Pauline Barnett

Declining professional dominance?: Trends in the proletarianisation of primary care in New Zealand

This paper explores the relevance of the proletarianisation thesis to the emergence of new forms of managed primary care in New Zealand. This concern is of particular interest because of primary care sector has persisted virtually unchanged, since the birth of the welfare state in 1938, despite numerous past state attempts at reform. Since 1993 collective action on the part of general practitioners has resulted in the formation of Independent Practice Associations (IPAs). In terms of Lights (1993) idea of countervailing trends to proletarianisation, IPA development represents a pre-emptive strategy designed to prevent the introduction of the kind of managerialism imposed on the secondary sector where some loss of autonomy has been sustained by health care professionals. At the macro-level, therefore, there has been little change in GP autonomy although at the micro-scale there has been some loss of freedom as the development of IPAs ironically has meant that the degree of control by GPs over the content of their work has changed. The results suggest that the notion of the profession acting as a countervailing force has been borne out. Furthermore, the proposition inherent in modern organisation-environment relations literature, that organisations not only adapt to their environment but may actively seek to change it receives some support.

Assessing the effects of the introduction of the New Zealand Smokefree Environment Act 2003 on acute myocardial infarction hospital admissions in Christchurch, New Zealand.

Objective: To examine trends in Acute Myocardial Infarction (AMI) hospital admissions in Christchurch, New Zealand before and after the implementation of the New Zealand Smokefree Environments Act 2003 in December 2004.

Policy Transfer and Policy Learning: A Study of the 1991 NewZealand Health Services Taskforce

Research into policy transfer and lesson drawing has been criticized asfew authors have convincingly shown how cross-national policy learning actually influences policy formation in a particular jurisdiction. This article addresses this gap by presenting a study of the development of the 1991 health policy in New Zealand. By studying the process of policy development, rather than just a policy document, it was possible to disaggregate different aspects of the policy and to identify sources and influences. This article finds that the ‘conspiracy’ model of policy formation does not fit this case as it presents an overly simplistic view, which allows little space for policy learning. This case illustrates the subtle and multifaceted influence of different jurisdictions, different institutions, and different individuals on a given policy.

Building a successful partnership between management and clinical leadership: experience from New Zealand

Recent New Zealand studies have shown important progress in addressing a key issue facing all health systems: the gap between clinical culture and governance or managerial culture. 1 2 The key terms in this progress are partnership, quality, clinical leadership, and professionalism. Three factors have been important. Firstly, New Zealand—with a national per capita income some 20% below the mean for member countries of the Organisation for Economic Co-operation and Development—has had to make difficult choices about health priorities. This has compelled greater collaboration between clinicians and management. In primary care, major budget management—of drugs, for example—is being seen …

Implementing new modes of governance in the New Zealand health system: an empirical study.

UNLABELLED Health governance internationally has become more complex, with both hierarchical and network modes of governance explicitly represented within single public systems. OBJECTIVE To understand the implementation of new modes and mechanisms of governance under New Zealand health reforms and to assess these in the context of international trends. Research methods sought data from key groups participating in governance policy and implementation. Methods included surveys of board members (N=144, 66% response rate), interviews with chairs (N=14) and chief executives (N=20), and interviews with national policy makers/officials (N=19) and non-government providers and local stakeholders (N=10). Data were collected over two time periods (2001/2002; 2003/2004). Analysis integrated the findings of both qualitative and quantitative methods under themes related to modes and mechanisms of governance. Results indicate that a hierarchical mode of governance was implemented quickly, with mechanisms to ensure political accountability to the government. Over the implementation period the scope of decision-making at different levels required clarification and mechanisms for accountability required adjustment. Non-government provider networks emerged only slowly whereas a network of statutory health organisations established itself quickly. CONCLUSION The successful implementation of a mix of governance modes in New Zealand 2001-2004 was characterised by clear government policy, flexibility of approach and the appearance of an unintended network. In New Zealand there is less tendency than in some other some other small countries/jurisdictions towards centralisation, with local elections and community engagement policies providing an element of local participation, and accountability to the centre enhanced through political rather than bureaucratic mechanisms.

Decentralisation, integration and accountability: perceptions of New Zealand's top health service managers.

This paper reports on the findings of a representative survey of senior managers within New Zealands health system. Respondents report most favourably upon the implementation of a new organisational structure, service management, which appears to have largely replaced the traditional division of health services into hospitals and community services. Service management, which is the decentralisation of decision making to integrated patient groupings, i.e. medicine, surgery, mental health, womens health, primary health care etc., appears to have been remarkably successful, in the view of the respondents, in achieving greater efficiencies, better quality care, better decision making about priorities and greater accountability of doctors. A majority of respondents consider that services have replaced hospitals as organisational entities. Significant progress is reported in the integration of hospital and community services, primary and secondary care, preventive and treatment services and of public, private and voluntary services through service management. The findings point to a new paradigm which may be of fundamental significance in the future organisation of health services.

Reshaping Community Mental Health Services in a Restructured State: New Zealand 1984-97

The concept of the hollow state has been proposed as a general framework for public sector restructuring, with New Zealand seen as a leader in reforming social and welfare services, including mental health. This article reports on documentary and interview research into the provision of community-based mental health services in terms of hollow state characteristics: privatization, decentralization and flexibilization. The evidence suggests that privatization occurred only at the margins, that decentralization led to significant regional differences in contractual arrangements and services and that flexibilization brought mixed blessings to the agencies involved. Consistent with findings from elsewhere related to hollow state mechanisms, performance assessment and accountability became more difficult. It is concluded that such frameworks are not appropriate for sectors such as mental health where there is high uncertainty and vulnerable service recipients. Recent policy changes suggest a retreat from privatization and flexibilization, and the emergence of a new balance between centralized and decentralized decision making.

Negotiating the Network: The Contracting Experiences of Community Mental Health Agencies in New Zealand

Structural options for reforming New Zealandspublicly funded health services included a hierarchy, a market model, or hybrid arrangements such as quasi-markets and networks. A survey of 28 community mental health agencies, contracting with the four regional health authorities, found that three structures emerged: a quasi-market, a coercive network and a beneficent network. Further reforms to the publicly funded health services created a single purchaser and preferred a network structure. Performance assessment of these reformed health services requires assessment of the whole network and not just individual components. The accounting profession, although closely involved in the public sector reforms, appears to have overlooked this task.

Decentralizing resource allocation: early experiences with district health boards in New Zealand.

Objectives In New Zealand in 2001, a system of purchasing health services by a centralized purchasing agency was replaced by 21 district health boards (DHBs) which are responsible for both providing health services directly and for purchasing services from non-government providers. This paper describes the processes associated with the allocation of health resources in the decentralized system and considers the extent to which four of the governments stated objectives are likely to be achieved. Methods Two rounds of interviews with national stakeholders and senior DHB personnel plus case studies in five districts which included key informant interviews, observation at board meetings and document analysis. Results The re-structuring of the health sector in New Zealand appears to have simultaneously enhanced and inhibited the achievement of government objectives. Local decisionmaking has encouraged greater local responsiveness and new funding arrangements have allayed concerns about inter-regional equity. The system is less commercially oriented than it was during the 1990s and collaboration between DHBs is improving. However, the combination of increased integration of purchasing and provision within DHBs and the focus on financial deficits in the early years appears to have inhibited the development of partnership relationships between DHBs and non-government providers, and of longer-term funding arrangements for high quality providers. Non-government providers perceive that DHBs have a tendency to favour their own providers when allocating contracts. Conclusions Decentralized decisionmaking is starting to make some inroads towards achieving some of the governments objectives with respect to resource allocation and purchasing.

Policy‐making in a Restructured State: The Case of the 1991 Health Reform Policy in New Zealand

The pressure for efficiency and accountability that led to reform of public institutions worldwide has had implications for public policy-making as well as the management of public services. The difficulties of providing a coordinated and efficient policy process that can respond to the requirements of a more managerialist style of government were evident in New Zealand in the 1980s and early 1990s. The policy process in 1990–91 leading to the introduction of health reform proposals provides an illuminating case study of the tension between participation and speed, and between traditional pluralist and managerialist approaches to policy development. The implications of this for subsequent implementation are discussed.