A Vigorous Rearrangement of Deck Chairs: Heather Simpson’s Neoliberal Prescription For New Zealand’s Health System

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MUCH WILL BE WRITTEN about Heather Simpson’s plans for the New Zealand health system. Most of the attention, if the media’s coverage so far is any indication, will centre on the abolition of the system’s already anaemic democratic elements, along with the acceptability or otherwise of the provision made for addressing the health needs of Maori. Virtually nothing will be written, however, about the verbal formula which signals that, in spite of all the vigorous rearrangement of deck-chairs, nothing of any real substance in our public health system is going to change.

What is that verbal formula? Easy. It’s the one which reassures the reader of the Report’s unwavering commitment to the “efficient and effective” management of public resources.

What’s wrong with efficiency and effectiveness? I hear you say. In and of themselves, nothing. Nobody in their right mind wants an inefficient and/or ineffective public health system. (Arguably, that’s what we’ve got now!) It’s just that whenever the two words are linked together in the context of providing public services, they carry a meaning over and above their simple dictionary definitions.

Anyone familiar with the political and administrative history of the past 35 years will recognise immediately that that those who use this verbal formula are offering a great deal more that efficiency and effectiveness:

E&E is code for: this institution is being managed according to the theories and practices of neoliberalism.

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E&E stands for the “funder/provider split” and against the existential threat of “provider capture”.

E&E signals the presence of a parasitic, grotesquely over-rewarded management layer dedicated to ensuring that scientific knowledge and professional expertise is kept in its place.

E&E means the payment of generous “performance bonuses” to those who prove, year-in, year-out, that more “outputs” can always be extracted from fewer “inputs”.

E&E has no interest in unions, professional organisations, or democracy.

E&E represents neoliberal managerialism uber alles.

Everything else in the Report flows from this verbal ritual of obeisance to the neoliberal paradigm. The breaking-up of the Ministry of Health. The establishment of competing centres of demand for resources and personnel. The elimination of what little remains of popular participation – via democratic elections – in the allocation of public resources. The assumption (or should that be the pretence?) that meritocracy constitutes the fundamental organising principle of the entire system. Everything, in short, that guarantees the system’s ability to go on resisting genuine and meaningful institutional change is summed-up in those two words: efficient and effective.

It was George Orwell who first made explicit the totalitarian practice of describing a regime’s actions by using words that describe the exact opposite. In his chilling dystopian novel, Nineteen Eighty-Four, the “Ministry of Truth” was where the regime concocted its biggest lies. The “Ministry of Peace” was the place from where Big Brother’s endless wars were planned and run. The “Ministry of Plenty” managed scarcity. And the “Ministry of Love” was where people were sent to be tortured. Under neoliberalism – the world’s most successful totalitarian ideology to date – we find exactly the same methods at work.

What could be more inefficient and ineffective than a health system which has been starved of human and material resources for the best part of four decades? What could be more guaranteed to produce sub-optimal results than the insertion of a layer of decision-makers charged with second-guessing and countermanding the advice and recommendations of medical specialists, doctors, nurses, carers and para-medics? What better way to produce the most dire and unintended consequences than allowing managerial staff to set financial “targets” achievable only by reducing the resources (beds, operating theatres, ICUs) that hospitals need to treat their patients?

If Heather Simpson had dared to produce a report that restored to “efficient” and “effective” their true meanings, then it would have recommended the complete abolition of both the Ministry of Health and the District Health Boards, and their replacement with an all-encompassing Department of Health and Wellbeing.

This new organisation would be equipped with a state-of-the-art IT system capable of tracking every patient and the resources expended in treating them. Each hospital would be run by a superintendent who was an experienced medical professional and overseen by a democratically-elected Health Review Committee.

The day-to-day management of the hospitals would be undertaken alongside and with input from the medical staff and their professional organisations. Within the department there would be sub-departments dedicated to public health, mental health, women’s health, children’s health and Maori health, along with a special bureau dedicated to financial management, and another to the maintenance and extension of health infrastructure.

The Department of Health and Wellbeing would be statutorily required to present an annual, publicly available, report to the Minister of Health detailing both its achievements and its failures of the preceding 12 months, and setting forth its financial, workforce and material requirements for the coming year.

It would be understood by both the public and their parliamentary representatives that the health and well-being of the people is not only the state’s prime duty, but also that, in fulfilling this most fundamental of collective obligations, the sums allocated will never be enough. They would also be resolute in their determination that “efficiency” and “effectiveness” must never again have their meanings twisted to produce a system that condemns vast swathes of the population – particularly New Zealand’s poorest and most vulnerable citizens – to lives that are unhealthy and unwell.

This is not the understanding which Heather Simpson’s report seeks to promote. What’s more, it’s clear that the news media and other groups commenting on its content and recommendations never expected it to. Proof, I would argue, of just how firmly the ideology of neoliberalism still has us in its grip.

The Coalition Government’s response to the arrival of the Covid-19 virus proved beyond all doubt that when money is urgently needed to serve the common welfare, it can always be found. If only Heather Simpson’s report had loudly and unequivocally proclaimed the urgency of the need to rebuild our public health system, and called upon New Zealand society to find both the money and the will to do it.

As it stands, Simpson’s $30 million report represents neither an efficient nor an effective use of public resources.

33 COMMENTS

  1. Again I must agree with you, Chris.

    Run the thing on the smell of an oily rag, and then reduce the size of the rag and the amount of oil on the rag because that is superficially more efficient. Never mind the burgeoning health crisis that afflicts society. That can be dealt with by disaster capitalism. Thus, the system staggers on until it doesn’t.

  2. While Chris makes valid points he is also bordering on rearranging the chairs unless the changes he proposes lead to following the old advice “Let food be thy medicine and medicine be thy food.” (Hippocrates) because what we eat & drink is in many cases making us sick. Recent events with the Coronavirus along with accidents & other causes of disease show the need for a high performing health system but it would be a lot easier to achieve that result if lifestyle diseases decreased. There was a NZH article a few weeks back that made the point that heart attacks used to be around the 50 year old age mark but measures to reduce smoking & promote healthier lifestyles have lifted that age substantially.
    Poverty is a substantial cause of unhealthy living so changing that would seem to be an obvious way to improve health outcomes which would be agreeable to many of the readers here.

    • Bonnie – Yep, but regardless of the cause, ill-health will always occur, and because we are human, we need systems and processes for alleviating it.

      Many conditions like MS, MND, Parkinsons, Leukemia, are of unknown origin; people get smashed in motor accidents and also by their partners and their parents; appendectomies need doing, gall stones torture. A toddler jumps on a sleeping dad’s spleen and ruptures it.

      I am old enough to remember when our hospitals were well run by medical superintendents i.e., by doctors.

      My GP recalled how efficient the now-obsolete ward sisters were in overseeing both the patients’ and junior medical staffs’ interests.

      A Wellington Hospital customer service representative – with an arts degree- whose job is processing family doctors’ referrals, complained to me that GP’s refer patients for, “things which they shouldn’t, like headaches.” The whole anti-doctor mentality left me gob-smacked.

      Know anyone who has died of a brain tumour ? I do, an oncologist’s wife. Another’s bad head was also indicative of a brain cancer and accompanying kidney failure – she eventually got a kidney transplant ok, but
      still died young, but the point is that a woman who could barely stand upright with head pain, may not now qualify for admission to hospital, dependent on the interpretation of an algorithm by a clerical worker.

      One medical specialist family member quit NZ after the last round of so-called health system reforms, saying that he would never work here again.

      I am not opposed to cost-effective medicine, and have been involved in vigorous discourse about it, but that is no excuse for barbarism inflicted upon undeserving persons, now reduced to ‘customers’ rather than being ‘patients,’ and the sad thing is that we used to do things much better than we sometimes do now.

      Doctors running hospitals is a no-brainer – and the women who trained as nurses on the ward as paid apprentices – rather than pc learnings in polytechs- worked very hard, and they were good.

      • Know anyone who has died of a brain tumour ?

        Yes. My mother. First diagnosed by the GP as arthritis, then lombago and then, finally, sent to the hospital where she was found to have cancer spread throughout her body including her brain.

        That was back in 1981 and its disturbing to know that it could happen again because the clerks were stupid.

        I am not opposed to cost-effective medicine

        The problem being that we don’t have cost-effective medicine. What we have is cheap medicine that’s not effective.

        We have the dubious distinction of being part of a culture that confuses cheap for cost-effective and its detrimental to our society. This has been happening in Britain and her colonies for centuries and usually at the behest of the rich who get to pocket the difference (usually through tax cuts) and it effects all areas of our nation. The Rena disaster happened because it wasn’t ‘cost-effective’ to have the necessary response teams on standby even as volunteers.

        • Draco T Bastard – I don’t think the clerical workers had the clout back in 1981, that they have now.

          However back then, the largely male-dominated medical profession often viewed women’s ailments as neurotic, simply because they were women. The oncologist’s wife – in that same time frame – was diagnosed as a depressive, and advised to go out get a job. She was subsequently correctly diagnosed, treated with chemo, apparently went into remission, before the cancer grabbed her again, and she died, leaving two small children motherless.

          The situation nowadays, where a GP’s letter of referral can be discounted, sends people who cannot afford it into the private sector, and that is what it’s all about.

        • “We have the dubious distinction of being part of a culture that confuses cheap for cost-effective ”

          Qftd. That’s the story of NZ, its effects can be seen in just about everything our private sector has built and continues to build.

  3. Over the 9 years of the Key/English government, I watched the virtual demolition of the NZ “health system” occur. Until my forced retirement in 1988 because of ill health, I was a highly qualified NZRN & was a trouble-shooter for nursing administrations at both Carrington Psychiatric & Auckland hospitals, the male “nurses” at Carrington were, in truth, jailers: they knew nothing about nursing. Terrible drugs were used as chemical straitjackets. I persuaded the 2 senior psychiatrists of the ward I managed to halve the dosage of one such chemical straitjacket. They were astonished at the effect on every patient prescribed that drug: they were able to shower, dress, feed themselves. Best of all, they were able to attend group therapy & MEANINGFULLY PARTICIPATE in the process. I don’t know what occurred after I left for a tutorial position. Bad as Carrington “hospital” was, I learned that the “treatment” of patients at Kingseat Psychiatric Hospital was considerably worse. E.g., patients were left outside when it was pouring rain. Read the Mason Report published 1988 on the incompetence, inefficiency & unethical behaviours of the Superintendent-in-Chief, the Chief Executive & the Chief “Nurse” of the Auckland Hospital Board – the 3 summarily sacked (but allegedly “given” a $250,000 golden handshake some months later). The 3 of them also went to court & succeeded in having their names blacked out through the entirety of that report. The Chief “nurse” also appointed Titewhai Harawira to run a Maori unit ((Whare Paia) at Carrington, wherein she & some of her sons saw fit to abuse physically & mentally, Maori patients supposedly in her “care”. ref.: https://breakingviewsnz.blogspot.com/2014/10/mike-butler-harawiras… (unfortunately, this link no longer exists)

  4. 9 years of National party health neglect,, and the hypocrisy of the right asking for David Clark’s head and that he’s out of his depth?

    • plus 2 years of Labour Party neglect!

      And thanks to this report we’re looking at further years of neglect but then who is really surprised. This will stop when the NZ public decides it has had enough.

  5. E&E signals the presence of a parasitic, grotesquely over-rewarded management layer dedicated to ensuring that scientific knowledge and professional expertise is kept in its place.
    E&E means the payment of generous “performance bonuses” to those who prove, year-in, year-out, that more “outputs” can always be extracted from fewer “inputs”.

    This is what happens when policies are adopted from outside the realm of the organisation. For instance, I think one CEO of the Social Welfare Department had been a seaport manager; he introduced a system of prioritising work according to perceived urgency, as for docking ships etc.

    One unreasonable imposed cost in the hospital system is, I believe, imposed on each DHB for the land they occupy, so they pay a sort on a sort of lease or land tax to the government from the amount they are budgeted to run the ‘public’ hospital on government land. This is something to do with having similar costs imposed on them that a private hospital would face so they can be compared for efficiency.

    Getting adequate funding to enable effective work to be done in a timely fashion, with sufficient staff, and the expensive equipment maintained and replaced when redundant would also help efficiency. Perhaps to gain more local staff, nurses could go back to apprenticeships in the hospital for much of their time, a year’s education learning basics before entering hospital service and then block courses away from the hospital.

    Perhaps looking at individual problems as perceived by those at the coalface and not those creating models sitting on chairs, and finding a way to solve them would be a way to make useful change. This would result in necessary changes to hospital practice from practical rather than theoretical requirements. Finding different ways to monitor efficiency than at present could help greatly. B

    ut the neolib economics thinking has penetrated so deeply that it seems that any intelligent move away from it would register as an inefficiency and be detrimental to the career of the venturer. The system rules OK and the chiefs at the apex can pad their pockets as they go, so why change till it breaks in plain sight!! I think regularly of Terry Pratchett and how he applied his mind to changes in the way that alzheimer’s disease was diagnosed for him, and he found there was no practical help given to him. He pressed forward to get what he knew he needed and changed the attitudes that were prevalent. Terry Pratchett RIP. Saviours of our good hospital system arise and press the buttons in the head of the androids who have taken over our hospitals, and massing for everything else.

    • “One unreasonable imposed cost in the hospital system is…….. etc”
      If that is the case, I wouldn’t be the least bit surprised. The neo-libs devised all sorts of other little mechanisms using the same sort of BS logic or “reasoning”. Things such as the Capital Charge.
      Then there are other neat little scams such as with purchasing (e.g. ‘Preferred supplier’ status).
      Little ‘use it or lose it’ policies on operational budgets, so that when the bean counters fucked up, they’d come grovelling – asking managers to see if they could ‘split invoices’ so they wouldn’t appear as capital expenditure.
      None of it would have been/be necessary if/when the neo-liberal virus is put to death (and incidentally, the additional costs that go with it by way of ticket clippers, various other hangers-on and faith-based adherents to the E&E viral religion)

  6. The report essentially proposes a return to the system that existed from 1997 to 2001.

    It also doesn’t recommend reducing or removing co payments for primary health services, saying that higher income people would benefit too much and it wouldn’t make a difference to health outcomes.

    • Denny – “The Privatisation of the NZ Health Service(s) is coming!” It’s here, and has been done by stealth for some years.

      Sufferers are crowd-funding, mortgaging, and borrowing, not just for diagnostic procedures, but for treatment.

      And these are not just old folk with crook hips, but young mums and dads with cancers, desperately buying treatments not available in the public system.

      Those sick Nats and Treasury sociopaths whose aim was for nothing to be ‘free’, are being aided and abetted by the current govt. What’s to stop them ?

      Stop them ? Nah. They are rewarded with knighthoods and damehoods for their war on the people.

  7. Ye totally agree with your post Chris.
    $30 million dollars for a report that just rehashes with slogans and cliches the same old neo liberal approach.
    How much did Heather get paid for this ?
    Good old neo liberalisim at work , pay someone a embarrassing amount of money to give the illusion that we really do care but hey we gotta keep those profits rolling in.
    As long as the market doctrine pervades every level of governance and the wider economic business community it really makes no difference if we a Labour or National led government it is the same outcome.
    Adern and her colleges are advancing feel good policies masked as reform that will ultimately fail and spend millions to hire experts to recommend like the tax and welfare working groups to be seen to be doing something while having no intention of doing anything at all.
    The more things change the more they stay exactly the same.

  8. Trapped in a time warp.
    Strange as it is, I’d never clapped eyes on her until that photo. I’m not sure how that happened. But if that’s her, she’s EXCTLY as I imagined her to be.
    (So …………), I have to admit she served H1 well as a shit-kicker. JA needs something similar but without the E&E (ultimately, in this space, going forward). She must be due for a QB or NY’s award in the honours list surely!
    Someone – shoot me NOW!!!!!!!!!!!

    • Actually it’s more to do with who she reminds me of as a nipper at an Anglican Missionary Church school as we were emerging from the first wave of colonisation. An old battleaxe without her habit on.

    • OwT
      Please suggest the award yourself, also one for Winston Peters. He would be a handsome addition to the peer group, and it has been earned for longevity and stickability and a number of other much better reasons. And also it would give him the thought that it is time to retire and go fishing.

      • Having attended an investiture ceremony for a rellie (ONZ – well deserved as it happens) a while back was enough for me. And now as I lose some fangs as a result of not being able to get to an emergency dentist during lockdown, I even have sympathy for the Guv at the time who almost lost his dentures.
        And now, as a new Pensioner at Large with curmudgeonhood as a right of passage, it’s hard to keep being relentlessly positive when I keep seeing the same old effects of the neo-liberal religion/virus happening.
        I’ll be dreaming of that bloody photo now. Thanks Chris!

  9. If only Heather Simpson’s report had loudly and unequivocally proclaimed the urgency of the need to rebuild our public health system

    Doing that would reduce the profits of the private health system and no present government would dare to interfere with profit as they’ve been trained (like Pavlov’s dog) to believe that profit shows things are working well rather than the reality that profit shows that things are working badly.

    Profit is a dead-weight loss. Competition is supposed to reduce/eliminate profit but competition itself is an inefficiency as it increases the amount of bureaucracy and regulation needed.

    If we truly want a viable health system then it must needs be a fully public system. Even the GPs would need to be within that system.

      • DT, bastard, is an okay guy I guess. Yknow I use to pro freemarket but all that’s gone now. Aussie GPs and public health services like radiology get to bulk bill straight to the federal government. The caveat I guess is Australia had 30 years of Paul Keating and then John Howard who are elite level veterans at hiding taxes mainly through superannuation, it’s like a pot of gold just sitting there waiting for someone to pick it up.

  10. It look’s and smells like a “One size fits all” which is a disaster with those who have ‘chemical intolerance or chemical poisoning’ as the current Ministry of Health has no protocols for treating such patients like me as I was chemically poisoned in a workplace accident and still suffer from this disease as Ministry of Health several times has confirmed to me and my doctor over the last two decades that they have no methods to treat chemical poisoning!!!!!!!

  11. Other terms and terminologies misappropriated and being ideological bent toward neo-liberal economic marketing over the past 30 years are:

    Business Model
    Private-Public Partnerships
    Cost-Benefit-Analysis
    Cost-Recovery
    Accountability / Governance / Procurement
    Economic Growth

    Any feasibility study in which the summary is swamped by these terms should be highly suspicious.

    Policies, guidelines and manuals produced by some consulting firms or individuals are just feeding into assets and wealth transfer from state to private sector.

  12. This is exactly the “reform” that hey had in the UK which left them unprepared for Covid 19. The whole point of this is to save money. Several DHBs were running deficits for two or three years now. They were threatened with commisioners being appointed. The deficits increased. More and more DHBs went into deficit. The idea that the funding formula that is used to make the budget was somehow now wrong was not on the radar.

    The deficits are broadly in line with population increases bought about by immigration. The fiasco of the last census has not helped as population figures in each DHB will be innacurate. Many people are now leaving Auckland and moving to other areas. If you can find an excellent of history or “reform” of the NZ health service. It is a litany of constant tinkering.

    • What’s worse is that Labour’s last budget had per-capita health spending (the best metric for sustainable investment in health) declining! What the fuck? I know, let’s get loads more immigrants in to NZ on dodgy work visas etc, let then have free health care (even though overseas they don’t do this – you must have health insurance), then wonder why DHB’s run deficits?

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