When an academic gets it badly wrong over health crisis

As a history student at Canterbury University I did a paper on EP Thompson’s classic social history The Making of the English Working Class. First published in 1963 (I read a 1972 reprint) I was enthralled by it.

Reinforced by extensive empirical data, this was largely due to how it sharpened my understanding  of ‘class’, specifically ‘working class’, as a relationship rather than a physical thing, occupation or job type.

Decades later, during my current month-long overseas trip, I’m rereading my well-thumbed 1972 reprint. It reminded me why I was so enthralled so many years ago and while it gave me so much pleasure.

However, with a troubling article published in Aotearoa New Zealand’s mainstream media on our health system in the back of my mind, it also reminded me of something else. That is, the importance of macro conclusions being consistent with micro-analysis and everyday experiences.

Thompson’s reminder

This reminder was Thompson’s invaluable discussion on how earlier historians had misinterpreted data on the incomes of artisans, labourers and weavers, primarily around the 1790s to the 1840s. This was due to their focus on average incomes only; that is, macro data.

But, in the context of these turbulent times, particularly the Napoleonic Wars (including its economic aftermath – inflation and unemployment) and technological changes, averages fudge the actual situation for many. So too was the misleading impression given by average percentage increases on low bases.

It was a period of old skills being replaced by new skills in the unfolding ‘industrial revolution’ and with much regional variation. Take weaving for example . For many decades it was the mainstay of English manufacturing. Weavers were a form of ‘labour aristocracy’.But this radically changed as the hand-loom was replaced by the power-loom.

Thompson did not confine his micro-analysis to incomes; he also applied it to mortality rates, particularly infants, and child labour.

The troubling article

The net result was that many more labourers, artisans and weavers suffered financial hardship, including impoverishment, than average incomes would suggest. It was this that struck me when reading the paywalled article published in the NZ Herald (11 November) by Peter Davis.

Emeritus Professor Peter Davis: a troubling article

Davis is Emeritus Professor of Population Health at Auckland University (also former elected member of the Auckland District Health Board and Chair of the Helen Clark Foundation):    Peter Davis: what health crisis?   .

Professor Davis opens with an assertion that:

Barely a day goes by without concerns loudly and forcefully expressed by advocates, health unions, lobby groups, and members of the public about the functioning of the health system.

In turn, these concerns are amplified by the media, such that we now apparently have a “health crisis” on our hands and the Minister of Health is then reviled for being loath to admit it.

His response to his own question, is there a health crisis is:

We simply don’t know – and we should. We should have objective, independent information available that would allow us to draw that judgment. But we don’t.

Davis justifies his conclusion by asserting:

…health funding has increased 40 per cent over the last five years, an increase I have never seen even close to being matched before in my near-half century academic career in health policy and health services research.

The five years Davis is referring to is from 1 July 2017 to 30 June 2022. Technically he is correct. But substantively he is misleading.  He could learn much from EP Thompson on what is missed when one relies on macro data. It would not have taken much to have drilled down a little further by using Treasury data on Crown health spending.

Treasury and other information ignored

Treasury data covering the years from 2005 to 2021 (this includes the first four of the five years referred to by Peter Davis). From 2005 to 2009 health spending increased by relatively high percentages.

Then there was a huge downwards spiral in the level of increases. By 2017, when the Labour led government took office, there had been a small upwards movement since 2015 but well below the 2005-09 increases.

Treasury’s data is consistent with the separate Vote Health budget analyses of both the Labour Party in opposition and the Council of Trade Unions (collaboratively with the Association of Salaried Medical Specialists). These analyses revealed that in real terms over $1 billion had been sucked out of health system funding. From 2009 to 2017 health funding was hit by austerity.

New Zealand’s austerity was much less severe than that imposed in some other countries such as the United Kingdom, Spain, Ireland and Greece. But it was cumulative and had a big negative impact on our health system’s ability to do its job.

Treasury’s data is broadly consistent with the 40% claim of Professor Davis but only from 2017 onwards. Davis fails to recognise that this is a big percentage increase on a low base. This matters.

Further, he also ignores other important factors. On the funding side, a significant part of the 2022 budget health spend went on writing off large district health board (DHB) deficits. In no small part these deficits were due to the cumulative impact of the 2009-2017 austerity. Further, a large amount is being siphoned off to meet the costs of the government’s restructuring.

On the cost side, the health system throughout most of the 2010s and early 2020s was whacked by increasing demand for healthcare primarily due to increased poverty (social determinants of health).

This was most dramatically illustrated by acute hospital demand increasing at a higher rate than population growth. This also had a significant impact on DHB deficits.

Other misleading assertions

The simplistic use of macro funding data is not the only misleading assertion made by Davis. He makes a big thing of the fact that during his three years as a board member, Auckland DHB was “…never tempted to call our circumstances a health crisis.” One could be equally tempted to respond that this board was badly out-of-touch! But that would be point-scoring.

It was not just Auckland that didn’t use this ‘c’ word. Neither did the other 19 DHBs. This was because contrary to politically motivated mythology our health system based on DHBs was highly centralised albeit more covert than overt.

There was significant  government control over DHBs including appointing their chairs and deputy chairs along with several board members, requiring them to implement its policies, and having the power to sack a board (replacing it with a government appointed commissioner).

In this context, no DHB chief executive wanting to retain their position would ever openly acknowledge that the health system was in crisis; no government would allow this. It would not be career enhancing.

Davis also goes on to assert that at Auckland DHB  management “…had to get senior doctors to be present on the wards at weekends to make judgment calls on whether or not patients could be discharged…”

For goodness sake! In all DHBs there had been a steady move over many years towards specialists on after-hours weekend acute call to come into their hospital as a matter of routine to check on patients rather than wait until called.

This was not just about discharging patients. It improved the quality of patient care because nurses and resident doctors on site could be given proactive advice. This was an evolving practice which varied due to factors such as the usual acuity of patients in a service. Workforce capacity was also relevant.

From a personal experience, in the late 1990s I was discharged by a specialist at Wellington Hospital. This was in the weekend.

Health academics should learn from Thompson

Macro data is insufficient to make a call on whether New Zealand has a health system crisis. Micro analysis is also required but so is the everyday experiences of health professionals at the frontline of healthcare delivery. Unfortunately Davis’s published tone is suspicious of this latter voice.

Healthcare delivery is of necessity highly labour intensive. Consequently health system crises primarily arise out of severe workforce shortages. These shortages were prevalent before the pandemic and have been further worsened by both it and continued government neglect.

These shortages prevail across the health workforce from specialists to nurses to a range of other critical allied health professionals. This is what leave those working in the health system and those observing it to conclude that we have a workforce crisis in our health system.

This conclusion is based on what is currently happening daily (including denied and much delayed access to diagnosis and treatment along with workforce exhaustion). It is reinforced by data on the level of shortages, rising acute admissions, and historical health spending patterns,

One of the points made strongly by EP Thompson was increased child labour exploitation in England during the years of his study. Many earlier historians had downplayed the seriousness of this exploitation but Thompson dug deeper and found more. While obviously not as severe, one of the consequences of New Zealand’s health system crisis is an exploited workforce paying for it with their health.

Thompson was required to undertake a much greater and more complex data search than Professor Davis did for his troubling article. He should reconsider this.