I recently recorded a Podcast for the Policy Shop, which is hosted by the University of Melbourne’s Vice Chancellor – Glyn Davis on the topic of the NDIS. The other guest in this conversation (apart from my terrible cold) is Bruce Bonyhady, the former Chair of the NDIA. In this episode we discuss how this policy came to be, the scheme’s rollout, and whether the NDIS will in fact improve the livelihood of people living with disabilities in Australia. The episode can be found here.
At the Public Service Research Group we recently launched our paper series, one of the ways we propose to communicate about our research. This series offers research-based thinking about topical themes for the public service. The PSRG paper series comprises two different forms of articles – Research Briefs and Issues Papers
Research Briefs are short papers that summarise the findings and implications of a recent piece of PSRG research. The intention is that these should be short and accessible summaries that set out some of the practical implications of recent research findings.
Briefing Paper No.1, November 2017 – Embedding Gender Equality in the Australian Public Service: Changing practices, changing cultures (The full report of Changing Practices, Changing Cultures is available here.)
Issues Papers are more substantial pieces that are an original exploration of a theme relevant to public services. These papers provide an account of the state of the art evidence and issues around an important theme for contemporary public services.
We recently launched two of these papers:
These papers received some significant media coverage including in the Canberra Times (on the topic of context and implementation) and the Mandarin (on the topic of stewardship and gender equity). If you are interested in my speaking notes from the evening that summarise the various things we have been doing this year you can find these here – Paper Series Launch notes 29.11.2017. As you can see from this it is has been a busy year so I’m off for a break and back some time in the new year.
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.
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.
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).
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.
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.
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)
|Output (action)||Output (action)||Outcome (change)
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.
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%.
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”).
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.
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.
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.
Reforming pharmacy services and the role of pharmacists is one of the recommendations made in a five-year review of the nation’s productivity, released yesterday. The Productivity Commission’s report, Shifting the Dial, highlights community-based pharmacy as a “significant unnecessary cost to the nation” and asks whether automated dispensing machines could replace pharmacists.
In recent years, community pharmacy profit margins have eroded as warehouse-style pharmacies offer lower prices and supermarkets and other retailers sell more non-scheduled medicines and complementary medicines. Some smaller pharmacy operators have questioned their viability and report feeling under threat. A number of pharmacists have already left the industry in anticipation of further pressures.
The Shifting the Dial report argues pharmacists are constrained in offering quality health outcomes:
the availability of unproven and sometimes harmful medical products and confectionery at the front of the pharmacy is not reconcilable with an evidence-based clinical function at the back.
The Productivity Commission’s answer is automatic dispensing machines, supervised by a “suitably qualified person”. Along with the machines, pharmacists would play a “new remunerated collaborative role with other primary health professionals” where cost-effective.
These changes would mean there would be less need for the current 20,000 pharmacists around the country.
The idea of using robots to dispense drugs is not a new one, either in Australia or internationally. Automated dispensing devices have been used widely in hospitals around the world since the mid-1990s as a way of reducing medication errors, improving patient safety and decreasing costs. Over the last decade these devices have expanded into community pharmacy settings as financial pressures have driven the search for efficiencies.
Automated systems can reduce the error rate in dispensing medicines, but they also introduce different types of errors into the system too. Entering prescription details wrongly or not loading the machine correctly can have significant impacts.
Automated systems are expensive to buy so may not be cheaper over the short term, particularly when we consider the average wage for pharmacists is relatively modest. A recent government report notes:
[in] Australia, pharmacy graduates had the lowest starting salary of all industries requiring higher education training.
Given the investments required to buy automated machines it may be that not all local pharmacies have these. We may see the emergence of a hub and spoke model. This involves prescriptions coming into pharmacies, being sent electronically to a centralised dispensing hub and then returned to the pharmacy to dispense. This can be done either in person or via courier delivery.
This type of model is argued to be cheaper than the conventional system as it requires fewer pharmacists to run overall.
In the UK there’s been pressure for community pharmacies to increasingly embrace automation for some time now. It’s well known their National Health Service has significant budgetary challenges and is looking for ways to save money. Plans to cut costs in pharmacy alongside commercial pressures from large chain providers, supermarkets and online prescription providers are predicted to cause the closure of up to a quarter of pharmacies.
This has, unsurprisingly, been met by significant resistance from the pharmacy profession as it challenges the existence of some jobs and will mean a move for others. But there’s good reason for others to be worried about these changes in terms of the impact on the broader health system.
The importance of pharmacists to the health system
Community pharmacists provide a number of functions that go beyond simply dispensing medications. In recent years we’ve seen pharmacists move away from just being those who fill our prescriptions, to people with a large amount of clinical knowledge who can advise how to take medicines safely and how to manage chronic conditions.
As increasing numbers of people experience chronic illness and take multiple forms of medicines, advice on how to do this in a safe and manageable way is crucial. Pharmacists are also probably one of the more accessible parts of the health system. Many of us will have sought advice from a pharmacist about how to manage an injury or illness, or what to do with a sick child if we can’t access a GP.
We’re seeing increasing calls to embed pharmacists within primary care teams to help better manage chronic disease. With growing numbers of individuals living with chronic disease and taking medication, pharmacists can play an important role in educating and advising on medication management.
This could improve medication use for consumers and reduce errors for those with chronic disease. Making greater use of pharmacists could reduce demand for GPs and other more expensive health professionals. For over a decade, pharmacists in the UK have been able to complete additional training that allows them to prescribe medication, helping to address shortfalls in the GP workforce.
Although the Productivity Commission report envisages a new role for a smaller pharmacy workforce, there’s little detail on what this might look like. And it underestimates the role pharmacists play within the broader health system.
If the changes outlined in the commission’s report are realised you might have your prescriptions dispensed by a robot in the future. But, it’s unlikely this will make a huge impact on the overall efficiency of the health system, and we would lose some of our most accessible clinical professionals in the process.
Last night I went on the ABC Radio show Nightlife to discuss how the NDIS is faring so far, a few months after the national roll out started. The show was hosted by Philip Clark and I was joined on the panel by Fiona May, CEO of ACT Disability, Aged and Carer Advocacy Service. We discussed why the NDIS came about, what some of the impacts have been and what needs to happen in the future. A number of callers joined us with their perspectives for the second half of the show.
If you missed it you can catch the show here.
Over the last few months myself and colleagues at the Public Service Research Group have been working with the ACT Government around their Emergency Material and Financial Aid (EMFA) program. The ACT Government is considering the nature and effectiveness of its EMFA program and we undertook an evidence review into EMFA programs, highlighting key tensions and issues in relation to Emergency Relief. In this review we set out an overview of the types of services that these programs comprise, the evidence base around their effectiveness and the types of challenges and issues that EMFA services encounter.
Earlier this year we used this evidence review to facilitate a discussion with a range of stakeholders in the ACT around the degree to which local patterns in EMFA services match those in the literature and what might be done to further develop existing EMFA services. The ACT Government is now embarking on a co-design approach that will seek to draw on key stakeholder perspectives and best practice in terms of the evidence base.
You can find the full evidence review here.
I have written much on this blog of late regarding the National Disability Insurance Scheme and the various research projects I am involved with around this. But Australia is not the only country to have adopted an individualised funding approach and there is significant evidence from other jurisdictions about these schemes.
What the review finds is some significant issues in terms of the quality of the research evidence. However, there are a number of factors that aid the implementation of these types of schemes.