Why And Where Are We Missing The Boat In Health?
Why And Where Are We Missing The Boat In Health?
CAPACITY-BUILDING AND DRIVERS FOR SUSTAINABLE GAIN: THINGS WE DON’T KNOW THAT WE KNOW.
Why And Where Are We Missing The Boat In Health?
Capacity-Building And Drivers For Sustainable Gain: Things We Don’t Know That We Know.
NEW ZEALAND SOCIETY OF
HOSPITAL AND COMMUNITY DENTISTRY
PALMERSTON NORTH FRIDAY 30 JULY 2004
ASSOCIATION OF SALARIED MEDICAL SPECIALISTS
Once again thank you for the opportunity to address your Conference. My comments are personal rather than official Association observations although I believe that they are broadly consistent. I have been asked to speak on the issues currently facing the health sector and I wish to focus on what is not going well rather than what is going well. While we should never lose sight of the latter because there is much that is going well, it is incumbent on us all to consider those matters where we are ‘missing the boat’ if the health system is to better perform.
In summary, our health system is facing a fundamental dilemma:
On the one hand, in contrast with the aberration decade of the 1990s, the underpinning principles of our health system, including legislative framework, are more or less aligned with the values and ethos of health professionals and the public.
On the other hand, in the main, health professionals are noticing little progress at the workplace where it counts; in fact, some maintain that the work environment has deteriorated due to factors such as workforce shortages, managerial styles and denial of access to elective services.
In preparing this address I am mindful of two noteworthy musings of quite different calibre and context. The first was by United States’ Defence Secretary Donald Rumsfeld who, in February 2003 in the context of the invasion of Iraq, pondered the relationship between the known and the unknown. He offered the following pearl of wisdom:
There are known knowns. There are things we know we know. We also know there are known unknowns. That is to say, we know there are some things we do not know. But there are also unknown unknowns, the ones we don’t know we don’t know.
On the basis of this statement, should Mr Rumsfeld be in a need of a job after the Presidential election later this year, he is tailor-made for one in health management in New Zealand; he talks the talk.
In fact, there is a fourth scenario not identified by Mr Rumsfeld—things we don’t know that we know. This is most apt in the health system and leads into the second noteworthy musing from Health Minister Annette King whose job is fortunately not under threat from Mr Rumsfeld. In a recent address she referred approvingly to an analogy by Professor Martin McKee of the London School of Hygiene and Tropical Medicine who promoted the notion of a shifting balance internationally between treatment and prevention with growing opportunities for early intervention. Professor McKee described this as a ‘person’s lifelong journey’ through the health system which the Minister translated to the importance of developing a ‘healthy travel map’. A geo-political map is something Mr Rumsfeld could have done with in his road to Baghdad.
What is Good about the Direction of Today’s Health System?
Since 1999 there have been many good, often inter-connected, developments in the health system, in particular:
The end of the ‘market experiment’ of the 1990s and the return to underpinning values more consistent with those of health professionals and the public, both in legislation and in the various health strategies.
There is a greater focus on overcoming fragmentation and promoting collaboration and coordination between DHBs, both regionally and nationally, as well as between primary and secondary care within DHBs.
Recognition of the importance of workforce development and planning both with the formation of the statutory Health Workforce Advisory Committee and the activities, albeit at an embryonic stage, of DHBNZ.
A greater emphasis on medium to longer term planning compared with the shorter term approach of the 1990s, which had been a direct result of the folly of attempting to run the health system on a commercial business basis.
A greater ability to address the perennial and difficult challenges of providing a national health system while also meeting local health imperatives.
The move away from the uncertainty of time-limited funding such as waiting times initiatives and the move to longer-term funding paths much more suitable for service planning and development.
The recognition of the role of primary care and the importance of enhancing access and building capacity, including through Primary Health Organisations. There appears to be more ‘buy-in’ to PHOs by GPs and others involved in primary care that might have been anticipated at the time of your last conference and more than I had previously anticipated. The government’s recent primary care funding announcement bringing forward by a considerable extent its previous schedule was an important decision which did not receive the full media coverage that it deserved, considerably less than the Opposition Leader’s ‘law and order’ speech. This still leaves uncertainty over issues such as whether PHOs are providers or networks of providers; the extent to which they might become duplicative bureaucracies alongside DHBs; the potential for excessive transaction costs; the potential for cost shifting from secondary to primary because of the greater amount of increased funding being channelled to the former; recognition of the pivotal role of general practice; and governance challenges in relation to GP ownership and capital investment in medical businesses.
The reinstitution of the no-fault accident compensation commission and its recently announced intention to expand into the previously restricted area of medical misadventure.
The Employment Relations Act with its emphasis on maintaining and enhancing the employment relationship in contrast with its predecessor Employment Contracts Act’s narrow contractualist emphasis. This has, notwithstanding all the difficulties, meant that we have been able, along with resident doctors and nurses, to enter into negotiations for national terms and conditions of employment, so important for equity, fairness, recruitment and retention.
Further, the government has not gone down the controversial and highly questionable route of the British Labour government with foundation hospitals, the Private Finance Initiative and the bureaucratic overloading of Primary Care Trusts. Much of this British route smacks of New Zealand’s market experiment of the 1990s.
But what is not so good?
However, these positives need to be seen in context. There are many negatives that contribute to frustrating the achievement of shared objectives between the government and health professionals. Potentially we are on the cusp of being able to make a qualitative movement towards a much improved, sustainable and effective health system. But, on the other hand, equally so, we are on the cusp of an engrained stagnation, neither forward or backwards, with the result being a widening of the gap between those who make decisions and policy and those that have work within their framework.
Many of the improvements described above relate to process rather than substance. Process is important but, unless and until it translates into substance, it is prone to devaluation or under-appreciation leaving the appreciation of the benefits confined to ‘policy wonks’, of which I must confess to occasionally being one despite my best efforts to shake it off. The critical point is that these benefits are largely unnoticed at the workplace where it all counts.
There are, albeit non-fiscal, similarities with the relationship between Elizabeth Taylor, when in-between husbands, and the infatuated but much less affluent journalist Bob Woodward of Watergate fame. The then young journalist would regularly supply her with flowers. However, the wealthy actress eventually felt compelled to ask that while the flowers were indeed pretty, when were the diamonds going to arrive, my dear? It was a short-lived relationship. The relevance of this story is that the government’s flowers are indeed pretty and appealing but the diamonds in terms of achieving effective sustainable progress and engagement in a manner that is discernible at the workplace, is not evident.
1. Workforce Development and Planning
Workforce development and planning is an example. This was a casualty of the 1990s ideology which regarded planning as akin to the negative stereotype of a Polish shipyard in Gdansk. The neglect so prevalent in that decade has left us with legacies that still impact and contribute to our current serious shortages. Since 1999 workforce development and planning has been seen as a good thing and this is reflected in the establishment and activities of the Health Workforce Advisory Committee. But this Committee is not set up to undertake the work actually required in the sector and instead is more of a scene-setter; an important role but not enough to advance the issue.
To its credit DHBNZ has picked up the cudgel with its Workforce Development Plan but this is embryonic, largely process-driven, and more long-term focussed. It is not that it is wrong; rather, like HWAC’s work, it is not enough and leaves the current imperatives untouched. Further, much of its impetus appears to come from earnest and commendable individuals rather than being embedded in the attitudes of DHB management.
2. The Gap between Strategies and Implementation
The various strategies are another example. They are stuck in the framework of high policy which is an important start-point but it is not the end-point. There are exceptions with the impressive Cancer Control Strategy at the forefront. This was a good example of a strategy being developed by a group with significant health professional and community involvement producing a report which has a high level of sector ownership. It straddles primary through to tertiary services along with significant community services. And now an implementation report has been prepared, currently at a draft stage. This is an impressive performance although it still has to be translated into action.
But it is relatively isolated. The approach to converting high policy strategies into tangible focussed and sustainable practical initiatives and planning is sporadic and unsystematic. The recent orthopaedic funding initiative arose out of effective engagement between the Orthopaedic Association and the government but, as good as it was, it was ad hoc and dependent almost entirely on the work of a well-organised and focussed professional association in a discipline that lent itself to good data and tangible outcomes.
3. Private Sector Relationships
A third example is the confusing messages coming out over privatisation and the role of the private sector. On the one hand, the government appropriately calls for capacity-building in public hospitals (including the recent orthopaedic surgical expansion), overcoming of fragmentation, and encouragement of greater clinical alliances between DHBs. On the other hand, this is being contradicted and undermined by short-sighted and unnecessary privatisation initiatives by the South Island Shared Services Agency (South Island DHBs) for pathology services and the Southland DHB for radiology.
The government needs to better develop its coherence and message over the relationship of the public health sector to the private sector in order that it is not contradicted and undermined and that health professionals and DHBs are not left in confusion over what its position is. The private sector does have a role which need not be incompatible with the public sector.
But there are also differences, including underpinning premises (profit and the need to make a financial return on capital investment compared with provision of an accessible universal public good; while unpredictability and uncertainty are a feature of markets, the public health system requires, as much as possible, predictability and certainty). These differences mean that some form of arm’s length relationship, as already occurs in the employment by DHBs of medical and dental practitioners who are also involved in private practice, is required in order that the problems of one underpinning premise does not undermine the other.
The private sector clearly has a role for patients with sufficient resources and where there is a market, and also in areas where there are capacity difficulties for the public sector both short-term and where it cannot provide such as primary care, both dentistry and medicine. But this latter point requires elaboration. The private sector may have spare plant capacity, usually due to the difficulties of anticipating market demand, but it does not have spare workforce capacity. And yet the main difficulty facing the public sector in meeting elective demands is lack of workforce capacity compounded by pressure of acutes. Any relationship with the private sector over elective services should be of a shorter term nature (including the Waitemata DHB’s short-term leasing of private theatres for some of the recently increased orthopaedic operations), not at the expense of building workforce capacity in the public sector, and not with the objective of propping up private sector difficulties, profit margins or share prices.
4. Workforce Affinity
A final example is my harsh observation that the government is not seen to have an affinity for the health workforce. The government could understandably claim unfairness over this observation. After all it has introduced progressive industrial legislation which is consistent with the values of health professionals, has recognised much more than its predecessor government, the importance of workforce development and planning, and has established a tripartite process involving CTU-affiliated health sector unions, DHBs and the Health Ministry. I have no doubt that the government respects health professionals but at the same time there is not the close relationship based on trust and confidence that is necessary in order to reach the higher threshold of affinity. Its focus is more on process and rights which is understandable but insufficient. From time to time policy drivers appear to fall in to the trap of the 1990s ideology of seeing the workforce through somewhat suspicious eyes and as a cost rather than a value-adding asset and does not see it as the most effective means of achieving sustainable improvements.
This is reflected in an apparent suspicious attitude towards the motivations of unions, and in a different context other professional bodies, as just being out for self-interest and ‘pay and rations’ whereas, in my assessment, they are much more interested in what they can put into the system rather than what they can extract out of it.. It is noteworthy that the Health Practitioners Competence Assurance Act was top-down driven with health professionals consigned to back-foot reactors rather than front-foot designers. Much, perhaps all of, the controversy and remaining concerns could have been avoided if the latter approach had been adopted. Nevertheless, while acknowledging that the circumstances of medicine and dentistry were different, coming from different existing legislative bases, the role of the Dental Association as an effective pan professional organisation deserves recognition and something which the medical profession should be envious of.
The net result then is, again in my assessment, while the government is not seen as anti-workforce, equally so it is not seen as pro-workforce. I know that the government will object to and reject this assertion because of its emphasis on process and rights but, because it does not extend into pro-active engagement, it seems to me to be a reasonable assessment to make and one which I believe is shared by other health unions.
Returning to the Past; what might be worse?
I have spent much of this address critical of government and it is important therefore not only to acknowledge the positives, which I hope I have done fairly, but also to comment on the main alternative. Although the National Party has not announced its health policy and health is not identified as one of its top five policy areas, there is enough to go on based on comments made on various health issues, including a meeting between their health spokesperson and our National Executive, and its continued identification with the market era of the 1990s. On the positive side, although little specifically has been said, National appears unlikely to formally restructure, leaving the DHB system more or less intact but perhaps with some evolutionary reconfiguration of boundaries including amalgamations. It rightly recognises the level of ‘burn-out’ among health professionals of endless restructuring.
On the negative side, however, it would not be surprising if a National government would open up accident compensation to privatisation and also, as part of this, let ACC handle all or most elective surgery in public hospitals. There are a number of reasons why this would be a major step backwards, including:
As discussed earlier, it would not address the main capacity issue in the public sector, workforce shortages, and we don’t have the alternative workforce capacity in the private sector. There is not a ‘reserve army’ of unemployed or under-employed health professionals, especially in a country of only four million people.
Invariably it would be more expensive. Owing to the need to maintain a reasonable profit, privatisation or contracting out requires a premium rate that costs DHBs an ‘arm and a leg’.
Public hospitals would still be left, at least in most cases, with having to provide the post-operative back-up, in particular intensive care. It is worth noting that when the Capital & Coast DHB decided to sub-contract some cardiac operations to the private Wakefield hospital it could only identify eight patients with sufficiently less complicated conditions to be unlikely to require the back-up of the DHB’s own intensive care unit. Although Wakefield is one of the country’s most developed private hospitals and it has received public relations assistance through earlier sympathetic Dominion Post coverage, it does not have the same level of essential post-operative back-up as the DHB’s public hospital.
It could only proceed on the basis of ‘cherry picking’, greater cost, and a strong ideological predisposition to make it happen, and would lead to the re-introduction of perverse incentives.
Some of the contracting out/privatisation arrangements of the 1990s badly went to ‘custard’ leaving legacies of bad will and acrimony.
The level of consequential fragmentation would obstruct, and distract from current efforts to further develop the capacity in order to achieve national health imperatives.
It would introduce more complications and obstacles in the efforts to establish more regional and national collaboration between DHBs in the provision of secondary services.
At a time when there is recognition of the benefits of closer integration of clinical and related services, including between DHBs and between primary and secondary care, this would encourage fragmentation and disintegration.
Public hospitals would become unattractive places to work in because they would be left with largely acute work, both more onerous and more dangerous, and without the necessary skill mix balance. While one can always argue over the balance, a reasonable mix of elective and acute work is critical for job satisfaction and skill maintenance and enhancement.
Bridging the Gap between Cup and Lips; Drivers for Sustainable Change
As I observed earlier we are on the cusp of something. It involves the gap between the cup and the lips which has the potential for much spillage. Much of this gap is connected to, but not caused by, the government’s sound and commendable focus on population health and primary care. But the implications of this focus are long-term and their relevance may have more to do with the effectiveness rather than the demand for care; it may lead to different demands and access needs. Unfortunately, although it need not be automatically so, this has led to a relative de-emphasis on the ‘here-and-now’ pressures on the system, particularly in secondary care.
Capacity-building is critical to bridge this gap and drivers are required to ensure this happens. The challenge is compounded by the fact that health managers are so much on the back foot in constant semi-crisis mode and trying to keep the system going that, much more so than health professionals, they struggle to take a long-term view and to see beyond their immediate patch. Further, while today’s paradigm has shifted (for the better) from the paradigm of the 1990s, many managers are still shaped and influenced by the attitudes and behaviour of the latter paradigm. These things take time to shift, frustratingly so.
Unfortunately, however, the government is reliant on the wrong drivers of sustainable improvement, in particular, DHB chairs and the Ministry of Health. But, while many Board chairs are people of stature and ability, they are distant and disconnected from operational and capacity issues to be a key driver of sustainable quality improvement. The expectation of an immediate cause-and-effect relationship between governance direction and operational shifts is misplaced.
The public lashing of an experienced and respected health manager by Canterbury DHB chair Syd Bradley (also chair of DHBNZ) highlights the point. Mr Bradley genuinely believes that a significant amount of health spending is not effectively utilised and, if it was, deficits would disappear and services would be enhanced. But when, in his own patch, Christchurch Hospital’s deficit continued to increase, the embarrassment and frustration of its public exposure became too much and in forthright terms he launched into the hapless manager, along with a dig at senior medical staff. And yet the main factors behind the deficit are unanticipated increased acute admissions along with some one-off additional external costs beyond the DHB’s control.
The other driver, the Health Ministry, also suffers from distance and disconnection. But more so there is a sense of inertia because much of the Ministry appears to comprise good intellects which then proceed to cancel each other out. In the late 1980s it discarded its operational functions in order to focus primarily on policy advice, along with some important regulatory functions. But it is now working in an environment where this is not enough. Although it has more levers than this, to me the Ministry is a policy body with a cheque book. Who holds the cheque book is always important. But this is insufficient if strategic capacity and other operational challenges are to be addressed.
Previously I have spoken on the New South Wales taskforce covering metropolitan services for a population of around five million. Its performance has been subject to an independent evaluation which was completed earlier this year. This evaluation confirms my belief that this exercise of clinician-led resource allocation and development is well ahead of what happens in New Zealand despite our legislative framework being more conducive to it. In summary, this was a three-year taskforce independent of the state health department led by clinicians and given a recurrent $(A)67m budget for expenditure of service development in metropolitan New South Wales. It made numerous recommendations to the health minister on service and resource development which were overwhelmingly accepted. The implementation of these recommendations should be of sustainable benefit to the New South Wales health system because they are based on clinical expertise and extensive engagement.
While noting problems associated with the first-time nature of this type of approach and the understandable tension arising out of the supplanting by this parallel process of the health department’s role, the evaluation was highly complementary of the taskforce’s work. Its conclusions included the following:
The most significant gains were in the acceleration of decision-making and implementation of new strategies and services and the development of clinical service networks.
Successfully improved clinical collaboration and interaction leading to clinicians having the opportunity to being involved in the development of clinical policy.
Clinicians were now engaging in ‘meaningful planning and decision making’ in contrast with the traditional advisory role based on invitations to participate.
Clinicians were able to make decisions from a broader system perspective leading to an enhanced level of cooperation and consideration of all aspects of health care delivery.
Clinical networking across the state was greatly enhanced which contributed to a breakdown between clinical boundaries.
Current ‘best clinical practice’ was used as the guide for the implementation of additional services which were more likely therefore to be of the best standard and in the right place.
Clinical networks are now facilitating the coordination of services and cooperation between clinicians across area health service boundaries so that patients have improved access to these specialised services without the need to establish a new service where the number of patients did not warrant such a service.
There was the opportunity, already being witnessed in some instances, to reverse previous dysfunctional relationships between the health department, area health services and clinicians and to establish (or re-establish) trust between all parties.
Clinicians were recognising the issues related to high cost/low volume services and, in some cases, had successfully halted unnecessary proliferation of some clinical services.
It revealed the potential for avoiding duplication of services and reducing the centralising of resources by better distribution of such resources (eg, stroke units and angioplasty services) to population growth areas.
Enhanced cross-disciplinary engagement has been engendered.
The independent evaluation concluded that the strengths of this clinician-led process should be sustained and built upon, including beyond the current focus on inpatient services into organisational and hospital-wide issues. This includes strengthening the shift in emphasis from initiatives to planning.
Although our government maintains that it is undertaking this approach the reality is that it is not. While the Cancer Control Strategy has some similarities with important elements of the New South Wales approach, elsewhere progress is patchy and sporadic; it is not part of a comprehensive and systematic planning process. What the government needs to initiate, in the first instance, is the development of a ‘health plan’, which is not as large an exercise as first might appear because of the work already undertaken including the various health strategies. In fact, it would be more of a scoping exercise to advise on where implementation might most suitably be pursued. Much of this implementation would best be done on a regional inter-DHB level although some lower volume/higher complexity services might best be followed through on a national level. This scoping exercise could address which services should be addressed regionally, including what the regional boundaries might be, and which services should be addressed nationally.
Three further points are important in this regard:
New Zealand has an advantage over New South Wales because our DHB system incorporates both primary and secondary care whereas Australia has an arbitrary federal-state divide between primary and secondary care that is a recipe for rigidity and cost-shifting.
The scoping exercise must be undertaken by a clinically-led expert group reporting to the Health Minister.
It should be wider than the inpatient focus in New South Wales to the full range of acute, chronic and elective services, and should also embrace primary care and population health.
Following the scoping exercise the next phase should be implementation which could be done by regional and national clinician-led taskforces authorised to recommend a specific implementation plan on resourcing, collaboration, and clinical networking or alliances, for example, for oral maxillo-facial services and community dentistry. Depending on their nature these recommendations should be either to government or the affected DHBs, as applicable.
In my assessment this adaptation and further expansion of the New South Wales approach has considerable advantages for New Zealand. There are elements of it in the ‘provisional agreement’ for a national collective agreement reached between the ASMS and DHBs’ negotiating teams with an emphasis on developing workforce capacity. But, if robust and sustainable capacity-building is to occur, two critical prerequisites are required—the political will from government to sanction and require it and a culture of pro-active engagement with health professionals.
Both of these we presently lack but the government would do well to recall the conclusion of Deputy Prime Minister and Finance Minister Michael Cullen at our Annual Conference last November. He stated that:
…gains in the efficiency of health-care delivery (gains that not only help spread resources further, but also provide patients with a better service) require that someone, somewhere takes responsibility for how the whole of the health system works, and for shifting the system so that its points of intervention in the lives of individuals are more oriented to maintaining health than to treating disease. To my mind clinicians must play the major leadership role in this regard.
Until Dr Cullen’s statement is enacted upon the health system is going to continue not to know what it knows, continue to depend on the less effective drivers for effective sustainable capacity-building, continue to fail to prevent spillage between cup and lips, the Health Minister’s ‘health travel map, will remain unachieved, and this government’s health legacy while not a bad one will be a bit of a dribble.