GUEST BLOG: Ian Powell – Business Leaders and Health System Improvement: A Canterbury Tale

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The daily online publication Writing impressed me with his investigative journalism. It certainly punches above its weight. Among its quality investigative reporters is Christchurch-based David Williams.

Among Williams’ subjects was the brutal, unprincipled and sadly successful assault on the senior management of the Canterbury District Health Board (CDHB) by those acting on behalf of the New Zealand government – in particular the Ministry of Health, the Health Section of the Treasury, the Government appointed Crown Monitor and Chairman of the Board of CDHB, and Business Consultants of Ernst & Young.

Collapse, destabilization and demoralization were the consequences. The ultimate responsibility for this shocking behavior lies with the Labor-led government and its health ministers. Political leadership has proven weak. Canterbury Labor MPs (Electorate and List) were ashamed of their silence.

the Democracy Project Last year, I published three in-depth articles dealing with aggression in its full context:

  1. https://democracyproject.nz/2021/02/09/ian-powell-when-business-consultants-are-commissioned-for-hatchet-jobs/ (February 9).
  2. https://democracyproject.nz/2021/04/15/ian-powell-a-very-bureaucratic-coup-part-one/ (April 15).
  3. https://democracyproject.nz/2021/05/19/ian-powell-a-very-bureaucratic-coup-part-two/ (May 19).

Meates interview

Now Writing published a revealing video interview by Williams of former CDHB chief executive David Meates, who now works in the south of England, primarily in health and integrating community and hospital care:

https://www.newsroom.co.nz/summer-newsroom/ex-dhb-boss-breaks 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.

TDB recommends NewzEngine.com

What emerges from Williams’ interview is the importance of integrity and ethics to Meates, his humility, his team spirit, his intelligence and his vision of where a system should go. public health (including the underlying principles it is based on). His departure is a loss for our health system.

Standout CEO

On the face of it, I would have known about 150-200 Chief Executive Officers of District Health Boards (DHBs) and their predecessors over the 30 years I served as Executive Director of the Association of Salaried Specialist Physicians.

With few exceptions, all impressed me as hardworking, committed and capable people. Many were impressive. In the nature of the organic dynamics of health systems, I would occasionally have strong differences with several CEOs (including Meates).

There were two standouts from an impressive lineup. One was Meates and the other his immediate predecessor at CDHB, Gordon Davies. While Meates was in mid-career when he was named chief executive in 2009, for Davies it was his last senior healthcare role before retiring after three years in the role.

Davies was arguably the most experienced person to be appointed chief executive of DHB with a career including both the leadership of a hospital board and a regional health board, and deputy chief executive of health. Although he is an accountant, he did not let this deficiency affect his cognitive knowledge.

Davies was well acquainted with CDHB before becoming managing director. He was intrigued by the growing collaboration between hospital specialists and general practitioners in Canterbury and the opportunities this offered to improve integration between community and hospital treatment. He also had a good understanding of demographics, including what the increased impact of an aging population would mean for nursing homes.

Clinically-led integration between community and hospital

I first met David Meates when he was just a “boy” in West Coast senior management. Previously, he worked in retail in the UK. Subsequently, he held health management positions in Hawke’s Bay and Northland before becoming managing director of Wairarapa.

And then came the CDHB. Meates came to be both respectful of Davies and very impressed with what effective clinical engagement and leadership could accomplish.

Meates inherited a DHB that was changing things and moving in an encouraging direction. He was impressed and used his leadership attributes to further support and expand it. The health trails have been very successful and have become world leaders.

They have done much to remedy the inability of DHBs to focus sufficiently on one of their fundamental goals – to improve integration between community and hospital care. Davies, who had played a key role in the creation of the DHBs, had already understood this well. Meates has come to understand it well too.

The success of health journeys depended on their conduct and clinical development. When this happened, it had a positive effect on the increasing pressure on nursing homes, the quality of patient care and the reduction in the number of patients who would otherwise have had to be hospitalized for acute care.

Since acute care hospitalizations are a significant cost driver and have contributed significantly to DHB deficits, the tax advantages quickly became apparent.

The culture of leadership, the real problem

But it’s not about who the best DHB CEOs are. I highly value Davies and Meates, but I also rate many current and former CEOs. Stephen McKernan was a good example. In the 2000s, he served as a successful general manager in two quite different DHBs – first Hutt Valley, then Manukau Counties.

McKernan and many others considered clinical leadership to be largely about the treatment and care of patients because of the specialized knowledge and skills of medical professionals. This included to one degree or another the organization of treatment and care. It’s good but limited.

But Davies and Meates took it further in improving the larger systems. After all, health systems, by their very nature, are very complex and governed by external factors beyond their control. Physicians in particular, but also other healthcare professionals, are masters of complexity. It is not a big step forward to apply the complex skills developed in one area to another related area.

However, individual CEOs and their leadership teams cannot improve systems on their own. They need a culture of leadership based on and driven by genuine engagement with their healthcare professionals. Of all the 20 DHBs, Canterbury has made the greatest strides in developing this culture of engagement. It was still a work in progress, but the progress was exciting.

Recipe for conflict escalation

But a commitment-based leadership culture presents a problem for top-down bureaucratic centralism. The more decision-making at the DHB level is driven by strong clinical engagement, the more this conflicts with more arbitrary and top-down decision-making by central government, primarily the Ministry of Health, where there is less expertise relevant.

When these two types of decision-making conflict, it is much more likely that the first will be right and the second wrong.

This leaves a DHB with a commitment-based leadership culture that has to deal with bad decisions made by central government. Add to this how to respond to devastating natural disasters (especially earthquakes) and the imperatives of rebuilding major hospitals backed by a flawed funding system and you have a recipe for escalating conflict.

To make the sad situation worse, the business consultants used to do the work of the hatchet on the senior management of CDHB are the beneficiaries. Ernst & Young has come as close as possible to being the government’s “go-to” corporate health consultancy despite limited experience in the sector.

In addition, one of their main partners (McKernan) leads the government’s transition unit set up to implement its so-called health reforms, including the abolition of DHBs. The abolition of DHB is likely to be very profitable for business consultants.

What bodes badly and what bodes well

This bodes ill for the development of leadership cultures based on commitment and for improving the integration of community and hospital care. But it bodes well for a more authoritarian leadership culture (bureaucratic centralism) and, needless to say, hired business consultants to reinforce that culture.

The previous national government left its successor in 2017 with a dilapidated public health system. Not only have four years of Labor-led government allowed this deterioration to continue and worsen; it also undermines one of the greatest potential and actual strengths of our health care system – the culture of leadership based on commitment.

Ian Powell was executive director of the Association of Salaried Medical Specialists, the professional union representing senior doctors and dentists in New Zealand, for over 30 years until December 2019. He is now a health systems commentator , labor market and political living in the small river estuary community of Otaihanga (the place by the tide). First published at Second opinion of Otaihanga

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