COTA SA SUBMISSION TO SA HEALTH ON TRANSFORMING HEALTH PROPOSALS PAPER Prepared by COTA SA 16 Hutt Street Adelaide SA 5000 (08) 8232 0422 www.cotasa.org.au Authorised by: Jane Mussared Chief Executive jmussared@cotasa.org.au (08) 8232 0422 Prepared by: Jessie Byrne Policy Manager jbyrne@cotasa.org.au (08) 8232 0422 2 March 2015
2 1. INTRODUCTION COTA SA appreciates the opportunity to provide this submission to SA Health on its paper, Delivering Transforming Health Proposals Paper: Meeting the Clinical Standards. COTA SA is the peak body representing older South Australians. Our aim is to advance the rights, needs and interests of older South Australians. COTA SA has 17,000 individual members and 250 seniors organisations with a combined membership of more than 60,000. We have 80 associate members including aged care providers, local government bodies, health units, and other service and educational institutions. As you are aware, South Australia is the second most rapidly ageing state or territory in Australia, ranking only after Tasmania. The 2011 census showed that 22.3 per cent of South Australia s population of 1.6 million people were 60-plus years of age. By 2031, it is projected that 26.5 per cent of our population will be aged over 65 years. That s more than one in four. Health and wellbeing are critical issues for older South Australians. As Transforming Health itself says, on average 40 per cent of patients in our hospitals are aged between 65 and 85 years. We also know that the population in the Central Adelaide Local Health Network includes the highest proportion of over 85-year-olds in the country. In any reform of the health system, therefore, the voice of older people is vital. COTA SA remains keen to work with the government as it pursues reform. In providing this submission, COTA SA draws on extensive public consultation with our stakeholders. In addition to direct input from the community, community groups and our policy council, we have received 40 written submissions from older South Australians and those who care for them. 2. THE NEED FOR REFORM COTA SA understands that budget imperatives as well as patient outcomes prompted the Transforming Health review. We accept that reform of the health system is necessary for greater efficiency, but most importantly to ensure best outcomes for patients at all times and in all places. COTA SA therefore supports in principle the state government s decision to undertake broad reform of the metropolitan public hospital system. We do so with three important caveats: that reform puts patients and patient outcomes first that Transforming Health be extended beyond metropolitan public hospitals to encompass the full continuum of the health and aged care systems that consumers and the community are integrally involved in the reform process in co-designing, evaluating and monitoring the reform. COTA SA raised all three issues in our first submission on Transforming Health, provided to the state government in November 2014. While we are pleased to see that the government has now acknowledged all three matters, to date there has been little substantive progress on any. COTA SA sees the next stage of transformation as the perfect opportunity to embed all
3 three principles in the reform process. Putting patients and patient outcomes first As outlined by the Australian Commission on Safety and Quality in Health Care, patients need to be placed at the centre of their own care and the health care system more generally and consumer- or patient-centred care is health care that is respectful of, and responsive to, the preferences, needs and values of patients and consumers. In other words, it puts patient wellbeing and patient-directed services ahead of systems, clinicians and budgets. It is COTA SA s view that the state s health system is still a long way from putting the patient first. Patient safety, patient wellbeing and the patient voice have sometimes been sacrificed for historic systems and vested interests. Our stakeholders express sincere gratitude for the hard work and care that is provided to them by health professionals and other staff. This said, a patient-centred approach requires wholesale cultural change, backed up by resource and system changes. COTA SA welcomes the Minister for Health s commitment in the Transforming Health Proposals Paper to a best quality, patient-centred system. It also welcomes Standard 1 of the Transforming Health standards: All aspects of care should be patient-centred and focus on quality outcomes. This includes service design, delivery and evaluation, supported by research and teaching. While the proposals paper grows the first flesh on the structural and service changes that the government is proposing, predominantly around buildings, capital investment, service centres, management and specialisation, it is on the whole silent on how to move to a patient-centred health system. Indeed, Transforming Health focuses on service location rather than on the local communities our health system services. The best reform must take account of both. Transforming Health also makes brief reference to those groups more disadvantaged in the health market. Indigenous South Australians, for example, have the worse health outcomes overall, with life expectancy considerably lower than the general population and chronic illness rates considerably higher. Those from culturally and linguistically diverse (CALD) backgrounds and from regional South Australia also experience differential health outcomes. The particular needs of these groups are a critical part of any reform. Consumer and community engagement will afford the government the opportunity to explore and embed this important standard into the transformation, including what it looks like, how it applies across all services, measurement standards, and evaluation and improvement. To assist with this cultural change, for example, investment in change leadership will be needed. While advocating a patient-centred approach, COTA SA would like to acknowledge the work of health staff in our public system. Our stakeholders consistently tell us about the high level of care they receive from individual workers and their gratitude for that care. We know that satisfied workers provide better care. Transforming Health should therefore also be about valuing our health professionals and providing them with support and opportunities for career progression, training, flexibility, and safe working environments. Expanding the scope of practice of many professionals will do this, as well as free up the time of more highly
4 qualified professionals to undertake more complex tasks. In this sense, COTA SA advocates person-centred not just patient-centred reform. This will also require a focus on older staff, whose retention is vital, but who may currently be overlooked for development opportunities and professional advancement. The continuum of health and aged care COTA SA continues to be concerned that Transforming Health is about public metropolitan hospitals rather than the full continuum of the health and aged care systems. No hospital is an island. We are nevertheless encouraged by the commitment of the Minister for Health, Jack Snelling, to broader reform, ie improving the links between GPs and community-based care and quality of care in the regions. A recuperation centre for older people awaiting entry into residential care is a welcome innovation. True reform must treat the entire health and aged care systems as a continuum. As one stakeholder told us: I understand the need to streamline public health services and it is clear this proposal aims primarily to save money through reducing duplication and inefficient practices, of which there are clearly many. However, an element that appears to be missing from the review is how the state funded health system integrates with federally funded aged care. Often blamed for 'bed blocking', older people are not being discharged in a streamlined manner and if there was better preventative health integration, many hospitalisations might be avoided Also there seems to be a lack of understanding about discharge to RACF [residential aged care facility] there are lots of vacancies, it seems, so it is not a lack of places causing 'bed blocks', rather a lack of integration between state and federally funded systems. From COTA SA s perspective, the links between primary care and preventive health, the hospital system and acute care, and then post-acute care and community and residential aged care are critical, for all South Australians but in particular for older people. Transforming Health looks at the push factors, ie what gets people out of hospital, but fails to address the pull factors, ie the systems and support needed to make leaving hospital safe and dignified. As one stakeholder told us: Most patients are sent home before they can stand up properly. A key failure of the current environment is that links across the entire health and care systems are weak or non-existent. Discharge planning is uneven, poor communication exists between GPs, community health centres, hospitals and aged care facilities, and there is inadequate provision of transition and post-acute care. The result has been poor patient outcomes, characterised by high hospital readmission rates, long (and often unnecessary) hospital stays, strain on carers, and poorly managed chronic disease. For older people, often living on their own or relying or partners who themselves are chronically ill, getting care in the home right must a priority for reform. It has also put enormous strain on health and aged care budgets. Cuts to primary healthcare and preventive health by all governments have dramatically increased the costs for acute care and hospitals. Similarly, failures in post-acute care rebound into the acute system.
5 While making South Australia s hospital system more efficient with better quality outcomes is vital, the greatest savings are likely to come from increased investment in downstream and upstream services, ie keeping people out of hospital in the first instance and then ensuring they have no need to return will deliver the greatest budget savings. Most importantly, the overall health outcomes for South Australians will be better. COTA SA appreciates the major reform on which the state has embarked and the resources dedicated to it. However, isolating hospitals from the broader health and aged care systems will provide partial reform at best and faulty at worst. Within the context of the government s current reform commitment, COTA SA therefore urges the South Australian government to immediately establish a mechanism that can inform and ground Transforming Health in a continuum-of-care, whole-of-system model. Consumers and the community must be an integral part of this approach. Consumers and community at the centre of reform Standard 2 of the National Safety and Quality Health is as follows: Partnering with Consumers, is as follows: Leaders of a health service organisation implement systems to support partnering with patients, carers and other consumers to improve the safety and quality of care. Patients, carers, consumers, clinicians and other members of the workforce use the systems for partnering with consumers. In brief, according to the Australian Commission on Safety and Quality in Health Care, this standard requires that: Governance structures are in place to form partnerships with consumers and carers. Consumers and carers are supported by the health service organisation to actively participate in the improvement of the patient experience and patient health outcomes Consumers and carers receive information on the health service organisation s performance and contribute to the ongoing monitoring, measurement and evaluation of performance for continuous quality improvement. This standard must be applied to reform as much as to the day-to-day operations of health services. To date, COTA SA has been disappointed with the level of consumer engagement in Transforming Health. We appreciate that there has been extensive communication, but there has been little input from consumers during the design stage of the reform and therefore little consumer impact on what has been proposed. This failure to formally put consumers and the community at the centre has contributed to high levels of anxiety and misinformation by those on the outside. At the next stage of reform we encourage the Government to undertake consumer and community engagement which is built more firmly around co-design and patient-centred principles. As the peak body for older South Australians, COTA SA would appreciate the opportunity to be an integral part of this engagement, including in assisting with co-design. We congratulate Ms Naomi Dwyer on her appointment as Chief Transformation Officer and look
6 forward to working with her and the transformation team. 3. WHAT TYPE OF TRANSFORMATION: OLDER PEOPLE S WORRIES AND HOPES The Transforming Health Proposals Paper recommends changes to the metropolitan public hospital system which will see four overarching changes: super-sites for major emergencies dedicated specialist centres for complex care, eg stroke specialist streams for elective surgery comprehensive models of care for rehabilitation services. In essence, the paper recommends a spine of three major hospitals (Lyell McEwen Hospital, new Royal Adelaide Hospital (RAH), and Flinders Medical Centre), with the remaining hospitals downgraded, refocused or shut. Only three hospitals will provide full emergency department (ED) services: the new RAH, Flinders and Lyell McEwen. The Repatriation General Hospital and Hampstead Rehabilitation Centre will be closed. St Margaret's Rehabilitation Hospital will no longer deliver rehabilitation services. A range of services will be distributed across the remaining facilities, with increased levels of statewide oversight for clinical streams. At the level of principle, COTA SA can see the value in this proposal and believes that public debate is vital. Many of our stakeholders see the need for change: Concentrating expert staff to deal with major emergencies makes sense Psychiatric emergencies deserve to be treated by specialists in that field. Generally I believe that the recommendations will lead to a more efficient health system in that people with serious illnesses will be admitted to the hospital which can best deal with them. Specialist surgery streams could also prove to be beneficial for the same reasons - all of the appropriate skills and equipment will be readily available. In addition, patients will know in advance just which hospital they will be required to attend and have more confidence that their outcome will be better as a result. I am supportive of the changes proposed. I have had experience with my late father where he was taken to an emergency department in one hospital and then had to be transferred to another hospital because of a different set of skills available to treat his condition. It was very traumatic for my elderly mother to have to move around. I have also had experience at the Repat Hospital with the patients in Ward 17 which is a substandard building to be in; a really bad environment for the staff and patients. A new dedicated mental health facility would be a positive step forward. My view is that I would want to be taken to the right hospital first time, every time thus giving me the best chance of getting treated with maximum efficiency, so bring on the changes. I support the proposals. With the growing elderly population, the increasing cost and complexity of medical technology, and the shrinking state budget, a city of our size simply cannot afford five major full service emergency departments, particularly if many specialists refuse to work on
7 weekends. Also it makes sense to rationalise other specialist services, rather than have them spread thinly all over the metropolitan area. However, given the paucity of detail in the proposals paper, COTA SA is not in a position to comment on the value or otherwise of particular proposals. For instance, the paper does not articulate how the Medical Services Stream will be affected across the state, yet older people are the largest users of general medical services. Certainly, a strong transition plan, better community communication and real resources will be needed to make the reform viable and to ensure that patient safety is not compromised. As one person said: The prime PRIORITY has to be to build the new facilities FIRST Before closing anything. Our stakeholders have raised a number of matters with us, in addition to the three key principles already listed, that they tell us are critical to any successful reform and which protect their interests and needs. Their comments are outlined below. Congestion of services Our stakeholders have expressed concerns about the concentration of services and the impact this will have. As our stakeholders have said: Noarlunga ED needs to continue acute role as FMC not coping currently & will have more attendances causing more pressure & potential for errors. Parking/space a nightmare at FMC already & difficult for older clients to access. I don't know how these people will be absorbed into an already stretched system. Reducing emergency services to three hospitals - the existing system is under stress so I can't see how this can be improved unless substantial money is spent to increase and improve facilities at the three nominated hospitals. In commenting on having a lower threshold ED at Modbury Hospital, one stakeholder said: A very short-sighted idea To lighten the load I suggest the hospital charges for non-emergencies therefore lessening the amount of people who attend the ED who could see their GP instead. Quality of service Many of our stakeholders believe the proposals have the potential to deliver better quality of care: I would rather be sent to a Hospital that has specialist knowledge in the area of my health because that will give me the best outcome. You cannot have this unless you re-arrange the current hospitals responsibilities. But there is concern about the type of care that is given at the larger hospitals, especially for older people, compared with that at (for example) the Repatriation General Hospital: What RGH does well is cater for assessment/treatment of older people &
8 those with chronic health conditions. FMC is a production-line type of medical care, getting people out as soon as possible without enough discharge services planning. Hence people will " bounce back" into hospital quite often. The bottom line should not be quick discharge as in the long-term it's more costly if they end up being re-admitted. Older people are stressed about how to access day surgery/hospitals on the other side of town & visiting their partner regularly in hospital becomes a day trip. This is not modern medicine but a retrograde step in so many ways. I am concerned about the downgrading and/or closure of hospitals and rehabilitation services. Our population is growing and with only three hospitals to cope with acute health care it seems to me that the "super" hospitals will be over stretched. Already there is ramping at Flinders. Older South Australians have expressed concerns about the absence of 24/7 specialist care: the absence of clinician services around the clock needs to be addressed. The difference in outcomes for patients dealt with out of normal hours and those dealt with in normal hours is scandalous and a disgrace. 7 day a week service is almost universally accepted, particular in covering a whole range of emergencies, not just those in the health system, so clinicians need to be persuaded to provide their services outside normal hours even if the proposals do not ultimately proceed. There continues to be concern that Transforming Health is more about cost cutting than patient outcomes: The driving force behind the proposals seems to be efficiency leading to significant cost cutting. The risk is that achieving the cost cuts becomes the real objective and the service improvements gradually fall by the wayside. I see this risk as very real in these proposals. I feel "transforming health" should read downgrading health services The hospital environment is an important element of quality, not only for patients but for carers and visitors. Older people generally experience longer hospital stays and the physical environment not only contributes to healing, but is an important factor in providing comfort, welcome and access to visitors who themselves may be older. Access and transit The coalescing of specialist services makes sense in terms of providing the best expert care in one or a limited number of locations. It also makes sense in terms of economic efficiency. So that patient safety is not compromised, access and transit are critical elements in reform. As our stakeholders have said: By concentrating services that are most in demand in fewer, more centralised locations compels those requiring those services to travel farther than might otherwise be the case. This does not necessarily improve care or provide better service; it does cause inconvenience, dislocation and cost to the consumer to achieve no measurable improvement in service or other benefit.
9 It is also a burden financially for seniors who can't drive or who do not have the means to travel across town to attend a specialist centre. I agree with major centres for 'Strokes' etc. but downgrading or closing other hospitals I fear will mean more travelling for patients. As will specialist streams for elective surgery. I like the fact that we can attend local hospitals for surgery and other medical services. Those without transport or who are unable to drive will suffer. As it is actually easier and faster to travel from downtown to the suburbs than vice versa, it would be more logical to establish emergencies in suburbs as after hours, when many accidents happen, the downtown has a relatively small population of residents. However, placing some services in suburban sites disadvantages those elsewhere. For example, should eye surgery, currently performed at a variety of sites, move solely to Modbury Hospital, patients (people aged over 65 years are the greatest users in Noarlunga) will face logistical nightmares to access the service. Those in the western and northwestern suburbs have expressed concern about the time in getting to the RAH in case of an emergency: This government health plan is unacceptable for all those who live at a distance from the emergency-able hospital in Metro Adelaide. Three monopoly emergency hospitals are insufficient. In our case, the northwestern Adelaide region critically needs emergency services preserved in the Queen Elizabeth Hospital as it takes between 30 and 50 minutes (depending on traffic) to get to the RAH-this is not acceptable in case of accidents, stroke and heart attack. My wife and I have benefitted greatly-medically and emotionally- from the proximity of the QEH, while living at West Lakes and Somerton Park on several occasions in differing circumstances per ambulance and private cars. Have the authors considered the value of willing private transport locally, saving millions in ambulance costs?? Stakeholders in the northeastern suburbs facing contracted services at Modbury - inform us that they will more likely present at the RAH than the Lyell McEwen Hospital in the case of a serious emergency for reasons both of access and perception of quality of care. This will further add to the congestion at the city location. Many are unhappy with travelling to either location: I object in the strongest terms about Modbury Hospital being downgraded with the loss of departments - the latest being heart. As I live [in the area], I will have to travel miles out to the Lyell McEwen or Royal Adelaide hospitals. Stakeholders in the south point out that the massive projected expansion of the population in that region mitigates against reducing services at the Noarlunga Hospital: The people who live in the City of Onkaparinga need to have their Noarlunga Hospital as part of the major plan and ED should be retained in our hospital. A population of over 100,000 deserve to be treated better
10 than what the government is proposing. Our stakeholders are concerned that parking, public transport and road congestion problems will be exacerbated by the concentration of services, such as emergency services. Parking at the Flinders Medical Centre is already at overflow levels. Paid parking at hospital sites across the city is costly, and can be a disincentive for those on fixed incomes and older people, who may more frequently visit hospitals, to seek the medical treatment they need. It is also a disincentive for carers and visitors, and has the effect of diminishing the important role they play. Traffic along North Tce in the city has long peak-hour standstills, which an ambulance may be able to bypass but which people in private vehicles and buses cannot avoid. This will affect not only those attending the RAH but, with the relocation of the Women s and Children s Hospital, will have serious implications for families, young children and pregnant women, ie the daughters and grandchildren of our stakeholders. In the absence of more detail, COTA SA supports the government s commitment to bolster ambulance services to ensure they take patients to the most appropriate hospital immediately. Communication Communication will be the key to successful reform. Already the community has demonstrated that it does not understand the current system, eg believing that full emergency services are available at the Noarlunga Hospital, and does not understand the reform, eg that emergency services will disappear entirely from the Queen Elizabeth Hospital (QEH). At the present time, this presents a political difficulty for the government. On the proposals paper, one person told us: An example of the current advertising - attractive template that tries to persuade without informing. Every promise leaves unanswered questions. Our stakeholders tell us that they are fearful that during transition, and once reform is in place, this failure in communication and understanding could result in patient mortality and disability. COTA SA understands, for example, that many ED presentations are walk-in. It will not be enough that paramedics and ambulances will know the most appropriate hospital to go to in the case of strokes or heart attacks the community will need to be fully aware of what is the right place if they are using their own transport. If they do not, delays and transfers may cause people harm. The issues of communication are compounded for those in the Indigenous and CALD communities, where the risk is already higher. Plain English and culturally appropriate communication will need to be part of any comprehensive and inclusive communications strategy. Health literacy Health literacy plays an important role in enabling effective partnerships between consumers and health and care workers as well as improving self-care and responsibility. Health literacy should allow every participant in healthcare to be able to give and receive, interpret and act on information. Better health literacy should result in reduced demand for healthcare and in particular acute care.
11 Standard 2 of Transforming Health addresses this issue: Health literacy should be promoted in the general population. The proposals paper makes no other reference to this standard. As we have said for patientcentred care, this area is considerably under-resourced. Consumer and community engagement will assist the government to pursue this standard and the allocation of funding to improve levels of literacy, engagement and self-management are urgently needed. Rehabilitation Stakeholders have expressed concern about the medicalisation of rehabilitation and the proposed removal of services from more person-friendly environments: I have been in rehabilitation for two weeks for my back. I know how important it is for the place to be right and the people to be right. Existing rehab centres are high quality at RGH & Hampstead as it's taken years to develop the rehab approach in all staff. You cannot just move them elsewhere & expect the same to happen One allied health professional pointed out that removing rehabilitation services to hospitals may well have adverse effects by encouraging people to see their situations from an illness rather than a wellness or recovery perspective. Travel for rehabilitation is not seen as desirable. Local is better: Rehabilitation services though really do need to be spelt out more clearly than to date and they need to be readily available right across the metropolitan area - ie there is no sense in making people travel from the far north to the far south to undertake hydrotherapy. One person asked the government to keep St Margaret s open as: People living on their own need that time to recover. It is worth noting that a large proportion of older people live on their own and do not have access to care or carers as and when they are needed. For most, private rehabilitation services are not a financial option. Veterans COTA SA has spoken with veterans representatives and is aware of the varying views within the veteran community about the proposed closure of the RGH and in particular the closure of Ward 17 and the development of a new service either on the current site or elsewhere. COTA SA understands that the government has committed to ongoing consultation with the veteran community, which we commend. In the interim, as one stakeholder has said: The department for post-traumatic stress disorders MUST be built before the present one is closed!!! Mental health COTA SA is pleased to see reference to mental health in the proposals paper. It is our understanding that separate work is being undertaken on moving mentally ill patients more quickly in acute beds, which we applaud. A new psychogeriatric ward at Flinders and expanded services at the Queen Elizabeth and Lyell McEwen Hospitals are welcome.
12 A number of stakeholders expressed concern that closure of the Repatriation General Hospital would have an adverse effect on mental health patients, where comfortable and supportive surroundings aided improvements in health albeit with the necessity of upgrading. Older people have expressed to us their anxiety arising from disruptive behaviour in public health services, and in particular in EDs. One stakeholder expressed fear about going to their ED due to the sometimes aggressive and volatile behaviour of other patients: Those who are on drugs or drunk should be put in a separate place from the waiting room to keep other people safe. It can be traumatic. COTA SA recognises that the greatest threat is often to staff and encourages the government to continue to improve the safety of our hospitals and in particular of ED workers. Mental health starts long before presentations at the ED. We therefore recommend that any review of mental health be collapsed into a broader Transforming Health reform that is grounded in the concept of patient-directed, continuum-of-care, whole-of-system models. Palliative care Palliative care services at the Repatriation General Hospital and at Modbury Hospital are highly valued by our stakeholders. The Transforming Health Proposals Paper says that palliative care services at the RGH will be integrated in other locations, but provides no details. As one stakeholder said: There is insufficient information about the alternatives proposed and what the Government is trying to achieve. For example, the hospice at Repatriation Hospital has been omitted from the proposal. The hospice has provided an important service to the community. What will happen to people in their last stage of life and to their families? Will they be forced to find a place for their loved one, if they require special care, in a nursing home? What does the Government propose for this? COTA SA is deeply concerned that this area of particular interest for older South Australians and their families has received little attention in the reform. 4. RECOMMENDATIONS In light our stakeholder views, COTA SA recommends the following for immediate consideration. This is not an exhaustive list of recommendations and reflects matters that have so far come to light. In the interim, we recommend that the government: expand Transforming Health to focus on the achievement of patient-centred care throughout the South Australian public health system ensure that Transforming Health values our health professionals and provides them with support and opportunities for career progression, training, flexibility, and safe working environments, with a particular focus on the continuing development and retention of older staff immediately establish a mechanism that can inform and ground Transforming Health
13 in a patient-directed, continuum-of-care, whole-of-system model consumers and the community must be an integral part of this approach involve consumers and the community as integral parts of the reform process in codesigning, evaluating and monitoring the reform design and deliver a comprehensive and inclusive communication strategy for the whole of the community around Transforming Health and which continues through the first two to three years of operation of any new system provide resources to increase health literacy programs, including for those from Indigenous and CALD backgrounds and from regional areas provide free ambulance (and air ambulance) services for all South Australians, as happens in most other Australian jurisdictions consider an extension of the Patient Assistance Transport Scheme in line with the proposed changes, with a view to providing support within the metropolitan area create a fleet of ambulances and support vehicles that can provide world-class intensive care en route to hospitals review public transport services to all public hospitals, including after hours review and improve physical access to facilities review and promote physical access review the training and post-training opportunities for paramedics review road traffic management near hospital sites reduce or cut parking fees at public hospitals continue to consult with veterans on the services they need incorporate mental health fully into Transforming Health immediately provide details about palliative care and how it may look under the proposals advocate for national reform which widens the scope of practice for nurses, care workers, paramedics and allied health workers to provide broader care services to patients and residents of aged care facilities. COTA SA recognises that Transforming Health requires medium-term and careful design and management. Change will not happen overnight and the transition may have significant impacts on patient health and safety. The voice of older South Australians must be a key component in health reform. COTA SA is therefore keen to work closely with the South Australian Government as Transforming Health unfolds and to offer our expertise on co-design to jointly create a world-class healthcare system.