GP Atkinson vs. brain surgeon Sir John

Last week I had the opportunity to interview two of the key protagonists in HB’s ongoing health saga … Kevin Atkinson, former chairman of the HBDHB and Sir John Anderson, Commissioner appointed by Health Minister David Cunliffe to right the (supposedly) listing DHB ship.

Here’s my takeaway.

Kevin Atkinson, without question, is a man committed to the Hawke’s Bay community and to improving the quality of health care its residents receive. As Chairman of the DHB, he devoted an average of 30 hours per week to the job, many of those hours spent interacting with individuals and families with health issues, as well as all sorts of community groups with health interests. So one might say, he was in a position to feel our pain.

If he were a doctor, I’d expect him to be the family doctor, a general practitioner.

At the same time, he is eminently qualified to oversee a major business enterprise, which, at $400 million per year, the DHB certainly is. Atkinson is one of only 106 individuals in NZ accredited as a corporate director … a peer-reviewed credential that recognizes substantial accomplishment in business, and business governance.

Even his nemesis, DHB CEO Chris Clarke, has written reports in the last two months for Commissioner Anderson that suggest the DHB wasn’t listing all that badly under the Atkinson regime. In one report, Clarke characterises the vaunted deficit of the DHB as rather minor in scale; in another, he characterises the current DHB strategic plan as on target. Hardly the stuff of ministerial purges!

In short, if you wanted to personify the case for locally-elected health boards — a combination of accessibility and acumen — it’s hard to imagine a better role model than Kevin Atkinson.

Which isn’t to say that his past, or any future, tenure would be without controversy.

As he puts it: “Health care is about rationing.” There will always be dissatisfaction stirred by consumers/patients wanting more, better, faster. But in a system where roughly 20% of the central government budget is already devoted to health, “more, better, faster” comes at high — perhaps unacceptably high — cost.

At the same time, he found less discretionary authority than he expected when he initially joined the health board. Most health policies and funding priorities are set in Wellington, the latter on a formula basis. He considers at most only $15-20 million of HBDHB’s annual budget to be discretionary in the sense of truly being allocable on the basis of local preferences and priorities. Not a lot of flexibility to keep the locals happy.

But looking at health care nationally, Atkinson sees ineffectiveness in localised management of health care infrastructure and technology investment that might be addressed by moving such decisions out of local DHB hands.

Clearly a man who understands and has his own informed, and possibly controversial, ideas about health care delivery. Add to these strategic ideas his views on governance, and you begin to see why he might make a typical CEO nervous.

Kevin Atkinson has a governance philosophy that seems considerably more “engaged” with senior management than many senior managers might prefer. According to activist Atkinson: “Boards never make big moves and eliminate risk through an excessive focus on what they cannot do.”

Further: “The board must increasingly play an active part in key decision-making. Management must move from being a provider of data and information to being a provider of knowledge to the board.”

And even more bluntly: “Issues and concerns with board governance generally arise because management is not delivering, and a weak and ineffective board is not doing enough about it.”

All in all, Atkinson would prefer to see a “healthy, creative tension” between board and management. It takes a strong and confident CEO (and other senior managers) to embrace this kind of activist Board philosophy. And here, it seems, is the root of the Atkinson-Clarke falling out.

Enter Sir John Anderson. If he were a doctor, I’d expect him to be a specialist, like a brain surgeon.

Sir John seems chiefly a money man, focused on balancing the budget. He has a “Future Directions” plan for swinging the HBDHB budget from a current year $6.7 million deficit (and $13.5 million deficit over the past three years) to a $1.5 million surplus within three years. Toward the end of this year, that plan will be presented to whomever the Health Minister might be, and Sir John will consider “mission accomplished.”

Assuming the plan is acceptable to the then-Minister, that Minister would presumably appoint a new health board for Hawke’s Bay, to serve until the next local body elections in 2010.

As he discusses DHB finances, the clear message is that the line of accountability is strictly between the DHB and Wellington … the Health Minister and Ministry. HBDHB health spending priorities have nothing to do with HB voters. As Sir John puts it: “The DHB is not responsible in any financial sense to the community.” We get to express our “confidence” (or not) in the way health services are being delivered in our region … and that’s about it.

In other words, we get to dump the health board if Auntie Tillie spent too much time waiting in the emergency ward, but we don’t get to allocate them more money because we want a higher level of service.

This isn’t a criticism of Sir John’s view … he’s simply reflecting the reality of the matter.

Interestingly, Sir John, exactly like Atkinson, stresses that top performing organisations are characterised by exceptional working relationships between boards and their top management. But while he insinuated so only obliquely (i.e., no specific examples given), he suggested that Atkinson and his Board “over-managed” the DHB staff. Sir John tends to use the word “monitor” to describe the Board’s role; this is a word (and role) Atkinson rejects as insufficient to getting top performance from any management.

But I got no sense that Sir John sees his role as carrying a case against Atkinson. No fireworks here that I could see. No clash of health strategies. Indeed, unlike Atkinson, Sir John didn’t really talk much about health issues per se. Sir John is in Hawke’s Bay to deal with “financial self-sufficiency” and proper governance … both generic concerns at the end of the day (he could just as well be trouble-shooting finance company failures).

And then on to other wise-man assignments somewhere else in NZ.

Meanwhile, on Monday August 25th, Kevin Atkinson will be right here in Napier at the High Court, when the legal challenge to his Board’s termination mounted by local authorities will be heard.

I asked him if he could foresee returning as Chairman of the DHB, whether because this litigation reinstated him, or a National Party Health Minister did so. “I’d have to think about that,” he said. “I could only do the job the way I did it before … 30 hours a week and deeply engaged.”

If I were convinced (I’m still ambivalent) that an elected health board might make a significant contribution to the quality of health care in Hawke’s Bay, then that’s the answer I would want to hear. GP Atkinson would be the right Chairman for me.

If I were Minister of Whatever, and I needed a seasoned troubleshooter, I’d call upon Surgeon Sir John.

Meantime, stay healthy!

Tom