Author: Sarah Mourney

System stewardship is increasingly well-defined in policy literature. It’s about creating the right conditions for actors within a system to deliver positive social impact, rather than trying to impose order top-down, or leaving service provision to the free market. This involves moving from mandates to relationships and incentives, from siloes to collaborative models, and shifting from thinking linearly to thinking systemically

However, as the Public Service Research Group notes, “to date there is no clear consensus about [system stewardship’s] key concepts or methods, and very little empirical evidence exists to guide system level stewardship practice for those working in government”.  

In our System and Market Stewardship practice within Commissioning NSW, we’ve been considering how to take the concept of system stewardship and turn it into practical frameworks that can help our stakeholders to reflect on their work and embed a stewardship approach. 

One idea we are testing in our current projects is adapting a framework called 'The Quadruple Aim', which was developed to drive healthcare system reform.  

 

The four aims are good prompters for system stewards to assess if they are taking a holistic approach to guiding their respective systems.  

Aim 1: Outcomes 

Outcomes are important. They enable us to set a clear vision and goals for what the system should be achieving. 

In all our projects, we want to achieve meaningful outcomes for the people of NSW (our ‘customers’) across a suite of public policy areas. We want our students to have improved literacy and numeracy skills, we want to decrease chronic diseases in our community, and we want disadvantaged members of our community to have improved opportunities in life. 

However, given the complexity of the systems that governments steward, it can be a challenge to identify the most appropriate outcomes that reflect the wants and needs of our communities.  

We are seeing more public servants in NSW using tools such as Outcomes Frameworks, Program Logics and Theories of Change to bring more rigour and focus to defining and measuring the impact of policies. At NSW Treasury, we have recently introduced outcomes-based budgeting, which is an important shift away from funding activities that lack a clear link to outcomes. 

However, focusing only on outcomes can lead us to problems in the future if we are taking our role as stewards seriously. This is where the other three aims come into play.  

Aim 2: Customer experience 

NSW government aspires to be a customer-centric government, meaning that it “recognises its people as customers and puts them at the centre of decision-making”. We want to achieve outcomes for people and make time to engage with communities, listen to their voices, and ensure that we deliver on what matters to them. We think that framing customer experience as its own aim is important, so it isn’t side-tracked by more typical ‘outcomes’ measures that focus on end goals. 

In our work on system stewardship, this means taking time to uncover lived experience early in system design, considering indicators that capture experience when evaluating policy, and investigating in co-design models. An example of this is when we spent time interviewing teenagers to understand what they saw as the value of a particular program, so we could include this perspective in developing new program guidelines.  

Ultimately, we also believe that a good experience of a government service also contributes to people having better outcomes too – through increasing the reach of and engagement with services and improving the design of services by drawing on customer experience tools such as journey mapping. This means that when we evaluate policy, we want to capture how people experience and perceive the services they receive, rather than only focusing on final outcomes.  

 

 

Our team, Commissioning NSW, using design techniques to build products that provide a good experience for customers 

 

Aim 3: Provider experience 

 The Quadruple Aim (in the health context) originally started as the ‘Triple Aim’, which did not include ‘provider experience’. The people who advocated for this aim wanted to make sure that system leaders considered the experience of staff working to deliver services when managing their systems – driven in part by concerns of burnout among health practitioners in an over-stretched system. They made the argument that burnout causes lower patient satisfaction, reduced health outcomes and sometimes increased costs.  

We think enabling positive experiences for providers is an important aim in any system. In our broader conception, provider experience includes the individual experiences of all actors in the delivery chain who contribute to realising the impact of a policy – from senior executives, to contract managers, to frontline staff (nurses, teachers, social workers). The commissioners in the delivery chain can make it easy to partner with and across government, or they can create counterproductive administrative burden that impedes service delivery. 

Regardless of whether services are being delivered by internal providers (e.g. public hospitals and schools) or external providers (e.g. private bus companies and not-for-profit Out of Home Care providers), we want the people (and organisations) who are interacting with customers to be supported at work so they can deliver the best possible services. This is ethically the right thing to do, but also in the long run is critical for achieving the rest of our aims.  

As part of this aim stewards should consider how they are structuring their relationships with providers to enable effective collaboration and identify what opportunities may exist to make it easier for providers and their staff to work optimally.  

 

Aim 4: Sustainability  

Original models of the Quadruple Aim talked about this aspect as ‘reducing costs’. We take a more holistic interpretation represented by ‘sustainability’ as it is important that governments adopt long-term approaches to thinking about managing resources (environmental and non-environmental) so we can meet our current and future needs. In a context of a growing population the best we might do is bend the ‘liability curve’ for government in the future, rather than reducing costs now. Additionally, in areas where there has been underinvestment, we may need to increase costs temporarily to deliver adequate services to address needs in the community. 

Sustainability is about considering efficiency, effectiveness and value for money – but it is also about resiliency. When working in complex systems, actions that seem to increase efficiency can undermine resiliency. This is often driven by decision-makers considering components of a service, rather than using a systems lens to consider the interplay of complex dynamics between all the components. 

For example, it might be cheaper and easier over the short term to award contracts to one or two large suppliers, however, this creates a critical risk to service delivery if the suppliers fail. This happened to the UK Government in 2018 with the liquidation of Carillion, a company at the time delivered over 32,000 school meals a day and was building hospitals. Sustainability means we should be considering the bigger, systemic picture (e.g. by promoting a diversity of providers), to ensure we are not making decisions that store up risk or expose government to future liabilities. 

 

Using the Quadruple Aim 

We are using the Quadruple Aim to inform our conversations about system stewardship with NSW Government agencies, and to structure evaluation approaches on some of our projects. Primarily, we see the Quadruple Aim as a helpful tool for reflecting on system stewardship and enabling us to have richer discussions about how we can strengthen our practice. We don’t see this model as static – as we use it, we want to innovate and iterate as we go along. 

If you have seen similar models in practice or have ideas about how to turn system stewardship into tools, please get in touch.