Presidential Address - Dr Jeff Brown
29 November 2012
Dr Jeff Brown
No mai, haere mai. Ko Jeff Brown tenei.
This is the 24th Annual Conference of the Association of Salaried Medical Specialists. You are the representative senior doctors and dentists who have been granted favour to attend by your colleagues covering duties at home. I am recording my tenth Presidential address on Wednesday morning in the national office of your Association. I trust my projected visage and voice help frame your discussions over the next two days under the guidance of your Vice President Julian Fuller who, I am certain, will imprint his own style on your proceedings. He will be chairing sessions exploring Clinical Ethics Networks, chatting with the Minister of Health, contemplating training Doctors of the Future, sharing a visit from the head of MPS, discussing with the Health and Disability Commissioner, examining implications of changes to the Health Practitioners Competence Assurance Act, and, of course, seeking guidance for our MECA negotiations.
I look forward to hearing the outcomes of your deliberations and the direction you give your Executive for the year ahead.
Object in the Mirror
After brief reflection on a journey over a decade, I will heap praise for good deeds, examine barriers and beliefs that impinge on our best efforts, dissect demands for disruptive change, and challenge the morality of missing health care.
In 2003 I pondered the triple aim of looking after the individual, looking after each other, and looking after the system. In 2004 I aspired for us be victims no more, but wondered whether we would grow apart, or grow up together. In 2005 I focussed on strengthening branches and leading clinical networks while supporting ourselves. In 2006 I challenged us to seize leadership. In 2007 I explored the rewards of connectedness, and the harm of disconnectedness. In 2008 I dissected leadership from power, claiming we were translational (as distinct from transactional and transformational) leaders. In 2009 I asked “are we there yet?” on the journey from competitive silos thrust upon us by Simon Upton’s reforms, away from the lingering toxic legacy of fighting each other, from the poisons still leaching out under pressure, to an integrated health journey in an integrated health system. In 2010 I wondered how we defined our best, and the benefits of reducing variability, optimising the known, and addressing more cleverly the unknown. Last year after tossing and turning I reported stories of heroism, stories of endeavour, and what we could learn from other disciplines about what drives us to act the way we do. This year I have owned up to mistakes I make, and will continue to make, while trying to grasp critical thinking.
During all these addresses I have been prepared to criticise, to cajole, whilst also encouraging and engaging. Optimism outbalancing pessimism. I know no other way.
Object in the Mirror
Let me hold up the mirror of praise. Praise first to Ian Powell and his tireless fight for a high quality public health system and those who work within it, and against those who deliberately or accidentally set out to destroy it. Praise next to the industrial team of Angela, Henry, Lyn and Lloyd who try to anticipate the machinations of managerialism and support members through tough times. And praise to the team led by Yvonne, who with Kathy, Terry, and Ebony run a highly professional national office. As membership increases, so do the demands and expectations on these hard working folk, therefore your Executive has determined that we should increase the industrial team and the office staff, and the office space thus required. Praise to your National Executive who agonise before, during and after their decisions made on your behalf.
I also praise the Minister of Health. He has laid down challenges with some targets which the system and fine individuals within it have risen to achieve. Childhood immunisations are now at an all time high, and the disparity between ethnicities has disappeared in many areas. Healthier lifetime outcomes will escalate for many who previously missed out on perhaps the most effective health intervention known to science. Cancer networks are redesigning their approaches to improve access to diagnostics, confirmation, and treatment. Access to elective surgery is improved. Rheumatic fever is being tackled. Some of the factors behind our shameful record in this and other diseases of poverty and poor housing, such as pneumonia, bronchiectasis and skin infections, will require much more joined up thinking with other Ministers and Ministries. Likewise our violent society has yet to effectively address the damage to our children from accidental and non-accidental injury and death.
I do pause to ask, as we accelerate down the road of productivity, whether we are carefully looking in the mirror for those we might leave behind? For those whose affliction does not match a target. For those whose health is compromised when, as with Pike River, production trumps safety. When the big bag of blancmange bulges elsewhere.
Object in the Mirror
So I raise objections to some of the demands driving perverse behaviours in those aspiring to be the best at their special craft. I object to appeals to the venal, paying piece rates to incentivise. I object to the stripping of bureaucrats in the back rooms without stripping of the bureaucracy. I have not noticed a reduction in the number of forms I have to fill in, the number of reports I have to write, the paperwork involved in any transition of health care or inpatient health care. The opposite is often true. I am finding I need to type more of my own correspondence, spend more time cleaning up messes, and grapple with increasingly archaic infrastructure. All blocks and barriers to my clinical productivity.
One of the challenges I continually grapple with as a provincial Paediatrician is the balance between the desire and time to seek the absolute best for the children and families I encounter every day, and the desire and time to improve the system we all work within so that others are eager to train and work here. To work with my colleagues at the coalface as well as those charged with the difficult but fundamental task of reverse-engineering a highly complex system whose inner workings are largely a mystery.
How can the finances of such a complex system be understood by capital city analysts who cannot forecast the nation’s operating deficit from one quarter to another? The last three month deficit to September was 27% bigger than forecast, provisional tax $103 million below forecast, source deductions and GST each $166 million below forecast. Yet the offices of these same analysts proffer PPPs to salve our DHB finances, along with other nostrums such as disruptive innovation. I will dissect some of these offerings.
Object in the Mirror
One of the imperatives of integrating primary and hospital care has been to deliver services, traditionally sited in hospital campuses, in settings closer to home, in homes, and by innovative craft groups and individuals. Objective analysis of outcomes has not always matched ideology, and while I am personally enmeshed in many activities seeking to innovate, integrate and challenge tradition, I also need to keep critical thinking post-its stuck to my mirror.
A few GPs in England are said to be pocketing millions of pounds from the sale of NHS funded out-of-hours GP service Harmoni to private health care company Care UK, at the expense of NHS Direct call centres. Meanwhile a report in the Medical Journal of Australia found 52 percent of patients who had been given advice by a healthdirect registered nurse to stay put or seek treatment in a non-emergency setting nevertheless presented to an ED. The report also found 73 percent of healthdirect referrals to emergency departments to have been appropriate, compared with an almost identical number for people presenting of their own accord. An accompanying editorial piece questioned whether healthdirect is a sound use of government health dollars. “In relation to whether an ED visit is required, it appears that a phone call will not answer the question”. Especially as a 17.5 percent increase in calls to June 2012 compared to the same period in 2011, will obviously drive even more referrals to EDs or doctors elsewhere. In the UK the shadow health minister Jamie Reed opined “As the private sector takes over out of hours services, it’s a dangerous mix of medicine and the money motive”. We need to beware of perverse outcomes from perverse incentives.
Another current fashion is to espouse the writings of Clayton Christensen, author of The Innovator’s Dilemma in 1997, and more recently focusing his Harvard badged lens on education and on health. He has promoted disruptive innovation as the cure for schools (Disrupting Class, 2008) and for the American healthcare system (The Innovator’s Prescription, 2009). He carries the accolade of the world’s most influential business management thinker in 2011. Some of his claims may resonate or at least sound familiar to you: 50% of all health care is driven by physician and hospital supply, not by patients’ needs, doctors work in a system where they are rewarded for the number and cost of the services they provide rather than by the value of those services in helping patients, fee-for-service is a runaway reactor in accelerating the rise in health-care costs, what we need is a system of new value networks that will disrupt the old business models in this industry, we need a new approach not just to insurance and reimbursement, but also to the places where medical services are delivered, the way we use technology, the way pharmaceuticals are developed, the way we educate medical professionals, and who performs what kinds of services. He also promotes electronic medical records, particularly personally held records, as a portable and proven (in sub-Saharan Africa) disruptive innovation, they can be ”the connective tissue that draws and holds together the individual elements of our care”. He cautions that until we make treatments and services effective and affordable, changing the way consumers pay for the services doesn’t fix anything, that changing one piece, or plugging an isolated innovation into an existing framework, will not solve the larger problem. He says that only by making lower-cost venues more capable that health care becomes affordable, not by expecting large hospitals to charge less.
But before admiring the new fashion in the mirror, let’s explore a few more of his mantras. Clay Christensen argues that physicians attempt to preserve incomes with dysfunctional service models, that we need “the visible hand of managerial capitalism” to “create a new business ecosystem, to get all parties to work together to bring about real change.” He is a friend from church and advisor to Mitt Romney, saying that how to apply Mormon gospel in the wider world drives Mr Romney’s life. Having also served as a bishop in the church, this business professor may be following the long tradition of Mormons sharing secular versions of their tenets, illustrated by Steven Covey’s “The Seven Habits of Highly Effective People” which Matthew Bowman calls Latter-day Saint theology repackaged as career advice.
Beware his acolytes if their disruptive change does not fit well with your intimate insights into this noisy, messy and complicated world we share. Do not sit on the sidelines while forced dichotomies masquerade as non-alignment. Argue with energy, with passion, with desire for the best, while preserving our obligations to one another.
In the counted tale of things a rule of thumb for sound inference has always been that if it looks like a duck, swims like a duck and quacks like a duck, then it probably is a duck. But there’s a corollary: if it struts around the barnyard loudly protesting that it’s a duck, that it possesses the very essence of duckness, that it’s more authentically a duck than all those other orange-billed, web-footed, swimming fowl, then you’ve got a right to be suspicious: this duck may be a quack.
Object in the Mirror
As I approach a decade serving you as President I have gained insights from wandering between the coal face and the centre. I struggle daily with the illnesses of children which should be banished from rich countries, which help frame our double jeopardy along with the silver tsunami of many living longer. We have to grapple with the health demands of the aging alongside the health demands of the destitute, and mostly, young.
I reflect on the chaos of earthquake-torn Christchurch and cringe at the advice of John Briere. This eminent psychologist, with experience of the effects of cyclones, terrorist attacks, gangs and torture, showed us last week that the worst effects on children, and adults, are three years and more after the initial disaster. We have to face very real and very present dangers.
As I pass two decades as a Consultant Paediatrician I find I am working harder in my own silo, even though I strive to integrate and regionalise my expertise. I am trying harder to do what I trained to do. The core of my clinical business is history and examination, then formulation of possible diagnoses complemented by appropriate investigations, then mutual construction of a management plan, supplemented with followup and reinforcement as necessary. How much of the first two processes, history and examination, do I conduct in the silo of my own clinic room? How much can I improve how I take a history and conduct an examination if I am not directly observed and appraised? By my peers, and more than once or twice. How can I argue for this quality control, especially when any time I might sit in a colleague’s clinic, or she in mine, is unproductive in the churn of FSAs and waiting time targets? The Medical Council and others are instigating very occasional and expensive practice reviews when we could be integrating more frequent feedback and support in our everyday workloads. Which is a better reflection of our practice and competence? A better modelling for our trainees and specialists of the future? A true training as part of clinical activity, not divorced from productivity. Which object are we pursuing?
Object in the Mirror
We are implored to deliver more productivity, more patients seen and less often, more handed over to other professionals, to their families, to volunteer carers, to themselves . We are implored to train our future colleagues more collegially, more productively, more comprehensively, more compassionately, more professionally, more quickly. These are often portrayed as competing ideals which cannot be accommodated. And those who try to accommodate both get enmeshed in omnishambles – the confusion of multiple shambles.
In this omnishambles we are working harder, faster, better, sooner. And very patchily, still stuck in silos. Some of these are of our own making, forced to build an empire or amplify a squeaky wheel to be heard above the din. Replacing the rhetoric of integration with the reality of the rationing in front of us. The rationing we did not design. The rationing we did not desire. The rationing of inertia.
Removing barriers to sharing the care of patients requires sharing basic information about them, trusting others to interview, examine, record, investigate, prescribe, opine, debate, reflect, and make it all as seamless and non-repetitive and non-duplicative as possible. To ease the patient journey by making them the centre of activity. And yet we allow our health system to sabotage sharing. Allow administration systems to block and prevent transitions of care. Allow non-use of proven electronic referrals, proven electronic prescribing, proven clinical portals.
How can it be ethical or moral for one DHB to block or prevent another acquiring more efficient systems, for a DHB to not invest in better systems a neighbour, near-neighbour, or another New Zealand DHB is using to provide best patient care? To waste clinician time and productivity and deny patients the care they could otherwise access if their journeys were joined up.
There is rightful indignation if proven medicines or procedures are not implemented, if complication rates vary wildly, if some patients are denied best outcomes because of antiquated medical practice, if clinicians do not keep up to date, if national targets are not met. I should expect to be criticised by my patients and my peers if I do not advise, prescribe, and advocate best practice. If I do not implement care and processes for the proven best outcomes and least variability in my actions. Yet we see behaviour in administrative silos that appears out of alignment with proven practices that can free up frontline professionals to look after patients better, sooner, and more conveniently.
Clay Christensen may not be wrong when he espouses electronic shared medical records as a disruptive means to an end. As a way to empower patients and centre care around them, rather than around us and our systems. Yet our DHBs are permitted to thwart the efforts of the National Health IT Board to implement robust clinical systems that can share vital information whenever and wherever a citizen encounters a health professional. Despite such sharing happening right now in pockets of enlightened networks. With demonstrable improvement in resource use, in patient access, and in reducing duplication. And better use of specialised and generalised care. We have to question the ethics and morality of not making these benefits available in any and all DHBs.
While needing to be careful to avoid the debacles of the MSD kiosk and the teachers’ payroll, we nevertheless need to interrogate the ethics of rationing healthcare according to the whims of infrastructure investment. If it is ethically and morally acceptable to your Board, or that of your neighbour, it may not be so to you as an SMO or SDO, and most assuredly cannot be so for your patients.
Object in the Mirror
The person you see in the mirror is the one who can demand and lead the necessary improvements, but only if you strive together, not in competition with others. Lift your head up from the instance of a patient encounter. Lift your head up from the urgency of a target. Lift your head up above the parapets and risk being hung for other’s crimes, drawn into conflict, courted by empire builders. Lift your head up, for others whose appreciation may only be expressed in their absence of objection. This is true clinical leadership. Leadership that is translational. That translates integrated pathways and patient desires into what might be achievable within the realms of medical miracles and funding envelopes.
This is the leader as servant, something I have strived to be for you, and for the system we dream of, together. For together we are greater than the sum of our individual ambitions.
Toi Mata Hauora
Our association, which represents the pinnacle of medical professionalism, and argues for the highest quality of our public health system, has for 24 years presented a somewhat monocultural face. I believe that a New Zealand organisation at the forefront of healthcare for Aotearoa should have an identity in te Reo. On your behalf I have sought advice and cultural counsel on how we might present ourselves. The offering we have is Toi Mata Hauora, which conveys the essence of us representing the pinnacle of healthcare. I am exploring how we can adopt this gift as part of how we represent ourselves to our members and to the wider health system we guide and lead. I propose that we arrange adoption of this addition to our name at a special gathering of the executive, branch presidents and vice-presidents early in 2013. I look to its adoption as a parting gift.
As I look to step aside from the Presidency next year, the ASMS will not recede in my mirror. I will still support and serve an organisation that is stronger and more relevant than ever. It could never be described like the Republican Party – appealing only to angry older white males. ASMS has stronger branches than it ever had, with branch officers taking local leadership. And is constantly striving to support and communicate with members through their highs and lows of specialist careers. Through the last decade we have endured tough battles and achieved much more than I or many may have expected, in fiscal matters and, even more importantly, in driving clinical leadership and other transformations in the lives of specialists, for the good of their patients.
Thank you for your engagement that enabled leadership. I respect the energy and commitment you display. I remain hopeful I can continue to help our specialist workforce strengthen their individual and collective roles in the leadership of our complex, frequently frustrating, and often brilliant, health system.