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A Croakey #longread: Localism – a way forward

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  [1] and the subsequent National Health Reform Agreement  [2] 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 [6] 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. [7] 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.[8] 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. [9] Sweden and its healthcare system is also held up as an exemplar of localism being effective as a local governance model. [10]

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. [9] Ewan Ferlie in his review of public management reform narratives [13] 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. [14] 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.

References

1. National Health and Hospital Reform Commission. A Healthier Future for All Australians. Canberra: Commonwealth of Australia; 2009. ISBN: 1-74186-940-4

2. Council of Australian Governments. National Health Reform Agreement. Canberra: Commonwealth of Australia; 2011.

3. Davies G. Public Hospital Commission of Inquiry Report. Brisbane: Queensland Health; 2005.

4. Forster P. Queensland Health System Review. Brisbane: Independent Review; 2005.

5. NSW Health. Special Commission of Inquiry into Acute Care Services in New South Wales Hospitals: Sydney; NSW Health; 2008.

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).

7. Florin D, Dixon J. Public involvement in health care. BMJ. 2004;328(7432):159-161.

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/

10. Bidgood E. Healthcare systems: Sweden & localism – an example for the UK? Civitas Online Report. 2013; Oct.

11. Hartwich O. A global perspective on localism. Occasional Paper. Wellington: The New Zealand Initiative and Local Government New Zealand; 2013.

12. HM Government. Decentralisation and the Localism Bill: an essential guide. London: Department for Communities and Local Government; 2010.

13. Ferlie W. Systems and organisations. Public management ’reform’ narratives and the changing organisation of primary care. London Journal of Primary Care. 2010;3:76-80.

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).

17. Hunter DJ, Killoran A. Tackling health inequalities: turning policy into practice?

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CroakeyNews
Cultural determinants of health
Digital platforms
Elections and budgets
Federal Budget 2019-20
Federal Budget 2020-21
Federal Budget 2021-22
Global health and climate change
2019-20 climate bushfire emergency
asylum seeker and refugee health
Climate emergency
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extreme weather events
flooding 2011
global health
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NZ Election 2017
WHO
health
Healthcare and health reform
abortion
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aged care
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Australian Medical Association
cancer
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Choosing Wisely
chronic diseases
co-payments
Cochrane Collaboration
complementary medicines
conflicts of interest
death and dying
diabetes
digital technology
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Equally Well
euthanasia
evidence-based issues
general practice
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health & medical marketing
health and medical education
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Health Care Homes
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HIV/AIDS
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journal articles
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Medicare Locals
men's health
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MyHospitals website
National Commission of Audit 2014
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naturopathy
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pharmaceutical industry
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Pregnancy and childbirth
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Primary Health Networks
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rural and remote health
screening
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social media and healthcare
suicide
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swine flu
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TGA
trauma
women's health
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Indigenous health
#CTG10
#NTRC
Acknowledgement
cultural safety
Indigenous education
Lowitja Institute
NT Intervention
social and emotional wellbeing
Uluru Statement
WA community closures
News about Croakey
PIJ Commissions 2021
Public health and population health
#PreventiveHealthStrategy
#UnmetNeedsinPublicHealth
air pollution
alcohol
consumer health matters
COVIDwrap
environmental health
Fetal Alcohol Spectrum Disorders (FASD)
food and nutrition
gambling
Government 2.0
gun control
health communications
health impact assessment
Health in All Policies
health inequalities
health literacy
human rights
illicit drugs
injuries
legal issues
marriage equality
Media Doctor Australia
media-related issues
nanny state
National Preventive Health Agency
obesity
occupational health
physical activity
plain packaging
prevention
public health
public interest journalism
road safety
sport
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Web 2.0
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Royal Commission
Social determinants of health
discrimination
education
justice
Justice Reinvestment
NBN
Newstart
poverty
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Summer reading 2020-2021
Tasmanian election 2021
Testing Croakey News category 1
The Croakey Archives
#cripcroakey
#HealthEquity16
#HealthMatters
#IHMayDay (all years)
#IHMayDay 2014
#IHMayDay15
#IHMayday16
#IHMayDay17
#IHMayDay18
#LoveRural 2014
Croakey Conference News Service 2013 – 2019
2013 conferences
Australian Centre for Health Services Innovation Forum 2013
Australian Health Promotion Association Conference 2013
Closing the Credibility Gap 2013
CRANAplus Conference 2013
FASD Conference 2013
Health Workforce Australia 2013
International Health Literacy Network Conference 2013
NACCHO Summit 2013
National Rural Health Conference 2013
Oceania EcoHealth Symposium 2013
PHAA conference 2013
2014 conferences
#IPCHIV14
AIDA Conference 2014
Congress Lowitja 2014
CRANAplus conference 2014
Cultural Solutions - Healing Foundation forum 2014
Lowitja Institute Continuous Quality Improvement conference 2014
National Suicide Prevention Conference 2014
Racism and children/youth health symposium 2014
Rural & Remote Health Scientific Symposium 2014
2015 conferences
#CPHCEforum
#CRANAplus15
#HSR15
#NRHC15
#OTCC15
Population Health Congress 2015
2016 conferences
#AHHAsim16
#AHMRC16
#ANROWS2016
#ATSISPEP
#AusCanIndigenousWellness
#cphce2016
#CPHCEforum16
#CRANAplus2016
#IAMRA2016
#LowitjaConf2016
#PreventObesity16
#TowardsRecovery
#VMIAC16
#WearablesCEH
#WICC2016
2017 conferences
#17APCC
#ACEM17
#AIDAconf2017
#BTH20
#CATSINaM17
#ClimateHealthStrategy
#IAHAConf17
#IDS17
#LBQWHC17
#LivingOurWay
#OKtoAskAu
#OTCC2017
#ResearchTranslation17
#TheMHS2017
#VMIACConf17
#WCPH2017
Australian Palliative Care Conference
2018 conferences