The opportunity for public voice is vital for the effective functioning of New Zealand’s health system. Inevitably voice boils down to the accessibility quality of comprehensive healthcare services for patients both at an individual treatment and population health level. This voice can come from a range of people including patients themselves, health professionals (whose duties include patient advocacy), and various non-government health advocacy organisations.
Voice is a form of self-generating empowerment that enhances the understanding and performance of the health system and its ability to meet patients’ needs individually and collectively. Only arrogant elitism and the narrowly focussed would see patient voice as a nuisance or threat.
Patient voice helps ensure that our health system decision-makers adhere to the values the system is based on. Decision-makers are relatively isolated from patient reality, especially when struggling to cope with underfunding. This puts them at risk of making short-term decisions with long-term negative consequences.
At the very least patient voice reduces this risk. At best it can add positively to the quality of decision-making. Voice adds value to decision-making by bringing into consideration experiences and knowledge that decision-makers often don’t have.
The Simpson review and ‘guided autocracy through centralised authoritarianism
The effectiveness of voice is better enabled by its proximity and accessibility to decision-makers. The greater the distance between them, the less its effectiveness. Herein lies the threat of the Heather Simpson review of the health and disability system.
The review recommends dismantling the 20 district health boards and replacing them with between 8 to 12 mega DHBs overseen by a new national health bureaucracy. This would create a highly centralised decision-making process thereby increasing the distance between those that provide voice and decision-makers leading to the muting of the former.
Managerialism versus distributed clinical leadership
In the 1990s and for much of the 2000s health system leadership was characterised by what is known as managerialism. That is, senior management itself was the driver of development and changes with health professionals such as hospital specialists and nurses subordinate. The inevitable result was narrowly focussed poor decision-making at the expense of the interests of good patient care and a corrosive clash of cultures with the health professional workforce. There were exceptions but managerialism was the norm.
This experience eventually led to the health system looking to go in a different direction that would enhance patient voice. In 2008 then Minister of Health David Cunliffe facilitated a national agreement titled Time for Quality between the DHBs and Association of Salaried Medical Specialists that focussed on clinical leadership and partnership with management.
The following year Cunliffe’s successor Tony Ryall, despite being from the opposite main political party, strengthened the direction of this agreement. Ryall did this with a policy statement titled In Good Hands calling for decision-making to move as close as practical to the workplace through a distributed engagement culture. Both these initiatives recognised that what makes good clinical sense also makes good financial sense.
Unfortunately this distributed engagement never sufficiently materialised largely because of the effects of prolonged underfunding and the resurgence of the leadership culture of managerialism. The Simpson review’s restructuring would see the emergence of centralised authoritarian leadership culture resting on the false assumption that distant top-down control leads to good decision-making.
I have described the restructuring advocated by Simpson elsewhere as leading to ‘guided autocracy’. That is, the emergence of this centralised authoritarian leadership culture would strengthen managerialism. Further, it would both marginalise and suppress intertwined patient voice and health professional and public engagement.
Elected Board members
The Simpson review also recommends that the current mix of elected and politically appointed Board members ends by removing elected members. Although not as significant has the factors discussed earlier this would also help further weaken voice. This doesn’t mean that elected members are representative of their communities. Their low rate of remuneration compared with elected members of city and district councils guarantees that those elected to DHBs would come disproportionately from the more affluent. But voice is more likely to resonate with them compared with political appointees.
Elected Board members are being unfairly blamed for past failures in order to justify a new centralised regime. Overwhelmingly DHB disasters have been due to the poor performance of politically appointed board members, particularly chairs, such as the IT fiasco at Capital & Coast over two decades ago, the appointment of disgraced Waikato chief executive Nigel Murray and the most recent leadership meltdown at Canterbury.
There have been some occasions where elected Board members have been unreasonably disruptive but in my experience these have been rare. In fact, there is no evidence that elected board members generally are less competent than political appointments. If anything the voice of elected representatives has been smothered by the current system.
Simpson restructuring undermines Simpson positives
A positive feature of the Simpson review is its recommendation of health planning by localities that might be based, for example, on local government boundaries. Locality planning would include health needs assessment, unmet need, what services should be provided, new network services, and expected outcomes. Each locality would have an indicative budget based on the age, ethnicity and deprivation of its population and would establish service networks.
Locality planning has potential to improve the health of populations particularly if it can focus on the social determinants of health, such as housing, which despite being external to the health system are the biggest driver of health demand.. But to be effective locality planning would require unimpeded community voice. The more mega the DHB, the further the distance between decision-makers and the community voice and consequently the greater the obstructiveness to that voice.
Another positive feature of the Simpson review is the proposal for a national health plan for what services our health system should be provided. This picks up from an initiative in the late 2000s from the Ministry of Health looking at long-term public hospital services. However, the National-led government had no interest in following it through.
To its credit the Simpson review has resurrected this initiative. It would be undertaken by either the new national bureaucracy proposed by Simpson (currently known as ‘Health NZ’) or the Ministry of Health expanded by increased capabilities – the latter is the more sensible option.
The health plan would specify what services, and at what level of services, should be provided in each public hospital. It is more than what bigger hospitals should provide high complexity low volume services such as neurosurgery and paediatric oncology. It includes the extent of sub-specialised services in medium-sized services and the range of services provided in smaller hospitals.
This is an important but challenging piece of work. But the more remote decision-makers are from where services are provided and the more bureaucratic the system is, the greater the prospects of the wrong decisions being made and services being lost or reduced for the wrong reasons.
Its success will be determined by how well DHBs know the health needs of their populations (much less likely if undertaken by mega DHBs) and whether or not the new leadership culture is managerialism reinforced by centralised ‘guided autocracy’.
At a time when we should be embracing and expanding the opportunity for voice about patient care to both better protect and improve our health system, we are being threatened by an ill-considered restructuring to a top-down decision-making system in which voice risks becoming voiceless.
Ian Powell was formerly the Executive Director of the Association of Salaried Medical Specialists for over 30 years until December last year. He is now a health commentator, editor of the blog ‘Otaihanga Second Opinion’, and based in Otaihanga on the Kapiti Coast.
This article can be republished under a Creative Commons CC BY-ND 4.0 license. Attributions should include a link to the Democracy Project.