Chief executives and health system improvement: A Canterbury tale

The online daily publication Newsroom has impressed me with its investigative journalism. It certainly punches above its weight. Among its quality investigative journalists is Christchurch based David Williams.

Among Williams’ subjects has been the unprincipled and unfortunately successful brutal assault on the senior leadership of the Canterbury District Health Board (CDHB) by those acting on behalf of the New Zealand government – specifically the Ministry of Health, Treasury’s health section, the Government appointed crown monitor and CDHB Board Chair, and Ernst & Young business consultants.

Meltdown, destabilisation and demoralisation were the consequences. Ultimate responsibility for this shocking behaviour rests with the Labour led government and its health ministers. Political leadership was shown to be poor. Rubbing it in was the Labour MPs in Canterbury (electorate and list) being shamed by their silence.

The Democracy Project last year published three in-depth articles by me discussing the assault in its full context:

  1. (9 February).
  2. (15 April).
  3. (19 May).

The Meates interview

Now Newsroom have published a revealing video interview by Williams of former CDHB chief executive David Meates who is now working in southern England, largely in health leadership and the integration of community and hospital care: silence?utm_source=Friends+of+the+Newsroom&utm_campaign=7d4792b5f8-Summer+Newsroom+10.01.2022_COPY_01&utm_medium=email&utm_term=0_71de5c4b35-7d4792b5f8-97923692.

David Meates

What comes through in Williams’ interview is the importance of integrity and ethics to Meates, his humility, his sense of being a team player, his intellect, and his vison of the direction a public health system should be taking (including the underlying principles it is based on). His departure is a loss to our health system.

Chief executive standouts

At a guess I would have known around 150-200 chief executives of district health boards (DHBs) and their predecessors during the over 30 years I worked as Executive Director of the Association of Salaried Medical Specialists.

With few exceptions all impressed me as hardworking, committed and able people. Many were impressive. In the nature of the organic dynamics of health systems, I would have occasional sharp differences with several chief executives (including Meates).

There were two standouts from among an impressive range. One was Meates and the other his immediate predecessor at CDHB, Gordon Davies. Whereas Meates was mid-career when appointed chief executive in 2009, for Davies it was his last senior health leadership position before retiring after three years in the role.

Gordon Davies

Arguably Davies was the most experienced person to be appointed as a DHB chief executive with a career including heading up both a hospital board and area health board, and deputy director-general of health. Although an accountant he didn’t let this deficiency affect his cognitive insights.

Davies knew CDHB well before becoming chief executive. He was intrigued with the increasing collaboration between hospital based specialists and general practitioners in Canterbury and the opportunities this provided for improving integration between community and hospital treatment. He also understood demography well including what the increased impact of the aging of the population on rest homes would mean.

Clinically led integration between community and hospital

I first met David Meates when he was a ‘boy’ in senior management at the West Coast. Previously he had worked in the retail industry in the United Kingdom. Subsequently he held senior health management positions in Hawke’s Bay and Northland before becoming Wairarapa chief executive.

And then came CDHB. Meates came both respecting Davies and highly impressed with what effective clinical engagement and leadership could achieve.

Meates inherited a DHB that was turning things around and moving in an encouraging direction. He was impressed and used his leadership attributes to further support and extend it. Health pathways became highly successful and world leading.

They went a long way to address the failure of DHBs to sufficiently focus on one of their fundamental objectives – improving the integration between community and hospital care. Davies, who had played a key role in establishing DHBs, already understood this well. Meates came to understand it well also.

The success of health pathways was dependent on them being clinically led and developed. When this happened it had a positive effect on the growing pressure on rest homes, the quality of patient care, and reducing the number of patients who otherwise would have required acute hospital admission.

Given that acute hospital admissions are a big cost driver and have contributed significantly to DHB deficits, the fiscal benefits soon became evident.

Leadership culture the real issue

But this is not about who are the best DHB chief executives. I rate Davies and Meates highly but I also rate many current and former chief executives. A case in point was Stephen McKernan. In the 2000s he was a successful chief executive in two quite different DHBs – first Hutt Valley and then Counties Manukau.

McKernan and many others saw clinical leadership as largely about the treatment and care of patients because of the specialised knowledge and skills of health professionals. This included to some degree or another the organisation of treatment and care. This is good but limited.

But Davies and Meates took it further into wider systems improvement. After all, health systems by their very nature are highly complex and driven by external drivers outside their control. Doctors in particular but also other health professionals are masters of complexity. It is not a huge leap to apply complexity skills developed in one area to another related area.

However, individual chief executives and their senior management teams can’t achieve systems improvement on their own. They require a leadership culture based on and driven by genuine engagement with their health professionals. Of all the 20 DHBs it was Canterbury that made the biggest progress in developing this engagement culture. It was still work in progress but the progress was exciting.

Recipe for conflict escalation

But an engagement based leadership culture presents a problem for top-down bureaucratic centralism. The more decision-making at a DHB level is driven by strong clinical engagement, the more this comes into conflict with more arbitrary and top-down decision-making from central government, primarily the health ministry, where there is less relevant expertise.

When these two types of decision-making come into conflict, it is much more likely that the former will be right and the latter wrong.

This leaves a DHB with an engagement based leadership culture having to deal with poor decisions made by central government. Throw in how to respond to devastating natural disasters (especially earthquakes) and major hospital rebuilding imperatives underpinned by a flawed funding system and you have a recipe for conflict escalation.

Compounding the sorry situation is that the business consultants used to do the hatchet job on CDHB’s senior leadership are the beneficiaries. Ernst & Young have come as close as one can get to being the Government’s business consultancy ‘of choice’ in health despite having limited experience in the sector.

Further, one of their senior partners (McKernan) heads up the Government’s Transition Unit set up to implement its so-called health reforms including the abolition of DHBs. DHB abolition is likely to very profitiable for business consultants.

What bodes badly and what bodes well

This bodes badly for the development of engagement based leadership cultures and improved integration of community and hospital care. But it bodes well for a more authoritarian leadership culture (bureaucratic centralism) and, needless to say, business consultants engaged to reinforce this culture.

The previous National led government left its successor in 2017 with a rundown public health system. Not only has four years of a Labour led government allowed this rundown to continue and worsen; it is also undermining one of our health system’s potential and actual major strengths – engagement based leadership culture.

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