Pinball Politics: Steering Healthcare Reform Through Volatile Times

We all enjoy an acronym. They are easy to remember and offer a common language across multiple industries. Terms such as VUCA - Volatility, Uncertainty, Complexity, and Ambiguity, are well-used to accurately describe the current state of numerous sectors including the economy and the healthcare sector. Other acronyms used to describe the challenges of the workplace environment and in strategic leadership discussions also include:

 TUNA -Turbulent, Uncertain, Novel, and Ambiguous, and CUTE -Complex, Uncertain, Turbulent, and Entropic.

The common challenge is uncertainty.

Reforming healthcare is a priority at both national and state levels, with the government in Australia spending up to $60 billion this year to bolster healthcare efficiency and equity. Healthcare reforms are a multifaceted challenge demanding a unique approach that considers the inherent complexity, uncertainty, and volatility of each state's unique healthcare system. Traditional strategies to address reforms have relied predominantly on centralised models, shared by federal and state governments, assuming both causality and a predictable outcome. However, these models are falling short in addressing the dynamic and increasingly turbulent nature of the healthcare systems active across the country, particularly following the COVID-19 pandemic.

During the process of implementing changes, more urgent challenges unexpectedly emerge, modifying the list of priorities but rarely the depth of the budgets or the available resources. Therefore, considering a CUTE or TUNA approach, the leaders and the policies they propose are persistently challenged to address healthcare reforms and deliver transformation.

Healthcare as a holistically responsive system

Healthcare systems are characterised by a vast network of interconnected departments. They interact in unpredictable yet synchronised ways to reach objectives. Patients, healthcare workers, policies, and cultural norms can be compared to pinballs in a machine. Following random trajectories influenced by some interactions whilst altering others' destinations as they move along. Simple or complicated systems evidence cause and effect relationships that are ordered and predictable. Complex systems are responsive to small interactions and changes that can have disproportionately large effects somewhere else in the healthcare system. Some effects are obvious and immediate whereas others are delayed but they do have an impact. Just like in a pinball machine with numerous parts active and moving at once, we tend to just keep our eyes focused on one little ball flying around causing chaos.

It is very difficult to predict or control the interactions of people within organisations. For example, recently nurses and midwives in NSW showed an objection to a pay increase offered by the Labor government. The NSW nurses were joined by Western Australia healthcare workers also demanding a pay increase. The nurses and midwives’ rallies and strikes resulted in postponed surgeries for some patients. Furthermore, some movements for salary increases resulted in up to 14000 healthcare workers uniting through unconventional means. This indicates the emergence of behaviours in response to uncertainty and turbulence.

Embracing uncertainty and volatility

In complex systems, uncertainty and volatility are often two sides of the same coin. When uncertainty or turbulence is minimised or ignored, volatility can result. This has been evidenced with the persistent negotiations of healthcare workers for salary reforms in the healthcare sector. Healthcare leaders must pay attention to the interactions among multiple variables or factors that are driving chaos and influencing behaviors and patterns at the micro levels in the healthcare organisations. This, in turn, increases the pressure on the adjacent and upper levels in the organisation, modifying the present and future functions of the organisation.

It is clear that leaders cannot control the trajectory of people’s behaviors in an organisation, but they can utilise it to benefit individuals, departments, and patients. Here is how.

A complex-adaptive approach to healthcare reforms embraces uncertainty by considering changes in behaviour patterns as they occur in real-time (see Figure below). This involves some degree of decentralised control that empowers local decision-making —such as hospitals, leaders, and community health workers—to respond to specific challenges quickly. For example, during the COVID-19 pandemic, decentralised models allowed regions and healthcare organisations to adapt their responses based on local conditions, leading to more effective and timely interventions.

Turbulence in healthcare can manifest as sudden surges in care demands (e.g. during epidemics), rapid technological advancements, or a resources crises. To limit volatility, there must be buffers to absorb shocks without the system collapsing. In a healthcare sector that is already significantly strained, how many buffers are available to absorb shocks?

What is emerging as a state of crisis in the healthcare sector, and at first glance what appears to be a shortage of healthcare workers as a result of inadequate pay, is perhaps a symptom of a more nuanced problem? Healthcare workers have also reported a limited availability of medical equipment in some areas affecting their ability to provide patient care. They also report burnout, high job demands and workloads, and occupational violence.

When these factors are considered together, are healthcare worker salary challenges a symptom of a more complex problem?

Which pinball in the machine is being looked at?

Additions to healthcare reforms: adaptability, resilience, and small innovations

Revamping healthcare efficiency and equity is a monumental undertaking. There is no quick solution. Implementing even minor alterations to this well-established system can carry economic and political consequences. Once the existing stakeholders and specific areas for change are pinpointed, the initiative kicks off. The initial step is incorporating incremental innovation which is crucial for effectively tackling the persistent complexities of the healthcare system. Emergent and unconventional approaches should not only focus on technological progress but also embrace adaptive leadership, innovative care models, policy frameworks, and improving holistic resource challenges. Next, promoting cultures of experimentation and the expansion of successful innovations can result in more resilient and flexible healthcare workforce and system.

  Reform efforts must be dynamic and adaptable to the uncertainty and volatility of healthcare demands. These three additions, for a start, help shape a system that can become capable of delivering high-quality care today but also become better prepared to meet the uncertainty and challenges of tomorrow.