Getting To A State Of Gruntlement

Getting To A State Of Gruntlement

ADDRESS TO

NEW ZEALAND SOCIETY OF

HOSPITAL AND COMMUNITY DENTISTRY

WELLINGTON, SATURDAY 29 JULY 2006

IAN POWELL

EXECUTIVE DIRECTOR

ASSOCIATION OF SALARIED MEDICAL SPECIALISTS

Once again thank you for the opportunity to address your Conference. My comments are personal rather than official Association observations although I believe that they are broadly consistent. However, to the extent to which my comments are too forthright or insufficiently forthright the responsibility is mine.

One of the achievements of our first national DHB collective agreement (MECA; 2003-2006) was the formation, in each DHB, of ASMS-DHB Joint Consultation Committees. In a lighter moment at our last Canterbury JCC a few months ago our representatives and managers were discussing whether we might be reaching an unheard of state of an absence of disgruntlement. We thought we were being clever in inventing a new opposite word, gruntlement. I reported this light humour to our next National Executive meeting only to discover that a technologically tuned Executive member quickly consulted his electronic dictionary and discovered that there is such a word. Roughly, gruntlement means a state of happiness, peacefulness and tranquillity.

And so it is the question of whether a path to a state of gruntlement lies before us or not and what might be required to achieve it which forms the theme of this address. In doing so I will refer to the lessons of a recent negative experience about privatising hospital laboratories, whether the culture of managerialism is undergoing a revival, and our health professional led approach. To help me through this I will also call upon the collective wisdom of Spike Milligan, Billy Connolly, and an Indian and French novelist.

First to Spike Milligan of Goon Show and other fame. Last month I read that detective work undertaken by a professor investigating the psychology of humour had concluded that the world’s funniest gag came from Milligan. It went like this:

Two hunters are out in the woods in New Jersey when one of them collapses. He doesn’t seem to be breathing and his eyes are glazed. The other guy whips out his phone and calls emergency services. He gasps: “My friend is dead! What can I do?”

The operator says: “Calm down, I can help. First make sure he is dead.” There is a silence, then a shot is heard.

Back on the phone, the guy says: “Okay, now what?”

I’m confident that many health professionals will note the immediate similarity with much of the ‘shoot first and ask questions later’ attitude that continues to pervade the political, policy and managerial leadership of our health system. While a Milligan fan I thought that Billy Connelly’s joke about unwelcome ideas also has applicability; “we need this as much as an astronaut needs a fart in their space suite”. Many health professionals will note the similarity between the welcoming effect of Connolly’s “fart in the astronaut’s space suit” and the arrival in DHBs of yet another Health Ministry tool kit.

For leisure I enjoy reading historical and political books. Partly in response to my significant other’s observations of “how boring” and also the need to widen my literary pleasure I recently decided to improve my reading in novels beyond the John Grisham and Michael Connolly thrillers. This journey has introduced me for the first time to novelists from India who in my limited experience to date focus less on story telling and excitement and more on admirable and at times beautiful subtle descriptions of life and relationships.

I was struck by the following brief passage from Amit Chaudhuri’s Afternoon Raag. Although about a relationship between two young people its similarity with the way in which our health policy is driven and develops resonated, at least for me:

When Sharma spoke, reality and fantasy, my past and his, became reordered in new proportions.

Rather like Milligan’s witty account of his embellished part in the downfall of Adolf Hitler, this merge and enhancement of reality and fantasy continues to pervade decision-making in the health system, contributes to current levels of disgruntlement, and prevents it from advancing to a more robust level.

A Case in Point: Public Hospital Laboratories

Public hospital laboratories offer an interesting case in point, in particular the recent decision of the Otago and Southland DHBs to privatise their hospital laboratories. Since 2001 DHBs have been responsible for the funding of the largely privately provided community testing (GP referrals). This had previously been the responsibility of the Health Ministry. DHBs inherited the challenge of increased costs of the market system of uncapped volumes, duplication of resources, and large profits for private businesses. It contrasted to the capped system of funding hospital laboratory testing whose drivers were from within public hospitals.

The Government and Public Provision

Community testing is an extravagant and lucrative cash cow for the private sector. It is highly profitable for these largely oligarchic businesses. Many hospital laboratories have the capacity (including plant and labour) to undertake community as well as hospital testing. The logical approach therefore would be to either allow hospital laboratories to take over community testing or to shift to a single private provider for community testing with a tight contractual regime to ensure fiscal control. It is not necessary or advantageous to place hospital laboratories at risk when trying to resolve a problem of community testing cost growth and over-capacity.

Further, the government’s own view on privatisation should have reinforced this view. For example, on 16 April 2006 Health Minister Pete Hodgson affirmed, in the context of the provision of secondary and tertiary services, that (Sunday Star Times, 16 April, p.A4):

The government believed “the private provision of health is always more expensive in the long run”. For that reason, he said, it wanted the public health system to dominate.

This belief in public provision was soon reaffirmed in a keynote address by the Minister on 1 May with his statement:

We believe in a health system that is predominantly publicly funded, with a strong core of secondary and tertiary services being publicly provided as well. Around that core of public provision sits private and not-for-profit provision, freely interacting with and needing each other.

Later in the same address, he contrasted National’s approach with that of the government’s:

National innately dislikes a public service working well. They have an underlying instinct to privatise or part privatise both the funding and provision of services. So they occasionally stress that the private sector should be used more, for the sake of it, or that part-charging has merit, or that a dominant role for public provision is somehow not the future, or that universality is wasteful.

That instinct is not openly aired and for good reason. We tried all that in the nineties. They were unhappy times for both the health system and the then government. National got through five Health Ministers in nine years, and more associates & crown health enterprise ministers than I can recall.

These comments, coupled with his other often repeated firm criticisms against what he describes as attempts to ‘Americanise’ our public health system, all serve to suggest the improbability of this government allowing privatisation of hospital laboratories. It is difficult to imagine a public hospital service that is more core than laboratories. While representing a small percentage of hospital costs (less than 5%), hospital laboratories affect 60-70% of all critical decisions in a hospital setting.

Otago-Southland Experience

But what does the Otago-Southland experience tell us? These two DHBs, with the Minister’s sign off, have privatised their public hospital laboratories (subject to a further legal action by the Medical Laboratory Workers Union). They are giving a taxpayers’ cheque for millions of dollars, into the hands of a private company, Southern Community Laboratories (SCL).

This was their second attempt at privatisation. The first, because it involved a merger of the two largest private businesses running laboratories, was knocked back by the Commerce Commission because it was anti-competitive. Learning from this the DHBs adopted a new path not involving a merger to get around the Commission’s jurisdiction.

Without giving a blow-by-blow account the summary points include:

• In the first attempt at privatisation there was clear evidence of the equivalent of ‘insider trading’. In May 2005 the chief executives of the two DHBs recommended in writing to their boards a week before they were to make their decision that the hospital laboratories’ bid should be approved for several reasons including a series of fiscal and other risks associated with privatisation and price (the hospital laboratory bid was lower). However, the private bidders learnt of this and, at 5pm the evening before the two boards were to meet, submitted a secretive lower bid. The two chief executives quickly forgot about the serious risks they had previously identified and reversed their recommendation which the less than scrutiny focussed two boards accepted (there are also reports of private lobbying of board members to help achieve this outcome).

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• The process was corrupted from the beginning when the DHBs resurrected the unsuccessful, narrow and artificial funder-provider split ideology of the 1990s. This led to the adoption of a process which prevented any integrated collaboration between the DHBs’ funding and planning divisions, on the one hand, and their providing divisions on the other. The practical effect was to cut the funding and planning divisions off from its valuable resource of in-house clinical, technical and managerial expertise. The DHBs did not have to go down this path; they had options. Ironically former Health Minister Annette King had previously warned DHBs against internally replicating the funder-provider split.

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• This then became the basis for the two DHBs’ determination to exclude their own in-house clinical expertise (eg, pathologists, haematologists), let alone its own technical and managerial expertise, from being involved in the decision-making process. It also contradicted repeated statements by health ministers in annual letters of expectations to DHBs for greater engagement and partnership with clinicians in DHB decision-making.

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• The Health Minister has previously said that while there was a role for management, there was no role for managerialism (the ideology of management knows best). But this process confirmed that managerialism is condoned and, in effect, encouraged by these two DHBs and this Minister.

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• While the savvy and street-wise SCL had its own expertise when it was negotiating the final contract, the DHBs did not. The DHBs delegated this responsibility to the Otago funding and planning division. Whatever the expertise in this division, it is not in the running of hospital laboratories. Those with expertise and experience (pathologists, technical staff, and operational management) continued to be excluded. Even the DHB’s own Chief Operations Officer was excluded. No prizes for guessing who was in the strongest negotiating position. This was rather like the former Health Minister in her new transport portfolio inviting panel beaters to design our traffic intersections.

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• The opportunity for South Island wide enhanced collaboration and rationalisation between hospital laboratories has also been compromised.

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• The Minister has given a signal to DHBs that he is a soft touch on privatisation and some are already titillated by the prospects.

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The Minister’s decision was extraordinary in part because he has in one short-sighted swoop removed a major point of differentiation in health policy between his governing party and the main political opposition. He has frequently attacked the National opposition over its favourable disposition towards privatisation (which he sometimes described as the ‘Americanisation of the health system’) but has now in effect approved a privatisation arguably larger than any single core public hospital service privatisation associated with the former National government of the 1990s. We are now left with an outcome of a core health service, which impacts on 60-70% of hospital outcomes, under the control of a profit maximising company which is now well placed to establish a near permanent monopoly position over the hospital laboratories.

‘Drop Dead Easy’, and Foolish to Boot

The Minister received narrowly based and unchallenged advice from his Ministry which in turn only received the case provided by Otago’s funding and planning division and the savvy SCL which, of course, reaps the profits. It is hardly surprising that the information would have been put to him in such a way as to make what he has described as a ‘drop dead easy’ decision. But there was no input from those with the strongest operational and clinical experience of running a hospital laboratory. This included understanding the true costs (eg, subsequent technology developments and disease demands).

Further, there was no input about other means of achieving significant savings. Contestable advice was not sought on the clinical and professional implications or on the fiscal claims of savings. Nor was advice sought on whether other options to privatisation were available that might achieve the same or similar purported fiscal gains and involve less fiscal risk to the Crown.

The past 15-20 years have been riddled with ‘drop dead easy’ claims. A Business Roundtable led government commissioned report of the late 1980s, known as the Gibbs report, claimed that 30% savings could be made from public hospitals. This claim was repeated by the head of one of the agencies, the Transitional Health Authority, set up to implement the National government’s market reforms in the early 1990s but by the end of the decade total public hospital spending had if anything increased rather than decreased.

Savings promised in the 1990s by business consultants (eg, Proudfoot in Waikato, Deloittes in Taranaki, and to a lesser extent Third Sight in Capital Coast and MidCentral) never materialised; millions were wasted on the business consultants producing reports that could not be implemented. And millions were wasted on the infamous Shared Medical Systems computer system that was going to solve our information technology problems in Capital Coast and Waikato. With all this known recent historical experience it is extraordinary that the Minister did not obtain comprehensive fiscal advice about the robustness of the financial analysis of the privatisation proposal and about alternative options. He made the decision ‘drop dead easy’ by returning to the laxity of the 1990s and abandoning fiscal responsibility.

Ministerial Shafting of Employment Rights

The ASMS had successfully applied to the Employment Court for an interim injunction halting the privatisation until a full hearing by the Employment Relations Authority of our full case was heard. However, the Minister’s decision to give the DHBs the authority to proceed with the privatisation and, in particular, to sign a legally binding contract with SCL sabotaged our case. While the Court’s conclusion that we had a ‘strongly arguable’ case had put us in a strong position this was undermined by the Minister allowing a legally binding, commercially sensitive, contract to be signed by a third party not directly covered by the action. This severely constrained the actions and orders that the Employment Relations Authority could have required. Repudiation of this contract would have been an improbable outcome as would have been our endeavours to obtain under discovery commercial documents that were critical for proper consultation. The Minister’s intervention made the exercise of the consultation rights for the pathologists and the ASMS futile.

The Minister maintains that this was not his intention. Perhaps this is so but one would have thought that he would have obtained employment law advice in advance. Further, there was no imperative for the Minister to make the decision he did and when he did. The previous week the DHBs advised that they already had contingency plans organised should our interim injunction application succeed or should the Minister either delay his decision or not approve their request for privatisation.

While it may be, as the Minister has asserted, not have been his intention to interfere thereby greatly assisting SCL’s business interests, a minister with this intention could not have done a more effective job. His intervention also enabled the two DHBs, backed by SCL, to deny us information that we needed for the full hearing as did the obstructive behaviour of Health Ministry officials over our requests for documents under the Official Information Act. In effect, we were confronted with a kind of ‘united front’ of the hierarchies of the two DHBs, SCL, Health Minister and Health Ministry. Political interference in the exercise of the pathologists’ employment rights was the outcome regardless of the intention and something that we should all be concerned about. The practical effect of this was that we were left with no option but to withdraw our case before the Employment Relations Authority.

The Minister of Health denies that he was approving privatisation but instead merely approving SCL’s leasing of public hospital facilities. This is unimpressive, cute and disingenuous. The fact of the matter is that the leasing was one prerequisite for a much wider privatisation of a core health service.

Conflicting Ministerial Positions

To cap it all off, the Health Minister was advised by his Health Ministry officials that his decision was limited to the protocol covering private use of public facilities. But the Minister has the right to insist that decisions by DHBs are consistent with the direction of government policy. The Minister can determine positions. His predecessor intervened with the Nelson Marlborough DHB over Murchison Hospital while the Ministry on Mr Hodgson’s behalf has instructed DHBs how to handle first specialist assessments. In particular, leasing public facilities was only part of what was a much larger privatisation which should have been considered under another more comprehensive protocol covering outsourcing. That protocol has a much higher threshold, which includes a preference for public provision and a requirement of demonstrable benefits.

Mr Hodgson’s advice that ministerial approval was not required is exactly the opposite of the advice given to his predecessor when she wrote to us on 20 June 2005 on exactly the same issue. Annette King was absolutely explicit that ministerial approval is required. Among her comments were:

Before Otago and Southland DHBs could contract out their laboratory services they would need my formal approval.

Further:

The need to seek my opinion is triggered by the Operational Policy Framework (OPF), which is a set of operational level accountabilities for DHBs, endorsed by the Minister of Health, which applies to service changes such as this…

Clearly the approach taken by Mr Hodgson is in conflict with the approach that would have been taken by his predecessor even though it is the same government and there has not been a notified policy change.

Lessons of this Outcome

There are several lessons from this unfortunate experience. These include:

• The Minister’s letters of expectations to DHBs about improving engagement with and involvement of health professionals are meaningless lines on paper. Those DHBs who believe in this will do so anyway and those that don’t will simply pretend they do and ignore it. The government despite its rhetoric is condoning of the culture of managerialism in our public hospitals.

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• There is essentially little substantive difference over privatisation of public hospital services between this government and the government of the 1990s when the market experiment was underway. Perhaps at best this government is more passive than promotional compared with its predecessor. The case for a Coalition of Public Health, or organisations performing similar roles, may well be as readily apparent now as it was in the 1990s.

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• There is an absence of a shared view between health professionals and the government over the importance and value of publicly provided secondary and tertiary health services. In fact, the government attaches more importance to publicly provided prisons than it does to publicly provided health services.

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Culture of Managerialism

One of the legacies of the 1990s era is the culture of managerialism based on the premise that a cult (senior management) within the system knows best. This still pervades, to one degree or another, today. This descriptor should not be applied to the many operational and practical managers who work daily alongside and support health professionals doing good work. Rather it is more applicable to a number of those involved in senior managerial roles distant from the workplace, including some funding and planning divisions.

Revival of Managerialism

Otago is at the forefront of the attempted revival of managerialism, as bad as the worst experiences of the 1990s (which may be underway), but it does not have a monopoly position. By way of example one can look at Capital & Coast where managerialism is responsible for a major part of its longstanding internal dysfunction and the well meaning but patrician approach in Nelson Marlborough. To provide some balance, however, it should be noted that some DHBs such as Lakes, Taranaki and MidCentral (and also possibly Bay of Plenty and Hawkes Bay) are working at encouraging a new culture to facilitate more constructive and effective engagement with their health professionals.

Managerialism is also rife in our current re-negotiation of the national DHB MECA. The DHBs’ position, although it may only be the more hard-line elements that are driving it, is to seek to enhance managerial control over senior doctors and dentists and cut back on existing terms and conditions of employment. This includes time for non-clinical duties, rights of consultation, sabbatical, the role of the Joint Consultation Committees and, as icing on the cake, requiring senior doctors and dentists contractually to adhere to “DHB values”.

Ministerial Managerialism

But the culture of managerialism is not confined to DHBs. It is in effect condoned by the government. In part, this is evidenced by the Health Minister’s approval of the hospital laboratory privatisation which was predicated on managerialism and the disempowering of health professionals. Further, this is compounded by his extraordinary decision not to appoint all four elected candidates to the Medical Council. Arrogance is a precursor of managerialism. The damage done to his reputation by this own goal will take a long time to overcome, if at all.

But this culture is also the modus operandi for the driving of decisions. The Minister is presently delivering a series of priority speeches in which interesting comments and expectations are announced. But his vehicle for implementation is largely limited to the hierarchies of DHBs (chairs, boards and chief executives) and the Ministry of Health. The ignoring by some DHBs of his predecessor’s call for removing the artificial divide between funding and providing and the disregarding by many DHBs of ministerial letters exhorting the importance of active engagement with health professionals confirm serious limitations to this approach.

Ministry Unilateralism

The Health Ministry also forms part of the managerialism ideology with its own top-down unilateralism. While the government advocates a whole of government approach to challenges and policy, the Ministry has yet to show signs of adopting a whole of Ministry approach. Instead it comprises a series of fiefdoms connected by electricity and email. It believes it knows best and everything would be just fine if those naughty health professionals would just behave themselves. Many Ministry officials function in an environment which is considerably oblivious to and in a state of denial over the real challenges facing the health system. But more than anyone else they are the ones that the Minister listens to and takes his advice from.

The cold letters from the Health Ministry to DHBs dictating what they must do over prioritising for first specialist assessments and on waiting lists also highlights this managerialism. In the absence of the willingness to work together to discuss and develop a strategy for meeting this unmet patient need it is simply data cleansing and dictating that GPs will be used as a dumping ground. Further, it is removing from the training of RMOs important basic elective procedures.

Ironically the government is encouraging two new processes of bipartitism and tripartitism; interesting terms but what do they mean. A useful analogy might be sex – bi is fine but tri is complicated. In summary, they are efforts to provide an environment of constructive engagement in recognition of the fact that this would improve effectiveness. Recognising that the DHB workforce is heavily unionised, bipartitism involves DHBs and the CTU-affiliated health unions (eg, ASMS, NZNO and PSA) while tripartitism brings in the government in the form of the Ministers of Health and Labour. This process has already produced the health sector code of good faith, a schedule to the Employment Relations Act, which provides important protections for more vulnerable employees and also the requirement for contingency plans for life preserving services in the event of strike action. But its potential remains under-utilised and contradicted by the Ministry’s own unilateralist behaviour.

Health Professional Led Approach

Prior to the 2005 general election an AC Neilsen poll revealed a high level of anxiety among the public about the performance of the health system and a widespread belief, around two-thirds, that the health system is deteriorating. Many health professionals at the clinical frontline in secondary and tertiary care share this anxiety and believe that improvements in the nearly seven years have been patchy, difficult to sustain, and hard to prove.

The government’s focus to date, including fiscal and capacity building, has been on primary care (and also population based care). This is essential to the long term future of health care delivery and it is important that it continues. However, it must be recognised that while this focus will lead to improving quality of life and effectiveness of care, it will not for the foreseeable future have a discernible effect on reducing pressures on secondary and tertiary care. In primary care at least, through improved access and greater detection, it might even increase these pressures which still have had to be managed with proportionately less of the increased health funding that has gone to secondary and tertiary care. In contrast to primary care and population health, the government lacks a vision for public hospitals which sit in the system like an after-thought and balance sheet liability.

New Strategic Direction Needed

We need a new strategic direction that can be validated by two yardsticks. The first is cost effectiveness and fiscal sustainability. The second is quality. Some of the most boring reading material in existence are the academic treatises on quality but we can summarise quality to its core essence—safety and effectiveness.

This new strategic direction should be health professional led. A health system that makes key decisions without engaging its considerable intellectual human capital (as well as its wealth of practical experience) is destined to make decisions that fall well short of standards of quality and cost effectiveness. Those that invented and then fully utilised the aspirin have made a far greater contribution to the quality and cost effectiveness of health systems than corporate policy wonks, bureaucrats and politicians. The same could be said for day surgery.

In October 2005 the ASMS, through the Council of Trade Unions, presented a paper to the incoming Minister on what we have called a health professional led approach which endeavours to capture what I have described. It draws upon some local New Zealand initiatives, the most noteworthy being the Cancer Control Strategy, and also the comprehensive clinician taskforce led approach for metropolitan New South Wales acute services. The Minister has described it as a gift but he does not know what to do with it. After having it for over eight months unwrapping the gift would be a good starting point. One can visualise the Hodgson home being full of unopened Christmas presents.

Generative Culture

We have advocated a comprehensive approach to chronic illnesses, electives and acutes in terms of how best to plan, organise, deliver and resource them both within and between DHBs, including regional and national coordination. It is underpinned by the need to have what is called in the literature a generative culture.

Professionalism is the basis of the generative culture and is the opposite of the top-down bureaucratic cultures that generally prevail. It provides the basis for bridging the gap between macro intent and micro performance. The key issue is one of a working relationship of trust and confidence in which health professionals are actively engaged and empowered in the engine-room of decision-making that goes beyond the level of rhetoric and reactively responding to immediate imperatives. Health professionals are the most critical resource, strategically and by location, but also the most untapped resource that the health system has available to it. They do not need to be motivated; they do not require crude incentives such as performance bonuses. Their motivation and the benefits that flow from it comes from being allowed to do what their professionalism drives them to want to do.

Workforce Challenges

Our health professional led approach underpinned by a generative rather than managerialism culture, also offers us an opportunity to rigorously address workforce challenges and the dilemma we face. At a micro level by having more services directly provided in our public hospitals by senior doctors and dentists and, in a pragmatic manner, enhancing the role of nurses and other health professionals, the need for the current level of RMOs in a number of DHBs might be considerably less than what it presently is. This is a legitimate discussion point although over hyped by the RMO strike experience. However, if we employ less we train less. Training less RMOs poses serious future workforce risks at a macro level.

Adapting our health professional led approach would better enable us to assess what sort of medical and dental workforce we might need in five and ten years time, including what one might reasonably expect senior doctors, dentists and other health professionals to do. Once we have undertaken this assessment which will include how our public hospitals are organised, we can better plan what sort of and how many RMOs we need to train and what procedures they should be doing as part of their training.

Inadequate Government Response

But, while describing our initiative as a gift, the Minister has not grasped its essence. To date, his approach and behaviour has supported the prevailing culture which can best be described as a managerialism hybrid with lots of bits of this and bits of that. The government appears more influenced by the wish to control bad news stories and responding to immediate imperatives and pressure points. The approach to first specialist assessments and waiting lists appears more influenced by political convenience rather than addressing the underlying problem of access (one hopes that this latest initiative announced earlier this week does not fall within this mould). At a certain point intellectual repartee risks becoming platitude.

A National Treasure

The government needs to adopt a more positive attitude towards our publicly provided secondary and tertiary health services by regarding them as a national treasure. Our public hospitals constitute an impressive system which deals with those complex and interconnected cases that cannot be dealt with in a primary care setting. What is done in primary and secondary care settings has not been and will not be static; it will naturally and sensibly evolve over time. But both settings are critical.

Publicly provided secondary services are effective, of high quality and the public has considerable confidence in what our health professionals do. They have the advantage of an absence of self-interest and commercial or profit motivations that have the potential to distort, corrupt and create perverse incentives. And they have their own internal in-built efficiencies. Just as GPs provide an effective external gate-keeping role which also includes fiscal responsibility, outpatient clinics provide an equally effective internal gate-keeping role. To the extent that the governing parameters and the culture of managerialism allow, it is difficult to find a more efficient and effective part of the health system.

Public anxiety about public hospitals is not over their standards of care but over the separate issue of access. Public hospitals provide comfort, reassurance and effective care for patients. I believe that the public itself regards public hospitals with sufficient affection and respect as one would expect of a national treasure and it is time that the government caught up with the electorate. It needs to give the same strategic importance to secondary care as it does to primary care.

Relationship with Government

The attitude and behaviour of the government is challenging the Association. In an undefined kind of way we had thought that we had a relationship with government that meant something. This was not based on political partisanship but rather a sense that we had broadly similar policy objectives about the direction of our health system including the importance of a publicly provided health system.

This did not mean that we have been uncritical of this government. In 2001 our National Executive adopted a motion of no confidence in the Budget for its cost cutting in public hospitals and I have had more than my quota of angry phone calls from a seething former health minister over things I have said.

But overall, albeit in part subconsciously, when one has what one thinks is a useful or collaborative relationship, no matter how ill defined, it shapes and softens the tone of your assessment and critique of government performance. The ASMS may have been lulled a little into a sense of seeing the relationship as being the basis of our influence with government when we should have seen it the other way around. We thought that we had shared policy directions but differed at times over execution.

In the 1990s the ASMS had a high profile as a strong public advocate of the integrity of our health system and was very critical of the market experiment. Although rough at times that gave us a level of respect and influence that we would not otherwise have had. The National government acknowledged this, albeit privately and begrudgingly, while the Labour opposition was all over us like a rash lapping up everything we said.

The government’s handling of health, and particularly the Minister in recent months, suggests that what we thought was a relationship never in fact existed; we have not even been a bit on the side! However, our response to this should not be to throw our toys out of the sandpit and engage in name calling or sloganising. Instead we need to learn from this and redefine our approach to government. We also must recognise that this government is capable of being seduced by the strategically focussed private health insurance industry which is cleverly endeavouring to portray itself as part of the solution and embellishing the significance and capacity of the public-private sector interface.

We must recognise that not only are the differences with government over execution more significant than we previously considered, but also that contrary to what we thought we do not have a broadly shared policy direction with this government, at least over secondary and tertiary care.

In my opinion the ASMS needs to more sharply and assertively emphasise our public advocacy role including promoting the advantages and importance of publicly provided services and that our public hospitals should be recognised for the national treasure that they are. In part, this would involve picking up some of the role of the former Coalition of Public Health. This will involve being more critical and direct than previously where government actions (and those of opposition parties) fail to measure up. We should do this alongside our kindred organisations such as the NZNO. We are probably the only medical and dental organisation able to do this. Most of dentistry is in primary rather than secondary care and therefore privately provided which probably rules out the Dental Association. The NZMA’s deafening silence over hospital laboratories suggests a lack of empathy with our direction and more of a private sector orientation.

By redefining our direction and approach we may be better placed as assertive and constructive advocates and critics to strengthen our influence. This then might become the basis for a new more substantial relationship with this government and the next one.

Everything about the Minister’s handling of his portfolio suggests that he has not grasped the essence of our health professional led approach, in particular the importance of a substantial cultural shift within DHBs. Instead he seems more comfortable with the current approach based on political, bureaucratic and managerial elites. It may be that he relegates the health professional led approach to a series of projects. While these might be generated by political expediency and immediate imperatives we should nevertheless not refuse to engage over them if they can produce tangible benefits. But we should be realistic about what we are involved in and not exaggerate its significance.

The government and the Minister are in serious trouble in health. Some of it is due to own goals scored and policy U-turn since the last election. But the AC Neilson poll before the last election is revealing. While the previous Minister may have kept bad news away from the headlines she did not make them go away. They bubbled away and the pot is now boiling over. In many respects Annette’s chickens have come home to roost on Pete’s post.

If the government and the Minister genuinely want to turn things around they must first recognise the seriousness of the problem and the perniciousness of the managerialism culture. They must turn this round in DHBs, in the Ministry and by their own behaviour. It is noteworthy that we have a new Director-General, an excellent choice, but he won’t turn the Ministry’s own unilateralism around overnight (we might give him a week!). The government needs to provide the lead by driving through the development of a generative culture the basis of which is our health professional led approach. It is only by this cultural change that effective and sustainable improvements will be delivered. This needs to be the Minister’s prime challenge.

Bring on Dumas Junior

I mentioned earlier my desire to read more novels. Another experience of relevance to this address was when I went to my local publicly provided library (thank goodness this government hasn’t privatised our libraries but perhaps I shouldn’t give it ideas) to look for novels by the famous French author Alexandre Dumas. Without looking too closely I selected one, The Lady of the Camellias, only to discover that it was written by his son. Further, the comments on the book jacket said that junior had written several previous novels but they were unreadable. However, despite this unpromising introduction I was pleasantly surprised. I was also struck by the following passage which in its own exquisite and precise way suggests the vision that a health professional led approach based on a generative culture in our health system can offer:

Doubtless it must seem a bold thing to attempt to deduce the grand results out of the meagre subject I deal with; but I am one of those who believe that all is in little. The child is small, and he includes the man; the brain is narrow, and it harbours thought; the eye is but a point, and it covers leagues.

The little, the child, the brain and the eye are health professionals. Dumas junior may not have been a successful novelist but perhaps he might have been an insightful and successful health minister? He might have been well placed to engineer the transition from a state of disgruntlement to a state of gruntlement in which we are all happily gruntled off.

Ends