GUEST BLOG: Ian Powell – Health boss appointment could define credibility and direction of health system leadership

The Government is expected to announce soon the new Chair of Te Whatu Ora (Health New Zealand). This follows the sudden resignation of outgoing Chair Dr Karen Poutasi whose term had been scheduled to end in December rather than this month.

Sitting behind this are some murky politics and agendas which, depending on how they unfold, will shape the credibility and direction of the health system under Te Whatu Ora’s leadership.

My approach is to focus on health systems rather than health leaders. Overwhelmingly the challenges facing Aotearoa New Zealand’s health system are systemic.

Where health systems go wrong is when form and structures rather than functions and culture prevail, as was the case with the Labour government’s health restructuring.

However, including their personality traits and beliefs, health leaders become intertwined. Just as ‘good’ people can make a bad system work, ‘bad’ people can both obstruct a good system and further worsen an already a bad system.

Collateral damage

Health minister Dr Shane Reti: top appointment risks his marginalisation and credibility loss

If the expected appointment is confirmed, then this is going to seriously marginalise health minister Dr Shane Reti and damage his credibility.

His marginalisation would be because the expected appointment would make it more difficult to achieve his objective of devolving decision-making regionally within Te Whatu Ora in order to be closer to where healthcare is overwhelmingly provided.

His credibility would be damaged because of the damaged credibility within the health sector of the expected appointee. Reti would become collateral damage.

The expected appointment

Prime Minister Luxon calling the shots on appointment

The expected new Te Whatu Ora chair is Dr Lester Levy. The driver of this decision is not the health minister.

Instead it is Prime Minister Chris Luxon whose known view behind closed doors is that the problem of health is than it is run by health.

Last week (14 May) I discussed this in my article published by Newsroom: The politics behind pending health boss appointment.

The focus of my article was on:

• the manner of the resignation of outgoing Chair Karen Poutasi;
• Prime Minister Chris Luxon’s views on the kind of person who should lead the health system and that his officials are running the appointment process;
• Levy’s record in health leadership since 2009;
• why Levy appeals to Luxon; and
• the expected consequences should Levy be appointment.

What you need to know about Lester Levy

For further background on Lester Levy, I refer to my two-part series published by Victoria University’s Democracy Project on 20 and 24 August 2021: The luck and comings of Lester Levy and The third coming of Lester Levy; a process glued together by hypocrisy.

Also relevant is a further subsequent article again published by the Democracy Project (24 September 2021): Reputations in tatters.

This above-mentioned article includes links to another two-part series published earlier that year on the theme of a ‘bureaucratic coup’ that Levy was a key player in against the pro-workforce engagement leadership of the former Canterbury District Health Board (DHB).

What makes health systems work better (and worse)

Health systems are labour-intensive, complex and internally independent. Consequently, relationships arising from cultures are critical.

This means that health systems function best when their prevailing culture is relational. Alternatively, they function worse when the culture is contractual.

Relational culture critical to health system performance

The more the former prevails, the greater the engagement, innovation and effectiveness of health professionals working in communities and hospitals where healthcare is largely provided. Patients are the winners.

The more the latter culture prevails, the greater the opposite occurs. Instead the culture is top-down command-and-control based on vertical managerialism. Patients are  the losers.

A paradigm unlikely to shift

Lester Levy is firmly located in the latter culture. His frame of reference is a narrow paradigm unlikely to shift. Shane Reti is more comfortable in the former although does not get it as well as he should (and hopefully might).

In the early to mid-2010s the then National-led government used a crown agency, Health Benefits Ltd (HBL), to rationalise what were disparagingly called ‘back-office’ functions, such as procurement, in the DHBs.

It was a laudable objective but to succeed required the right culture in order to get things right. It didn’t, it was very hierarchical, and the consequences were damaging and costly.

Levy was a critical part of HBL’s leadership then both as deputy chair and the most influential figure in the leadership of the three large Auckland DHBs.

The contractual culture prevailed in the relationship between the three Auckland DHBs and the  primary care in the region through their Primary Health Organisations. Consequently, the relationship between them was destructively terse and conflict-ridden.

To varying degrees this contrasted with the largely more relational cultures in the country’s other DHBs. This contrast was most pronounced in Canterbury DHB.

Canterbury’s successful internationally recognised health pathways between community and hospital would not have occurred without this culture.

Shamefully the former Labour government sent Levy to Canterbury as a crown monitor to help bring this culture down.

Likely consequences

If the expected appointment to the Chair of Te Whatu Ora occurs, then Minister Reti’s wish to devolve decision-making within the organisation further down the hierarchy will be led by someone whose practice has been to favour the opposite.

It will also damage Reti’s credibility within the health system. He has already been damaged by an appalling government decision which was not of his making.

This was repealing New Zealand’s world-leading tobacco control legislative amendment. That was a huge rat for him to be forced to swallow, especially as a general practitioner.

Now he may have a new head of Te Whatu Ora with a strong undermining connection with the prime minister.

Further, this head adheres to a culture likely to make the already dysfunctional organisation even more vertically controlling (and consequentially even more dysfunctional).

In other words, Health New Zealand would most likely become more prone to making the wrong service provision and fiscal decisions as well as further demoralising an already demoralised workforce.

Few things would marginalise and damage the credibility of a health minister than this.

 

 

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