Diana the undaunted: Chocolate fish, reforms and the shadow of Sir Ashley

On her first day as director-general of health, Diana Sarfati loaded a plate with chocolate fish and walked around her new workplace, introducing herself to colleagues.

A tour of the sprawling Ministry of Health buildings on Molesworth Street took longer than the one hour she had expected, but it was worth it.

Her father, retired GP John Sarfati, tells New Zealand Doctor Rata Aotearoa: “She got to one person who said to her, ‘and what team do you work for?’”

The clueless colleague was so embarrassed they refused to tell Dr Sarfati their name when she asked, but was dobbed in by co-workers.

“But, you know, this is all taken in good fun,” Dr Sarfati senior says.

The anecdote speaks to one of his daughter’s strengths, he says – a good sense of humour. “She can laugh with people…I don’t think she takes herself over-seriously.”

It’s one of the attributes that make her a good leader, says her dad. “I think probably the critical things are, one, she’s a team player and, two, she has a sense of humour – they’re quite important, actually. I would add a third one, integrity.”

He adds, jokingly: “And she has a very good father.”

Dr Sarfati stepped into the role of director-general of health on 1 December 2022, having acted in the role for six months after the retirement of Ashley Bloomfield. Dr Bloomfield would go on to become Sir Ashley for his high-profile health leadership during the arrival and early years of the COVID-19 pandemic.

You would think these were formidable shoes to fill. Dr Sarfati doesn’t see it that way.

“He was the right person, in the right place, at the right time, and he did a fantastic job,” she says. Her own job is different, “so I don’t have any sense at all of stepping into his shoes”, she told New Zealand Doctor in a Zoom interview late last month.

The pair are old friends and are in regular contact – she describes him as a great sounding board. But she has “no wish to be high profile” in the way he was, with constant media appearances leading to his adoption into popular culture via tea-towels, T-shirts and mugs.

“If I become as high profile as Ashley, something has probably gone wrong,” she says.

Approached for comment for this article, Sir Ashley politely declined, saying he didn’t think it would be appropriate and he didn’t want to take focus away from Dr Sarfati.

COVID-19 largely dominated Sir Ashley’s time in the role, but its relative importance had started to wane. “[The] focus needed to shift to the reforms, so that’s my focus,” Dr Sarfati says.

If I become as high profile as Ashley, something has probably gone wrong

It’s “an exciting time” to be leading the health sector, she says. “There’s lots going on. It’s really exciting to watch the health system evolve and transform towards what it will look like once we are through these reforms.

“I think the reforms create extraordinary opportunities for how we deliver health services. Having said that, the health system is a big and complicated beast and those changes won’t happen quickly so it will take a while to be able to make the changes and bed down those changes in the short term in order to be able to get the benefits in the medium term.”

She says the reforms are at the “difficult transition bit” but are going well, with some benefits already being seen. For example, it is already easier to move patients or clinicians around to adapt to staff shortages by having a national view of the system and removing some of the bureaucratic barriers.

Addressing workforce shortages will also be easier, by taking a national view on recruitment instead of 20 DHBs competing for the same people.

“And, in addition to that, we’re seeing the iwi Māori partnership boards being set up, which will be an extraordinary mechanism to make sure we can deliver services in a way that serve Māori well, and with Te Aka Whai Ora in place they’re really focused on that.”

Bedding in the reforms and addressing the workforce crisis are the two biggest challenges and priorities of her five-year term, Dr Sarfati says.

“The system is under pressure as a direct result of those workforce issues. These are found everywhere in the world at the moment, so it’s a global phenomenon, which adds to the challenge – because if it wasn’t a global phenomenon, it would be easier to bring people in, at least temporarily, to fill gaps that we might have now.”

Health workers are “doing an extraordinarily good job” under difficult circumstances, she says, so the goal is to increase numbers in general, but also to support and grow the domestic healthcare workforce.

Looser immigration settings would help with attracting international workers, as would funding nurses to return to the workforce for short stints, she says. The ministry is also looking into health professional scopes and regulatory systems.

“But, in terms of growing the workforce, you can’t just suddenly discover another 1000 nurses in New Zealand and, ultimately, we want to be growing our own workforce, so that’s the goal. But again, it will take some time.”

Growing the workforce is “top of the agenda” for the ministry, Te Whatu Ora and Te Aka Whai Ora, she says.

“There are a whole lot of actions going on at the moment at each of those short, medium and long-term time horizons…[We] just need to be able to make sure we can get the numbers of people in the health system that we need, that we support them to stay, we acknowledge how incredibly important they are to us and to the population that they serve.”

Dr Sarfati was inspired to go into medicine after watching her father – “an old-school, white-coat wearing, home visiting” GP – at work when she was growing up in Wellington.

“He had patients he delivered and then he watched them grow up and then delivered their babies in turn,” she says, describing him as “extraordinarily committed to his calling of medicine”.

So much so that, at the age of 87, he still spends a day each week studying to keep up to date with latest developments.

As a child, “I just thought that looked really cool”, Dr Sarfati says. She especially wanted “to know the stuff he knew”.

“If there was a car crash, dad would get out and he would know what to do.”

She decided at a young age she would be a doctor, and “then I never really shifted from that”.

Her career took a different trajectory, though. Graduating in medicine from the University of Otago in 1991, she worked as a hospital doctor in New Zealand and London, then specialised in public health medicine and became an academic.

At her alma mater, her research focused on how the health system works, on inequities and how they can be addressed and, increasingly, on cancer systems.

She was appointed chief executive of Te Aho o Te Kahu – Cancer Control Agency in late 2019 and guided the cancer response through the COVID-19 pandemic.

A response that medical oncologist and University of Otago professor Chris Jackson says was “truly world class, and better than almost every other country in the world”.

“As a result of that leadership, we saw almost no significant reduction in cancer diagnoses or treatments delivered in New Zealand, which was a true international outlier,” Professor Jackson tells New Zealand Doctor.

“Whenever I meet with people internationally around cancer outcomes, they go, ‘how did you guys do that?’ and the answer is Di’s leadership and the cancer agency and the team there. So, it’s been a massive success, in my opinion.”

Professor Jackson, who has worked closely with Dr Sarfati for 10 years through their respective roles in cancer, says she is a “true international intellectual heavyweight”.

Her move from academia to the public service was a huge personal risk, he says.

“[She] will bring an ability to synthesise extraordinarily complex information, distil difficult concepts quickly, to apply a rigorous evidence-based approach to many issues, to be diligent, hard-working, extraordinarily fair, thoughtful, thorough, and with an engine for hard work like no one I’ve ever seen, so I think she will be wonderful.”

Professor Jackson adds: “I think the impact she will have on the New Zealand healthcare system will be profound and we’re lucky to have her in that role.”

Dr Sarfati herself says she never mapped out a career path but has simply taken up opportunities that came her way.

When working clinically, she discovered an interest in cancer through oncology and palliative care. Then through her research on how health services work, she found cancer was a good barometer of the system as a whole.

“With cancer, you’ve got everything from primary care and presenting with symptoms, and prior to that you’ve got a whole lot of elements you can prevent…and then treatment at every level of the health system – pathology services, radiology services – there’s really no part of the health system that isn’t involved in that model of care, if done well. And it has to work well together.

“So, it is quite a good model for thinking about how the health system in general should work ideally.”

Dr Sarfati, who has three children (now adults) and is a keen CrossFitter, has spoken previously about how addressing inequities in the system has been a motivational force in her career.

Asked if she will be able to make a difference in her role, she says: “Achieving equity is a foundational part of the new health system reforms, so I think there is a really good opportunity here to make substantial gains in equity.

“It’s a group effort, so I’ll be working alongside my colleagues in Te Aka Whai Ora and Te Whatu Ora and others, but we have better structures and mechanisms to really change the way we deliver care, and I think there’s a number of advantages to that.

“There’s the obvious one of reducing inequities and making sure that people get the care that they need and that outcomes are similar regardless of who you are and where you live.

“But also, if you focus on addressing inequities and you focus on making the health system more responsive to people, more available to people, more acceptable to people, that’s actually going to improve the health system overall. So, it’s a win-win.”

Dr Sarfati is clearly driven by wanting to make a difference, Professor Jackson says, “and I think she does every day” – not just through policies and programmes, but in the way she treats people.

“She’s respectful, warm, she’s quite funny and she has great qualities of a leader,” he says.

“She’s got a nose for bullshit and can sniff it out at a hundred miles, and is demanding and exacting of the people around her to make sure they deliver highquality work.”

Outspoken as an academic, Dr Sarfati will be constrained in her current role but, he says, her impact and influence will be far greater in the public service. “[She] doesn’t need to be heard [publicly] in terms of her words, because you will see her fingerprints on everything.”

Her father is not worried about the pressures of the role or its potentially high-profile nature, saying: “Oh no, she can cope with that very easily.”

He describes her as capable and conscientious, and someone who inspires others.

“I think she’ll do very well,” he says.

“Her mother [Phillippa, a lawyer] died a couple of years ago. She would have been very proud of her daughter.”