GUEST BLOG: Ian Powell – Ministry of Health: feudal fiefdoms and a culture of obliviousness

Several Director-Generals of Health ago I recall a senior official bemoaning that the Ministry was made up of feudal fiefdoms connected only by email. The Ministry was not functioning as an integrated organisation. At the time this resonated with me.

Last week I was reminded of this by the public exposure of the controversy over the removal of important comparative data from a report from the Ministry’s mental health and addictions directorate. Its implications extend behind mental health.

The controversy is well-covered by two powerful pieces of writing. The first was by Stuff journalist Henry Cooke:. The second was by freelancer Oliver Lewis in The Guardian:.

Fiefdoms to obliviousness to organisational culture

This exposure got me to thinking whether, several Director-Generals later, the existence of Ministry fiefdoms had changed. It seems not. But there is more to the fiasco than this. In today’s world fiefdoms within such an important institution as the Health Ministry indicate a high level of obliviousness. This goes to the heart of undermining the overall trust and confidence in the Ministry of government, the wider health sector (including health professionals, district health boards and non-government organisations) and the public.

Obliviousness has two different (not necessarily alternative) meanings. The first is lacking remembrance, memory, or mindful attention. This isn’t the case in this instance. But the second, lacking active conscious knowledge or awareness (especially the latter) applies.

This led to think about organisational culture. I discovered the following interesting description which sums up the Health Ministry leadership culture well:

“Obliviousness exists at the individual level, it becomes reinforced at the cultural level, and, in turn, cultural practices are entrenched institutionally by policies. Organizational obliviousness may not be malicious or done to actively exclude or harm, but the end result is that it does both.“

The fiasco

The controversy involved a routine annual report, usually published another year after the year in question, from the Ministry’s mental health and addictions directorate. There was an unprecedented battle between Ministry officials to reduce the amount of data in it, including the removal of wait-times, suicide statistics and the overall proportion of the population using specialised mental health services. As noted by the “gobsmacked” independent Mental Health Foundation this data, which isn’t published elsewhere, was important to track changes over time.

Owing to Covid-19 and this battle the eventual recently published report covered two years (2018 and 2019). Those senior officials who wanted the removal succeeded. Despite covering two years the slimmed down report was 15 pages shorter than the 2017 report. The Ministry’s feeble defence was that it had simply ‘modernised’ the report.

Back in March 2020 a draft report for 2018 had been completed by the officials responsible for writing the report each year. Director-General Ashley Bloomfield signed off on it in July. But then there was kick-back by the directorate leadership under the intriguing means of a ‘risk lens’. Ministry officials really need to be more careful over their choice of words. Unfortunately the kick-back’s ‘risk lens’ prevailed.

Fiasco context

The quality of the exposure of this fiasco left the Ministry looking both dysfunctional and appearing to censor information that might not reflect well on its performance. Underpinning this is a serious difficulty. Following receipt of a report it commissioned on mental health services the Government endorsed a new direction that extended services to wellbeing by including addressing anxiety.

In principle this was a good initiative but it is very difficult to successfully implement such an extension of this magnitude when existing acute mental health services are being increasingly overwhelmed, largely due to severe shortages of psychiatrists, psychologists and other relevant health professionals. The net result is that both acute services and non-acute extensions suffer.

This suffering is a policy implementation and workforce investment failure made worse by the Ministry’s leadership culture of obliviousness.

Implications of PR train wreck

There are political implications arising out of this public relations train wreck. Surprisingly, for such a capable minister, Health Minister Andrew Little’s initial response was to support the Ministry’s conduct. But Prime Minister Jacinda Arden got it quickly distancing herself from the Ministry (as did then Little).

Already before the 2017 election there was a lack of confidence in the Ministry by the Labour Party. This has continued despite generally very good leadership from the Ministry and its public health units in the response to Covid-19. This sits behind the Prime Minister’s support the recommendation of the Heather Simpson review of the health and disability system to establish a second national health bureaucracy (currently branded ‘NZ Health’).

Ardern’s support for the additional bureaucracy flies in the face of strong opposition from Ashley Bloomfield. The last thing he needed was a fiasco such as this that further shakes Government confidence in the Ministry. But the buck stopped with him over this oblivious bureaucratic feudalism. The logic behind creating an additional national health bureaucracy is weak because there is no reason to believe that its leadership culture would be any less feudal or oblivious. But the emotion behind it is strong.

The Health Ministry is populated by people who work hard and work well but are undermined by this cultural obliviousness. This sort of behaviour also undermines the trust and confidence relationship that is vital for the Ministry’s credibility with the wider health sector and especially health professionals who are regularly confronted with the pressures and suffering of ill people in the real world outside its feudal edifice.

There are two take-home messages from this sorry saga. First, sadly and unfairly, the good work done by the Ministry’s workforce will be remembered less than the endeavours by its leadership to suppress uncomfortable data will be. Second, the saga further confirms the obvious; that is, our health system desperately needs leadership culture change, not structural change.

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.