GUEST BLOG: Ian Powell – When health bosses operate in an isolated bubble

When delivered by district health boards (2001-22) Aotearoa New Zealand’s universal health system was one of the centralised in developed countries. Central government exercised considerable control although it was largely invisible.

Nevertheless, there was a good degree of scope for local decision-making. DHBs were charged with the responsibility of the health of their geographically defined populations, including undertaking needs analysis.

Given that healthcare is overwhelmingly provided locally, it meant that there was a closer understanding of what works well and what does not compared with central government. This was a strength of our system that has now been lost.

However, when a health system becomes both even more centralised and vertical, the greater its top leaders are likely to live in an isolated bubble talking to themselves about themselves. The quality of decision-making consequentially declines.

This is what has happened with the abolition of DHBs and their replacement with Te Whatu Ora (Health New Zealand).

A right clanger

The most recent evidence was a clanger last week by the organisation’s Director of Living Martin Hefford when speaking at a regular webinar to update health professionals, among others, on its work.

Martin Hefford: starting a muddle

In the context of the severe general practitioner shortages that plague our health system, he said:

We are not going to be able to train enough doctors to cover the GP shortage that we forecast and we need to look at other ways of managing access and managing health problems and demand.

This led him to assert that about 40-50% of GP work could be done by telehealth consultations. Telehealth is when patients have appointments with their GP via video or phone calls rather than face-to-face.

Of necessity GPs resorted to telehealth during the pandemic lockdowns. Unfortunately Hefford tried to extrapolate too much from this extraordinary situation even going so far to suggest that some telehealth consultations could be done from overseas.

Adding salt to the GP wound was Hefford’s further dubious claim that 20% of general practice work could be undertaken by physiotherapists.

Media covers another Te Whatu Ora muddle

Hence we have another Te Whatu Ora muddle. This was fully discussed by TVNZ health correspondent Rowan Quinn: Dismay over Te Whatu Ora claim that up to half GPs’ work could be done via telehealth.

It was also covered (paywalled) by experienced health journalist Martin Johnston in NZ Doctor: Telehealth boost could worsen GP shortage.

Dr Sarah Clarke did some damage control over Te Whatu Ora muddle

Radio New Zealand’s Checkpoint that same evening  included an interview with Dr Sarah Clarke, Te Whatu Ora Clinical Director of Primary and Community Care: More online doctors! Owing to Dr Clarke’s feet being closer to the ground of GPs she was able to do some limited damage control.

Responses from the dismayed health frontline

The General Practitioners Owners Association (GP owners, corporates and not-for-profits) Chair Dr Angus Chambers was forthright in his response to TVNZ stating that Te Whatu Ora did not understand the work of GPs.

Dr Angus Chambers values telehealth but as a complement, not a substitute for GPs

Dr Chambers has no argument with the value of telehealth:

Telehealth was a great complement to general practice for matters that did not need face to face intervention, but there was other care that could only be achieved by being in the same room with someone.

That included “opportunistic care”. That was where doctors might notice another problem or take the chance to talk to their patients about a matter they had not come to the doctor about.

But it was ”second” best for many conditions and not a “cheaper option in the long term noting that “People with regular access to GPs cost the system less and live longer.”

Further:

We’ve been warning of the workforce shortage for decades and they haven’t really done anything about it. One might wonder if the system doesn’t want people to live longer because they cost a lot more once they get over 65 but that might be a cynical view.

Emergency medicine and rural hospital medicine specialist Dr Ruth Large is the Chair of the New Zealand Telehealth Forum.

Telehealth supporter and leader Dr Ruth Large adamant that it isn’t a solution to GP shortages

Martin Johnston reports that she is adamant telehealth won’t solve the GP workforce shortage. Dr Large advised that in this context:

It could even make it worse. You could have doctors going into telehealth and removing themselves from in-person care. And there is a risk that trying to do more telehealth could lead to GPs shifting out of rural areas.

By virtual of her position alone Dr Large obviously supports the use of telehealth. She notes that it works well in a “hybrid model”. That is, GPs doing a mix of teleconsultations and in-person care within the one area.

Irihāpeti Mahuika: telehealth claim undermines GPs and disadvantages patients including Māori and Pacific

Another critical voice was Health Hawke’s Bay (Primary Health Organisation – PHO) chief executive Irihāpeti Mahuika who said that Hefford’s webinar telehealth comment “undermines the hard work our GPs do in our communities.”

Like Drs Chambers and Large, she saw a positive role for telehealth. However, as reported by Johnston:

We see patients presenting with more complex conditions and although many present with just one condition, a doctor can conduct various routine tests that can help them understand a wider picture of a patient’s condition or identify other areas of concern which can’t be done over a telehealth appointment.

…for many in our Māori and Pacific populations, telehealth is not a suitable substitute, and should this become the norm, we will see many in these communities stop engaging with primary care, resulting in poorer health outcomes.

We already know that these communities have poorer health outcomes. We need to work with our communities to ensure they can access primary care in a way that engages and connects with them, their whānau, their tikanga and mana.

Johnston reports another PHO chief executive (ProCare’s Bindi Norwell) responding that suggesting up to half of GP appointments could be done by telehealth “…disregards the importance of continuity of care and the value of face-to-face interaction between patients and their general practice team”.

Blame what created Te Whatu Ora’s leadership bubble

Martin Hefford is an experienced operator in the health system. He has been around the primary care traps for many years holding several different positions. This muddle was not the result of an incompetent, flustered or ‘spring chicken’ bureaucrat. The cause is systemic.

Leadership bubble created by centralisation and verticalisation

When a health system becomes so centralised and verticalised, as New Zealand has since July 2022, and in the absence of a devolved engagement culture, high level leadership bubbles are formed which becomes increasingly isolated from workforce reality.

In this environment, and with continuing unabated pressures, the most serious of which is workforce shortages, even the most experienced and smartest operators will fall to the temptation of magic bullet solutions. It is a systemic generator of errors and misjudgements.

Criticise but don’t blame the leadership bubble; blame what created it.

 

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