Episode 11: COVID-19
International Comparisons between Australia and the U.S.
Stewart Dowrick, Chief Executive, Mid North Coast Local Health District
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Next up in our special COVID-19 series on Fireside Chat, we sat down with Stewart Dowrick, CEO of Mid North Coast Local Health District (MNCLHD) in Australia. We discussed the COVID-19 pandemic, which is tracking similarly in Australia and the United States. 

Please note: The number of COVID-19 cases and the situation referenced in this episode were based on reported data at the time of the interview and are subject to change.

Please note: The number of COVID-19 cases and the situation referenced in this episode were based on reported data at the time of the interview and are subject to change.

For more than 25 years, Stewart Dowrick has advocated for and worked towards greater access to quality health care for communities.

Appointed the Chief Executive of the Mid North Coast Local Health District in January 2011, Mr Dowrick works with the region’s clinicians and the community to provide health care through strategic and quality management.

Mr. Dowrick began his career in health care administration at the then Children’s Hospital at Camperdown in 1989. He moved to the Central Coast Area Health Service in 1993 and the Mid North Coast Area Health Service in 1999.

Since 2000 he has held Area Health Service executive positions on Mid North Coast and North Coast Area Health Services, overseeing health projects from Taree to Tweed Heads. He was also involved in the return of Port Macquarie Base Hospital to public ownership and has overseen the $104M expansion of Port Macquarie Base Hospital and the $81.9M Kempsey District Hospital Redevelopment Project.

Mr. Dowrick holds Post and Undergraduate degrees from the University of NSW and University of Newcastle and is a Fellow of the Australian Institute of Company Directors. Mr Dowrick continues to be actively involved with a range of community and sporting activities.


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Stewart Dowrick 0:03
In Australia, we have a health direct line that people can find if they believe they have symptoms that have been overwhelmed at the moment so they are signing up to the local public health, just so that the testing has been an issue. We just got to keep working our way through there.

Gary Bisbee 0:17
That was Stuart Dowrick CEO Mid North Coast Local Health District, New South Wales, Australia. Commenting on the Coronavirus information hotline in Australia. I’m Gary Bisbee and this is Fireside Chat. We’ll hear an update on the coronavirus pandemic in Australia where Stuart will discuss similar pressure points that we have in the US. Namely, testing availability, social distancing, access to timely information, and hospital ICU and ventilator capacity. Stewart also provides an excellent summary of the Australian hospital payment model, why DRGS will not be going away and how health services are organized. Stuart’s an engaging person with a deep understanding of the Australian health system. We’re delighted that he’s with us today. Let’s welcome Stuart.

Stewart Dowrick 1:09
Morning, Gary. And thank you very much for giving me a chance to have a discussion with you.

Gary Bisbee 1:16
Well, we appreciate your time this morning, joining us to compare notes on the Covid 19 pandemic, which is surging as near as I can tell, almost the same pace in Australia as it is in the US. But we’d love to hear any lessons that you have for us. Why don’t we quickly cover your personal background and it’s very similar to other CEOs of large health systems in the United States. Undergraduate degree near Case University of New South Wales, Graduate degree at University of Newcastle. Stuart, When did you become interested in health care?

Stewart Dowrick 1:53
About 1980, Gary and I started in metropolitan Sydney after finishing University and then worked in Metro Sydney for a while and then branched into the regional areas of New South Wales and cleaned up for 20 years and a chief executive now since 2011. In our Regional Health Service, it’s probably four hours north of Sydney, a coastal area, aging population. Roughly 25% of our population is over 65. So with that growth in that space, we actually are, I guess, the nation’s future. They were already way ahead of the curve. But also a growing area and it’s about four hours north of Sydney, covering 11,000 square kilometers. I’m not sure what that’d be in miles, Gary, but 250k to 300,000 population.

Gary Bisbee 2:58
Oh, by the way, congratulations. I see you received an honorary doctorate degree last year from Charles Sturt University. Well done.

Stewart Dowrick 3:07
Thanks, Gary. It was very unexpected. And it was a nice recognition from the University Council. And then it was just a nice recognition to get that and also, it was actually still working rather than not working or passing away. Sometimes, it was actually nice to receive that for my services to probably regional health care in New South Wales Regional Health Services.

Gary Bisbee 3:29
Well, next time we get together, Stuart, our referred to you as Dr. Dowrick. How’s that?

Stewart Dowrick 3:34
This is totally fine, Gary.

Gary Bisbee 3:48
Well, at any rate, could you describe your health system for us? In terms of facilities and population and payment profile and so on?

Stewart Dowrick 3:56
Yeah, sure, again, four hours north of Sydney covering a geographical region, which takes about three hours to drive to top the North coastal with a real, strong rural component to tourism, education and health are probably the three biggest industries. We have a healthy private market here, which is through our private health insurance and self pays. And I look after the public health side of things, which is the seven eight facilities of which we are the major provider in our region properly. We cover about 70% of the acute healthcare sector here and they are growing, and we’re funded predominantly through the state and federal governments, but there’s also revenue and we paid under a DOJ system I guess we call that closest for the US would have today. Our staff are predominantly award based medical staff sort of across over what we call individual contractors and what we call visiting medical offices in Australia or award based positions and those with the award base are actually growing in this district. So we’re sort of becoming a model that the new generation of millennials are starting to like, as opposed to sitting on a practice. That’s it, that’s a cultural shift, at least in Australia. May not be elsewhere in the world, but it’s sort of becoming more popular here. So our population is aging. And again, it’s about 250 to 300 pairs where the most self sufficient, rural, regional Local Health District, South Wales, at 94% of acute care delivered in our footprint are a little bit different than what others rely on. People go out of areas that we are actually very self sufficient. And we’ve got pockets of problems, you know, we do have areas where we have deficiencies in and overall, we’re not too bad.

Gary Bisbee 6:08
What about just in terms of your revenue sources? What percentage of your revenue would come from governments?

Stewart Dowrick 6:16
80% from governments and 20% from other revenue sources.

Gary Bisbee 6:20
How do you see that changing over time?

Stewart Dowrick 6:23
In the Australian context, those with private health insurance, which in Australia, after the age of 30, there, it’s been sort of compulsory. You must take out private health insurance or you pay a higher levy on your tax, every Australian pay, but we call it Medicare Levy. We have a universal health system in Australia, which I think is well known to those in the US. It’s not more than a safety net. So the basic standards and principles of equity, equity and access and 30% of our market, or more than that it’s actually the private hospital group or charity group that the Catholics or Anglicans run large hospital systems in Australia. The amount of Australians with private health insurance is in decline. And it’s a challenge for policy makers. And, again, there is that issue that needs to be dealt with. I think the next team needs to be a big challenge for us with the aging population, wanting to have a really good private health system, which we do in Australia, a very good public system, which sort of walks side by side. They’re not in competition, I sort of have different natures, what they’re trying to address and cover. So we need to have both healthy and strong so they can both work together in that space, Gary, but I’m not sure the next we will stay with an activity based model. But I do think it’ll be overlaid more with a population focus as well. I think places like New Zealand apply and have a population model, which might have an advantage and disadvantage, the National price which is set nationally through the Commonwealth, and the states have an individual price to what we call activity based funding or Dr. g funding will stay for some time. I don’t think that’ll be a challenge.

Gary Bisbee 8:15
Well. We’ll be interested in tracking how your payment system evolves. There’s certainly a lot of discussion here about the community based payments and health systems being responsible for the community. If we could then turn to the Coronavirus status. A lot of Americans are familiar with the fact that there is Coronavirus in Australia because a couple of United States movie stars. Tom Hanks and his wife were in Australia, I think in Queensland, shooting a movie and contracted it so we’re familiar with that. But on a more serious note, how are things going? How has it surged and what state of the surge is the coronavirus pandemic now?

Stewart Dowrick 8:58
Yeah, thanks, Gary. I think the first case in Australia was about the end of January. The 25th-26th of January. And the first day we had he was early March, the first of March the second of March in Australia and I guess the number of cases here it’s presently around the 300 mark across Australia, New South Wales we where I’m situated in is that 200 cases in the state of New South Wales and that’s been growing and most of its focus in the Sydney metropolitan area of New South Wales. So you know the mid North case now hence residents who have coronavirus but they actually came into Australia with it after traveling to Italy. And during isolation seniors they didn’t actually get it here as such. It is a moving custom Gary . I think governments get some early actions federally about China and some of those countries initially, but now we’re putting in place stronger measures around social distancing, and gatherings of people below 500. People taking responsibility. For people who don’t sell fast like we’ve now put in place. Anyone who comes in from overseas or otherwise has to self isolate for 14 days. So there’s a thing about the new measures that came in last week, and we’re enacting now, but it is a movie issue every day our schools remain open. Though some schools that I’ve seen when they identify someone with a virus, they are taking action themselves. Social disconnect, the universities are taking their own action around online learning, modifying the university intake, and people are changing their behaviors, it’s very clear, unfortunately, there is some of these panic buying going on as food gardens and actually a little bit crazy, but the retail sector is responding to that as well. But it has demonstrated, unfortunately, some of those behaviors without seeing people but we can understand why they’re doing it as well. So a lot is occurring, Gary, but in the north case, we’re just preparing that there will be cases here in our region. And I guess we’re lucky that our system, we have 15 local health districts to they’re all working quite cooperatively and sharing lessons learned lessons from each other, but good things, working together about upscaling our intensive care beds and facilities and equipment, purchasing ventilators and bypass looking at our surge capacity. In our facilities, I guess the aim of Australia and New South Wales is to hopefully their strategy was to sort of not have that spike, we know we’re expecting anywhere up to a 20%- 25% increase in sort of having that gradual through that. The next few months, we’re coming into our winter period, which is also a busy influenza period. So we’re trying to flatline that expected increase, as opposed to having a dramatic spike, which is probably what you saw. And now your country like Italy, and what’s occurring in spine and elsewhere, that dramatic increase. It’s overwhelmed everybody where we’re trying to sort of contain and do our best to manage that increase. And also look after your staff Gary, and then for anyone in the US, I’m sure they might be looking at sustainability, and supporting staff is important. We are looking at what we would have to reduce the staff members for like critical levels to start winding back, what are the non essential things and use that word carefully. They see how we go but the protection of our staff and they will begin inside most really importantly, states ensure that our staff have new leave arrangements for those affected by kriner and virus with canceled or ABCs travel of any health service staff they can’t go overseas. And over the next few months and we’ll work towards there are people can take normally, but the decision making for that has been raised to a higher level that is we can probably would reduce the amount of delay that people will take over the next few months because of the expected search garion services is there’s a lot going on.

Gary Bisbee 14:06
What is the attitude of the average person on the street? Are they particularly concerned about this or treating it just as another flu?

Stewart Dowrick 14:19
I think there’s a mix of people who really thought this wasn’t gonna be as bad as it was. Actually last week, or even worse, when I realized that these restrictions are coming in as a group. The mortality that we’ve had here and across the world has been predominantly nice, elderly but we have had people across all ages affected. I think it is a real reality that has accelerated sort of chases souls and chases the problem as opposed to getting ahead of the problem. And that’s an important issue that had an immediate response to this. People want to be able to photo the first Corona patient, the first Coronavirus patient which we must treat and manage privacy. We don’t want people who are initially affected to be handled by the local media and treated like a leper. And we don’t want that in our communities. Because we know that so many people will be over time getting these stories, but we don’t want those initial early ones being treated differently. And that could happen, that could fairly happen. And we just have to manage it in the media. And it’s nice messages, some of them excellent. And these are the case as well.

Gary Bisbee 16:44
What about testing? I know there’s been problems here in the US with the tests themselves and having enough diagnostics to underlie the test, then the labs, we just announced that there’s now many more places that can do the test. Testing has been an issue in New South Wales.

Stewart Dowrick 17:04
We’ll be testing lots of people for the crimes that’s been occurring in my district and others for some time now, since like January when this first started, and it has been a consistent issue when I was in New South Wales pathology, were supported by the New South Wales pathology and they are working really hard to ensure the turnaround times quicker. And then the scan that they’re showing that support supplied reagents for the testing. That is something that’s being monitored daily. And it is an issue where that is what isn’t the primary key or the GP setting or the public health system. We encourage people to do this. In Australia, we have a health direct line that people can find if they believe they have symptoms that’s sort of been overwhelmed at the moment. So they aren’t signing up with the local public health facility, the testing has been an issue. And we just got to keep working our way through there. And combine the scanning from an A yesterday a new set of articles ology were indicated I believe they’ll have they’ll have enough reagents to supply that it’s going to be skinny and tight for some time. And getting a license is tricky as well.

Gary Bisbee 18:17
You referred to this earlier, but what about capacity, in terms of bed capacity, ICU capacity, ventilators, that sort of thing? What’s your current thinking about that Stewart?

Stewart Dowrick 18:29
Always definitely planning to increase ICU capacity. Gary, and surge beat capacity and the last few weeks and today and we’ll keep doing is looking at options either within our facilities, which is the key and just converting wards or new areas into surge beds, COVID boards, we haven’t done that yet. But we’ll probably get very close to creating this, creating extra we will need extra capacity. There’s no doubt about that. There’s been about a 10% increase in emergency attendances with increased respiratory illnesses presenting. We’re seeing that greater than last year, whether that’s the worried Well, I don’t think it is fair, but people are probably nervous coming in, in. We have very good emergency departments here and enlisted in North case in Australia who are very good at what they do, but their capacity for them and supporting them is going to be a trick and difficult and we are setting up respiratory and fetal fever, respiratory clinics, obviously use the word fever clinics, supporting our emergency departments. And I’d like another front door. We haven’t just set those up yet, but by the end of the week, we’ll have those set up just to be another door to the ad, which people will be directed to as opposed to or can’t refer to by the GP they come to our hospital. And in the primary care space. I’ll be looking at spiritual clinics, which is a bit different. Absolutely the clinic. So there’s all different paths ice use important. Gary, this could be equipment, ordering additional equipment, making sure the basic supplies the biomedical guys are very busy, New South Wales as an entity is organized on mess, as well. And we’re also looking at whether it’s time to increase surgical capacity before the real wide seat, can we bring forward some other elective surgery, which will be done later in the two now, before the I guess we have maybe a four week or an eight week six week window before we really expected a big number to come through. And we are sort of at what capacity we’ve got as well, to free up beds later in the winter months.

Gary Bisbee 20:45
How much have you used telemedicine in New South Wales? And is that something you see growing in the case of pandemic like this?

Stewart Dowrick 20:56
Where we’re doing it is in the rural areas. We could actually do a lot more of it. And this situation, while this has given us a great chance to accelerate the testing and utilization that was for outpatient clinics. But we see there’s an opportunity to expand and utilize it much better than we have in the past, we’ve done it based on mental health or emergency, our smaller EDS refer into major places. But I guess we serve as an opportunity for our patients to be at home and use utility medicine as an option. Family coming in more so than done before. So this is things like this. That’s, I think, for all of us to think about what are the learnings that can come out of this that can actually reform healthcare in the future? Which would be lessons learned that we control during this period? We just have to because of what could happen. Expanding telehealth is one of those.

Gary Bisbee 22:05
I think that’s right. Learnings definitely are second and third are impact. What about just in that category? Oh, there’s been some thinking in this country, because there’s been a lot of discussion about hospital beds, do we have too many hospital beds? And when something like this happens, it tends to focus people on the fact that these provider organizations are really part of the domestic infrastructure, a vital national asset? And I suspect that there will be policies developed out of it here in the US, what do you think about Australia?

Stewart Dowrick 22:43
Australia actually has one of the highest inpatient capacity to thousand people in the world. And I think we’ve been criticised that we sort of have this appetite for beds and our community sector may not be as great as elsewhere in the rest of the world. It’s now looking at how we can surge and find capacity and people will do that the right way. If they can. Now I think people will have your comment about us being seen as a national asset is a really important point. I think people realize, in Australia, how much I appreciate the economic impact of the country, that we are smaller than just a social service, or a hotel service. I think we actually and this, the impact of this on the economy, what we see around the world, the global markets, which isn’t financial is actually a health issue, I think demonstrates, and will change to the thinking of healthcare thinking of the future. I totally agree with you, and especially in public health, a lot of our public health teams, tremendous and how we support them and infectious disease, splices supporting some of those services and probably pulling this down a bit in the last few years, at least in my district could have done more there. But they’ve been tremendous, but I think there’s a space here in the public health sector and health promotion in particular as well. But there’s going to be a lot to come out of this. Over the next 12 to 18 months, we’ve got to really sit back and evaluate and it’s finished.

Gary Bisbee 24:30
What about your pandemic or disaster planning? I know, in talking to CEOs here in the US, there’s a lot of thinking that they’re going to upgrade their plans for this sort of pandemic. What about you, are you comfortable with your plan? Are you thinking that it could be upgraded somewhat going forward?

Stewart Dowrick 24:52
Oh, look, Gary every district would be. I would doubt anyone’s got the ideal pandemic plan when winning New South Wales fall into, you know, we have a state emergency response. And then below that, at the state level, we have what we call a state emergency operation center and state emergency public health center who really oversee all the local health districts and provide support and they’re in there, actually, they activated now and over a number of weeks and but locally, and we refresh the report up to that coordination. But we’ve been monitoring our planes, that the whole area around residential aged care aged care facilities has been something which we’ve had a strong Gary. The sector is outside the public hospital sector that’s near and had to reach into and sort of work out how we can cry to prepare our planes. So we’ve been doing a risk assessment point of view where a greater truth, it is an area that we’ve had a real look at when you look at bandwidth then people having to work from home, do we have the capacity to support them working from home, more so than ever before. So we’ve been looking at those from a risk assessment every day and modifying those as we go and just working hard, I guess. We’ve had recent issues, which has caused us to look at how we respond to emergencies locally, for some time, but he said something very different, as opposed to an environmental issue. This is something to the public health issue. And I guess ensuring that we got things like enough protective equipment for our staff, modify updating the training of our staff, or sub scan that much more better than we have in the past. It’s something to look at. That’s been ongoing. So yeah, we’ve been rejected that all the time. And I’d be naive for anyone not to look at that and put a risk lens over that and, and be open and frank, your executive and your board and others as well about where those risks could be or not. But it is finally just night at the flexibility that we need to increase on.

Gary Bisbee 27:11
I think that’s right, definitely a second order impact. Well, this has been a terrific interview. As we wind down here. Let me ask three questions. One, what do you think has really worked well, up to this point to what do you think has not worked so well? And three, is there anything that you would do differently in the future for this kind of pandemic? Let’s go back to the first question. What has really worked? Well, what has gone smoothly and impressed you up to this point?

Stewart Dowrick 27:53
I think trying to stay calm, address the issues as they arise. Of course, it seems nice to me can do better, and as people will be critical of what we’ve done, but this is an unusual event. So I think the staff have been very good. And I guess keeping it if I could say keeping civic, at other regional health care providers away a lot has made a lot of work with their private colleagues to make sure they’re aware of what we’re up to our elected members of government, make sure that they know where we’re up to. I think councils, residential aged care, Australia is a very big Aboriginal or native population medical service we call the Aboriginal medical, the kind of make sure that we all know we’re here and our primary care. So just trying to make sure we all know we’re a part of the hill family. And bringing that together splitting. Great has been improved, consistently brought everyone together, like the lessons, I seem to just see issues around, I’d have to say it in equipment, we probably could have bought ourselves better, get up there and just engage with our local staff, minutes staff are part of the community. I think the messages have been from now on father, she’s such an expression of all the issues. I think that they’re hearing different messages. They’re a part of the community that is improving, and we started doing that recently. This is an important cog in this crisis. And they are vital to us. So just say, communications, but then again, it’s sort of that some of this has been on the run to and it’s no one’s fault. That’s just because it’s ongoing.

Gary Bisbee 29:45
Is there one thing that you do to prepare differently the next time there’s an epidemic or pandemic?

Stewart Dowrick 29:52
Look, I think, I think if anything to really stand back to your earlier question, Gary. It is just ensuring those pandemic preparations. I think it’s just that preparedness of a pandemic time and your time you can do your best. We actually do our best to plan and prepare. I think this has brought to attention some of the areas of weakness, I think they got a cry put a greater focus into that preparation and planning and contingency and have we got it all right. And that’s just something that the lesson for us into the future. But again, health does respond to emergencies quite well, we have to ensure the American system does assignments. But this is something very different from sustainable, long term nature, this is kind of a test for the next 6-12 months. So something very, very different. It might be unfair to say we should have all claims for something like this. I don’t know that it’s something that again, people that it wants to use or write about. And so we should or shouldn’t have. I don’t know. But it’s something that comes to mind, Gary,

Gary Bisbee 31:03
Well, Stuart well said and why don’t we land here, thank you so much for your time. And it’s always great to compare to other systems and healthcare and other places you make the point there’s a lot of similarity between Australia and the United States and how our healthcare system is governed and managed. So well done.

Stewart Dowrick 31:31
Thanks Gary.

Gary Bisbee 32:01
This episode of Fireside Chat is produced by Strafire. Please subscribe to Fireside Chat on Apple Podcasts or wherever you’re listening right now. Be sure to rate and review fireside chat so we can continue to explore key issues with innovative and dynamic healthcare leaders. In addition to subscribing and rating we have found that podcasts are known through word of mouth. We appreciate your spreading the word to friends or those who might be interested. Fireside Chat is brought to you from our nation’s capitol in Washington DC, where we explore the intersection of healthcare politics, financing and delivery. For additional perspectives on health policy and leadership. Read my weekly blog Bisbee’s Brief. For questions and suggestions about Fireside Chat, contact me through our website, firesidechatpodcast.com, or gary@hmacademy.com. Thanks for listening.

Transcribed by https://otter.ai