We are surrounded by broken systems.

The report from the Royal Commission into Victoria’s Mental Health System highlights that the state’s mental health system is failing to support those who need it, with many describing it as broken.

The Royal Commission into Aged Care Quality and Safety states: ‘A profound shift is required in which the people receiving care are placed at the centre of a new aged care system. In the words of one commentator, aged care does not ‘need renovations, it needs a rebuild’.

I have no doubt that we will hear similar findings from the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability.

So, how do we fix a broken system?

First, we need to understand what a system problem is.

Imagine a person standing beside a river. They see another person being washed past, clearly struggling. They wade in and rescue them and call an ambulance to come and help. Then they see another person being swept past in the river, and another. They are exhausted trying to rescue all these people. Another passer-by approaches and the first person desperately asks them to help. The passer-by shakes their head and continues walking. The first person is shocked. ‘What are you doing?’ they cry. The passer-by looks back and replies, ‘I am heading upriver to fix whatever is causing all these people to end up in the river in the first place’.

Clearly, unless we have a good picture of the whole system (think river) and the capacity to make change at all points in the system (think upstream), we will be trapped in an endless cycle of urgent repairs.

I cut my public health research teeth in obesity prevention. It was clear from the outset that this was, and still is, despite all our efforts, a system problem.

Multiple parts of society need to be involved in the solution. It requires actions aimed at the food system, our health care system, our schools, our communities, our workplaces, our maternal and child networks, and our social services. It also needs action by individuals, families, businesses and government. The behaviour of individuals can only have so much effect when factors upstream are working against making healthy personal choices.

Obesity prevention has another hallmark of a system problem, commonly known as the ‘whack-a-mole’ effect. You try to fix one part of the system, but this just causes another problem to pop up somewhere else. Think restricting television ads for junk food without a plan to prevent an increase in digital ads targeted at our teens. Or think de-institutionalising mental health services, to reduce stigma and discrimination, without a plan to deal with the ‘missing middle’, those who fall between inpatient services and services for people with less severe mental health problems.

A third indication that obesity prevention is a system problem is the substantial knock-on benefits of addressing large ‘system drivers’. Going back to our river analogy, these drivers are the how and why people are ending up in the water and the factors stopping those who want to help from rescuing them. Identifying these drivers is critical to how we approach our current, broken systems.

Of course, the urgent needs to happen. We need weight loss treatments to be effective and available. We need young people out of residential aged care. And we need compulsory treatment for mental health to be used as a last resort.

But at the same time, we need to address the big system drivers. And the good news is that we know how. We know what the key steps to addressing system failures are.

Fully engage all those involved across all parts of the system. This group will grow as the understanding of the system grows and includes those with lived experience as well as those who are the architects of the system.

Visualise the system together. Building a map of the system together is one of the most powerful ways to develop a common understanding of the problems, and to identify fixes for both the urgent issues and the large system drivers.

Collectively identify the how and what to change. This includes thinking about who has the power and capacity to make the changes required, thinking about the flow-on effects, and identifying any unintended consequences of a change.

Track the changes and their impact. This really speaks for itself. But the important thing is that this is not a simple four-step process. We are dealing with complex systems, and continual attention and adaptation will be needed. So, we must constantly gather intelligence and continue this cycle, evolving who is engaged, what the system looks like, and what change is needed next.

We all agree that these systems, which profoundly affect the health, wellbeing, dignity and care of all Australians, are broken. Now we also need to agree that fixing the system requires us to look at the entire river, not just plugging holes when the water hits us in the face.


This article was originally published in Issue 9 of MJA Insight+ and is republished here with permission.