Diagnosing ills in health sector

By VICKI JAYNE

After more than a decade of reconstructive surgery, health sector management is looking sicker than ever in some quarters.

As Auckland's health administration went back under the knife last year, senior medical staff from major hospitals openly questioned management judgment. They believed proposed restructuring would jeopardise patient safety.

Last week, clinical leaders at Auckland hospitals were again up in arms at news that more cuts are needed.

A similar clash between clinical and managerial roles is plaguing Canterbury Health.

Such flashpoints highlight an underlying divide. Doctors and nurses want what is best for individual patients; management is more focused on organisational - and financial - priorities.

That can be a problem if managers and clinicians end up talking past each other on touchy issues such as resource allocation, says Jane Bryson, senior lecturer at Victoria University's school of business and public management.

Her doctorate and subsequent research have focused on this ethical divide and its potential to breed conflict.

"Doctors end up caught between the needs of patient and manager, managers between the needs of employees and funding agencies."

She believes failure to recognise and support the value of these different perspectives in health workplaces will "hinder the long-term development and improvement of health organisations".

Ian Powell, who heads the Association of Salaried Medical Specialists, says the problem is that management thinks it has all the answers when it comes to decision-making.

"While they may talk to [clinical] staff from time to time, there's a lack of clinical empowerment or democracy in the way policies are driven."

Because there is no structure to bed in clinician input, Powell says their involvement in policy- and decision-making depends on the beneficence of management - which varies from one organisation to another.

The shift in power between the two professional groups has been a prickly issue since health reforms in the 1980s introduced a more corporate model of governance into the health sector.

In came managers from the private sector, many with a strong focus on finance and processes and little feeling for how the industry operated on the hospital floor.

"I think we got a bit seduced by management hype from the private sector in the early 90s," says Waitemata Health chief executive Dwayne Crombie.

"It's good we had some of it. Certainly we can count and cost things better. But some of [that management] was far too financially focused.

"The biggest issues still facing our sector are around safety and quality. Those are critical; the budget will always be under pressure."

As a doctor turned manager via specialisation in public health practice and an MBA, Crombie has personal experience of both perspectives. He says his early medical training tended to encourage tunnel vision.

"Doctors have a high degree of autonomy and a focus on individual benefits, which contrasts with management need to see the bigger picture and develop the arts of advocacy, coalition and negotiation."

Managers, on the other hand, can get too bound up in political directions, policies and processes, and fail to cut to the chase in terms of service delivery, says Crombie.

"You have to get [clinicians] looking up from individuals to communities of interest and managers coming down from all this process and policy to what are the practical needs.

"When you get them in the same room talking, there's a surprising degree of commonality. Both want to deliver the best possible service without wasting money."

Jane Holden had similar experiences as chief executive of Hutt Valley Health.

The former nurse, who had stints as head of both West Coast Health and Hutt Valley, now heads the Royal NZ Foundation for the Blind.

"For me the biggest thing in working well with clinicians was a decision to share all the information - so there is not the feeling that managers are making decisions in the dark," she says.

"There may still be a feeling managers are not making the right decisions, but everyone understood all the parameters that had to be taken into account."

At Hutt, clinical teams played an advisory role for managers and their greater involvement in decision-making helped them understand management limitations, says Holden.

"The idea was they think not only about the benefits for a particular patient, but the patient 20 along if this is the total budget they have."

Relations at Hutt Health were not good when she arrived and her approach to contentious financial issues was to shelve stalled discussions.

"I said I didn't want to talk money. They'd been doing it for four years and it hadn't gone anywhere."

Instead she focused on improving clinical practice in areas where money can be wasted - getting diagnoses correct, providing the right treatment first up and discharging at the right time.

She found coming from a clinical background helpful, but warns that managers have to leave any clinical bias behind when they do.

This is probably why some who have made the shift get flak from former colleagues for being turncoats - and from higher powers for not toeing the policy line.

"They can become the meat in the sandwich and get burnt out," says Powell.

The latest initiative, says Bryson, is a system of clinical governance where management teams have a mix of both clinical and managerial expertise. Crombie seeks just such a mix in Waitemata Health's administration and believes there is cause for optimism in a more partnered approach.

Perhaps a more pressing management problem is that health has served as a political football to successive governments for so long that it has seriously lost its ability to bounce out of confrontational scrums.

More on that next week.

* E-mail Vicki Jayne

* More than 100 people raced to the postbox to pitch for copies of the book Management Gurus and Management Fashions, featured last week. The lucky five are: Rowan Johnston, Auckland; Fui Teivale, Tangaroa College, Otara; Leonora Pebody, Kerikeri; R. Gamble, Glenfield; Kaaren Smylie, Tauranga.