Defence Health Service or Health Advice Agency – An alternative reality to the Steven’s Review

Abstract

In 2003 MAJGEN Paul Stevens AO (Retd), assisted by GPCAPT Helen Doherty, commenced a review of the ADF Health Service on behalf of HDPE. He tabled his recommendations, colloquially referred to as “The Stevens Review”, in 2004. The purpose of the Review was to:“evaluate whether the Defence Health Service will be able to meet Defence needs for health services in the short to medium term – broadly until 2010; and propose any changes that may be necessary in order to ensure it can do so” (Stevens Review, p.i). The Review made a number of recommendations for future DHS business. In establishing revised outputs for the Defence Health Service Division, staffs have found it useful to refer back to the underlying philosophy, environment and recommendations of the Review to better understand intended future development requirements. Did MAJGEN Stevens get it right or was he limited by the terms of his commission? By applying an alternative filter to the background conditions of the report and its subsequent recommendations, it is apparent that an alternative reality may have been possible for the Defence Health Service. This paper will substitute these base assumptions and offer up an alternative Defence Health Service that may have been considered within this hypothesised alternative reality. In doing so, the author intends to present the Review as a background for debate and in no way intends to critique either the persons or professionalism of MAJGEN Stevens, GPCAPT Doherty, or any other person or organisation, in any way. Keywords: Governance, health system review, strategic health policy Conflict of Interest: The author is a full-time member of the Defence Health Service

Introduction

In 2003 MAJGEN Paul Stevens AO (Retd), assisted by GPCAPT Helen Doherty, commenced a review of the Australian Defence Force Health Service on behalf of the Head, Defence Personnel Executive.They tabled their recommendations, colloquially referred to as “The Stevens’ Review” but more correctly as the ‘Review of the Defence Health Service’, in 2004.¹

The purpose of the Review was to:

“evaluate whether the Defence Health Service will be able to meet Defence needs for health services in the short to medium term – broadly until 2010; and propose any changes that may be necessary in order to ensure it can do so”.¹

The Review made a number of recommendations for future Defence Health Service (DHS) business.In establishing revised outputs for the Defence Health Service Division, staff officers have found it useful to refer back to the underlying philosophy, environment and recommendations of the Review to better understand intended future development.

But did MAJGEN Stevens get it right or was he limited by the terms of his commission?By reviewing the background conditions of the report andits subsequent recommendations, it is possible to suggest that an alternative reality may have been possible for the Defence Health Service.

This paper reviews the policy environment existing at the time of the Review, and will focus on the fundamentals of command and control, in order to offer up an alternative Defence Health Service that may have been possible in an hypothesised alternative reality.Whilst doing so, this paper intends to provoke debate but in no way seeks to be critical of either the persons or professionalism of MAJGEN Stevens, GPCAPT Doherty, or any other person or organisation.

Background

In the past decade the Department of Defence has been the subject of an almost continuous series of reviews into its higher command and control arrangements, subordinate activities and business systems.On 15 October 1996, the Minister for Defence established the Defence Efficiency Review (DER). The review was tasked to assess efficiency and effectiveness of management and financial processes in Defence generally, and make recommendations for reform where appropriate.With respect to Defence health services, the review report released in 1997 stated that:

“Responsibility and accountability for the provision of health services are fragmented and diffused through the Defence Organisation.Scope exists to improve the efficiency and effectiveness of deployable health support capability as well as in the provision of in-base health support”. ²

The efficiency review went on to recommend the establishment of a single, integrated, joint health organisation to control all health activities – both deployable and base support (ibid).

Concurrently, the Australian National Audit Office (ANAO) was undertaking a more focused review of the Australian Defence health services.³ Whilst focused on the economic impacts of efficiency and effectiveness, the ANAO found that the existing administrative structures were complex and fragmented, with Single Service division of responsibilities leading to different priorities, and with significant costs with regard to health care expenditure.With regard to organisational effectiveness, the ANAO concluded that “tri-service cooperation has been identified by Defence as a significant problem in the delivery of health services”.Then, as now, organisation of the health service below the strategic level remains essentially along single Service lines.The ANAO recommended that:

“the Surgeon General be given responsibility for the command and control of all ADF health resources, that appropriate human and financial resourcing be transferred to the OSGADF and that formal agreements be developed with operational commanders in relation to the provision of resources for operational purposes” (Recommendation 6, para 3.18)

Whilst a documented response to the DER conclusion noted earlier has not been found, the Steven’s Review documents Defence’s agreement with the above recommendation given that the DER came to the same conclusion.

Issues leading up to the Stevens Review

In their 1997 report, the ANAO concluded, and Defence agreed, that Defence health services could be more effectively managed if the Surgeon General had full control, rather than technical control, of ADF health services.A follow-up Audit by the ANAO in 2000-2001 noted that the strategic level health organisation had been restructured into the Defence Health Service Branch.⁴ Base support had also undergone reform, with the establishment of the Joint Health Support Agency [JHSA} tasked to coordinate provision of health services in the National Support Area on a joint basis.However, with respect to the key recommendation 6 from 1997, the follow-up audit found that the Surgeon General had not been given command and control of all ADF health resources.Additional persisting concerns included the relationship between JHSA and the single Services, and the palpable division between (and within) the operational and the non-deployable health service environments through single Service retention of deployable health units, personnel and resources.

Defence responded to the ANAO follow-up audit findings regarding the failure to transfer full command and control for health services to the Surgeon General Australian Defence Force (SGADF)as follows:

“Action to address this recommendation has been slow.Establishment of the DHSB and JHSA partially implemented the recommendation.However, full command and control of all health resources has not been transferred to the DHS as Defence considered such an arrangement to be inconsistent with the overall command and control paradigm in the ADF” (p.14)

The Macquarie Dictionary defines paradigm as the set of all forms containing a particular element, a pattern, or a set of concepts, stock illustrations, etc shared by a community.⁵ In none of these elements is paradigm linked or associated in any way with appropriateness, authority or legitimacy.Sound academic analysis of all options, based on well developed governance models and accountability principles is required before any option can be discounted as unworthy of further consideration.Defence’s dismissal of the ANAO recommendation based on the current paradigm preference should therefore be challenged.

Stevens Review

The purpose of the Stevens Review was to evaluate whether the Defence Health Service would be able to meet Defence needs for health services in the short to medium term, broadly out to 2010.¹ The report examined a broad range of issues across Defence health, including command and control, DHS structure, standards and policies, operational, and National Support Area (NSA) support issues.

Stevens noted that command and control of health support to the ADF is a command responsibility currently vested in the Chief of the Defence Force (CDF) and the single Service Chiefs.The review identified a number of alternative options for higher leadership of the Defence Health Service.In all, the review report made 41 recommendations encompassing;

• Command and control of the DHS,
• Structure of the DHS,
• Health standards and policies,
• Support to Operations,
• Support in the NSA,
• Permanent staff,
• Reserve management,
• Health logistics, and
• Health records.

However, given Defence’s previous decision to decline the recommendations made by the ANAO ^{3, 4} for Defence health to be placed under command of the Surgeon General (or under current arrangements, the Head Defence Health Service (HDHS)), the most pragmatic major organisational recommendation from within four options was offered.The recommended option was to establish structured strategic level supervisory committee arrangements to coordinate single Service and joint health service management.This option left the command and control environment across the Services unchanged.

The Issue

It cannot be argued that significant reform in joint management of the Defence health environment has not resulted from the Stevens’s Review, DER and ANAO reviews.Improvements have been made through the reorganisation of the senior leadership group in the Defence Health Service Division (DHSD), establishment of the JHSA and other strategic level rebalancing.The key concern that remains and upon which our alternative reality swings is Defence’s decision not to transfer command and control of all health resources to the DHS as recommended, based on a preference to maintain the existing “overall command and control paradigm”.¹ This simple decision remains critical to the current health leadership, health service culture and health system efficiency, effectiveness and future.Whether this decision has been tested by systematic analysis against alternative organisational models is not known (and unlikely), but serious analysis should be strongly argued to ensure that any potential to enhance Defence health efficiency, effectiveness and economy is not left untested.

Discussion

The Steven’s Review was conducted in a Defence policy environment that supported the status quo of shared responsibilities for health service support, being between the single Services for operational capabilities, and the Defence Health Service Division (DHSD) for strategic and technical guidance and through the Joint Health Support Agency (JHSA) for clinical and corporate governance of base support functions.

The terms of reference that directed MAJGEN Stevens to consider “whether DHS will be able to meet Defence’s needs for health service in the short to medium term”, in the context of the above, required reflection on the adequacy of these shared responsibilities.The review could only briefly examine alternative command and control models, but still resulted in final report recommendations that were confined to the reality of the existing shared responsibility paradigm.

An alternative reality therefore gives us an opportunity to examine the relationship between the higher Defence health leadership and the lower operational, tactical and base support functions.In such an environment, the drivers upon which review of the command and control functions rely are the limitations inherent in the current technical control authority of the Head, Defence Health Service and related issues arising from the broader command and control doctrine as it currently exists.

Command and Control Options

Command and Control of ADF health support is outlined in Australian Defence Doctrine Publication (ADDP)1.2 Operational Health Support.⁶Under this doctrine, the HDHS is responsible for technical control of all elements of the Defence Health Services, including operational health support units.Technical control is defined as “the specialised or professional guidance and direction exercised by an authority in technical (professional) matters”.Within Australia, during peacetime, operational health elements and personnel are under the command of the respective single Services.Whilst the HDHS and DHSD staff are involved in strategic level health support planning, any further command or leadership responsibility down to lower levels is constrained by the single Service command arrangement.

Internationally, things are very different.The South African Military Health Service and the Zentraler Sanitätsdienst (Central Medical command of the German Bundeswehr) are separate, fourth arms of their national defence organisations.Providing leadership and command responsibility from the top down, these organisations continue to support their respective environmental services through imbedding or standing support arrangements.This system is considered by their respective governments to be more efficient as the duties of the medical services personnel are seen as beingprimarily medical rather than military in nature, as well as providing for the care and support of armed force personnel more efficiently.Unfortunately, the Steven’s review was insufficiently resourced in terms of time, academic support and scope to seriously examine this option, but suggested somewhat negatively that “the fourth arm concept reproduces on a small scale the administrative structure of the current single Services”.¹ In the author’s opinion, this and all other options remain open to closer formal modelling and analysis before discounting any as worthy for further consideration by the ADF.

Moving closer to single Service arrangements, but with a greater degree of integrated command responsibility for health service support, is the United States Joint Health Service Support Strategy.Taking the Army Health Service Support System as a model for review, the Army Medical Department (AMEDD) encompasses all levels of medical, dental, veterinary, and other related health care from the policy and decision-making level to the combat medic in the field.⁷As head of the (United States) Medical Command (MEDCOM) the Surgeon General (TSG) commands fixed hospitals and other AMEDD commands and agencies. This system unites in a single health service leader both the duty to develop policy and budgets (acting as the Army surgeon general) and the power to execute them (as the MEDCOM commander). This arrangement ensures that senior health leadership is developed, and remains engaged, from the lowest ranks, and that the senior health leadership is fully responsible for both the success and failures of the integrated health system.But even in the highly developed U.S AMEDD system, criticism exists around continuing single Service arrangements.The U.S systems have been subject to federal scrutiny similar to our ANAO and Stevens’ Reviews. For example, the National Defense Authorisation Act for fiscal year 2000 requested that the U.S. Secretary of Defense submit a study identifying areas of military medicine in which joint operations might beincreased.Areas to be considered included organisation, training, patient care, hospitalmanagement and budgeting. The study team was asked to discuss the merits and feasibility of establishing a joint command, joint training curriculum and a unified chain of command and budgeting authority.⁸The conclusions of the U.S finalreportare not known, but given these concerns it could be argued that single Service arrangements inherently hamper joint cooperation and efficiency.

In contrast, the Canadian Military Health Service arose out of a much bolder reform program for the Canadian Armed Forces.⁹ The Canadian Forces Medical Service (CFMS) was established in 1959 to centralise the administration of all medical operations and permit development and application of common policies. On 2 May 1969, a year after the Royal Canadian Navy, the Canadian Army and the Royal Canadian Air Force were themselves integrated to form the Canadian Armed Forces, the CFMS was authorised as a personnel branch of the Canadian Forces, completing the administrative process of amalgamation. Despite this relatively long history of amalgamation, the Canadian force structure is also not without problems, with Audit Office reviews in that country also finding significant inefficiencies along similar lines to the findings of the ANAO in this country.Over the years, the CFMS had evolved to focus increasingly on the peacetime needs of the Canadian Forces, to the point (claimed in an Auditor General’s Report of 1990) that its ability to respond to operational demands was compromised. In 1993, the Canadian government found it necessary to address wider deficit reduction, and oversaw the closure of three of the six Canadian  Forces Hospitals and an overall reduction in number of military health care providers from 3,000 to 2,400 all ranks. Before the cuts, uniformed personnel provided the full range of health care services at specialised facilities.Subsequently, the CFMS has drawn on civilian facilities for services delivered in garrison and restructured itself into units designed primarily to support Canadian operational deployments.

The third option is a single Service led health service.In this model, all health personnel might be required to transfer their allegiance to the hosting service.Whilst providing all health capabilities from within a single organisation would reduce (but not fully eliminate) single service rivalry issues, this option is less likely to be broadly accepted by individual health service members than transferring to a ‘fourth arm” of the defence force.Notwithstanding this concern, such transfers of responsibility for entire trade or capability groups have occurred in other defence capability areas.Most notable was the transfer of rotary wing aviation (but perversely not rotary wing aeromedical training) from the RAAF to Army and Navy in 1986; and air traffic control responsibilities progressively from the three services to the Air Force around the turn of the last century.A more palatable option may be simplyto maintain personnel ostensibly in their preferred services but to better align the strategic health leadership through command responsibilities to joint operational planning, support and subordinate health capabilities assigned to each of the three environmental commands where appropriate.

Whilst each of the previously discussed models could be further examined for adoption in the ADF, the most critical consideration is that each inherently accepts that health is a specialist domain rather than a subset of personnel or logistics function. This is an important technical and cultural consideration that has ramifications on organisational leadership, support, recruitment and retention.Unfortunately, none of them were seriously considered given the existing ADF command and control environment as discussed earlier

What are Command and Control?

The above heading is not a grammatical error.The concept of ‘command and control’, often uttered as an inseparable binary term, is itself contentious and generally poorly understood. The terms ‘command’, ‘control’ and ‘command and control’ are essential to be well understood in military affairs, but are outdated, circular, redundant and generally unhelpful.In a paper published in the Canadian Military Journal in 2002, Dr Ross Pigeau and Carol McCann¹⁰ deconstructed both of these mutually exclusive but highly complementary concepts.Command is defined in their discussion as “the creative expression of human will necessary to accomplish the mission”.Control is described as “those structures and processes devised by command to enable it and manage risk”.In their analysis, command cannot be exercised without control, but control (such as technical control) is meaningless without command competence, authority, and responsibility with which to manipulate the levers of control.

The ADF recognises seven principles of command, which need to be considered from the outset in the formulation of an appropriate alternative command and control regime. These are:

• unity of command,
• span of command,
• clarity,
• redundancy,
• delegation of command,
• control of significant resources, and
• obligations to subordinates.

In accordance with Land Warfare Doctrine publication 0-0 Command, Leadership and Management,¹¹ the command perspective encompasses legal authority, leadership (moral authority, influence and motivation) and management (plans, organisation, control and direction).All of these combine to influence people and utilise the resources provided to achieve directed tasks.Command creates and changes the structures and processes of control to suit uncertain military situations, and is inherently pre-eminent.Therefore it can be deduced that for the HDHS and the DHS, technical control alone is inherently inadequate in meeting existing and future challenges that the flexibility, creativity and competence dimensions of command would be better able to address.

Operational Capability and Efficiency

In an ‘Ideas and Issues” section of the 2007 Winter edition of the Australian Army Journal¹², LTCOL Shaun Fletcher critiqued the current health unit structures within Land Command against a backdrop of operational health support challenges as presented by complex war fighting on ongoing operations overseas.LTCOL Fletcher identified a number of ‘pinch points’ in Army health planning and support.Fundamentally, he reflects on the effects of integrating Army health capabilities into the logistics arena under the ‘Army for the 21st Century (A21) reforms of the 1980’s.’His article argued that this reform has had a detrimental effect on Defence Health’s place in operational health planning.As LTCOL Fletcher states; “Health and logistics do not have the same aim or outcomes.Logistics is about sustainment, Health is about force protection and force preservation”. ¹¹

Further in his discussion, LTCOL Fletcher notes that our current coalition partners organise their health capabilities in health brigades that exist alongside, but separatelyfrom, their logistics organisations.In the context of the Australian Army, he argues that centralising all of Army’s Role Two and Three Combat Health Support (CHS) units could realise significant force preparation and mobilisation gains almost immediately.Areas of efficiency identified include a reduced staff organisation overhead, the centralisation of the specialist staff roster within a single organisation, and improvements in health capability development from within a single health led command.Examples given of highly effective organisations which have already undergone similar restructuring include Special Operations Command and 16 Aviation Brigade.To a lesser extent, the restructuring of the Logistics Support Force (LSF) into 17 Brigade (Logistics) also consolidated and clarified lines of command and control within that operational support organisation.Each of these examples have concentrated highly specialised and limited capabilities into more effectively led, coordinated and focused formations, albeit still within the Army program.

To some extent it can be argued that the Naval Health Services traditional management ofits health personnel through shadow postings and dual shore and afloat responsibilities is a form of integration and flexible organisation.More significantly, the Royal Australian Air Force (RAAF) has taken much more bold decisions in recent times and as a result made significant progress in integrating their health capabilities under a single health led organisation along the lines suggested by LTCOL Fletcher.The RAAF Health Services Wing (HSW) is responsible for all operational aspects of the raise, train and sustain functions for Air Force health assets (equipment and personnel) as well as the provision of base health services, readiness of deployable health capabilities, and aeromedical evacuation and expeditionary health support training.¹³

The brigading of health assets into consolidated, even joint health establishments or units, could greatly enable health capability through providing for flexibility of training (through coordinating base health support provision), deployability and staff professional development across a more streamlined organisation. A review of the impact of the RAAF HSW reorganisation would be greatly instructive in examining similar alignment of health capability and command and control arrangements across the ADF.

Culture and Cooperation

The fundamental inputs to health care extend across a continuum. Quality of health care does not start at the single service/operational level, but extends downwards from the macro policies – injury prevention, recruiting standards, workforce development, clinical governance, health financing, procurement and logistic support; all the way to health capabilities provided from each of the three services, their units and individual health professionals and technicians. At the end of the day, capability is provided by people who live and work within professional and single service defined environments.Single service divisions and strategic/operational/unit loyalties intertwine to influence joint culture and communication, both in collective groups and as individuals.Fundamental rebuilding of the health organisation around an integrated and valued health culture is required as “problems will never be solved within the culture in which they were created” (Albert Einstein).

Effective health capability command and control of the resources to deliver quality of care through a cooperative culture must address wide-ranging personnel and technical considerations.Careful consideration of alternatives to current systems is required to achieve balance amongst competing tasks and resource priorities and ensure maximum flexibility, utility and efficiency in capability delivery.Health governance and command and control must therefore extend from the very top down to the lowest levels.

From an operational support perspective, there is very little that should preclude the HDHS from commanding a combined, integrated defence health service.If given full command of the health services, HDHS would be responsible for the entire system: leading from the strategic level to exercise command through Headquarters Joint Operations Command (HQJOC) health staff, and staff cells supporting each of the single Services and environmental commands, to provide health components for deployable capabilities.Forces required for operations are currently assigned from the single Services to Vice Chief of the Defence Force (VCDF) for prosecution of ADF Operations.Where operationally appropriate, health capabilities would be assigned to Joint Force commanders as currently enabled by operational doctrine.Such force assignments already occur when capability elements and units from each of the single Services are assigned to joint task forces.Examples include the assignment of maritime or air assets to joint force commanders in support of land operations.In addition to operational support, HDHS would gain fullresponsibility for the entire spectrum of base health support, ‘raise, train, sustain’, ‘fit and health’ force, preventive health and health treatment functions.

Conclusion

In considering the place of healthin an alternative reality, we can reflect that the senior health executive group are health professionals who have individually made significant career commitments to ADF health capability over a number of years.The senior Defence Health leadership therefore collectively encompasses significant military professional development, health unit leadership and operational experience sufficient to afford them command responsibility for an integrated health service.

An alternative organisational structure cannot be offered without a much deeper and serious examination of the potential gains, and pitfalls, of all possible alternative models.Presenting an alternative line diagram here would be reckless and offer nothing to the serious requirement for a better led, integrated and jointly focused health service to support the broad range of ADF operation requirements as well as maintaining a highly skilled and motivated health workforce.This paper should therefore be considered part of a wider reconsideration of the fundamental policies and paradigms underpinning current command and control arrangements and future health capability evolution.

In presenting this paper the author believes that the Defence Health command challenge is not empire-building nor a self-aggrandising grab for control of the health system by the senior health executive group.Defence Health’s foremost task is to provide health support to the men and women of the ADF.Everything else falls out from this simple but highly complex human and capability obligation.The DHS objective therefore should be to foster a professional health service culture around a defined, clearly delineated, single health organisation that has no internal boundaries and provides a total, integrated, seamless capability package to joint capability for Government.Serious concerns, and strong recommendations, have been made by a series of reviews and audits into the Defence Health system.The status quo of technical control is not an option.If not allowed to wield the authority, responsibility and competence inherent in command, the Defence Health Service will remain limited to impotently manipulating the levers of control without the command ability to affect effective change.