‘Take a hiding for nothing’

On 27 February 2008 then-Health Minister David Cunliffe fired the seven freshly elected members of the Hawke’s Bay District Health Board and appointed outsider Sir John Anderson as Commissioner to run the DHB.

After months of political and legal jockeying, and a change of Government, new Health Minister Tony Ryall in February 2009 re-instated the elected members, including Kevin Atkinson, who had served as Chair. But Sir John was left in place as Chair.

Did these machinations matter one bit to the quality of health care anyone in Hawke’s Bay received over the span of this kerfuffle?

Should we care whether we have an elected Health Board or not?

Elusive Sir John

Preparing this article, I emailed Sir John a few questions, including: In general, do you think it is better for DHBs to be chaired by a suitably qualified elected local, as opposed to an appointed “outsider”? Would it be your wish to serve again as Chair of HBDHB in the new term?

He responded diplomatically: “The question is … rather who is the most appropriate/experienced person to appoint as chair, following the election of seven members and the appointment of four members to the Board.

“The 21 DHBs currently have a mix of chairs, some of them are appointed board members/some of them are an elected member. The issue for DHBs in rural areas sometimes revolves around having some directors willing to stand for election who have experienced commercial expertise and/or the knowledge of how Government/Ministries operate in the management of the sector. The Ministry/Minister would normally take the skill sets of the elected members into account and seek to fill any skill gaps in considering the appointment of the appointed members.”

Other than mentioning that his own term ended in December, he didn’t comment on his future intentions. [Here is Sir John’s complete response.]

Sir John’s main achievement as DHB Chair has been to hire a new CEO. His other main mandate, bringing the DHB’s budget into balance, has failed … but would have failed regardless of who or how the Board was led over the past two years. The main factors driving escalating health costs in New Zealand are a population that is both older and living longer, absorbing more (and more expensive) health care, and, in our region, poor lifestyle choices with respect to smoking, drinking and diet.

No Board or Chairman’s wand could wave these problems away.

In the face of these underlying dynamics, our local DHB and its leaders have little flexibility or discretion as to how they can spend the health monies dispensed by Wellington. The funding itself is driven largely by population-based formulae, and the spending is mostly allocated by Health Ministry-dictated priorities and strategies.

Operating at the margins

Consequently, our Hawke’s Bay DHB influences health care in our community at the margin … How do we meet the dialysis needs of patients in Wairoa? Is the Wellesley Road Health Centre the best facility to provide health services in Napier? Should addiction services be provided in this building in Napier, or that one in Hastings? Which piece of expensive medical equipment should we replace first … or should we air condition the in-patient mental health facility instead? How do we deal with the public rebellion against fluoridation in CHB?

To the patients and communities involved, these are not small, theoretical or inconsequential questions. But neither are they, taken individually, matters of grand strategy, as opposed to:

• If Hawke’s Bay’s elderly (age 65+) population doubles in the next 35 years, becoming 26% of our community, how will we (the DHB) pay for all those additional in-patient days, the expensive treatments they will expect, the medications and, when we’re through, the hospice care?
• If 45% of all babies born in Hawke’s Bay at this point are Maori, and Maori already have the worst health problems, and we haven’t the capacity today to deliver health services effectively to the existing Maori population, how will we (the DHB) ever improve the health profile of this community?
• Or, if we (the DHB) have no control over whether junk food is sold in our schools, or over the money paid to primary care providers (GPs) for what purposes or priorities, and patients increasingly wind up at the hospital with preventable conditions, how do we intervene?

You get the picture! Improving the health condition of our region is a pretty challenging job that must be done in a context of scarce resources and limited authority. It’s easy to disappoint; nearly impossible to satisfy. As Lawrence Yule commented to me: Health boards can “take a hiding for nothing.”

Who would want that job?!

Elected boards

I put that question to Kevin Atkinson, who like other incumbent DHB Board members, as well as new prospects, will be pondering the matter in coming months.

He laughed, then side-stepped into his “take” on the big picture.

And in his view, the big picture is first and foremost about a nasty word: “rationing.”

Atkinson notes that overall, New Zealand allocates about 25% of its public budget to health care, comparable to other OECD countries. He thinks that’s a reasonable allocation in the face of other competing societal needs, and accepts it as a given.

So long as that politically-sanctioned “cap” is in place, improving and expanding health care will require making do with what we have – achieving greater efficiencies in administration, procurement, and service delivery; emphasizing preventive care and health education to minimize downstream ill-health and expensive treatment; trying innovative models of care-giving; and centralizing specialist services.

But even assuming all that, given the underlying demographic factors already mentioned, there won’t be “enough” health resources to totally satisfy need. For example, home care is now provided to the elderly at a level that can’t be sustained as the senior population grows so dramatically in Hawke’s Bay. Or, if levels are to be sustained, what other needs will be served less?

How does local DHB governance play into this?

Atkinson sees elected local boards taking the difficult responsibility for “developing strategies for rationing the services we are able to provide.” And to do that in a manner that the community trusts and accepts, the DHB must be “the eyes and ears” to the community. It’s clear that he thinks many of the tough choices must be made locally and in a manner that is responsive to the community. That’s the rationale for locally-elected health boards.

To give local DHBs this focus, Atkinson would take some other responsibilities off their plate. He believes there should be a single 50-year health asset management plan for the country. Management of the vast public health asset base and infrastructure – where to build what facilities, what medical technologies and equipment to purchase, etc – as well as the capital funding responsibility for this, should be put in the hands of appropriately experienced senior executives, who would make such decisions on a nation-wide basis, perhaps administered over 3-4 regions.

“Why should several DHBs be struggling with the same question of what radiology equipment to purchase?” he asks.

Taking these issues off their plate would permit the DHBs to focus on what is more reasonably within their local competence – utilizing the assets to deliver services and devising ways to better provide services in their communities.

(Ed note: To that, I would add the local advocacy role of DHBs. If a politically-sensitive local Health Board can’t educate other local bodies about health risks in the community – local PM10 air pollution, poor water quality, toxic contaminated sites – and press them to do something about it, then who is to play that role?]

Giving local DHBs a job they can actually do, in a manner that provides local political accountability, is not merely an academic subject.

Recently in Management magazine, Health Minister Ryall commented:

“Good governance is critical to our DHBs. But they are very complex and very large businesses … What we have in DHB governance at the moment is very committed people who are sometimes too narrowly focused on their own experiences or [the interests of] their professional colleagues. There is a clear lack of complex business experience on many of the boards.”

Minister Ryall emphasizes that DHBs – with huge budgets and life-affecting responsibilities – are seriously more demanding environments than can be managed by “hobby” directors.

For now, the Minister seems content to push DHB Boards to “raise the bar”. But, as the Government has shown in another context – firing the entire regional council in Canterbury! – it might not be shy about questioning the very utility of elected DHBs at some point … perhaps in a second term.

Back in Hawke’s Bay

We are left pondering the fate of our own elected Board. Who will stand for the tough job of DHB board member?

To a very important degree, this depends on what role the Health Minister has in mind for elected versus appointed board members? In DHBs the Chair appears to be in total command. That is certainly true in the case of HBDHB and Chairman Anderson. He dictates the style and substance of what goes on, full stop.

The re-instated elected Board members have marked time since their rebirth. But it’s difficult to see why these busy community leaders would chose to spend three more years passively saluting Sir John when they could make far more significant personal contributions elsewhere. And certainly if you have formerly been an activist and inclusive chairman like Kevin Atkinson, I would imagine it’s even more difficult to see much opportunity for service in that environment. For any of these people, or others with an interest in the region’s health care, why even bother running for a seat in that closed shop.

So, will Kevin Atkinson run? No decision yet. But he would get at least two votes. I asked previous defenders of Atkinson and the elected Board, Mayors Yule and Arnott, to comment on the situation. Said Arnott: “I support a locally elected Board … it is now time for thoughtful democracy, clear voices and strong action. The community supported the elected Board through the hardest times and I would support them again for all the same reasons.” As for Atkinson, “I’d be very happy to see him as chair.” Said Yule: “Kevin Atkinson offers outstanding value to the community, and he’s highly respected by the community. I would like to see him run for the Health Board and I would like to see him appointed as chairman.”

But referring to fact that the Health Minister appoints the chair, and not necessarily from the elected members, Yule continues: “That said, no one knows how the Government is going to handle these situations” … a comment echoed by Arnott.

It’s fair to call the question of Minister Ryall: You say you want the bar raised. Then you should empower our elected Board members and choose a Chair from among them. Is that the plan you have for Hawke’s Bay and, if so, when will you signal it so that would-be candidates can make intelligent decisions about seeking office?

MPs Tremain and Foss graciously put that question to Minister Ryall for BayBuzz. Replied the Minister in a statement: “The HBDHB will return to normal elections this year and will be no different to any other DHB around the country. In addition to the elected members the Minister will appoint four members to the Board. The Minister will then appoint the Chair and Deputy Chair. This is no different to any other DHB in the country.”

As you can see, there’s no preference indicated in those comments for choosing the Chair from the elected members, leaving the fate of the Chairman twisting in the wind. Minister Ryall is keeping his treatment options open!

Tom Belford