The ship with no captain: Health’s two sides struggle for the helm

Tension becomes a problem when those starting from each side regard the motivations of those on the other side as mercenary or venal

We have just emerged from a year of strained relationships between the government agencies responsible for our publicly funded health services and the professionals who deliver them.

It’s tempting to lay the blame at the door of individuals – and some blame, no doubt, was due. But much of the discord arose out of inevitable tensions between health professionals and government officials.

While many issues of policy substance were raised during 2017, just as important was a fundamental question about health policy processes.

In short, how should the ship of state, in health, be steered?

On the one hand, because governments are accountable for close to $17 billion of spending on health – more than 20 per cent of public expenditure – they are expected to, and entitled to, call the shots.

The contending view is that the health system is, ultimately, a product of the work of health professionals, such that substantive change can be built only from the bottom up.

To understand this basic tension, a look at the history of health services in high-income countries is in order.

The medical profession developed the enduring, fundamental architecture of health services and systems in the early 20th century.

Governments entered the picture between the world wars, when paying for medical services was beyond the means of even the middle class.

They did this either by regulating the emerging health insurance industry (as in many European countries), or stepping in to pay for healthcare directly (as in New Zealand, UK and Canada).

In countries where taxation became the dominant means of funding health, governments assumed a heavy mantle of responsibility. As Nye Bevan, the key architect of Britain’s National Health Service, commented in the 1940s, “the sound of a dropped bedpan in Tredegar will reverberate in Whitehall”.

Dropped bedpans, or at least their modern equivalents, make for sure-fire headlines, so health policy presents governments with a high degree of political risk.

Even so, for the remainder of the 20th century, governments had remarkably few levers for steering health policy other than to build more bits and pay more staff.

In primary care, GPs did what they did and sent the government the bill for some or all of that work.

For hospitals, governments wrote the cheques, but exerted little control beyond that.

In New Zealand, when the direction in which the health system sailed was the product of multiple individual clinical decisions, the systemic effects included: large gaps and inequities of access; limited understanding of why many citizens (and Māori in particular) were not accessing services; major inefficiencies and regional inequities; and inability to deal with the increased prevalence of multiple, chronic conditions.

The move to exert substantive control over health policy – to set sail for improved population health, reduced inequities, improved efficiency or any other goal – began in earnest in the 1980s.

Democratically, this was an important development. Despite such motivation, however, there is no guarantee government agencies have the necessary capacity and capability to steer effectively.

Indeed, the track record of governments (in New Zealand and elsewhere) being able to deliver substantive health policy change is rather sobering.

Often, the ambitions of governments (for better or worse) are thwarted during implementation. When this happens, some blame poor policy design, while others blame the inertia, fragmentation and/or material interests of health professions. Usually, there is an element of truth in both these explanations.

In our high-stakes Westminster political system, this tension between government and health professionals is a permanent backdrop to health policy, and persists, whatever the particular views and attitudes of individual bureaucrats and those who work at the coalface.

Tension itself is not a bad thing. It becomes a problem, however, when those starting from each side regard the motivations of those on the other side as mercenary or venal. This ill will becomes more likely when the sector is put on meagre rations over a sustained period.

By contrast, good health policy processes are built on the possibilities of creative tension. Change cannot be created without the willing and committed participation of those representing the State, and those articulating the views of the health workforce.

This is when protagonists acknowledge the legitimacy of the others’ starting point, but then work to build a rationale for change that makes sense to both sides.

We are lucky in New Zealand that we do not have highly structured, interest-group bargaining in health policy, which generally clogs up the gears. This means we have a better chance of getting productive health policy processes. We just haven’t seen enough of them yet.

Tim Tenbensel is head of the health systems group at the University of Auckland