GUEST BLOG: Ian Powell – How a leadership culture conflict escalated in New Zealand’s public health system

Earlier this month the Democracy Project hosted by Victoria University published my first article of a two-part series on a very bureaucratic coup against the chief executive and the rest of his senior management team at Canterbury District Health Board (CDHB).

It covered a very dark period in New Zealand’s public health system from the second big Christchurch earthquake in February 2011 through to the 2017 election.

Engagement vs bureaucratic centralist cum command and control leadership conflict

It is often the case that conflicts are driven by personality clashes. Despite perceptions and assertions to the contrary, primarily this escalating dispute involved conflicting leadership cultures between the Ministry of Health (MOH) and CDHB.

The former was bureaucratically centralist and top-down while the latter had a stronger emphasis on engagement with both others in the Canterbury health system and its own workforce.

In DHBs the predominant leadership culture was managerialist where management was the source of system leadership and change and, outside more narrowly confined formal clinical leadership positions, the role of senior doctors, for example, was largely restricted to the diagnosis and treatment of patients.

Managerialism was organically aligned with MOH’s bureaucratic centralist leadership culture except that its position at the peak of the bureaucracy hierarchy meant that it wasn’t a big leap for its leadership style to morph into command and control. This meant that the more a DHB was committed to engagement with its own workforce and non-government organisations working with its defined population, the more likely it was to come into conflict with MOH.

But, despite the prevalence of managerialism in DHBs, it varied with some more interested in engagement through clinical leadership distributed throughout the workplace from individual service departments to the chief executive; the greater the scope and quality of this engagement culture, the more it affected the culture of DHBs senior management teams for the better. Canterbury wasn’t an engagement paradise. Instead it was work in progress. But it was well ahead of the pack when compared with other DHBs and was admired internationally.

Even within DHBs there was variation with some parts having different leadership cultures either more managerial or more engagement based. Obviously this was most evident in the larger DHBs. But over the years working for the Association of Salaried Medical Specialists I was struck by the extent of this variation within the smaller DHBs. For example, during much of the 2000s and 2010s the paediatric department at Tairawhiti DHB covering Gisborne and East Coast was a shining light for internal engagement; senior management was much more managerialism-based elsewhere.

Responding to a natural disaster

But leadership culture clashes don’t occur in isolation. They require a lightning rod and what could be more effective than responding to a natural disaster. The MOH-CDHB conflict was in the context of responding to the devastation caused by the massive Christchurch earthquakes of 2010 and (especially) 2011.

In fact, CDHB had to face with more than one natural disaster. There were the subsequent out-control fires and the Kaikoura earthquake. Although not a natural disaster, there was also the murderous terrorist mosque attack to deal with in 2019. All DHBs were under severe pressure due to the combination of sustained under-funding and increasing illness within their populations. But none faced anything like the magnitude of Canterbury disasters.

The escalating conflict began almost immediately after the 2011 earthquake with MOH advocating reduced funding based on a flimsy and disapproved assumption of a large population loss in Christchurch. Instead the city’s population grew significantly.

This was followed by:

• pressure to force CDHB to support a Public Private Partnership for the rebuild of Christchurch Hospital;
• a MOH attempt to prevent CDHB keeping its insurance payments for the capital works costs it incurred and paid for damaged facilities;
• MOH refusing to accept CDHB’s assessment of the mental health impact of the earthquakes;
• the response to the implementation of non-recommendations of a PricewaterhouseCoopers review (these were suggestions that largely CDHB had no legal authority to implement);
• CDHB’s more networking and relationship-based approach to shared services between the South Island DHBs compared with the MOH supported Health Benefits Ltd (HBL) more rigid and high transactional contractual approach; and
• pressure to force CDHB to support financially disadvantageous new food and laundry business cases from central government.

Throughout this there was a growing view among the MOH leadership that CDHB’s senior management team was too influenced by its senior medical staff and, in particular, the Christchurch Hospitals Medical Staff Association. This supposed influence was, in fact, a level of management engagement with senior doctors that was overall higher than other DHBs during this period.

Confirmation of Health Ministry’s objective

MOH’s best endeavours to ‘command and control’ CDHB was confirmed by Sir Mark Solomon’s dramatic public revelation in the Christchurch Press (4 September 2020). Solomon stated that after an induction meeting at MOH, following his appointment as Chair of CDHB in 2016, he was told by then Director-General of Health Chai Chuah to “get rid of David Meates” (Meates was CDHB’s chief executive) and his senior management team.

Solomon responded that Chuah’s directive was “totally inappropriate behaviour.” At the induction meeting itself Solomon said that he and other Board members “…got an hour’s dump at how terrible the board and management of Canterbury was.” 

From sunshine to greater darkness

In opposition the Labour Party had condemned MOH’s behaviour and committed to turning this around if elected government. Hopes were high in the health system that Labour would deliver on its commitment because MOH’s relationship with DHBs generally was so difficult (Canterbury’s was compounded by the leadership culture conflict in the context of responding to earthquake devastation).

But, after an encouraging start initiated by new Health Minister David Clark, the sunshine of hope was dramatically replaced by an even greater darkness. My second article Democracy Project article will discuss how this happened, who made it happen, and Labour’s extraordinary u-turn.

 

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.