Local implementation of integrated care reforms: The interplay between regional context and collaborative commissioning policy in New South Wales, Australia

Background: Most public health systems necessarily entail a division of responsibility between central and local authorities – with the relationship between levels defined through a combination of hierarchical, contractual and financial structures.  The implementation of new policies and initiatives are increasingly devolved to local levels for adaption and implementation; but set within boundaries of broader central policy. 

Collaborative Commissioning is an initiative of New South Wales, Australia with the vision to develop regional alliances between hospital and primary care authorities for implementing local integrated care. Each region is required to establish a case for entering the initiative; moving through formal phases of community consultation, feasibility and implementation. Joint governance committees and planning are a requirement of participation. We sought to determine how and why programs in each region converged and diverged and in terms of focus, ways of working and underlying principles in implementing the initiative.

Approach: We undertook document review, key informant interviews and key stakeholder workshops with program designers, managers, service providers and other stakeholders in 4 regions that had moved into the ‘feasibility’ phase of the initiative. We then developed a localised theory-of-change (ToC) for each region that was further refined with participants. To compare and contrast regions, we then identified the core focus as well as underlying theoretical assumptions across each ToC. 

Results: As was an expectation of the central initiative, each of regions focused on a different target cohort based on mapped local need (e.g. older patients, diabetes, heart disease and urgent care). Local programs different significantly in terms of ways of working and underlying theory; which we stratified into 4 groupings. Group 1 developed local programs around identifying assumptions about process – specifically patient entry and flow. Group 2 focused on relationships (contractual, financial, professional) between various local service providers and identifying agents of change. Group 3 identified key equity problem clusters in unique local circumstances. Group 4 focused on balance between service supply and demand as well as risks to longer term sustainability. Overall, elements of local context that determined focus and underlying principes ranged from population characteristics; payment models, contracting and availability of service providers; equity; geography; experience with other integrated care initiatives and aligned resourcing; and interprofessional relationships.

Implications: Local implementation of central authority initiatives is highly dependent on a range of factors that stretches beyond local population need. This impacts on the extent to which the underlying purpose of devolution can be fulfilled.