Co-construction of outcomes: Working with communities
(The 550k powerpoint presentation is also available.)
Introduction
Long, long ago, well at the beginning of my career, I wrote an article on the
science of "muddling through". I'd fallen across Lindblom's work and, as one
does, I'd followed up the theme and found Etzioni. I was in my first management
job – Deputy Medical Superintendent at Dunedin Hospital, and I was certainly
finding that 'command and control' as a management concept had limited value in
an environment where there was a strong imbalance in information and we were
seeking change and adaptability. So I was delighted to find there was a
'science' to feeling your way, testing out and iterating a pathway forward,
within an overall 'contextuating' framework. Put the science and the jargon in
and the reality is much more sophisticated than what you might think by the
term 'muddling through' but the concept is critical indeed to working with
communities. If you throw a stone you can predict and control its trajectory –
if you release a bird, you can't. Devolved decision-making is like releasing a
bird. For most of us it requires us to do things differently.
Rational
Let me back up a bit – why do we want central government working with
communities? Why do we want co-construction of outcomes? I take you back to the
theme of this conference which is "A difference in practice" – we are wanting
to put managing for outcomes into practice. If we are to get changed outcomes
in the health and disability sector (and I invite you to make comparisons
across other sectors) we must actually have devolved decision-making. The
imbalance of information is so great, and complexity so relevant at community
and individual level that effectiveness is only achieved by freeing up those on
the ground to make decisions and to get ownership of solutions. If we want
communities to support healthy choices, to climb on board smoking prevention,
healthy eating, healthy action, etc, then local decision-making is imperative
to getting ownership and indeed to getting the right solutions as the centre
does not have sufficient information to prescribe the local approach. So –
making progress here lies in first understanding why the bottom-up approach is
critical – and this cannot be merely paying lip service – we have to understand
that in the centre we do not know it all and if we think we do, we'll get it
wrong.
At this time you will be thinking "but how do we deliver on government
expectations if we have to leave it to communities – and what of the cost of
doing everything by trial and error many times over – after all we are a small
country?"
This is, of course, where frameworks and contextuating decision-making comes in.
An overall architecture is necessary. Centralism and localism are not a zero
sum game. It is not "either/or" – they are "and" – it is the balance that
allows for the benefits of iterating solutions locally within a central
framework or strategy that provides guidance locally. This allows risk to be
managed – but a key point I wish to make is that devolved decision-making and
working with communities is not risk free. On the other hand – if we don't, we
won't get the outcomes we want – so my argument is we must do "differently",
engage communities, and give them space to bring their local expertise to bear
on the co-construction of outcomes. Hopefully having convinced you of why we
need to take this different approach, I want to turn to a Health example.
Practical Example
District Health Boards are crown entities established in legislation to take
responsibility for the health of their local populations. They have
participation designed in with a locally elected component of their boards and
with 21 across the country, the intent is to be close to their communities.
If we are to successfully manage the burden of disease facing most "western"
nations, we, as a country, must aim to get in front of ill health – prevent if
possible, treat early and support New Zealanders in their efforts to stay
healthy and to self-manage illnesses. DHBs need a tool to help them achieve
this outreach task. The Government is therefore investing more money at the
primary/community care end (fence at the top of the cliff) and we are creating
Primary Health Organisations (PHOs) which bring traditional general practice
(doctors and nurses) together with population approaches (smoking reduction,
exercise, etc) and through teams of professionals and community workers working
together, to create a community focus.
Now I have said enough for you to realise that if this is going to work, firstly
the Ministry needed to provide the context, ie: "The Primary Health Care
Strategy" and then needed to avoid telling DHBs and PHOs and communities
exactly how to do it. We had to allow for local innovation – genuinely! We knew
this, but we still started off at the very beginning being too prescriptive.
Fortunately our networks are good and we were soon told – "you've given us
tramlines and they won't work" – so we revisited and finished up with eight
pegs in the ground – conditions that had to be met
[OVERHEAD]
and then it was over to the organisations coming together to form the PHO and
the relevant DHB to decide if they could launch: and launching was only the
beginning of a process of ongoing development. PHOs had to have genuine
community engagement – and who was to judge that? We in the Ministry would have
a view but the informed judgements rested locally.
This is risky, despite the 'science' – allowing 'muddling through' locally, does
produce risk – and it equally produces some truly impressive results!
On the risk side – we put in place management strategies. We try to keep
compliance costs low but naturally we have mechanisms that tell us how things
are going – and whether we are beginning to achieve the results we want. Given
there are big culture changes we are asking for, we also put in place some
'softer' measures. These include some members of our primary health care team
and myself visiting DHBs and meeting their PHOs with them. I have to say I'm
impressed – despite all the challenges.
[VIDEO CASE STUDY]
Lessons
So – "muddling through" is indeed a reputable strategy. I use the term here
(have to be careful where and how you use it!) – because I think it highlights
the discomfort we sometimes feel as a central agency encouraging genuine bottom
up initiatives. Only by exposing that discomfort for ourselves and our staff
can we acknowledge that co-construction of outcomes means that we do not
control that process. Actually – we never did (!) but occasionally we deluded
ourselves. Doing it differently allows us to be much more effective in this
complex environment where 'working with' is more often the better tool than
"instructing".
How have we re-orientated the Ministry of Health so we can deliver on this
different approach? It's a work-in-progress. When under pressure it easy to
revert to 'telling' rather than seeking bottom-up solutions.
DHBs help keep us honest – they have the local responsibility and give us
feedback if they think we overstep: we encourage staff to be responsive to that
feedback. We also do secondments of staff into DHBs, to assist us in obtaining
a DHB view of the world.
We encourage staff to understand that the system of which the Ministry is a
part, is not mechanistic but dynamic – that relationship skills are critical
and we have made them part of our Ministry core competencies. Influencing and
persuading are skills we value.
In strategy development we engage those who are going to be innovating locally
in order to deliver on the strategy – and whilst this is an (old) requirement,
there is now a better understanding of why it is so critical – if the framework
is overly constraining it will not work locally – networks only transmit what
they believe in, so mutual understanding is critical.
As DHBs were established, the Ministry created its Directorate structure to be
responsive and visible to the various Health and Disability communities – but
more important is the emphasis on the process of engagement. We try to set
clear expectations and then support staff – especially when they get caught in
the crossfire – of "tell us what to do" – or, often from health professionals
"where are the rules?"
And of course, although I've talked of Health – in order to influence health
outcomes, our links with Education, Social Development, Housing, Justice, etc.
are imperative – both centrally and locally – and communities understand this –
so they are an integrating force locally.
Conclusion
Key messages for working with communities in the co-construction of outcomes:
-
Set frameworks within which local innovation can occur
-
Genuinely facilitate local engagement (do not try command and control)
-
Accept there is risk and manage it
-
Prepare to be brilliantly surprised at what can be achieved.
References for those intrigued:
KO Poutasi "Muddling Through Population Based Funding" NZ Health Review 1984,
4.2
CE Lindblom "The Science of Muddling Through" Public Administration Review XIX,
1959 pp 79-88
A Etzioni "The Active Society" A Theory of Societal and Political Processes"
1968 Collier-MacMillan Ltd, pp 282-309
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