Primary Care Article 6 Gervais ENG

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ARTICLE 6

Policy makers and strategic vision of the twenty-first century:

managing collaborative care in complex context and dealing with uncertainties Michel Gervais, MD, FRCPC, MBA

These days, there are concerns about those citizens who suffer from mental illness and who become homeless, wandering around town. At times, it is suggested that we should rebuild the old-fashioned psychiatric hospitals in order to give them a shelter. Many people see a causal link between the significant growth of homelessness and the closure of psychiatric institutions. It is as if they have not noticed that our society as a whole has evolved in postmodern conditions and that we are on a path of no return. In other words, as the Stone Age did not end because we ran out of stones, homelessness is not the result of a shortage of psychiatric hospitals.

People tend to look back nostalgically to solutions of the past that are unfit for current challenges. For instance, hierarchy, bureaucracy and compliance to institutional ideology have given way, for better or for worse, to human autonomy, adhocracy and individualism. As for any other individual living in a postmodern society, the majority of homeless would likely choose the freedom in self-determination, in spite of its related risk of a painful rupture of social bonding, rather than being locked up in a asylum and forced to receive assistance from caretakers who know best what is good for them.

This is a striking illustration of how the paradigm shift, from modern to postmodern conditions, radically transforms the managerial approach of the mental health care network. It also shows how the

management of the mental health care network is consistent with the desired transformation of the healthcare system governance into a bureaucracy of the twenty-first century and how it could become the spearhead of this change.

In modern conditions, development is based on science and technology that have allowed the industrial revolution. In postmodern conditions, "science is denied any privilege.”¹ This echoes a very strong trend in the world of mental health where the lived-experiences of consumers are considered as a source of

"expertises" and as worthwhile as opinions of any health care professional.

As a consequence, contextualization and inductive reasoning have precedence over empiricism and deductive logic. Diversity and uncertainty stand out as new key variables. They call for a reduction of top-down control and an empowerment of bottom-up processes.² Again, all these dimensions of the managerial approach adapted to post-modern conditions are perfectly aligned with the complex context of the mental health care system.

1 Bogason, Peter 2005. Postmodern public administration. Chapter 10 in the Oxford Handbook of Public Management, Oxford University Press, edited by Ewan Ferlie, Laurence E. Lynn Jr. and Christopher Pollitt (November). ISBN: 978-0-19-925977-9

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The network concept is proposed as an alternative way of “managing complex interactions around policy formation, implementation or service delivery ... it stresses the interdependency of various organizations in realizing policy initiatives, it challenges the central position of public actors in decision making and implementation processes and it challenges the way policy processes are managed and evaluated.”³ Networks appear designed to "deal with ’wicked problems’ that do not fit within a single jurisdiction ..."⁴

This perspective fits in perfectly with the world of mental health that spreads out like a web in all directions. This is especially true for the context of collaborative mental health care and the Chronic Care Model. Bureaucracy and networks are not antinomic: “Rather than a challenge to the continued existence of bureaucracies, therefore, networks are more likely to provide greater focus on a range of relationship both formal and informal.”⁵ Networks increase the capacity of bureaucracy to act upon

"connectivity," a key factor for managing in complex contexts.

The network society calls for more horizontal forms of governance. This is a bottom-up approach that allows for tailoring the formulation and the implementation of policy to the local context. A public manager should aspire to be a “network manager,” a term coined to describe the role of the actor who

“performs and implements the coordination activities required to ensure that the interaction and joint decision making between actors, which is necessary to achieve outcomes in an interdependent world, actually takes place.”⁶ His or her role is radically different from the classical top-down model. The network manager can sometimes be involved as a mediator or facilitator, seeking for common values and goals, working on perception accommodation, building shared meaning and relationships, and so on.

Collaborative mental health care appears as an outstanding opportunity to improve clinical governance, one component of this horizontal governance mentioned above, and is mostly a bottom-up process.

Clinical governance “requires structures and processes that integrate financial control, service

performance, and clinical quality in ways that will engage clinicians and generate service improvements ... (collaborative care supports) power sharing implications of more integrated and team based

approaches to clinical work and its evaluation ... a systematisation of clinical work."⁷ Collaborative care, to the extent that it will improve clinical governance, is an opportunity to narrow the gaps between the clinicians, the managers, the consumers and the policy makers.

There is potential for the transformation of societal power structures by using complexity-inspired principles and networks management. This is the idea of a new “horizontal” form of governance, designed and led by complex networks of actors, which can counterbalance the power of the pyramidal

3 Klijn, Erik-Hans 2005. Networks and inter-organizational management – Challenging, steering, evaluation, and the role of public actors in public management. Chapter 11 in the Oxford Handbook of Public Management, Oxford University Press, edited by Ewan Ferlie, Laurence E. Lynn Jr. and Christopher Pollitt (November). ISBN: 978-0-19-925977-9

4 Meier, Kenneth J., Gregory C. Hill 2005. Bureaucracy in the 21st century. Chapter 3 in the Oxford Handbook of Public Management, Oxford University Press, edited by Ewan Ferlie, Laurence E. Lynn Jr. and Christopher Pollitt (November). ISBN:

978-0-19-925977-9

5 Meier, Kenneth J., Gregory C. Hill 2005. Bureaucracy in the 21st century. Chapter 3 in the Oxford Handbook of Public Management, Oxford University Press, edited by Ewan Ferlie, Laurence E. Lynn Jr. and Christopher Pollitt (November). ISBN:

978-0-19-925977-9

7 Degeling, Pieter J., Iedema Maxwell, David J Hunter 2004. Making clinical governance work. British Journal of Medicine, volume 329 (September): 679-81.

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hierarchy. This governance by networks is driven by intensive interactions among actors with mutual dependencies and who share common interests in spite of their asymmetric power relations. “Because existing democratic institutions have a strong focus on vertical forms of accountability,”⁸ some people call into question the legitimacy of this horizontal governance.

Conversely, others see it as being close to the democratic ideal. “The new horizontal forms of

governance inspired by ideas of more participative democracy often do not mix very well the traditional political institutions.”⁹ It creates a tension, between elected politicians and horizontal governance, that raises the question of how to tie this "complex decision-making processes" with the institutions of parliamentary democracy.

The hypothesis advanced here is that the institutions of parliamentary democracy, as much as the classical model of scientific management, belong to the era of modernism and that, with the transition to the conditions of postmodernism, original forms of management and governance adapted to the complexity of this "new world" are emerging before our eyes. Managing the relationships among individuals, sub-systems and systems (namely the connectivity) becomes a key factor of success for implementing change in complex contexts as well as a new source of power. “The essence of power becomes control of communication in networks.”¹⁰

In the days of budget cuts and the never-ending financial crisis of the health care systems, institutions have reached the limit of their problem-solving capacity. They are stretched thin and need more skilful engagement with communities. Our lifeline could be in the direction of enhancing collaboration – optimizing connectivity among the stakeholders– which may release untapped potential that exists in every community. This perspective could create a new salutary balance with the citizen no longer being considered a passive recipient who waits for his means of sustenance from the welfare state, but who is an active participant in building a healthier environment.