A Vigorous Rearrangement of Deck Chairs: Heather Simpson’s Neoliberal Prescription For New Zealand’s Health System.

Efficient and Effective? If Heather Simpson had dared to produce a report that restored to “efficient” and “effective” their true meanings, then it would have recommended the complete abolition of both the Ministry of Health and the District Health Boards, and their replacement with an all-encompassing Department of Health and Wellbeing. Sadly, she did not dare.

MUCH WILL BE WRITTEN about Heather Simpson’s plans for the New Zealand health system. Most of the attention, if the media’s coverage so far is any indication, will centre on the abolition of the system’s already anaemic democratic elements, along with the acceptability or otherwise of the provision made for addressing the health needs of Maori. Virtually nothing will be written, however, about the verbal formula which signals that, in spite of all the vigorous rearrangement of deck-chairs, nothing of any real substance in our public health system is going to change.

What is that verbal formula? Easy. It’s the one which reassures the reader of the Report’s unwavering commitment to the “efficient and effective” management of public resources.

What’s wrong with efficiency and effectiveness? I hear you say. In and of themselves, nothing. Nobody in their right mind wants an inefficient and/or ineffective public health system. (Arguably, that’s what we’ve got now!) It’s just that whenever the two words are linked together in the context of providing public services, they carry a meaning over and above their simple dictionary definitions.

Anyone familiar with the political and administrative history of the past 35 years will recognise immediately that that those who use this verbal formula are offering a great deal more that efficiency and effectiveness:

E&E is code for: this institution is being managed according to the theories and practices of neoliberalism.

E&E stands for the “funder/provider split” and against the existential threat of “provider capture”.

E&E signals the presence of a parasitic, grotesquely over-rewarded management layer dedicated to ensuring that scientific knowledge and professional expertise is kept in its place.

E&E means the payment of generous “performance bonuses” to those who prove, year-in, year-out, that more “outputs” can always be extracted from fewer “inputs”.

E&E has no interest in unions, professional organisations, or democracy.

E&E represents neoliberal managerialism uber alles.

Everything else in the Report flows from this verbal ritual of obeisance to the neoliberal paradigm. The breaking-up of the Ministry of Health. The establishment of competing centres of demand for resources and personnel. The elimination of what little remains of popular participation – via democratic elections – in the allocation of public resources. The assumption (or should that be the pretence?) that meritocracy constitutes the fundamental organising principle of the entire system. Everything, in short, that guarantees the system’s ability to go on resisting genuine and meaningful institutional change is summed-up in those two words: efficient and effective.

It was George Orwell who first made explicit the totalitarian practice of describing a regime’s actions by using words that describe the exact opposite. In his chilling dystopian novel, Nineteen Eighty-Four, the “Ministry of Truth” was where the regime concocted its biggest lies. The “Ministry of Peace” was the place from where Big Brother’s endless wars were planned and run. The “Ministry of Plenty” managed scarcity. And the “Ministry of Love” was where people were sent to be tortured. Under neoliberalism – the world’s most successful totalitarian ideology to date – we find exactly the same methods at work.

What could be more inefficient and ineffective than a health system which has been starved of human and material resources for the best part of four decades? What could be more guaranteed to produce sub-optimal results than the insertion of a layer of decision-makers charged with second-guessing and countermanding the advice and recommendations of medical specialists, doctors, nurses, carers and para-medics? What better way to produce the most dire and unintended consequences than allowing managerial staff to set financial “targets” achievable only by reducing the resources (beds, operating theatres, ICUs) that hospitals need to treat their patients?

If Heather Simpson had dared to produce a report that restored to “efficient” and “effective” their true meanings, then it would have recommended the complete abolition of both the Ministry of Health and the District Health Boards, and their replacement with an all-encompassing Department of Health and Wellbeing.

This new organisation would be equipped with a state-of-the-art IT system capable of tracking every patient and the resources expended in treating them. Each hospital would be run by a superintendent who was an experienced medical professional and overseen by a democratically-elected Health Review Committee.

The day-to-day management of the hospitals would be undertaken alongside and with input from the medical staff and their professional organisations. Within the department there would be sub-departments dedicated to primary healthcare, healthcare for the disabled, public health, mental health, women’s health, children’s health and Maori health, along with a special bureau dedicated to financial management, and another to the maintenance and extension of health infrastructure.

The Department of Health and Wellbeing would be statutorily required to present an annual, publicly available, report to the Minister of Health detailing both its achievements and its failures of the preceding 12 months, and setting forth its financial, workforce and material requirements for the coming year.

It would be understood by both the public and their parliamentary representatives that the health and well-being of the people is not only the state’s prime duty, but also that, in fulfilling this most fundamental of collective obligations, the sums allocated will never be enough. They would also be resolute in their determination that “efficiency” and “effectiveness” must never again have their meanings twisted to produce a system that condemns vast swathes of the population – particularly New Zealand’s poorest and most vulnerable citizens – to lives that are unhealthy and unwell.

This is not the understanding which Heather Simpson’s report seeks to promote. What’s more, it’s clear that the news media and other groups commenting on its content and recommendations never expected it to. Proof, I would argue, of just how firmly the ideology of neoliberalism has us in its grip.

The Coalition Government’s response to the arrival of the Covid-19 virus proved beyond all doubt that when money is urgently needed to serve the common welfare, it can always be found. If only Heather Simpson’s report had loudly and unequivocally proclaimed the urgency of the need to rebuild our public health system, and called upon New Zealand society to find both the money and the will to do it.

As it stands, Simpson’s $3 million report represents neither an efficient nor an effective use of public resources.

This essay was originally posted on The Daily Blog of Thursday, 18 June 2020.

Cooking The Medical Books: Citizens suffer in stoical silence so National can keep taxes low.

Suffering In Silence: The Government and its cash-strapped DHBs are relying upon the decency and stoicism of the average citizen to get them off the fiscal hook.

 

FUDGING THE FIGURES is what governments do when effective policy solutions are ruled off the table. According to Radio NZ News: “New research shows nearly 40 percent of patients who need hip and knee operations in at least two district health boards are not getting them because of budget restrictions. The study, published in The New Zealand Medical Journal, which looked at Northland and Hawke's Bay, found the drive to cut wait times has left 36 percent of patients with moderate to severe pain and disability untreated.”

 

Clearly, the now retired National Party Health Minister, Tony Ryall, was unable to persuade his fellow “Brat Packer”, Bill English, to appropriate sufficient funds to keep our public health service up to the job of actually serving the public.

 

One doesn’t imagine that English, an essentially decent politician, was very happy about this. But with his colleagues demanding lower taxes for the wealthiest New Zealanders (and some modest covering reductions for the rest of us) he was left with little choice. It would require a Labour-led government of more than usual fortitude and radicalism to institute the fiscal reforms necessary to ready the New Zealand health system for the influx of ageing Baby Boomers steadily falling prey to all the ills that flesh is heir to.

 

Tony Ryall’s response to his increasingly underfunded health system was, however, ethically extremely radical. According to the study published in The New Zealand Medical Journal, he simply invisiblised upwards of a third of New Zealanders in need of non-urgent surgical interventions.

 

Chairman of the Canterbury Charity Hospital Trust, Christchurch surgeon, Philip Bagshaw, told Radio NZ that focusing on the length of time people were waiting, rather than the length of the waiting lists themselves, was “a great way of hiding the scale of the problem”.

 

“It’s become smoke and mirrors”, said Mr Bagshaw. “They’ve created a self-fulfilling prophecy, so they say the waiting list is only six or four months, but that’s because they only allow that many people onto the waiting list.”

 

Smoke and mirrors it may have been, but the practice permitted Tony Ryall to boast that the time spent waiting for elective surgery was steadily decreasing. According to Mr Bagshaw, haemorrhoids, cataracts, hernias and varicose veins – among a host of other debilitating conditions – are simply not being treated in the public system until such time as serious complications render them acute – and costly.

 

Allowing the condition of sufferers to deteriorate to the point where they are forced to seek emergency admission to public hospitals is, not surprisingly, a considerably more expensive proposition, long term, than providing treatment early. “Investing in health early on is not only humane but also makes good economic sense because to do things in a timely way is the cheapest way,” Mr Bagshaw confirmed. “If you deny people treatment ... they come back later with bigger complications and cost more money.”

 

As scams go, however, this is a particularly clever one, because, obviously, not all of those sufferers rendered invisible will end up undergoing emergency surgery. Most will simply go on suffering, unheard and untreated.

 

In other words, the Government and its cash-strapped DHBs are relying upon the decency and stoicism of the average citizen to get them off the fiscal hook. Their deeply cynical – but apparently accurate – expectation has been that the voters will evince little interest in how Mr Ryall’s miracle is being achieved, just so long as the waiting period for elective surgery keeps decreasing. And so it proved. On Election Day, most people accepted without demur that John Key’s government was managing our public health system with considerable skill.

 

So, it’s ‘all good’ for the Government? Well, not necessarily. As the Baby Boomers find themselves relying more and more on the public health system, they are bound to flex their still massive demographic muscles to ensure that sufficient funding is appropriated to meet their growing needs. With everything to fight for in terms of free medical care, there is nothing to suggest that the ageing Boomers will not emulate the exemplary levels of electoral participation demonstrated by older voters generally. In securing their self-interested health objectives, the Boomers will be aided by the short-sighted failure of so many young voters to participate in the electoral system.

 

The politicians of the future will respond to the medical demands of the Boomers in the way politicians always do when presented with a choice between serving the interests of citizens who vote and the needs of citizens who stay at home. If young New Zealanders want a viable public health system to still be in place when they reach their 60s and 70s, then they’d better start voting in the same proportions as their elders. Otherwise the health statistics being fudged will be their own.

 

This essay was originally posted on The Daily Blog of Saturday, 8 November 2014.