When the Government announced its response to the Health and Disability System Review in April 2021, the PSA invited members to provide feedback to a Working Group made up of delegates from the DHB and Community Public Services sectors. An email address has been set up exclusively to gather these member responses.
To further guide feedback, a health reform presentation [PSA, 2021] was produced in June containing three specific consultation questions for discussion. Below is a response to these questions.
1. Suppose you could develop a charter for the NZ health workforce, what values should be included to create what type of culture for workers?
A charter for the New Zealand health workforce has been proposed by Health Minister Andrew Little. In his announcement of the Government’s response to the Health and Disability System Review, he said: “A key element in creating a new culture will be a new New Zealand Health Charter, designed with health and care workers, to set down the values and principles of the national system” [Minister of Health, 2021].
Development of this charter, however, does not occur in a vacuum. Health and care workers may make our own culture, but we do not make it under self-selected circumstances; rather under circumstances existing already, given and transmitted from the past. It is worthwhile to briefly and critically review the historical context.
A clear signal about salient circumstances transmitted from the past has been given in the Minister’s choice of language. Both the title and the description of this proposed document clearly reference the previous New Zealand Health Charter [Department of Health, 1989]. This earlier, short-lived charter contained five principles to guide the development and operation of the New Zealand health service.
- Respect for individual dignity
- Equity of access
- Community involvement
- Disease prevention and health promotion
- Effective resource use
Viewed critically, it possible to discern how prevailing historical ideologies of the time may have shaped the selection of these values and principles and to what extent they might not be fit for purpose today. The description of “Effective resource use”, for example, as “extracting more health for more New Zealanders from every dollar of health expenditure” is a clear statement of neoliberal values (or in the more descriptive Australian terminology of the time, “economic rationalism”).
Equally, “Respect for individual dignity” elevates Margaret Thatcher’s mythical “sovereign individual”. Even “Equity” is described as “a dimension of individual dignity”. In addition, it is framed as equal “access” (or opportunity), rather than equal health outcomes, reflecting the shift from post-War social democracy towards a Blairite social liberalism which was starting to take place in Aotearoa at the time.
Viewed from the vantage point of 2021, it also striking that the principles in the 1989 New Zealand Health Charter make no reference to Māori values or Te Tiriti o Waitangi. Indeed, the word “Māori” never even appears. And yet this charter, launched by Health Minister Helen Clark, does contain some useful starting points.
Having considered the purpose and background, here are five possible values and culture statements which could be included in a charter for the NZ health workforce (note that proposed translations have not been subject to consultation with mandated Tangata Whenua representatives, either within or or outside of the PSA, and represent my thoughts as Tangata Tiriti only):
- People-centred/He Tangata, He Tangata, He Tangata: A shift from designing health systems around diseases and institutions towards health services designed around, and for people means that service users and communities should become active partners in improving health service delivery.
- Egalitarian/Mana Taurite: When the contribution of each person in the health workforce is valued without regard to social stratification, it fosters a health and disability system response attuned to each person’s health need.
- Democratic/Manapori: “Work culture is positive, trusting and effective through strong industrial democracy mechanisms that give workers strong collective voice through their union” [PSA, In publication].
- Equitable/Taurite Ora: “In Aotearoa New Zealand, people have differences in health that are not only avoidable but unfair and unjust. Equity recognises different people with different levels of advantage require different approaches and resources to get equitable health outcomes” [Ministry of Health, 2019].
- Respectful/Mana Tangata: A just culture allows people to report and learn from mistakes. Shifting from a culture of blame to a mana-enhancing culture of respect and trust has the potential to deliver significant benefits for the health system in terms of saved lives, harm prevented and resources freed up for the delivery of more and better care. [Ministry of Health, 2001a; E Tū, 2017]
- Bicultural/Tikanga Rua: Colonisation, failure to honour te Tiriti o Waitangi and institutional racism have established and maintained relative disadvantage for Māori within the wider determinants of health, and within the health system. Overcoming monocultural perspectives is necessary to end victim-blaming and deficit thinking about Māori and other groups under-served by the system, improve system performance and support Equity [Health Quality & Safety Commission, 2019].
2. How can we make sure that community health services are better valued, understood and integrated into the health system?
“Community health services” (also known as “Tier 1” services) span a myriad of different structures and functions, from Primary Health Care to Disability Support, Aged Residential Care to Community Pharmacies, Dentists, Māori and Pacific providers and Laboratories. The task of better valuing, understanding and integrating them is extremely complex and involves daunting challenges, for which there are no easy answers.
The case for valuing, understanding and integrating them has been clear since at least as far back as the 1989 New Zealand Health Charter, which highlighted the need for “Community involvement” in order to direct greater attention to “Disease prevention and health promotion”. It is also very clear in the final report of the Health and Disability System Review [2020].
The recommendations in that final report for driving integration all have merit. It speaks, for example, of creating more interoperability of digital systems across hospitals and community health services. It recommends planning on a locality basis, from a population health perspective, and so on.
A New Zealand Health Charter as suggested above, which values People-centredness/He Tangata, He Tangata, He Tangata, could also make a difference. But there are barriers to system integration, like the circumstances shaping workplace culture, which are given and transmitted from the past. And these are significant.
The Health and Disability System Review [2020] recommends the creation of a NZ Health Plan which looks ahead 20 years, as a mechanism for valuing, understanding and integrating community health services. This too is a worthy goal.
But similar long-term strategies for Tier 1 have been created before. The Primary Health Care Strategy [Ministry of Health, 2001b], which established Primary Health Organisations two decades ago, was also intended to drive integration and planning on a locality basis, from a population health perspective. This was followed by “alliancing”, with the same goal. And yet it remains the case, as the Health and Disability System Review [2020] reported, that “the system is characterised by limited national planning, so that decisions which could be made once for the whole population are repeated multiple times.” Why has so little progress been made?
The fundamental problem, which dates back to the creation of the modern public health system by First Labour Government in 1938, is clearly articulated in the case of Primary Health Care by Crampton [2005], Matheson [2017] and Gauld et al. [2019]. “The elephants in the room”, they write, are that “GPs, after all, are largely private business people” and “Ownership confers governance responsibility (ultimate control) for an organisation, and accountability for its actions.” The Ministry of Health, as system steward, can plan for integration of community health services and universal coverage. But ultimately, it is up to private businesses to decide how, when and where Primary Health Care is delivered, and at at what cost to patients.
Gauld’s conclusion is applicable not only for Primary Health Care, but for many other community health services: “Further research is needed into the business ownership model, including whether this is fit for purpose for the future in meeting the increasingly complex health needs of diverse communities.” This issue has not been addressed at all by the current Labour Government.
Neither has the contracting model, based on the “funder-provider split”. This was introduced to the health system in the 1990s, as part of radical neoliberal reforms aimed at creating a competitive health care market and fully commercialised health and hospital services, as precursor to privatisation of the public health system. A sustained wave of popular protest and low-level industrial action by unionised health workers managed to overturn some of the most unpopular reforms, such charging patients in public hospitals, but the funder-provider split remained intact [Hamed, 2013].
Under this neoliberal model, accountability for service delivery was to be delivered to departmental CEOs through contractual obligations (rather than, say, through tiers of democratically elected, Bicultural/Tikanga Rua governance, from the health service provider on upwards). These contracts, which now rule the provision of community health services, typically run for periods of one to three years and are regularly put up for tender.
The model is institutionally racist and inimical to Equitable/Taurite Ora values, producing shorter contracts and a heavier compliance burden for Māori health providers [Came et al., 2018]. The fixed term contracts drive short term thinking, prevent strategic system planning and integration and undermine the “predictability of funding” for Tier 1 which was called for in the Health and Disability System Review [2020]. Retaining this neoliberal model will almost inevitably defeat the proposed 20-year NZ Health Plan, as well.
For all the talk, in Health and Disability System Review [2020] and Department of Prime Minister and Cabinet [2021], about the need for need new structures “which ensure government is both closer to communities, and more nationally connected”, the fundamental structures of “embedded neoliberalism” in the health system [Kelsey, 2015; Bertram, 2020] have not been touched.
Given that the Labour Government appears to have no appetite for dismantling neoliberalism, options for civil society actors such as unions, community groups and health service providers are limited. Nonetheless, they do exist.
One such option for the PSA to make sure that community health services are better valued, understood and integrated into the health system is to pursue bold industrial strategies. MECA coverage across both directly-employed Health NZ staff and those in the Community Public Services Sector, for instance, would reduce the incentives for outsourcing (disaggregation), foster a culture of “one team” and drive integration. Fair Pay Agreements setting common pay and conditions across the myriad of community health service providers would greatly reduce the incentive for competitive tendering for contracts, which tends to undermine integration.
Ultimately, however, ensuring that community health services are fully valued, understood and integrated into the health system will require the political will to grasp the nettle of private ownership and control, under a very different social and economic system.
3. How do we make sure that workers’ voice will guide the future health system?
The health system should be guided by the voice of all workers, in a way which recognises their different contributions. Broadly speaking, the types of worker voice can be categorised as clinical and non-clinical. The differences in contributions between these two groups are related to differences in training, along with professional obligations and legal requirements.
The benefits of clinician guidance in a health system are well established. In the New Zealand context, they have been confirmed by the Ministerial Task Group on Clinical Leadership [2009]. The New Zealand Nurses Organisation Tōpūtanga Tapuhi Kaitiaki o Aotearoa [2019] comments that, “Nurses can add real value to strategic decision-making in health care governance through their in-depth knowledge and experience of the human aspects and logistics of service delivery”. The Association of Salaried Medical Specialists Toi Mata Hauora [2015] concludes: “A health system led by clinicians is better for patient care and safety, and makes better use of available resources.”
Two components of this clinical worker voice have been defined. Both are necessary for the future health system: “Clinical governance refers to the system where clinical goals are set and reported on. Clinical leadership is the operational system that allows health workers to do what is needed based on these goals” [ASMS, 2015].
Despite the widely recognised benefits of clinician leadership and the promotion of the idea by Health Ministers for the last 20 years, little progress has been made [ASMS, 2019]. Over this time however the barriers to progress have been clearly identified and well documented. If we are to ensure that the clinical workers’ voice guides the future health system, then these barriers must be overcome:
- Lack of time, coupled with chronic workforce shortages. It’s very difficult to make room in the diary for clinical leadership activities when there aren’t enough clinicians for the clinical work required.
- Professional capture. Clinical governance and leadership must be genuinely interprofessional and multidisciplinary, rather than a synonym for “doctors making the decisions”.
- Insufficient opportunities for training and mentoring. Leadership and governance by clinicians requires investment and a willingness to delegate and collaborate.
- Outdated management attitudes, shared by incumbent leaders of health systems who have risen within the hierarchy based on command and control methods.
Management attitudes reflecting hierarchical, as opposed to Egalitarian/Mana Taurite values suppress worker voice among clinicians and non-clinicians alike. These attitudes are sustained, in turn, by other factors. Attention is turning increasingly towards one in particular.
Since the start of 2020, organisations in the UK with more than 250 employees have been legally required to disclose the “pay ratio” between the salary of their CEO and their lowest paid employee. One of the reasons for this new requirement is that, “High CEO-employee pay ratios… send a message to company employees that a main purpose of the company is to serve individual self-interest. As social science studies reveal, this focus on self-interest gives rise to unethical cultures within companies” [Dallas, 2017].
There is a negative correlation between worker voice and CEO pay: “CEO pay is clearly lower in countries with greater worker voice in corporate decision-making” [Baker et al., 2019]. Capping CEO pay ratios in the health system therefore will have a material effect on strengthening worker voice.
One further mechanism for ensuring worker voice in health system guidance is co-determination – the practice where workers employed by an organisation have the right to vote for representatives on its governance board.
New Zealand lags behind in this practice. Board-level employee representation in the public or private sector is already required by law or custom in a majority of OECD countries, and in 19 out of 28 EU member states [Williamson, 2016]. Concerns which have been raised by unions and employers as to how worker representation at board level could work in the UK – for example, over co-option, confidentiality or skill deficits – have been addressed by the Trades Union Congress [Williamson, 2013].
Other parts of the wider New Zealand Public Service already have staff representatives on their governance boards. Under Section 171B of the Education Act 1989, for instance, every tertiary education institution must have at least one elected member of the teaching and/or general staff on their Council. Section 119 of the Education and Training Act 2020 requires that the Board of a State school must include a staff representative.
The Government has shown its willingness to make bold changes to the health system – in particular in its decision to create a Māori Health Authority, with full commissioning powers. To make sure that workers’ voice guides the future health system in a way which reflects Democratic/Manapori values, they should require elected clinical and non-clinical staff representatives on the boards of publicly funded health providers. Given that almost 80 percent of the healthcare and social assistance workforce is female [Stats NZ, 2018], elected worker representation will also tend to create co-benefits for gender equity, alongside what must be respect for Bicultural/Tikanga Rua values and te tino rangatiratanga of Māori health workers.
Finally, existing legal protections for health worker voice must be respected and extended. These include the obligation in Section 6(1) of the Public Health and Disability Act 2000 for DHBs (and by extension, Health NZ and other parts of the future health system) to “be a good employer”. And it definitely includes the right for health workers to comment publicly and engage in public debate on matters within their expertise and experience (enshrined in Schedule 1B of the Employment Relations Act 2000 and elaborated in collective agreements for many occupational groups).
References
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ASMS. [2019]. ASMS Research Brief – Collective leadership: harnessing the knowledge and skills of clinicians to transform health care. https://www.asms.org.nz/wp-content/uploads/2019/08/Research-Brief-Distributed-clinical-leadership_172592.2.pdf
Baker, D. Bivens, J. & Schieder, J. [2019]. Reining in CEO compensation and curbing the rise of inequality. https://www.epi.org/publication/reining-in-ceo-compensation-and-curbing-the-rise-of-inequality/
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Grant Brookes | Nurse & Trade Unionist 