Social Services Futures and the Productivity Commission

Anyone who follows me on Twitter will know that I am a big fan of the folks over at Power to Persuade and the good work that they do in analysing policy for a community sector audience and they have a new publication which is worth checking out.

PtP have been running a Social Service Futures Dialogue and I have previously blogged about the piece I wrote for this on the National Disability Insurance Scheme.   In response to the unfettered enthusiasm for markets within recent Commonwealth policy, the aim of the dialogue is to provide a more balanced and well-rounded perspective on issues of marketisation, in particular by exploring critical public sector market failures in areas such as employment services and vocational education and training.

The various blog posts published as part of this dialogue have now been brought together in one document.  This includes pieces on productivity, competition in social services, market-driven innovation, competition reform, market-based reform of human services, and the marketisation of health services.  For anyone interested in the impact and operation of markets across social services it is well worth a read.  The full document can be downloaded from this link – PtP Dialogue Productivity Commission FINAL copy.


Working boundaries: how insights from feminist thinking can make us better at collaboration


I was recently invited to be part of a panel at the recent Power to Persuade’s Women’s Policy Forum focusing on ideas around evidence, voice and agency. I spoke on the topic of how feminism can make us better at collaboration and the text below is a summary of what I had to say.


Collaboration is, of course, a key concept in thinking about policy. In fact it is probably difficult to find a policy document in recent years that doesn’t make multiple allusions to the idea that government needs to be better at collaborating across different agencies and with non-governmental organisations and the broader citizenry.


We have been told time and again that collaboration has become and will continue to be central to high quality contemporary governance and public servants need to be equipped with the appropriate skills so that they can work effectively in a collaborative fashion. Collaboration will be the means through which the most pressing and challenging issues that our society faces will be overcome.


Yet, when we start to look at the evidence we see that that there is somewhat of a gap. We don’t have great evidence that collaboration improves outcomes – although this is probably a debate for another time. And neither do we have high quality evidence about what is needed in order to produce effective collaboration.


A few years ago, a study by Sun and colleagues found that in the 10 years following 1998, approximately 400 journal articles per year were published on the topic of integrated care alone. Yet despite the size of the evidence base we lack a clear sense of what needs to be in place to develop an effective collaborative approach.


And I think that feminist thinking could play an important role here. Yet, as Gemma Carey and I illustrated in a special edition of the Australian Journal of Public Administration, women in general – and feminist theory in particular – do not feature strongly in the mainstream public administration literature.


In a paper published in 2013, I argued that a lack of evidence about collaboration is, in part, due to a tendency of academics to focus on collaboration as a ‘science’ and not as a ‘craft’. What I was referring to here is an approach found in some areas of the literature where researchers try to find a consistent set of factors that typically relate to things around structures or financing processes or job competencies that can be reproduced across different settings. What is searched for is the singular truth about which are the factors at the centre of effective collaboration so that this can be ‘mastered’.


Such an approach, I argued, tends to ignore the fact that collaboration is a highly relational activity that is done (or not done) by people. Collaboration is not something that can simply be achieved through bringing together the right set of ingredients. It is a craft. It requires practice and, to draw on northern English vernacular, it needs graft (i.e. hard work) to get right.


In the book Performing Governance I make the case that there has been a tendency to focus on collaboration as a technical and almost mechanistic and linear approach that has served to ignore much of the activity that happens in and around collaborative approaches. A further implication of this is that accounts focus often on the structural facets and provide little room for agency. Aside from claims about the importance of ‘strong leadership’ for collaboration, most accounts are devoid of agentic action. To counter this we would be well served to draw on feminist thinking in order to better understand these processes.


A feminist lens bring a much needed poststructural turn to the collaborative literature, recognising that knowledge, truth, rationality and power are constituted in dynamic relationships, rather than a possession or something that only one individual can lay claim to. Meaning is contested, as are truth, knowledge and power.


Providing a focus on power and politics is much needed within the collaboration literature as these factors are all too often absent. Indeed, in the late 1990s, politically influential authors such as Tony Giddens argued that the collaborative turn was a new way of doing government that went beyond politics. Many spoke about this politically neutral way of doing business, but we can see that the effects were often anything but. We know all too often that where groups speak about political neutrality this often results in a number of groups becoming marginalised. This is particularly important in the context of discussions around policy, disadvantage and inclusion.


Employing feminist theories to the practice of collaboration can help illustrate that boundaries are not just material and constraining entities, but can be constitutive forces. Boundaries have meaning and produce effects, rather than just simply stopping actions. This draws attention to the fact that some boundaries are coercive and boundary-crossing practices employed in collaboration can be disruptive. At present there is insufficient accommodation made in the literature for disruptive practices as there is an overwhelmingly positive and altruistic flavour to the collaboration literature.


Employing notions of positionality – the idea that there is no view from nowhere – is illustrative in thinking about collaborative and where we will inevitably work with individuals or groups with different positionalities. All too often collaboration is concerned with consensus and yet feminist thinking would suggest that this is difficult to achieve in a legitimate way when working with multiple positionalities and is not necessarily desireable. Good collaboration is not just a product of consensus and disagreement and debate is needed for effective policy.


Feminist theories remind us that when we think about social actions, such as collaboration or negotiation over policy implementation, we embody particular cultural and historical possibilities. At the same time, we also enact those possibilities. What this means is that collaboration is always historically conditioned by a set of presuppositions that shape how we act. By paying more attention to these ideas of performativity we can understand how actors construct relationships and create boundaries in between themselves and others, and the ways in which they are shaped by the histories of particular individuals and groups (for example, past experiences of collaboration or of other actors). With a deeper interrogation of the positions that actors speak from and why particular actions are taken we better ascertain why certain dynamics emerge within collaborative settings.


Feminist thinking is ultimately concerned with unsettling assumptions and challenging orthodoxy, focusing on accommodating diversity and giving voice to actors. If we think that collaboration is about more than just simply coordinating activity across a number of actors and is truly about better equipping society to deal with the ‘wicked’ and complex issues with which we are faced we will need a better literature to help us through this. Feminist thinking can help us give a better account of the nature of collaboration and the ways in which agency are important to these processes. Commitment to the accommodation of diversity and giving voice will be crucial if we are to tackle wicked issues in a meaningful way.






How your doctors’ job satisfaction affects the care you receive

Helen Dickinson, University of Melbourne and Paul Long

When employees are engaged with their work and organisation, they’re more likely to perform well. This is particularly important in the context of health, where engagement improves the efficiency and effectiveness of services, reduces staff absenteeism and turnover, increases patient satisfaction and improves safety.

Highly engaged doctors, in particular, do much better on a wide range of important measures. These include clinical performance, financial management, safety indicators, patient experience and overall quality standards.

When doctors aren’t engaged, things can go tragically wrong. In the United Kingdom, this was vividly illustrated at the Mid Staffordshire hospital, where a public inquiry found a culture of fear and poor leadership had taken hold in the late 2000s. As a result, between 400 and 1,200 more people died than would have been expected between 2005 and 2008.

Some patients were left hungry, thirsty and in soiled bedclothes, with calls for staff often going unanswered. Other patients received wrong medications. Decisions about who to treat were left to receptionists. And junior doctors were sometimes responsible for critically ill patients they were not sufficiently able to manage.

Since the mid-2000s, a concerted effort has been made to enhance medical engagement in the UK.

The issue hasn’t received the same sort of attention from Australian governments. Initiatives to improve clinician engagement have therefore been piecemeal.

Our research from 12 sites across Australia and New Zealand, involving more than 2,100 doctors, reveals we have lower levels of medical engagement than in the UK. Doctors in Australia feel they aren’t actively and positively contributing to the performance of their hospital.

This doesn’t mean doctors aren’t actively engaged in individual patient care. But they feel they’re making (or are being asked to make) fewer contributions at the organisational level, which has an indirect impact on patients.

We found significant variation between different specialities and types of organisation. There is no consistent national pattern, although engagement is higher in some parts of the country than others.

Hospitals in the UK, where doctors are highly engaged, deliver better patient experiences. This leads to an improved safety and quality culture, resulting in fewer errors, lower infection rates and stronger financial management. Staff have higher morale, less absenteeism and stress.

So, why are Australian doctors less engaged?

Australia has a fragmented health system, which spans the public and private sectors. Funding and responsibilities sit at different levels of government. This means doctors may work across both the public and private sectors and for multiple institutions, making it difficult to engage with each organisation.

Engagement of doctors is also influenced by contracting regimes, education processes and the activities of regulatory regimes. Medical colleges, hospitals and other employers must therefore provide the right training opportunities, supportive and collaborative work environments and development pathways, and give staff purpose and direction.

A recent study found Australia lags behind other countries in setting out pathways for doctors to become more engaged in organisations through, for example, progression to leadership and management roles.

Doctors who move into management often have poorly defined tasks, blurred lines of accountability, no budget and no staff. Yet they are expected to take a leadership role in managing services, quality of care and performance.

Health providers need to involve junior doctors in service-improvement projects, ensure they are involved in meaningful decision-making at all levels of the organisations and provide leadership development programs. They also need to ensure doctors have the time to participate.

The pay-off of a more engaged workforce offers a significant reward that can’t be overlooked: better patient care.

Helen Dickinson, Associate Professor, Public Governance, University of Melbourne and Paul Long, Visiting Fellow, Australian Institute of Health Innovation

This article was originally published on The Conversation. Read the original article.