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Message To Health Minister: Get The Foundations Right Beginning With Being ‘Relational’

When the Labour led coalition government came into power in October 2017 it inherited a health system in crisis, primarily due to the interlocked pressures of rising acute demand and severe workforce shortages compounded by underfunding.

Unfortunately that government allowed these pressures to intensify while it embarked on destructive restructuring that seriously destabilised the health system.

Consequently, in November 2023, the National led coalition government inherited an even greater crisis than its predecessor had six years earlier.

The challenge for the new health minister

Addressing this crisis now rests with new health minister Dr Shane Reti. On the positive side, as a general practitioner and former district health board member,  of all the MPs in the new Parliament, his feet are closest to the ground over the true state of the crisis.

On the other hand, his government’s credibility over health has been damaged by the extraordinary surprise decision to repeal Aotearoa New Zealand’s only recently adopted world-leading smokefree legislation. This was in order to use tobacco tax revenue to help fund its tax cuts.

This bonus for the tobacco industry has made Dr Reti’s challenge even more difficult despite not being responsible for it. He has been forced to swallow a very large dead rat.

I discussed this in detail in my last Otaihanga Second Opinion post: When smoke gets in your eyes the outcome is perversity.  

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Be that as it may, over the festive summer break Dr Reti has an opportunity to consider what his approach should be. He has already made a good appointment with Ken Whelan as his ‘crown observer’ for Health New Zealand (Te Whatu Ora).

With extensive experience in health system leadership in both New Zealand and Australia, Whelan will be invaluable as the Minister’s eyes and ears.

Finding the fundamentals

But much more than this is required. To succeed the fundamentals must be sound. Dr Reti would do well to consider the comments of ‘international health policy surfer’ Professor Chris Ham (my descriptor, not his).

In November he had a paper published by the NHS Confederation (a national body of United Kingdom health system organisations) and the Health Foundation (an independent London based ‘think-tank’) which discussed health systems improvement: Improving health and care at scale.

He had a section specifically discussing the innovative health system improvement of the former Canterbury District Health Board. It’s worth a read:

Canterbury District Health Board in New Zealand serves a population of around 500,000 in the city of Christchurch and surrounding areas. Its quality improvement work has focused on integrating health and social care to tackle growing demand for care from an ageing population. Increasing use of hospital services stimulated its leaders to seek ways of providing more care outside hospitals by strengthening primary care and investing in services that helped avoid hospital admission and facilitated early discharge.

The health board’s leaders worked with staff to articulate a vision based on Canterbury having ‘one system, one budget’. They understood that realising History and context 22 – Improving health and care at scale: learning from the experience of systems this vision depended on fully engaging staff in finding more effective ways of meeting patients’ needs. This meant creating a social movement for change in which over 2,000 staff were engaged in the first six weeks in a programme known as Xceler8, beginning in 2007.

An investment was also made in providing training for staff in the skills required to improve care. Improvement methods such as Lean and Six Sigma were used, alongside visits to organisations like Air New Zealand and New Zealand Post that had achieved impressive results using these methods. The board’s chief executive, David Meates, was explicit in giving staff permission to change the system. These actions delivered results through the aggregation of marginal gains rather than a major breakthrough. An example was the Health Pathways programme in which hospital doctors, general practitioners and their teams worked together to agree what the care pathway should look like for common medical conditions. This included identifying the work that general practitioners and their teams could carry out and the resources they needed to do so. As a result, more care was delivered in the community. When patients arrived at hospital, much if not all of their investigative work had already been undertaken. Health Pathways are one way in which rising demand for hospital care was moderated.

Create the context for improvement based on high trust and low bureaucracy

System leaders involved in the work reported here expressed concern that top-down performance management and associated behaviours might derail improvement, which hinges on the intrinsic motivation of staff and a belief in commitment and not compliance to bring about change. Don Berwick’s report following Mid Staffordshire was explicit in its warnings about the toxic effects of fear and blame and the barriers they create to learning and improvement. The recent Messenger review of NHS leadership found ‘too many reports to ignore of poor behavioural cultures and incidences of discrimination, bullying, blame cultures and responsibility avoidance’.

There is a stark contrast with the work of one of our international exemplars, Canterbury District Health Board in New Zealand, where chief executive David Meates adopted a ‘high trust, low bureaucracy’ philosophy in leading transformational changes. This is quite different from the emphasis in the NHS on assurance, ‘constant checking and reporting’ in the words of one interviewee, and upwards accountability.

I have discussed Canterbury DHB’s innovative engagement culture on several occasions. For example, on 19 June 2021, I posted on how the Cardiff & Vale health authority in Wales learnt from Canterbury how to better cope with the onslaught of the Covid-19 pandemic: Cardiff & Vale learn from Canterbury.

This year (30 October) I posted on Wales deciding, after trialling it, to rollout ‘health pathways’ nationally: Wales rolling out health pathways.

It’s all about being relational

There are important lessons to take from Professor Ham’s narrative that form the foundations for Dr Reti to provide the political leadership necessary to help take the health system out of its continual crisis mode and into the space where innovation and system improvements can flourish.

Universal health systems, such as New Zealand’s, are highly complex. This is the nature of an integrated system significantly driven by 24/7 acute demand and covering interconnected and interdependent care in communities and hospitals.

Consequently health systems have to also be highly adaptive. Fortunately they possess health professional workforces who are natural solvers of complex problems.

Engage them in systems improvement and the system gets to first base. But something else is required in order to advance further.

Health systems are labour intensive; their workforces are integrated and interdependent. They are relationship-dependent. What they therefore require is to be able to work in a culture that it relational.

Contractual, ‘command and control’ or rigid cultures (or cultures based on financial levers) prevent health systems from progressing beyond first base.

So much flows from, and depends on, being relational. It explains why workforce shortages must be addressed. Health systems require workforces with the right capacities and capabilities.

It also explains why proactive engagement should be ‘business-as-normal’ rather than occasional narrowly based formal consultation.

So my message to Dr Shane Reti is that before you decide anything, think relational. It trumps everything else.

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