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Annual Conference Presidential Addresses

14TH ANNUAL CONFERENCE - A NEW ORDER OF THINGS
DR PETER ROBERTS

There is nothing more difficult to take in hand, more perilous to conduct or more uncertain in its success, than to take the lead in the introduction of a new order of things. Because the innovator has for enemies all those who have done well under the old conditions and lukewarm defenders in those who may do well under the new.
-Niccolo Machiavelli, Il Principe, 1532

Many have imagined republics and principalities which have never been seen or known to exist in reality; for how we live is so far removed from how we ought to live, that he who abandons what is done for what ought to be done, will rather bring about his own ruin than his preservation
-Niccolo Machiavelli, Il Principe, 1532

Introduction
A comment from last year's Annual Conference consumer survey said that the Presidential Address was a bit too "personal." Well, if that were the case as I talked about the health system's culture and our need to understand chaos and a complex adaptive system paradigm in order to better understand what we do, this is going to be so intimate that some might find themselves blushing.

Over the past six years, people's comments have convinced me that whatever is exercising my mind often has resonance in other people's experience. Although today I adopt a 500 year-old perspective that may seem foreign to doctors at first, I suspect that perceptions about the nature of human endeavour have not changed very much.

Not "The end justifies the means," but "Si guarda al fine" 1

As many of you know, I have spent the last four years formally studying public policy. During my academic course I have proceeded through stages of understanding. Initially, I struggled with policy's developmental embryology. Then I wrestled with the pathophysiology of policy making and made forays into socio-political psychopathology. See, you can take the doctor out of medicine, but you can't take medicine out of the doctor.

At the end of the study, I decided to review Machiavelli's The Prince for a historical perspective of my new craft. On reading his ideas I found that he had written 500 years ago about what has been on my mind- he wrote trustworthy generalisations about what makes people tick.

His two great books, The Prince, about how individual rulers get power and keep it and The Discourses, about the history and nature of democratic republics in pursuit of good government seemed to have contradictory principles. However, this apparent contradiction can be explained by the difference between what a ruler must do in facing a threat and how a people establish and maintain an order of things. His letters to and from historian Francesco Guicciardini are felt to be the finest example of Renaissance correspondence. He looked at history knowing that man only has limited facets to his character and there is rarely anything new under the sun. From this he attempted to create generalisations and models of states, a word that he invented. He looked to the past to learn what may occur in the future. He also knew that times and context change and that only rarely were men able to change their worldview in time to match the situation. In his correspondence with the historian they discussed how the same policy or strategy could have diametrically opposite outcomes because of the context in which they occur. But underlying all of these realistic insights is his clear view of how pursuit of the perfect and unattainable can interfere with the practical and how planning for a utopian future can have devastating consequences for people in the present.

One other aspect of his perceptions that has not been adequately emphasised is his mistrust of base incentives. His greatest concern was how to make his state, Florence, safe from external threats and internal corruption. He waged a constant campaign against mercenary armies and expended all his energy to create a citizen-based militia. What is left out of the various interpretations of the man's thinking2 is that he valued above all else loyalty and trust as the means of obtaining the most desirable outcome.

I hope you see where I am going with this. In his approach of looking to the past to anticipate the future, considering the effect of shifting contextual elements on the outcome of policy changes, recognising the danger of ideologies and simplifications that do not reflect human nature, capabilities or common aspirations and valuing loyalty and trust above all else, I see strong parallels between what Machiavelli faced in the order of his state and the disordered state of New Zealand's health system. His warnings have merit in today's context.

Looking Back
We don't actually need to look too far back into our history to see many of his themes repeated. The Presidential Addresses over the last thirteen years have given an account of risk shifting and unbalanced control modes, in the form of Managerialism, unquestioned simplification of such complex relationships as Consumerism and Contractualism and an unchallenged faith in the effectiveness of preventive measures that depend on humans behaving in nonhuman ways. The underlying assumptions of these ideological models miserably fail to fit the reality of human existence. The vocabulary this engenders misuses language. For instance accountability, is a surrogate for blame and irresponsible butt-covering, corporate fiscal accountancy mechanisms deny responsibility for safety or comfort, and bizarre bureaucratic redefinition of suffering justifies denial of access for sufferers to effective humane care.

There are some insidious aspects of this for the patients we are trying to help and for virtually all professionals. One managerialist perception is that professionalism is unjustified marketplace domination by privileged groups who will just "capture the process" anyway. Managerialism does not respect our profession of values or dedication to expertise in performance. These attributes have been seen as an obstruction to getting the lowest possible price for our labour in a globalised market. The fact is that on world prices, New Zealand has enjoyed very reasonable health care provision because we value altruism and a sense of community. However, over time our relationships have systematically been reduced to the lowest common denominator and our industrial relationships with our employers continue to deteriorate. Will they improve if we move back to a national bargaining structure? More to the point, is the siren call of cheaper labour source in areas of high technical expertise not too strong for decision makers to resist?

Where does managerialism fit into Machiavelli's perceptions? Remember that The Prince was written in response to what he saw as a transient need for charismatic leadership to save Italy from external threats. The simplistic concepts introduced to New Zealand's public service since 1984 demand blind obedience to hero-like CEOs with guiding visions often derived from Internet word-salad websites. In response to a chronic perception of crisis and emergency, management structures have been set up on models of small princedoms peopled by princelings where empire-builders and organisational psychopaths enjoy significant advantages over cooperative collegial professionals and effective teams of individuals from a variety of backgrounds. The promise that "I can fix that for you, boss" often brings inordinate resource largesse and sustains marketplace winners and losers. Ideal models appeal to decision-makers who are vulnerable to simplistic answers for complex problems. Is there a strong and effective Medical Staff Group in the country that can challenge this ideology and be heard by decision-makers? I doubt it. Divide and rule was well recognised by Machiavelli and has been used with devastating results since the early 90's.

In such an environment, the tension between learning and control always favours control. So too does production over protection. We shall see how this maintains a blame culture no matter how fair the commissioner tries to be. The organisational words and structures forced on us make fairness and responsible behaviour so much harder to accomplish. The negative aspects of managerial paternalism are no better than that of arrogant doctors. Worse, in fact, it does not even face wary colleagues' challenge or moral codes.

There is also an element of arrogance and paternalism among planners so ready to deny resources to those patients, piling up at the bottom of the cliff, who need an ambulance so that an unproven, even theoretical, costly fence can save abstract victims from imagined harm at the top. The Swine Flu debacle is a textbook case, but the lesson is repeatedly forgotten.

What is the present context?
Some of our public hospital employers' names have changed, yet again, but their marching orders and leadership goals have changed very little. Some District Health Board board members recognise the classic double bind of accountability for their spending but no control of what must be spent. The concept of Primary Health Organisations has theoretically attractive elements in terms of preventative strategies, but our GP colleagues rightly see similarities with managed care style organisations that enforce risk shifting onto those who cannot easily bear it. Planning for smaller hospitals anticipates primary care processes that theoretically will prevent hospital admission. The problem is that many proposed processes are unproven and certainly unproven in the New Zealand context.

At the same time, we do not measure our effect. The DHB "Balanced Scorecard" has various sections that are supposed to represent an overview of the organisations' function? For instance, the "Patient and Quality" section includes consumer satisfaction scores, waiting time for emergency department triage, percentage of complaints resolved and blood stream infections acquired in hospital. Only the last one is a significant clinical performance indicator, the others are production line measures drawn from hotel and airline management. Likewise, the "Organisational Health and Learning" section lists staff turnover, staff stability rate, sick leave rate and workplace injuries. Notice that this CCMAU leftover has no staff satisfaction scores. The "Process and Efficiency" and "Financial" sections are also standard corporate business measures. How strange it is to see qualitative data such as patient opinion/satisfaction reduced to a single digit to be averaged with other digits.

There seem to be various agendas relating to health care, some more obvious than others. Some in the media would try to embarrass and promulgate blame for every suggestion of less than flawless performance. They have raised hindsight bias to an art form. Politicians, on the other hand, insist that evermore-arcane structures be put in place to prevent further (political) embarrassment in this highly charged area. The unrealistic monitoring systems set up for the beleaguered screening programmes, for instance, function like inspectors regularly pulling up plants to see if the roots are growing. Interestingly, the Health and Disability Commissioner notes a drop in consumer complaints to his office this year, but I wonder if he knows of all the time spent by sharp end staff dealing with consumer complaints.

Leaky Gowns and Lost Patients
Our context reflects confused priorities. Reflecting how accountability processes overwhelm responsible behaviour, here is the winner for this year. A public hospital surgical colleague of ours noted several holes in the sleeve of his theatre gown while performing a procedure. He dutifully asked for a replacement and finished. He took the gown to the theatre manager and pointed out the holes. The manager said, "Oh, yes, we know, we did an audit and 80% of the gowns are defective. We haven't replaced them because we haven't budgeted for it this year." The manager had, of course, reported up the line and up the line had reported up the line, but no one did the responsible thing for the good of patients or staff. Has anyone who makes these sorts of decisions been held accountable? Perhaps the manager who makes them, whether or not they have a medical degree, just missed the corporate team day on risk management. Worse, did he go to it and learn a complex business calculation that justified taking chances with other people's lives and safety?

In the end, professional dysfunction becomes endemic. Have any of you found that community mental health teams keep assiduous records of frustrated calls from families and concerned medical staff but abjectly refuse to go, see and assess worrisome patients thought to be a potential danger to themselves or others? These stories are standard fare at every congregation of hospital doctors I attend.

In spite of all that is said about pursuing a just culture, our system is primarily arranged to manage blame. It strives to make a superb record of exactly what went wrong. That is not the same thing as not letting things go wrong in the first place. Astronomical sums are spent on proving who is not to blame and proving that bosses made sure all the right procedures were written down. Learning from mistakes has become strangely permuted. Investigating adverse events and complaints have become surrogates for the wary professionals who anticipate and double-check their practice. When you think about it, any system that depends on complaints and adverse events to make improvements is a failure by definition.

- Si guarda il fine.

For Appearances' Sake
There is certainly a perceived need for decision-makers to be seen to be doing something to control practitioners to prevent any more bad health stories. In addition, it has become clear that ASMS was right seven years ago when we expressed concern that the market was not going to produce enough people to do the work. Because of their political sensitivity, these have become the major drivers for the legislative and policy agenda. The prominent set pieces have been the resurrection of the confused Health Practitioners Competency Assurance Bill, which has come to be the means to many ends, and the output of the under-resourced Health Workforce Advisory Committee.

HPCA Bill
At the core of the Health Practitioners Competence Assurance Bill are two assumptions:
The first is that external processes, such as credentialling, can somehow assure competence, an apparent, not concrete quality of people's performance. The 2001 Health Ministry document about credentialling, Toward Clinical Excellence, says that the reasons for focusing on senior medical officers include the:

· Historical lack of supervision of this group once vocationally registered 3
· Level of responsibility held by senior medical officers including the supervision of junior medical staff and
· Disproportionate representation of senior medical officers in high profile cases where practitioner incompetence resulted in an unacceptable outcome for the patient.

Analysed objectively, these reasons lack any credibility and conveniently confuse the complex systemic problems that resulted in the media storms surrounding Bottrill or Parry's "high profile" cases with the fact that both of them are senior doctors.

Hidden agendas?
The main policy mechanism is the definition of "scopes of practice" for not only medical, but also all other practitioners eventually. Colleagues who work in hospitals that have credentialling say that it is no big deal. Scopes of practice initially applied to hospital practice seem to be a relatively benign and straightforward bureaucratic exercise. It almost seems banal to doctors because we even swear an oath "not to cut for the stone."

However, if you were a bureaucrat or politician who believed that it was worthwhile to create nurse-anaesthetists or extend the autonomy of nurse practitioners into areas of medical expertise, all that is needed is the Nursing Council to describe a new 'scope of practice' for nurse anaesthetists that the Minister approves. Voila, the market has new players, nursing schools create a whole new range of programmes and a gun is held to patients' heads if doctors refuse to cooperate. This is exactly the sort of advice that the government was taking at the height of the "unfortunate market experiment". A number of economic advisors have pushed for the doctors' grip on the market to be broken. When you think of it, this may well be the true height of New Zealand's market experiment!

History has shown that ideological zealotry can use society's engines to its own ends. Once scopes of practice are in place for all new registration bodies, the capability for new forms of competitive behaviour among health care professional groups is possible in ways that simplifying Simon Upton never dreamed.

The second core assumption is that there must be ever-greater levels of accountability imposed on professional groups because this legislation was formulated using a blame culture ideology and justification. It seems the socialisation process that develops a professional culture is of little or no value for the people of New Zealand. Hence, professionals' expectation to be self-regulating ends and the Minister imposes controlling political appointments to the regulatory body. This overwhelming need to be seen to be in control is some sort of political imperative, but that is no less real. From where does this advice come? -Si guarda al fine.

HWAC
Although the HPCA Bill has little hope of advancing anything other than a few people's agendas, it has little capacity to address its stated aims. The Health Workforce Advisory Committee, on the other hand, carries a huge responsibility for correcting the worst excesses of the market experiment so that New Zealand can plan and provide for our needs in terms of health workforce. However, its recent discussion document, Framing Future Directions is very disappointing and seems to have been captured by similar ideological zealots. At the launch of the document, the committee had a visiting "systems expert" present some of the thinking that went into it. He used a series of confused analogies and cyclical arguments to justify the case for a thing known as a "generic health worker".

The committee's advisors' argument goes something like this:
· The present health care workforce is the result of historical accidents- "custom and practice". It was not planned or organised in a logical and regular fashion.
· The present professional qualification system is too cumbersome and specialised to allow the market to provide sufficient workers at a market price acceptable to employers and economic theorists.
· A creative and efficient answer to the market failures of the professional model would be to create "generic health workers," who have a uniform basic training somewhere between a nurse and junior house officer who can then acquire a variety of certification tickets that allow them to carry out a range of services in a flexible way that adapts to market demand.
· This also appeals to concepts of equality and equity for those who provide technical health services and controls and eliminates the power inequalities perceived between non-medical and medical practitioners.

Mr Mant, a UK visiting consultant presented a seminar about "Applying systems thinking to health care systems." He says that the construction of a health care system is similar to the necessary planning for a human body-to answer a particular question.
"The trick to building an effective system is to ensure that its internal value-adding workings are aligned with the desired outcomes in the surrounding environment. The rule is that purposes should determine work processes and processes should determine organisational structure. The structure of our bodies represents the answer to a particular question in the natural world.

The truth is that, over the years, many health systems have accreted all kinds of functions and activities which have little, if anything, to do with the health and welfare outcomes we now desire in our communities. Custom and practice rather than logic, have tended to dictate system growth and development, much as cancerous cells distort the normal operation of the human body. All health systems need to go back to the basic questions of purpose and outcome in order to devise a more natural and logical response to community health problems.

Are doctors and nurses who have arrived where they are through custom and practice cancerous cells? Mr Mant, fortunately, has never had responsibility for constructing an ideal body and thankfully God, or whoever actually designed us using "custom and practice"4 understood that the body needs to answer multiple questions simultaneously in a natural world, not a clockworks. The designer understood the value of both pluripotential cells with a low degree of specification and highly specialised cells that can think and create in a fashion that Mr Mant's linear model fails to understand.

In spite of poor advice, and to be fair to the Committee's efforts, the section on promoting a healthy hospital environment has many enlightened comments about establishing a supportive workplace culture. However, in the end, the committee uses the complexity of the system as an excuse not to make concrete suggestions about how many and in what kind of workers we should invest. The advisors have gone no further than the 1999 Ministry discussion document about letting the market decide how and who should be doing the work.

Aspirations and Fair Dealing with our Colleagues

What have I got against nurses in the new order of things? Just in case anyone wants to know, the patients and I depend on nurses, and always have, to carry out a wide range of extremely important roles in our care as team members and they have always been autonomous practitioners. We depend on nurses to look at things through nurse's, not doctor's eyes. Without nurses doing their job, I can't do mine and visa versa. However, it is a gross oversimplification to pretend that what we do is technically or functionally the same thing. Most nurses I know don't want to be doctors and some of those who have become doctors bemoan the loss of those joys and insights that we trust and rely on in nurses' practice- the close and personal comforting and protecting people at their most human and vulnerable. Nurses see the world quite differently to doctors and it is that very important perception, called requisite variety by Karl Weick5 , which we need to provide effective teamwork that protects and succours our patients. Mr Mant's model threatens the very significant danger of "group think."
- Si guarda il fine.

A New Order of Things: What would Machiavelli say?
Above all else Machiavelli knew that ideology interferes with the practical and possible. He knew that context determines a policy's outcome and that men usually fail to change their worldview to match context changes. He knew that loyalty and a sense of community were trustworthier than mercenary considerations. He recognised that when trying to introduce a new order of things that one must anticipate strong opponents who have done well out of the present state of affairs and weak allies from those who might benefit, but have little idea what the new order holds for them.

The environment is confusing right now. One simplistic idealised model follows another, but changes very little in substance. Have we actually escaped the blame culture or the market model? I suspect neither. Which are salaried doctors- strong opponents of a new order of things or weak allies of change that may benefit them? In upcoming changes is there benefit for the relationship between helper and sufferer or between team members?

Machiavelli recorded the progress of his time and warned that those who abandoned what worked for what should theoretically work bring about their own ruin rather than preservation. We have been subjected to the unfortunate market experiment and I have a growing suspicion that the experiment is far from over. The vocabulary has not changed; accountability still means blame; antagonism for doctors is palpable; the sense of a need to control and supervise doctors continues to grow. The legislative and workforce agendas hold little promise to facilitate our helping our patients in ways that we can trust.

What prescription would Dr Machiavelli write for our profession in our times? Would he write for a Prince or a Republic? Would he recommend a powerful leader to come from our ranks and sweep all before us by whatever means came to hand? He would note that we would continue to have diminishing control over resources based on poor or at best weak theoretical grounds that dictate preventive measures. This will be at the arrogant and paternalistic sacrifice of those we are trying to help.
In our employment we may be moving back into a national bargaining structure. ASMS has provided a superb national network, through Ian's, Henry's and Angela's moving among us. Our employers may not need to talk to us at all in such an environment. They may certainly talk to those doctors to whom they chose to listen, but there is no guarantee that they speak for us all. ASMS may well find it harder to remain a strongly unified and unifying organisation. I fear that we will find ourselves more frustrated and angry, perhaps threatened less by "new players in the labour market" than disruption of teams of people who come from different disciplines with therapeutic intent and a willingness to cooperate for our patients' benefit.

Machiavelli recognised one other thing in his time and it cost him his most beloved job. The Florentine Republic leader delayed taking advantage of an enemy's weakness because he was too kind and made a habit of being seen to be considerate and careful. So too are doctors pathological to a fault at being careful and considerate. While this may be a worthwhile practice in medicine, it is not necessarily the wisest or most effective response to policy changes. Some times doctors need to say a unified and unequivocal "NO", and they need to say it for the good of their relationship with their patients, their colleagues and their society.

There may be a powerful medical prince who will come to lead us at some price- be it freedom or loss of integrity. However, there have been times in the past when doctors were far more collegial and supportive. In those times negotiations took place between the profession and society in an environment of respect and trust. Machiavelli recognised that there was greater strength in the Republic than the principality, but he also knew that it was harder to get the people to recognise the need to cooperate to make it happen, especially in times of crisis. If our value system and dedication to health care expertise is to survive the continuation of the experiment, we must pursue a realistic new order of things that we know will be of this world. We can build on the strength of what ASMS has done, rebuild our hospital medical staff groups and enlist our collegial might through supporting NZMA and CTU- not because it is what we ought to do, but because if we don't, other models will bring about our ruin.

Thank you.

DR PETER ROBERTS
NATIONAL PRESIDENT

We are much beholden to Machiavel and others that write what men do and not what they ought to do.
-Sir Francis Bacon, Advancement of Learning, 1605

1 - Machiavelli, N (1532) The Prince (XVIII). "…in the actions of all men, and especially princes, where there is no impartial arbiter, one must consider the final result."
2 - How many people in history have had their name come to stand for ideas? ¾ Plato(-nic), Christ (-ian), Roger (-nomics), Ruth (-enasia), perhaps.
3 - Why is it called a self-regulating profession in every country in the world?
4 - Some call this evolution, a non-linear event. Systems analysis tickets are apparently available in cereal boxes these days.
5 - Weick, K (2001) Making Sense of the Organization Oxford, Blackwell.