The review into Canberra's public health system in 2019 did not uncover anything surprising.
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It reaffirmed what everyone had already known; bullying and harassment were rife and the culture was poor. The government chose to have a watered down government-commissioned review instead of bowing to calls for a board of inquiry with royal commission type powers.
But it was a chance to reset how Canberra and Calvary hospitals dealt with known issues around poor culture, and to finally make reform a priority.
For this reason, revelations the group tasked with overseeing implementing the review's recommendations has not met since June are concerning.
Changing the culture of a public health system is a very long-term game, one that has to contend with staff turnover and inevitable changes in ministers and governments.
Then there are curve-balls like COVID-19.
But reform must be able to happen regardless of the structural changes occurring in the background.
The culture review oversight committee is the group tasked with keeping the government on track in implementing the review's recommendations. It is supposed to meet at least once every two months to do this. However, it has not met formally since June, and is not scheduled to again until next year.
While in the long run this may not prove to be too damaging to the health system's reform agenda, history will tell us it's a slippery slope to the group, and cultural reform, simply dropping off the priority list.
We've seen it all before.
In 2015, KPMG conducted a similar review of ACT's clinical health culture.
A clinical culture review panel - chaired by then director general Nicole Feely and made up of ACT Health employees - was created and tasked with implementing the report's recommendations.
It ultimately fizzled out and achieved little. It was disbanded in December 2019 and had not met since May 2017.
In documents released under freedom of information laws, then executive director of people and culture Janine Hammat conceded the clinical culture committee had not been as effective as planned. It failed to implement a number of recommendations made after the KPMG review.
The current group has been established in better faith than the one established in 2015. It is also true there is greater transparency around its operations.
Crucially, its members include unions and external stakeholders, not just department executives. But the system must learn from the lethargy it has previously treated culture reform. Because good intentions will mean nothing if past mistakes are repeated.