On February 18, the reconstituted “Governance Board” of the Hawke’s Bay DHB held its first meeting. The session was brief and uneventful … all the players were on their best behaviour. What might have added tension was defused by the non-attendance of Chief Executive Chris Clarke, who had announced his resignation days earlier.

So now what?

Awkward interregnum?

Until the next local elections in 2010, an awkward situation will persist. The new DHB “Governance Committee” is still chaired by Commissioner Sir John Anderson. To very clear, in the legal sense, he still is the ultimate authority for the HBDHB. And he reports to the Health Minister, not the community. He is now chairman of a full committee that includes the three Commissioners he appointed, plus the seven elected Board members, led by Kevin Atkinson.

Theoretically, an issue could come before the Governance Committee where Sir John was disposed one way, and the elected members disagreed. Whose view would prevail? Legally, Sir John’s. Practically or politically? Hmmm. Sir John strikes me as the astute sort of fellow who would prefer to operate by consensus.

One participant in brokering the deal that reinstated the elected members said that a very clear and emphatic message was delivered to all participants by Minister Ryall: Play nice!

At the same time, the elected members have each returned with the understanding – shared by one and all – that they are to exercise all the responsibilities and authorities that they were originally elected to exercise.

Time will tell how seriously Chairman Sir John involves his new Committee members … Will they be fully briefed? Will public discussions be robust or pro forma? Will consensus be sought? How will they participate in the selection of a new Chief Executive? We’ll see.

Long-term accountability

But perhaps more important is the fundamental accountability issue this episode raises for the long term – who really is responsible for the quality of health care in Hawke’s Bay and the health priorities to be pursued.

If you think it is your elected health board, think again.

According to the Health & Disabilities Act, here (abridged) are some key objectives and functions of the district health boards:

* improve, promote, and protect the health of people and communities;
* reduce health disparities by improving health outcomes for Maori and other population groups;
* foster community participation in health improvement, and in planning for the provision of services and for significant changes to the provision of services;
* issue relevant information to the resident population, persons in the health and disability sector, and persons in any other sector working to improve, promote, and protect the health of people;
* foster the development of Maori capacity for participating in the health and disability sector and for providing for the needs of Maori;
* regularly investigate, assess, and monitor the health status of its resident population, any factors that the DHB believes may adversely affect the health status of that population, and the needs of that population for services;
* promote the reduction of adverse social and environmental effects on the health of people and communities.

An impressive list of responsibilities, right? We elect members of the DHB thinking that they – because they have the requisite power and authority – will advance these purposes, responding to our local sense of needs and priorities.

Well, it doesn’t quite work that way.

All health policies and programs – and their funding levels – are determined in Wellington by Government and its Health Ministry. Here’s how Stephen McKernan, Director-General of Health & Chief Executive of the Ministry of Health described the accountability situation in his affidavit for the Cunliffe litigation:

“DHBs are not fully autonomous entities … the Crown, through the Ministry and the Minister, retains explicit powers to ensure accountability, and to maintain direction and control. DHBs deliver on the health priorities of the Government of the day and the signals that are outlined in the Minister’s annual letter of expectations to Boards. DHBs were set up as Crown entities. Although they are partially elected and have, as one of their key features, a need to engage actively with their local communities, the establishment of DHBs did not alter the core accountability of DHB boards to the Minister of Health.”

So, the DHBs simply implement the policies and funding decisions of the Health Ministry, tweaking them around the edges. For example, Kevin Atkinson estimated to me that the local HBDHB has discretion over only $20-30 million of an annual budget around $400 million … about 5-7%.

Thus, when the Crown Health Financing Agency projects the health system will be $1.6 billion in the red by the end of fiscal 2010/11, that’s not something the local DHBs are going to fix on their own. That’s why it was ludicrous for David Cunliffe to target the elected DHB for financial mismanagement … and why the Hawke’s Bay DHB financial situation is essentially unchanged after a year of Sir John’s fiscal babysitting. In fact, our local DHB will run a deficit exceeding $6.5 million … and this with a sizeable increase in revenue provided by Wellington.

With so little real power, one might indeed ask: “Why do the elected DHBs exist at all? Why not just let the bureaucracy handle it?”

Public health advocacy

My own view is that ensuring public health and quality health care is simply too important to each of us to not have some responsive avenue for local community expression of priorities, needs, satisfaction or dissatisfaction.

Paraphrasing from the list of key objectives and functions mentioned earlier, I see the raison d’etre of local elected health boards to be public advocacy – fostering community participation in health improvement, investigating and monitoring any factors that the DHB believes may adversely affect the health status of its local population, and promoting the reduction of adverse environmental effects on the health of people and communities. And the DHB should provide strong advocacy even if its locally-informed views are not comfortable to central or local government.

So, as it re-assumes its responsibilities, shared with Sir John or otherwise, our elected Hawke’s Bay DHB should be judged on how well it performs this public advocacy function. Over the past year, the Commissioner and staff-led DHB has failed in this defining responsibility. It has been stunningly silent and passive on a number of important issues affecting public health in the region. Some examples:

1) As required by Government policy, the use of inefficient woodburners that exacerbate PM10 pollution in the Bay’s urban airsheds must cease. The adverse health consequences of fine particle pollutants is irrefutably established. A report just published in the NZ Medical Journal called NZ’s care for respiratory illnesses like asthma “deplorable in a First World country.” Yet some local elected officials are making downright stupid and misleading statements about the health effects of PM10 so as to fuel public opposition to more stringent regulation. A public consultation period is now underway, with the public largely ignorant of the health implications. Where is the DHB’s forceful and public explanation of how serious the health hazard – and need to act – actually is?

2) The Regional and local councils have dragged their feet in responding to widespread concerns about water quality and health threats from water pollution, and more lately, even about the supply of safe drinking water in rural Hastings. Where is the voice of concern from the DHB? Instead of leadership, again and again the DHB passively defers to local bodies who have zero health expertise, even on matters like erecting public warning signs on polluted streams.

3) Local residents in Whakatu complain repeatedly about health effects and risks from neighboring industrial operations, in the form of air emissions, water discharges and use of hazardous chemicals. Why doesn’t the DHB investigate the issues on their behalf?

4) When local citizens are concerned about losing much-needed community-based health care or addiction facilities of proven effectiveness (e.g., Springhill Centre in Napier), is the DHB friend or foe?

I fully appreciate that the final authority to remedy these matters might lie elsewhere. But DHB must serve as the proactive authority in getting at the underlying facts as they affect public health, and insisting that those facts drive community understanding, as well as local body policy, regulation and enforcement activities.

Frankly, whether the HBDHB can balance its budget or not is immaterial. Health care funding is an immensely vexing national challenge, and central government decisions drive the equation. As Kevin Atkinson says, the portfolio of the Health Minister is probably the most daunting and politically charged of all. He observes: “Health care is always about rationing. No government in the world could put enough money into it to satisfy the community.”

And therein lies the real importance – and justification – for an elected health board. There must be a local voice. And that voice must be responsive to its community and their unique public health requirements … whether, as in Hawke’s Bay, those stem from environmental threats or local demographic factors, such as disproportionate Maori and senior citizen populations.

So I’m happy to see the “sacked seven” re-seated. But the challenge now falls on them to listen to and represent the community and to make a real difference.

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