How can we think about stewardship?

The concept of “stewardship” is increasingly being looked to as a driver of contemporary public service practice in Australia, and elsewhere. The diversity of contexts in which stewardship has arisen suggests a concept that is capable of broad application to achieve many outcomes. But, how can we meaningfully identify and understand stewards and their role in contemporary public policy?

The concept of “stewardship” is rising in prominence as a driver of contemporary public service practice in Australia and internationally. The Productivity Commission recently described it as being core to the reform and delivery of human services in Australia; the Commonwealth Superannuation Corporation identifies it as the crux of the trust relationship with its members and the Australian Future Fund has adopted it to guide its long-term asset strategy. The Department of the Prime Minister and Cabinet describes its entire role in stewardship terms.

Although stewardship might seem like a new term in a public service context, it is, in fact, one that has been around for some time and has been applied in diverse ways over the years. In this article we provide some clarity around the concept of stewardship, drawing on our recent research.

Defining stewardship

Reviewing the academic literature reveals at least three universal features of stewardship models. First, definitions or descriptions of stewardship invariably involve a steward taking responsibility for some object or cause to the benefit of others.

Second, stewardship is adopted when resources are constrained. Restricted resources, include environmental, financial, personnel and informational. In some cases, stewardship is required because individual actors do not recognise that the resource is constrained. For example, an individual might not consider their carbon emissions to be a problem, but collectively, emissions have significant consequences for the climate system.

The third common factor shared across definitions of stewardship is that of abeneficiary. Beneficiaries can be clearly identifiable as a group within the community, such as participants under the National Disability Insurance Scheme, or they can be of a more indeterminate character, such as the whole community (to varying degrees) in the case of environmental contexts where ecosystem services, such as clean air and water, are stewarded.

If we examine the literature carefully, we can distinguish between the outputs and outcomes of stewardship. Stewardship outputs are actions driven by a need or desire to achieve an outcome that might need to endure beyond, or operate independently, from a defined policy goal. Stewardship outcomes comprise measurable change/s in at least one of the three universal stewardship components as a result of the stewardship outputs: (1) resource constraints: constraints on a resource are measurably reduced or eliminated; (2) beneficiaries: measurable increase in benefits to beneficiaries; and (3) responsibility: individuals or groups take on a (greater) level of responsibility for a resource, cause or process.

Typology of stewardship approaches

From our research, we developed a typology of stewardship approaches, comprising four composites, each viewing the role and means of stewardship in different ways. These types are not intended to be understood as individuals, per se, but rather are collections of individuals who share beliefs about the purposes and activities of stewardship approaches. It is possible that a number of these different types could be present in any given stewardship setting.

The Guide

Remains responsible for the resource on behalf of the beneficiary

The Guide is defined by a position of responsibility in relation to constrained resources that inevitably means making decisions of compromise. An example of this is a government agency tasked with allocation of public funding in a manner that seeks to achieve fair and equitable distribution of resources while best meeting the objectives of the community. The Guide approach is particularly driven to ensure accountability. The Guide is likely to operate at large scales and set goals over long temporal periods (e.g. government departments with broad responsibility for achieving reduce climate emissions).

The Gatekeeper

Grants access to privately held or controlled resource

The Gatekeeper will have direct control over a resource but will not typically be involved in policy-making processes. Engagement with these actors is necessary to meet policy objectives (e.g. landholders engaged in environmental conservation, private company that controls a publically important resource, or a hospital with good community relationships). Governments (often acting as the Guide) would seek to work with these kinds of stewards to gain access to these resources, but would often not seek to hold the resource directly. The Gatekeeper often operates on local scales and observes success over shorter timescales.

The Giver

Makes a sacrifice for the ‘greater good’ that increases the value or abundance of a resource

The Giver is motivated by a desire to make a contribution by means other than financial or direct reward. In contrast to the Gatekeeper approach, ‘the Giver’ actively seeks to sacrifice individual benefit for that of the collective. Through such a sacrifice, they can effectively extend the resource base (e.g. augmenting payments or delivering service beyond what is required). As with Gatekeepers, the Giver approach typically operates on a local scale, although the giving may be towards a globally significant goal. Such a perspective is likely to favour shorter-term goals, where efforts can be seen to make a positive contribution but can also lead to longer-term collective goals. It is possible that the Giver and Gatekeeper approaches are adopted concurrently.

The Maximiser

Distributes resources for maximum efficiency, utility and benefit of the collective

The goal of the Maximiser is to create “collective benefits” outside of any concept of ethics, volunteerism or sacrifice. This approach might involve processes to help improve the efficiency of allocating resources within a system, attempting to reduce duplication or overlap between public and private resources to achieve greater ‘bang for buck’. For example, this type of approach might be used to generate multiple community health benefits by designing education programs that simultaneously appeal to different sectors. Such a perspective also seeks to identify co-benefits by strategic allocation of resources. In doing so, a Maximiser perspective is not wedded to a particular temporal or spatial scale, but works according to context.

We offer that this typology can be a useful tool in identifying the purposes, beneficiaries and levers of stewardship when developing such an approach (Table 3, see full Issues Paper for more detail). The typology can be a helpful resource to use with stakeholders to discuss the aims and objectives of any stewardship approach and help to identify where potential challenges might arise in terms of different stewardship initiatives conflicting with one another during implementation processes.

Strengths and weaknesses

The below table summarises the strengths and weakness of stewardship approaches as well as the dominant object of stewarding and levers.

  The Guide The Gatekeeper The Giver The Maximiser
Strengths Overarching, powerful Controls the resource Strongly motivated by social levers Fiscally responsible
Weaknesses Politically sensitive, changeable, high level Competing priorities No direct resource access Motivated to externalise costs
Dominant object of stewarding Outcome (change)

Process

Output (action) Output (action) Outcome (change)

 

Dominant levers Administrative Legal Social Economic

Adapted from ‘Is All Stewardship Equal? Developing a Typology of Stewardship Approaches’ by Dr Katie Moon, Dr Dru Marsh, Dr Helen Dickinson, Dr Gemma Carey from the UNSW Canberra Public Service Research Group.

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Withdrawing funding for hosptials’ mistakes probably won’t lead to better patient care

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If you get an infection in hospital, they’ll receive less funding for your care under a new plan. Presidencia de la República Mexicana/Flickr, CC BY-SA

Helen Dickinson, UNSW

Update: I also did a radio interview with 2SER on this article and the podcast can be found here

The Commonwealth government has just announced a change in the way they fund hospitals, effectively withholding part payment where patients have avoidable complications. The initiative aims to improve the quality of hospital care and reduce overall costs, but without other measures, this probably won’t do much to stop hospital-acquired complications from occurring.

The new plan for hospital funding

Public hospitals are funded by an activity-based system in which they receive money for the services they deliver. Diagnosis-related groups are used to classify hospital episodes of care into a number of codes, which are then reimbursed at amounts set by the Independent Hospital Pricing Authority.

Complications that occur during hospital care, and where there is good evidence these could have been reduced through clinical risk mitigation strategies, are known as hospital-acquired complications. These include things like surgical complications, pressure injuries, falls and health care associated infections.

If you experience a hospital acquired complication then the complexity of your care is likely to increase and you may stay in hospital for longer. This means the cost of care for this treatment goes up. Estimates suggest where you have a health care associated infection the cost of your care increases by 9%, renal (kidney) failure by 21% and malnutrition by 7%.

Pricing Framework for Australian Public Hospital Services 2018-19

From July next year, if you experience a hospital-acquired complication, the hospital will get a reduced rate of funding for that care. Of course, the chance of you developing a hospital-acquired complication will depend on a number of characteristics (such as age and the reason you’re in hospital), and not just the quality of care you receive.

So the amount of money the hospital loses is determined using a risk adjustment model. Assessment against a range of characteristics determines whether an episode of patient care is low, medium or high in terms of complexity, and this score is used to determine the funding reduction.

If a patient is at low risk and experiences a hospital-acquired complication, the hospital will receive funding for that person’s care reduced by the full incremental cost of the hospital-acquired complication. If a patient is at high risk then the funding for that episode of care will be reduced by a proportion of the incremental cost of the hospital-acquired complication. The new policy builds on a change to funding systems that was introduced in July, which withdrew funding for serious errors (so-called “sentinel events”).


Read more: Punishing medical errors won’t improve hospital safety or quality


Why this approach is being introduced

It’s estimated that for the years 2014-15 and 2015-16, there were just over 101,000 and over 104,000 cases in Australian hospitals of hospital-acquired complications, respectively. So the money spent on these cases could have been put to other uses across the health system. The Independent Hospital Pricing Authority estimates A$280 million will be saved by introducing this policy.

The idea is this scheme will mean hospital managers and staff work harder to ensure they avoid these issues occurring. The scheme is not designed to eliminate hospital-acquired complications entirely – this would be very difficult to achieve in a complex system like a hospital.

But the intention is the threat of losing some funding should drive processes of improvement. The resulting impact for those receiving hospital care can be significant if it means you avoid a significant or traumatic complication that compromises your health.

What could be some of the negative impacts of the approach?

The challenge with this type of approach is we don’t know whether pay for performance works. It’s widely debated, but on the whole hasn’t achieved the expected gains in health effectiveness and safety.

Where should we use robots in care services?

Rarely a day goes by without a story in the media about robots and the various threats and opportunities they pose to various aspects of our day-to-day life.  The Public Service Research Group has recently been awarded a research grant by the Australia and New Zealand School of Government to investigate the use of robots in care services and the implications for government in stewarding these technologies.  Led by myself and Gemma Carey, this project also involves Catherine Smith (Melbourne Graduate School, University of Melbourne) and Nicole Carey (Self Organizing Systems Research Group, Harvard University).

The good folk over at The Mandarin have published a piece from us today on this project (you can find it here).  If you are interested in finding out more about this project or potentially being a case study then please get in touch with us.

Innovation funds and impact investing

The Victorian Council of Social Services (VCOSS) publishes a magazine called Insight, which is made available to members.  This publication is focused on finding ways to end poverty and disadvantage and making the clear case for change.  It explores important themes and features research, ideas, analysis and commentary from leading thinkers and practitioners on social justice. Insight is published three times a year by VCOSS, with national editions in collaboration with the Australian Council of Social Service (ACOSS).

In the latest issue I have a piece on innovation funds and impact investing that explores some of the different models being used to drive change across Victoria and internationally.  The piece describes some of these different methods and the evidence of their effectiveness and concludes on a note of caution about these approaches and their ability to ‘solve’ complex problems.

The article – and others in the issue – can be found here.