Politics Of ‘Livid Pus’ To Politics Of Nudging

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

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”. 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 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:

Cross-dressing central health leadership

Wither clinical leadership

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.

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. 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. Although the then 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 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.

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 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 2008 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 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.

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 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. 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 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:

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. 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.

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.

The case for strengthening collaboration in service delivery between primary and secondary care, another government objective, is compelling. The potential for better 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.

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.

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 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.

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

ENDS

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