Breaking the Mould – Empowering Individuals and

Families to Shape Systems


Presentation to the ACROD 2003 National Convention

Competing Voices

Hobart

Vern Hughes - Executive Director, Social Enterprise Partnerships


In this paper I explore the emergence of a new service delivery paradigm in the human services around the notion of ‘empowerment’, and examine why the managerialism of the previous paradigm emerged in the 1970s, was refined in the 1980s and 1990s, and is now breaking down. I explore the prospects for the displacement of the managerialist paradigm by ‘empowerment’ as both a new paradigm in service delivery and a person-centred and relationship-centred ethic.

By ‘empowerment’ I mean person-centred arrangements and relationships in social policy and service delivery, as distinct from institution or agency-centred systems. By ‘paradigm’ I mean a way of think and doing and organizing that is hegemonic in a particular time and place. Managerialism as a service delivery paradigm in social policy was hegemonic in the three decades from 1973 to 2003, meaning that it presented itself to governments, service providers, policy makers, advocates, ‘client’s and their families alike, as the ‘natural’ or ‘common sense’ way in which human services should be organized and delivered.

The structure of this paradigm was quite straightforward, and came to be summed up in the notion of the ‘purchaser/provider split’. In this model, the supply-side funder is simultaneously the purchaser, buying the provision of services to a range of client groups on a contract basis. Providers, being contracted to the funder/purchaser, are accountable to the purchaser, not to their ‘clients’. Contracts are terminated or renewed by the purchaser, not by the ‘client’. The delivery of services was typically discipline or function-based, corresponding to the departmental structures or ‘silos’ of government rather than the configuration of needs embodied in presenting ‘clients’.

This paradigm emerged in the 1970s as part of a world-wide phenomenon of expansion of the public sector under the intellectual leadership and direction of the social movements of the New Left. More specifically, there were three factors which coincided in shaping its formation. The first was an ideological trend, also global in its dimensions, towards the absorption of voluntary, charitable and mutual forms of social support and provision into the publicly-funded sector. Alongside this was a global trend towards the professionalisation and managerialisation of charitable and community-based forms of social support and the creation of a field of activity that came to be known as ‘human services’. And thirdly, there was an explosion of activism from disadvantaged persons and their families for more and better services. Activists, families and service providers found they had a common interest in a rapid expansion of service provision. Formerly voluntary and charitable bodies found it easier to seek and obtain public grants for their operations, than fundraising privately. And with ideological currents favouring state direction and funding of social provision, a push-pull dynamic forged a model of service delivery in human services that seemed to meet the needs of its various stakeholders.

Observed from above, and with the advantage of hindsight, we can now say that this supply-side service delivery paradigm came to be characterised by an extraordinary fragmentation across provider types, disciplines, jurisdictions and sectors. With a proliferation of service and program types, built around new disciplinary architecture and managerial functions, this supply-side service system was exceedingly complex to navigate, with deep information and power asymmetries between the consumer and the service system.

Moreover, it generated ‘passivity’ on the part of its ‘clients’, initially as an indirect consequence of its operational dynamics, and subsequently in its mature phase, as a rationale for the structural form of the supply-side system. In indigenous communities, there is a now a widespread acceptance of the Noel Pearson thesis that the condition of ‘passive welfare’ has been generated by the very service delivery paradigm intended to ‘help’ blacks. Amongst people with multiple disadvantages including disability, mental illness, homelessness, substance and gambling addictions, family dysfunction and unemployability, the phenomenon of ‘passive welfare’ is now the principal legacy of the supply-side paradigm, and recognition of this is driving its deconstruction.

Because this service system across fields of health, welfare, disability, mental health, aged care, early childhood development, education, employment and training, family supports and community supports was built around a plethora of contracted providers rather than persons, ‘advocacy’ emerged as a means of connecting persons with this complex service system. On the assumption that the service system existed prior to and independent of, persons, advocates were needed to assist persons of disadvantage to access its benefits. Publicy funded advocacy thus came to be an integral part of the supply-side paradigm. And advocacy and delivery functions frequently came to co-exist as operational units within the same service provider. 

Activism within this paradigm assumed a particular set of functions. It cohered around the procurement of rights-based procedural entitlements for clients. That is, no matter how difficult it might be to navigate the service system and find integrated care for a person with complex needs, that person still had a ‘right to complain’ and channels for the expression of grievances. Consumer ‘representation’ was sought as a means of improving the ‘fit’ between the individual and the service system. And in the absence of market mechanisms to allow for the expression of consumer voice, activists sought more and more differentiation in supply-side delivery to client types by gender, ethnicity, and disadvantage type. This came to mean still more fragmentation in the service system, driven by an assumption by activists, providers and governments alike, that more and more  service delivery meant better services.

In fact it came to mean more fragmentation, less likelihood of integrated care, an entrenchment of a ‘passive welfare’ culture, and greater difficulties for governments in monitoring outcomes across provider, program and disciplinary boundaries.

At the start of the twenty first century, this supply-side service delivery paradigm is passing because its alliance of stakeholders no longer share a common stake in its continuation. Funders are unable to monitor cross-disciplinary or cross-departmental outcomes with such program complexity. Tailoring programs to individual needs is operationally difficult when the offending disadvantage shows scant regard to program and disciplinary boundaries. Consumer responsiveness is not guaranteed by differentiation in provider types by cultural group or gender. In turn, the capacity of individuals and families to acquire and self-manage their supports, and strengthen their relationships and natural supports, is not enhanced by supply-side delivery systems, and for people with complex and multiple disadvantages, it is eroded further. Dependence, not individual capacity, is strengthened by complexity and fragmentation. And a person’s relationships and community supports do not fit into supply-side frameworks.


The emerging new paradigm may be illustrated by two case studies.

Person by Person is an initiative of families of children and young adults with intellectual disabilities in Melbourne . Sick of standardized services for their children, these families have successfully negotiated with the Department of Human Services to have their service entitlements quantified in dollar terms, and these funds transfered to and administered by a budget-holder of their choice. The families in small groups select and appoint a support co-ordinator for their dependents: the support co-ordinator purchases a mix of services chosen by the family (which may be education, home help, day care, singing lessons, respite care) with the budget-holder administering the financial allocations and acting as the employer on behalf of the family. They call this model ‘family governance’.

The initiative here came from the families concerned, who assumed responsibility for creating a solution to a problem well known to them, namely, reworking the relationships in the disability system to personalize the lifestyle and individual choices of their dependents. This agenda of empowerment for the individuals and their families required a shift to a consumer-directed flow of resources, and sufficient flexibility in the relevant funding body, the department, to allow the transfer of a quantifiable allocation to a budget-holder of the family’s choice. In this particular case, Person by Person emerged within a single program, which made it manageable as a pilot project. The families, however, now seek a pooling of funds from various program streams to their preferred budget-holders, and in doing so are aiming to expand this family-governed process in its scope throughout the human services.

In Melbourne ’s western suburbs, the only consumer-owned primary health centre in the country is pioneering new models in health care. South Kingsville Health Services Co-op is a community-initiated venture owned and run by its patient-members. It bulk-bills its members for medical services (others pay a fee) and engages dentists and allied health practitioners to provide low-cost services. It attempts to integrate health care with social supports, with volunteer inputs in supporting the sick and elderly and an emphasis on breaking social isolation as a health care strategy. It is trying to entice health bureaucrats to move from episode-of-care payment systems to capitation-based models so that it can focus on keeping its patient-members well and out of hospital, rather than intervening only at their points of ill-health.

It would be fair to say that politicians, health policy makers, and middle-level bureaucrats are utterly baffled by this grass-roots innovation in South Kingsville , a most inconspicuous low-income suburb.. Because it is a self-funding business, South Kingsville is not regarded as a community health centre or a public health institution. Because it is owned by its consumers, it is not part of any provider industry lobby. And because it actually contracts with practitioners, pathology companies, and general practice training providers, it is not regarded by the so-called ‘consumer health’ networks as a lobbyist for the consumer viewpoint. Only in a supply-side health system jointly dominated by politicians and providers could this kind of consumer innovation be regarded as unusual.

South Kingsville has argued that its patients/members should be able to ‘cash out’ their Medicare contributions, their share of Pharmaceutical Benefit Scheme (PBS) expenditure, and their share of Home and Community Care (HACC) programs and have these funds paid directly to the co-operative. South Kingsville consumers who elect to ‘cash out’ these entitlements should also be able to receive a cashed-out share of commonwealth and state expenditure on public hospitals.  These financial entitlements would be adjusted for health risk according to age and health status, so that consumers with a higher health risk profile attract a higher payment. This would mean SKHS would receive a capitation-based proportion of total Medicare and PBS expenditure for each of its enrolled members, adjusted for their health risk profile, payable as an annual up-front payment to the co-operative. In turn, SKHS would be required to meet the full cost of all medical services, public hospital services, and PBS pharmaceuticals for its enrolled consumers. It would be permitted to levy its own membership fees, co-payments and/or insurance tables as it sees fit to supplement its receipt of Medicare and PBS income.

For fifteen years, policy makers in health departments have heard these arguments, marveled at the initiative, and considered the South Kingsville proposal to allow a pilot. Yet despite private assurances that this model of primary health care is inevitably the shape of things to come in health care, it remains too far out in left field to be approved. There is added complexity in the South Kingsville proposal for ‘cashing out’ entitlements across several programs, compared with Person by Person which originated in just one, and politically, there is more at stake. Health care provision is a universally needed product, while disability supports are not. But despite the difference in complexity, the proposals for service redesign through the empowerment of consumers in both cases are similar in their core features and requirements.


The emerging new paradigm in human services is being built around these grass-roots innovations. It shifts the focus away from standardized supply-side delivery to demand-side personalization for consumers/users and their relationships. It involves a consumer-directed flow of resources held on their behalf by a budget-holder of their choice. The focus for participation, innovation and decision-making shifts from the service provider to the end-user or consumer, their relationships and their community, often through mutual forms of association which empower the consumer in making their choices.

The structure of the new paradigm entails a shift from the provider/purchaser split to a three-way funder/provider/purchaser split, where the purchaser is the individual and their family or agent, and not the government. An agent or broker role to access and purchase preferred services on behalf of the consumer becomes a critically important component of this paradigm. With a distinguishing of the purchasing function from the funding function, consumer responsiveness and accountability are served through market mechanisms rather than consultative and advocacy mechanisms, while mutual forms of consumer association and solidarity enhance the consumer’s market confidence and bargaining power.

There is, however, a huge deficit in infrastructure development on the demand-side in the human services that will require rectifying before the emerging paradigm can supplant the old. New demand aggregation, mediation and contractual mechanisms are needed before initiatives like Person by Person and South Kingsville dominate the human services landscape.

Five innovations, in particular, are needed.

First, new information systems for consumers in human services are required. In the old paradigm, information about the service system was accessed through the providers. In the new, information must be independent of providers and channeled through agents or brokers. Sources of comparative price and service quality data are needed, and new technology will enable market-based regulators of price and service quality to emerge in response to demand from agents and brokers.

Moreover, a person-centred information system containing a consolidated record of consumer history, interventions, supports and care plans that is transferable across provider, program and disciplinary boundaries is essential. A variety of initiatives along these lines are currently being explored. Government-initiated systems face a common problem is finding suitable incentives for providers to use the consolidated record. Systems which are consumer-held are more likely to find viable market-based incentives for take-up which link use of the record with contractual arrangements between providers and consumers and their agents.

A second demand-side innovation is new forms of budget-holding and financial management for consumers in pooling allocations from various funding streams and transacting payment to providers. Again, new technology has opened up the field to many consumer-friendly devices. Partnerships with financial institutions will also form part of the new mechanisms.

Third, new brokerage and contracting tools for individuals and families are needed as part of this empowerment agenda. These tools must also be independent of both governments and providers, and must enhance the market-based leverage and capacity of the consumer in purchasing services. For their part, governments will be required to price an increasing range of services and products in the human services for consumer purchase.

Fourth, new forms for making available comparative price and service quality data on service options are needed. Again, this must be independent of both governments and providers, so that it may function as a market-based regulator of price and service quality. New technology innovations make provision of this kind of data feasible and accessible.

Fifth, individuals and families need new financial tools to manage and grow their financial capacity. Life-long managed investments for people with disabilities to acquire financial assets like the rest of the population are needed, and matched savings and investment accounts of the kind championed recently by Mark Latham would form part of this set of tools. Partnerships with financial institutions and fund managers can take many forms in supplying these financial instruments, and both private and charitable sector involvement in matched savings schemes are on the agenda.

These technical components of the empowerment agenda are important. But the primary dynamic remains the building of consumer capacity and the generation of social capital through an acceptance of mutual responsibility in growing that capacity. And for this activity, the creation of civil space in which communities can allow relationships to form and follow complex paths of mutuality and shared responsibility is vital. Person by Person and South Kingsville have created this space and then used it to build relationships and social capital as strategies for service redesign. The building of relationships is not, and can never be, a function of government. Nor can it ever be supplied by an agency.

The most important thing governments can do in social policy is to create space of this sort and support communities in creating solutions to their own problems in partnership with support agencies. This will mean a joining of the discussion about social capital to social policy reform in ways that have scarcely begun in the public arena or in government departments.

The role of government remains important. Its business is to facilitate institutional redesign for the empowerment of individuals and families. In the new paradigm of empowerment, government is a funder not a purchaser, a regulator not a manager.

The obstacles to empowerment remain formidable. There is a residual managerial culture in government and service providers, an oppositional culture amongst advocacy and activity groups who see consumer empowerment as leading to their redundancy, and a strongly paternalistic culture amongst politicians, who must, it seems, always have to be seen to be delivering something for one or other group of voters. The poorly developed infrastructure on the demand-side remains the critical obstacle.


Institutional redesign to empower individuals and families remains the key policy objective so as to enable a wide variety of grass-roots innovations such as Person by Person and South Kingsville . Strength and resilience on the part of individuals and families is nurtured on a daily basis by many support agencies in the disability and other human services. But unless this personal nurturing is assisted by an institutional orientation towards empowerment, the service delivery system can undermine the best efforts of dedicated support staff and carers. ‘Empowerment’ should be our guiding orientation, as both an ethic and a new paradigm in the human services.


Vern Hughes is Executive Director of Social Enterprise Partnerships and a member of the National Roundtable on Not For Profit Organisations.

Vern Hughes
Executive Director
Social Enterprise Partnerships
2 Elm St

North Melbourne
Vic 3051
Phone - 03 9326 4481
Fax - 03 9326 8030
Mobile - 0425 722 890
Email -
vern@partnerships.org.au

 

 

       
   
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