GUEST BLOG: Ian Powell – Time to end health system’s headless chook leadership
Chicken Licken (also known as Chicken Little) was a children’s story that fascinated me (briefly) as a young child. As Chicken-Licken was going to the wood one day an acorn fell from a tree on to its head leading it to conclude that the sky had fallen on him. The moral of the traditional story is to have courage, even when it feels like the sky is falling. It is also the daily lived reality of health professionals working in New Zealand’s district health boards (DHBs).
Subsequent versions of the story ended in tragedy with the panicking chook ending up inside Foxy-Loxy’s stomach. Another has Foxy-Loxy about to lead Chicken-Licken and other chickens into his den to eat them but then the then sky fell on him. All this got me to contemplating the expected announcement by Minister of Health Andrew Little (no relation to Chicken Little) on 21 April of the Government’s response to the Heather Simpson review of the health and disability system.
Raining acorns
For some time now, and increasingly so, there have been several articles published in the mainstream media highlighting serious failings in our health system. A recent example is a powerful article by Stuff health journalist Bridie Witton on the effects of serious hospital midwife shortages
Witton is not alone. Other journalists have produced hard-hitting pieces exposing serious and deteriorating conditions in a range of health services including emergency departments, maternity, women’s health, access to cancer diagnosis and treatment, hospital bed blockages, and mental health (to rub it in also bureaucratic censorship of important data).
This media coverage of serious failings in Government leadership of the health system has overall been on the mark. While those overly sensitive to criticism of the Labour Government may allege media bias, the reality is that this is largely good quality investigative journalism that resonates with both health professionals at the clinical frontline and patients (and their families).
I exclude from this assessment Covid-19 where the coverage of vaccine implementation has often missed the boat. While the border/quarantine coverage has exposed some serious failings they should be seen in the wider context of a successful elimination strategy.
Political leadership failings
Underlying these seriously deteriorating conditions is the failure of successive governments to invest in the health system, especially its fatigued workforce where we have serious, sometimes dangerously so, shortages. Ironically this workforce comprises those most able to identify how best to improve the health system and to implement these improvements.
Successive governments have seen the health system’s workforce as a financially liability instead of an asset to invest in for a healthier population and, consequently, improved economic wellbeing. This failure is the result of a poor health system leadership culture.
The 2017-20 Labour-led government inherited a rundown public health system from its predecessor due to the cumulative effects of nine years of leadership failures and underfunding (light austerity but austerity nevertheless). The new government had an opportunity to turn this around but lost its way seemingly distracted by the mistaken belief that the Simpson review and restructuring would fix things. This approach allowed the rundown to continue and worsen. It failed to address key pressures in the health system particularly around severe workforce shortages and leadership culture.
While this headless chook leadership hasn’t led to the sky falling on the health system it has meant that those working in it, those being treated by it and those being denied access to it have been whacked daily by raining acorns.
The Simpson report (March 2020 following an interim report in August 2019) was disappointing. As a blueprint for improving the health system it failed. It had an excessive focus on restructuring bureaucracy whereas experience tells us that structural change of itself doesn’t improve the system.
While the interim report provided a good description of the pressures on the system, the final report failed to explain how its recommendations would improve it, especially those involving restructuring. The final report has been aptly described as comprising dots and lines not joined up.
What should the Government be doing
The Labour Government’s heart is in the right place and has some good brain power within its parliamentary team. But, to date, it has been influenced too much by pre-determined positions, not enough health system expertise, obsession with restructuring, and reliance on business consultants.
The Government needs to take corrective action. In summary this should include:
- Recognition that if social inequities are to be eliminated then the externally driven social determinants of health that drive much of the demand on and cost of the health system must be addressed. Much can be effectively done by government policy and regulatory decisions such as the recent anti-smoking proposals from Associate Health Minister Ayesha Verrall. This needs to be much more comprehensive across all social determinants.
- Stop regarding restructuring as the key driver of system improvement. Any structural change should follow cultural leadership and process change. Culture always trumps structural change, especially in highly complex labour intensive health systems.
- Ceasing its dependence on business consultants (they can still be used to assist in certain more technical areas but shouldn’t be the implementation driver). There is a reason why panel-beaters don’t design traffic intersections.
- While recognising the need for the health system to become more nationally cohesive, accept that this should not be through increasing centralist bureaucratic control. Recognise that there is a natural tension in universal health systems between national and local and that this can be a positive.
- Recognition that its greatest asset for improving the performance of the health system is its health professional workforce.
- Recognition that the two most serious immediate threats to the health system are severe workforce shortages and a narrow managerialist leadership culture.
- Development of a strategic approach to workforce recruitment and retention to address these severe shortages. This will vary in form and extent depending on the occupational group, including those such as medical specialists who are in an Australasian labour market.
- Transition from a top-down managerialist leadership culture to one that is relational based on engagement and that recognises the benefits of clinical leadership distributed right down to the workplace to system and process improvement.
- Recognition of the benefits of further integrating healthcare between community and hospital through initiatives such as Canterbury DHB’s successful health pathways. This needs further investment in health professional workforce capacity in order to extend nationally.
- Ensuring that in rebuilding so much neglected hospital infrastructure business cases must incorporate clinical, population health and environmental expertise which approval processes must recognise.
- Requiring there to be national and local hospital planning based on extensive clinical and other engagement and providing for unmet patient need.
- Requiring DHBs to undertake locality planning including addressing social inequities and unmet need.
- Reforming the funding system of major capital works so that depreciation doesn’t come out of DHB operational costs (or is otherwise offset) and the unfair and unnecessary capital charge is removed.
Big opportunity for Little
Andrew Little has a big opportunity to end this headless chook leadership with his forthcoming announcement. He signalled this in a well-crafted article published in the Sunday Star Times today.
The article cleverly implies that the Government has listened to concerns about the flaws of the Simpson review and understands that structural change is not the driver of health system improvement. Hopefully this wasn’t weasel words. The proof will be in the eating of the pudding but it is to be hoped that health professionals will no longer be showered by acorns.
If his announcement fails too far short of this objective than the Minister will either be giving Chicken-Licken prophet-like qualities or putting the Government at risk of being seen as Foxy-Loxy by the public and judged accordingly.
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.
1. The savings made from reducing the number of DHB’s should be itemised. Unlikely to be much against the lack of knowledge of whats going on in the districts.
2. In order to make a particular health service more efficient a project manager should be used. A department manager is too busy to have the time and resources to be effective at this.
3. Each service needs a tick of approval to say yes that service is operating about 90% efficiency. Very hard to reach 100%. This should be linked to volumes. How does an increasing volume affect efficiency. Where volumes increase funding should increase where needed.
4.The Boards have some very skilled people (elected board members). But the structure only allows a superficial box ticking which does not utilise their skills. Many actually have conflicts of interest.
5. The board members should be linked to each project. Eg the accountant to financial systems review.
6.The DHBs managers have a siege mentality. Everyone is at them for money and as a consequence they do not listen.
7. There is a big difference between consultation to engagement. Engagement is asking the questions which is never done well.
8.The Ministry of Health have a short sighted approach. So a new hospital is built as small as possible. But adding on later will cost twice as much-if its even possible.
9. Every 150K immigrants is a new small hospital somewhere. We squeeze the immigrants into the current system. Need to get real here.
In general the problem here is a lack of the right skills within the DHB’s. People good at data collection and analysis. People good at planning and project management. Those people we used to call boffins/nerds. The sort of people who wear walk shorts and brown shoes and who could get 300, 000 troops off the beaches of France without breaking a sweat. (FYI no Im not describing myself here)
‘Hopefully this wasn’t weasel words.’
Hope, the desire for a favourable outcome in the face of highly unfavourable facts.
I’ll never be fooled by him again.
Massive infrastructure and staffing funding.
Employ more to meet population demand, pay better to retain quality clinicians and build better to meet surgery and recovery demands.
And lastly from personal experience, better clinical governance at DHB corporate level. We have people employed with zero interpersonal skills and an entitlement mentality. As long as they are in charge and are only interested in their position and not change for good, nothing will happen.
It is a mystery to me why the architect of the current failed DHB model was given the job to review it. Why do we try and run a national health system at such a local level? The parochial independence of the DHBs is reminiscent of the old Fire Boards that were ditched back in th 70’s. I have an NHI number but that’s as far as the ‘National’ health system extends. It is time for all public hospitals to be amalgamated and use one system. The covid crisis has highlighted just how disjointed our health services are – fine tuning a failed model is not the solution.
Yep. When I busted my arm last year I went to Whangarei Hospital (Northland DHB) and they are so totally slammed I could not even get an appointment for assessment (severe multiple fracture of the humerus). Maybe because I didn’t roll up in an ambulance? They could not even get anyone to look at the X-rays.
Waited a couple of days in Paihia, kept ringing for an appointment, got nowhere. Gave up and went back to Auckland to try and get into the system at Auckland DHB. A local GP took one look at the X-rays and called an orthopaedic surgeon in the private system. The guy took a couple of days to look at my case but when he did he realised it was pretty fucken bad (needing surgery to reassemble all the shattered bits of bone in my arm) and set me up with an urgent referral to Auckland hospital.
Finally went to Auckland hospital and sat around all morning in the waiting room while the nurses or admin people tried to figure out what to do with me, later that afternoon I got surgery to insert a couple of stainless steel plates and screw all the bits of bone pack in place.
It took 10 days from the accident to actual treatment. My case would have slipped through the cracks if I didn’t have people helping and a change to go back home to Auckland for treatment. Not to mention it was before the COVID lockdowns when they chucked a bunch of people off waiting lists. Who knows how much pain and suffering that caused. Going into Greenlane hospital during lockdown for a follow up assessment, the place was a ghost town. What a waste of resources.