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.
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.
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.
Last week I had the pleasure of going on the program Life Matters on Radio National to discuss the NDIS. I was part of a panel brought together to discuss the roll out of the NDIS, some of the successes to date and some of the challenges now and in the future. I was joined on the panel by two wonderful people – Leah van Poppel of the Youth Affairs Council of Victoria and Kevin Stone of the Victorian Advocacy League for Individuals with Disability.
We had a great discussion of the NDIS and its impacts on disabled people that involved research, advocacy and consumer perspectives. You can catch the version of the discussion here.
I have written before about the fact that I have the great pleasure to be involved in an NHMRC-fundedCentre of Research Excellence in Disability and Health (CRE-DH). This is the first of its kind internationally and is Australia’s new national research centre to improve the health of people with disabilities.
Last week we had our public launch with a debate titled ‘what makes us healthy’. The event was hosted by Julie McCrossin, and guest speakers included the Disability Discrimination Commissioner Alastair McEwin, performer Emily Dash, and journalist and appearance activist Carly Findlay, speaking about their personal experiences of health and happiness. It was a great launch and if you missed it there is a great write up of the event and the centre’s approach on the Power to Persuade site written by Celia Green and Zoe Aitken and you can find this here. Croakey also republished this piece with pictures of the event and some tweets from the audience here.
Co-lead for the CRE-DH, Professor Anne Kavanagh was busy in the run up to the event writing pieces for the Australian on Pauline Hanson’s suggestion that children with disabilities should be excluded from mainstream schools, link for this is here. Anne also did a piece for Pursuit on the new CRE-DH, which can be found here.
If you are looking for a research role there is a postdoctoral fellow in health inequities being advertised by the University of Sydney and you can find the advert here. Stay tuned for more updates about this exciting initiative.
We have been doing a lot of promotion of the research we did funded by the Melbourne Social Equity Institute into the National Disability Insurance Scheme of late. One of the things we had the chance to do was to present at the Victorian Parliamentary Library. Myself and two of the community researchers presented the findings and took questions from an audience including a number of MPs from the Victorian government. Other community researchers joined us in the audience and took part in the discussion that followed.
In addition to having a wonderfully beautiful library, the librarians are very adept with knowledge translation via social media and have produced a short video clip on our research. You can find this here (if you can bear to look at my face for a few minutes).
The National Disability Insurance Scheme (NDIS) is “on track in terms of costs”, according to a position paper released by the Productivity Commission this week. The report further stated that:
if implemented well, it will substantially improve the well-being of people with disability and Australians more generally.
But the Commission’s paper also expressed some significant concerns at the speed the scheme is being rolled out, and that this could undermine its overall effectiveness. The report highlighted a number of areas that are proving challenging for those accessing the scheme. It noted that such barriers to access are, in fact, contributing to keeping the costs on track.
Where the NDIS is succeeding
Rarely a day has gone by in recent months without a news story about the perceived failings of the NDIS. The scheme has been reported as “plagued with problems” and concerns aired about a potential “cost blowout” .
As a result, the government asked the Productivity Commission to undertake an independent review into the overall costs of the scheme, its value for money and long-term sustainability. The full report is due by September.
The current position paper goes to great lengths to acknowledge the size of the challenge in delivering the NDIS. It argues that the
scale, pace and nature of the changes it is driving are unprecedented in Australia.
When fully implemented, the scheme will involve the delivery of individualised support to 475,000 people at a cost of A$22 billion per year.
There is no doubt the NDIS is complex, but the Commission finds that there is “extraordinary” commitment to the success and sustainability of the scheme. It notes that making the scheme work is not simply the job of the National Disability Insurance Agency (NDIA), but also that of government, participants, families and carers, providers and the community.
Based on the data collected, the Commission finds NDIS costs are broadly on track with the modelling of the NDIA. A greater number of children are entering the scheme than expected, leading to some cost pressures, but the report notes the NDIA is putting initiatives in place to help deal with these challenges.
The report also finds benefits of the NDIS becoming apparent, with many, but not all, NDIS participants receiving more disability support than previously and having more choice and control.
Problems with the scheme
Many people who are dissatisfied with the scheme have reported they couldn’t find care providers to deliver their funded and approved plans. This kind of under-utilisation of services is a factor contributing to keeping costs on track. Such findings are in line with recent independent research into consumer experiences of the scheme.
Overall the report finds there is insufficient flexibility in the NDIA’s operational budget and that money could be spent more in a way that reflects the insurance principles of the scheme, such as greater amounts of funding being invested in prevention and early intervention services.
The process of care planning needs greater attention. Pressure on the NDIA to get numbers of people on to the scheme means that the quality of the care planning processes have been decreased in some cases. This has caused “confusion for many participants about planning processes” and has resulted in poor outcomes for them.
There is a significant challenge in relation to the disability care workforce. The Commission estimates that one in five new jobs created in Australia in the next few years will need to be in the disability care sector. The report notes that current approaches to generating greater numbers of workers and providers are insufficient.
A range of responses required to address these include a more targeted approach to skilled migration, better market management, and allowing formal and informal carers to provide paid care and better price monitoring and regulation.
The interface between the NDIS and other disability and mainstream services has also proved problematic. There is a lack of clarity in terms of where the responsibilities of different levels of government lie and who should be providing which services. Some people with a disability have lost access to supports they used to get as state government disability services close down.
Need for political will
The Commission describes the roll-out to the full scheme as “highly ambitious” and expresses concern it risks not being implemented as intended. Indeed the speed of the NDIS roll-out is described as having “put the scheme’s success and financial sustainability at risk”.
The report concludes that if the scheme is to achieve its objectives there needs to be a
better balance between participant intake, the quality of plans, participant outcomes, and financial sustainability.
The NDIS is taking a number of steps to deal with these issues but the Commission “is unable to form a judgement on whether such a refocus can be achieved while also meeting the roll-out timetable”.
What all of this means is that we will need to see some enormous political will to enable the scheme to be supported to reach its full potential. This will likely involve some slowing of the timetable for implementation and some difficult work to deal with a number of the areas that have been identified as problematic. Whether the government has an appetite to see this through remains to be seen.
This week two articles on the National Disability Insurance Scheme have made it to early view with Social Policy and Administration. Both deal with important aspects of the scheme drawing on data collected with a variety of different stakeholders from across the system.
The first with Catherine Needham, compares the introduction of individualized budget policies for people with disabilities in Australia and England. Data is drawn from semi-structured interviews undertaken in Australia with politicians, policymakers, providers, disability rights groups and care planners, along with analysis of policy documents. This data is compared to the authors’ earlier research from England on the personalization narrative. We argue that the National Disability Insurance Scheme (NDIS) currently being introduced in Australia deploys an insurance storyline, emphasizing riskpooling and the minimizing of future liabilities. This contrasts with the dominant storyline in England in which attention has focused on the right to choice and control for a minority of the population. This difference can be explained by the different financial context: the NDIS needed to build public and political support for a large increase in funding for disability services, whereas in England the reforms have been designed as cost-neutral. Tensions in the English narrative have been about the extent to which personalization reforms empower the individual as a consumer, with purchasing power, or as a citizen with democratic rights. We conclude that Australia’s approach can be characterized as a form of social investment, evoking tensions between the citizenship of people with disabilities now and the future worker-citizen.
The second is with colleagues at the Public Service Research Centre on the topic of market stewardship in the NDIS. We argue that personalized care and market-based approaches to public service provision have gained prominence in a range of Organisation for Economic Co-operation and Development countries. Australia has recently joined this trend, launching a complex and expansive programme of individualized care funding for disability through the National Disability Insurance Scheme. Public sector markets (i.e. where governments either directly fund a market by way of competitive tendering, or through personal budgets) have been embraced by actors at different points of the political spectrum and for a range of reasons, including efficacy and efficiency gains, empowerment of citizens and efforts to cater for diversity. Despite the growing dominance of public sector markets and individualized funding, many questions about the role and responsibility of governments in managing and regulating these markets remain unanswered. In this article we outline different roles governments might assume in the creation and management of public sector markets, based on the types of risks governments are willing to take responsibility for. We argue that to fulfil the social contract between government and citizens, governments need to ensure that markets are properly stewarded and embedded in broader social safety nets. This, we contend, can ensure citizens receive the gains of market models while being protected from market failures or market-produced inequities.
Our research into the NDIS continues and expect more papers to follow.