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Care systems worldwide regularly undergo reforms and adjustments in the hope of system improvements. In many ways this can align with calls for governments to be more 'adaptive' and 'agile' to changing care demands. However, such continued adaptations can create turbulence for the care sectors in question. In this article, we examine the large-scale reform of the Australia National Disability Insurance Scheme and the impact of a series of adaptations on the disability care sector in Australia. We find that the disability sector in Australia is experiencing turbulence and a lack of clarity about the rules regarding the programme, resulting in increased administrative burden and financial pressures. Such turbulence has flow-on effects on the level of care that is able to be accessed by people with disability in Australia.

BACKGROUND: Researchers and policymakers are increasingly concerned that personalisation schemes in social and health care might be worsening social and health inequities. This has been found internationally, where better outcomes from such schemes have been found amongst those who have higher education and more household income. METHOD: This study looks at one of the world's largest personalisation schemes, the Australian National Disability Insurance Scheme. Using publicly available data we examine the allocation and utilisation of NDIS funds according to social gradient. RESULTS: We find that the rate at which people with disability 'spend' or effectively use their disability care funds follows a social gradient. That is, those in areas of higher socioeconomic disadvantage are not spending as much of their allocated budgets on care services across the year compared to people in areas of higher socioeconomic advantage. This represents a clear issue of equity in the use of public money to people with disability in Australia. CONCLUSION: We argue that this points to the need to provide targeted supports for the use of disability care funds in areas of higher socioeconomic disadvantage. Without effective supports for fund use, the NDIS and other personalisation schemes may be positioned to worsen existing social inequalities.

Markets are increasingly used by governments to deliver social services, underpinned by the belief that they can drive efficiency and quality. These ‘quasi‐markets' require on‐going management to ensure they meet policy goals, and address issues of market inequity. This has seen debates emerge around ‘market stewardship' and ‘market shaping’ that center on how best to manage markets toward optimal policy outcomes. At present, there is a significant gap in both literature and practice with regard to what types of actions are most effective for market stewardship. In this article, we outline a framework that helps diagnose different quasi‐market problems. We delineate two dimensions of public service quasi‐markets—sufficiency and diversity—using the example of a disability personalization market to show how this framework can unpack different types of quasi‐market states. Lastly, we outline the types of interventions that might be adopted to help deal with ineffective quasi‐markets. Evidence for Practice Market mechanisms are increasing being used by governments around the world to drive innovation and efficacies. Increasingly it is being recognized that these markets need intervention in order to meet policy goals. This paper provides a framework for conceptualizing types of market problems, and offers solutions for the scenarios outlined.

The Australian Productivity Commission (PC) is an inquiry body of international renown, which Australian governments engage to obtain objective evidence‐informed recommendations regarding a wide range of policy issues. Despite its prominence in the Australian policy landscape, there has been little empirical investigation into its practices. This study sought to understand the processes by which evidence is produced and communicated by the PC, with an emphasis on understanding its role within the policy process. Our findings unsettle the notion of the PC as an arms‐length, independent body from government – revealing a more complex interplay of interpersonal strategies in both the production of evidence, shaping of recommendations, and communication of both. We identify practices undertaken by PC staff commonly attributed to policy entrepreneurs – or individuals seeking to influence policy and political processes. Our findings suggest that in different contexts and at different times, the PC shifts between being an apolitical or political actor.

Previous research has indicated that administrative burdens are particularly high in personalised funding schemes such as the Australian National Disability Insurance Scheme (NDIS), because these schemes are predicated on very high levels of self-advocacy. Administrative burdens tend to be inequitably distributed, thereby entrenching existing social inequalities. This is the first study to look at the lived experiences of administrative burden within the NDIS explicitly-and particularly those of women, who are underrepresented within the scheme. The research involved qualitative interviews with 30 women with disability who were either NDIS participants or had considered applying for the NDIS. We argue that like other marginalised groups, women with disability are experiencing significant administrative burdens within the NDIS, which are barriers to obtaining sufficient disability support. Based on this finding, we recommend the NDIS implement a gender strategy, as well as address burdensome administrative processes in general.

Markets are increasingly used by governments to deliver social services, underpinned by the belief that they can drive efficiency and quality. These ‘quasi-markets' require on-going management to ensure they meet policy goals, and address issues of market inequity. This has seen debates emerge around ‘market stewardship' and ‘market shaping’ that center on how best to manage markets toward optimal policy outcomes. At present, there is a significant gap in both literature and practice with regard to what types of actions are most effective for market stewardship. In this article, we outline a framework that helps diagnose different quasi-market problems. We delineate two dimensions of public service quasi-markets—sufficiency and diversity—using the example of a disability personalization market to show how this framework can unpack different types of quasi-market states. Lastly, we outline the types of interventions that might be adopted to help deal with ineffective quasi-markets.

Background: Many countries use market forces to drive reform across disability supports and services. Over the last few decades, many countries have individualised budgets and devolved these to people with disability, so that they can purchase their own choice of supports from an available market of services. Key points for discussion: Such individualised, market-based schemes aim to extend choice and control to people with disability, but this is only achievable if the market operates effectively. Market stewardship has therefore become an important function of government in guiding markets and ensuring they operate effectively. The type of evidence that governments tend to draw on in market stewardship is typically limited to inputs and outputs and has less insight into the outcomes services do or do not achieve. While this is a typical approach to market stewardship, we argue it is problematic and that a greater focus on outcomes is necessary. Conclusions and implications: To include a focus on outcomes, we argue that market stewards need to take account of the lived experience of people with disability. We present a framework for doing this, drawing on precedents where people with disability have contributed lived experience evidence within other policy, research, knowledge production and advocacy contexts. With the lived experience evidence of people with disability included, market stewardship will be better able to take account of outcomes as they play out in the lives of those using the market and, ultimately, achieve greater choice and control for people with disability

Abstract Background Care services in industrialized nations are increasingly moving towards individualized funding models, which aim to increase individuals’ flexibility, choice and control over their services and supports. Recent research suggests that such schemes have the potential to exacerbate inequalities, however none has explored gendered dimensions of inequality. The Australian National Disability Insurance Scheme (NDIS) is a major individualized funding reform, and has a female participation rate of only 37%, despite women and girls making up half of the disability population. Methods The objective of the study is to explore possible gendered barriers to applying for and receiving adequate support through the NDIS, and to suggest directions for future research. We report on semi-structured interviews with 30 women with disability and explore their experiences with the NDIS and their perspectives on challenges associated with being a woman seeking disability support in Australia. We analyse the results using thematic analysis. Results Most women in our sample reported differences between the experiences of men and women seeking disability support in Australia. Commonly reported gendered barriers to women being able to access the right supports for their disability involve a) confidence, negotiation and self-advocacy, b) gendered discrimination in diagnosis and the medical system, which has implications for disability support access, and c) support for and recognition of caring roles. Conclusions These results suggest that women are not receiving equitable treatment with regard to the NDIS, and that further research and policy reform are needed to ensure that women with disability are not further disadv

With the rise in popularity of market-based responses to social policy challenges, the stewardship of quasi-markets or public service markets, is a key concern for governments worldwide. Debates about how to manage quasi-markets have focussed on high-level decision-making processes. However local actors, in particular street level bureaucrats, are a key part of the complex work of managing quasi-markets. We examine how street level bureaucrats act as local market stewards in a new quasi-market for disability care, the Australian National Disability Insurance scheme. We find that the street level bureaucrats, known as local area coordinators, act as shapers of local markets but that their contributions are informal and often restricted by formal structures and processes. For example, we found evidence that the use of key performance indicators can disrupt effective local stewardship efforts towards a procedural approach. We conclude that introducing principles of the polycentric governance approach can improve connections between local market knowledge holders and central decision-making agencies, thereby improving market stewardship and outcomes.

Over the last 30 years, governments have sought to give citizens greater choice and control of the public services they utilise. As a result, we have seen the creation of various forms of public sector markets, including through contracting and tendering processes and, more recently, by utilising individualised or ‘personalised’ care budgets. Under the latter, individuals are given money to purchase services that meet their needs. There is growing evidence that personalisation schemes may actually be entrenching administrative burden, due to their unprecedented emphasis on individual skills and advocacy. Moreover, reviews internationally have found that such schemes tend to be administratively complex. This paper uses a systematic review of existing research to explore experiences of administrative burden within the National Disability Insurance Scheme (NDIS). We found that the scheme is administratively cumbersome overall, and that burdens are exacerbated for particular social groups. We apply concepts of habitus and capital from Bourdieu to theorise why burdens are experienced differently by different groups, and how to address this in practice. In doing so, we can see that addressing exclusion within the NDIS requires us to move away from problematising individuals to including those individuals in different stages of the design and implementation of administrative systems.

Over the past three decades social inequality has risen in almost all OECD countries, reaching historical highs. Social inequality is created and maintained not just by the specific focus or goals of particular policies, but by the norms, values and processes of our government institutions. This special issue looks at how administrative burden is constructed in a range of Australian social policy areas.

This study focuses on the agency of governments engaged in implementation processes that take place over a number of years and through multiple stages. The long timeframes associated with staged implementation leave reforms vulnerable to the institutional effects that may ultimately derail policy aspirations. Governments engaged in staged implementation need to be able to plan longitudinally (foresight capacity) and analyse whether implementation processes are creating endogenous sources of institutional change and the likely impact of such change (reflective capacity). In this paper, we argue that being able to exercise foresight capacity and reflective capacity is necessary but not sufficient, if long‐term policy goals are to be realised. Governments must also be able to navigate the inconsistent objectives that arise across the different stages of an implementation process by modifying implementation approaches in ways that reduce the likelihood of unwanted implementation effects occurring—what we have labelled “mitigation capacity.”

Personalisation schemes and associated markets for social care have been a growing trend in industrialised countries over recent decades. While there is no single approach to marketisation of social care and personalisation, often funds are devolved to clients of care services to be used to purchase services directly from market. Such arrangements are vulnerable to market failures and ‘thin’ markets, causing the need for stewardship of the social care markets. We present findings from a 2018 survey of 626 care service providers in the Australian National Disability Insurance Scheme market on their experience of market conditions. Over 46% of respondents listed ‘addressing pricing’ as their top action for addressing market problems. Qualitative findings show that central price setting is detached from service delivery realities, affecting service quality and capability building potential. We argue that devolution of price setting to, or at least flexibility and discretion at, the local level is likely to be a key to solving pricing dilemmas in personalisation schemes.

As governments worldwide turn to personalised budgets and market-based solutions for the distribution of care services, the care sector is challenged to adapt to new ways of working. The Australian National Disability Insurance Scheme (NDIS) is an example of a personalised funding scheme that began full implementation in July 2016. It is presented as providing greater choice and control for people with lifelong disability in Australia. It is argued that the changes to the disability care sector that result from the NDIS will have profound impacts for the care sector and also the quality of care and well-being of individuals with a disability. Once established, the NDIS will join similar schemes in the UK and Europe as one of the most extensive public service markets in the world in terms of numbers of clients, geographical spread, and potential for service innovation. This paper reports on a network analysis of service provider adaptation in two locations-providing early insight into the implementation challenges facing the NDIS and the reconstruction of the disability service market. It demonstrates that organisations are facing challenges in adapting to the new market context and seek advice about adaptation from a stratified set of sources.

BACKGROUND: Personalisation is a growing international policy paradigm that aims to create both improved outcomes for individuals, and reduce fiscal pressures on government, by giving greater choice and control to citizens accessing social services. In personalisation schemes, individuals purchase services from a 'service market' using individual budgets or vouchers given to them by governments. Personalisation schemes have grown in areas such as disability and aged care across Europe, the UK and Australia. There is a wealth of evidence in public health and health care that demonstrates that practically all forms of social services, programs and interventions produce unequal benefit depending on socio-economic position. Research has found that skills required to successfully negotiate service systems leads to disproportionate benefit to the 'middle class. With an unprecedented emphasis on individual skills, personalisation has even greater potential to widen and entrench social inequalities. Despite the increase in numbers of people now accessing services through such schemes, there has been no examination of how different social groups benefit from these schemes, how this widens and entrenches social inequities, and - in turn - what can be done to mitigate this. METHODS: This article presents a meta-review of the evidence on personalisation and inequality. A qualitative meta-analysis was undertaking of existing research into personalisation schemes in social services to identify whether and how such schemes are impacting different socio-economic groups. RESULTS: No research was identified which seeks to understand the impact of personalisation schemes on inequality. However, a number of 'proxies' for social class were identified, such as education, income, and employment, which had a bearing on outcome. We provide a theoretical framework for understanding why this is occurring, using concepts drawn from Bourdieu. CONCLUSION: Personalisation schemes are likely to be

We explore personalized funding schemes and associated changes for accountability within new welfare governance reforms. Using the case of the Australian National Disability Insurance Scheme as hybrid institution, requiring mixed accountability arrangements, we examine the implications for broader discussions of accountability in personalized welfare arrangements. Methods used were semistructured interviews with government actors and disability service providers in Australia. In describing how accountability structures emerge, we argue that the way that layers fit together during implementation are often imperfect because of the conditions under which they arise. As a result, critical gaps can emerge in layered systems, which can put end users at risk. We demonstrate that theories on accountability in new public governance welfare reforms must also be informed by context and history informed qualitative analysis of case studies.

In this article, we identify the unfolding unintended consequences which flow from one instance of policy layering in Australia's National Disability Insurance Scheme (NDIS). We show how use of a causal diagram, which highlights feedback loops and emergent properties, to map complex chains of causal factors can assist policy scholars and policy practitioners to understand the likely direction of change and possible responses. In the case of Australia's National Disability Insurance Scheme, our analysis suggests that the likely direction of change will work against two of the fundamental design features of the NDIS: providing participants with more choice and control and ensuring all eligible Australians are able to access appropriate services and supports regardless of where they live. Our analysis points to the use of price regulation as the site of potential intervention because of the role it plays in subsequent feedback loops and the development of the two, unwelcome, emergent properties.

© 2017 Taylor & Francis Group, LLC. Significant restructuring of bureaucracies has occurred to facilitate joined-up working. This article draws on new institutionalism to explore the rationale behind the use of structural change for the promotion of joined-up working. It argues that a strong institutionalized myth has emerged which has created isomorphic pressures in the public sector to instigate structural changes in the name of vertical integration. These combine with informal institutions in ways that can be both productive and unproductive, highlighting the need to find a balance between formal institutional change and informal institutionalized practices, which often go unacknowledged as a powerful influence on policy.

Personalized care and market‐based approaches to public service provision have gained prominence in a range of Organisation for Economic Co‐operation and Development countries. Australia has recently joined this trend, launching a complex and expansive programme of individualized care funding for disability through the National Disability Insurance Scheme. Public sector markets (i.e. where governments either directly fund a market by way of competitive tendering, or through personal budgets) have been embraced by actors at different points of the political spectrum and for a range of reasons, including efficacy and efficiency gains, empowerment of citizens and efforts to cater for diversity. Despite the growing dominance of public sector markets and individualized funding, many questions about the role and responsibility of governments in managing and regulating these markets remain unanswered. In this article we outline different roles governments might assume in the creation and management of public sector markets, based on the types of risks governments are willing to take responsibility for. We argue that to fulfil the social contract between government and citizens, governments need to ensure that markets are properly stewarded and embedded in broader social safety nets. This, we contend, can ensure citizens receive the gains of market models while being protected from market failures or market‐produced inequities.

Australia's National Disability Insurance Scheme (NDIS) represents the latest in a worldwide shift towards individualised funding models for the delivery of care services. However, market‐based models for care deliveries bring new considerations and dilemmas for accountability. Drawing on previous work by Dickinson et al. (2014), we examine a range of accountability dilemmas developing within the early implementation of the NDIS. These relate to accountability for the following: care outcomes, the spending of public money, care workers, and advocacy and market function. Examining these accountability dilemmas reveals differences in underpinning assumptions within the design and on‐going implementation of the NDIS, suggesting a plurality of logics within the scheme, which are in tension with one another. The contribution of this paper is to set out the accountability dilemmas, analyse them according to their underpinning logics, and present the NDIS as having potential to be a hybrid institution (Skelcher and Smith 2015). How these dilemmas will be settled is crucial to the implementation and ultimate operation of the scheme.

© 2017 Institute of Public Administration Australia. Australia's National Disability Insurance Scheme (NDIS) represents the latest in a worldwide shift towards individualised funding models for the delivery of care services. However, market-based models for care deliveries bring new considerations and dilemmas for accountability. Drawing on previous work by Dickinson et al. (2014), we examine a range of accountability dilemmas developing within the early implementation of the NDIS. These relate to accountability for the following: care outcomes, the spending of public money, care workers, and advocacy and market function. Examining these accountability dilemmas reveals differences in underpinning assumptions within the design and on-going implementation of the NDIS, suggesting a plurality of logics within the scheme, which are in tension with one another. The contribution of this paper is to set out the accountability dilemmas, analyse them according to their underpinning logics, and present the NDIS as having potential to be a hybrid institution (Skelcher and Smith 2015). How these dilemmas will be settled is crucial to the implementation and ultimate operation of the scheme.

© 2017 John Wiley & Sons Ltd Personalized care and market-based approaches to public service provision have gained prominence in a range of Organisation for Economic Co-operation and Development countries. Australia has recently joined this trend, launching a complex and expansive programme of individualized care funding for disability through the National Disability Insurance Scheme. Public sector markets (i.e. where governments either directly fund a market by way of competitive tendering, or through personal budgets) have been embraced by actors at different points of the political spectrum and for a range of reasons, including efficacy and efficiency gains, empowerment of citizens and efforts to cater for diversity. Despite the growing dominance of public sector markets and individualized funding, many questions about the role and responsibility of governments in managing and regulating these markets remain unanswered. In this article we outline different roles governments might assume in the creation and management of public sector markets, based on the types of risks governments are willing to take responsibility for. We argue that to fulfil the social contract between government and citizens, governments need to ensure that markets are properly stewarded and embedded in broader social safety nets. This, we contend, can ensure citizens receive the gains of market models while being protected from market failures or market-produced inequities.

INTRODUCTION: Systems thinking has emerged in recent years as a promising approach to understanding and acting on the prevention and amelioration of non-communicable disease. However, the evidence on inequities in non-communicable diseases and their risks factors, particularly diet, has not been examined from a systems perspective. We report on an approach to developing a system oriented policy actor perspective on the multiple causes of inequities in healthy eating. METHODS: Collaborative conceptual modelling workshops were held in 2015 with an expert group of representatives from government, non-government health organisations and academia in Australia. The expert group built a systems model using a system dynamics theoretical perspective. The model developed from individual mind maps to pair blended maps, before being finalised as a causal loop diagram. RESULTS: The work of the expert stakeholders generated a comprehensive causal loop diagram of the determinants of inequity in healthy eating (the HE2 Diagram). This complex dynamic system has seven sub-systems: (1) food supply and environment; (2) transport; (3) housing and the built environment; (4) employment; (5) social protection; (6) health literacy; and (7) food preferences. DISCUSSION: The HE2 causal loop diagram illustrates the complexity of determinants of inequities in healthy eating. This approach, both the process of construction and the final visualisation, can provide the basis for planning the prevention and amelioration of inequities in healthy eating that engages with multiple levels of causes and existing policies and programs.

It is well established in the public management literature that boundary spanners – people or groups that work across departments or sectors – are critical to the success of whole of government and joined‐up working. In studying recent unprecedented change to central government agencies in the Australian context, our research identified that intra‐departmental boundary spanners also play a critical role in the functioning of government departments, particularly during restructuring. Although most contemporary literature in public management concentrates on boundaries across formal organisational entities (departments, agencies, sectors), boundaries also exist within departments. Our research has found that without dedicated intra‐departmental boundary spanners, significant role confusion and dysfunctional practices arise. In turn, this has serious implications for the quality of policy advice given to Cabinet. Further research needs to be undertaken into both the role of intra‐departmental boundary spanners and how to nurture and manage the practice of intra‐departmental boundary spanners. This is especially the case if changes in Australia represent a fundamental shift more broadly in the way central government agencies operate.

Introduction: Systems thinking has emerged in recent years as a promising approach to understanding and acting on the prevention and amelioration of non-communicable disease. However, the evidence on inequities in non-communicable diseases and their risks factors, particularly diet, has not been examined from a systems perspective. We report on an approach to developing a system oriented policy actor perspective on the multiple causes of inequities in healthy eating. Methods: Collaborative conceptual modelling workshops were held in 2015 with an expert group of representatives from government, non-government health organisations and academia in Australia. The expert group built a systems model using a system dynamics theoretical perspective. The model developed from individual mind maps to pair blended maps, before being finalised as a causal loop diagram. Results: The work of the expert stakeholders generated a comprehensive causal loop diagram of the determinants of inequity in healthy eating (the HE2Diagram). This complex dynamic system has seven sub-systems: (1) food supply and environment; (2) transport; (3) housing and the built environment; (4) employment; (5) social protection; (6) health literacy; and (7) food preferences. Discussion: The HE2causal loop diagram illustrates the complexity of determinants of inequities in healthy eating. This approach, both the process of construction and the final visualisation, can provide the basis for planning the prevention and amelioration of inequities in healthy eating that engages with multiple levels of causes and existing policies and programs.