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Policy in the Ministry of Health. First class policy; first class health outcomes

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Policy in the Ministry of Health First class policy; first class health outcomes Consultation document outlining proposals 28 October Introduction 3 Purpose 5 Background 5 The consultation process
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Policy in the Ministry of Health First class policy; first class health outcomes Consultation document outlining proposals 28 October Introduction 3 Purpose 5 Background 5 The consultation process your feedback is welcomed 6 The consultation document 6 Key issues identified by the assessment 7 Quality of policy advice is generally perceived to be variable 7 Proposed options for improving policy advice 10 Culture 12 Capability 13 Leadership and strategic management 15 Systems 16 Structure 17 Position summaries 34 Purpose and responsibilities of key proposed positions 34 Purpose and responsibilities of generic positions 39 Impact of proposals 41 Next steps 47 2 Introduction This document proposes a way forward to substantially improve the quality of our policy advice. Core to the raison d ệtre of the Ministry of Health is the provision of policy advice to the Government of the day and in particular the Minister of Health. Policy advice is so essential to the Ministry s purpose and credibility that unless we carry it out with excellence, and are perceived to be excellent, that our ability to gain the confidence of Ministers and our ability to positively influence health outcomes can be substantially diminished. We do not develop and deliver policy advice as well as we should. We do not have the right skills set; we do not spend adequate time on training and mentoring staff; and we do not, as often as we should, develop strong public policy advice on health and disability issues. These are not the conclusions of one individual, but summarise the views of many Ministry of Health staff and stakeholders who contributed to the Assessment of the Ministry of Health s Policy Function by MartinJenkins in late August and September. Staff recognise there are challenges and are keen to do something about it. Having received the assessment, and having noted the views of the Ministry and external stakeholders, there is a clear need for change with urgency. Therefore, I am putting this document to you as a proposed pathway forward. This document builds on the desire expressed by staff to participate in a programme that will see the improvement of the quality of policy advice. The proposals, if implemented with integrity, support and buy-in from Ministry staff will deliver better quality policy advice advice that will be more effectively and efficiently produced and more clearly driven by a strong strategic direction. The proposals are wide-ranging and encompass changes to culture, capability, leadership, strategy, systems and structure. While different components of the whole may be implemented at different times, it is important that they be seen as an overall package no one component can stand on its own, and there are interdependencies between all of them. Improving the culture of policy within the Ministry is critical to achieving positive change. I expect to see all staff engage positively with this process and recognise the need to change the way that we work our values, our ways of communicating and responding to emerging issues. Ultimately we all need to take increased responsibility and pride in the final policy that we produce. To achieve this, we will need strong leadership and a renewed focus on what we are trying to accomplish. The proposed changes are designed to give us renewed confidence and credibility to provide inspirational policy direction to the sector. We also need to focus on the key behaviours and expectations that we should expect of each other. These have been articulated before, but are worth restating. In particular, there is a need to: be responsive to Ministers and the Government, providing policy options, creative ideas and free and frank advice 3 collaborate across the Ministry, ensuring that key policy initiatives are developed in a way that incorporate all parts of the Ministry that have something to contribute prioritise our work, so that we are working on Government priorities and those issues of long-term importance to the sector make decisions and deliver, avoiding processes and convoluted procedures that don t add value but cause frustration and delay. The document proposes substantial structural change to the Ministry s policy functions. The spread of policy functions across a number of different directorates and subject areas creates a lack of clarity, uncertainty and duplication that was identified by many contributors to the Assessment. It is clear that without addressing the structural impediments to bringing together a cohesive policy group that can provide real coherence, the necessary culture, capability and systems changes will be virtually impossible to get traction on. Therefore, I am proposing: Establishment of a single policy business unit with responsibility for development of strategic, systems and population health policy Establishment of the Chief Medical Officer business unit with responsibility for regulatory functions and support for a number of committees, in addition to the clinical leadership role proposed as part of Implementation 2010 Elevation of the Chief Nurse to a tier two position, with responsibility for the Nursing Innovations team and Provider Regulation Operational policy functions to be split from other policy functions. I am also proposing that the title directorate be changed to business unit to more accurately reflect the nature of our work and the business of government. There is a sense, from some, of restructure fatigue within the Ministry and that variations on most structures have been tried previously. However, there is also internal frustration at the lack of clarity of roles and functions arising from the fragmentation of policy, and a strong desire to see this rectified sooner rather than latter. Given the conclusions of the MartinJenkns assessment, and the clear need to improve our policy capacity, I too think it is important that certainty is provided to both staff and stakeholders by addressing the issues raised as comprehensively and quickly as possible. In summary this document is about prioritising the Ministry so it develops first class policy to contribute to first class health outcomes. I look forward to your feedback on what is proposed and how we can achieve excellence in delivery of health policy. Andrew Bridgman Acting Director-General 4 Purpose This document outlines my proposals for improving the effectiveness and quality of policy advice within the Ministry of Health. The document forms the basis for consultation with staff on the future of policy within the Ministry first class policy, first class health outcomes. I invite your feedback before I make any decisions. The proposed changes are comprehensive and wide-ranging. For this reason, the consultation will be conducted in two phases. The first phase (as detailed in this document) proposes the establishment of a new structure, centred on an integrated policy function and the establishment of new Business Units including the Chief Medical Officer and the Chief Nurse. A second phase (to overlap with the first phase) will focus on consequential impacts across the wider Ministry including details relating to the splitting of operational and policy functions currently located in Population Health and SCI. This will include consideration of team structure at tier four in the Population Health Policy group and potential implications for SCI. Background The consultation document is based on the findings of an assessment of the Ministry s policy function conducted by MartinJenkins from August through till October The issues were identified by MartinJenkins through a comprehensive range of internal and external interviews, staff focus groups and a review of relevant documentation. The identified issues were tested at a workshop with the Ministry s Executive Leadership Team (ELT). MartinJenkins then recommended specific options for improvement. The assessment was conducted independently of the Review of Expenditure on Policy Advice led by Dr Graham Scott. A Steering Group has been convened to oversee the review as a whole (consultation through to implementation of decisions). The members are Peter Hughes (Chief Executive of the Ministry of Social Development), Paul Reynolds (Chief Executive Ministry for the Environment), Paula Rebstock (economic consultant and professional director), and myself. I believe that the proposals contained within this document represent an effective way forward for the Ministry to improve the way we formulate policy. The assessment process found a strong mandate for change quality, process and capability issues are widely acknowledged both within the Ministry and externally. The assessment also identified a strong desire within the Ministry to improve the quality of policy, as well as the need to move from advice dominated by reactive work, to advice that is informed by a consistent framework and an increased focus on strategic and system-wide policy development. MartinJenkins assessment report is available under the About MoH section on the Portal. The current proposals are drawn from the assessment document. I look forward to your feedback on the proposals referred to in this document. 5 The consultation process your feedback is welcomed Key steps in the consultation process are outlined below. Further details are found in the section titled Next steps (including further details on how to provide feedback) on page 47. Information on available support and the Ministry s Change Protocol can be found on pages 48. Table 1: consultation process, key steps Step Date Consultation document released 28 October 2010 Presentations on proposals within the consultation document 1 and 2 November 2010 Workshops with Population Health and SCI managers on potential options for splitting operational and policy functions 3 and 4 November 2010 Closing date for submissions on consultation proposals (Phase 1) 5pm Thursday 11 November 2010 Decision document released (Phase 1) 9 December 2010 Implementation of final decisions Following release of decision document Phase 2 consultation document released containing details on operational/policy split in Population Health and SCI To be advised, approximately week of 15 November 2010 Closing date for submissions on consultation proposals (Phase 2) To be advised, approximately 26 November 2010 Decision document released (Phase 2) To be advised, approximately 9 December 2010 New structure takes effect To be confirmed, approximately 28 February 2011 The consultation document The remainder of the document is set out as follows: key issues identified by the assessment (page 7) proposed options for improving policy advice (page 10) position summaries for key roles within the proposed structure (page 34) impact of proposed structural changes (page 41) next steps (page 47). 6 Key issues identified by the assessment The assessment found widespread agreement that the Ministry is not currently seen as the leading player in the provision of health advice to the Minister. While there are strengths and successes, the quality of advice is widely understood to be variable. Overall the Ministry s policy function: does not provide a clear strategic overview and direction for the Ministry and the system as a whole is often inadequately formulated, lacking clearly articulated arguments and options, poorly timed, and risk averse shows inconsistency in approach, frameworks and understanding of requirements. The reasons for this were consistently identified by a wide range of stakeholders, both internal and external to the Ministry. The contributing issues include weaknesses in leadership, insufficient generic policy capability, a culture that does not overtly value policy skills and a structure that is fragmented and obstructive. The assessment process found a strong mandate for change quality, process and capability issues are widely acknowledged both within the Ministry and externally. The assessment also identified a strong desire within the Ministry to improve the quality of policy, as well as the need to move from advice dominated by reactive work, to advice that is informed by a consistent framework and an increased focus on strategic and system-wide policy development. Quality of policy advice is generally perceived to be variable Policy advice within the Ministry is, on the whole, perceived to be of variable quality in terms of responsiveness and the technical quality of options and analysis. Consistent feedback about the quality of advice was received from both external and internal stakeholders. Quality issues were cited by internal Ministry staff at all levels. Within the Ministry there are pockets where high quality analysis produces good quality advice. The Ministry has some individuals who are highly skilled in policy and the Ministry relies heavily on these individuals, particularly when under pressure to deliver advice. This group is estimated to consist of 20 to 30 individuals (out of a total of approximately 160 full-time equivalent staff [FTEs] inputting into policy advice spread over 450 individuals). 1 1 This figure has been obtained from Ministry figures prepared for the Review of Expenditure on Policy Advice in September Strengths of the Ministry s policy function were identified as: the ability to react quickly to high profile presenting issues (eg the Swine Flu pandemic) clinical and operational advice is generally well-evidenced and credible; in particular, advice relating to specific population or health and disability sector areas is underpinned by high credibility in areas of clinical and sector expertise a high commitment and passion within the Ministry towards improving the health of New Zealanders good relationships and networks with the health and disability sector, including with clinicians and DHBs areas where Ministers are clear on direction are well implemented; the Ministry has successfully delivered and implemented a number of policies over the last few years and has performed many of its business-as-usual core functions to a high standard. The key issues with the quality of advice were identified as: not thinking strategically over time and about the system as a whole and not recognising and responding swiftly to contextual changes policy advice is often untimely, risk averse and arguments and options are not well constructed or identified policy is being developed without regard to consistent public policy frameworks, resulting in inconsistency in advice and approaches to policy solutions. Specific deficiencies commonly identified within policy papers were: papers advocating a personal position and lacking robust evidence inadequate problem definition dense, overly long papers unclear logic reluctance to disclose limitations/consequences or acknowledge shortcomings lack of options, or options not fully explored. This perspective is supported by independent reviews of the Ministry s policy advice. The most recently available NZIER analysis of the quality of advice identified an increase in quality over previous analyses, 2 but areas of concern still remain, in particular: recommendations being given without basis lack of international evidence lengthy papers advocacy dominating rational analysis. The net effect is that the Ministry is not currently seen as the key advisor on health and disability issues to Ministers. As a result, the vacuum has been filled by a number of players, resulting in 2 NZIER, Taking the temperature B, Quality of Advice, Regular review, Report to the Ministry of Health, October the Ministry being one player in a field which is widely acknowledged to be contestable. Ministers welcome advice that is free and frank, provided that it is of good quality. The Ministry is caught in a reactive cycle resources are predominantly tied up with short dated work. Once in this reactive cycle, the Ministry has found it difficult to lift its perspective beyond the urgent work being driven by Ministers requests, and balance this with a more strategic view. The assessment also highlighted poor links between the Ministry and other players in the public sector and the health and disability sector. The Ministry is not strongly networked into, nor consistently influential in the work of other social sector agencies especially in the strategic sphere. Currently, the Ministry is involved in a range of cross agency work, but not commonly seen as leading the work or making strong contributions. In addition to this, communication and relationships between the Ministry and Central Agencies are variable in some cases the relationship is constructive, whereas for others, relationships are characterised by miscommunication and frustration. Factors contributing to variable quality advice A range of factors were identified that have contributed to the current state of policy advice in the Ministry: strong, coherent leadership and stewardship of the policy agenda is not evident the Ministry lacks agreed strategic priorities and an explicit framework; in addition to this, the Ministry lacks a clearly prioritised policy work programme that is agreed across ELT a lack of agility in redirecting resources to new priorities; this seems to be related to a lack of re-prioritisation disciplines and related decisions to shift resources to respond to emerging priorities many policy advisors do not come from a generic policy background and therefore lack basic policy skills; this is coupled with inadequate quality assurance the lack of policy capability in the Ministry results in policy papers often being written by staff without sufficient skills or with sufficient oversight and mentoring the structure is not that of a conventional centralised policy shop: the fragmented structure does not support clear and timely allocation of resources and decision making for policy; because policy functions are dispersed across the structure, accountabilities for delivery are sometimes unclear or overlapping, and there is limited flexibility to move policy resources around to meet emerging needs as they are locked into highly specific topic areas; there was also evidence of tension between different policy teams causing delays and difficulties (eg between strategic and implementation policy teams) clinical backgrounds rather than generic policy skills are common, sometimes creating a tendency towards advocacy or not analysing a full range of options a management culture of not always holding staff accountable for non-delivery of key tasks on time (and in some cases, unclear direction, task assignment, scoping and planning) lack of a strong policy culture manifests as: insufficient critical thinking; reluctance to be challenged and an unwillingness to seek input and buy-in from a wide range of stakeholders at the beginning of a process; reluctance to explore or question the rationale behind Ministerial directives. 9 Proposed options for improving policy advice This section outlines proposed changes to improve the effectiveness and efficiency of the Ministry s policy function. The proposals are wide-ranging and encompass changes to culture, capability, leadership, strategy, systems and structure. As shown in Figure 1, the proposed changes are all connected and inter-dependent. Figure 1: proposed change components Strategy Culture Capability Systems Leadership Structure 10 Figure 2 (below) summarises the proposed change components, and presents the expected outcomes that I am expecting for the Ministry in the future. The remainder of this paper provides further background and detail for each of the proposed areas of change. Figure 2: proposed changes - moving from the current state to the future state Silos and fragmented thinking sometimes driven by individual clinical areas of interest; tendency towards advocacy; reactive/slow to re-prioritise; not enough focus on Minister as a key client CULTURE Clear expectations about behaviours, re-balanced skill
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