New Zealand's health providers in an emerging market

Narratives of Change: Discourse, Technology and Organization

This article develops an understanding of organizational change predicated on the idea of organization as a performance or an effect, rather than a stable social structure. It uses the concept of ‘narratives of ordering’ to make sense of the processes that constitute organizations and the various mechanisms of ordering and organizing employed by organizational actors. It does so via a case study of change in a New Zealand hospital during a period of public sector reform. The ‘clinical leadership’ narrative introduced into the hospital at that time was simultaneously discursive in its appeal to economic notions of efficiency and enterprise, social in the development of new accountabilities and relationships within the organization, and material in its use of information technology. The contribution of the article lies in the theoretical approach used to analyse organizational change. This extends organizational discourse analysis by providing a more integrated treatment of change that accounts for the materiality of organizational relations.

Enterprise Discourse, Professional Identity and the Organizational Control of Hospital Clinicians

Recent reform of the healthcare sector in New Zealand involved the corporatization of public hospitals, and the contractualization of social relations between and within institutions. Various attempts were made to incorporate hospital clinicians within some system of organizational control in order to make them accountable for the resources consumed as a consequence of their treatment decisions. This paper considers how the general intention of government to control, curtail or influence the professional autonomy of hospital clinicians was played out in the context of a single New Zealand hospital. It considers the possibility that power effects of discourses associated with such neo-liberal programmes of reform could influence the subjectivity of hospital clinicians, aligning their clinical behaviour with the broader goals of the governmental programme. It explores how individuals manoeuvre in relation to these discourses of management and enterprise, whether in acceptance, resistance or compromise. The resulting outcomes are complex and varied, as individuals negotiate dominant discourses in the construction of identity and self.

Access to private and confidential health care among secondary school students in New Zealand

PURPOSE

Private and confidential health care is an important indicator of the quality of health care for adolescents. The objective of this study was to determine the prevalence of health care utilization and private and confidential health care among a nationally representative population of high school students.

METHODS

A two-stage cluster sample of 9,107 students (grades 8-12, response rate 73%) from 96 New Zealand high schools (response rate 84%) participated in a 2007 health survey using Internet tablets. Questions included when and where they had accessed health care, if their health care provider had explained that their health care was confidential, and if they had been seen in private by their health care provider.

RESULTS

Although 83% of students had accessed health care in the previous 12 months, only 27% of students reported receiving private and confidential health care. Students who had accessed health care from a school-based health center (adjusted relative risk [95% confidence interval] 1.54 [1.42-1.66]) or family planning/sexual health clinics (adjusted relative risk = 2.1 [1.9-2.26]) were more likely to report receiving private and confidential health care compared with students who had not accessed health care from these settings.

CONCLUSIONS

While most young people access health care from their family doctor or general practitioner's clinic, rates of private and confidential health care were low suggesting that opportunities to adequately explore and respond to important yet sensitive topics are compromised in primary care settings.

Integrated care in New Zealand

BACKGROUND

New Zealand's health system has long been seen as providing highly fragmented, poorly co-ordinated services to service users. A continuing policy challenge has been how to reduce such fragmentation and achieve more 'integrated' care, that is, 'co-ordinated' care that provides a 'smooth and continuous' transition between services, and a 'seamless' journey as service users receive health, support, and social welfare services from a range of health and other professionals.

DESCRIPTION OF POLICY PRACTICE

The paper takes as its starting point the view that achieving integrated care needs to be supported by a "coherent set of methods and models on the funding, administrative, organisational, service delivery and clinical levels" [1]. The paper considers how fragmentation in financing, planning, funding, and service delivery have contributed to poorly co-ordinated care in New Zealand; discusses how integrated care was to be supported by recent major reforms to the health system and whether such reforms have succeeded or not in achieving more integrated care for service users; and discusses the challenges New Zealand still faces in achieving more integrated care over the next few years.

DISCUSSION AND CONCLUSION

The paper concludes that although key financing, planning, funding and service delivery reforms aimed at delivering more integrated care to service users have succeeded in integrating planning and funding functions, few changes have occurred in the ways in which services are provided to users. It is only now that significant attention is being paid to changing how services are actually delivered in order to achieve more integrated care, but even then, change appears to be slow, and significant challenges to integrating care in New Zealand remain to be resolved.

Managerialism, information technology and health reform in New Zealand

Recent health reform in New Zealand has transformed public hospitals and related health services into Crown Health Enterprises (CHEs), which have a statutory objective to operate as successful and efficient businesses. Examines managerialist interpretations of a proposed executive information system (EIS) at one CHE. Arguably, the use of computerized information systems signals managerial competence and rationality, and there was an implicit assumption among senior CHE managers that "business-like" and "efficient" management required the use of information technology. In the end, in the context of continuing organizational restructuring, the EIS was never implemented.

Towards general practice-led integrated healthcare in New Zealand

New Zealand's recent painful experience of health system reforms has shown that professional incentives are more powerful than market incentives, and that medical leadership, with accountability for both cost and quality, may be the key to success.

Management of health system reform: a view of changes within New Zealand

This paper reports on the context and process of health system reform in New Zealand. The study is based on interviews conducted with 31 managers from three Crown Health Enterprises (publicly funded hospital-based health care organizations). A number of countries with publicly funded health services (e.g., UK, Australia and New Zealand) have sought to shift from the traditional 'passive' health management style (using transactional management skills to balance historically-based expenditure budgets) to 'active' transformational leadership styles that reflect a stronger 'private sector' orientation (requiring active management of resources--including a return on 'capital' investment, identification of costs and returns on 'product lines', 'marketing' a 'product mix', reducing non-core activities and overhead costs, and a closer relationship with 'shareholders', suppliers and customers/clients). Evidence of activities and processes associated with transformational leadership are identified. Success of the New Zealand health reforms will be determined by the approach the new managers adopt to improve their organization's performance. Transformational leadership has been frequently linked to the successful implementation of significant organizational change in other settings (Kurz et al., 1988; Dunphy and Stace, 1990) but it is too early to assess whether this is applicable in a health care context.

To supplant, supplement or support? Organisational issues for hospices

This paper provides an analysis of organisational issues in palliative care. Palliative care services have spread to many parts of the world and in the process have adapted to the context in which they are situated. This analysis draws on data from a small study of 18 hospices in the North Island of New Zealand. Key informants were interviewed about the organisation of health care workers, the range and nature of services offered and use of volunteers. Data collection and analysis were guided by the methodological principles of qualitative evaluation. Four main types of hospice were identified; (1) in-patient units with medical staff, (2) nurse led services, (3) volunteer led services which employed no health professionals and (4) hospital based palliative care teams. This paper proposes a conceptual analysis of the role of hospices in health care around three major issues: to supplant, supplement or support. Comparisons are drawn between the development and organisation of British and New Zealand hospices.

Consumerist ideology and the symbolic landscapes of private medicine

The consumption of health care has generally been examined by geographers in terms of patterns of service utilization by patients. The sites of service provision have been viewed as locations rather than as contributors to, and constituents of, urban landscapes. In this paper we argue that perspectives of the so-called "new" cultural geography can assist in interpreting the urban landscapes of health care. The case of accident and medical clinics in New Zealand is examined and used to argue that the underlying ideologies of private provision and consumerism is reflected in the symbols used in both the built environment and in advertising.

Beyond ideology: the emerging roles of New Zealand's crown health enterprises

New Zealand has experienced radical public sector restructuring over the last decade, including the corporatization and subsequent privatization of state trading units and the reform of social services, including health. In 1991 a new government proposed and then implemented more radical health reforms, which included the corporatization of state-owned provider units (23 crown health enterprises) and the creation of an internal market with purchasers (four regional health authorities) separated from providers. Interviews with chief executives of crown health enterprises suggest that provider units are seeking a wider role than envisaged, with an interest in the health needs of their populations and undertaking some purchasing on their behalf. The purchasers see a narrower role for crown health enterprises. Both purchasers and providers report that competition between providers is not particularly helpful (and with only limited opportunities for this to occur), with collaboration being seen as more useful. Providers are critical of purchasers ability to adopt a strategic approach. Unlike other aspects of New Zealand's restructuring, there appears to be a retreat from some of the more radical facets of the reforms, reflecting both the resistance of the health sector and a newly uncertain political climate.

Lost in the market? A survey of senior public health service managers in New Zealand's 'reforming' health system

In 1993, New Zealand implemented radical health sector reform, separating purchaser from provider and creating a competitive market. This paper reports on a 1994 survey of senior managers' perceptions of how well public health services were adapting to this more commercial environment. An initial questionnaire to chief executive officers of Crown health enterprises, the main providers of public health, as well as secondary treatment services, was followed by a telephone survey of managers of public health services. Chief executives expressed generally positive views about the importance of public health, especially health promotion, within their organisations. Public health managers indicated a wide range of negative and positive views about the new system. They were concerned especially about service fragmentation, diminished information-sharing and decreased collaboration, especially with Maori and general practice providers. Questions were raised about the compatibility of competition with the need for collaboration in public health. The major issue was the inefficient, costly, conflicting and fragmented purchasing arrangements for public health. Managers wanted united systems and fewer purchasers. More positive views were expressed on an improved focus on outputs and clearer directions, and none wanted to return to the former era of an entirely separate system for public health services. The abolition of the Public Health Commission during 1995 should lead to increased integration of purchasing and policy making, but important questions remain about the place of public health services, especially in their links with primary care.

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 Zealand's 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, women's 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.

Decentralisation of general management within the New Zealand health system

The radical organisation changes implemented in the New Zealand health system in recent years are discussed and analysed in this study which is based upon a review of documents and interviews with general managers of area health boards. Service management, which involves the decentralisation of general management to programme or product groupings (medicine, child health etc) has been widely implemented in almost all boards completely replacing the traditional disciplinary hierarchies. It is also leading to a population-rather than an institutional-based system of management. General managers report positively on the achievements of service management including greater accountability and commitment of clinical staff, innovation and team building, improved performance and service quality, the integration of hospital and community-based care and a customer rather than an occupational orientation. There is an increasing trend towards the recognition of primary health care as a key service entity.