Self-evident health system truths

On 1 February BusinessDesk published an article by me on two self-evident truths in Aotearoa New Zealand’s health system. One involved the woeful neglect of workforce shortages (especially health professionals) and the other was the decision to abolish district health boards (DHBs) an undeclared state of emergency

My use of the term ‘self-evident truths’ came from the Declaration of Independence adopted in 1776 by the 13 British colonies of what now constitutes the eastern seaboard of the United States. The Declaration includes powerful words “all men [sic] are created equal” with certain  “inalienable” rights including life, liberty and the pursuit of happiness. This equality and these rights don’t require further elaboration because they are deemed to be self–evident.

US Declaration of Independence, 1776

The first self-evident truth: workforce shortages

The first self-evident truth is the importance of the health workforce to DHBs. This is not just doctors and nurses but a range of other skilled health professionals including laboratory scientists, physio and occupational therapists, radiation therapists, psychologists and physiologists. Then there are also the administrative staff, cleaners and others whom health professionals depend on.

These are the people that make the health system work and add value to its performance and effectiveness. They are the basis of an enormous amount of intellectual human capital which, if allowed to be resourced and used for systems improvement rather than just diagnosing and treating patients, can significantly improve assess to healthcare, the quality of healthcare, and the fiscal performance of DHBs.

Instead we have the opposite. We have severe health professional shortages leaving in their trail an overworked and overstretched workforce struggling to cope. The workforce is at best fatigued and at worst burnt out. This is dangerous not just for the workforce who pay for it with their health. It is dangerous for patients.

The fact that this is a result of nine years neglect by a National led government and over four years neglect by a Labour led government does not mitigate the irresponsibility of the latter. Labour knew what they had inherited and chose to continue rather than address this neglect (except when pushed hard by nursing strikes). This makes Labour as culpable as National.

In my BusinessDesk article I concluded in respect of the workforce self-evident truth that:

The ignoble self-evident truth is that the failure of this government (compounding the failure of its predecessor) to address severe workforce shortages despite being in office since October 2017 is responsible for New Zealand’s health system being in an undeclared state of emergency now that omicron has arrived.

Second self-evident truth: restructuring during a pandemic

Health Minister Andrew Little has introduced into Parliament the Pae Ora (Heathy Futures) Bill. The Bill includes two proposals I strongly support – establishing the Maori Health Authority and a new public health crown agency. These are not new ideas. The principles behind them have been widely discussed and debated over many years. Their time has come.

Health Minister Andrew Little introduced Pae Ora Bill

The same can’t be said for a third proposal,  the abolition of DHBs. It was not part of Labour’s election manifesto in 2020 (quite the opposite) and was not part of a preceding debate. The strongest advocates appear to be Ernst & Young (EY) business consultants who are in the driving seat of the Transition Unit set up to implement the Government’s restructuring. The Unit is led by EY senior partner Stephen McKernan.

International uniqueness of DHBs

DHBs were established in 2001. Apart from a short interlude with area health boards in the late 1980s and early 1990s, this was the first time statutory bodies were established to be responsible for the health and well-being of geographically defined populations and integration between community (including general practice and aged residential care) and hospital care.

This full responsibility across the spectrum of health has been a strength of our public health system ever since. This includes the obligation to “regularly investigate, assess, and monitor the health status of its resident population”.

Structurally this has given New Zealand significant advantages over many other modern health systems where, for different reasons, community and hospital care are much less integrated by being more structurally separated.

In fact, the structure of DHBs is well-placed to better assist the effectiveness of both the Maori Health Authority and the public health agency crown. Both these new bodies resonate philosophically and operationally with DHBs that know their own defined populations.

DHBs and vaccine rollout

A close consideration of the international data confirms that DHBs have done very well with the vaccine rollout. New Zealand’s fully vaccinated rate is one of the highest in the world. It was even higher than the European Union which had the massive advantage of both being able to negotiate as a powerful collective bloc with the monopolistic pharmaceutical companies and having vaccine producing countries within its membership.

The uniqueness of having statutory local structures responsible for geographically defined populations proved to be a major factor in this success. Despite having no control over supply, DHBs were able to compensate for our big disadvantage as a small economy far away from vaccine producing countries.

Earlier in the rollout some DHBs were singled out for criticism. But the fact of the matter is that DHBs comparative milestone achievements ranked according to workforce size and population density.

The bigger DHBs workforce and the denser their population, the sooner they achieved the vaccination milestones. It was the DHBs with smaller workforces and lower population density because of rural communities that were comparatively slower.

Omicron threat

The omicron variant of Covid-19 is going to put the whole country’s health system under unprecedented dangerous pressure, especially our public hospitals. No longer will the impact be confined to a region.

Transmission will be too high and fast to prevent increasing hospitalisations. This will likely increase mortality rates. Hospitals already subject to severe workforce shortages are also likely to be bogged down by ‘long covid’ where the effects of the virus continue for weeks or months beyond the initial illness.

It is much more likely than not that omicron won’t be the last Covid-19 variant this year. Some of its successors will be less and others more virulent.

Political wobbles

Many in the health system are acutely aware of the risks of abolishing DHBs during a pandemic. But in this controlled and pre-determined environment it is difficult to raise these concerns at all, let alone openly. On those few occasions where these risks are expressed internally, McKernan in particular is known to come down on those concerned rather like a verbal ton of bricks.

EY senior partner Stephen McKernan driving DHB abolition and reportedly coming down hard on those warning of risks during the pandemic

The New Zealand Medical Association, after raising its concerns with the select committee hearing the bill, received a berating call from the Health Minister’s office. Very unprofessional attempted intimidation.

There are, however, political sensitivities within government. Health Minister Little decided to offer DHB chief executives the right to continue their current employment for three months after the scheduled abolition of DHBs (ie, from 1 July) with the right of renewal for a further three months to the end of the year.

This was opposed by EY’s McKernan but Little rejected his advice. However, this decision incorrectly assumes that chief executives are the DHBs when they are simply they are the operational head of what sits below them. It is the functions of DHBs that are important, not the head of their operational structure.

Further, few have been more devalued, disrespected and  scapegoated by the restructuring process and those leading its implementation than DHB chief executives. Now they are being asked to help out with risk minimisation. Overwhelmingly they are underwhelmed. Few are expected to accept the ‘offer’; not those who already have something else to go to or have no wish to be associated with this new system.

Height of leadership incompetence and irresponsibility

Abolishing DHBs is wrong and will be counter-productive. Losing statutory bodies that know their defined populations well compared with a national body will set back the effectiveness of the health system. It is compounded by the fact that there is little idea other than ‘prototypes’ what will be the replacement for the community care functions of DHBs.

But, in addition, doing this during a still unravelling pandemic is not just incompetent; it is dangerous. It is dangerous for both patients, for those that work in the health system (especially those involved in treatment).

In my BusinessDesk article the penultimate paragraph concludes:

So what does the government do? In the midst of this calamity it abolishes the bodies responsible for the health and wellbeing of their defined populations including public hospitals. The second ignoble self-evident truth is restructuring the health system in the middle of a pandemic is not just sheer madness; it is the height of leadership incompetence and irresponsibility.

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