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Ian Powell
Executive Director
FROM THE POLITICS OF ‘LIVID PUS’
TO THE POLITICS OF NUDGING
ADDRESS TO
THE HOSPITAL AND COMMUNITY DENTISTRY CONFERENCE
QUEENSTOWN, 31 JULY 2010
Ian Powell
Executive Director
Association of Salaried Medical Specialists
www.asms.org.nz
FROM THE POLITICS OF ‘LIVID PUS’ TO THE POLITICS OF NUDGING
Thank you for the opportunity to address you again. As always my comments are
personal observations although in broad terms at least I believe they are consistent with
the Association’s view on the matters discussed. My theme today is how one should
approach some of the key challenges of the moment.
But first I would like to briefly pay tribute to one of your highly respected colleagues,
John Hawke who passed away earlier this year. John was elected to the Association’s
first National Executive in 1989, was our third National President (1995-97) and was our
first life member. It is difficult to think of a more decent honourable person than John. It
has been interesting to learn of the high regard of so many ASMS members who trained
under or worked with him in dentistry and intensive care in Auckland. One of our
National Executive members who had trained under John aptly described him as one
out of the box. He adhered to values which stand the test of time and one became a
better person by knowing him. He was also known for his wicked sense of humour
often used as a weapon to treat people with respect. Aside from his telephone jokes,
my personal favourite comes from a Tauranga anaesthetist who had trained under him
– John used to say to registrars in his unit that he would give up his career if he could
become a rich woman’s plaything.
The inspiration for the title of this address came from an article I read on a phenomenon
in France, Paris in particular, in the 1780s prior to the French Revolution. The article
was a fascinating account of a surprising number of semi-underground scandal writers
who made their name and income writing about the French nobility and monarchy in the
most unflattering manner. Their level of abuse would make Michael Laws look like a
diplomat. But they were also in competition with each other attacking their rivals in
similar tone.
I was struck by the vivid language of one writer attacking another
describing him as having “a mouth from whose corners there is a constant trickle of livid
pus”.1 Sometimes the passionate and angry debates in the health sector can have a
trickling ‘livid pus’ feel about them.
Trickling ‘livid pus’ (or frothing at the mouth) may be a useful release for pent up
emotions (personally I doubt it) but it does not advance a good argument. Instead I like
1
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‘Paris: Notes from the Underground’, Colin James, New York Review of Books, 13 May 2010, p.41.
2
to think of the ASMS as a compulsive ‘nudger’. Rather than dribbling mouths and bad
hygiene, we nudge, we nudge there, and we nudge everywhere.
In a generally
incremental manner we seek to prod, push, persuade, nag and bore the government of
the day and DHB leaders in the direction we believe the health system should go. We
are like a dog with no teeth. These dogs have strong gums and can suck very hard.
Rarely are decisions made as a result of a ‘big bang’ approach, knock-out punches are
few and far between, and there are no magic bullets.
Persistent nudging is our
methodology. It recognises the wisdom of Will Rogers who observed that “even if you
are on the right track you’ll get run over if you just sit there” but also recognises the
futility of drama queen behaviour. It is interesting to note that there is a theory of
economics called ‘nudgenomics’ located somewhere between Friedman and Keynes.
Having said this I am tempted at times by the observation of General MacArthur that
“whoever said the pen is mightier than the sword, obviously never encountered
automatic weapons.”
Within the context of nudging rather than ‘livid pus’ the main issues I want to discuss
today are:
1. Cross-dressing central health leadership
2. Wither clinical leadership
3. Specialist workforce incapacity
Cross-dressing central health leadership
The politics of government are fascinating at the moment. It takes be back to a family
scandal of mine that did generate some ‘livid pus’. Last year I attended the centennial
celebration of a most remarkable wedding at Kaka Point in Otago’s Catlins.
The
wedding, on 21 April 1909, was of my great, great aunt Agnes (Nessie) and one Percy
Redwood (Percival Leonard Carol Redwood), son of a wealthy Waikato farming family
and nephew of the head of the Catholic Church in New Zealand, Archbishop Francis
Redwood. The engagement had been encouraged by Nessie’s parents. This had the
real feel of upwards social mobility as great, great, great Grandfather and Grandmother
George and Martha Ottaway ran a successful private accommodation house, especially
George Ottaway’s given conviction for the illegal sale of liquor during a time of local
prohibition.
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Reinforcing the delight of the Ottaway family were beautifully written letters from Percy’s
mother in Hamilton who was fully intending to make the long trip south for the wedding
of her beloved boy. The wedding was a success and the marriage confirmed despite
the last minute non-appearance of Mrs Redwood due to the unexpected competing
wedding of another offspring.
But then the world fell in. Before day turned to night creditors appeared concerned
about Percy’s many debts (there had been an expectation his mother would pay them
on her arrival). George and Martha insisted that my Uncle Percy and Aunt Agnes not
depart for their honeymoon and also sleep in separate rooms until the matter was
sorted. The uncertainty ended five days later when the police arrived from Dunedin. It
was then that the family and community learned that Uncle Percy was in fact Aunty
Amy. In particular, he was the infamous con woman Amy Bock who had a litany of
convictions, fines and imprisonments over many years in Victoria and New Zealand.
She also had strong attributes in music, singing and, appropriately given the
correspondence of Mrs Redwood, calligraphy. At her subsequent trial she was declared
a habitual criminal and imprisoned. She is also the subject of a fascinating recently
published book I recommend.2 So, for a period of five days I had a relative known as
Uncle Percy aka Aunty Amy. I am also proud that the first person who worked it out
was my grandmother, then a small child. One day Percy had visited the Ottaway home.
My grandmother opened the door and called out to her elders that the visitor was a
woman dressed as a man. All would have been different if she had been listened to.
This cross-dressing story has relevance to the government’s health policy if one puts
the habitual criminal behaviour to one side. If senior doctors and dentists were listened
to more and earlier as my perceptive grandmother should have been, we would have a
much more effective and fiscally robust public health system.
Further, this is not a reference to the striking ties and shirts combinations of the Minister
of Health; unlike many commentators, as someone with no dress sense I’m in no
position to comment.
Rather it is the significant contrast in policy from the National led government of the
1990s to the National led government of today. In the 1990s it was committed to an
ideology of market forces to drive the public health system.
2
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Jenny Coleman, Mad or Bad? The life and exploits of Amy Bock, 2010.
Although the then
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government most likely had not heard of it this unsuccessful policy was based on the
Lauderdale Paradox which originated from the observation of the 8th Earl of Lauderdale,
James Maitland, who observed in 1804 that private riches could be expanded by
destroying public wealth.
The Earl’s example was land ownership and water.
He
concluded that individual riches could be augmented by landowners monopolising the
water of wells and charging a price for what had previously been free; artificial creation
of scarcity as a way in which those with private wealth and resources robbed society of
its real wealth.
Or, to quote John Maynard Keynes on financially driven systems, “we are capable of
shutting off the sun and the stars because they do not pay a dividend.”
Although the National Party campaigned in the last election on greater use of the private
sector, government practice to date suggests its policy constitutes a cross-dressing of
market forces and Stalinist centralism. Despite the pejorative Stalinist reference many
of these initiatives are welcome.
Much of the Labour led government’s health policy in its nine years of office was
commendable including overturning the market force legislation, increased health
funding and improving access to primary care largely by reducing costs. But it seemed
to believe that by providing largely good legislation, establishing statutory authorities
(DHBs) to fund and provide health services to their populations, increasing funding and
developing several commendable high policy strategies, this would be sufficient. It was
not. There was an increasing need for, but glaring absence of operational leadership
capacity at a national level. The Ministry of Health was largely locked into a funding,
regulatory, monitoring and policy advisory role. This only started to be addressed by
Director-General Stephen McKernan when he commenced in 2006 and former Health
Minister David Cunliffe in the last year of the former government.
But rather than going in the opposite direction to re-create a market forces regime
Health Minister Tony Ryall has strengthened this direction.
The creation of a new
workforce unit in the Ministry of Health, Health Workforce New Zealand is a case in
point. In the 1990s then Health Minister Bill English rejected a proposal from an expert
advisory group to establish a workforce body and instead relied on the market to sort
out workforce issues, fatally as it proved to be with long term negative consequences. If
Tony Ryall had recommended establishing Health Workforce New Zealand over a
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decade ago, Bill English would have accused him of trying to re-establish a shipyard in
Poland’s Gdansk.
Similarly the powers of the Ministry of Health through its National Health Board and the
transfer of procurement of medical devices from DHBs first to the new Shared Services
Agency and then Pharmac would have been unthinkable in the 1990s.
The
establishment of the new Quality and Safety Commission, including the excellent choice
of Professor Alan Merry as interim chair, is a positive incremental development building
on the pioneer work of the outgoing statutory Health Improvement Committee.
Further, the government has directed the four regional DHB groupings to prepare
regional services plans. There is now a bill before Parliament, largely supported by the
ASMS, seeking to give explicit requirements on DHBs to collaborate regionally and
nationally and given central agencies the ultimate power to deliberate where disputes
remain. If the South Island DHBs can’t resolve the configuration of neurosurgery, then
under its new powers central government is likely to.
This is not a return to a market forces regime even though there are some impulses in
that direction. Contrast this with the recent savage article in the Wall Street Journal
attacking quality expert Professor Don Berwick recently appointed by President Obama
to head up the main federal public health institutions, Medicare and Medicaid, for
advocating government central planning in health and for not wanting Americans to
have to rely on the “darkness of private enterprise” for access to health care.3
We also need to remember that New Zealand’s health system compares very well
internationally with other developed economies. As Commonwealth Fund data confirm
as a country of only four million (and with two of them being Chris Carter and Andy
Haden) we punch well above our weight. There is much improvement to make but it is
based on strong foundations.
Whither clinical leadership
There is increasing recognition that if we are to have an effective and efficient,
sustainable, quality and accessible health system, clinical leadership has to be in the
engine room of decision-making at all levels of DHBs. It is rather like what Winston
Churchill said of the United States – it can always be guaranteed to make the right
decision but only after it has exhausted all other options. After playing around with
3
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‘Who Pays for ObamaCare?’, Wall Street Journal, 12 July 2010, A14.
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managerialism, commercialisation and high policy strategies, the penny is dropping despite a history of lip service that the way forward rests with the enormous human
capital that exists within the health system, its health professional workforce. At last
there seems to be acceptance by decision-makers of the homily of Confucius that “real
knowledge is to know the extent of one’s ignorance.”
Tony Ryall grasped this when he addressed our Annual Conference in 20084 soon after
becoming Minister. He said:
Around the world, clinical leadership is recognized as the fundamental driver for
improved care. But here in New Zealand health professionals have an increasingly
limited say on how health services are provided. And we think it is this failure to
engage the people who have the expertise, the doctors and nurses who keep the
pubic health system going, that is eroding the health services’ ability to provide
patients with the care that they need.
Doctors and nurses and other health
professionals need to be able to make the most of their skills and commitment.
Recent research [McKinsey and Co] across 126 hospitals in Britain has found a very
clear link between strong clinical leadership and hospital performance. The research
has found that the best practices and approaches in hospitals reduced infection rates,
improved productivity, readmission rates, patient satisfaction and value for money.
And the key to this success was the level of involvement of clinicians in running their
hospital services. Stronger and more direct involvement by doctors, nurses and other
clinicians means better service and better quality.
National wants to ensure that
doctors and nurses and health professionals have more say in the New Zealand
health service, how it’s being developed and improved. We’re going to do this by
requiring District Health Boards to involve health professionals in decision making and
we want to work with you to make sure that this happens.
Both the Time for Quality agreement between the ASMS and DHBs and the
government’s In Good Hands policy statement help set the scene as does the forward
thinking Health Sector Relationship Agreement between the DHBs, CTU health unions
and government.
There is an underpinning theme in these documents of active
engagement of staff as close to the workplace and work unit as possible and that
clinical leadership is not simply positions of clinical leadership such as chief medical
advisers and clinical directors. They involve empowering those working at the clinical
4
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Speech available on ASMS website www.asms.org.nz.
7
coalface. There are several positive signs in this direction which include the Minister’s
own attitude and commitment.
The contrast in appreciation of the expertise and experience of a vocationally trained
professional workforce between Mr Ryall and the Minister of Education over the
misleading populist slogan of so-called national standards, for example, in valuing the
advice and experience of their respective workforces could not more stark. I say this as
a teacher’s spouse and on behalf of all those teachers’ spouses whose pillow talk has
been destroyed by anger and frustration over the Education Minister’s top-down
insistence on ineptly formulated and developed superficial ‘national standards’.
But there are also negatives.
There are enormous potential benefits in enhanced
integration between primary and secondary care providing it is centred in genuine
clinical leadership across the affected spectrum of care. But rather than progressing
this objective, the government’s ‘expression of interest’ business case process in some
areas was a set-back. In the development of the original ‘expressions of interest’ many
DHBs (and consequently their health professionals) were consciously excluded from
involvement. In the development of the subsequent nine business cases the time of the
year and time frame made it very impractical to actively engage with secondary care
clinicians, especially in proposals that affected more than one DHB. The objective of
clinician led improved primary-secondary care integration through networks and other
arrangements needs to be pursued but through a more suitable process than we have
recently experienced.
The debacle over the merger of the Otago and Southland DHBs into the new Southern
DHB is another negative experience. In response to its failures with its two previous
chief executive appointments instead of risking a third fiasco the Southland DHB opted
to invite what it considered to be a safe pair of hands in Otago to also be its chief
executive. This led to a second tier regional management team across the two DHBs.
Despite the shaky context then came the merger. The Minister of Health was led to
believe that there would be savings of one million or so dollars arising out of
restructuring. Senior medical staff in Otago were largely lukewarm while in Southland
they (and nursing staff) were strongly opposed.
Whereas the ASMS argued that
structure should follow form and that before merging it was important to develop more
robust clinical service relationships across the two provinces, the two DHBs believed
that structural change would drive substantive service delivery change.
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They were wrong and the Minister poorly advised.
Immediately after the top-down
merger decision the chief executive embarked on a major restructuring change involving
both management and clinical leadership positions. While something did need to be
done about management below second tier, the proposal for clinical leadership
positions was a shocker; basically reducing the positions and increasing their
responsibilities. It was unworkable and strongly opposed. The large geographic span
of the combined region and the distance between the two base hospitals was not
sufficiently appreciated.
Consequently the whole proposal was virtually completely withdrawn. The net result is
effectively two DHBs functioning under the name of one with a cumbersome
management structure, no cost savings and an unimpressed Minister. In Southland our
members fear a takeover from Otago while in Otago our members fear an
encroachment of Southland management. It is difficult to see a more poorly thought out
and wasteful decision. Had there been bottom up engagement with clinicians (health
professionals) it could have been quite different.
The practice was contrary to the
rhetoric.
Another set-back is the lack of action in the implementation of In Good Hands. This
farsighted document recommended that to give it teeth DHBs be required to report on
its application. Following a productive meeting between the Minister of Health and
ASMS, Mr Ryall last July set up a group to advise on reporting guidelines. His group
did its job completing the task in August. It recommended a series of questions for
DHBs to complete after engaging with their various clinician consultation forums. In the
case of senior medical and dental staff it was the ASMS’s Joint Consultation
Committees in each of the DHBs.
Then things went silent. We subsequently learned after much searching around, that
immediately prior to Christmas the Ministry of Health’s National Health Board had sent
all DHBs a ‘performance measure’ to complete in the fourth quarter of the financial year
(April-June – the standard deadline for these reports is the 20th of the following month;
ie, July). The ‘performance measure’ was a watered down version of the Ministerial
advisory group’s recommendation – truncated questions and removal of the reference
to engage with the consultation forums.
Once the ASMS learnt of this a few months later, as well as venting some ‘livid pus’ in
correspondence to the Minister, we started enquiring of DHBs how they were
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approaching the ‘performance measure’ and were they engaging with clinicians. The
response was one of extraordinary confusion by a bunch of chooks running around
looking for an axe to be beheaded by. Despite, at a national meeting with the DHBs last
June, them advising us that they had to complete it by 20 July this year, some DHBs
have told us that it applies to the 2009-10 year, some say it applies to the 2010-11 year
and at least one states that it does not apply at all.
How on earth can we have
confidence in the capacity of the Ministry of Health and DHBs to effectively promote and
introduce clinical leadership and engagement after this dog’s breakfast? Quite simply
they don’t know whether they are Amy or Percy.
It is at times like this that Helen Keller’s assertion is timely: “There is one thing worse
than being blind and that is having sight but no vision.”
The ASMS is also concerned that in some cases the consultation obligations and
responsibilities in our multi-employer (national) collective agreement (MECA) are being
ignored or honoured in their breach.
Much of this is due to the intense financial
pressures on DHBs. Reducing the rate of funding increase by about half is harsh and
risks panic, hasty and short-sighted decision-making.
But this is no excuse and
undermines the credibility of the government’s and DHBs’ commitment to clinical
leadership.
If this failure becomes more widespread we risk resembling a twin-engine airplane that
when one engine fails it always has enough power left to get you to the scene of the
crash.
These failures are disappointing and deflating. But I am mindful of the extraordinary
generosity of Aunty Agnes and Granddad George Ottaway who wrote movingly to the
magistrate hearing Aunty Amy’s trial saying they bore the fraudster no ill will and
encouraging leniency.5 If they could forgive perhaps the ASMS can as well!
Specialist workforce incapacity
The government has a number of objectives that the ASMS endorses; some we
advocated it adopt when in opposition. The Resident Medical Officers Commission
noted that service provision had got out of hand and compromised the quality of
5
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Letter in Balclutha Museum.
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training.
In essence it recommended that specialists take greater responsibility for
resident doctor training and, in effect, that they take a greater role in service delivery.
These recommendations were endorsed by government. In order to achieve this there
will need to be a shift to one degree or another from specialist-led to specialist-provided
services. There is much that is laudable in this and the ASMS is keen to get in behind
and do its bit. But there is simply not the specialist workforce capacity in New Zealand
to achieve this. Instead we have an overworked, over-stretched workforce suffering
from clinical overload and struggling simply to keep the health ship afloat.
There are also other important commendable government objectives that require a
much more sustainable specialist workforce capacity which we do not presently have.
In particular:
1. The government has correctly identified that comprehensive clinical leadership is the
way forward in terms of ensuring high quality and cost effective health services. This is
not simply formal positions of clinical leadership but drilling down below to the unit of
work so that all senior medical and dental staff are able to participate in leadership
beyond their immediate clinical practice. As Professor Des Gorman, Chair of Health
Workforce New Zealand has said on a number of occasions leadership is not
discretionary for a health professional.6
But comprehensive coal-face level clinical
leadership requires time and time requires the numbers that DHBs simply do not have.
Even formal clinical leaders are struggling for time, let alone the level of engagement
expected by Time for Quality and In Good Hands.
2. Quite correctly the government is promoting greater regional collaboration between
DHBs. This is sensible recognising that DHBs can’t function in splendid isolation and
that it is essential for clinical and financial sustainability.
DHBs are currently
developing regional services planning which largely focus on building clinician-led
clinical networks and strengthening public hospitals. It is not centralisation and if it
were to become centralisation it would fall over.
While this has the potential to
strengthen ongoing specialist workforce capacity it will not happen unless the right
investment is made to achieve the necessary capacity to get it up and running in the
first place. We do not have this capacity.
3. The case for strengthening collaboration in service delivery between primary and
secondary care, another government objective, is compelling. The potential for better
6
Most recently at the Inaugural World Health Care Networks Conference, Auckland (22-24 July 2010), when participating in a panel discussion on ‘creating
confident, skilled, imaginative leaders to shape a future health system’, 24 July.
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patient outcomes, improved patient access, and a better return for the health dollar is
immense and largely untapped.
But this depends on active engagement with
secondary care specialists who simply do not have the time.
4. In the lead up to the last general election and for a short period of time once assuming
the Treasury benches the National Party promised 20 additional elective operating
theatres in public hospitals in order to increase elective throughput. Unfortunately this
promotion focussed too much on plant and not enough on workforce. It is interesting
that the government has been silent on this policy for some time. The most likely
explanation is the recognition that New Zealand does not have the workforce capacity
to deliver on increasing electives to the expected level, especially as it is now clear that
some of the recent increased elective volumes are due to the re-designation of ACC
patients.
This capacity need includes the specialist workforce including surgical,
anaesthetist and diagnostic.
New Zealand’s specialist workforce capacity is trapped. It is struggling to keep up with
increasing clinical demands (often described by our members as ‘clinical creep’) with
one of the casualties being the ability to use non-clinical time to support professional
activities and development. We are increasingly dependent on overseas recruitment
and are by far the most dependent OECD country (much higher than second highest
Australia) despite the recommendation of the former Medical Training Board that we
gradually reduce our dependence (a recommendation incorporated by the RMO
Commission and adopted by government). We have the lowest ratio of specialists per
capita in an OECD survey, even pipped at the post by Turkey.7
Australia is our greatest threat particularly in specialties where there is not a strong
private sector in New Zealand.
The threat is compounded by proximity, closer
economic relations, and similar reciprocal training schemes.
New Zealand can’t
compete on employment conditions against Australia in international recruitment; we
are losing senior registrars to Australia seeking opportunities for specialist appointments
where there are shortages; and there is continuing corrosive trickle of specialists from
New Zealand to Australia.
This is an unsustainable recipe. To be absolutely blunt it is a crisis staring us in the
eye. It is a crisis that prevents ongoing sustainability. Its severity undermines the
7
Health at a Glance, OECD, 2009; also “New Zealand Medical Specialist workforce hits international rock bottom,” The Specialist, March 2010.
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government’s ability to achieve its commendable objectives. It does not diminish the
ASMS’s wish to work with government to achieve them but it guts our ability to do so.
Solutions to this crisis are multi-factorial.
But addressing Australia’s superiority in
employment conditions tops the pops in my assessment.
This superiority includes
salaries, superannuation, professional development support (including continuing
medical education expenses), a unique system of salary sacrifice (which more than
compensates for the forthcoming tax cuts), more specialists on the roster, and more
senior registrars to provide support. Some of these we can’t fix because they are the
result of the difference in critical mass. Others we can but not necessarily all at once.
The single most important measure we could take in this area is to address our salary
scales. The differences between the two countries are stark and striking. Whereas
New Zealand has a 15-step specialist scale ranging from the high $120,000s (NZ) to the
mid-$190,000s, the average Australian scale is about nine steps from the mid$190,000s (A) to under $260,000. It is a no-brainer that until we find some way of
addressing this crisis will continue and the government will not achieve its objectives
above a threshold of superficiality and tokenism.
Before fiscal panic buttons are pressed it needs to be emphasised a pathway approach
would be required.
Further, there are offsetting savings that would occur as a
consequence. If we can end up being competitive with Australia on core salaries, we
can improve recruitment and stabilise retention. This has flow-on benefits of reducing
locum costs, reducing recruitment costs through stabilising retention (I understand from
DHBs that the cost of recruiting from overseas is roughly three times the amount of the
annual salary), and reducing the dependence on overseas recruitment by retaining the
future specialists we train (recruiting New Zealand trained senior registrars to specialist
positions is cheaper than recruiting overseas trained specialists).
But this is all small change compared with the difficult to quantify but potentially much
larger savings through the benefits which are derived by improved effectiveness and
efficiencies in areas such as comprehensive ‘shop floor’ non-discretionary clinical
leadership, enhanced primary-secondary integration, strengthened regional and
national collaboration, workforce development, and early intervention to prevent
electives becoming more costly acute or complex cases.
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This will require government recognition that investing in the employment of senior
doctors and dentists should be among its top expenditure investments and recognition
of the enormous returns (as well as savings) this will bring. Many developed nations
recognise that health should be seen as an investment in economic well being and not a
cost.
It is time for a mind set change in New Zealand. The government needs to put its
investment priority where its political mouth is. With a bit of nudging reinforced by a
touch of cross-dressing and political will, and without ‘livid pus’, it is doable. To quote
that delightful American ‘intellectual’, former Vice President Dan Quayle: “if we don’t
succeed we will have failed.”
If the government fails Quayle-like then its biggest risk is that its commendable ‘Better
Sooner More Convenient’ becomes the opposite of commendable ‘Better Sooner More
Cocked Up’.
Ian Powell
EXECUTIVE DIRECTOR
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