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Panacea for all ills, or waste of time?
Panacea for all ills, or waste of time?
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POLICY PUZZLER
Health and social services organisations are moving towards collaboration, and the expectations are high, writes Tim Tenbensel
Don’t be fooled that more joined-up health and social services will save government money
Collaboration between health sector organisations has been a theme of many columns I have written for New Zealand Doctor Rata Aotearoa in the past four years.
Depending on the people you ask and what you read, interorganisational collaboration is either the panacea for our health system’s ills, as implied by the Pae Ora (Healthy Futures) Bill, or a waste of time, as hinted at by the Final Report of the Health and Disability System Review.
In this light, a new report issued by the Productivity Commission earlier this month makes for fascinating reading. Together alone (no, not the Crowded House album) assesses the state of play of collaborative initiatives in the social sector.
Collaborative initiatives exemplify a much broader trend in policy. Perhaps the central policy debate of the 20th century revolved around the role and size of government vis-à-vis non-government.
The pendulum swung towards a larger role and size in the middle of the century but, by the end of the 1990s, the advocates for smaller government were in the ascendancy. Social and health services – between which there is a very blurry line – were at the forefront of these swings in policy fashion.
While that debate has not gone away entirely, a striking development since the 1990s has been the blurring distinction between government and non-government. Some political theorists have gone as far as to say this distinction hardly matters any more. What matters instead is “governance”.
In this context, this refers to the collective efforts of a range of participants – public sector, private sector, non-profits, communities – in responding to policy problems.
Social sector collaborative initiatives come in many shapes and sizes and can be initiated by any type of organisation. Some involve coordination between government agencies, others are initiated by non-government, community-based social service providers.
By far the largest example is Whānau Ora, instigated in 2010 by Dame Tariana Turia, then associate health minister. Whānau Ora is an infrastructure that covers a broad range of collaborative initiatives, which all share the kaupapa of being whānau-centred rather than provider-centred. This involves an integrated approach to whānau needs and aspirations, in contrast to the “five cars up the driveway” approach that has traditionally characterised social services provision.
Whānau Ora is also a flagship for a new type of entity in public policy that is neither government nor nongovernment, but has a status defined more in terms of Te Tiriti o Waitangi. (The Māori Health Authority will be another space to watch here.)
Other examples of collaborative initiatives include primary care provider South Seas Healthcare, as well as a number of initiatives aimed at combating family violence. What they have in common is that multiple organisations and communities, with different but potentially complementary resources and remits, pool their resources, strengths and capabilities to address problems and meet needs that cannot be addressed by single organisations.
The Together alone report synthesises some important lessons drawn from 18 collaborative initiatives.
First, the good news. When collaborative initiatives are successful, they are built on trusting relationships, clear and shared objectives, shared data and feedback processes, effective governance arrangements, and adequate staffing and resourcing. And they are less successful when one or more of those conditions are absent. No surprises there.
Where the report excels is in its clear-sighted account of the ways in which collaborative initiatives are “swimming upstream”. It is unreasonable to expect that social services (regardless of who funds and provides them) can address the broader range of social and economic causes of poverty and inequality, and this applies just as much to collaborative initiatives.
Funding and workforce limitations bite collaborative initiatives just as they bite more traditional models of service delivery. Don’t for a moment be fooled that more joined-up health and social services will save government money. The more likely outcome is that they will highlight an extensive swathe of unmet needs.
The Productivity Commission’s findings are highly pertinent to the unfolding health system reforms.
It is highly likely that the reforms’ localities approach will pick up on these trends of interorganisational collaboration. This will mean primary care providers and organisations will increasingly be working collaboratively with Māori providers and social service providers.
The collaborative turn is being embraced by a wider range of practitioners and organisations in health, as they sense that joined-up problems require joined-up solutions. But the aspirations of collaborative governance are high, and therefore the potential for disappointment is also heightened.
Some public policy commentators smell a rat in the “cult of collaboration”, and see it as a diversion that covers up broader failings in social policy. They would prefer that we devote more attention to the big policy questions of the 20th century: what is the role and responsibility of the State; which things should (and shouldn’t) be treated as public goods? And then there are bigger questions of taxation and workplace relations.
Regardless of whether social and health services are poorly resourced or well resourced, the question of how they are delivered matters. For helping us think through these issues, the Productivity Commission’s Together alone may turn out to be a landmark recording that should have a prominent place on our playlist of important government reports.
Tim Tenbensel is associate professor, health policy, in the School of Population Health at the University of Auckland
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