Epiphanies and improving the health system

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Decades ago, when I was an impressionable young student at Victoria University, I attended a student union meeting to debate a resolution to remove the two chaplains’ halls (Anglican and Catholic ) of the student union building.

With such a subject, it was not surprising that the participation rate was high and the debate heated. It was quite an experience to see. The resolution was rejected although I voted for it.

Among many fine speeches, the one that stood out to me was from a student who may have supported the resolution. What impressed me was his articulate, intelligent and precise presentation of his argument that New Zealand was a secular society and why that was a good thing. This underpinned his support for the resolution.

Epiphanies twice

This student had a revelation while he was at university when he became a socialist and attracted to trade unionism. After graduating in economics, he quickly became a prominent trade union leader in the private sector. This included election to the national executive of the then Federation of Labor.

It was quite an achievement for a former student; at the time, few students worked for unions (at least in the private sector), and even fewer became union leaders.

Then, in the era of ‘Rogernomics’ that began in the mid-1980s, there was a second epiphany with a sudden realization that the future lay in market forces rather than the labor movement. He started his own consulting firm and went on to become a successful professional manager. The rest was money-making history.

I remember meeting him shortly after that epiphany. I had started working for the Association of Salaried Medical Specialists and was faced with the double whammy of the anti-union law on employment contracts and the national government’s intention to introduce a competitive commercial market into the health system.

He advised the latter’s transition unit on labor relations. His view was that the various consultation requirements negotiated by health unions were a barrier to the management capacity of health bosses.

Epiphanies three times

More recently, he had a third epiphany which was, in part, a healthier lifestyle. From defending tough management positions, the tone shifted to a softer line. Compassion and the need for fairness now figure more prominently in his public discourse.

My own encounters with him as a student were only occasional. But, despite the differences over the years, the contact has always been friendly. He was never personal and respected those who weren’t on the same page as him.

Now this student chairs the interim Health New Zealand (HNZ) board which comes into force on July 1, replacing the District Health Boards (DHBs) and taking over some key functions from the Department of Health.

As much as I disagree with the undemocratic and ill-thought-out decision to abolish DHBs, Health Minister Andrew Little’s decision to appoint Rob Campbell to the post is one of the few sensible decisions he has made.

The spin-off (March 13) provides some interesting facts about Campbell in an interview prior to his appointment as HNZ Acting President: Paradox by Rob Campbell.

After welcoming Campbell’s appointment, hopefully without unintended praise, a recent interaction with him reveals concerns about his approach to improving the health care system.

A revealing interaction

May 23
business office published an article by me: Distracted Leadership in Health Means Neglect of Leadership. My argument was that in 2017 the Labor-led government inherited four crises in the healthcare system – severe shortages of manpower, infrastructure, a culture of top-down managerial leadership and drug supplies.

But the government’s concern for restructuring led it to neglect these crises, thus allowing them to worsen.

On May 27, Rob Campbell responded on LinkedIn:

Yes, “four inherited seizures”. To which we should add the inherent inequity for Maori, Pasifika and other groups.
Simply pumping more money into a structure unable to respond effectively to these crises would be madness.
Pae Ora [the new health
legislation restructuring the health system translated as
healthier futures] is this government’s response that is based on many studies and many other experiences on the options. It will undoubtedly have imperfections but it offers a structure capable of dealing with these crises.

Whether we can use it to do so will depend on the skills, goodwill and determination of everyone working in and around the structure.
Those who stand back and only mock will not solve crises.
In the old system, people found many ways to innovate and create, to patch up and make do, to work around and overcome limitations and shortages. This is what we will base ourselves on.
Pae Ora, the National Health Service and our Maori partners, are a pragmatic response from within to deep crises, as will be evident to all when careful, fair and fiscally responsible changes come into effect.

Campbell begins by saying that there has been another legacy crisis: “built-in inequity for Maori, Pasifika and other groups”. I would say it differently.

Unmet needs have continued to rise, including disproportionately for Maori and Pasifika, mainly due to the growing impact of social determinants of health and the four crises I have mentioned have made it more difficult to mitigation of their impact by the health system.

However, discussing this aspect in more detail leads to a semantic debate about which comes first – the chicken or the egg. Better not say more about it.

Fourth epiphany required

But the rest of his answer is disappointing. He essentially blames existing structures (mainly DHBs) for health system crises, including unmet needs. No proof of this is provided; it is simply declared.

The main drivers of unmet health needs (and resulting inequalities) are the social determinants of health, such as low income, poor housing and limited educational opportunities.

But these driving determinants are external to the health system. Only government action through targeted legislation and policies can remedy this. At best, the health system can only mitigate their effects.

The DHBs cannot be blamed for the failure to address these social determinants. Nor can DHBs be primarily blamed for the failure to mitigate their effects on the healthcare system. To begin with, the central government determines the funding that the DHBs receive.

In addition, the central government is primarily responsible for the failure to address severe labor shortages, neglect of infrastructure, and restriction in drug supply. This has been made more difficult by the central government’s top-down leadership culture towards the DHBs.

Time for an Epiphany Rob

Precisely, Campbell has as scapegoats the existing structures for the crises of the health system, he also turns to the legislative restructurings to solve them. But, contrary to his brief reference to “numerous studies,” the overwhelming experience is that restructuring does not bring lasting improvements to the health system.

As is often said, cultural change trumps structural change in the continuous improvement of health systems. It’s an ABC that business consultants often ignore. It’s time for a fourth epiphany Rob! Go on; you can do it. I say it without mockery!

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