Power sharing and the “long view” of implementation

Jun, 2021

While there are many elements to the reform arising from the reports of the Royal Commission into Victoria’s Mental Health System, I want to focus on two I think are vital to preparing for reforms: power sharing, and scale of the “highway” building, to use the words of Penny Armytage AM.

Firstly, both power sharing and scale of implementation require time and cannot be hurried.

The outcome of such conversations should be what Professor Ken Rockwood, a geriatrician, calls the “Mitnitski doctrine” after his long-time collaborator and friend the late Professor Arnold Mitnitski, an applied mathematician:

“When people from different disciplines ’discover’ something, the discovery is most likely true when each can explain it to the other in terms that neither finds objectionable. A means of bridging mutual incomprehension, it requires of each a glad heart.”

The scale of these reforms requires both the ability to see the bigger and the “longer” picture. To see this longer picture requires sustained attention by all people involved in implementation, at all levels, right from the beginning.

Given the complex adaptive nature of health systems, it can lead to the emergence of changes that are neither straightforward nor binary. A long timescale may not sync with political cycles; this has been anticipated in the Final Report and measures have been taken, which while necessary may not be sufficient. Eternal vigilance is necessary.

The challenges of bringing people together

Secondly, both power sharing and scale of implementation require gatherings of peoples with a wide variety of expertise, not just competence. One needs not only lived experience experts, clinical experts, academic experts but those with expertise in advocacy, in bringing people together, in politics, economics, monitoring and so on.

Existing evidence suggests that although knowledge and content matter are important, expertise is domain specific and does not translate across domains. This is important because those in charge of putting reform into practice may assume otherwise, which has the potential to cause harm.

It is also important to consider that even within groups of apparently similar power, some are more equal than others and who is in power can vary over time. Recognising this and managing it requires another kind of expertise.

Defining outcomes

Thirdly, both power sharing and implementation scale require definition of expected outcomes with as much clarity and as early in the reform process as possible.

Power can influence outcomes, which may get chosen because it matters to those with power – power to fund, power that comes with a greater share of funding, and so on. Such endpoints may be irrelevant to both the recipients of care and those who deliver care.

Implementation scale may push groups to choose outcomes or endpoints that are closer in time rather than to those that take time to develop. Outcomes that are meaningful to consumers and providers, regardless of whether the providers are lived experience experts or clinical experts, are also likely to lead to more collaborative work and a greater sense of control in what they do.

This is important because the zone in which consumers and providers interact is where change must occur. This zone should be a relational thinking-feeling space that is both evidence-informed and sensitive to the other.

Work in this space is hard work, so, both the consumer and the provider need incentives. At the very least, consumers should be better informed, feel heard, and be able to explore alternatives that matter to them, and providers should not only be skilled but be well supported. It is only then that reforms will blossom and be meaningful to the community.

A/Prof Ravi Bhat is Divisional Clinical Director at Goulburn Valley Health. His academic interests include Delirium, Suicide in Older Adults, Migrant/Refugee Mental Health, Mental Health Service Delivery.

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