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Health System Synthesis: From Time To Culture, Struggle And Hope

Yesterday (18 May) I was honoured to participate in a panel discussion at a symposium organised by Women in Medicine in Wellington.

In its relatively short existence, WIM has become a critical and influential voice on the plight and key issues of Aotearoa New Zealand’s once world leading health system. It has a strong leadership team chaired by Auckland general practitioner Dr Orna McGinn.

The panel discussion I was involved in levered of the Dragon’s Den television concept. Originating in Japan this now global programme involves entrepreneurs pitching for investment from the dragons (venture capitalists) willing to invest their own money.

The panel was called ‘Three Wise Men’. Those selected were former Te Whatu Ora (Health New Zealand) Chair Rob Campbell, general surgeon and former Medical Council Chair Andrew Connelly and me.

In the context of hope we were each were to pitch two ideas to improve the health system. My fellow panellists were more numerically accurate than me. I pitched one idea with four parts to it.


This is a unique event for me.  Over the past around 35 years in and around the health system I’ve addressed hundreds of gatherings. But, if I understand the Dragon’s Den concept correctly, this is the first time I’ve ever pitched a message to entrepreneurs and venture capitalists.

This is also an interesting selection of three notionally wise men. Rob Campbell is a former ‘pinko’ who, as a man of many epiphanies, appears to be on a haphazard journey back towards these roots.

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As a surgeon Andrew Connelly comes from that branch of medicine that has no comprehension of ambiguity. That leaves me as a dialectical ‘pinko’; like the health system, driven by contradictions.

There are two relevant self-evident truths in our health system. First, most health demand and costs are externally driven by social determinants of health beginning with income.

The health system can’t fix these. At best it can mitigate. Fixing requires legislation and government policy.

Second, the biggest immediate threat to our health system is its severe workforce shortages.

But, even if these shortages were resolved, our health system would still require much more to be clinically, equitably and fiscally effective.

I condense achieving this effectiveness to four elements – time, which provides the foundation, and then culture, struggle and hope.


In the early nineteenth century in Lowell, Massachusetts, a young woman Lucy Larcom wrote poetry in her spare time. In her working day she was employed in a local textile mill in the midst of clattering machinery. Eventually out of frustration she resigned.

Her paymaster asked her if she was going to a better paid job. No she responded; I am going to where I can have more time.

Several decades later, in 1865, and an ocean away, Karl Marx observed in an address the International Working Men’s Association that “Time is the room of human development.”

Both Larcom and Marx were discussing time outside employment. However, an intellectual contemporary and admirer of Marx, English ceramic artist and poet (among several other things) William Morris put time in a different context.

In his words, there was “good work” to be had “not far removed from a blessing, a lightening of life.” In contrast, “bad work” was “a mere curse, a burden to life”.

So time linked to human development at work should be considered as the critical starting point in our highly integrated and labour intensive health system.

Time for ongoing professional development and education within the job is critical if the practice of medicine is to be done well. But more than this, practicing medicine requires mastery of complexity.

Integrated health systems, especially 24/7 hospitals, are highly complex. The ability to master complexity is also an invaluable asset for ensuring sustainable health system improvements, based on an underlying premise that what makes good clinical sense also makes good financial sense.


But even if there was sufficient workforce capacity, time would be ineffective without the right culture.

Maximising time for system improvements requires recognition that the main source of innovation comes from within the health workforce. It does not come from business consultants or corporate management.

It also means having a much higher level of decision-making where the overwhelming majority of healthcare is provided – in communities, including their hospitals – and where it is more likely to be patient-centred.

Modern health systems require a relational  culture. It has to be centred, not on consultation, but on much stronger proactive engagement  where workforce and leadership values align. Where clinical and operational leadership is distributed throughout the system.

This is the opposite of the prevailing command-and-control, micro-management, and managerialism. It is the opposite of having a top leadership functioning in an isolated bubble talking to themselves about themselves.

It is the opposite of a Te Whatu Ora head office micro-managing staff appointments at local levels. It is the opposite of describing funding cuts as “overspends”.

And it is the opposite of resorting to (and misunderstanding) Star Wars  mythology  in order to create fix-it positions called the ‘wayfinders’ of the ancient Sith.

District health boards were mixed over organisational culture. Managerialism was evident to one degree or another in all of them. But, there were also many excellent examples of pro-active distributed clinical leadership.

The DHB which advanced this most systematically was Canterbury until it was crushed by central government command-and-control.  


Consequently culture has to be fought for. It requires ongoing struggle. As a university student I was heavily influenced by a book by historian EP Thompson called The Making of the English Working Class which focussed on rising working class consciousness in the 1830s.

His argument was that consciousness comes from struggle. The struggle he described was exercised in many forms from moderate to militant.

In our context, struggle needs to be persistent and visible. It needs to be actively promoted and voiced by professional bodies and the health unions.

But it also needs to go beyond this to health professionals at their workplaces insisting on the workforce capacity necessary to enable the implementation of this distributive leadership culture.

As Malcolm X said so long ago – ‘by any means necessary’! Metaphorically, not literally, speaking that is.


From consciousness comes hope. Health systems can’t be protected and enhanced without hope.

Ancient Greek philosopher Aristotle said: Hope never abandons you; you abandon it. Martin Luther King said: We must accept finite disappointment, but never lose infinite hope.

I have another authority on the importance of hope – my father. He once advised me that the glass is almost always half full rather than half empty. Nothing new about that statement.

But, he added, on those few occasions where its half empty just add a drop, only a drop mind you, of whiskey in it; that will fix it.

To impress people with this medicinal advice he also recommended that I should claim Mark Twain said it because no-one will ever know.

So, with Rob and Andrew perhaps providing a thesis and antithesis, I hope I have provided the dialectical synthesis. This conclusion recognises that contradictions are the motor force of human society.

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