Glass walls and health calls: A saga of moving and managing

Now it is just Lester, one of the few folk in the upper echelons of the health sector to be recognised by a single name

It has been a crazy fortnight.

After a bout of COVID-19, I returned to the office to start packing it up and make the move to our new home in the street with a name like a silent-screen movie star, Augustus Terrace.

At a point in that process, I managed to walk full force into a glass wall. Hey, it was a sunny day, and the glass was spotless and the new opaque film trumpeting its existence was still in transit.

A lump, which started out closer to the size of a golf ball, has been gradually receding on my forehead. I’m going to blame that unfortunate bump for my struggle to focus on exactly one thing for this editorial.

I find my mind zipping between a number of issues. Corporate ownership – are its days numbered? PSAAP-ing across the universe – is that even a thing? What the heck is heated tobacco, and why does it deserve to have its excise tax cut in half?

And that was all before health minister Shane Reti announced the ascension of recently appointed Te Whatu Ora board chair Lester Levy to the role of health czar, that is, Te Whatu Ora commissioner.

It’s not a great surprise – most of the board had resigned or chosen not to stay on at the end of their term. But, still, given the attention to ensuring the appointed board had the required mix of skills needed to run a large, multidisciplinary, multibillion-dollar enterprise employing 90,000 people and contracting another 300,000, it was a surprise to see the board shunted aside so easily.

Now it is just Lester, one of the few folk in the upper echelons of the health sector to be recognised by a single name. Lester and his hotline to the health minister (and possibly another to the prime minister).

For now, it appears chief executive Margie Apa will stay, which when you read the Cabinet paper explaining Dr Reti’s decision to bring in a commissioner, is a little surprising. The board comes in for heavy criticism but so does senior management. Nevertheless, while Ms Apa is staying to shepherd in Lester’s changes, the drive to reduce the hierarchy between herself and the patient, from the current 14 levels to six, means a number of the managers in the tier beneath her will go, either to more regional roles or out of the system altogether. And spare a thought for the seemingly valueless masses – the “backroom” workers – who are routinely painted as expendable by virtue of the fact they do not lay hands on a patient. It’s a go-to rhetoric for the politicians but out of step with the fact most people working in the sector are trying to do a decent job – the lack of leadership does not lie at their feet.

The key facts of the board’s demise detailed in Dr Reti’s Cabinet paper are as follows: Te Whatu Ora is overspending at a rate of $130 million a month; at that rate, it would be expected to face a $1.4 billion operating deficit by the end of 2024/25; and without action, the agency will exhaust its cash reserves.

Additionally, attempts to constrain spending have failed; the highly centralised model was problematic, cutting out clinical voices and local expertise; performance reporting was ineffective; governance oversight and transparency were lacking; and IT was a shambles.

Can it get much worse? Yes. The agency must now save that $1.4 billion, which assumes that the anticipated $1.4 billion deficit was due to profiligacy and not a sign that the system remain seriously underfunded.

Where does this all leave general practice and primary care?

In his letter of expectations to Lester as chair, which remains in place, Dr Reti called for “resetting the direction for primary and community care and iwi Māori partnership boards”.

Unless Lester does what no other senior health official has dared – except for some in Canterbury – and follows the evidence and raids secondary care in favour of primary and community care, that “resetting” is likely to either be further delayed or be conservative at best.

The Government’s shifting of more healthcare costs to patients through increased practice copayments – in the wake of an inadequate capitation increase – gives little hope of substantial change ahead for primary care. Unless, that is, an epiphany occurs.

And something must happen. If the large networks continue to haemorrhage staff and increase reliance on locums and telehealth, their costs are going to balloon and there is no guarantee their owners will want to continue in the market. For smaller networks and practices, the spectre of “walking away” will loom. For patients, it adds up to longer wait times, less access and higher costs.

In the meantime, as Lester goes looking for his $1.4 billion, he might consider (a) reinstating the excise on heated tobacco – any little bit helps – and (b) checking the small print in the contract of consultants EY, the agency that drew up the current structure.

Ultimately, what started as the Simpson Report called for by former health minister David Clark, was reshaped by EY consultants working in the Department of Prime Minister and Cabinet, then morphed into the big Little revolution courtesy of former health minister Andrew Little, then shepherded briefly by Ayesha Verrall, has now become Dr Reti’s reform.

While the minister has been adamant he is not about to restructure the system again, the changes announced represent the start of a clear change in direction from the path travelled in the last two to three years. Time will tell whether Dr Reti will be the minister to see these reforms out.