CENTRE FOR MILITARY AND VETERANS� HEALTH by Mg7kd8

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									Centre for Military and
                                          2007-2008 THINK TANK
Veterans’ Health
                                FUTURES IN MILITARY AND VETERANS’
Mayne Medical School Building
                                    HEALTH SERVICE DELIVERY
Herston Road Herston QLD 4006


                                  WORKSHOP #5 FINAL INTERIM REPORT
Telephone: 07 3346 4873

Facsimile: 07 3346 4878

www.uq.edu.au/cmvh              The future of joint operations and interoperability:
                                  how can we prepare to deliver quality health
                                   services to military personnel and veterans?
                                                    6 June 2008
                                                         CONTENTS
BACKGROUND ................................................................................................................. 3
DRAFT PROPOSALS AND CONCLUSIONS FROM WORKSHOP 5 ................................ 4
FUTURES METHODOLOGY AND WORKSHOP PROCESS ............................................ 4
PRESENTATION BY ACM ANGUS HOUSTON, AC, AFC, CHIEF OF THE DEFENCE
FORCE .............................................................................................................................. 6
PARTICIPANTS’ FIRST TAKE-OUT POINTS .................................................................... 7
OUTCOMES OF FUTURES WHEELS – DRAFT PROPOSALS AND CONCLUSIONS ..... 7
RESPONSE BY BRIG BILL ROLFE, REPATRIATION COMMISSIONER, DEPARTMENT
OF VETERANS’ AFFAIRS ................................................................................................. 8
RESPONSE BY COL GEORGEINA WHELAN, COMMAND HEALTH OFFICER, LAND
HEADQUARTERS, AUSTRALIAN DEFENCE FORCE ...................................................... 9
COMMENTS .................................................................................................................... 10
CONCLUSION ................................................................................................................. 11
ATTACHMENT 1 – SUMMARY OF PRESENTATION ..................................................... 12
ATTACHMENT 2 – TAKE OUT POINTS.......................................................................... 15
ATTACHMENT 3 – SUMMARY OF FUTURES WHEEL FOR EACH TABLE ................... 18




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               2007-2008 Think Tank Workshop #5 DRAFT Interim Report prepared for CMVH by Jane Palmer
                CENTRE FOR MILITARY AND VETERANS’ HEALTH
                              2007-8 THINK TANK PROGRAM
    FUTURES IN MILITARY AND VETERANS’ HEALTH SERVICE DELIVERY
                          WORKSHOP 5: INTEROPERABILITY
 ‘The future of joint operations and interoperability: how can we prepare to deliver quality
                     health services to military personnel and veterans?’
                                         6 June 2008
                                  The Boathouse, Canberra
BACKGROUND
Following is a report on Workshop 5 which completed a series of workshops in the Centre
for Military and Veterans’ Health (CMVH) Think Tank program for 2007-08, on the future of
military and veterans’ health service delivery. The workshops have looked at five priority
issues agreed after a horizon scanning process by CMVH and wide consultation within the
Defence, Veterans’ Affairs, and government and non-government health sectors.
47 participants attended the Workshop, with high-level representation across ADF services
and DVA, and including representatives of AusAid, Department of Health and Ageing and
other health service organisations.
The aim of Workshop 5, the last in the series, was to focus on future interoperability in joint
military operations and whole of nation responses, and the implications of this for military
and veterans’ health. The workshop was addressed by the Chief of the Defence Force, Air
Chief Marshal Angus Houston, who provided an overview of the importance of
interoperability in ADF operations, and the issues affecting delivery of health services to
ADF personnel and veterans.
Groups of participants then used a ‘Futures Wheel’ (see ‘Methodology’ below) to look at
the future impacts of the issues raised in ACM Houston’s presentation. The proposals and
conclusions arising from the Workshop concerned the development of relationships
between military and civilian agencies through models for cooperation, establishment of
systems for interoperability, and the transition from serving member of the ADF to veteran
in the civilian community, with a special focus on mental health.
The proposals and conclusions of the groups falling within these three general areas are
shown below.




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DRAFT PROPOSALS AND CONCLUSIONS FROM WORKSHOP 5
Models for cooperation
Develop partnerships between government, states, military, DVA, NGOs, professional colleges
and boards
Engage pre-crisis, regularly, at all levels
Ensure a common understanding of each agency’s role(s), resources, limitations
Develop through leadership a model for cooperation in 4 steps:
1. Shared knowledge management (using CMVH and ACPMH, international links)
2. Shared models of care – academics, service providers and policy makers
3. Shared processes for logistics (delivery), work with agencies
4. Evaluation (role for DHSP)

Systems for interoperability
Develop common concepts to reduce fragmentation and build trust
 Develop common standards, systems and behaviours
 Reach agreement on experiments, exercises, effects, locations etc
Provide for a ‘head operation authority’
Develop common training courses, access portals, terminology, communications equipment – at
domestic, international levels
Whole of government responses to include:
 Defence to play an enabling role
 A lead agency with overall responsibility (need not be ADF)
 Use of non-ADF resource capacity (logistical and material)
 Systems, contracts and agreements ‘pre-positioned’ for future emergency
Undertake exercises and re-evaluation to continually improve health information systems
Develop media management strategies to reduce negative impacts arising from mis-information
New military/civilian interfaces to look at:
 Health care models in Australia
 Preparedness planning nationally
 National policies such as e-health
 Common training and career paths for personnel

Transition from serving member to veteran
Develop transition paths from ADF to DVA and civilian community, and back into ADF
Develop paths for individual to access an ex-service community on separation
 Focus on concept of alumni
 Improve two-way relationship between Defence and ESOs
 ESOs to unify their purpose and their methods
Develop a model for health services (especially mental health)
Change health delivery business model from illness to wellness


FUTURES METHODOLOGY AND WORKSHOP PROCESS
Futures Methodology
The approach used in structuring the Workshop was based on the methodology of Causal
Layered Analysis, as developed by futures theorist Professor Sohail Inayatullah (who is an
adviser to CMVH on the Think Tank program).


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          2007-2008 Think Tank Workshop #5 DRAFT Interim Report prepared for CMVH by Jane Palmer
Causal Layered Analysis is a layered approach which allows us to look at what is
happening at a number of levels:
 Lists of reported ‘facts’ and figures (litany)
 Economic, political and historical (systemic) causes
 Ethical, cultural and political views, and underlying structures (culture or worldviews)
 Deeply held myths and archetypes (metaphor)
Both the presentation and the ‘Futures Wheel’ process (see below) used with the
discussion groups were aimed at encouraging a foresight process to look at future
implications of interoperability for the year 2020, and divergent, open-ended thinking which
went beyond facts and figures (the litany level), and tackled at least systemic and cultural
(or worldview) issues.
Workshop Process
After the presentation, each participant wrote down their most significant ‘take-out’ point
(see ‘Participants’ First Take-Out Points’ below). Tables were then asked to each prepare
a short-list of what they considered the most important topics for discussion. A facilitated
general discussion then allocated one main topic area to each table. A total of six topics
were selected for discussion:
Leadership for cooperation – Table 1
Common concepts for interoperability – Table 3 (Table 2 dispersed between other groups)
Military/Civilian interface – Table 4
Transition from serving member to veteran – Table 5
Enabling systems for interoperability – Table 6
Whole of nation responses – Table 7
The Futures Wheel was then used to structure a brain-storming process. The Futures
Wheel is a diagrammatic way of representing the future implications of a trend or issue
(see below), and enables participants to follow through first order impacts in more depth to
second order, third order etc, thus engaging in a foresighting process which opens up a
range of future possibilities.




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                      THE FUTURES WHEEL (after Inayatullah, 2007)
Table groups considered the future impacts of the issue allocated for discussion and
recorded these on the Futures Wheel as ‘first order impacts’ and ‘second order impacts’.
Groups then considered strategies for responding to the challenges presented by these
impacts. At the conclusion of the Futures Wheel process, a group spokesperson reported
back on the conclusions and proposed strategies of each table, followed by responses
from a Defence representative and a DVA representative.
A summary of the presentation, the outcomes of the Futures Wheel process and the
responses from Defence and DVA representatives are below, with more detail on outputs
at Appendix 2.

PRESENTATION BY ACM ANGUS HOUSTON, AC, AFC, CHIEF OF THE
DEFENCE FORCE
Interoperability is a part of everything the ADF does, operating as joint services or with
other nations’ military, agencies and governments. Our current failing is our inability to
obtain the best integrated approach at the civilian/military interface, for example in
Afghanistan. It is delivery of this ‘soft power’ which is the issue.
The importance of interoperability as it applies to the military is evident in Iraq and
Afghanistan where integrated military health systems operating in conjunction with other
nations has meant that casualties can be evacuated and treated at excellent facilities. It is
very important that the standard of service provided by our military partners is of a
standard acceptable to Australia.
Working with civilian agencies from other countries can raise both language and cultural
issues, especially when confronted by the chaos of a natural disaster. Interoperability is


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          2007-2008 Think Tank Workshop #5 DRAFT Interim Report prepared for CMVH by Jane Palmer
essential after a disaster to establish order, allow service delivery and prioritise health care
needs.
Australia will continue to be involved in missions with whole of nation and multilateral
responses, small nation stabilisation, and natural disasters and will require assistance from
the civilian sector. While the military has high preparedness for short notice tasks, the rest
of the nation does not have that capability.
How can we as a nation improve elements of national power without relying totally on the
military, which is a finite resource?
In terms of health service delivery, we do well while people are in the military. People are
also able to return to work in the ADF despite lack of physical functionality. However,
transition from the ADF is a real challenge, especially for those with mental health
problems. During service people are looked after by their unit, but when they find
themselves on the outside they can find access to DVA services difficult.
After the report of the Board of Inquiry into the F-111 reseal/deseal issue, an advocate’s
office was established which helped members of that community to access the health care
services they needed.
At present the transition from ADF to DVA needs more definition and more work. We need
to break down ‘stove pipes’ and organisational boundaries. This needs leadership,
communication, and a focus on constructive relationships. .
Instead of putting platforms ahead of people, we need to put people ahead of platforms.
(A more detailed summary of ACM Houston’s presentation, and of questions and answers
at the end of the presentation, is at Attachment 1).
PARTICIPANTS’ FIRST TAKE-OUT POINTS
Many participants’ recorded several take-out points from the presentation, focusing on the
following areas:
 Culture of health service delivery (4 comments);
 Relationship-building with other nations’ agencies (7 comments)
 Relationship-building between Australian military and civilian agencies (25 comments)
 ADF to veteran transition (11 comments)
 Mental health services (13 comments)
A detailed record of participants’ take-out points is at Attachment 2.
OUTCOMES OF FUTURES WHEELS – DRAFT PROPOSALS AND CONCLUSIONS
Below is a summary of the central issues selected by each group for their Futures Wheel,
and their responses and conclusions.
Further detail is at Attachment 3.




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CENTRAL ISSUE                   DRAFT PROPOSALS & CONCLUSIONS OF EACH GROUP
Leadership in developing        Develop a model for cooperation in 4 steps:
a model for cooperation         1.     Shared knowledge management (with CMVH and ACPMH, international
 - responding to rapid                 links)
    knowledge                   2.     Shared models of care – academics, service providers and policy
    development                        makers
 - changing contexts            3.     Shared processes for logistics (delivery), work with agencies
    eg whole of nation          4.     Evaluation (role for DHSP)
    responses
Common concepts                 Interoperability at the levels of:
 - reducing                         Concepts                           Standards
   fragmentation                    Communications                     Behaviours
 - building trust                   Consistency
                                Will build trust to enable:
                                    Experiment                         Exercises
                                    Systems                            Locations
                                    Agreed effects
Military/civilian interface     Develop relationships between government/ states/ military/ DVA/ NGOs/
- merging models of             colleges/ boards – engage pre-crisis, regularly, at all levels
     health care                These interfaces to look at:
- robust                            Health care models in Australia
     communications                 Preparedness planning nationally
- common career                     National policies such as e-health
     paths                          Common training for personnel
Transitions from military       Develop paths for individual to access an ex-service community on separation
to civilian and back again         Focus on concept of alumni
 - individual                      Improve two-way relationship between Defence and ESOs
 - organisational                  ESOs to unify their purpose and their methods
     systems                    Develop a model for health services (especially mental health)
 - external society             Change health delivery business model from illness to wellness
Enabling systems                Common training courses, portals, terminology, communications equipment – at
 - health information           domestic, international levels
    systems                     Acceptance of a ‘head operation authority’
                                Liaisons/partnerships between militaries/agencies/NGOs
                                Common understanding of each agency’s role(s), resources, limitations
                                Exercises and re-evaluation to continually improve health information systems
                                Media management strategies to reduce mis-information
Whole of nation response        Develop models and policies for mixed capability responses
- defining concept              Whole of government responses to include:
- inclusion of all                 Defence to play an enabling role
   sectors                         A lead agency with overall responsibility (need not be ADF)
- empowering civilian              Use of non-ADF resource capacity (logistical and material)
   sector                          Systems, contracts and agreements ‘pre-positioned’ for future emergency

RESPONSE BY BRIG BILL ROLFE, REPATRIATION COMMISSIONER,
DEPARTMENT OF VETERANS’ AFFAIRS
The responsibility which Defence takes for its own members is well known and
understandable, but this also creates issues for DVA, for example in the management of


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resources depending on whether a person is ‘theirs’ or ‘ours’. These cultural barriers are
reflected in parlance and methods of collecting information, and represent pitfalls in aiming
at interoperability.
The issue is how to overcome these pitfalls. While there have been good ideas presented
today, there is a sameness to the buzzwords, and convincing effort is needed to
implement the ideas. The CDF is committed to action in the ADF, but how can this
translated into DVA?
DVA requires early intervention to promote its long term efforts; which means it needs to
invest in the ADF without in any way interfering with ADF command.
There has to be a collaborative approach, which is what we are working towards.
Continuity of care, the accuracy and accessibility of information we collect and how it is
used, will all be measures of collaborative success. These issues are likely to exercise us
and be testing for all parties for several years to come.


RESPONSE BY COL GEORGEINA WHELAN, COMMAND HEALTH OFFICER,
LAND HEADQUARTERS, AUSTRALIAN DEFENCE FORCE
To remain effective, relevant and capable, and have the ability to be interoperable, we as
an organisation need a level of mastery in what we do in our own environment, and then
we can work towards common outputs. Whether it be an Australian military, international
military or a civilian organisation, the principles are still the same: it’s all about a fit and
healthy force pre-, during and post-deployment, casualty prevention, casualty treatment,
evacuation and comprehensive health information systems.
What I will be talking about is based in part on work done by COL Kerry Clifford in
Workforce Planning, Defence Health Services, and Group Captain Tracy Smart as OC
Health Services Wing, RAAF, as well as work by other officers.
We work in complex, often austere environments, and health personnel are increasingly
challenged to provide safe, best practice. We’ve talked about the challenges in these
workshops over the last 6 months, including having health technical regulatory
frameworks, practicing honest and effective clinical governance, challenges within our
communities to ensure we are funded and resourced to undertake effective training, and to
remain clinically current.
We face daily the challenge of working in an integrated civilian and military health
environment, both in garrison health support, and on war-fighting, stability, humanitarian
and disaster relief operations. It’s about culture and cooperation. In working with other
agencies, how far can we ‘stretch the Defence health piece of string’? Do we need to
have three separate health systems run within single service ‘stove pipes’? How effective
is the current overarching ‘purple’ executive within Defence Health?
We need to get it right in Defence Health before we can engage the civilian community.
We need to ensure we are relevant in terms of coalition operations, and to make sure that
our service personnel have effective health care pre-, during and post-deployment and in
their transition to agencies such as DVA when they move into the civilian environment.
It’s about being effective, relevant, and capable, but within Defence Health and the ADF,
it’s also about being honest with ourselves and collaborating towards a positive future as
opposed to one which is three separate colours but occasionally pretends to be purple.




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COMMENTS

The following comments were received from LTGEN Ken Gillespie, VCDF to the draft of
this report circulated 12 June 2008:

Models for cooperation

The Report's recommendations in relation to models for cooperation seem appropriate.
Through the Defence Health Services Division, I would expect defence to develop the
partnerships that you have outlined in your model. Through CMVH and ACPMH as well as
our International and ABCA links, Defence will continue to cooperate effectively nationally
and internationally with the various professional and military organisations.

Systems for interoperability

Defence Joint Health capability needs to be capable of working in combined operations.
We are doing this effectively and need to continue to explore the needs and redefine the
required capability. America Britain Canada and Australia (ABCA) forums have been used
effectively to ensure links are current and meaningful.

Defence places high priority on proving best practice health care solutions and maintains
close links with various Health related civilian, College, Federal and State agencies. These
links are most important at a time when there are National Review bodies examining and
recommending change in the various health care delivery models.

Transition from serving member to Veteran

This is a current Area of interest for Defence Health. Relationships are well established
and the issues are being identified and addressed. Defence places high importance on
Mental Health and this has been recognised by the recent announcement addressed of
the Mental Health Review that is now being conducted.




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CONCLUSION
The objectives of the CMVH Think Tank program on the future of military and veterans
health service delivery are:
    1. Describe the likely future 2020 environments in which the Australian military and
        veterans’ health services delivery will occur;
    2. Describe what health services delivery would look like in these alternative
        environments;
    3. Determine the impacts on research and skills enhancement needs for future health
        services delivery, for use by Defence, DVA, CMVH and others in planning research
        and professional development programs; and
    4. Establish a mechanism for ongoing horizon scanning with regard to health and
        health services by CMVH in partnership with Defence and DVA.
The Workshops are intended to look at a range of possible futures, based on expert input
from speakers and participants’ own understanding of the issues (Objectives 1 and 2).
The presentation and discussion about future interoperability and its implications for the
health of service personnel and veterans pointed to a need for extensive relationship-
building between military and civilian sectors, cultural change to break down organisational
barriers, forward planning for policy and system change, and a focus on ‘whole-of-life’
health care in the transition from serving member to veteran.
The interim proposals and conclusions of the Workshop 5 discussion groups address:
  systemic issues such shared health information policies and systems, common
     standards and career paths, national health models, national preparedness training,
     across both military and civilian sectors
  cultural issues such as collaboration and cooperation, leading versus enabling,
     building trust, putting people ahead of platforms, and early and constructive
     engagement between agencies and nations
  shifts in metaphor, for example reducing fragmentation, breaking down organisational
     ‘stove pipes’, removing the separation of people into ‘theirs’ and ‘ours’ .
The workshops are concerned with divergent thinking, to provide as wide a set of inputs as
possible to the culminating 2 day Think Tank planned for August 2008.
This main event will commence with descriptions of 3 generations of a family in the
services which capture the issues raised in the workshops – George who is a Vietnam War
veteran, his son Bruce who is a Gulf War veteran, and Bruce’s daughter Kylie who is in the
Air Force in the year 2020. In discussing alternative future scenarios for health service
delivery for Kylie as a serving member and then as a veteran, there will be an opportunity
to review possibilities and come up with potential paths forward for consideration in
Defence/DVA planning (Objectives 3 and 4).
A watching brief will continue to be undertaken by CMVH on this topic and other workshop
topics in the lead up to the major event in August. Articles and other inputs will be brought
to your attention during this period and your input will be sought to further build the
knowledge around this issue.




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ATTACHMENT 1 – SUMMARY OF PRESENTATION
PRESENTATION BY AIR CHIEF MARSHAL ANGUS HOUSTON, CHIEF OF THE
DEFENCE FORCE
Whether in Iraq, Afghanistan, Solomon Islands or East Timor, interoperability is part of everything
the ADF does, operating as joint services or with other nations’ military, agencies and governments.

Our current failing is our inability to obtain the best integrated approach at the civilian/military
interface, for example in Afghanistan, where an integrated approach is needed to deliver services
which will improve the life of Afghanis. It is delivery of this ‘soft power’ which is the issue.

The importance of interoperability as it applies to the military is evident in Iraq and Afghanistan
where integrated military health systems operating in conjunction with other nations has meant that
casualties can be evacuated and treated at excellent facilities, particularly during the crucial ‘golden
hour’ after injury. In these circumstances, interoperability with other nations, and speed of action
are essential.

Health support planning is very important to the military, as is the standard of service provided by
military partners eg the high standard offered by Australia’s Dutch partners in Afghanistan. Some
other coalition partners have not been able to provide health services to a standard acceptable to
Australia.

Interoperability was key to Australia’s operations after the tsunami in Indonesia, as Australian and
New Zealand doctors worked with the Indonesian government and civilian volunteers. Working with
civilian agencies from other countries can raise both language and cultural issues, especially when
confronted by the chaos of a natural disaster. For example, in Indonesia, the ADF got C-130 aircraft
over there quickly, but there were problems with the airfield, and no system in place to task them
and connect them to delivery mechanisms.

Interoperability is essential after a disaster to establish order and allow service delivery. In health,
this is particularly important, in terms of prioritising who needs health care.

Australia will continue to be involved in missions with whole of nation and multilateral responses,
small nation stabilisation, and natural disasters eg cyclones in the South Pacific. The military
cannot resolve all of these problems by itself, but will require deployment of the civilian sector.
While the military has high preparedness for short notice tasks, the rest of the nation does not have
that capability.

How can we as a nation improve elements of national power without relying totally on the military,
which is a finite resource?

In terms of health service delivery, we do well while people are in the military. If someone is
seriously wounded, they can be evacuated, rehabilitated and returned to service in the ADF. Gone
are the days where the loss of a limb meant leaving the military. It is important and necessary that
people are able to work despite lack of physical functionality.

The mental health area still requires a lot of work. In terms of statistics, the reason many people
leave the service is because of post-operations mental health problems. People need support in
this area both while away on operations and when they come back. One problem is that when
someone comes back from deployment, they are looked after by their unit in accessing services,
but when they leave, they find themselves on the outside.

Access to DVA services can be difficult. Transition from the ADF is a real challenge, especially for
those with mental health problems. Not just combat operations, but those such as the tsunami
disaster relief have impacts on people which will last the rest of their lives.



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In the area of occupational health and safety, the F-111 reseal/deseal community is a group of
people who worked in an unsafe environment which changed their health forever. The Board of
Inquiry identified failures of command, of health service delivery, and of leadership. Many people in
that community had found themselves on the outside of the military system, suffering mental and
physical health problems and with difficulty accessing services.

After the report of the Board of Inquiry, an advocate’s office was established which helped members
of the F-111 reseal/deseal community to access the health care services they needed. These
people are still suffering from problems and will need to be looked after over the long term.

At present the transition from ADF to DVA needs more definition and more work.

There is much we can do to improve culture to support the ADF and veterans. We need to break
down ‘stove pipes’ and organisational boundaries. This needs leadership, communication, and a
focus on relationships. Nothing good comes of adversarial relationships, but good comes from
constructive relationships, teamwork and harmony.

How can we change the culture of how we deliver support in the ADF and after, so no-one falls
through the cracks, especially when a person’s problems are not completely obvious eg PTSD and
mental health problems. In the US experience in Iraq, there have been as many mental health
problems as physical.

Instead of putting platforms ahead of people, we need to reverse this and put people ahead of
platforms.



Questions from participants to ACM Houston

Q: As well as focusing on veterans, we also need to focus on veterans’ families.
A: Families are very important to the ADF. One reason we lose people is the stresses of service
on families, so the ADF is putting more effort into developing family-friendly policies. The Defence
Community Organisation is focused wholly on families, and does a good job although it has limited
resources. To retain people, we need more family friendly policies. The Americans note that ‘you
recruit the soldier, you retain the family’. The new Defence White Paper to be released soon will be
very focused on families.

Q: Can you comment on the statistic that the number of mental health claims from service in
Afghanistan has fallen since 2004, while the number has increased from Iraq?
A: We need to get better at collecting the right sorts of data. Screening occurs but the problems
with the male part of the population is admitting they have a problem. It is good that more people
are now coming forward. Afghanistan is generally a more pleasant posting than Iraq. In addition,
those serving in Iraq more recently have had more difficult experiences, in terms of relationships
with local people, IEDs etc, than those serving during the initial reconstruction phase.

Q: There is a different model now for ‘wounded in action’ where you do not have to be ‘fit for
deployment’ to be retained. What about those suffering from mental health problems?
A: We are now very focused on rehabilitation for both physical and mental health problems. For
example, Holdsworthy have a state of the art rehabilitation unit, which provides excellent
compassionate care in helping young people return to service. We need to come to grips with
mental health as an issue. A review of mental health is occurring at the moment.

Q: What is the role of the civilian health sector in military health service delivery and professional
development for members of Defence health services?
A: The connection between military and civilian is very strong through the deployment of reservists
on operations, especially surgeons. However we should be more open and accessible – people
don’t need to be in uniform to provide health support to the military. For example in a major
conventional engagement, there would not be enough surgeons in the reserves and we would need


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other civilian surgeons as well. Sending ADF health personnel out to the civilian sector happens
already as a matter of course and needs to happen as much as possible because that’s where the
leading edge is in the health community in Australia.

Q: Interoperability at the macro level, developing a whole of nation response to crises in the region.
AFP, DOHA, AusAid representatives are in the audience today. Who are the major players in a
whole of nation response?
A: Those are the agencies. We have an excellent relationship with the AFP and work closely with
them. Of more concern is the ability to deploy. At National Security Committee of Cabinet, we
needed lawyers to go to Baghdad, but no civilian lawyers could be found. We subsequently found
51 reservist lawyers willing to go. The same happened in trying to get civilian doctors to go to
Darfur, which is a violent and dangerous place, challenging enough for the military and therefore
very difficult for others. In broken countries, we need to deploy right across the board. For example
AusAid needs to be able to find expertise in agriculture, industry, health. We have not had a
problem in the Solomon Islands where AusAid have people in most government ministries, finance,
treasury etc. Afghanistan however is a problem. The risk in Afghanistan is very high for the military
eg we expect to take casualties, so it is difficult to get civilians to go there, even with military
protection.

Q: When people transition out of the services, they may have some case management but no
longer have a mother/father figure to help people look after their health. Do we need to look at
providing this kind of assistance to people, eg as occurred for the F-111 reseal/deseal community?
A: This is exactly what occurred with the F-111 reseal/deseal advocate, who had outstanding
leadership qualities. He became mother and father to that community, and found out how to get
support for people from other agencies. He then had other veterans accessing him to find out how
to get support. This is the problem with transition – morale is good while a person is in their unit,
but when they are on their own, if they are depressed, and therefore find it hard to access the
bureaucracy, they need help to be able to find the right services.




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           2007-2008 Think Tank Workshop #5 DRAFT Interim Report prepared for CMVH by Jane Palmer
ATTACHMENT 2 – TAKE OUT POINTS
Culture of health service delivery
    1. Put people ahead of platforms
    2. No medical discharge for those wounded in action. What about those not wounded in
       action but sporting injuries etc?
    3. Our commitment to humanitarian response is only as good as our commitment to the
       welfare of our own people
    4. The need to improve the culture of the health services

Relationship-building with other nations’ agencies
   1. Interface with forces of other nations who have different health standards
   2. Interoperability in service activity as well as wider humanitarian aims and requiring ‘all of
       government’ approaches
   3. Cross-cultural, competency and interpersonal issues in delivery of ‘all of government’
       approaches
   4. Working with other countries requires health care providers to Australian personnel to have
       accreditation equal to Australian standards – difficult in a coalition or UN operation where
       the health support may be a given and not negotiable (but it should be)
   5. Interoperability and communication is key to success for provision of health (especially in
       multilateral operations)
   6. Relationships
   7. Health support planning important to ensure that the required standard of care can be
       delivered by our coalition/civilian counterparts (on operations or in NSA)

Relationship-building between Australian military and civilian agencies
   1. Interoperability with deployable agencies
   2. We should identify points of commonality between agencies/departments as the
       points/areas for integration
       Need for data collection and sharing between organisations
   3. Inter-agency deployment
   4. Need to develop whole of nation response capacity
   5. Comprehensive approach to operations overseas. Requires whole of government approach
       to delivery.
   6. Interoperability in a military sense is becoming broader and more complex through a
       number of means eg the need for more civilian and other agencies’ involvement in disasters
   7. Role of leadership to drive relationships between organisations
   8. Need in the future to better work with NGOs so that when a humanitarian response is
       required there are established interface procedures
   9. Key points:
       Whole of government interoperability
   10. Need to plan to bring other elements of national power to the operational zone earlier
       We are limited in capability – should do what we are good at and let others do same
   11. Relationship building
       Communication
   12. Multiple agency interoperability
                Government
                NGOs
                QANGOs

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           2007-2008 Think Tank Workshop #5 DRAFT Interim Report prepared for CMVH by Jane Palmer
                    Civilian
          Language, communications
    13.   Interoperability depends on goodwill and good relationships between services/agencies at
          both the corporate and individual level
    14.   C4I systems – deployed
          Bandwidth for transmission
          Medical systems (pre/post) integrated into C4I systems
          DVA hooked into C4I
          DVA through life support systems
          Language specialists – deployed
          ADF → DVA → DFAT → public medical → all records available
    15.   Relationships important in operations (with other military, other agencies)
    16.   ‘Culture’ of health community needs to build on partnerships
    17.   Managing the interfaces/boundaries
                    individuals
                    systems
                    enablers
          Joint trajectory – no change
    18.   Much discussion of forward thinking, ‘integration’, ‘interoperability’, but only the ‘need’ to
          look at these issues behind us
    19.   Military-civilian humanitarian interoperability is key to success of Australian Government
          initiatives (focus on military objectives, civilian objectives and link-building before there is a
          disaster)
    20.   Civil/military interface is in need of review
    21.   There is a need to improve the civilian military interface and whole of government approach
          This is essential in order to look after those who are/have served in the military
    22.   Military-civil interface with health
                    deployability
                    C2
                    models – e-health
          TMS → transition to provide support
          Some potential short-term gains]
    23.   Interoperability needs to extend to include whole of government/whole of community focus
          Immediacy of health care needs to flow through to full rehabilitation
    24.   Interoperability with civilians for humanitarian operations
          Culture of health service delivery – break down stove pipes
    25.   Need to plan for health interoperability
          Need to integrate civilian agencies (in national responses)

ADF to veteran transition
   1. Transition, transition, transition
   2. Interoperability re military-civil transition of members (particularly mental health)
   3. Link up ADF/DVA interface
   4. Transition
   5. Individuals in need, need advocacy support, but how can we define this need and resource
       it?
       As people move out from under a CO, what can we do to help their needs to be met,
       without retelling the story excessively?
       What are we doing to handle the ‘repetitive’ veteran and the future veteran who fights form
       a home-based, ‘safe’ location?


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             2007-2008 Think Tank Workshop #5 DRAFT Interim Report prepared for CMVH by Jane Palmer
   6. Transition to civilian life
       Role of DVA working with ADF central
       Cultural environment can work against above
   7. Key points:
       Transition
   8. Identify non-visible conditions
       Transition – command
       Advocates
       Unit support – what about when leave?
   9. The viability of the health continuum, extending to operations, (warfighting, peace support
       and stabilisation, humanitarian and disaster response), through support to personnel in
       barracks and after transition to civilian life
   10. Transition management for health care between in-service and post-service environments
       requires attention

Mental health services
   1. Mental health support avenues and services need to be more available to ADF personnel
       and veterans
   2. Military-civil interface with health
                mental health
   3. Mental health interoperability within the Australian community is a priority
   4. Mental health and TMS
   5. Need to improve coordination in Australia for management of ill health, especially mental
       health across Defence, DVA, community
   6. Civilian/Military interface
       Using knowledge of problems to change mental health delivery in ADF
   7. Impact of dealing with disaster on people’s well being, from a psychological performance
   8. Transition from service to civilian life: How do we manage the person with mental health
       issues?
   9. People – who are they, where are they?
       How can we help them when we know who they are?
       Mental health is not obvious, it could be anxiety or depression, not recognised
   10. The gap between military service and support to veterans for acutely unwell, particularly
       psychological
   11. Key points:
       Mental health
   12. Has Defence moved from a retention based on deployability towards retaining wounded in
       action, and how will this extend to PTSD and others with significant disability
       DVA’s delivery model not suitable for mental health going forward
   13. The significance of mental health issues




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           2007-2008 Think Tank Workshop #5 DRAFT Interim Report prepared for CMVH by Jane Palmer
ATTACHMENT 3 – SUMMARY OF FUTURES WHEEL FOR EACH TABLE
    TREND                    FIRST ORDER IMPLICATION                           SECOND ORDER IMPLICATION
TABLE 1 - LEADERSHIP
Rapid                        Competing models of care
knowledge                    between partners – who
development                  decides model of care
and changing
nature of health
service delivery             “Missed opportunity” - don’t get
in context of                proper sharing of information,
whole of nation              therefore duplication of effort in
response                     knowledge management


Dilution of                  Potential loss of knowledge in
veterans in the              broader community
community,
dispersal of
knowledge                    Veterans find it harder to get
                             what they really need

STRATEGIES
Need to develop a model for cooperation in 4 steps:
1.     Share knowledge management (with a role for CMVH and the Australian Centre for
       Posttraumatic Mental Health (ACPMH) and international links) – “Welcoming knowledge by
       risk averse individuals”, military/civilian interface management
2.     Develop shared models of care – academics working with service providers and policy
       makers
3.     Develop shared processes for logistics (delivery), working with agencies
4.     Evaluation (CMVH’s Deployment Health Surveillance Program (DHSP) could help here)
The above model would also address the dilution of veterans in the community, especially, for
example, in the development of shared health records.
The model needs to encompass community-based and specialist care




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           2007-2008 Think Tank Workshop #5 DRAFT Interim Report prepared for CMVH by Jane Palmer
    TREND                     FIRST ORDER IMPLICATION                            SECOND ORDER IMPLICATION
TABLE 3 – COMMON CONCEPTS
Bigger problems
with bigger
solutions/options


                              Share:
                               Surveillance
                               Research
                               Exercises
Lack of trust                  Think Tank


                              Build an ongoing conversation                     A standing advocacy organisation –
                              with continuity                                   a single service through the chief
                                                                                ADF advocate


Fragmentation                 A single health information                       Records management
of systems and                system very important
organisations                 (legislated)
(driven by
accountability
requirements)

STRATEGIES
Systems issue is whether to be common or compatible
Approach needs to progress through:
  Independent – Interoperable – Integrated
Interoperability must be built on trust - needs to work at the levels of:
  Concepts
  Standards
  Communications
  Behaviours
  Consistency
A single health information system is a strong convening concept
The above approach will build trust to enable:
  Experiment
  Exercises
  Systems
  Locations
  Agreed effects




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            2007-2008 Think Tank Workshop #5 DRAFT Interim Report prepared for CMVH by Jane Palmer
    TREND                    FIRST ORDER IMPLICATION                            SECOND ORDER IMPLICATION
TABLE 4 - MILITARY CIVILIAN INTERFACE
Models of health             e-health and other policies are
care delivery                truly ‘national’
merge


                             Civilian health care service                      Technology/equipment
                             delivery becomes deployable                       interoperability


Communications
across health
care agencies                Merging C2 models
are robust



Career
continuums for               Recognition of common training                       military          civilian
health service               is equal in civilian and military
personnel
merge
                                                                                  deployed            home



STRATEGIES
(Assume increasing requirement for health service delivery (both from civilian and military –
displaced persons, natural disasters, coups))
Interfaces/relationships need to be developed and maintained between government/ states/ military/
DVA/ NGOs/ colleges/ boards etc – needed now, pre-crisis, regular, at all levels
These interfaces need to look at:
  Health care models in Australia
  Preparedness planning nationally
  National policies such as e-health
  Common training and career paths for personnel




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           2007-2008 Think Tank Workshop #5 DRAFT Interim Report prepared for CMVH by Jane Palmer
    TREND                      FIRST ORDER IMPLICATION                           SECOND ORDER IMPLICATION
TABLE 5 - TRANSITIONS
                               Healthy

Individual
                               Unhealthy


                               Reintegration of reserves
Organisational
systems
                               Interface Defence/DVA/ESOs             t


                               Engage the ESOs
External society

                               ESOs engage politicians

STRATEGIES
Develop transition paths from ADF to civilian sector (and back again)
Find a way for an individual to access an ex-service community on separation eg RSL/DVA – focus
on concept of alumni
Develop a model for health services (especially mental health)
Change health delivery business model - change focus from illness to wellness especially within
DVA
Better two-way relationship between Defence and ESOs
  ESOs to unify their purpose and their methods
  Communicate ex-service issues to the community




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             2007-2008 Think Tank Workshop #5 DRAFT Interim Report prepared for CMVH by Jane Palmer
    TREND                    FIRST ORDER IMPLICATION                           SECOND ORDER IMPLICATION
TABLE 6 – ENABLING SYSTEMS
                             Agency/agency information
Greater reliance             systems
on Health
Information
Systems for
planning and                 Military/military information
delivery of                  systems
health services

                             Military/agency information
                             systems


STRATEGIES
Common training courses
Common access portals (security)
Common terminology (international)
Common communications equipment – to work at domestic, international levels, after disasters
Common understanding of each agency/element’s role(s) in the interoperability process
Common strategies to clarify whole of government, national response
Liaisons/partnerships between militaries/agencies/NGOs
Greater visibility of all resources/limitations
Exercising of the various groups and re-evaluation to continually revise and improve health
information systems (exercise at tactical level, not just strategic level)
Acceptance of a ‘head operation authority’
Media management strategies to reduce negative impact on inter-agency relations due to mis-
information
Respect NGO independence but MUST have oversight of where resources are being deployed and
what support is needed and what rules must be obeyed




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           2007-2008 Think Tank Workshop #5 DRAFT Interim Report prepared for CMVH by Jane Palmer
     TREND                              FIRST ORDER                                 SECOND ORDER IMPLICATION
                                        IMPLICATION
TABLE 7 – WHOLE OF NATION RESPONSE
                                A shared response, avoiding
Lack of whole of                duplication of capability or silo
nation capability               concepts of responsibility to agencies
response concept:
  What capabilities
   do we need?                  Logistical/material support required to
  How do we                    support deployed civilian/military
   structure and                personnel (not necessarily ADF)
   develop those
   capabilities?
  How do we
   support/sustain
   responses?
  How do we risk
   manage all of
   this?


                                Contracting and finance needs to
Whole of nation                 support access and sustainment
resonse involves
commercial as well
as ADF, government              How do we coordinate, control and               t
and NGO                         support mixed source capabilities:
capabilities                      Injured/killed
                                  Long term health effects
                                  Equity of entitlements


                                More than just Defence, but Defence
                                will play an enabling/transition role to
Empower civilian                whole of government
agencies to
contribute to disaster
and conflict recovery           Defence assets may not be available
responses                       for political or other tasking priorities:
                                  What is emergency response?
                                  What is standard business eg for
                                   AusAid?

STRATEGIES
Models and associated policies for mixed capability responses need to be established
Defence to play a role in enabling a whole of government response which will include:
Lead agency responsibility and coordination - national (civilian/military) coordination response
agency
Use of non-ADF resource capacity (logistical and material)
Systems, contracts and agreements need to be ‘pre-positioned’ for future emergency


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            2007-2008 Think Tank Workshop #5 DRAFT Interim Report prepared for CMVH by Jane Palmer

								
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