Don’t give up the fight: The Northland DHB boss has not forgotten his GP past

1990: Nick Chamberlain enters the GP training scheme and before the end of the year had purchased Tim Buckley’s Whangārei practice.

1998: He contracts dengue fever in Kuala Lumpur and discharges himself from hospital on his birthday.

On moving towards management in 2002: “I wanted to make an impact for all of Northland rather than just my 3000-odd patients. General practice can be incredibly rewarding, but it’s incredibly demanding as well, just that ‘boom-boom’. It’s an onslaught at times, I felt that too, so I was ready for a change and to do something different. I was aware that (general practice) wasn’t what I wanted to do for the next 30 years.”

2003: He begins his MBA while working as primary care advisor for the meningitis vaccination programme in Counties Manukau.

2006: He completes his fellowship in medical administration and becomes general manager of planning and funding at Capital and Coast before returning, homesick, to Northland in 2007, as general manager clinical services.

2011: Takes on role of Northland DHB chief executive.

On new uses for old skills: “I have found consultation skills are something you don’t lose, you’re able to engage reasonably easily. At times, I have to remind myself to keep doing that and check with how someone’s doing because there is so much to do, and you want to get in.”

Highlights: “Every time I delivered a baby, that was awesome, a huge privilege and sometimes it was pretty cool when they were getting into trouble and you could help them out.”

On rumours he had been put forward as a potential

director-general: “It’s not a role that would fit me so I couldn’t work long term in that environment. And I think the guy who’s doing it is probably okay.”

On equity: “I don’t think it’s a narrative, I think it’s a general acceptance with more people embracing te reo Māori. The debates on Māori wards and various things, which is great, you wouldn’t have had that in the past. I think Māori, and communities in general, need to have a greater voice and say in their own healthcare and we need more kaupapa Māori services which are, to some extent, self-determined.”

On getting more GPs to Northland: “It’s about changing that model of care and changing the funding that’s available. Then you change the whole narrative.”

Northland DHB chief executive Nick Chamberlain can see big changes on the horizon for the health sector, and says COVID-19 has shown him the wagon they will ride in on.

“I found out that you can print money,” says Dr Chamberlain.

I’ve occasionally been annoying…it’s about challenging the status quo and having a strong sense of what’s right

A leader in the 20 DHBs’ joint efforts on primary care, and a former GP, he has struggled for 30 years to get Ministry of Health officials and Cabinet ministers on board with his vision for how the health system should work.

Among his causes has been the handful of Northland practices that missed the deadline for Very Low Cost Access accreditation and remained poorly subsidised. By early last year, he felt he was “this close” to securing changes to the primary care funding formula. “Then COVID-19 came along and so, understandably, everything got wiped,” he says.

But the pandemic brought a different approach from the Government – “money suddenly was available”.

“And, okay, there is a time when you have to pay that back, but it did make me realise that, if there had been a greater boldness, we could have solved a lot of problems,” Dr Chamberlain says.

THE PROBLEMS HE refers to aren’t peculiar to Northland, but the region has them all: an ageing, rapidly growing and far-flung population, increasing economic disparities, increasing rates of comorbidities, poor housing, and wellcanvassed difficulties recruiting GPs.

The key fixes, he says, involve workforce growth, changes to funding for general practice, and new models of care, each demanding a slightly different flavour of the boldness he is calling for.

In 1991, to cap off his first year as a general practice owner, he contracted extrapulmonary tuberculosis. A mosquito bite in 1998 left him in intensive care with haemorrhagic dengue fever and failing kidneys, and, more recently, he has survived locally advanced prostate cancer. But that’s not all, and just to add some emotional turmoil, “a little life event” left him sharing custody of three children.

On the plus side, negotiating such events leaves you, he says, with “a sense of the big picture, and helps you realise you can’t always please everyone”.

Dr Chamberlain, you see, is very keen on looking at big pictures.

“[They help you to be] clear in where you want to go, especially when you feel like you’re doing the right thing (which doesn’t mean you don’t listen and change direction). It’s when, you think: ‘Oh, I have this great idea.’ Then you talk to people and [find] maybe it’s not such a great idea.

“But, with some help, some listening, and a willingness to change direction and admit you were wrong, it can still become a good idea.”

He is confident health-system change is on the way, “change that will be particularly positive for higher- needs regions like ourselves”.

“But you can’t just say: ‘Come on, be positive.’ You need to have the right conditions to work towards that, but there needs to be an understanding that we’re not going to solve our recruitment issues and some other things without getting to that point [of positivity].”

General practice is not seen as an attractive specialty and that needs to be fixed, he says.

It hasn’t always been this way. When he was a teenager, doctors were cool and general practice was going to be his forever job.

This lasted until 2000, when he became frustrated by the delays his patients aced in accessing care (“does this sound familiar?” he asks). He developed the relatively new role of GP liaison with Northland DHB.

It was a job requiring a different sort of big picture, one he calls “the helicopter view”, studying the lay of the land and identifying pressure points and crucial players before dropping back down into the trenches.

“That higher view is also especially helpful in, not only understanding different people’s perspectives, but recognizing there will be perspectives you won’t understand,” he says.

HE RECKONS ALL perspectives are, to some extent, valid and, by drawing them together, “you might be able to find a strategic direction to get where you want to be”.

Which suggests his many roles have not come about by accident. As well as eading Northland DHB, he is the DHBs’ lead chief executive for primary care and chair of the Health Quality & Safety Commission’s integrated advisory group.

And, the way he tells it, these all flow back to the dreams of his teenage years. His mother, a “Northlander born and bred”, had been a registered nurse, midwife, Plunket nurse and district nurse around the region. But he was mostly impressed by the doctors who tended his injuries at the emergency department. (How has he lived this long?) Medical curiosity may be a family trait. Dr Chamberlain’s youngest sister is a doctor, his middle sister is a nurse, and the three children from his first relationship line up as doctor, dentist, doctor.

Even so, becoming a GP wasn’t so much a quest as a best fit. “I was interested in lots of aspects, but not in love with any of them,” he says.

Starting at the University of Otago in 1980 and graduating at age 22, he divided his house-officer years between Canterbury and Northland hile gaining his diploma in obstetrics. Then he left for overseas experience: “I asked where the best place to live in England was, they said Bath, so that’s where I applied for a job.”

After seeing the world and gaining a diploma in anaesthetics, he returned to Northland in 1990 and enrolled in the GP training scheme, while also taking the odd anaesthetic locum at Whangārei and Kawakawa hospitals.

By the end of the year, he had bought a practice from Tim Buckley, a Whangārei GP who had taken it over from his father, Tim Buckley Snr, and who had delivered “baby Nick”. As a practice of long standing with a reputation for obstetrics, it was a favoured destination for young mothers; over nine years, Dr Chamberlain delivered approximately 1000 babies.

But that wasn’t quite enough and, in 1992, he took up the role of drug and alcohol medical officer at Whangārei Hospital, while also looking after a geriatric hospital.

Sport was also a passion, so, in 1996, Dr Chamberlain completed a diploma in sports medicine and worked with teams such as the Northland provincial rugby side. He was soon invited to join the medical team travelling to the 1998 Commonwealth Games in Kuala Lumpur.

A slow start from the New Zealand team meant the media pack were in need of a story, so they pounced when a random bug bite sent him to hospital with dengue fever.

Three members of the Australian team’s advance party also fell ill but, semi-conscious and in intensive care for five days, Dr Chamberlain became front-page news. “We hadn’t won [any medals], so I was famous for about five minutes,” he says.

Finding intensive care KL-style “an experience”, he celebrated his birthday by discharging himself. “I was nearly in liver failure by that stage and had a few months’ recovery.”

Undeterred, he was on duty again for the 2000 Olympic Games in Sydney, before leading the New Zealand medical team at the 2002 Commonwealth Games in Manchester, England.

He sees this work as among his career highlights: “Looking after and helping some of these elite athletes, knowing that, if you hadn’t made an intervention, perhaps while they were away at a Games, they may not have done as well.” (He’s not naming names.)

Back in Whangārei, he was beginning to drift away from general practice. Keen to make a difference, at this point he took on the role of part-time, hospital- based, GP liaison. But it turned him into a complaints officer: “I wanted to work on some systems things I felt good about, and which people would perceive as ‘oh wow, that’s good’,” he says.

However, at the end of the year, he would review the work he had carried out: “I had answered 68 complaints, 30 patient complaints and 200 GP complaints and, you know, what [really] had I done?”

DR CHAMBERLAIN HAD also been getting pushback from his peers. When his own practice became too busy to handle, he enlisted a few colleagues to help out, before merging it with Central Family Health. By 2003, his workload had dropped to the occasional GP locum, “and there was now a fair criticism I wasn’t in general practice the whole time”.

He looks on it as a “push–pull” situation with himself in a no-man’s land between management and medicine. However, his gaze now fixed on the big picture, he kicked off an MBA in 2003, which led to a qualification in medical administration.

“That was my second fellowship. I had my GP specialist qualification, but I really wanted this, I guess to validate what I was doing, but to also give me the opportunity to step up from an advisory to a management role.”

It is telling that the only certificates hanging on his office walls are the MBA and administration fellowship.

If he had any doubts over his career shift, they were short-lived. During the first year of his MBA, Dr Chamberlain was primary care advisor to the meningococcal vaccination programme. Once a week he would rise at 4am to drive south to Counties Manukau DHB and assist with the pilot programme.

He recalls an audit that found a 16 per cent failure rate for the temperature-sensitive vaccine. So he used what he had learned from studying ethics to urge the ministry to add $4 million to the programme’s $200 million budget to buy 1000 new vaccination fridges. It worked.

This was validation and another career highlight: “That was what I was doing at that time, probably being a bit annoying to the ministry.

“I’ve occasionally been annoying. Some people get to where I’ve got without doing that, but I don’t mean to be, it’s about challenging the status quo and having a strong sense of what’s right.”

He was still finding his way; few GPs had moved into management, so role models were scarce. When GP John Bell took a management job at ACC, Dr Chamberlain questioned why one would leave clinical practice. But he then found himself following in the footsteps of Win Bennett, another former Whangārei GP who jumped ship, by taking over as general manager planning and funding at Capital & Coast DHB in Wellington.

He lasted about 16 months, during which time he tapped into enough outrage to win a funding battle over the purchase of a linear accelerator. Homesickness pulled him home: his son was head boy at Whangārei Boys’ High School and was to give a speech at the end-of-year assembly. Dr Chamberlain had been working every second weekend so he could fly home for four-day stretches, but wasn’t there for his son’s big moment.

“I realised I was missing all these life Events…I’d been looking after the kids a lot, I had them to myself half the time, so that convinced me to return home.”

Luckily, Northland DHB was in need of a general manager of clinical services, and he held that role from 2008 until 2011, when he made the jump to chief executive, and promptly split his old job in half.

Having observed the big picture, he decided to have two GMs with planning and funding roles. “I felt very much that those GMs with expertise in, say, the health of older people should also have the contracting for community services in that area.”

Which brings us full circle to the changes now being planned as a result of the Health and Disability System Review. Dr Chamberlain is confident the review will force change, especially around equity.

He supports the majority of review panel members’ “alternate” proposal for a fully resourced Māori health authority with commissioning powers. And he hopes for a new, ring-fenced funding model for primary care that acknowledges the factors, such as poverty, that make it so complex.

While there will be GPs arguing for the status quo, he hopes they will take part in the process rather than remain on the sidelines.

“As long as [system change] is done and co-designed with GPs, with primary care, and with clinicians, rather than done to them, then it will work,” he says.

“But it’s also about what patients, family and community want, because we haven’t been great at tapping into that.

“A collective community view is really important, so incorporating that whole concept of neighbourhood, with local information informing what services they want, is really important as well.” His lead primary care role for the DHBs ensures he will have a voice in the process, and it is clear he will be pushing for big moves.

“I don’t think there has been enough change. I would say there’s been tinkering for the past 20 years…I was involved in the formation of the DHBs, and we’re nearly 20 years into that structure. I don’t mean that was wrong, but there were things in the primary care strategy that were clearly supposed to have been implemented and weren’t.”

THE FAIRER AND more equitable funding mechanisms recommended by 2015’s so-called Moodie Report on primary care, in which he was also involved, have also never been actioned.

“Primary care must be funded appropriately, and in a way that acknowledges complexity,” Dr Chamberlain says. Services in high-needs regions and for the elderly need significantly more funding, he adds.

“At the moment, funding is the same if you are living up here or in Remuera. There’s a little Services to Improve Access funding around the margins but, apart from that, there is little difference. If you are a VLCA practice, you might get a bit more, but you also have to cap your fees, whereas in wealthy areas you can charge more.”

All in all, he can only see it as a messed-up system, making cities and “nice places” more attractive to work in, and everywhere else “really hard work”.

He says models of care must be made more rewarding: “Practitioners can’t be frustrated the whole time at not having the services they need to help their patients, and there’s nothing worse than that because it causes a moral dilemma.”

Given all that, would Dr Chamberlain ever consider a return to general practice?

“Today? Maybe no. Tomorrow? Maybe. I guess I’ve been an optimist all my life, but I do believe there has to be change, and things have to get better. You cannot have the core of the health system in such difficult strife, particularly in the higher-needs regions.

“But I do get asked this and I think I wouldn’t mind doing locums again. I don’t think I’d own my own practice, I don’t think I have the energy, and I’ve still got my GP fellowship, but it’s now ‘brackets non-clinical’, so I’d need some support and training.”

Dr Chamberlain says general practice has changed immensely since he was in it. “I’m married to a GP so I get to see a bit of that. I think the big changes are around compliance, the amount of time spent on inboxes, and patient complexity.

“We also didn’t have as many accident and medical clinics taking the ACC stuff, and we were seeing a lot more children. I think it was easier back then, and you got to do cool stuff like rushing out of your waiting room and saying ‘sorry, I’ve got to go deliver a baby’ and, even though it’s wrecked half their day, they all go ‘oooh’.

“But that was another highlight, every time I delivered a baby, that was awesome, a huge privilege, and sometimes it was pretty cool when they were getting into trouble and you could help them out.”

Having a role in rebooting a primary care system might feel pretty cool as well.