How can New Zealand’s health system get out of this crap

Last month I gave two addresses to the New Zealand Branch of the Australian and New Zealand Oral & Maxillo-Facial Surgeons (ANZOMS) at their annual general meeting held in Queenstown.

I discussed the first address in Otaihanga Second Opinion on 17 August:   Evolution of New Zealand health system up to Pae Ora Act 2022  . This address is also available at Evolution of New Zealand health system.    

The second address discussed the risks now facing Aotearoa New Zealand’s health system as a consequence of the Government’s massive health restructuring.

It then considered what Health New Zealand (Te Whatu Ora) needed to do to make the health system work better for patient care: Making it better for patient care.

Both addresses had sub-titles. The first was How did we get into this crap while the second was How can we get out of this crap.

The crap we are now in   

I described the main features of the new health system as:

• increased influence of business consultants in design and operation;
• marginalisation of the influence of those with experience in health systems;
• driven by structural rather than cultural change;
• removal of a level of statutory decision-making close to the point where most community and hospital healthcare are provided;
• vertically centralised decision-making setting the foundations for a control culture; and
• threatened by failure to address widespread workforce shortages and increasing health demand.

I referred to hospital occupancy as an excellent barometer for highlighting the precarious position the health system now finds itself in:

In 2022 our public hospitals hit 100% occupancy more than 600 times. That is, on average, each day roughly two public hospitals around the country were running at an occupancy higher than they were resourced for.

Hospital occupancy of 100% was occurring back in 2017 but nowhere of this magnitude. Hospitals were in crisis in 2017. In 2023 it would be more appropriate to call it scary crisis+. Carnage might not be overstating it.

Both long before and after my Queenstown presentations there has been much mainstream media coverage of this crisis manifesting itself in so many different ways.

A recent case in point is Te Whatu Ora advising general practitioners not to refer any patients to specialists at Wellington Regional Hospital’s women’s health service for non-acute conditions, other than cancer, as reported by Ruth Hill for Radio New Zealand (22 September): GPs not to refer non-acute patients to Wellington Hospital’s women’s health service.    

Meanwhile New Zealand Doctor (26 September; paywalled) reports a similar situation affecting Christchurch Hospital’s women’s health service: Wellington Hospital’s non-cancer difficulties also occurring in Canterbury. 

Putting patient centred care at the core of the health system

Some of my second ANZOMS presentation involved discussing the joint paper targeted at Te Whatu Ora by my political opposite Heather Roy (former ACT MP, health spokesperson and deputy leader) and I in January.

My political opposite Heather Roy and I urged Health New Zealand to take the new health system’s temperature to find the fever so it could work better for patients

The paper was titled Te Whatu Ora: Achieving Patient Centred Care and Wellbeing followed by a subheading: “If you don’t take the temperature you can’t find a fever”. Appropriately it was about how to make the system we now have work better for patients.

Expand patient-centred care for treatment of individual patients to the core of health system decision-making

The essence of our argument was that patient-centred care should be put at the core of the health system. Patient-centred care is normally associated with the treatment of individual patients.

Heather Roy and I argued that it should also become  the yardstick of system decision-making. Every non-clinical decision, before proceeding further, should be assessed on whether it advances or hinders patient-centred care.

The two most critical things required to locate patient-centred care at the core of health system decision-making are resolving the severe workforce shortages and changing the system’s culture from control to engagement.

I have previously discussed our joint paper in Otaihanga Second Opinion (31 January): Take the temperature to find the fever.

Powell-Roy joint paper: taking the temperature to find the fever

Resolving workforce shortages

A ‘meet the candidates’ election event (8 August) on health hosted by Health Coalition Aotearoa in Wellington is revealing. Three political parties were represented – Labour (Ayesha Verrall), Shane Reti (National) and Chloe Swarbrick (Greens).

The final question to them was what is the biggest barrier to achieving health outcomes in Aotearoa. Verrall said it was the lack of embodiment of the Treaty of Waitangi, Swarbrick said it was poverty, and Reti said it was workforce shortages.

Here is a very abbreviated clip, distributed by Reti, which does not include Swarbrick’s response: Briefly summarised Verrall and Reti responses on biggest barrier to health.

Here is the full video clip of the whole meeting: Full ‘meet the candidates’ event on health. 

From the standpoint of health professionals working in an environment that varies between crisis and carnage, Reti was the candidate absolutely right on the mark.

Dr Shane Reti: top marks for identifying biggest barrier to health

If the crisis cum carnage did not exist then Swarbrick would have been on the mark. Poverty is the biggest of the external social determinants of health which, in turn, are the biggest driver of health demand (and cost).

However, in terms of immediacy, even addressing poverty is trumped by the compelling need to resolve workforce shortages.

Chloe Swarbrick: good response but not the same immediacy for health system

But the surprising shocker was Verrall. Her response exemplified the problem when an intelligent decent person resides in an intellectual abstraction bubble isolated from the reality of what is happening at the clinical frontline.

It isn’t callous; instead it’s disappointingly sad.

Dr Ayesha Verrall: on a different planet from health system reality

The highest priority needs to be given to resolving the severe workforce shortages. More than anything else it is workforce that enhances the effectiveness of healthcare delivery.

Te Whatu Ora’s recently announced workforce strategy falls well short of what is required. Its estimate of doctor shortages, for example, is a woeful underestimation confusing official vacancies with actual shortages.

Historically there has been a stronger emphasis on retention than recruitment. There is a relationship between the two; stronger retention benefits recruitment when natural attrition occurs.

But this has changed since salary increases were severely constrained from the 2010s, not by district health boards, but by both National and Labour-led governments. This is compounded by the aging of the workforce.

Recruitment is now more pressing competing with both Australia and the private sector.

Health New Zealand needs to adopt action orientated workforce strategies towards the health professionals it employs.

These strategies should recognise the different labour markets of the different occupational groups; specialists, nurses and over 40 critical allied health professional groups.

Shifting to a proactive distributed leadership engagement culture

In my words:

Crises in health systems are the genesis of risks – to patients (including access and safety), workforce health and safety, innovation, quality, and systems improvement.

Obviously severe workforce shortages and rising health demand (particularly acute and chronic illnesses) have to be resolved. But they won’t be until there is a substantial culture change within Te Whatu Ora.

The ‘culture’ of Te Whatu Ora’s leadership is totally consistent with the restructuring that created it. It is the most vertically centralised national entity that our health system has ever had.

Ian Powell: “prime culture driver is vertical centralisation”

Again in my words:

Its prime culture driver is vertical centralisation. It is as destructive as the culture of running the health system as a commercial market was in the 1990s; arguably more destructive.

This, and the distance between its top leadership and from where healthcare is provided, makes its culture top-down. What is needed therefore is a shift to a culture that is engagement based, empowering and relational.

Health inequities, social determinants of health and culture

There are several things that can be done to make Aotearoa’s system better for patient care, however, beginning with its governing legislation, the Pae Ora Act, specifically its purpose clause.

 The Act creates an expectation on the health system to do what it can’t do; to eliminate health disparities (inequities), including for Māori.

But these disparities are driven by external social determinants of health such as low incomes, poor housing, limited educational opportunities, and healthcare access. Only governments can eliminate through legislative and policy actions. The health system can only mitigate.

Consequently the purpose clause of the Act needs to be rewritten to be realistic over what it expects of the health system. This rewriting also needs to include critical elements covering an engagement and empowerment culture.

I have discussed this recently in Otaihanga Second Opinion (20 September): Getting the health system culture right; aligning moralities.

Drilling down further

It is important to drill down below workforce, culture and social determinants. There are other important measures discussed in my second ANZOMS address which would help make the new health system better for patients.

A greater level of decision-making authority should be delegated to where healthcare is overwhelmingly provided and where much innovation occurs (communities and hospitals; districts or regions).

Use intellectual human capital of workforce, not external business consultants

A strategic and operational engagement culture based on workforce empowerment is required recognising the enormous intellectual human capital of health professionals. This should include distributed clinical leadership.

The more the health system uses its own intellectual capital the better; the less it uses external business consultants the better.

Integrating healthcare between communities and hospitals, including health pathways, improves assess to and quality of health services. It is an effective means of  acute admissions risk management. This should be a policy priority.

A new approach is required for major capital works. Hospital rebuilds should be consistent with the relevant clinical and operational expertise. They must also be future proofed for anticipated health demand.

Clinical networks are invaluable for promoting innovation. To ensure this continues and expands, plans to transfer them into Te Whatu Ora’s operational structure, thereby stifling innovation, should cease.

Te Whatu Ora should be promoting local integrated care systems providing a mix of general practice, 24/7 urgent care, and less complex non-acute hospital services. Polyclinics is a term which can be used to describe these facilities.

Recognising its community wellbeing responsibilities, the role of local government should be enhanced by providing a statutory voice for the health status needs of their populations.

Primary care organisations have become the most reliable and experienced institutional glue remaining across primary care. Their continuation should be embraced and supported.

Apply ‘Mark Twain’ wisdom

The state of the health system is depressing and it is difficult not to despair. But consider some advice from my father.

Mark Twain on wisdom: ‘attribution’ and actual

That is, usually the cup is half full rather than half empty. But when it isn’t put a drop of whiskey in it until it is half full.

Then say that Mark Twain once said this. No-one would ever know!

What Twain actually said on wisdom, however, was that “It is wiser to find out than suppose.” Very apt.

If Jacinda Ardern’s government had elected to find our instead of suppose then our health system would not be the debacle that it now is.