Health Leadership Control Culture Threatens Mental Health Services (and Beyond)

Tuesday, 12 September 2023, 6:28 am
Opinion: Ian Powell

Thank goodness for investigative journalism. As Aotearoa New Zealand’s health system becomes less and less transparent, the work of investigative journalists becomes more and more important.

This is especially so when it provides voice to those who know what is really going on but don’t feel safe saying so.

A case in point is Alex Spence who is a senior investigative journalist for the New Zealand Herald. Previously he spent 17 years in London, including working for the Times.

On 3 September Spence had published a powerful article on dubious plans by Health New Zealand (Te Whatu Ora) to overturn community mental health services in the greater Wellington area (Wellington, Hutt Valley, Porirua, Wairarapa and Kāpiti): We don’t need this bullshit say exhausted mental health staff.

The “bull***t”

Spence reports the “backlash” from psychiatrists, psychologists, nurses and social workers in this busy service who believe that these managerial planned reforms could put more pressure on an overwhelmed and increasingly unsafe public system.

The plans include dismantling the region’s central triage and crisis response teams as part of a wider restructuring (ridiculously part of which is reduced staffing). But they fail to solve what these directly affected health professionals assess to be:

… their most pressing issue — a desperate shortage of skilled and experienced clinicians able to support patients with severe mental illnesses.

Spence reports that these expert health professionals warn that the ‘reforms’:

…could worsen staffing pressures by pushing already overworked and stressed-out clinicians to leave or reduce their hours. Staff turnover in the service is already unsustainably high.

Like similar mental health services throughout Aotearoa, this specialist service has suffered from years of poor planning, underfunding and understaffing.

This has occurred at a time when increasing “…numbers of people are seeking help for severe and complex psychiatric conditions and acute mental distress.”

No wonder that one of the affected health professionals graphically declares to Spence “We don’t need this bull***t. We just need to be resourced to do our jobs.”

Spence reports the severity of the effects of shortages and under-resourcing. These include excessive workloads, inability to support extremely vulnerable patients, unsafe conditions for patients and staff, and staff illness. Attempts to resolve these with Te Whatu Ora were unsuccessful.

Instead the new health bureaucracy has proposed a plan that both ignores and increases this severity.

Mushing half an apple

Sarah Dalton, Executive Director of the Association of Salaried Medical Specialists (ASMS), gets it right with her reported responses:

Instead of [health authorities] saying, ‘We know that we’re really short-staffed so we’re going to have to look at what services we can safely limit or how we manage this’, they go, ‘Let’s just do a service review or a model of care review.’

Which, in really crude terms, is [like saying], ‘We need a whole apple, we’ve only got half an apple, let’s try chopping it up in a different way and laying it out, and could that then turn into a whole apple?’ It’s never going to turn into a whole apple. It’s just a monstered half-apple that’s now mush.

This is well put reinforced by her apple and half-apple analogy. I would only add that the half apple starts with a rotten core which survives as an expanded part of the ‘monstered mush’.

Employment obligations disregarded

A final decision on management’s plan is expected to be made in October. But there is something Te Whatu Ora appears not to have appreciated; its consultation and engagement obligations to its employees.

The strongest of these can be found in the national collective agreement negotiated by ASMS and covering senior doctors, including psychiatrists, employed by Health New Zealand. For context, it begins with a strong statement on employee wellbeing:

The parties acknowledge that employee well-being is important and may impact on the efficient and effective delivery of health services, patients’ treatment outcomes, patient safety, employees’ ability to meet the accepted professional standards of patient care and employees’ clinical practices.

Accordingly, pursuant to the Health and Safety at Work Act 2015, the employer and the employee agree to take reasonable steps to protect employees against harm to their health, safety, and welfare by eliminating or minimising risks arising from work and to promote employees’ well-being.

Then, more specifically (Clause 2), it clarifies the relationship between senior doctors and managers in matters to do with service design, configuration and service delivery:

Managers will support employees to provide leadership in service design, configuration and best practice service delivery.

There is no ambiguity. The planned restructuring of mental health services in the wider Wellington region come clearly within service design, configuration and delivery. There is also a ‘best practice’ threshold which psychiatrists rather than managers know best.

In other words, management’s role is not to lead but to support psychiatrists in a leadership role (along with their psychologist, nursing and social worker colleagues).

There are other obligations but the most standout relevant to this issue is Clause 43.3:

Before the employer undertakes any review which might impact on the delivery or quality of clinical services, it shall consult and seek the endorsement of the Association as to the purpose, extent, process and terms of reference of such review and will give due regard to the Association’s advice.

It is blatantly obvious that this has not happened in any substantive manner, if not even technically. There is a reason for this clause and the others discussed above in the collective agreement (I should know, I was the advocate).

Time to end control culture

Unless proposed changes to how health services are designed, configured and delivered are proactively health professional led they are almost certain to not only fail but also lead to poorer outcomes for patients.

The application of Te Whatu Ora’s top-down control culture is not confined to community mental health in the greater Wellington region.

Nor is it confined to mental health. It is embedded in the design of Te Whatu Ora and applies across all health services.

This control culture is the greatest obstacle to its ability to resolve the growing threats and challenges to the health system.

Te Whatu Ora needs to realise this and recognise its control culture is harmful for patients and harmful to the health professionals it employs.

The leadership for this culture shift should be insisted upon by Health New Zealand’s board led by its Chair, Dr Karen Poutasi. It is not time to do it; its overdue.

© Scoop Media

Ian Powell

Otaihanga Second Opinion is a regular health systems blog in New Zealand.

Ian Powell is the editor of the health systems blog 'Otaihanga Second Opinion.' He is also a columnist for New Zealand Doctor, occasional columnist for the Sunday Star Times, and contributor to the Victoria University hosted Democracy Project. For over 30 years , until December 2019, he was the Executive Director of Association of Salaried Medical Specialists, the union representing senior doctors and dentists in New Zealand.

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