Have you ever noticed in so many areas of life things come in pairs? There are two genders, nose pickers and handkerchief users (are they split on gender lines too?), cups and saucers, the weird quantum world and the reality we inhabit, computer literates and Luddites, rugby league players and normal humans … the list is long.

In health policy circles, there are two kinds of people too. They separate into those who think the health system is a rock and those who think it’s a bird.

Implicit in the belief system of those in the rock camp, the health system is a tangible, concrete thing. If you throw it you can predict where it will land. There’s even some formulae to describe rock-throwing. Non-statisticians can glaze over the next bit. But here’s a picture to show it for you:

Those who think the health system is a bird are qualitatively different conceptualisers. Deep down they reckon the health system is a complex adaptive system which is not amenable to prediction. There is another schematic for them:

If you think the health system is a rock, an inanimate object, everything can be definitively analysed and calculated. That thinking leads to attempts to restructure and control it.

If you think the health system is a bird, a complex system with a mind of its own, it needs to be fed, nurtured, and developed. So which are you, and what signs does your favourite policymaker, minister or bureaucrat exhibit for preferring one or the other? Assuming you have a favourite, of course.

The evidence that restructuring does any good, by the way, just to confirm everyone’s actual experience, is plain and simple — it doesn’t. Studies have shown that if you keep on restructuring complex organizations like teaching hospitals they become less not more efficient and reorganizing area health boundaries (NHS Trusts in England) put people back about eighteen months.

Which brings me in a roundabout way to Commissioner Garling’s report on the New South Wales health system, due out this week. The lessons about health Inquiries are obvious — we need fewer of them because we already know what they are likely come up with, as there have been so many of them in recent years.

In fact we analysed eight Inquiries in six countries, and they said pretty much the same things — some health care was far below standard, teamwork and communication need more emphasis, more confidence in the system was needed and patients and patient safety should come first.

But the worst of the Inquiries recommended reorganising the system by changing the boxes on the organizational chart to look more streamlined. I’d settle for a report from Commissioner Garling that built on the strengths we already had, tried to arrest the chronic morale and managerialism problems, and treated it like a bird not a rock. That will mean re-energising the health system at its core, and liberating it, not re-structuring the organisational chart and micro-managing everything, thereby stifling it. We will know soon enough which he is.

Jeffrey Braithwaite is Professor in the School of Public Health and Community Medicine, Director of the Institute of Health Innovation, and Director of the Centre for Clinical Governance Research at The University of New South Wales.

Peter Fray

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