GUEST BLOG: Ian Powell – ‘For the love of god’; why say so much when saying so little?

‘For the love of God’ is a commonly voiced expression. Generally it involves a high level of frustration or exasperation. Often it also includes a call for something corrective to be done.

This was my initial private response to the editorial in 15 August issue of the New Zealand Medical Journal by Lester Levy, Chair of Health New Zealand (Te Whatu Ora):     Saying so much in order to say so little. [free subscription required to access]

Under the eye-catching heading ‘Reforming Health New Zealand: confronting crisis, sustaining recovery, the three-page editorial skilfully manages to say so much while, at least in substance, says so little.

ASMS: “Propaganda”

Journalist Steve Forbes reports same day critical reactions

In a NZ Doctor paywalled online article later that same day, Steve Forbes reported immediate critical responses. One was from the Association of Salaried Medical Specialists (ASMS): Propaganda editorial. In Forbes’ words:

But Association of Salaried Medical Specialists executive director Sarah Dalton isn’t impressed with Professor Levy’s editorial, which she describes as propaganda.

“Where’s the recognition of the workforce shortages we’ve seen over the last two years, which Te Whatu Ora has refused to address in any meaningful way?”

Ms Dalton says the cuts to Te Whatu Ora data and digital team over the last two years have also undermined any plans to improve productivity in the sector.

“So I think it’s disingenuous for him to talk about productivity gains,” she says. “We need to stop this constant game of smoke and mirrors in health.”

There was also scant mention in the editorial of primary healthcare, she says, even though addressing the problems in general practice is vital to fixing the pressure on the country’s hospitals.

Full Disclosure: I’m not in the Lester Levy fan club!

I agree with this response including the “propaganda” descriptor. But I should disclose that I’m not a member of the Lester Levy fan club. However, in saying this, I have no sense of loneliness.

I also need to disclose that while Levy has many critics, I have probably been the most persistently publicly vocal about his approach to the health system.

Living in semi-rural Otaihanga has been a conducive setting for my published thoughts

By way of examples I refer to the following of my published pieces:

1. Democracy Project, Part 1 – A very bureaucratic coup (15 April 2021).
2. Democracy Project, Part 2 – A very bureaucratic coup (19 May 2021).
3. Otaihanga Second Opinion, Dirty politics and smear campaign (3 June 2021).
4. Democracy Project, Reputation in tatters (24 September 2021).
5. Newsroom, Feudal baron (26 July 2024).
6. Otaihanga Second Opinion, IT slash and burn (15 December 2024).

Ever-decreasing decision-making circle

While the ASMS critique of the editorial is sound, there is more that can be said. Since the vertical centralisation of decision-making created by the Pae Ora Act 2022, decisions are being made from by an ever-decreasing circle.

This outcome is more due to the false construct of the Labour government’s restructuring than the people left in charge of leading the health system.

But the latter have not helped. The decreasing circle continues to decrease despite claims of devolution.

While the top leadership circle decreases, the gap between it and the workforce expediently increases. The debate now is not whether they are on the same planet. Now the debate is whether they are in the same solar system.

Ignoring the Horn review

This is the context of Lester Levy’s “propaganda” editorial. His opening description of the state of the health system by the early 2020s focuses only on symptoms (and only superficially) rather than the root causes.

Health minister Tony Ryall established the Horn review

It also ignores the Horn review (2009) by a working group established by then National Party health minister Tony Ryall. Chaired by former Treasury head Murray Horn, a large part of it was recommending greater centralisation of the health system.

This function of increased centralisation was structurally implemented although not in the form of the structure proposed.

Instead of a new structure the function became the responsibility of the health ministry and a national board sitting both within and alongside it.

Although there were different ideological perspectives, there were similarities with the thrust of the Heather Simpson led review on the health and disability system (2020) which, in big part, was abandoned on Labour health minister Andrew Little’s watch.

The problem was that the culture of those responsible for exercising this function within the Ministry of Health were too top-down and, both in aspiration and where doable in practice, adopted to varying degrees a ‘command-and-control’ leadership culture.

None of this was recognised by the Levy editorial. More important the root causes were also ignored beginning with increasing workforce shortages.

Dodging root causes

These shortages first became evident from around 2007 with salaried medical specialists.

Ignoring root causes is why Lester Levy’s editorial is so wrong

These shortages were largely driven by dramatic  and unexpected developments in the competitive Australian specialist labour market which made it much more competitive than previously.

By the mid to late 2010s these severe shortages had extended across the full spectrum of health professionals, including the largest occupational group (nurses).

Second, Levy ignores the biggest driver of health system demand (and cost), the biggest driver of ‘bed blocking’ in public hospitals, and the biggest obstacle to achieving the health targets from the mid-2010s.

This is when acute hospital demand rises at a rate greater than population growth. This represents a turning-point threshold for the worse. This demand can’t be clinically deferred.

Between 2024 and 2023 inpatient acute hospital discharges increased by 24% whereas population growth only increased by 16%.

Drilling down further, compared with the 24% increase in acute discharges, the inpatient non-acute discharges actually decreased by 1%.

Whereas Levy’s editorial manages to say so little by saying so much, this little data snippet succeeds in saying so much. It reliably speaks volumes.

Linked to underfunding (discussed below) increasing acute hospital demand was the prime driver of district health board financial deficits from the mid-2010s.

Third, health funding declined relative to demand driven health costs. Again the Levy editorial is silent on this root cause.

Controlling for inflation and population, the per-person spend grew on average 4.7% percent per year during the Helen Clark Labour-led government (1999-2008), compared with 1.3% during the John Key-Bill English National-led government (2008-17).

Finally, the editorial is also silent on the increasing and demoralising ‘command-and-control’ leadership culture of central government, mainly through the health ministry,  over district health boards. This arose out of the implementation of the above-mentioned Horn review.

It included the crudely demonising of critical support staff under the guise of the ill-fated Health Benefits Ltd drive to slash so-called ‘back office’ support. Ironically, Levy was the deputy chair of HBL for much of this time.

These large failures of analysis through conscious omission inevitably led to editorial misdiagnosis. This includes the causes of underperformance and why the Labour government’s restructuring “faltered”.

They also contributed to exaggerated claims over both financial performance, largely achieved by ‘slash and burn’ (even including critical IT support) and service performance.

Capping it off is a brief unsubstantiated and superficial assertion of a turnaround in productivity. That is, ‘productivity’ involves both what can relatively easily be counted and what is politically convenient to count.

Back to the harsh reality

Levy’s concluding claim of cautious optimism was quickly contradicted by two media revelations.

Experienced journalist Andrea Vance brings reality into Levy editorial claims

The first was the paywalled article on 1 September by national affairs editor Andrea Vance in The Post: Secret staffing data withheld.

Vance reported that Health New Zealand had been ordered to apologise after the Ombudsman found it acted unreasonably and unlawfully in withholding data that shows more than a third of all public hospital shifts in 2024 were understaffed. Subsequently a public apology was issued.

The second, also on 1 September, was by the NZ Herald deputy political editor Adam Pearse covered leaked failing emergency department wait-time targets: Leaked data show major hospitals failing.

If this was not enough this week there were two national one day nursing strikes mainly over increasing patient safety risks.

Who does one believe – Health New Zealand’s Chair in an ever decreasing circle or fatigued nurses on the clinical frontline having to deal daily with these ever increasing risks? A rhetorical question if ever there was one!

From a health policy perspective: ‘Glaring gaps’

Professor Jackie Cumming: The final word

The final word on Lester Levy’s editorial should be left to independent health policy researcher Professor Jackie Cumming as covered in the above-mentioned NZ Doctorarticle. Steve Forbes reports her as saying that:

…there are glaring gaps in Professor Levy’s editorial, where he fails to mention some key issues affecting the health sector.

Dr Cumming says that includes his almost total disregard of staffing and workforce and public health in the paper, which she says is “really concerning”.

“I think that’s something that’s missing from this editorial and other parts of the Government agenda. The lack of focus on primary healthcare is also a concern and there’s also no mention at all of funding levels.”

For far too long, she says, successive Governments have failed to provide sufficient funding to meet the increasing costs associated with maintaining a high-performing publicly funded health system.

Dr Cumming says it’s interesting that one of the things Professor Levy attributes the financial deterioration of Te Whatu Ora to is restructuring under the previous health reforms. But she says since Professor Levy was appointed as commissioner in July last year, his proposed solutions have focused on more restructuring.

Perhaps Professor Cumming (and many others) might have also muttered ‘for the love of God’ when first reading the NZM editorial! Or maybe she might have been more Anglo-Saxon in her choice of words!

 

Ian Powell was Executive Director of the Association of Salaried Medical Specialists, the professional union representing senior doctors and dentists in New Zealand, for over 30 years, until December 2019. He is now a health systems, labour market, and political commentator living in the small river estuary community of Otaihanga (the place by the tide). First published at Otaihanga Second Opinion