On 5 September the only New Zealand owned national mainstream print and online media outlet Stuff published an editorial on the toxic relationship between the Ministry of Health and Canterbury District Health Board. As well as online it was also published in the print issues of Christchurch’s Press and Wellington’s DomPost dailies.
Literary debunking and slap-down
The editorial begins with a scathing debunking of claims that Ministry pushed cost savings would not lead to service cuts (claims made by the politically appointed CDHB Board Chair John Hansen and the Health Minister’s crown Monitor Lester Levy). It does this by referring to the “embarrassing” discovery of the failure of the new Hagley block to deliver on the intended emergency department development and children’s ward “…simply because there is not enough money to staff them.”
How’s this for a literary slap-down? “Freshly built but unstaffed wards are an almost perfect image of a health system in which something has gone wrong.” It reminds me somewhat of the famous British ‘Yes Minister’ comedy on the well-functioning hospital without patients. Except that Yes Minister was very funny and clever but Hagley real life is neither.
The editorial observes that this isn’t just a local story. It could happen anywhere. Correct. Anticipate conflict with the huge Dunedin Hospital rebuild which is the next to come. Other rebuilds such as Nelson and Whangarei Hospitals are further down the line. The conflict will largely be around when clinically led recommended business cases clash with arbitrary narrowly short-term focussed decision-makers in central government.
Government responsibility and role
As the editorial notes the Government can’t claim that that it wasn’t warned of the implications of the drastic Health Ministry driven deterioration of its relationship with CDHB. On 2 separate occasions CDHB’s Clinical Leaders Group wrote to Prime Minister Jacinda Ardern alerting her to this deterioration and its risks.
Further, Health Minister Chris Hipkins unwisely but revealingly rejected data released by outgoing CDHB Chief Executive David Meates confirming that responsibility for the deficit primarily rests with the consequences of the earthquake and the Ministry’s response on behalf of governments of the day. Instead, on TVNZ News (6PM), the Minister expressed stated a clear preference for the position of his Ministry and Treasury. It was as if Yes Minister had suddenly morphed from being a comedy into a documentary.
Hipkins’ response was surprising from a liberal technocrat politician for whom empiricism would normally be expected to form part of his analysis. Only the CDHB executive management team have been prepared to back up their position with data; unlike the Ministry and Treasury.
Simpson report and incorrect conclusion
The Stuff editorial is on the button in its analysis of the toxic environment. But it gets itself into a tangle when discussing next steps. It points to the report of the Heather Simpson review of the health and disability system and then singles out its recommendation to drastic reduce the number of district health boards. After noting that 19 out of the 20 DHBs had deficits in the previous financial year, it gives the recommendation implicit support by declaring that it is “…clear that an overhaul is required.”
This conclusion ignores key facts. Deficits are driven by the failure of health spending for over a decade to keep up with the increasing costs of growing health needs. One of the main cost drivers of deficits is acute patient demand increasing at a higher rate than the rate of population growth. This is expensive. It is due to factors such as the aging of the population (including increased frailty) and increased poverty-related illnesses.
Ironically, CDHB has been the most successful of the other 18 DHBs with deficits in responding to this cost driver because of its innovative clinically developed and led health pathways between community and hospital. CDHB managed to bend the curve of rising acute demand thereby saving millions of dollars.
The Simpson report recommends the establishment of 8 to 12 mega DHBs in a new system that will be tightly controlled by central government. This will make DHB boards and chief executives more subservient to central government and less likely to advocate the health and wellbeing needs of their populations despite them being statutory required to do so.
The editorial gets it wrong because it looks to a structural change to resolve what is a cultural problem. This is always bound to fail. A modern vibrant public health system requires the opportunity for voice including from the public, patients, health professionals and managers. The Simpson report is about creating structures to silence voice.
The kindest interpretation of the conduct of the Health Ministry towards CDHB is that it has adopted a culture of authoritarian centralism. Applying the Simpson recommendation would both structurally strengthen this repressive culture and enable it to be extended to the rest of the country.