ADF Health November 1999 - Volume 1 Number 1

The Defence Health Service - the formative steps

Brigadier Paul TR Buckley, AM, MB BS

Synopsis

The Defence health services, in one form or another, have been providing medical support since the Sudan campaign in 1885.
Two major reviews have shaped recent restructuring of Defence health services.
The Australian National Audit Office (ANAO) Performance Audit of the Defence Health Services examined the full spectrum of health service support and identified areas for improvements in efficiency and management.
The Defence Efficiency Review (DER) focused on key management and financial practices, and the thrust of its recommendations in relation to health were similar to those of the ANAO audit.
The DER recommended that a single, integrated, joint health organisation, the Defence Health Service, should be formed to control all Defence health activities.
The DER led to the Defence Reform Program, which aims to refocus the Defence organisation on its prime role - combat capability-with changes impacting on the entire Defence organisation, but particularly on personnel and health.

1 Key recommendations of the Australian National Audit Office Performance Audit

Establish the minimum level of health services resources essential to meet military operational requirements and then assess the scope for achieving economies in the provision of non-operational services through other means, such as rationalisation or commercial support.
Give a higher priority to the development and implementation of common standards and processes associated with ADF health care.
Update the corporate plan of the Office of Surgeon General ADF, with clear guidance for future action.
Give the Surgeon General responsibility for the command and control of all ADF health resources, and transfer appropriate human and financial resourcing to the office of the Surgeon General.
Undertake a detailed costing of all ADF hospitals and medical centres, and rationalise the provision of beds costing more than those in equivalent civilian facilities.
Reach agreement with the necessary civilian health authorities for ADF personnel to work in areas where they will be exposed to emergency treatment of wounds and injuries.
Examine the costs and benefits of either contracting out pathology services or centralising all routine pathology screening in an existing ADF laboratory.
Develop systems to monitor and control all expenditure on health services.
Accord a high priority to the development of effective ADF-wide health information systems.
Give greater attention to epidemiological research into injuries and illnesses in the ADF, develop both short and long term strategies aimed at reducing the level of injuries and illnesses, and identify all costs associated with compensable injuries and illnesses in the ADF.
Review ADF dental services.
Conduct a comprehensive review of the availability and use of therapeutic substances in the ADF.

2 Recommendations in the addendum to the report of the Defence Efficiency Review 10

The maintenance of individual health readiness should become the principal focus of on-base health support.
New common standards and program entitlements should be developed by the head of the health organisation with a view to eliminating expenditure on those conditions and procedures not related to individual readiness.
There should be a single, common medical employment classification system applicable to the three Services.
A common system of health documentation should be introduced.
When not deployed or training, deployable health personnel should provide on-base support to the maximum extent possible. All remaining on-base health support should be market tested.
A single integrated, joint organisation should be formed to control all Defence health activities.
Health and health-related activities should be managed as a single programming activity within Defence.
The Surgeon General Australian Defence Force should head the Defence Health Service and should have full portfolio-level responsibility and accountability for all health and health-related expenditure.
The human science elements should be brought together into a Defence Centre for Human Performance, which should achieve significant efficiency, but, more importantly, greatly improve effectiveness in dealing with human performance issues.

The Australian Defence Force has a proud record of service in support of the nation both in war and peace. Our officers, soldiers, sailors, airmen and civilians have performed admirably, 1,2 and helped a small defence force build a giant reputation. A major part of that achievement, and indeed our military culture, has been the Reserve-the part time members, the citizen soldiers.

A vital element in our contribution has been the health services of the Navy, Army and Air Force. Long tested in battle and officially documented by Butler, 3 Walker, 4 and O'Keefe, 5 the Defence health services, in one form or another, have been providing medical support since the Sudan campaign in 1885. 6

Recently, as strategic policy, national interests and global factors dictate, the ADF has become increasingly involved in operations other than war - in peace support operations, truce monitoring, joint humanitarian assistance and disaster response, often as part of a multinational force. The health services have played a major role in such deployments, being a highly accepted means not only of providing medical services, but of gaining local and regional support and the goodwill of the host nation. In 1995 the RSL ANZAC Peace Prize was awarded to the Australian contingent in Rwanda (Operation Tamar). The citation reads: ". . . in recognition of an outstanding Australian achievement which has promoted the concept of international understanding and which, in so doing, has made a contribution to world peace in accordance with the best tradition exemplified by ANZAC."

Since then, the Defence health services have undergone two major reviews:

The Australian National Audit Office Performance Audit of the Defence Health Services; 7 and
The Defence Efficiency Review. 8

These reviews led to to redevelopment of the health services along integrated joint service lines, creating the Defence Health Service, which has continued the tradition of excellence, culminating recently in accolades for our disaster response in Papua New Guinea (Operation Shaddock) in 1998.

This article outlines the direction and outcomes of the recent reviews, and looks ahead to the future of the Defence Health Service.

Australian National Audit Office Performance Audit

The Australian National Audit Office Performance Audit (ANAO) was presented to Parliament on 26 May 1997. The objective of the audit was to "assess the efficiency and effectiveness of the provision of health services to the ADF regular forces" and it examined the full spectrum of health service support. The ANAO concluded that the "Australian Defence Force provides high quality health services to its members with a strong emphasis on preventative health care. ADF health services have demonstrated the ability to provide effective health support to military operations in particular through the deployment to Rwanda on behalf of the United Nations." 7,9 The report established that costs associated with ADF health care were high when compared with health costs in the Australian community. The report also identified many problem areas where efficiency and management could be improved.

Of 19 recommendations made, 18 were accepted by Defence. These recommendations have provided much of the rationale and drive for our recent and planned changes. ANAO key recommendations are summarised in Box 1.

The Defence Efficiency Review

This review was established on 15 October 1996 by the then Minister for Defence, Ian McLachlan, and focused on key management and financial practices. It was led by Malcolm McIntosh, Chief Executive, CSIRO, with review teams comprising military and civilian Defence staff and external experts. The ANAO Defence Health Service Review Team provided advice and preliminary findings to the Defence Efficiency Review (DER) and, in relation to health, the thrust of the two reports is similar.

The recommendations outlined in the Addendum to the Report of the DER (Secretariat Papers) are given in Box 2. 10

The recommendations in the actual Report of the DER 8 which impact on health were:

Medical services should be pulled together and rationalised, taking account of community expectations and civil arrangements.
All basic non-military training, where appropriate, should be merged across the three Services, contracted out to recognised civil institutions, and then topped-up on the job in military facilities.
A single Personnel Executive should be formed with the specific intention of achieving greater commonality, integration and efficiency in personnel administration and management among the three Services and the Department. 8,9

The review team felt that there was "scope to improve the efficiency and effectiveness of deployable health support capabilities as well as in the provision of on-base health support . . . a single, integrated, joint health organisation should be formed to control all Defence health activities." 8,9

The Defence Reform Program - the vehicle

The Minister for Defence released the report of the DER in April 1997 and announced the Defence Reform Program. 11

This program is aimed at refocusing the Defence organisation on its prime role - combat capability - and espouses the key principles that the Defence organisation is to be structured for war and adapted for peace, and that the reforms should act as a catalyst for change. 11 Savings from the reforms are to be redirected to the combat area. As a consequence of the Defence Reform Program, revised higher management arrangements and organisational structures were implemented on 1 July 1997. 9,11

The Defence Health Service

The changes under the Defence Reform Program affect the entire Defence organisation, but particularly personnel departments and health.

As part of the higher structural changes, the Service Personnel Divisions for each Service were merged with the Joint Personnel office to form the Defence Personnel Executive, commanded by Head Defence Personnel Executive at two-star rank level.
The office of the Surgeon General ADF was redesignated as the Defence Health Service Branch and placed within the Defence Personnel Executive. Although recommended to be at two-star level (full time), 10 the position of the Surgeon General was subsequently changed to part time.
The senior full time position for the Defence Health Service was designated the Director General Defence Health Service at a one-star level.

The change from a previous full time Surgeon General (two stars) and three Directors General Health (one star and representing both joint functional and single Service Head of Health roles) represented a major change for Defence health.

The new structure of the Defence Health Service Branch 9 commenced on 17 January 1998 and concomitantly the Joint Health Support Agency was established to coordinate the provision of health support in the National Support Area.

The Defence Health Service Branch is a joint organisation and structured along functional lines. It is staffed by full time and part time uniformed members of the Defence Health Service, and by civilian members of the Australian Defence Organisation.

The Defence Health Service Branch and the Joint Health Support Agency represent the strategic headquarters for the Defence Health Service, and as such provide a link with the Defence Personnel Executive, the single Services and the other programs or groups.

At the operational level, Headquarters Australian Theatre (HQAST) provides the operational planning headquarters and again is a Joint Headquarters.

So we have commenced the journey into the future. The Defence Reform Program is but one vehicle of change and change will continue. The formation of the Defence Health Service has shown the way towards integration for other joint Service initiatives. It has developed joint, integrated headquarters, but continues to use the benefits of diversity. Single Service health personnel bring a wealth of environmental experience, traditions and culture. They are important spokes in the Defence Health Service wheel.

The future

The Defence Health Service Strategic Plan outlines our five objectives. They are to:

Provide a fit and healthy force which contributes to ADF mission success;
Minimise preventable injury and illness;
Provide appropriate and timely treatment;
Develop the capability of the Defence Health Service to support ADF requirements; and
Provide a well managed, adaptive and adequately resourced quality health system.

These objectives, coupled with our values of initiative, professionalism, teamwork, ethical conduct, caring and tenacity, provide a blueprint for our future - a future that will see more change and an increasing focus on preventive health strategies. In terms of ADF deployable medical assets, the vision is of a joint and seamless system of health support optimising health, fitness and casualty prevention. By making full use of technology and automated information systems, we will provide quality forward treatment and effective patient care during evacuation. Integration with the civilian health infrastructure will be an important component of that care continuum.

This vision and the capability it entails is encompassed in JP2060, a joint project aimed at developing and securing the ADF deployable medical capability required for joint operations in 2010. 12

In terms of training, strategic alliances will continue to provide a practical example of the military-civilian interface being used to provide real training benefits for Defence Health Service personnel. The Defence Health Service will expand the initiative now being piloted at Sydney between Liverpool Hospital and First Field Hospital.

The logical extension of such an alliance-to incorporate an ADF health training element, a human sciences research element and an academic centre-would be a Centre of Excellence for Military Medicine, linked with an appropriate university.

Having taken the first steps towards a Defence Health Service of the future, the pathway is full of challenges, but, most importantly, opportunities. It is up to all of us to take them.

References

Hartley J. The future battlefield. Geelong: Deakin University Press, 1997.
Hickling FJ. The future battlefield. Geelong: Deakin University Press, 1997.
Butler AG. The official history of the Australian Army Medical Service - The War of 1914-1918 (3 volumes). Canberra: Australian War Memorial, 1930-1943.
Walker AS. Australia in the War of 1939-1945. Series five medical (4 volumes), Canberra: Australian War Memorial, 1953.
O'Keefe B. Medicine in war. Medical aspects of Australia's involvement in South East Asia 1950-1972. Sydney: Allan and Unwin (in association with the Australian War Memorial), 1994.
Pearn JH. Arms and aesculapius. Brisbane: Amphion Press, 1996.
Barrett PJ. Australian Defence Force Health Services. Department of Defence. The Auditor-General Performance Audit 1996-97. Canberra: AGPS, 1997. (Audit Report No. 34.)
McIntosh M, et al. Future directions for the management of Australia's Defence. Report of the Defence Efficiency Review. Canberra: Department of Defence, 1997.
Pearn JH. Defence health reform and the Surgeon General. Med J Aust 1999; 170: 278-279.
Future directions for the management of Australia's Defence. Addendum to the Report of the Defence Efficiency Review Secretariat Paper. Canberra: Department of Defence, 1997.
Barratt PH, Barrie CA. Defence Annual Report 1997-1998. Canberra: Department of Defence, 1998.
Defence Health Service Newsletter 6 April 1999: 3-4.

Brigadier Paul Buckley is Director General Defence Health Service. He served as Director Health Services for the Papua New Guinea Defence Force (1984-1985), and was Director Medical Service 3rd Military District (1988-1990) before being posted to Canberra as Director Clinical Medical Policy in 1990. He was subsequently promoted to Brigadier and Director General Army Health Service in 1992, before being appointed the first Director General Defence Health Service in 1998.