Analysing the strengths and weaknesses of clinical governance in contemporary health service delivery in New Zealand.
In contemporary situation, the agenda and meaning of Health care system is referred to be collaborative functionality of professionals, resources, institutions and medical systems to deliver quality healthcare services and products. This healthcare delivery is highly dependent on the quality of performance management because healthcare services are superlative deliveries in form of patient outcomes. Hence, quality improvement and maintenance has been major focus of health service delivery system since ancient times (Levett-Jones & Bourgeois, 2010).
In 1990s, a new term named “clinical governance” emerged as a revolution to improve quality and performance management in health service delivery system. This clinical governance is now a very important part of contemporary healthcare system (McSherry & Pearce, 2011). This study focuses on understanding the contemporary health service delivery system of New Zealand analysing the strengths and weaknesses of clinical governance in this contemporary system determining its power. The learner, working as healthcare practitioner in New Zealand reflect on the experiences gained as a professional in contemporary health service delivery system in New Zealand.
Demonstrating Knowledge and Understanding of Contemporary Health Service Delivery in New Zealand
New Zealand being an island country having population of 4,441,300, involves 68% immigrants from Europe, Asia and other regions of globe. With more than 85% of population living in urban regions the scope of development, urbanisation and advancement has always been high in New Zealand. This requirement of advancement is also developed in the health sector of the country where Ministry of Health (MoH) works to meet the challenges of contemporary healthcare system (Health Service Delivery profile: New Zealand, 2012, 2016). The public of New Zealand persist good health outcomes and increased life expectancy because patients are placed in the centre position of service delivery system in this country. Fineberg (2012) indicated that ‘clinical integration’ being basic concept of functionality in New Zealand healthcare system. This clinical integration means that regular development and improvement in competencies are required to meet the complex needs of patients allowing good health.
According to Best et al. (2012) the four basic objectives of health service delivery system described by MoH involves health workforce empowerment, getting health service delivered at home or closer to home, improving funding and improving old-age health. The provider network of New Zealand health system persist District health boards (DHBs) at the top most position. These DHBs work to plan, manage, provide and purchase healthcare services for their region population and service delivery for healthcare organisations working in their zone. Further, followed by DHBs there are various other public and private organizations like PHARMAC, PHOs, Health regulatory authorities, colleges and private organisations that work for health system in New Zealand (Health Service Delivery profile: New Zealand, 2012, 2016).
Gauld (2013) studied the categories of health delivery system in New Zealand that involves primary care and community services (primary healthcare organisation and NGOs), secondary and tertiary services (public and private hospitals) and long-term care services (residential, home support and rehabilitation). Fineberg (2012) studied the ‘Service delivery model’ of New Zealand healthcare functionality where a large, dynamic and complex number of organisations, networks and people work together to provide healthcare, currently involving 96% of the New Zealanders in care process. There are national, private, regional and local funding system that establishes effective health delivery system. There are both public and private involvement in New Zealand health care delivery model to provide maximum possible health services and care.
Analysing the funding of New Zealand health delivery system, Griffiths et al. (2012) indicated that the total health expenditure in New Zealand is higher than other countries like Canada, United Kingdom, and European regions. The funding system is mixture of public and private funds where major option in compensated by public funding sources. In financial year 2010/2011 this funding involves 83.2% public funds (central and local government), 4.9% private funds (insurance companies) and 10.4% other payment sources. The MoH allows three quarter of funds to district board members, who use this fund for planning, managing and purchasing the healthcare services. Some of the healthcare services are even free-of-charge in New Zealand involving palliative care, public hospital care, some community care and health promotion services (Health Service Delivery profile: New Zealand, 2012, 2016).
Further, Gauld (2013) studies the human resource competencies of New Zealand healthcare system, where 56% of medical professionals are specialist having highest possible qualifications. Further, 77% of medical registrations belong to international graduates providing highly skilled and versatile medical workforce in New Zealand. Ryan et al. (2010) opined that quality standards in health delivery system are under the control of National Health Quality and Safety Commission (HQSC) that works as per indicators and factors related to quality assurance in health service delivery system.
In contrast, Entwistle et al. (2012) highlighted the contemporary issues in this health delivery system of New Zealand. The workforce shortage and limitation is one such major issue that has lead to shortage of tertiary services been delivered to people. There are sufficient workforce availability for primary and secondary care delivery, but tertiary service system confront workforce shortage in New Zealand. Further, healthcare system is highly fragmented and variable not able to compensate the high healthcare needs of population. Gauld (2013) studied some of the basic issues in the health delivery system of New Zealand that involves coordination gap between clinicians, high patient access barriers and cost related issues that have restricted the overall successful functionality of New Zealand health delivery system. As per learners viewpoint, based on this literature study, these issues in contemporary health delivery system requires better governance and management system to overcome the workforce, cost effectiveness and various other issues for proper healthcare delivery. In the below provided section, working as a medical practitioner, learner discusses the contemporary clinical governance and management in New Zealand health care system for determining its functionality.
Figure 1: The structure of New Zealand health sector
(Source: Health Service Delivery profile: New Zealand, 2012, 2016)
Demonstrating Knowledge and Understanding on the Concepts of Governance, Management and Clinical Governance in New Zealand Health Care System and Reflecting on Personal Practice E#xperience as a Healthcare Professional in New Zealand’s Health Care System
To overrule the contemporary issues in the medical care delivery system there are various concepts, strategies and processes in clinical governance and management in New Zealand working together for the betterment of care system. “Clinical governance” is considered as future of contemporary healthcare system success and heights (Gauld & Horsburgh, 2012). According to Brown et al. (2011), traditional practices in the health care delivery system of New Zealand were dependent on the decision and activities of long-term elected governing board that has lead to the lack of effectiveness in working with the health sector. A new concept of “clinical governance” successfully implemented by NHS of United Kingdom is now attaining popularity in the contemporary health sector of New Zealand and various other countries. But, as this clinical governance is an innovative concept there are certain strength and weaknesses in the clinical governance system of New Zealand.
Bennington (2010) indicated that clinical governance is a simple concept where healthcare professionals are involved in decision-making processes related to clinical planning, managing and funding in their organisation. This clinical governance helps to establish professional standards and quality service in the health sector. As per clinical governance principle, health care professional should make two contributions in service delivery system, first to provide high-quality care and second to improve quality care by monitoring, evaluating and decision-making process. Now, this clinical governance at organisation level depends on various factors like management strategies, leadership, professional competency and interpersonal functionality.
According to Rosen (2010) in the 20 districts of New Zealand for implementing effective clinical governance, in 2009 the government gave specific instructions to the organisation managers for establishing leadership structures that involve clinical professionals in the entire health delivery process. However, as per learners experience as healthcare professional, this structure of clinical governance critically depends on the managers and clinicians relationships, strategies and performance management to work in a collaborative manner. As per personal experience organisation system working as per managers are always underdeveloped, lacking fundamental concepts and professional overawed with duties. The managers provide less possible options for professional to get involved in organisation decision-making process.
As a healthcare professional, learner performed two studies of implementing clinical governance in New Zealand. As per the first study which as a survey performed in Gauld, Horsburgh & Brown (2011) research, indicates that from 2010 to 2012 health professionals established a good score of improvement as per Clinical governance development index in New Zealand. In contrast, as per the second study provided by Gauld (2012) involves a case study for determining the mechanics of clinical governance in New Zealand. As per findings of this organisation based case study, clinical governance requires better manager-clinical alliance, effectual development technique, professional training and organisational arrangements to implement clinical governance in New Zealand health delivery system.
Further, Gauld & Horsburgh (2014) indicated minor defects in clinical governance concept of New Zealand healthcare that there is the lack of clinical boards, which should work to bring managerial and clinical professionals to work together as leaders. The clinical governance and service delivery arrangements are very complex and lacking effective governance structures in New Zealand health delivery system. In contrast, Gauld (2014) indicated that DHB has now implemented Clinical Board that maintains clinical safety, quality enhancement, emergency management and consumer satisfaction in the clinical scenario. As per DHB of New Zealand, clinical governance can be defined as measures and processes to ensure quality care making stakeholders responsible for planning, managing and monitoring functioning standards. Further, there are primary and secondary governance structures or clinical boards established by DHB members to ensure effective clinical leadership governance in primary and secondary healthcare settings. However, as per learners experience, still, there is the requirement of more refined clinical leadership strategies to implement effective governance in New Zealand clinical environment. The reasons behind this viewpoint are lacking opportunities for health professionals to get involved in clinical governance processes, lacking robust clinical governance across board members and no effective clinical governance implementation and leadership strategies (Clinical governance: A guide for primary health organisations, 2016).
Brennan & Flynn (2013) in their study mentioned about most effective initiatives that strengthen the overall clinical governance system in New Zealand. Firstly, the establishment of the Executive leadership team of 24 members including general physicians, directorates, PHOs and leaders helped in successful initiation of clinical governance in New Zealand. Further, the clinical leadership council panel established by DHB members involved NGOs helping in the establishment of clinical governance at local level. There were partnership models tested and implemented to introduce effective leadership in clinical governance practices at organisation level. Lastly, the establishment of “Clinical practice committee” demanded by clinical members helped to review the clinical innovations, strategies and technologies at the organisation level. These are some of the most powerful features of clinical governance in New Zealand that lead to a proper establishment in the clinical scenario.
Further, Brown et al. (2011) studied the ‘In good hands’ report representing clinical governance transformation in New Zealand. As per this report, the clinical governance structure in New Zealand health system is considered as one of the most important strengths of this process. This structure involves DHB members, Chief executives, DHB governance, and Clinical governance as a complete clinical governance structure. The DHB board report effectiveness and outcomes of clinical program at the national framework, Chief executives establishes effective leadership and cooperate management. Further, DHB governance ensures clinical governance functionality at the organisation level and lastly, clinical governance involves management team (managers and clinicians) that ensures quality outcomes in the clinical scenario.
As a professional, learner experienced that, clinical leadership in New Zealand governance system should involve a whole spectrum approach where moving from inherent to peer-elect, clinical appointments, management appointments and the clinical board should perform align management in clinical performance. Further, DHBs team should process method to capture professional clinical leaders allowing them training to develop skills for establishing clinical governance competencies as leaders. Further, as a professional learner confronted that clinical governance leader in New Zealand lacks the idea of proper qualities required as a professional leader. For fulfilling this weakness of clinical governance system, DHB board should provide training as per NHS leadership Qualities Framework that makes a leader a communicator, manager, scholar, professional, collaborator and medical expert (Gauld & Horsburgh, 2012).
Figure 2: NHS leadership qualities framework
(Source: Gauld & Horsburgh, 2012)
The overall health service delivery system in New Zealand is very effective where more than 96% of the population are able to get involved in the care process. The funding and human resources are considered to be two most powerful potentials of this system in New Zealand. However, workforce shortage, availability and coordination gap are some issues hindering the effective care delivery process. These issues are also affecting the clinical governance in the health care delivery system of New Zealand.
This country has a complex clinical governance arrangement that requires more simplification for better performance. Further, lack of competent professional leaders, effective clinical leadership, opportunities for professionals and lacking robust clinical governance are hindering the pathway of successful implementation of clinical governance in New Zealand. As a professional, learner predicts that there are some minor defects in the clinical governance system of New Zealand to establish a perfect health delivery system in the country. By processing the suggested recommendations, these weaknesses can be overruled providing an effective clinical system in New Zealand.
Gauld, R., & Horsburgh, S. (2012). Clinical governance assessment project: final report on a national health professional survey and site visits to 19 New Zealand DHBs. University of Otago.
Levett-Jones, T., & Bourgeois, S. (2010). The clinical placement: An essential guide for nursing students. Elsevier Health Sciences.
McSherry, R., & Pearce, P. (2011). Clinical governance: a guide to implementation for healthcare professionals. John Wiley & Sons.
Bennington, L. (2010). Review of the corporate and healthcare governance literature. Journal of Management & Organization, 16(02), 314-333.
Best, A., Greenhalgh, T., Lewis, S., Saul, J. E., Carroll, S., & Bitz, J. (2012). Largeâ€system transformation in health care: a realist review. Milbank Quarterly, 90(3), 421-456.
Brennan, N. M., & Flynn, M. A. (2013). Differentiating clinical governance, clinical management and clinical practice. Clinical Governance: An International Journal, 18(2), 114-131.
Brown, J., Connolly, A., Dunham, R., Kolbe, A., Pert, H., & Pocknall, H. (2011). In good hands: transforming clinical governance in New Zealand.
Entwistle, V., Firnigl, D., Ryan, M., Francis, J., & Kinghorn, P. (2012). Which experiences of health care delivery matter to service users and why? A critical interpretive synthesis and conceptual map. Journal of Health Services Research & Policy, 17(2), 70-78.
Fineberg, H. V. (2012). A successful and sustainable health system—how to get there from here. New England Journal of Medicine, 366(11), 1020-1027.
Gauld, R. (2012). New Zealand's post-2008 health system reforms: toward re-centralization of organizational arrangements. Health Policy, 106(2), 110-113.
Gauld, R. (2013). Questions about New Zealand's health system in 2013, its 75th anniversary year. The New Zealand Medical Journal (Online),126(1380).
Gauld, R. (2014). Clinical governance development: learning from the New Zealand experience. Postgraduate medical journal, 90(1059), 43-47.
Gauld, R., & Horsburgh, S. (2014). Measuring progress with clinical governance development in New Zealand: perceptions of senior doctors in 2010 and 2012. BMC health services research, 14(1), 1.
Gauld, R., Horsburgh, S., & Brown, J. (2011). The clinical governance development index: results from a New Zealand study. BMJ quality & safety, bmjqs-2011.
Griffiths, F., Cave, J., Boardman, F., Ren, J., Pawlikowska, T., Ball, R., ... & Cohen, A. (2012). Social networks–the future for health care delivery. Social science & medicine, 75(12), 2233-2241.
Rosen, D. (2010). Six countries, six reform models: The healthcare reform experience of Israel, The Netherlands, New Zealand, Singapore, Switzerland and Taiwan: Healthcare reforms “under the radar screen”.
Ryan, C., Nielssen, O., Paton, M., & Large, M. (2010). Clinical decisions in psychiatry should not be based on risk assessment. Australasian Psychiatry,18(5), 398-403.
Clinical governance: A guide for primary health organisations. (2016). bpac. Retrieved 28 September 2016, from https://www.bpac.org.nz/resources/campaign/other/bpac_clinical_governance.pdf
Health Service Delivery profile: New Zealand, 2012. (2016). wpro. Retrieved 28 September 2016, from https://www.wpro.who.int/health_services/service_delivery_profile_new_zealand.pdf