Author: Helen van Eyk
van Eyk, Helen, 2005 Power, Trust and Collaboration: A case study of unsuccessful organisational change in the South Australian health system, Flinders University, School of Medicine
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Internationally, health systems have been undergoing an extended period of endemic change, where one effort at health system reform inevitably seems to lead to further attempts to make adjustments, re-direct the focus of the reform effort, or bring about further, sometimes very different changes. This phenomenon is described as churning in this thesis. Churning is a result of continual efforts to adjust and "improve" health systems to address intractable "wicked" problems, often through applying solutions based on neo-liberal reform agendas that have influenced public sector reform in developed countries since the early 1980s. Consistent with this, the South Australian health system has been caught up in a cycle of change and restructuring for almost thirty years. This qualitative study explores a case study of unsuccessful organisational change initiated by a group of health care agencies in the southern metropolitan area of Adelaide, South Australia, which took place between 1996 and 2001. The agencies sought to develop and establish a regional health service through a process they called "Designing Better Health Care in the South" which aimed to improve the way that services were provided in the area, and to enable the agencies to manage the increasing budgetary and workload pressures that they were all experiencing. A significant policy shift at the state government level meant that this initiative was no longer supported by the central bureaucracy and could not proceed. The agencies reverted from a focus on regional planning and service delivery to an institutional focus. The changes that are described within the scope of the case study are universally recognisable, including centralisation, decentralisation, managerialism and integration. The experience of Designing Better Health Care in the South as an unsuccessful attempt to implement change that was overtaken by other changes is also a universal phenomenon within health systems. This study locates the case study within its historical and policy contexts. It then analyses the key themes that emerge from consideration of the case study in order to understand the reasons for constant change, and the structural and systemic impediments to successful reform within the South Australian health system as an example of health systems in developed countries. As a case study of organisational change, Designing Better Health Care in the South was a story of frustration and disappointment, rather than of successful change. The case study of Designing Better Health Care in the South demonstrates the tensions between the differing priorities of central bureaucracy and health care agencies, and the pendulum swing between the aims of centralisation and regionalisation. The study uses the theory of negotiated order to understand the roles of the key themes of trust, partnership and collaboration, and power and control within the health system, and to consider how these themes affect the potential for the successful implementation of health care reform. Through analysis of the case study, this thesis contributes to an understanding of the difficulties of achieving effective reform within health systems in advanced economies, such as the South Australian health system, because of the complex power and trust relations that contribute to the functioning of the health system as a negotiated order. The study is multidisciplinary and qualitative, incorporating a number of social science disciplines including sociology, political science, historical analysis and organisational theory. Data collection methods for the study included interviews, focus groups, document analysis and a survey.
Keywords: health care reform,organisational change,negotiated order,South Australia
Subject: Public Health thesis
Thesis type: Doctor of Philosophy
School: School of Medicine
Supervisor: Professor Fran Baum