Is our health leadership in a state of kef?
Article by Ian Powell - The Specialist, Issue 89, December 2011
Kef is an interesting noun I recently came across. It originates from the Arabic word kaif and means a state of drowsy contentment. It is also a word that seems to sum up (if a little generously) the state of leadership in the public health system at the moment. Interestingly another derivative of kaif is keef which is a substance, especially a smoking preparation of hemp leaves, used to produce this state of kef. I’m not looking to push this analogy as far as to suggest that the system’s leaders are ‘stoned’, especially as that born again hippie Don Brash is not the Minister of Health.
Tony Ryall spent his three years as opposition health spokesperson (2005-08) very effectively seeking and comprehending the pulse of the health sector. His efforts were impressive and an excellent model for his successor opposition health spokespeople to follow. In the history of the ASMS, along with Annette King (who did something similar in the late 1990s), I can’t think of another politician who became health minister so well prepared for the portfolio.
Off with a hiss and a roar
While a significant number of improvements to the health system had been made by the previous government (1999-2008) including legislative reform removing the requirement for public hospitals to operate as if they were competing commercial businesses, he was able to identify some serious weaknesses. These included the precarious state of the DHB workforce (particularly senior hospital doctors), lack of progress in achieving extensive clinical leadership, the need for clinical networks, increasing inter-DHB clinical service collaboration, and enhancing primary-secondary integration.
In March 2009 Health Minister Tony Ryall forwarded to DHBs with his endorsement a document titled In Good Hands. This commendable document built on the Time for Quality agreement between the ASMS and DHBs the previous year. But In Good Hands took it further with a more explicit focus on ‘distributive clinical leadership’, of which formal positions of clinical leadership (eg, clinical directors, chief medical officers) were only a small part. More important was the involvement of the wider mass of senior medical staff in decision-making beyond their immediate clinical practice through the lens of quality improvement and what makes good clinical sense.
This was part of a package of initiatives some of which involved legislative change although not of the magnitude that had to be introduced by Annette King back in 2000. This change largely arose out of an influential report (commissioned by the new Minister) by a committee headed by the current Chair of the National Health Board, Murray Horn, known as the Ministerial Review Group report. That report was rather weak in analysis (including a predilection towards ‘market forces’) but did identify a number of needed functional changes.
Arising out of this a number of sensible structural changes were introduced. The Ministry of Health was given a more operational focus in respect of DHBs with the creation within it of the NHB; a new more practically focussed health workforce body was established within the Health Ministry (Health Workforce New Zealand – HWNZ); the Health Quality & Safety Commission (separate from the Ministry and chaired by Dr Alan Merry); and the revised National Health Committee (now chaired by Dr Anne Kolbe).
It is still early days to make a call on the latter two organisations. But the NHB has got off to a good start with its influential expert panel on South Island neurosurgery and its insightful investigations into systemic issues at Dunedin Hospital and health services in Wakatipu that have led to recommendations being adopted by the governing Southern DHB.
But regrettably in terms of health system leadership this is largely as good at it gets.
Specialist workforce crisis
Up until October 2010 Tony Ryall was still accepting that there was a hospital specialist crisis and that it was his number one priority. But, presumably because it was election year, we started hearing statements initially from HWNZ and then both the Prime Minister and Mr Ryall that there had been 500 more hospital doctors since 2008. Subsequently this increased to 800.
This was then cynically used to, in effect, assert that because of an increase of 800 hospital doctors the hospital specialist crisis had been solved (this success was, by implication, due to government policy including the work of HWNZ). But there is a problem for this politically generated narrative – it’s called the truth. For example:
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The alleged 800 extra hospital doctors include resident medical officers. However, the Health Ministry does not differentiate (or chooses not to).
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The Ministry now calculates senior medical officer full-time equivalents (fte) on the basis of what it names ‘employed ftes’ in a way that inflates numbers. In summary, fte is seen is a 40-hour week. Someone who works less than 40 hours for their DHB is pro rated under this approach (eg, someone who works 30 hours for the DHB is counted at 0.75. Someone who works more than 40 hours per week is, however, counted as 1.0 (eg, someone who works 50 hours for the DHB is counted as 1.0). This may be more robust than previous forms of calculating medical ftes but it is not a headcount. If job sizing reviews lead to increased paid hours to part-timers (eg, from 30 hours to 40 hours per week), the total fte increases but not the headcount; it is the same senior doctor. There has been a lot of job sizing over the past two to three years, including in the more populous three Auckland DHBs. Part of this is the greater recognition of time for non-clinical duties.
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Information provided by the DHBs to the ASMS shows that the number of specialists has increased by around 240 (plus another 40 or so medical officers). If the extra 800 hospital doctors’ claim was correct then over 500 of them would have to have been RMOs. This seems unlikely (the Resident Doctors’ Association would dispute it). Contributing to the inflated calculation may be the shift in the wider Auckland region from locum to regular salaried RMO employment (ie, same RMOs but previously not counted and now counted).
Whatever the explanation for this inflated claim the specialist workforce crisis in public hospitals and related services remains largely as it was three years ago, the systemic issues that cause it (as outlined in Securing a Sustainable Senior Medical and Dental Workforce: the Business Case jointly developed and agreed by the DHBs and ASMS in November 2010) remain unchanged, and the government’s position has shifted to the polar opposite, in becoming a crisis denier.
Health Workforce New Zealand
HWNZ was a welcome creation. In the 1990s any question of workforce planning was seen as an attack on market forces which, according to the ideology of the day, were supposed to be the driver of the public health system. There was a positive change from 1999 with the encouragement to promote workforce planning but, in the main, this was largely analysis of the issues and scene-setting. The formation of HWNZ with its more practical orientation was seen as an advance.
While there has been some interesting work in primary care and some useful things might arise out of its commissioned service reviews, increasingly HWNZ is being seen as an impediment to workforce development (exactly the opposite of what it was formed to be). The feed-back the ASMS receives from the ‘clinical shop floor’ is that HWNZ has been scattergun in its approach, failed to get incremental ‘runs on the board’, has a ‘decree issuing’ rather than engagement approach, produces generic communications to explain specific issues, and is out-of-touch with how public hospitals work.
A couple of examples come to mind:
1. HWNZ has produced an alarming proposal on the prioritisation of funding for postgraduate medical training. Its text (what there is of it) and conclusions range from difficult to understand to incomprehensible. It has been widely criticised by the various medical professional bodies for lack of robustness. The comment was made at the ASMS Annual Conference that it would not meet the standards for publication in a respected peer reviewed medical journal. The main problem is that HWNZ is trying to use government health targets to the prioritisation of funding for training in the medical specialties. But the former has a short-term focus while the latter requires a much longer term approach. Further, the targets only cover a portion of the needs of the health system. On the positive side HWNZ has noted the firm critical responses and is producing a new version of the proposal which is expected to be circulated soon for further discussion. But the previous proposal caused considerable damage to HWNZ’s reputation.
2. HWNZ has got overexcited over the physician assistant pilot/demonstration at Middlemore Hospital’s general surgery department and consequently overstated its significance. Its public comments confuse the contributions of two outstanding and experienced individuals with insights into the relevance and value of physician assistants in a New Zealand context. Further, there is no appreciation of the practical needs of the general surgery department in terms of the form of support for specialists and the service they provide.
HWNZ started out as a promising good idea but is increasingly seen by many at the frontline of healthcare delivery as a missionary in search of a mission. If this continues it is at risk of being seen as a fundamentalist in search of a crusade or jihad. HWNZ needs to reposition its feet on the ground, establish its street credentials with the professions, and focus on getting practical runs on the board.
Polymorphous DHBs
Sadly there has been no improvement in the ability of DHBs to work together nationally in the experience of the ASMS despite their express desire (and that of successive governments) to do so. Their conduct in the DHB MECA negotiations, and particularly over the jointly developed Business Case, has been both a betrayal of trust and disgraceful. Even on a smaller issue of developing agreed guidelines for the engagement and employment of senior medical staff in regional service collaboration between DHBs, the DHBs through their chief executives have overturned an agreement between the ASMS and DHBs.
At a national level DHBs are polymorphous and very unreliable to work with. The calibre of chief executives is highly variable. Overwhelmingly they are competent (several are very impressive) but too many of them struggle to see beyond a short-term local lens and to be more that a hospital manager when cast into a national context requiring a broader vision. Distributive clinical leadership is seen by some chief executives and others in positions of DHB leadership as a threat to their perceived ‘right to manage’. This is behind much of the hostility towards the Business Case even if only from a minority of chief executives. But minorities drive down the majority.
The consequence of this is that adherence to agreements reached with their representatives can’t be relied on. There is a systemic dishonesty in the way in which they work together nationally because they can’t function in an integrated and functional manner. A change of personnel in the national chief executive leadership can make the world of difference. We experienced this in our MECA negotiations. The hostile attacks on the ASMS leadership and abandonment of the principles of the previously agreed Business Case coincided with the changes in the key positions of the chairs of the national chief executives group and the DHBs’ Employment Relations Strategy Group.
It is simply not sustainable to argue that the quality of national leadership by the DHBs has improved; in fact, it has arguably declined.
Hasn’t at least clinical leadership advanced
It would be nice to believe that clinical leadership has improved. It is a flagship of Tony Ryall; In Good Hands had the potential to be transformative. For a time many in the sector, including the ASMS, said the time was now right for achieving substantial clinical leadership.
Mr Ryall is not the first health minister to promote clinical leadership in DHBs. Annette King did with forthright statements in her annual letters of expectations to DHBs as did her successors Pete Hodgson and David Cunliffe. But the outcome was responses from DHBs claiming that they were actioning this expectation but little substance to back this up. Genuine comprehensive clinical leadership runs into conflict with the ideology of managerialism, which remains engrained below the radar, and a narrow approach to what chief executives see as their ‘right to manage’.
Tony Ryall learnt from this and proceeded to establish a good working group to write In Good Hands. But, according to private comments from DHB leaders, the Minister apparently gave the ASMS and DHBs conflicting messages. To the ASMS he was explicit stating that it was government policy. But DHBs say he never explicitly said that to them. If this is correct, and even despite his support for In Good Hands, this gave the DHBs wiggle room to treat it in the same way as they treated the former Labour health ministers’ letters of expectations.
Whatever the truth of the matter, the fact remains that In Good Hands required an attitudinal and cultural change by the DHBs; particularly at the top with boards, chief executives and senior management which overall has not happened.
This does not mean that there have not been success stories of distributive clinical leadership. The ASMS Annual Conference last week featured one last week – the remarkable performance of Counties Manukau achieving the six hour target in one of the busiest acute hospitals (Middlemore) in the southern hemisphere. But fundamentally it is no different to what has occurred for two decades. The impressive ‘Canterbury Initiative’ based on collaborative clinical pathways between primary and secondary care has been an incremental development over many years even before Mr Ryall became opposition health spokesperson in 2005. What we have is what we have had for two decades – oases of splendid success surrounded by a huge desert of lost opportunity. All that has changed is the location of the oases.
Lost opportunity
The government had a wonderful opportunity to turn this around by championing the Business Case which provided the wherewithal to deliver on the aspirations of In Good Hands by investing in the capacity of the senior doctor workforce in DHBs in order to deliver on these aspirations. But it made the conscious decision not to and instead rely on the mythology of 800 extra doctors and the proclamations of HWNZ. A simple case of lost opportunity.
This unfortunate state of kef means that our health leadership is characterised by obscurantism (opposition to the increase and spread of knowledge; deliberate obscurity or evasion of clarity) when we need the universal wisdom or knowledge of pansophy. If we are not careful then perhaps kef will evolve into keef.
Ian Powell
