Is the consequence of the Simpson Report proposals for restructuring the health system poorer accountability to people?

When in doubt, centralise‘ has been a persistent theme in New Zealand public policy throughout our history. The current government is no exception. Here are some examples.

- The regional polytechs have been merged into a single mega-polytech, New Zealand Institute of Skills and Technology.

- The proposed changes to the State Sector Act (to be called the Public Service Act) consolidate the power of the State Services Commission.

- The Minister of Maori Affairs proposes to amalgamate all the diverse Maori news media into a single entity, an extraordinary move since a basic principle of media in a democracy is competition rather than monopoly.

And now the Health and Disability System Review (the Simpson Report) proposes to further centralise the health system by, among other things, fully appointing all the members of the District Health Board (DHB) governing boards.

Such is the complexity of health care, any design of a health system is fraught with difficulties and involves compromises. Let’s go back to basics starting with patients. (The report calls them ‘consumers’, an indication of how persistent the framework of commercialisation is in New Zealand.)

Patients want high quality care with adequate resources. They do not want interference from the state in the treatment.

However, there are two caveats. If something goes wrong, the patient, or their family, want someone or the system to be held to account. I’ll come back to this, but here mention that I could find only one reference in the Simpson Report to the Health and Disability Commissioner in endnote 144 on page 257 – which indicates how little attention the report gave to the issue.

The second exception is that patients generally expect the state to fund treatment. The public cost of the health and disability system is huge and, understandably, the state is anxious that those funds are used effectively. Historically our hospitals were locally funded which led to their governing boards being locally elected. The current system of part locally-elected and part centrally-appointed boards is a compromise between history and fiscal imperatives.

The Simpson Report proposes that the elected representatives be eliminated and the centrally appointed boards be totally accountable to the government. You might say ‘they would, wouldn’t they?’; the more political of you may observe the increased power of the patronage.

Personally, I am not unsympathetic to the state wanting to hold the boards accountable for the resources they are provided with. As long as they stay out of treating the patients.

But the business culture of those on the boards is quite different from the professional culture of the health carers. Sometimes the two cultures clash.

This is well-illustrated by the conflict between the management and the professionals in Canterbury in the mid-1990s. The Health and Disability Commissioner, Robyn Stent, reported that ‘unnecessary deaths occurred’ and thought ‘it was a miracle that more people did not die’. Insofar there was a human angels it was the health professionals not the hospital managers. Why did we have to wait until those deaths before there was an investigation and action was taken? (There are other examples but this is one the best documented.)

The Simpson Report gave attention to the accountability of Minister of Health. In principle he or she is subject to public scrutiny in parliament and by the media. One is not greatly impressed by the parliamentary record. (Sometimes it is not unreasonable to think of ‘MP’ being pronounced ‘wimp’.) Often the issue is converted into a party political dispute with little real interest in the underlying issues. Journalists do better, but good specialist health reporters are a dying breed.

Accountability at the centre tends to be reactive to failure rather than the pursuit of continuous improvement with the prevention of failure before it occurs. That concern is hardly a focus of the Simpson Report, and yet it is surely critical in the design of the health system.

Charging the appointed boards with this responsibility cuts across their governance role. Their accountability is up to the minister. They are noyt accountable to the general population.

Once upon a time, hospitals had ‘hospital visitors’ to whom one could take one’s grumbles. Electing locals to the governance board did not work because the accountability-down function (from the centre) is quite different from the accountability-up to the people – the patients and potential patients. It is not at all surprising that many good people elected to the DHB boards stayed for only one term after finding that they had little influence.

Instead, there needs to be a separate accountability system. One way would be an elected committee whose responsibilities specifically exclude governance functions but instead focussing on monitoring the quality of care. The lay people would be elected on the basis of local electorates, perhaps the wards in the territorial authority (thereby avoiding the current farce where individuals are elected on a region-wide basis and have little connection with their electors).

Perhaps there should also be some members of the committee elected by the professional staff for this should be a cooperative exercise concerned with quality, not an antagonistic one – a` bit like how the patient-professional relationship should be.

I would expect that the elected lay members would deal with grievances and grumbles. But no doubt patterns of systemic failure would become evident and improvements would be triggered – more or less continuously.

This is just a suggestion. The key issue in this column, is that we do not need centralisation without adequate accountabilities.

An earlier column, ‘Reorganising the Governance of DHBs’, elaborates some aspects of this argument. I shall write another column on the number and structure of District Health Boards.

This column was drafted before David Clark stood down from minister. The advise to the income minister is not to make any decisions before there has been genuine public consultation and to indicate to the ministry that the government is open minded so it should be considering a wide range of options.