This week we will learn much about the current government’s vision for the health system through the federal budget. Amongst the revelations will be the future of Medicare Locals. Many thanks to David Briggs, Chair of the New England Medicare Local, for allowing us to republish his editorial on localism from the Asia Pacific Journal of Health Management.
Dr Briggs writes:
The implementation of the national health reforms has seen the introduction of the word ‘local’ into the reform agenda. It is used in the name of State jurisdictions acute care providers and in the national primary health care framework organisations currently described as Medicare Locals. Why is this so? Why has ‘local’ become central to the language of national health reform and of the organisational structures that deliver health services across Australia?
A review of the Final Report of the National Health and Hospital Reform Commission  and the subsequent National Health Reform Agreement  provides limited indicators as to why ‘local’. Neither document includes an underlying philosophy or clear public policy that enshrines ‘local’ with a clear definition or implications about how the word might drive the reforms and the subsequent organisation and delivery of health services. The Final Report sets the word in the context of health system levels describing what might be done at ‘national, regional and local levels’.[1, p.8] It also talks about ‘connection ‘ and ‘integration’ and the need to ‘redesign health services around people’, [1, p.6]‘foster community participation’ [1, p.7] and to ‘foster local implementation models’. [1, p.8]
The National Health Care Agreement is more specific in intent, describing objectives in terms of acute services to ‘improve local accountability and responsiveness to the needs of communities…’ and to ‘decentralise public hospital management…’, ‘to shape local service delivery according to local needs…’, to integrate services and improve the health of local communities’. [2, p 46] According to the Agreement the strategic objective of the newly created Medicare Locals is to identify health needs of ‘local areas’ and the ‘development of locally focused and responsive services’ and in achieving this objective they are to reflect their local communities and health services in their governance arrangements’. [2, p.50]
There is nothing further in the documents to provide us with guidance on how to understand this attempt at localism. Perhaps the introduction of ‘local’ heralds a move away from the highly centralised control of health services, in place prior to the reforms, towards greater decentralisation. It may just be an adjustment of the ever-present tensions between those who favour highly centralised control in favour of the proponents of decentralised organizational and service delivery forms? It is a likely recognition that it was desirable to move away from the negativity of prior centralised systems as demonstrated in formal Inquiries of some State jurisdictions at the time. [3, 4 , 5 ]
Bell and colleagues  draw our attention to the importance of language and its effect on practice in discussing health reform – this time in Scotland – focused on ‘integration’. They suggest that the rhetoric in their example fails to connect with the practice of health professionals and managers and despite the language of reform, the ‘dissonance between rhetoric and reality stubbornly seems to remain’. [6, p.41]
So is this the case in the Australian reforms? Where did ‘local’ come from? Why is it important in the Australian context? Localism is not just a feel good word to assuage community negativity about the state of its health services nor is it just an assumption that it is an intrinsic public good.  It is a form of governance that has recently been legislated as government policy in the United Kingdom public sector.
The implication is that the NHS could be affected by a radical shift of power from the centre to local communities. In the more devolved NHS, diversity has been allowed and four different devolvement models have evolved, termed as professionalism in Scotland, markets in England, Northern Ireland has permissive managerialism and Wales has adopted localism.  Sweden and its healthcare system is also held up as an exemplar of localism being effective as a local governance model. 
Localism is based on the principle of subsidiarity that states that ‘government should only fulfil a subsidiary functionfor those tasks that cannot adequately be dealt with by lower tiers [11, p.11] In the British legislative initiative this is described as a shift from ‘…big government to big society…’.[8, p.1; 12, p.1] Six ‘essential actions’ are described to bring about this transition:
• Lifting the burden of bureaucracy
• Empowering communities to do things their way
• Increasing local control of public finance
• Diversifying the supply of public services
• Opening the government to public scrutiny
• Strengthening accountability to local people [8, p.7;12, p.2]
The logic of localism is said to be ‘based on two uncontroversial statements…These are that services are often provided in quantities and ways that do not reflect or involve the local communities’ and that they are essentially sickness services without much emphasis on reducing illness and improving health and wellbeing. [9, p.12] The Welsh devolvement policy towards localism sees a health policy emphasis towards public health and greater engagement and towards the development of local solutions to population challenges.
This approach has the potential to move to local participation, integration of effort and a change in emphasis from service provision to population health.  Ewan Ferlie in his review of public management reform narratives  describes some of the prevailing preferred approaches as ‘hierarchies’, ‘quasi markets’ and networked based approaches. He describes ‘new localism’ as a candidate narrative that is ‘a reaction against the target led and top down nature of… the NHS’. [13, p.39] He goes on to suggest that for ‘primary care this new localist idea suggests a greater role for non-profit organisations, more localised decision making and resource allocation’. [13, p.79]
So what does this trend to localism as public policy reform mean in the Australian healthcare context? Well, if nothing else it might give us the opportunity to build on the initial enthusiasm engendered by the health reform for the local health districts or hospital authorities and the Medicare Locals to work together to do things better at the local community level. But it will require government(s) to provide generative space that will allow this and give permission for local governance structures and managers to respond to opportunity.
This generative space at the moment is cluttered with the language of performance management, targets and indicators, a preoccupation that has limited value and diverts attention from achievement of more effective care; [14,15] an approach that should be replaced with discussion and debate about how to do things better, being effective ahead of efficient and how might we add value. So in the context of health reform, the well intentioned language is about integration, collaboration, coordination, partnership, inter-agency, single system, whole system, fit for purpose, seamless patient journey, responsive to local need, resourced rigorous and resilient, evidence-based, best practice. [6,16]
There is little published evaluative evidence that under our centralised hierarchies these practices have been substantially advanced or that the structures have been effective in the implementation of these well intentioned practices. In the end we need to move away from the emphasis of governance on rules around form and structure (institutional power) to governance by rules around practice.  At the local service delivery level we need flexible opportunities to garner localism through strategic use of quasi markets, contestability, community and relational governance and the governance use of fit for purpose networks.
It is likely that we will need to utilise a number of these approaches, flexibly. According to Morrell these are conceptual models for describing prevailing patterns of organising work and the allocation of resources. [14, p.57] This search for differing solutions suggests ‘wider changes in society and the role of government’. [14, p.56] Others suggest this involves delivering solutions that are ‘place-based’, local strategic partnerships/plans, neighbourhood renewal strategies.
How do we put this language into practice? Perhaps in the spirit of localism and the concept of subsidiarity, Government should focus on what only it can do best. Firstly, work towards the removal of perversity in funding and payment systems, the impediments to workplace reform that all currently limit initiative and innovation. Secondly, allow generative space and incentives for providers to pool resources to meet common agendas through better use of existing resources. Thirdly, make all new program funding contestable, requiring collaborative partnerships or networks to be developed and governed locally. Fourthly, provide innovation funding for new models of governance and service delivery that substantially address identified local need. Fifthly, reduce the performance management reporting regime to manageable proportions.
It would be good to start the discussion and, perhaps debate about how we might make a real difference in the Australian healthcare system through localism by utilising a diversity of governance models at the local level that engage both communities and stakeholders.
See the original publication here.
3. Davies G. Public Hospital Commission of Inquiry Report. Brisbane: Queensland Health; 2005.
6. Bell K, Kinder T, Huby G. What comes around goes around: on the language and practice of ‘Integration’ in health and social care in Scotland. Journal of Integrated Care. 2008;16(4).
8. Institute of Local Government Studies. The world will be your oyster? Reflections on the Localism Act of 2011. Raine J, Staite C. Edgbaston: School of Government and Society, University of Birmingham; 2012.
9. Greer S L. Four way bet: how devolution has led to four different models for the NHS. London: The Constitution Unit, The School of Public Policy, UCL; 2004. Available from http://www.ucl.ac.uk/constitution-unit/
14. Morell K. Governance, ethics and the National Health Service. Public Money and Management. 2010;26(1):55-62.
15. Commission for Health Improvement. What CHI has found in acute services. London: CHI;2004.
16. Regan P. Critical issues in practice development: localism and public health reforms. Community Practitioner. 2011;84(3).