Health care delivery to the military and veterans’ communities in 2020
Graeme Cannell and Niki Ellis
Abstract
In 2007–2008, the Centre for Military and Veterans’ Health Think Tank program considered the likely future health delivery scenarios that are expected to exist in 2020 for the defence and veterans’ communities.
Workshops were held to consider the five most important issues and their potential impact on military and veterans’ health services delivery in 2020: health workforce; consumer empowerment in health; mental health; genomics and converging technologies; and interoperability.
A series of common themes emerged from the workshops, including the need for a seamless health system for serving personnel and veterans, technologyassisted health systems, new models of care, health consumer-centric systems, and a focus on preventive health.
Future scenarios for health services delivery in 2020 were developed and “back-cast” to 2008, to determine the strategic directions for health research and professional development that should be adopted now if military and veterans’ health services needs in 2020 are to be met.
DURING 2007–2008, the Centre for Military and Veterans’ Health (CMVH) Think Tank program considered the likely future health delivery scenarios that are expected to exist in 2020 for the defence and veterans’ communities. The environment and issues influencing the nature, type and cost of health services required in the next two decades are expected to vary significantly from the current setting, given potential future changes in operations, technology and advances in health care.
A Think Tank steering committee was chaired by Professor Niki Ellis, Director of CMVH, and comprised Colonel Brendan Byrne, representing Defence Health Services; Rear Admiral (retired) Simon Harrington, representing the Department of Veterans’ Affairs (DVA); Professor Sohail Inayatullah, a leading international futurist; Professor Stephen Mugford and Jane Palmer, consultants to the project; Professor Mark Creamer, Director of the Australian Centre for Posttraumatic Mental Health; and CMVH Think Tank staff. The steering committee devised the program to meet the following objectives:
Describe the likely environments in which health services will be delivered to Australian military personnel and veterans in 2020;
Describe what health delivery services would look like in these alternative environments;
Describe the impacts on research and skill enhancement needs; and
Establish a method for ongoing assessment of these future environments.
Issues affecting future environments
A critical futures study methodology developed by Sohail Inayatullah, known as causal layered analysis, was adapted (as described elsewhere 1) and used to develop a horizon scanning discussion paper, released in October 2007. 2 This report identified 16 issues of importance to the future of military and veterans’ health services delivery; these are summarised in Box 1.
Consultations were undertaken with senior personnel in Defence, DVA and other government and non-government organisations to determine which of these issues were the most important. Workshops on the top five issues were then held. At each workshop, a leading expert presented on future directions for the area of interest, and Defence, DVA and other stakeholders considered the impact these directions were likely to have on military and veterans’ health services delivery in 2020. The topics and presenting experts were:
Health workforce shortages - Maintaining operational capability and quality health service delivery for military personnel and veterans: are we prepared if there are not enough doctors and nurses? Robert Fitzgerald, Productivity Commissioner, who previously led a review into Australia’s health workforce.
Consumer empowerment in health - The democratisation of health: implications for a command-control work culture. Dr Mark Parrish, Physician Executive Asia Pacific, Microsoft.
Mental health - Improving mental health responses for Defence personnel and veterans towards 2020. This was conducted as an interactive online workshop in April–May 2008, led by the Australian Centre for Posttraumatic Mental Health and CMVH. In addition, an email survey was undertaken of 150 stakeholders, including health professionals and leaders, to test reaction to statements about this topic.
Technology and how to cope with the pace of its development - At the forefront of genome research and converging technologies: how do we anticipate and respond to new developments? Professor John Mattick, Institute for Molecular Bioscience.
Interoperability - The future of joint operations and interoperability: how can we prepare to deliver quality health services to military personnel and veterans? Air Chief Marshal Angus Houston, Chief of Defence Force. Reports on each of these five events were prepared and are available on the CMVH website. 3-7
1 Issues of importance to future health service delivery
Air Chief Marshal Angus Houston, Chief of Defence Force, presenting on interoperability at a Think Tank workshop.
2 Scenario for preferred future of health services delivery
A video was produced that depicted the hypothetical trajectory of one family’s experience with Defence and Department of Veterans’ Affairs (DVA) health services over the course of three generations: George, born in 1945 and in the Army during the Vietnam War; his son Bruce, born in 1970 and in the Navy during the Gulf War; and his granddaughter Kylie, born in 1995 and taking part in future deployments (speaking in 2020).
The story illustrates three scenarios: the historical (George), a more recent scenario (Bruce), and a preferred future (Kylie), as identified by stakeholders through a consultation phase and the workshops on futures in military and veterans’ health service delivery. An outline of the scenario is at Appendix 1 of the Think Tank workshop report. 8 The video is available from the Centre for Military and Veterans’ Health on request.
As shown in Kylie’s future scenario, the systemic, cultural and metaphor dimensions of health services in the future are as follows.
Systemic issues: Health services for service personnel are characterised by technological sophistication (including data management technology), economic “value for money”, and integration with post-service (DVA) health services to ensure whole-of-life support.
Cultural issues: Health services for both serving personnel and veterans are based on a culture of shared responsibility for health, seeing the patient as a consumer empowered with information, and with access and technology to provide freedom of choice in health services.
Metaphors: The integrated health services for serving personnel and veterans see themselves as providing a transparent, navigable network of services that supports and empowers personnel through the whole of their lives.
In the future scenario, Kylie saw herself as being at the centre of a supportive, multi-node network, which empowered her to take control of her health and wellbeing.
Main emerging themes
There was remarkable agreement between the findings of each workshop, and a series of main themes emerged. These included the need for systemic and world-view changes, such as:
A seamless process across Defence, DVA and civilian health services; it was recognised that there is potential to address health workforce shortages by drawing the Defence and DVA health systems much closer together.
Technology-assisted health, especially electronic health records, automatic data mining for information on exposure to biological hazards (eg, environmental and biological monitoring devices worn on uniforms with automatic transmission back to base and analysis of data), and genetic testing.
Reorganisation of health services, with new models of care, such as treatment of musculoskeletal injuries by physical trainers supervised remotely by physiotherapists using telehealth; rehabilitation driven more by the injured person and supported by rehabilitation provider and web-based case management; creation of more efficient health teams on deployment by use of physician assistants; and expansion of mental health capacity by integration into general primary health care.
People-centric systems, rather than the historical structure of health systems that pivot around the health professions. In the future, services will be designed around consumers, who will have a much greater say in their health care and will be expected to carry more responsibility for their own health.
Shift of focus to prevention; illness and injury will be seen as systems failure, and the focus will instead be on the identification and management of risk factors in individuals.
Despite the broad agreement in findings, there were also some points of difference, such as balancing between organisational needs and individual needs (not resolved), and the extent to which the future system will be an integrated Defence–DVA system, or one in which the civilian sector will feature more prominently (ie, greater outsourcing).
Future scenarios
On 14–15 August 2008, 58 people attended a final workshop, opened by the Minister for Veterans’ Affairs, to determine alternative futures for military and veterans’ health services delivery and recommendations for research and professional development. 8 The outcomes of the previous workshops were synthesised into a single presentation by Professor Ellis, and a video was shown that compared the health experiences of three generations (historical past, relatively recent, and future serving members) of one hypothetical family (Box 2).
Under the direction of Professor Inayatullah, small groups at the workshop developed scenarios for health services delivery in 2020, then “back-cast” these from 2020 to 2008 (what happened in 2010? 2011? 2014? 2018?) to elucidate what led up to the predicted future of 2020.
Recommendations for research and professional development
Having defined future scenarios, participants were asked to develop strategic directions for health research and professional development that should be adopted now if health services needs in 2020 are to be met.
Some of the strategic directions identified for health research were:
Attitudinal research to support organisational change of health services delivery, including
attitudes (opportunities and barriers) of consumers (Defence personnel and veterans) to future health services, including technology;
attitudes (opportunities and barriers) of providers in Defence (uniformed, contractors, civilian) and DVA to future health services, including technology;
effective and appropriate change management models; and
evaluation of change management interventions.
Health services research and evaluation to assist
evidence-based policy and program development for new models of care, especially for mental health, prevention and rehabilitation, and battlefield injuries; and
integration of Defence, DVA and civilian systems, starting with an audit of what services are currently provided by whom and how they inter-relate.
Horizon scanning for health technology, especially in relation to genomic developments and artificial intelligence for environmental and biological monitoring of exposures.
Some of the strategic directions identified for professional development were:
Reconfiguring the health workforce, including extending roles of existing professions and craft groups and creation of new assistant roles, to ensure better use of available personnel.
Training to support new models of care.
Determining competencies unique to the Defence–DVA paradigm and ensuring all providers (garrison, deployment, veterans’ health), including contract staff, have these.
Developing multiple modality health learning programs for consumers and their families, including
serving members; and
veterans, regarding their own health, and also as peer facilitators in self-management.
Developing programs for non-health commanders and managers on maximising performance through health.
Providing a program on leadership for health innovation to appropriate health personnel.
Conclusion
Feedback from participants on this Think Tank program indicates that the opportunity to be exposed to civilian expertise on significant issues relevant to military and veterans’ health was valued by Defence and DVA. A better understanding was gained by all parties on how best the CMVH Think Tank function could be used to provide inputs to Defence and DVA health policy development. The CMVH Board has requested that, in 2009, the Think Tank drill down on some of the issues raised by the program, starting with considering how an innovative health services delivery model could be developed for mental health services in the Brisbane area.
Competing interests
None identified.
References
Palmer J, Ellis N. A layered approach to horizon scanning: identifying future issues in military and veterans’ health. J Futures Stud 2008; 12 (4): 77-92.
Centre for Military and Veterans’ Health. The future of military and veterans’ health service delivery: discussion paper. Draft, 3 Oct 2007. http:// www.uq.edu.au/cmvh/docs/ThinkTank/CMVH_2007_TT_Discussion_ Paper_webupload.pdf (accessed Oct 2008).
Centre for Military and Veterans’ Health. Maintaining operational capability and quality health service delivery for military personnel and veterans: are we prepared if there are not enough doctors and nurses? Workshop #1 interim report, 30 Nov 2007. http://www.uq.edu.au/cmvh/ docs/ThinkTank/Think_Tank_Breakfast_1_Final_Interim_Report.pdf (accessed Oct 2008).
Centre for Military and Veterans’ Health. The democratisation of health: implications for a command-control work culture. Workshop #2 interim report, 15 Feb 2008. http://www.uq.edu.au/cmvh/docs/ThinkTank/CMVH_ Think_Tank_Workshop_2_FINAL_Interim_Report.pdf (accessed Oct 2008).
Australian Centre for Posttraumatic Mental Health. Improving mental health responses for Defence personnel and veterans towards 2020. Interactive online workshop interim report, 16 Jul 2008. http:// www.uq.edu.au/cmvh/docs/ThinkTank/Mental_Health_Think_Tank_interimreport. pdf (accessed Oct 2008).
Centre for Military and Veterans’ Health. At the forefront of genome research and converging technologies: how do we anticipate and respond to new developments? Workshop #4 interim report, 6 May 2008. http:// www.uq.edu.au/cmvh/docs/ThinkTank/CMVH_Think_Tank_Workshop_ 4_Final_Interim_Report.pdf (accessed Oct 2008).
Centre for Military and Veterans’ Health. The future of joint operations and interoperability: how can we prepare to deliver quality health services to military personnel and veterans? Workshop #5 final interim report, 6 Jun 2008. http://www.uq.edu.au/cmvh/docs/ThinkTank/CMVH_Think_Tank_ Workshop_5_final_Interim_Report.pdf (accessed Oct 2008).
Centre for Military and Veterans’ Health. Futures in military and veterans’ health service delivery. Major Think Tank Workshop, 14–15 Aug 2008. Draft report. http://www.uq.edu.au/cmvh/docs/ThinkTank/DRAFT_ MAJORTHINK_TANK_REPORT.pdf (accessed Oct 2008).
(Received 10 Oct 2008, accepted 13 Oct 2008)
Lieutenant Colonel Graeme Cannell joined the Army Reserve in 1983 as a specialist service officer. His civilian research career has covered pharmacology, toxicology, mathematical modelling of biological processes, and drug metabolism. He is author of more than 100 papers in refereed journals. He holds an adjunct academic appointment at the Centre for Military and Veterans’ Health and is currently SO1 Research in Defence Health Services.
Professor Niki Ellis is an occupational and public health physician and is the Foundation Director of the Centre for Military and Veterans’ Health. Professor Ellis was the Inaugural President of the Australasian Faculty of Occupational Medicine from 1992 to 1994 and has written a book for Oxford University Press called Work and health: management in Australia and New Zealand. She has worked extensively in Australia and overseas assisting organisations to manage workplace stress, with interests in organisational health, occupational stress and development of practical interventions for workplaces.
Centre for Military and Veterans’ Health, University of Queensland, Brisbane, QLD.
Graeme Cannell, BSc(Hons), DipEd, GradDipSec, GradDipIT, MBA, PhD, Associate Professor; Niki Ellis, MB BS, FAFOM, FAFPHM, Professor and Director.
Correspondence: LTCOL Graeme Cannell, Centre for Military and Veterans’ Health, University of Queensland, Mayne Medical School Building, Herston Road, Herston, QLD 4006. g.cannell@uq.edu.au
