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Posted 22 September 2003 - 12:45 PM
have a closer look at the graph around xmas/January period for each year.
This is from the 2002 confernce:
http://pssm.ssc.govt.nz/previous/2002/pape...rs/caygilld.asp
David Caygill
I want to tell you a story and make about three points. This is a story about the changing nature of the public service. And more particularly about the changing nature of public services.
Like many stories, it is best told with pictures, in this case a single, graphic picture. I want to describe what's been happening over the last six years at the ACC. This graph condenses this story into a single two-dimensional relationship. Everyone at ACC is familiar with this graph. It's what we call our "tail graph". It shows the number of ACC claimants on the ACC "tail", that is those who have been receiving earnings-related compensation for more than 12 months. In the middle of 1997 there were roughly 30,000 such claimants. Today there are less than 15,000. I want to share with you the story of this achievement.
ACC is a social insurance scheme. It collects premiums, or, as the government prefers to call them, levies. (They are compulsory, after all, and are paid by the whole community irrespective of their circumstances ie. people are not insuring themselves). As you probably know, the scheme has been going since 1974. You might think of it as a special feature of New Zealand. Few other countries have such a comprehensive, no-fault scheme. Many countries provide workers' compensation, but often supplementing rather than replacing the arbitrary lottery of civil liability.
Social insurance schemes like ACC are responsible for the most seriously injured for the remainder of their lives. So the number of long-term claimants grows from the start of the scheme until eventually it levels off when the number of seriously injured claimants coming on to the scheme is equalled by the number going off. Thereafter one would expect the number of long term claimants to reflect the growth in population and the work force. But in ACC's case the number of long-term claimants grew until the mid 1990s and then fell. About the time that people were beginning to wonder what figure the scheme would level off at, the number declined. This is as unprecedented as it was unexpected.
No single factor explains this result. But two policy changes, both initiated in the mid 1990s, contributed significantly. Both required legislation - in 1996. The first allowed ACC to contract directly for surgery for its claimants. This was controversial, because arguably it meant that ACC claimants jumped the queue of patients waiting for public surgery. But it also meant that ACC stopped paying people lost wages while they languished on public hospital waiting lists.
At the same time, in a second change, we stopped paying people who had been rehabilitated. That is, who were able to work but could not find work. Back in 1990 it had been estimated that perhaps up to 10% of ACC claimants were actually fit for work, though not necessarily for the work they had been doing prior to their injury. So the nature of the ACC scheme changed. It stopped compensating accident victims for the loss of a particular job and it no longer doubled as unemployment insurance, but instead it focused on the task of rehabilitating those who suffer injury - particularly serious injury. The result of these changes has been that the average length of time spent on ACC has fallen, the number of long term claimants on the scheme has also fallen as, have most of the premiums or levies paid for ACC.
In many ways the most dramatic change of all is that ACC is no longer essentially a compensation scheme. Of course it still pays out several hundred million dollars each year in compensation. But it spends even more on rehabilitation. Today ACC is basically a rehabilitation scheme, which pays compensation to those it hasn't yet been able to rehabilitate - rather than a compensation scheme which is also charged with injury prevention and rehabilitation.
The key point I want to make is this: rehabilitation is a different kind of service from that of paying cash benefits. Payment puts a cheque in the mail, or more likely these days a direct credit to a bank account. Rehabilitation is one on one. It is more demanding and more personal. Case management, which is how we describe dealing with individual claimants, is challenging. Some claimants are difficult, for example those with brain injuries. Some have other "issues". These days, for example, ACC is venturing into drug and alcohol rehabilitation, even where such conditions pre-dated the injury that brought a claimant to ACC. If the alcohol or drug addiction is preventing their recovery then we need to address that.
Of course, case management is not unique to ACC. WINZ also practices it, as do a number of other public service agencies. Like ACC, they know that good case management is demanding of staff. It requires an emphasis on training and frequently generates higher than average staff turnover. But by concentrating effort where it seems to be needed most, and by streamlining the handling of minor claims that typically can be dealt with over the phone, by such means as encouraging health providers to lodge claims electronically, ACC is continuing to reduce the length of time spent on the scheme. The question is, can we learn from this. Are there lessons here for the wider public service?
We know for example that time off work from illness is 4-5 times as large as time lost through accidents. Yet there are few programmes in place to manage back to work those who are sick - even when they are in receipt of sickness or invalid benefits. And what if we were to employ case management techniques in other contexts - Corrections, for example? I know we couldn't release inmates from jail earlier, but what if we aimed to reduce their chances of subsequently re-offending. Now there's a thought. My question is simply, whether intensive, individually-oriented services may have a wider application in place of broad brush, largely payment-oriented services in the public service of the future?
ACC's emphasis on case management rather than the payment of compensation has been assisted by a second development. Once again, ACC is merely an example of what I know is happening elsewhere in the public sector. Like many other state agencies, ACC sits on a mountain of information. Furthermore, as a national organisation, it is peculiarly able to draw conclusions from that data. So, over the last two or three years ACC has begun to use its electronic information to profile injuries, to form expectations of treatment. For example, last year every physiotherapist was advised of their position relative to their colleagues in terms of the number of treatments they take to address particular injuries. Unsurprisingly perhaps the mere distribution of this information appears to have reduced the average length of treatment. Such information has enabled ACC to identify preferred providers, initially amongst surgeons and now, increasingly, amongst primary providers. A further use of such electronic analysis has been the better identification of potential fraud - a risk faced by all large structures.
The twin challenges I have described, those of more individual, claimant-oriented service and the deeper use of electronic analysis, mining electronically stored data are by no means unique to the ACC. Rather, the same challenges present themselves to many other parts of the public service. Let me give you just one further example.
Let's take something as basic as tax collection. The public may not care for it, but the rest of the public service depends on it. The Inland Revenue is one of New Zealand's largest departments. And it has developed a seemingly unusual approach. That is, it relies, far more than on most countries, on voluntary compliance. So we have some of the simplest tax forms in the world. More than that, the IRD has worked hard and long to reduce the number of forms and the amount of administration required of taxpayers. Just as for the ACC, taxpayers may even file tax returns electronically. And here's another link with the ACC (both metaphorical and literal): the IRD uses computer technology to classify taxpayers into the groups likeliest to require follow up investigation. Well, they would, wouldn't they?
My thesis is that the nature of public services is changing both as the nature of society changes and also as technological changes make it possible to analyse more information more quickly and to focus the benefits of that analysis on individual beneficiaries. Conceivably the public service of the future may be less remote and less uniform, whilst the services it provides may be more tailored and more responsive. Whilst the nature of the services we provide in future is important, how they are delivered is equally important.
On the subject of how services are best delivered, I would like to share with you a recent personal experience from which I am still recovering. It's simply a chance observation of a psychologist who recently addressed a firm of lawyers. The psychologist was struggling to explain to the lawyers the importance of the partnership's personality profiles she was at that moment handing out. What she said was: "How you behave affects your results". Well, of course. And it is that simple. How we behave affects how we perform. The sum of personal behaviours affects our collective performance. Why wouldn't that be the case? Yet it seems to me that often and for great lengths of time we behave as though this isn't true. As though how we organise and interact as individuals is somehow independent of our collective performance - the results we get. Much public debate apparently assumed that the nature of public programmes is all that matters - not the sympathy or engagement with which they are delivered.
Earlier, I argued for a change in the nature of the public services - what we do. My argument is that public services can be and may very well become more individualised, more intensive, and better monitored than in the past. But that is not all we need to do. The manner of delivery also matters. We need to think about the how of delivery - not just the what.
Now let me end with different point. Much debate in the 1990s addressed neither how, nor what, but who. That is, the fascinating question of where the boundary between public and private services should be drawn. It's the easiest thing in the world to be dismissive of the period of history through which one has just come. The question of the proper roles of the public and private sectors - which seemed to bedevil the 80s and 90s - is still an important question. But it is not in my view the question that agitates the general public most. If one thinks of the notion of public service - it is my judgment that there is much less resonance to the word "public" and much more significance attached to "service" than the other way round. What I wanted to do this afternoon is to challenge our concept of public services - both their content and mode of delivery - so that in turn we may think again about the true nature of public service.
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