A London friend ended up in his local hospital with one of those multiple medical conditions. (He went home on over a dozen different medications.) Because his support group was scattered around Britain, there was nobody there when some of the care went badly wrong. (Sadly the British government has so run down the National Health Service that, stretched for resources and experienced staff, medical misadventures occur too frequently.)

Instead, Tony contacted his local (territorial) councillor who acted on his behalf. (The territorial council is responsible for the hospitals.) I was impressed how well she did.

This incident came to mind when I was voting for my local district health board. It was not just that I was asked to rank 23 candidates, most of whom I had never heard of. I had not the foggiest idea what job they were expected to do. From their electioneering blurbs, neither did they. (As an aside, STV, which I support, works best when you have to choose a few people; having to choose seven is ridiculous.)

The origin of the election of local representatives goes back to the founding of charitable hospitals in the nineteenth century. They were funded by local efforts – donations and fees and, later, local rates. Over the years, that local funding was replaced by funding from central government, which understandably wants to make the appointments to the governance board to run the hospitals it was funding. However, we continue to elect some local representatives.

We do so in the name of ‘democracy’ but that is just a slogan. What exactly it means is unclear. How do we want the hospital to address particular local issues? Surely we want our local hospital to do much the same things as any other hospital in the land. Suppose we want a change in policy, say, better scanners. Then it makes sense to press the central government, including the Minister of Health. After all, the associated funding has to come from the government

In fact, studies have shown that there is little democratic input into the DHBs despite the election of representatives. Anecdotally, I’ve had friends who got elected to governance boards and lasted only one term because they found they had so little effect. (You might ponder, then, on those who keep coming back for re-election; perhaps they like the status and the salary.)

The New Zealand Health and Disability System Review said ‘the Panel has not formed a definite view on whether DHB elections are an effective or an essential way of achieving … effective avenues for [communities] guiding the direction of health service planning and delivery.’

Stimulated by Tony’s friend from the local London council, let me suggest a different approach. Some of us need public support when things are not going well when we are in hospital. I have never heard anyone elected to a governance board providing that. Let’s go back to basics and see if we can do better.

Observe the hierarchy in the way hospitals are organised. It goes something like:

            Patients

            Professional medical staff

            Managers

            Governance board.

You may feel a little uncomfortable with this ranking, because it is usual to put the board and managers at the top and patients at the bottom. I am for patient-centred hospitals, not management-centred ones.

Mind you, end up as a patient in a hospital and you are pretty powerless. Yes, the doctors and nurses will attempt to provide adequate care and informed consent but, as Tony found, with the best intentions, sometimes things get out of hand; rotating staff seems to be a common problem.

The medical professionals are generally treasures doing their best to work in your interests. Sure, they have an element of self-interest, but far less than the hospital managers. However, there are many aspects of a hospital that the professionals are neither competent to run, nor even interested in running. For instance, they expect the building to be properly managed. And they are not very good at allocating the limited resources among the different medical activities.

That is where the managers come in – managing the resources. But keep them out of medical decisions. Typically they do not deal with individual patients, but I know of a number of instances where managers took decisions with insufficient attention to the medical advice; patients died.

The function of the boards is the governance one – to ensure the managers are under some sort of control and that they do not get carried away with their self-importance – to hold them to account. (Medical professionals are held to account by their professional bodies and the Health and Disability Commissioner.)

Sounds all very logical, except that by the time you get to the governance board, patients are almost forgotten. What is additionally needed is some place in the system which independently represents patients and the community’s wider health perspective; locally elected persons on the governance boards hardly do this.

So I suggest we introduce another layer in the system. The body of community representatives would consist of locally elected members who would represent the community’s wider perspectives and act on behalf of patients who were in difficulties – analogous to Tony’s council friend. You would elect one for each ward – say a dozen for Capital-Coast’s region, so each of us would have to vote for only one candidate. The voters would be far better informed and it would be meaningful: who do you want to approach if there is a foul-up while you are in hospital? They would be kind of MPs, representing you when an institution fails you.

As well as dealing with individual complaints and working where they can with GPS, the members of the new body would meet regularly. To give it leverage, it would elect three, say, of its members to the full governance board. I would have the professional staff also elect three members

I shall ignore the objections of the neoliberals to such an arrangement; after all they would prefer hospitals to be run as capitalist enterprises. Businesses would be uneasy because it would, in effect, be putting consumers and workers on the board. However, hospitals are not businesses and only partially run on business lines. For instance, competition is lacking; the consumers – the patients – do not have much choice. You go to your local hospital or you die. Nor do managers have much professional medical or patient knowledge; their governance body needs to tap into that.

I would expect the governance boards to be dominated by government appointees selected for their governance skills. But the court would, on occasions, go to the government with its health concerns. (There have been some very uneasy cases in recent years at some DHBs, which the central government got involved far too late, suggesting the governance system has not been working properly; the recent goings on at the Waikato DHB have been just dreadful.)

Where does the Health and Disability Commissioner fit in? He or she gets involved when there has been a system failure so catastrophic that there is a death or substantial damage. That did not happen to my London friend, because of the intervention of his local councillor. I am in favour of dealing with crises as early as possible, instead of waiting for a coroner.