No Pressure Dr Reti But Starting On The Right Foot Is Critical

Tuesday, 7 November 2023, 7:32 pm
Opinion: Ian Powell

With the final election count now confirmed it is clear that Aotearoa New Zealand will soon be governed by a National-ACT-NZ First coalition.

Further, not that there was any prior doubt, Dr Shane Reti (a general practitioner) will be the next minister of health (this is as close to certainty as can be).

Arguably Dr Reti has more experience, including as a GP and district health board (DHB) member,  in the health system than any other member of the new Parliament, including outgoing health minister Dr Ayesha Verrall.

Amusingly, in the 2010s, Dr Reti was appointed by three Labour health ministers in the 2000s as a member of Northland DHB; a tribute to both those ministers and him.

This makes Shane Reti well-placed to make a difference for the better for New Zealand’s health system. However, it is not as simple as that. It is about ensuring that the health system has both the right capacity and culture in order to enable the right capabilities to be unleashed.

One has to go back to the Labour Party’s Annette King (1999-2005) to find a health minister who inherited a health system in such a state of crisis, albeit it for different reasons (ideological in the former and elitist incompetence in the latter).

I have discussed how New Zealand’s health system evolved into what it is now and how it might get of this current crisis in two addresses last August to the Australian and New Zealand Oral Maxillo-Facial Surgeons (NZ Committee).

They were elaborated in two separate Otaihanga Second Opinion posts (17 August and 27 September): Evolution of New Zealand health system and Getting out of the crap.   

Urgent priorities – workforce and culture

There are two urgent issues that Dr Reti will need to get immediate traction on if he is to succeed.

The first is the continuing widespread severe workforce shortages across all health professional groups (community and hospital and each with their own labour market) while the second is culture. The former is about capacity and the latter about enabling and enhancing capabilities.

I discussed this recently (1 November) in my ‘perspective column (paywalled) published by Stuff (including The Post): Two urgent things for the next health minister to resolve.

On workforce I observed that the severe shortages across all health professional groups in both hospital and community based care:

…are crippling our health system and harming the health of this workforce. Their severity is worsening by rising acute hospital admissions increasing at a higher rate than population growth.

We need a mindset shift from seeing the workforce as a cost liability to an investment in both the health of the population and economic performance.

What is required is effective workforce planning and development backed up by targeted practical action plans focusing on the here-and-now.

On culture I observed the further centralising, by verticalising, due to the massive restructuring of the health system.

This had led to the emergence of a negative ‘command and control’ leadership and operating culture, either by design or default (or both).

To begin to turn this around Dr Reti needs to incorporate into the Pae Ora Act 2022 purpose clause two “e” words – empowerment and engagement. They needed to be applied in practice to where healthcare is overwhelmingly provided (local) and with its health professional workforce.

I concluded with the following:

Virtually all of healthcare is determined by these two challenges [workforce and culture]. They are the foundation for both the rescue of our crisis-ridden health system and the opportunity to make it world-leading.

Avoiding slip between cup and lips

The indications are that the heir apparent minister gets this. This is encouraging but there is much that could be slip between cup and lips. Perhaps an ancient Greek philosopher might have something to offer.

The first indication of whether there will be spillage from Reti’s worthy cup and lips is what he does with the government appointed board of Health New Zealand (Te Whatu Ora) that he will inherit.

If he continues with the current board then it is most likely that it will continue with its senior management team. That is, no change; business as normal.

If he significantly changes the board then it almost certainly means that there will be changes in its senior management team.

At this point one has to be careful and respectful. The health system is in a state of chaotic crisis (carnage is what it often feels like to those at the clinical frontline).

Where does accountability for current crisis rest

But who should be held accountable for this – those who designed the restructured health system or those charged with implementing it? In my view it is the former (the Labour government and the business consultants it preferred to get its advice from).

Te Whatu Ora’s management at times has not helped by their own actions. However, it was not responsible for the mess it inherited on 1 July 2022. It was placed in an invidious and  poorly defined position.

Unfortunately the scale of the restructuring, the lack of engagement over whether it was justified, and the marginalising of those with experience of how health systems work, meant those with this experience and expertise were devalued.

Most former DHB chief executives are outside the new health structures. Further, many of those with expertise in managing hospitals, in particular, have also gone elsewhere. Too many capable people (not all) who know health systems work have been lost.

What Shane Reti should do

What Health New Zealand needs at a leadership level (both board and management) are those who understand the criticality of both workforce capacity, as the main driver of systems improvement and innovation, and the capabilities that a governance and operational culture of empowerment and engagement.

I have discussed in a fuller context how to get our health system culture right in an earlier post of Otaihanga Second Opinion (20 September): Getting health system culture right.  

Consequently Dr Reti needs in the first instance to appoint a new board with these attributes tasked with the responsibility of embedding them within management.

Given the seriousness of the vulnerability of the health system and the consequential risks to patients, he would also be wise to make the head of the board an executive chair, at least for an interim period, to ensure that visible steady progress is made.

It has to be remembered that the health system was in a dire situation before 2017. The Labour  government made an existing mess worse.

There is simply no sense in Dr Reti replacing the advice of those responsible for making the mess worse with those (or those of their ilk) who were responsible for making the mess in the first place.

The latter includes those who believe the health system can be improved by the use of financial levers and incentives. They are simply wrong.

Health systems improve through continuous quality improvement from a stable workforce with the right capacity working within a valuing culture of empowerment and engagement.

No pressure Dr Reti. Just saying!

© 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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