How a government strategy of active performance management has influenced District Health Boards' delivery of publicly funded elective services

New Zealand, like most countries, is limited in the amount of publicly funded non-emergency (elective) medical and surgical services that it can provide to its population. In 2000, the ‘Reduced Waiting Times for Public Hospital Elective Services: Government Strategy’ outlined the systematic approach New Zealand would take with elective service waiting time management. The approach included the Government’s use of active performance management, namely, the setting of accountability and clear performance expectations; the ongoing monitoring, measurement, and reporting of performance; and the management of system change using facilitative networks. Since 2001, District Health Boards (DHBs) have been accountable for implementing government electives policy. The thesis examines how the Government’s strategic use of active performance management has influenced DHBs in their delivery of publicly funded elective services. In order to better understand and evaluate elective service delivery outcomes, (in particular that equity of service access has been achieved), and to evaluate the improvement of health service decision-making, there is a need to understand how decision-makers at the macro, meso, and micro levels of the health system are influenced by performance management practices. The research has examined influence from a multi-stakeholder and performance management system perspective. Methods include interviews with DHB and government stakeholders, review of Nationwide Service Framework and government policy documents, and the analysis of ten years of publicly available DHB performance reports to understand compliance patterns. The research narrative synthesised from study data is interpreted using a blend of neo-institutional meta-theories and institutional logics. The research found the government uses two performance models: an administrative control performance model which relies on information collection, control logic and performance feedback, and a professional services performance model which relies on the management of change using networks. Each DHB has established organisational practices in response to active performance management which are largely concerned with the promotion of DHB legitimacy. The influence of the two performance models and the interests of multiple DHB stakeholders is explained by considering the interplay between fifteen organisational practices, the government institutional logics of Active Performance Management and Service Improvement and the organisational field-level institutional logics of Population Health Management, Service Management, Medical Professional, and Integrated Care. Overall, the research concludes that ‘Active Performance Management’ has made a significant contribution reducing public hospital waiting times. It focuses the attention of DHB service managers who are concerned with mitigating risks of financial penalties and loss of leadership legitimacy. However, there are different ‘supply’ decision-making agendas and criteria operating at different levels of the health system. In particular, it is difficult to lock in appropriate accountability arrangements with primary care, and the strategic use of active performance management has led to tensions between DHB management and hospital specialists. If New Zealand wishes to expand its evaluation of health service delivery to take into account outcomes measures, there needs to be a better understanding of the aggregated impact of performance management practices on the health system.