GUEST BLOG: Ian Powell – How to immobilise a health system’s primary statutory adviser and monitor
It is easy to not understand what a ministry of health does in health systems; why they exist. This is because much of its work is invisible to most.
At the very least, it is below the radar. This certainly applies to the Ministry of Health in Aotearoa New Zealand’s health system [it has to acknowledged nevertheless that at times its leadership culture has not helped].
Consequently the Ministry is vulnerable to coming under attack from a government driven by political agendas and whose line of attack is delivered by erroneous or deliberately misleading soundbites rather than analysis.
The Ministry has become an institutional scapegoat of political convenience.
Public Service Association doing a good job representing health ministry staff
This vulnerability is compounded by the fact that, as a public service, the health ministry can’t defend itself although it has to be recognised that the main union, the Public Service Association, is presently doing a very good job.
Scorching the health ministry
The vulnerability was highlighted when the fireball of the right-wing, and somewhat dystopian, National-led government cuts to public service staffing scorched the health ministry on 4 April.
I discussed the wider issues of these public service cuts in my other blog, Political Bytes (1 April): Function versus form.
While the public service cuts overall were supposed to range from 6.5% to 7.5%, the announced slashing of 134 health ministry jobs represented a much higher 18% cut.
The implementation of these headcount based cuts confirm that the government is putting form before function when it should be the other way around.
It also perpetuates the demonisation and devaluing of the so-called ‘back office’ in relation to the ‘frontline’.
In my above-mentioned Political Bytes blog I outlined how this demonisation and devaluing was imposed on district health boards under the previous National-led government (2008-17).
Journalist Andrea Vance demolished political credibility of public service cuts
Andrea Vance, National Affairs Editor for The Post and Sunday Star Times, has done a devastating credibility demolition job on the Government’s public service cuts.
This includes arguing political double standards and hypocrisy by ministers asserting that actioning these cuts are operational rather than political decisions: Politicians absolving politicians of blame.
The truth is that back office functions are integrated with frontline functions with the former dependent on the latter. This false narrative from government is made more disingenuous by the fact that almost all the health ministry does is back office.
What does the Health Ministry do
But the work of the ‘back office’ ministry is integral to the functioning of the whole health system. Its function is to be the primary adviser to the government on health. This includes priority setting, policy and system performance.
It is responsible for the administration of legislation. This includes the Pae Ora Act 2022 which governs the health system.
Also included in this responsibility is the Health Practitioners Competence Assurance Act which determines the competence of health professionals in the context of the safety of the public.
A further critical legislative driven function is protection and regulatory. This includes (along with many others) environmental, health professional competence, medical examinations of children, and critically, new medicines approvals through MedSafe based within the Ministry.
Suicide prevention
The Ministry also plays a key role in supporting or leading projects focused on critical healthcare issues. Suicide is a case in point.
In 2019 the then Labour-led coalition government created a small ‘suicide prevention office’ within the health ministry.
Its focus is on strategy, policy, regulation and monitoring the outcomes achieved by the system as a whole. This includes an emphasis on proportionately high suicide risk populations, particularly Māori, Pacific, and youth.
The relative newness of the office, coupled with the prolonged disruption due to the pandemic in the midst of which was unhelpful earlier health restructuring, limited what it could achieve within its short existence.
Owing to the nature of suicide prevention the office’s effectiveness can’t achieved by quick fixes. Nevertheless it was a busy, needed and diligent unit.
The effect of the headcount approach to the cuts meant that the office would disappear without any assessment of the continued relevance of its function. Again form before function.
Mental health minister Matt Doocey left with political egg yolk running down his face
The revelation of its demise led to political egg yolks running down ministerial faces. The most affected was new mental health minister Matt Doocey.
This was unfortunate because he has demonstrated a considered thoughtful approach to mental health issues.
Political embarrassment has now led him to require the health ministry not to close the office. However, the net effect may be little different with the high risk that reduced staffing will severely compromise its performance.
Compromising tobacco regulation effectiveness
Successive Labour and National-led governments have been committed to achieving a smokefree New Zealand. In 2023 the former Labour government amended the smokefree bipartisan legislation in order to strengthen and accelerate this objective.
However, the unexpected and secretive influence of the tobacco industry led to the new government repealing the legislative amendment.
I discussed this earlier in Otaihanga Second Opinion (11 December) when the decision to repeal had been announced but not yet implemented: Perversity of pending smokefree repeal.
At the time the Government claimed that it was developing an alternative smokefree approach.
However, the lie to this claim was evidenced by the revelation in the NZ Herald(8 April) that the health ministry staff responsible for tobacco regulation would be slashed by 38%: Slashing tobacco regulation capacity.
This specific slash should be seen the context of both the overall 18% cut for the health ministry in which the office was based and the 6.5-7.5% for the whole public service.
It could be argued that function came before form in this decision. If so, the function would have been to protect and enhance the tobacco industry’s profitability while the form was slashing the health ministry’s regulatory capabilities.
Earlier destabilisation
This is not the Ministry of Health’s first recent restructuring. Two years earlier it was restructured by losing its responsibilities for funding, planning and delivering health services.
In conjunction with the abolition of district health boards, its relevant staff were transferred across to the new Te Whatu Ora (Health New Zealand) by July 2022.
Inevitably, while there were no overall job cuts, it was still destabilising for those remaining in the much downsized organisation. Under new leadership the restructured Ministry had limited opportunity to do much more than find its way before it was whacked by these staffing cuts.
I have previously been critical of past leadership of the health ministry, particularly since the mid-2010s. This was primarily over the narrowly focussed ‘control culture’ of its top leadership.
It is too early to tell whether this criticism can be reasonably applied to the current relatively new leadership team.
Such is the Ministry’s reduced role since the creation of Te Whatu Ora that this ‘control culture’ has simply migrated to the new body but more vertically centralised than previously and with the ‘control culture’ expanded to include ‘command’.
Despite my concerns with this ‘control culture’ however, I was also impressed by the diligence and commitment of many Ministry staff closer to the operational engine-room of activity.
The functions they performed were both critical for the performance of the health system and invisible to the wider public and even to many within the health system itself.
The most likely outcome
So what is the most likely outcome of these public service cuts to the health system? As sure as night follows day, bad processes lead to bad outcomes. Inadvertent consequences is a polite description.
The Government has put form before function and used the blunt arbitrary instrument of headcount staff cuts to do this. The health ministry has been sent on a pathway towards immobilisation.
Consequently a decline in the quality of the Ministry of Health’s advice to government, its administration and monitoring of the health system, and performance of critical regulatory functions will most likely diminish; arguably inevitably.
It won’t just be the demonised and devalued public servants who have lost their jobs that are the casualties. Immobilising the Ministry also means the health system will be a casualty as well.
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
Simple thing is – I don’t want my doctor to have to do his own photocopying. As it is the poor bugger has to spend about seven minutes of a 15 minute consultation filling in forms on a computer.
When my husband’s surgeon rang me late last night to report on hubby’s surgery yesterday, he too sounded exhausted.
It was a long and complicated bit of surgery. There were surprises.
He said husband had had a ‘bit of a hammering’.
I don’t think my husband was the only one. I feel the whole theatre team had had a day they’ll remember for a while. This all takes its toll on people. They are expected to go back today or tomorrow and do something similar, all over again.
To imagine the support staff, back-room people might not be there to keep the system ticking over so that front-liners cannot do their jobs properly, doesn’t bear thinking about. How can frontline staff work if the back-room is gutted, simply to show ‘form’ It sure isn’t function.
When ministers, who are usually jack-of-all-trades kind of people, not experts, say they don’t need to assess reports, study results, read impact statements and then make decisions based on what they learn, is ridiculous. This business of not wanting to really know what’s going on, is extremely dangerous.
Those who work by that idea of course, assume they and their families will never be caught out by a system that doesn’t work well for them. They can always buy themselves better care. They think inadequate administration workers will never be a problem for them. Good luck. This will come back to bite them, personally, sometime.
All the best to you and your husband Joy.
Yes lets give landlords a massive tax cut and leave the brand new 150 bed surgical hospital on the north shore empty and with no funding to hire staff and to open it .At the same time we will pull the pin on another new same size unit in Whangarei which would have meant people would not need to travel from Kaitia to North shore for treatment .
Thats ok because when the tennant passes away from lack of health care the land lord will be able to charge an extra $100 per week from the tennant and probably be able to keep the dead persons bond as well .
That’s all well and good Gordon but Bob the first couldn’t give to fucks.
Many of our Public hospitals are full of foreigners getting procedures courtesy of my taxes, blood banks full of Indians referred by their Indian GP in the meantime we have to fight to have these tests or be feisty and demand them. Not good enough. Reti useless as ever a lame duck sitting back waiting to put another knife into Maoridom.
That photo. Dr Cigaretti belts out a cover of ‘ Be Mine Tonight’, with special emphasis on the “Asian cigarettes”
Our health ‘system’ was doomed from the days of the Key government. They were discreetly privatising it from Tony Ryall’s day.
Once the Head Prefect of AGS (ACT Grooming School) Dr Jonathan Coleman (an ACTor at heart, not a Nat) got the portfolio, he almost openly headed for the privatisation of health and then, hey presto, when Labour won, JC resigned and was immediately appointed a senior executive of a private health conglomerate.
No surprises there!
Don’t expect Dr CigaReti to change anything – the privatisation forces are against him.
You stated that you were reserving judgment on the new government. Well as a health professional all i can see is cut’s To see smoke free gone is enough of a legacy for Reti who cowardly didn’t want to handle it and quickly handed it over to a tobacco lobbyist. He knows that the mantra for all doctors “first is do no harm “ he should be struck off for less. Now we find out that she left out the massive overall health savings that would have been achieved with smoke free. I remember how critical you always were of the Labour government no sitting on the fence there. So surely as a doctor there should be absolutely no ambivalence in your attitude to this awful government. The urgency on the smoke free legislation in their first 100 days should have quickly made up your mind. Smoking harm is all pervasive throughout the health system and as you know affects many medical specialties. So my advice to you Dr. Powell is to quickly call this government out for who they really are in pandering to big tobacco ie. money before people’s health
I’m not a doctor first. Second, I’ve been critical of both Labour and National-led governments over many years.
I see you are afraid to call them out for what they really are doctor or not. You speak on health matters on a daily basis, you continuously called out the Labour government, some of us have long memories Dr.Powell and I am thinking you are a tad biased when talking all things political.
Actually. Mr Powell, I don’t think you addressed NMGs claims.
Your thoughts on this governments appalling health governance since it came into power please?