Working Together: Governance at the interface between primary care and public health

Abstract

This thesis investigates governance processes at the intersection between primary care and public health. The way in which primary care and public health work together needs to change to respond to changing health need, particularly the rise of non-communicable diseases where the traditional ‘command and control’ methods of governance are no longer suitable. Consequently, the way in which decisions are made about health service design, development and implementation has to change to reflect the need for a joint approach to governance that steers activity between the two areas. This research looks at the governance processes in public health initiatives delivered in the primary care setting. Until now, these processes have been largely implicit. This research aims to make the governance processes explicit, by investigating two overarching questions: • what is the nature of the governance processes that operate at the overlap between primary care and public health? • what impacts on and shapes those governance processes? The study aims to show that governance arrangements impact on the types of services that are delivered and how they are delivered, which ultimately impacts on the health of populations. Using grounded theory as a method of data collection and analysis, this two-phase study looked at governance processes in initiatives shared between primary care and public health. The first phase investigated patterns of activity in New Zealand through interviews with participants in all parts of the health system (from Ministry of Health to community level) who worked in primary care and public health. In the second phase, New Zealand results were discussed with UK and Netherlands experts to make comparisons with other jurisdictions to see whether phase one findings were applicable beyond New Zealand. The study found that while policy and some literature assume a defined and agreed space of ‘the interface’ and ‘governance’, they are both concepts that are strongly contested and that remain uncertain. This research shows that ‘the interface’ is more than a service overlap or a point on a continuum of services. It is at once a domain of service, a set of relationships, and a space where different value sets weigh against each other. In short, it is a ‘contested space’. At times there is more friction than synergy in the process of governing initiatives at the interface as different parts of the health system work together. This energy is underpinned by less visible processes of building infrastructure and learning, challenging and renegotiating values. Similarly, the research found that the concept of governance remains uncertain - who steers initiatives, using what information, and how? The interface between public health and primary care is a place where different professional norms, personal values and approaches to public health are played out. In practical terms, this research highlights the relational in making the interface work. The quality of the exchanges between the areas is the key, as well as the nature of the exchanges. It highlights that learning by experience and changing training help improve the quality of the exchange at the interface, and that people capable of thinking about systems, good communicators and respectful dialogue - have a big impact on the quality of the interface between the two areas. It highlights the importance of financial levers, as well as education and training and communication as areas where effort can be put to affect change, and that among all the levers for change that are available, focussing on those ones is likely to affect the most change. The study describes the critical points of working together at the interface, explains what drives, supports and frustrates people working on governance at the interface. It details implications for policy and practice by detailing the levers policy makers and practitioners can use to improve governance in shared initiatives between primary care and public health. Most importantly it reframes governing as a human interaction and an exchange of values, rather than a technical exercise.