GUEST BLOG: Ian Powell – ‘Slash and burn’ increases poor health system decision-making: witness maternity and gynaecology

In Aotearoa New Zealand’s health system there are 36 branches of vocational (specialist) medicine registered by the Medical Council.

These are called ‘scopes of practice’ which allow doctors to work independently of supervision (doctors with general scopes of practice require some form of supervision).

Overwhelmingly these specialities have one or two names such as ‘dermatology’, ‘general practice’ and ‘orthopaedic surgery’.

Consequently, a speciality with ‘and’ between two words is unusual. Obstetrics and gynaecology (usually referred to as O&G) is an ‘unusual’.

They are somewhat like twins or close cousins. Whereas the former is obviously about birth, the latter involves the treatment of women’s diseases, especially those of female reproductive organs.

‘Slash and burn’ strategy

Like almost all the other vocational scopes of practice, O&G suffers from a crisis of severe workforce shortages due the political neglect of successive governments.

‘Slash and burn’ the core of Commissioner Lester Levy’s leadership style

Cutting maternity beds at Wellington Hospital is part of a wider ‘slash and burn’ strategy led by Health New Zealand (Te Whatu Ora) Commissioner Lester Levy over the past 12 months.

I have discussed this strategy previously in the context of health IT (15 December):    Slash and burn health IT strategy. I have also discussed it in the context of gutting specialised health teams (22 January): Gutting specialised health teams.

The maternity service crisis is national, not just local. By way of example, Hawke’s Bay Today (8 July) reported that more than 900 women in Hawke’s Bay are waiting to see a gynaecologist, many of them facing “unbearable pain”: 900+ Hawke’s Bay women suffering unbearable pain.

‘Slash and burn’ leads to poor decision-making

On 7 July a story by health journalist Ruth Hill on Radio New Zealand’s Morning Report revealed a shocking new development: Cutting maternity and gynaecology beds in Wellington Hospital.

RNZ’s Ruth Hill reports impact of cutting maternity beds

Health New Zealand was planning to cut beds from its gynaecology and maternity wards in Wellington Hospital in a trial aimed at making more room for patients from its overcrowded emergency department.

While management claimed that the maternity wards often had empty beds, those with the experience and expertise to know more (O&G specialists and midwives) disputed this. Instead, they feared there would be huge pressure to discharge mothers and newborns too quickly.

The Midwives Union MERAS (Midwifery Employee Representation and Advisory Service) Co-Leader Caroline Conroy said Wellington Hospital’s maternity unit was “one of the busiest in the country”.

Further:

The monthly stats we get at staffing meetings show the bed utilisation is over 100%. So it’s a really busy unit.

She also made another interesting observation with her suspicion that the Government’s health targets for emergency wait times and elective surgery were squeezing capacity elsewhere.

This is one of the problems when they set targets, and we’ve seen this in the past – when the focus and funding goes on those targets, and other services are not given priority.

O&G specialists college slates maternity bed cuts

Meanwhile Royal Australian New Zealand College of Obstetrician and Gynaecologists vice president Dr Susan Fleming said, in the above-mentioned Ruth Hill piece, a further squeeze on maternity resourcing was disturbing.

Demand in obstetrics is not predictable. Even ‘elective’ procedures like caesareans are not truly elective. You can push them back hours or even days sometimes, but you don’t have a lot of flexibility.

When there’s a peak of demand around acute presentations in labour and a demand for inductions and caesarean sections, then there’s no flex capacity, and then the only thing you have is to discharge women from the post-natal wards early.

Further:

…my understanding is that most maternity units across New Zealand are still struggling with midwifery resourcing, and particularly with the smaller units, with obstetric resourcing.

The following day (8 July) Morning Report covered further staff distress over the maternity bed cuts: Maternity staff beg Health NZ not to cut beds.

Inglorious backdown

Former British Labour Prime Minister Harold Wilson is known for several ‘pearls of wisdom’. One which is often repeated is that a week is a long time in politics. This is equally so with health systems; sometimes only a couple of days.

By late 8 July Health New Zealand was reporting a complete backdown by reversing its decision to cut maternity beds. This was covered the following day by Morning Report:     Backdown. Also see later in the programme the item by senior reporter Natalie Akoorie:  Senior doctors welcome U-turn.

This backdown was a huge embarrassment for the national health bureaucracy statutorily responsible for Aotearoa’s planning and provision of healthcare.

Health Minister Simeon Brown’s simplistic soundbite advocacy hasn’t helped

Rather than management on the ground, however, prime responsibility rests with the poor political leadership of the health system by the current and previous governments.

This was reinforced by Commissioner Levy’s destabilising ‘slash and burn’ strategy coupled with Health Minister Simeon Brown’s simplistic soundbite advocacy.

Take-home points

Health New Zealand was created in 2022 by an unwanted restructuring and has been internally restructured ever since. Instability and all that consequentially follows have been the inevitable outcome.

A big part of this outcome was the large loss of experienced senior and middle level health managers with operational experience. These managers often had a health professional background.

It is highly likely that those managers responsible for the decision to cut the maternity beds had much less experience and insight over the risks than those employed by the former Capital & Coast District Health Board before its disestablishment on 1 July 2022.

The short-lived but distressing bed-cutting decision demonstrates a failure to recognise where relevant expertise and experience resides.

At the point when the idea of cutting maternity beds arose there should have been immediate engagement with O&G specialists and midwives over the implications and risks. Further, having received their advice, they should have heeded it.

The final take-home point is the importance of voice in healthcare. I have previously discussed this importance in BusinessDesk (6 September 2022): Healthcare accessibility depends on health professional voice.

It was the voice of the midwives and O&G specialists (and their unions, MERAS and Association of Salaried Medical Specialists, plus the O&G professional college) along with good reporting by Radio New Zealand that forced the backdown.

Nothing more and nothing less!

 

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