This note is work in progress which I circulated to some colleagues.

This paper is about the importance of culture in the healthcare system. It argues that the changes to it should focus on enhancing a patient-centred approach by paying more attention to the culture of the medical professions. Without doing so, the changes in the structure and administration of the system will be largely ineffective while additional spending will be less effective.

To begin with a parallel, familiar to most clinicians. The patient comes in with a number of health concerns. The clinician goes through them, explains how each can be treated and adds something like: ‘These treatments will alleviate your health problems but they won’t resolve them because you are smoking, you are drinking too much, you are not getting enough exercise and you are overweight. You need to address these lifestyle issues if you want the treatments to work fully.’ The patient explains, impatiently, that they just want the treatment which they will pay for if necessary; they are quite happy with the way they live.

Culture – one’s lifestyle – is an important component of one’s health. And the culture of those who work in the healthcare system is critical to the system’s success. Yet it is rarely discussed and usually ignored when further change to the system is being considered.

The rhetoric is of ‘patient first’, although that is rarely mentioned when the changes are being made. Patients and the professional culture are connected. As Simon Sinek put it:

Senior doctors and especially hospital administrators don’t know what their job is. When you ask them ‘what is their priority’, the say ‘patients’. It’s not. It is to take care of the people who work in the hospital – of the people who take care of the patients. Every administrator, every senior doctor, every senior nurse should be preoccupied with one thing and one thing only: are my doctors OK, are my nurses OK, is my staff OK? And if they get that right, they will devote their time and energy taking care of each other and the patients. We have a broken system in which they think money is more important …

This is not the impression one gets of the current state of the New Zealand healthcare system. It seems designed to suppress that wisdom. The 2023 centralisation of the public healthcare system created layers of management which are unconnected with the medical staff. Meanwhile local management, who are able – if they are so inclined – to take care of the people who work with patients, have been disempowered.

It is illustrated by medical professionals so frustrated by their working conditions that they are continually appealing to the media, presumably on the basis that the Minister of Health will respond from the public pressure and direct a response from the upper echelons of the healthcare system. Presumably the professionals have failed to get adequate responses at the local level either because the administration has not the authority or it has not the empathy and understanding.

The administrators’ difficulties are compound by the cult of the generic manager which focuses on generic skills rather than specific knowledge about the activities and purposes of the agency – in this case the healthcare system – they are managing; sometimes their ignorance leads to patients dying (as the Stent enquiry instanced).

Perhaps the strongest tension is between the administration’s concern to restrain expenditure to stay within its budget and the quite different culture of the healthcare professions. Its ethic says that faced with a patient in need – say with a heart attack – the medics should give their total commitment without a thought of the cost, or a concern that any of their efforts may reduce the resources available to others in need of healthcare.

In the decades of teaching health economics, I began with writing on the board ‘either healthcare workers take responsibility for the resources they use or accountants will make treatment decisions’. The students listen dutifully but rarely incorporate the principle in their practice. Today many decisions about the availability of healthcare are, in effect, made by accountants – as in ‘waiting times’.

There is no easy resolution to this tension, but it would be reduced if the administrators talked more with the healthcare workers instead of announcing decisions on high about resource deployment – such as staffing and expenditure cuts. Not only would this lead to a better understanding among the workers (and perhaps even some improvement in the way resources are used) but it is likely to lead to a coalition between administrators and healthcare workers going to the public and politicians for more funding.

So how do we put patients at the centre of the healthcare system? An obvious step is to have enough healthcare workers to treat the patients. Unfortunately, the task of workforce planning has been neglected for decades and there is no easy remedy. Creating a culture more favourable to the workers would be a help, given that some workers say they are leaving the sector because of their employment conditions. (But it will not be enough.)

Favourable working conditions are part of the Sinek criteria. The best way the administration – in this context including the Minister of Health – can put the patient at the centre of the system is by supporting healthcare workers because they put patients at the centre. (Most do, although there are odd exceptions especially in the private sector.)

It is partly an attitude from the administration. Their management ethos has to change to one where they are more knowledgeable about what they are administering and the staff in it, moving away from the principles which drive the cult of the generic manager. That does not mean doctors and nurses would be running the health system but its administrators need to have more knowledge of healthcare and empathy with healthcare workers. Perhaps there would be some merit in the management style in which administrators have to spend a day a week, say, as orderlies on hospital wards.

That strategy requires decentralisation so each administrator is closer to the healthcare patient-face. And that implies we need to return power and agency to localities, in effect re-establishing the District Health Boards (even if generic managers will insist on calling them something else). Critically that would enable the administrators of these decentralised agencies to work more cohesively with their healthcare workers.

This would be a big change. Cultural change – in this case it is actually cultural rebalancing – is much harder than structural change driven from the top.

However, there is one structural change which might be helpful in addition to the decentralisation back to localities. DHBs, or whatever they may be called, have major property obligations – including entire hospitals. It may be useful to separate their property activities into a separate entity – even a publicly owned corporation. That would concentrate the focus of the administration on funding and staff. (There would, of course, be a bilateral relationship between the administration and the property relationship.) I put this proposal forward tentatively. Perhaps initially we should experiment with the administration separating out its property activities internally.

I conclude by repeating the main focus of the paper. Whatever the structural and funding problems the healthcare sector faces, a greater priority is to place patients at its centre and that requires a different relationship between the administration and healthcare workers than currently exists.