A report finds our health system is too top-down.
Listener: 8 March, 2008.
Keywords: Governance; Health;
“There does not seem to be the understanding that several actions – for example, writing a policy or reminding staff about a concern – are actually very weak actions. There is also little indication that general clinical staff are involved in the improvements.”
Dr Mary Seddon’s recent report for the Health and Disability Commissioner is indicative of an approach throughout our health and tertiary education institutions. Generic managers may make policy decisions – in this case about safety practices – but unless the specialist professional staff (in this case clinicians) are involved, the decisions will not be effective.
The ineffectiveness seems to have intensified in the past 20 years following the public-sector reforms of the late 1980s. They strengthened the administration relative to those who actually deliver services to the public, making the organisations top-down rather than bottom-up.
The additional generic managers knew little about the issues faced by deliverers, and often seem insensitive to the deliverers’ concerns. Perhaps it is because their theory – insofar as there is one – consists of fashionable slogans and buzz-words rather than rigorous thinking.
The top-down approach arose because the reformers were deeply suspicious of professionals, assuming they acted only in their own self-interest. (With the exception of the reformers themselves, they thought everyone did.)
As a result, there can often be bitter antagonism between professionals and managers. Seddon cited only three district health boards – Canterbury, Waikato and West Coast – as having “patient-centred” approaches. Given that clinicians are usually patient-centred, the implication is that most of the remaining 18 DHBs have administrations that are not.
The disjunction is not peculiar to hospitals. Academics grumble about their administrations too. They may have the noble objectives of the liberal university, which Wilf Malcolm and Nicholas Tarling vigorously defend in their recent Crisis of Identity? The Mission and Management of Universities in New Zealand.
But too often they are bewildered about what their university actually believes. Its statute may say it has a role as a critic and conscience of society, but there is little evidence of pursuing such an objective. Instead, the purpose of teaching and research seems to be to fund the registry.
Talks to staff by vice-chancellors, if they still occur, do not get across the problems their universities face. Most academics seem to have no idea about what is going on and assume that registries do not either, except in terms of narrow financial objectives. It’s as if the finest minds in this country are incapable of analysing themselves, while the finest teachers cannot transmit their understandings.
The financial incentives that fund our universities do not align with the sort of principles that Malcolm (a former vice-chancellor) and Tarling (a former deputy-VC) espouse. Since there is no funding, universities do not promote public intellectual activity, even in cheap ways like awarding it honorary doctorates.
Whether DHBs face a similar problem of alignment is unclear. What is evident, though, is that many hospitals’ administrations do not seem to appreciate the most elementary rule of pastoral farming: to ensure high productivity, keep your livestock happy.
You see this in the circumstances at the Capital & Coast DHB where an incident precipitated Seddon’s report. (Although for all the cases I know about, the patients have nothing but praise for Wellington Hospital’s clinicians.) Staff are shortly to move into a new hospital building. During its design, many of the clinicians felt they were not listened to.
As a result, they don’t “own” the new arrangements. As things go wrong – which is inevitable in the start-up of any new facility – they will become increasingly grumpy. Hopefully that won’t affect the treatment of their patients, but it will further increase the distance between administration and clinicians.
The grumpiness will not be resolved by a top-down administration producing, without the wholehearted involvement of it clinicians, yet another report, nor by it announcing it is “building a culture of success”.
<>One DHB told Seddon its buzz-words were “all well implemented and a part of how we do things”.