How To Immobilise A Health System’s Primary Statutory Adviser And Monitor

Thursday, 11 April 2024, 9:15 am
Opinion: Ian Powell

It is easy to not understand what a ministry of health does in health systems; why they exist. This is because much of its work is invisible to most.

At the very least, it is below the radar. This certainly applies to the Ministry of Health in Aotearoa New Zealand’s health system [it has to acknowledged nevertheless that at times its leadership culture has not helped].

Consequently the Ministry is vulnerable to coming under attack from a government driven by political agendas and whose line of attack is delivered by erroneous or deliberately misleading soundbites rather than analysis.

The Ministry has become an institutional scapegoat of political convenience.

This vulnerability is compounded by the fact that, as a public service, the health ministry can’t defend itself although it has to be recognised that the main union, the Public Service Association, is presently doing a very good job.

Scorching the health ministry

The vulnerability was highlighted when the fireball of the right-wing, and somewhat dystopian, National-led government cuts to public service staffing scorched the health ministry on 4 April.

I discussed the wider issues of these public service cuts in my other blog, Political Bytes (1 April): Function versus form.       

While the public service cuts overall were supposed to range from 6.5% to 7.5%, the announced slashing of 134 health ministry jobs represented a much higher 18% cut.

The implementation of these headcount based cuts confirm that the government is putting form before function when it should be the other way around.

It also perpetuates the demonisation and devaluing of the so-called ‘back office’ in relation to the ‘frontline’.

In my above-mentioned Political Bytes blog I outlined how this demonisation and devaluing was imposed on district health boards under the previous National-led government (2008-17).

Andrea Vance, National Affairs Editor for The Post and Sunday Star Times, has done a devastating credibility demolition job on the Government’s public service cuts.

This includes arguing political double standards and hypocrisy by ministers asserting that actioning these cuts are operational rather than political decisions: Politicians absolving politicians of blame.          

The truth is that back office functions are integrated with frontline functions with the former dependent on the latter. This false narrative from government is made more disingenuous by the fact that almost all the health ministry does is back office.

What does the Health Ministry do

But the work of the ‘back office’ ministry is integral to the functioning of the whole health system. Its function is to be the primary adviser to the government on health. This includes priority setting, policy and system performance.

It is responsible for the administration of legislation. This includes the Pae Ora Act 2022 which governs the health system.

Also included in this responsibility is the Health Practitioners Competence Assurance Act which determines the competence of health professionals in the context of the safety of the public.    

A further critical legislative driven function is protection and regulatory. This includes (along with many others) environmental, health professional competence, medical examinations of children, and critically, new medicines approvals through MedSafe based within the Ministry.

Suicide prevention

The Ministry also plays a key role in supporting or leading projects focused on critical healthcare issues. Suicide is a case in point.

In 2019 the then Labour-led coalition government created a small ‘suicide prevention office’ within the health ministry.

Its focus is on strategy, policy, regulation and monitoring the outcomes achieved by the system as a whole. This includes an emphasis on proportionately high suicide risk populations, particularly Māori, Pacific, and youth.

The relative newness of the office, coupled with the prolonged disruption due to the pandemic in the midst of which was unhelpful earlier health restructuring, limited what it could achieve within its short existence.

Owing to the nature of suicide prevention the office’s effectiveness can’t  achieved by quick fixes.  Nevertheless it was a busy, needed and diligent unit.

The effect of the headcount approach to the cuts meant that the office would disappear without any assessment of the continued relevance of its function. Again form before function.

The revelation of its demise led to political egg yolks running down ministerial faces.  The most affected was new mental health minister Matt Doocey.

This was unfortunate because he has demonstrated a considered thoughtful approach to mental health issues.

Political embarrassment has now led him to require the health ministry not to close the office. However, the net effect may be little different with the high risk that reduced staffing will severely compromise its performance.

Compromising tobacco regulation effectiveness

Successive Labour and National-led governments have been committed to achieving a smokefree New Zealand. In 2023 the former Labour government amended the smokefree bipartisan legislation in order to strengthen and accelerate this objective.

However, the unexpected and secretive influence of the tobacco industry led to the new government repealing the legislative amendment.

I discussed this earlier in Otaihanga Second Opinion (11 December) when the decision to repeal had been announced but not yet implemented: Perversity of pending smokefree repeal.   

At the time the Government claimed that it was developing an alternative smokefree approach.

However, the lie to this claim was evidenced by the revelation in the NZ Herald (8 April) that the health ministry staff responsible for tobacco regulation would be slashed by 38%: Slashing tobacco regulation capacity.

This specific slash should be seen the context of both the overall 18% cut for the health ministry in which the office was based and the 6.5-7.5% for the whole public service.    

It could be argued that function came before form in this decision. If so, the function would have been to protect and enhance the tobacco industry’s profitability while the form was slashing the health ministry’s regulatory capabilities.

Earlier destabilisation

This is not the Ministry of Health’s first recent restructuring. Two years earlier it was restructured by losing its responsibilities for funding, planning and delivering health services.

In conjunction with the abolition of district health boards, its relevant staff were transferred across to the new Te Whatu Ora (Health New Zealand) by July 2022.

Inevitably, while there were no overall job cuts, it was still destabilising for those remaining in the much downsized organisation. Under new leadership the restructured Ministry had limited opportunity to do much more than find its way before it was whacked by these staffing cuts.

I have previously been critical of past leadership of the health ministry, particularly since the mid-2010s. This was primarily over the narrowly focussed ‘control culture’ of its top leadership.

It is too early to tell whether this criticism can be reasonably applied to the current relatively new leadership team.

Such is the Ministry’s reduced role since the creation of Te Whatu Ora that this ‘control culture’ has simply migrated to the new body but more vertically centralised than previously and with the ‘control culture’ expanded to include ‘command’.

Despite my concerns with this ‘control culture’ however,  I was also impressed by the diligence and commitment of many Ministry staff closer to the operational engine-room of activity.

The functions they performed were both critical for the performance of the health system and invisible to the wider public and even to many within the health system itself. 

The most likely outcome

So what is the most likely outcome of these public service cuts to the health system? As sure as night follows day, bad processes lead to bad outcomes. Inadvertent consequences is a polite description.

The Government has put form before function and used the blunt arbitrary instrument of headcount staff cuts to do this. The health ministry has been sent on a pathway towards immobilisation.

Consequently a decline in the quality of the Ministry of Health’s advice to government, its administration and monitoring of the health system, and performance of critical regulatory functions will most likely diminish; arguably inevitably.

It won’t just be the demonised and devalued public servants who have lost their jobs that are the casualties. Immobilising the Ministry also means the health system will be a casualty as well.

© 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.

Contact Ian Powell

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