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Ian Powell: The Dialectics Of Incrementalism And Transformation

The incoming new government can be transformational, especially with help from the Greens. According to health commentator Ian Powell this is especially apparent in the health sector.

In the lead up to the general election I was predicting a Labour-Greens coalition with, as a second option, a Labour majority government. The first was based on an assumption that Labour would not get the necessary 62 seat majority. The second assumed that the Greens would either not return to Parliament or, if so, only just and with less representation. I didn’t anticipate both parties expanding their respective votes. In contrast, National and ACT competed against each other for a reduced combined vote.

Consequently this has led to post-election discussions in which the bigger party doesn’t actually need a formal coalition party although it is mindful of the value of an ongoing relationship with the smaller party. Much of the discussion by journalists and other commentators has been expressed through a formal framework. Should there be a formal coalition perhaps with some Green ministers outside cabinet or a looser cooperation arrangement (or nothing at all). Lost in this structural approach to political analysis has been the dynamic of dialectics in politics.

Linked to this discussion is whether the next government led by Prime Minister Jacinda Ardern will be incrementalistic or transformational. In the 2017 election Ardern said she sought to lead a transformational government but the experience has been that her government provided the kind of transformation you have when you aren’t having transformation.

The election outcome was resounding with a much stronger Labour Party no longer dependent on the Greens emerging despite the latter unexpectedly emerging stronger as well. Labour has a mandate to choose to either form a government on its own or in coalition with the Greens. While Labour is into incrementalism (with a few transformational twinges), the Greens are closer to transformational (in a reformist rather than revolutionary way).

Importance of political voice

Since they were first elected to Parliament in 1999 the Greens have successfully added a political voice to important issues and struggles. This has served to heighten public awareness, at least, and empathy if not always support. This has served them well to become the first junior coalition government party to return to Parliament with an increased vote and MP numbers despite in a number of areas, particularly health system policy, being a muted public voice and the ‘green school’ debacle.

The effectiveness of Eugenie Sage as conservation minister, for example, to confront the crisis faced by nature and the need for a nature-led recovery is well made by Forest & Bird Chief Executive (and former Green MP) Kevin Hague.

But Labour doesn’t need the Greens. A Greens offer of a supply and confidence agreement in exchange for ministerial portfolios inside or outside cabinet would be insufficient temptation. Any Green ministerial appointments including outside cabinet would be subject to Labour’s control. But this assumes that the ‘baubles’ of ministerial office are the only or most effective means of achieving political influence and change.

The Greens are rightly invigorated by their impressive electoral success. They already have talented articulate MPs capable of giving voice to important issues and now are joined by more. They can be supportive of Labour initiatives which support nature’s struggle, protect the climate and promote social justice (including health and employment relations policy) and be a critical opposition where Labour falls short or goes in the wrong direction.

Former Green MP Keith Locke has argued well the case for whatever the Greens relationship with Labour, it must not be at the expense of their independent voice. This would not preclude a cooperation agreement on specific issues such as tangible measures towards the Hague highlighted nature-led recovery.

Role of noise

With or without a non-muting cooperation agreement with the next Labour government, the Greens are well-placed to exercise voice in order to better pursue the advocacy of issues important to them. Holding ministerial portfolio can operationalise political influence with considerable effect but only if the dominant governing party needs you. Labour doesn’t. Consequently the Greens political influence would be most effectively exercise through public advocacy including being critical of Labour where justified.

Like its predecessors the Ardern government responds to noise. To the extent that the Greens can win the hearts and minds of the public on issues, they have talented MPs to effect noise. If an arrangement with Labour is entered into that mutes their advocacy then the Greens will go into the 2023 election in a vulnerable position.

But, if the Greens follow Locke’s independent voice advice, they will go into 2023 in a much stronger position and likely to be critical to Labour’s ability to form a subsequent government. This could enable them to ministerially operationalise their influence much more than over the past three years. The Greens have a great political opportunity through their successful election outcome but not in the way that its leaders might have envisaged.

Liberal technocrats

Commentators tend to describe the Labour Party as ‘centre-left’ often to differentiate from National which they label ‘centre-right’. But, while convenient, these labels reflect static thinking, lack precision and resemble more shipping flags of convenience. It is better to describe Labour as liberal technocrat; socially liberal with a bent towards collective responsibility and a more active role of the state in the economy. This also includes a predisposition towards respect for experts and science which explains its willingness to accept the advice of mainstream public health specialists and other experts in the successful by international standards to Covid-19, something we should all be grateful for.

But liberal technocrats tend towards structural thinking at the expense of a sense of dynamics and processes. Their viewing lens struggles to achieve peripheral vision as witnessed by its speedy ill-considered support for the Heather Simpson review of the health and disability system proposed massive centralised restructuring of our health system.

Dialectics

While Labour can be legitimately criticised for incrementalism rather than being transformational, it is not as simple as that. This is where dialectics comes in. Dialectics is the general theory of how things come into existence, change and then die out. Eighteenth century German philosopher Immanuel Kant described dialectics as having three stages of development. It started with a thesis which led to the second stage of a reaction in the form of an antithesis that contradicts or negates the thesis. The third stage was the tension between thesis and antithesis leading to a synthesis between them.

Kant’s dialectics theory was popularised by another German philosopher Georg Hegel in the early 19th century. Hegel’s younger admirers Karl Marx and Friedrich Engels ‘appropriated’ his popularisation by shifting its ideas basis to one that was more materialist.

These admirers also emphasised that at a certain point ongoing changes in degree can become changes in kind (ie, a series of quantitative changes become qualitative) which is relevant to the relationship between incremental and transformational change.

Transformation by incrementalism?

The future direction of New Zealand’s health system sits within this dialectics framework. Labour veers towards incrementalism while the Greens veer towards transformation (although there is no such word as ‘transformation-ish’ there should be).

At a certain point, where the independent voice of the Greens gets currency with enough of the public, practical incrementalism can morph into changes of a more transformational nature even if this new synthesis provides stronger building blocks rather than the full deal. Translating to health, the greater the commitment to heavily invest in incremental improvements to our health system, the greater the prospects of transformation in various forms.

Social determinants, unmet need and population health

Significantly reducing (preferably eliminating) social determinants of health would generate transformational change in our health system. Although external to the health system, they drive much of health demand. They include housing access and quality, educational opportunities, environmental factors, occupation, income level, food insecurity, racial discrimination and gender inequity.

We need political advocacy on how the health system might operate both nationally and at a DHB level to reduce them. Increasing capacity and capability for an expanded role for health system responsibility for these determinants including strengthened health protection services would be a starting point.

The high level of unmet patient need (conservatively estimated at 9% of the population) is significantly driven by these social determinants of health. But both the former National and outgoing Labour led governments have been disinterested in pursuing this research further. If we are to have transformation in health we need to have this research undertaken as a priority to better inform an action plan to address it.

Health systems are not just about patient diagnosis and treatment. Population (public) health, which includes assessing healthcare needs, is also critical but has been under-valued. It should be significantly upgraded. Its importance has been highlighted by the vital role of epidemiologists in providing excellent advice over how New Zealand should respond to Covid-19. Investing in the population health workforce, including public health specialists, would enable incremental improvements to social inequities and their underlying social determinants of health to be achieved with the potential to evolve into transformation.

Empowering health professional workforce

Being transformational in health means engaging and empowering its health professional workforce through distributed leadership at all levels including the clinical frontline. There are three main things responsible for driving innovation in health – highly skilled workforce (a driver as health is labour intensive), technology (as an enabler), and a distributed leadership engagement culture (creating greater opportunities for continuous quality improvement to flourish).

The most critical part of the health workforce are those involved in clinical, diagnostic and population health work. They are the ones, more than others, who have the capability to improve the quality and financial performance of the health system (what makes good clinical sense also makes good financial sense).

Health professionals comprehend the complexity of the health system. They possess the wherewithal to problem-solve and address systemic challenges. Two things are required to achieve this – capacity (ie, address severe shortages – around 24% in the case of DHB employed specialists) and an engagement culture given oxygen to this capability.

The opposite of workforce engagement is managerialism which currently dominates the health system. Managerialism culture pervades the Health Ministry-DHBs relationship and within DHBs themselves. Transformation would involve overturning the dominant managerialism leadership culture in which management or bureaucracy is the driver and controller rather than supportive enabler.

Health investment improves economic performance

The sooner the new government recognises that investing in health benefits the performance of developed economies such as New Zealand. Investing in health being good for economic performance is accepted as valid by no less than the International Monetary Fund. Covid-19 is further evidence of this. New Zealand’s economy would be in a more parlous state than it is now had it not been for the health system’s proactive firm response, including the first lockdown.

Health should be seen as an integral part of New Zealand’s Covid-19 economic recovery by investing in its workforce so that the system can cope with increasing acute and chronic illness patient needs. It also means ending the tunnel-visioned scandal where hospital rebuilds are not based on expert clinical and epidemiological advice and instead built for short-term capacity needs. In order to turn around the rundown state of public hospitals, we need a paradigm shift where job rich major capital works for environmentally sustainable longer-term rebuilds should form a central part of the next government’s Covid-19 infrastructure fund (refer here).

There is a need to review how DHBs are funded. The Population Based Funding formula has much to commend it but it is not suitable for funding DHBs coping with natural disasters (the Christchurch earthquake). A different way of funding major capital works also needs to be developed that doesn’t attract the costly capital charge which the Auditor-General has acknowledged serves no good purpose.

Finally, continuing patient co-patient payments for general practitioner consultations should end. They are a barrier to both access and the further development of health pathways between community and hospital care. They are also inconsistent with health being an investment in economic performance.

Avoid destructive restructuring

Not only is large-scale structural change not transformational, it is also unlikely to achieve incremental improvements. Unfortunately the Simpson review recommends massive and disruptive restructuring by increasing centralisation through the creation of both a much smaller number of ‘mega DHBs’ (most likely based in Auckland, Hamilton, Palmerston North or Hastings, Wellington, Christchurch and Dunedin) and an additional powerful new national health bureaucracy. This restructuring would enable increased top-down decision-making and reduced engagement and voice in the health system.

This would impede the most critically needed coordination and integration which is between community and hospital care. This is where effectiveness and innovation is best able to improve the health system’s capability to contribute towards reducing social determinants of health and unmet need.

The Simpson restructuring would undermine a strength of our DHB system which is its statutory responsibility for the healthcare of geographically defined populations from community to hospital. It creates a construct for enabling integrated care based on a focus on the continuum of care between community and hospital.

It would not be transformational to bin this proposed structural overhaul but it would be counter-transformational to proceed with this because it would lead to a centralised authoritarian leadership culture that would further entrench managerialism. Community and health professional voice is critical for the effective functioning of a health system. It is a form of self-generating empowerment that enhances understanding and performance. It should be unmuted rather than muted more than it presently is.

The proposed restructuring would not only lead to around five years of disruption for health professionals and management, it would be downright dangerous at a time when New Zealand is surrounded by a world dominated by a worsening pandemic. Destabilising the health system in the midst of a pandemic is Trumpian at its most destructive.

Instead of restructuring, public provision of hospital services that have been previously privatised should be restored. The new political environment should be conducive to seizing the time and reversing these privatisations which have occurred over the years under both National and Labour led governments. This is especially the case for some of our hospital laboratories such as Wellington and Dunedin. Hospital laboratories affect around 70% of clinical decision-making in hospitals. They need to be highly integrated with the rest of the hospital rather than structurally fragmented and driven by profit-maximisation pressures.

In adapting to this new exciting political environment we should not pigeon-hole incrementalism and transformation. Labour does have a mandate at the very least for making incremental improvements to our health system as discussed above. The Greens through independent voice and noise rather than ministerial portfolios to further push these improvements to the tipping point of when quantitative changes becomes qualitative transformation.

This advocacy becomes a question of language. Learning from the late Jim Anderton the Greens need to translate perceived transformational ideas into plain ‘salt of the earth’ language recognising that most people have an innate sense of goodness and cooperative spirit which are what public health systems are all about.

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.

Originally published on The Democracy Project here.

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