Multilevel governance of primary health care

1. Multilevel governance of primary health care Paul Dugdale Healthgov Workshop Menzies Centre for Health Policy Australian National University, 13 May 2011

2. Multilevel governance of primary health care • What is multilevel governance ? • The governance of primary health care • Working the democratic deficit • From neoliberalism to tendering for government • Governing the professional patient

3. What is multilevel governance? • Intergovernmental arenas (international, national and provincial) often with non government actors at the table. • Characterised by continual negotiation (Hooghe and Marks) • At its core, moves functions and authority across jurisdictions (Kay 2011) • In Australia, multilevel governance has expanded at the same time as there has been a shift from cooperative to integrated federalism (Fenna2009).

4. What is multilevel governance ? • Multilevel governance has occured with an intensification of regionalism. • Australia has seen an energetic governmental arearisation of administration by national and provincial governments over the last 30 years. • in Europe, ‘no policy area is more centralized at the national level in the year 2000 than in1950, nor is there a single country in which regional governance has become weaker over the same period’ (Hooghe and Marks 2001 p.xii)

5. What is multilevel governance? • A self aware culture of multilevel governance has been able to emerge in Australia with some distinctiveness (an Australian comitology?). • This is evident in the possibilities that are now being imagined in a wide variety of policy domains. • MLG is now indispensable in fields where functions and authority overlap in Australia’s federal system such as education, natural resource management, and health.

6. The governance of primary health care • Major players are RACGP, Divisions of General Practice, large public regional health services, state health departments, and DoHA. • Divisions of General Practice will evolve into Divisions of Primary Health Care: “Medicare Locals”. • Rudd’s proposed transfer of community health from regional health services to Medicare Locals was dropped at COAG February 2011.

7. The governance of primary health care • The Commonwealth is gradually adding allied health benefits into the Medicare Schedule • State specialty health services (renal, cardiac, respiratory, endocrine) are increasing their community service offerings for people with their conditions of interest. • The increasing burden of chronic disease is transformative for primary health care and community services and drives policy.

8. The governance of primary health care • WHO report 2008: “Primary health care, now more than ever”. • Current Australian governance of primary health care is fragmented and lacks energy. • Care shifting between primary and tertiary services is central to the blame game. • Will Medicare Locals, creatures of COAG, end the blame game in primary health care?

9. Working the democratic deficit • Like Multi-Level Governance, the term democratic deficit was first used over 20 years ago in relation to the EU. • It referred to the transfer of powers from the exercise of democratic member states to be exercised by the institutions of the EU, recognising that there is no EU-wide enfranchisement (Hindess 2002).

10. Working the democratic deficit • A moral case in favour of multilevel governance is that it can work to overcome the ‘democratic deficit’. • However, ‘the conventional case in favour of democratic deficit reflects a more general concern to defend the proper work of government against corruption’ (Hindess 2002 p.31) by populism.

11. Working the democratic deficit • The discipline of intergovernmental contest and cooperation , shielded from direct democratic interference, could nourish a more entrepreneurial style of governance where creation and sharing of information, mustering of resources and coordination of action is the order of the day. • Or it could harness the participation of the public in deliberative activities within specific fields. Such participation can be more readily shaped to the contours of the governance job at hand than consultations organised by single levels of government.

12. From neoliberalism to tendering for government • The retreat from the welfare state (Graycar) in the 1980s was driven as much by a radical disenchantment with the welfare state (Papadakis) as by the small government movement. • Neoliberalism (Thatcherism, Reagonomics, Rogernomics) saw an expanded use of market-like mechanisms for state services.

13. From neoliberalism to tendering for government • Extensive use of contracting to achieve government at a distance (Rose) created spheres of mixed state and non-state actors working on governance together. • The tenders for Medicare Locals is perhaps the first time government has tendered out governance itself (Findlay). • However, neither statutory authority nor program funds are being transferred (at this stage)

14. From neoliberalism to tendering for government • Medicare Locals will thus be consultative bodies with lobbying credentials. • Some may sizzle, many will fizzle. • The inculcation of trust will be crucial, as it always is in multilevel governance arenas • The creation and availability of relevant, comparative data could drive transparency and invigorate reform.

15. From neoliberalism to tendering for government • Based on wider experience with multilevel governance, we can expect to see Medicare Locals invest a fair bit of energy in the formationand reformation of objectives. • This continual negotiation will foreclose on their ability to deliver management by objectives. • Corporate governance will loom large, with a heavy strategy and compliance burden falling on potentially ill-equipped boards.

16. Governing the professional patient • The novel is a fictionalised story based on our universally true inner self. • ‘The great literary invention of the eighteenth century was, thus, not simply a genre but an attitude toward that genre. Our state of mind when we pick up a novel today – our knowledge that it’s a work of imagination; our willing suspension of disbelief in it – is in fact one half of the novel’s essence.’(Franzen in the New Yorker 18/4/11 p.86)

17. Governing the professional patient • How can the governance of primary health care drive patient centred care? • Can the attitude of patients toward care become less patient and more professional? • Could an alliance between patients and specialists, mediated by eHealth technology, actually govern continuing care by the primary health and community based services sector?

18. Governing the professional patient • What if the chronically ill become better educated as their numbers burgeon? • What if they become more self centred and more demanding of better services? • Perhaps the central challenge for the governance of primary care is to feed the expectations of people with chronic disease, • and lobby to create channels through which they can negotiate with health services to get what they want.