Public health needs break from surgery

By VICKI JAYNE

What the public health sector most needs if it is to stop haemorrhaging talent and money is a few years in recovery position.

It's barely sitting up after one major restructuring operation when it's hauled back into the political theatre for another.

The problem for those running the system is that there's not enough time to check what, if any, improvements were delivered by one op before the next starts. Meanwhile, those closest to the patient are increasingly frustrated they're not consulted as to best treatment.

The general feeling amongst senior health managers is that each major restructure kills innovation for a year - and innovation, says outgoing Counties Manukau District Health Board CEO David Clarke, is what improves performance.

"If improved performance is the aim, then structural change alone won't do it," he says.

"And if, as is the case in public health, some of those changes have happened for political reasons and don't add any value in terms of delivering better healthcare, then they're very hard to justify to those working at the coalface - the nurses and doctors."

Since health reforms started in the late 1980s, there have been whole tsunamis of restructuring, each bringing new acronyms and ideology, changes to financing systems, reporting requirements, language and letterheads.

Corporate governance muscled aside clinical governance and a three-tier split between health funders, purchasers and providers was designed to introduce more competition. Managed Crown Health Enterprises replaced old elected area health boards. The CHEs were initially charged with making profits, until that proved too much even for imported private sector managers.

The 23 CHEs later morphed into 22 hospital and health services, and funding allocation was shifted from regional health authorities (RHAs) to one central Health Funding Authority (HFA).

Then the Government changed and district health boards and regional funding returned.

Now Auckland DHB is undergoing its own major restructure as it tries to shove more services under fewer roofs, and comes under Government pressure to reduce a deficit approaching $70 million.

The changes have gobbled up money, energy and goodwill.

One executive's lament that there has been "too much restructuring, too much pain" is echoed in wards and boardrooms - even in streets when discontent spills over into strike action.

Absolutely, there is change fatigue, says one senior figure whose ensuing comments about the "unprecedented" levels of political interference in the health sector help explain a decided reluctance to talk on the record.

For many managers, this is crash-and-burn territory. Caught between competing demands for more health services and a requirement to reduce delivery costs, some are admitting defeat.

Managers, says one, are put in an "extraordinarily difficult" situation.

They want to maintain quality and expand services but the money that's coming in doesn't even meet the increased cost of existing services - especially where the population base is growing.

Neither does management have access to the sort of controls available in the private sector where, if something is losing money, you either increase its cost or eliminate it.

Instead, there's a clamour to spend up large on the latest, best and usually more expensive drugs or procedures.

As one manager puts it, New Zealand wants a first-world health system on third-world funding, and nobody's prepared to tell the political leaders this isn't possible.

The stress cracks are becoming particularly evident in Auckland, where planned new services are under threat and changes are again being dictated from the top down.

Senior clinicians from National Women's Hospital wrote in a letter to the district health board late last year that they'd expected consultation to be open and meaningful, rather than the "application of a veneer to what appeared to be a predetermined plan".

The worry is that those determining the new structure don't have a good understanding of the business and the nature of the roles they are changing. The fear is that more good people will be driven out of already under-resourced services.

A focus on structural change is also diverting attention from the sector's real target of delivering safe, quality healthcare at the lowest possible cost, says Jane Holden, former CEO of Hutt Valley Health and now head of the Royal New Zealand Foundation for the Blind.

"Health still seems to be looking for messiahs - someone with the big answers," she says. "I think there's probably 1000 ways to skin the cat. What we need is stickability to one approach, and allow good practice to bed down."

She says change is not a threat if people see it as "a better place to go".

But a system constantly in turmoil doesn't allow space for creative thought.

There would, she says, be "huge returns" if front-line staff could just stop and think for half a day every so often.

David Clarke believes the latest restructure does at least represent a better place. That's because the move to make district health boards accountable for community "wellness" along with population-based funding, provides the necessary incentives for performance improvement.

Any further restructuring, he says, would be counterproductive for three reasons.

"It's too expensive, we can't afford to lose another year, and we need to bed in these structural changes and incentives."

* vjayne@iconz.co.nz