
Lindsay Grayson is professor of infectious diseases at the University of Melbourne.
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