Secrets, fears and empty chairs

Media outlets, feeling the early impact of online competition, had started to shrink their reporting staff. The era when reporters attended several board and committee meetings each month slowly slipped by, and hasn’t returned. Meetings also have become less frequent.

The reforms had brought communications managers into the health boards, just as it had in corporate life where public relations’ control of the messaging had long been standard practice. (See “$1million for five media releases” below)

The relationships built through reporters fronting up regularly at board meetings were well gone. Instead, a battleground was forged, in which DHBs claimed journalists were only after bad news and journalists claimed DHBs weren’t telling them anything. In the meantime, the seats reserved for the public at board meetings were mainly empty.

Waikato DHB board member Mary Anne Gill has seen it all. Her 30 years in journalism began with regional reporting for the Wanganui Chronicle in Ohakune, and later with the Taranaki Daily News in Taumarunui. Journalism runs in the family. Two siblings have made a name for themselves as foreign correspondents: Michael Field in the Pacific and Catherine Field in Europe.

Mrs Gill covered the gamut of community politics – county and borough councils and hospital boards – and loved it.

She recalls Taumarunui County Council meetings that lasted all day. At some point in the 10 hours of sitting, councillors would go “into committee” (excluding the public) to discuss a footpath or a pothole in a country road.

Mrs Gill says she would push back, not out of any sense of right or wrong but because “the public will want to know about this, because that pothole is on the road where Fred takes the kids to school”.

Moving on to the Waikato Times, she would routinely pick up a council agenda and write five or six articles ahead of the meeting, much to the chagrin of councillors wanting her to wait until they had discussed the matters.

No, was her reply; the information is in the agenda, it’s public. She was well known for fighting council attempts to keep stuff out of the public eye.

Her next role, communications manager for Waikato DHB was, she says, a shift to the “dark side” (journalism-speak for public relations). She got a closer look at agendas and became a stickler for common-sense language, telling managers, if she couldn’t understand the agenda, they couldn’t expect the board or the public to understand it.

“Sometimes I would win, sometimes I wouldn’t,” she says. “Sometimes greater minds than mine would prevail.”

She would identify the agenda items that might get media interest, and tip off the media. Some reporters might have been suspicious of her intentions, but she says it was her reporter-self passing on what she felt was “quite a good story”.

When the board held discussions involving money – for example, the purchase of new machinery – it would automatically go into committee. The reason cited would be the need to discuss contractual issues around a tender going to market. But Mrs Gill questioned that, and says she continued to do so in her next role – as an elected board member.

Right from her first meeting, she says, she pushed back. She noted the board was planning to discuss some agenda items in secret because, it appeared, someone felt uncomfortable discussing them in public.

“I get that you keep the price out of it, but don’t put the whole paper into committee simply because at some point you discuss prices,” she says. “In fact, let’s have the discussion in open [meeting] about the need for [the new service/machine] and what’s driving it.”

Organisations hold meetings behind closed doors because they think it is less risky.

“So you get your typical bureaucrat, looks at the paper and thinks, Oh, we’re mentioning that we are going to have to consult with contractors. So, boom, put that into committee.”

Mrs Gill doesn’t believe there is anything inherently sinister about matters discussed with the public excluded.

But why is it an initial fallback position? Mrs Gill says confidentiality is drummed into the board from the start. It becomes a mindset. There are people who have been on councils and they come from a different environment and they will push boundaries.

Pushed on what fear gives rise to the risk averse behaviour, Mrs Gill says, “I honestly can’t put my finger on it. One of the things I said quite regularly as a communications manager is ‘we need to front foot this, this is our story’.” Sometimes it comes down to the personality of the chief executive.

I just can’t see the ability as a board member to make a huge difference. It is just really limited – Mary Anne Gill

AGENDAS MATTER. They are the first port of call for a member of the public wanting to engage with DHB governance.

The New Zealand Public Health and Disability Act allows DHBs to exclude the public from all or part of a meeting for various reasons, and refers to the Official Information Act. The Crown Entities Act provides a framework for the governance of crown entities, like DHBs, and for accountability.

Rules around how meetings should be run are provided by the State Services Commission.

An official information request by New Zealand Doctor to all DHBs reveals they know the rules.

Here’s a typical scenario, described by Bay of Plenty DHB legal executive Cherie Martin. When an executive team member submits a paper for the agenda, they identify whether it should be discussed in the public or confidential session. The chief executive and chair then confirm which items will be dealt with out of sight of the public.

The board secretariat and in-house adviser then identify the relevant clause in legislation that applies for each item to be discussed behind closed doors. The board chair is ultimately responsible for making the decision.

As a past chair of two DHBs – Counties Manukau and West Coast – Gregor Coster has made many calls on what subjects appear where on a DHB agenda.

Like Mrs Gill, Professor Coster cites commercial activity as an area where the public will often be excluded; issues relating to health and wellbeing of individuals and matters relating to fraud are also mainly discussed in closed sessions.

While chair of Counties Manukau, he created a policy paper on making these decisions; he introduced the policy at West Coast DHB.

He says it might be appropriate to discuss privately whether a certain building contractor should be awarded a contract to build, say, a mental health unit. But the board can go back into public session to resolve that the tender be approved. Any prices will show up in the books eventually, so the board might as well make them public, he says.

It’s clear boards differ greatly on how risk averse they are with agendas, Professor Coster says.

He doubts any holding back of information is driven by central government politics. In his experience, health ministers of various hues support DHBs being as open as possible.

“I’ve seen a strong desire to see as much discussed in public [as possible], consistent with the purpose of the act. They are publicly elected boards, they are there for a reason.

“The principle should be, if this can be in public, then we should do it in public…if you believe that, and don’t use the public-excluded option to hold three-quarters of your meeting with the public excluded, then I think you’re on the right track.” (See “How secretive is your DHB?”)

If a decision is passed in a public session and no one is there to hear it, is it secret?

If someone takes the time to read the agenda, the minutes should reveal decisions made and acted on in the public part of the previous meeting. And it’s worth remembering, board meetings are a tiny part of the business of running a DHB. There are other avenues for accountablity and transparency – the annual plan process, the annual grilling by the health select committee and consultation on specific processes.

As New Zealand approaches local body elections later this year – with DHBs included – a few people may trickle in to board rooms to have a listen. But voter turnout figures suggest the romance with elected boards is dying.

In 2001, 50 per cent of eligible voters placed a vote; in 2016, 42 per cent did. The New Zealand Herald surveyed DHBs last year about the cost of the 2016 board elections; 13 responded, the cost totalling $3.59 million.

Mrs Gill last year called on the Government to defer this year’s DHB elections while the Health and Disability System Review is under way, given the review is likely to make changes to DHBs.

In response, health minister David Clark told the Herald he did not want to prejudge the review outcome, and any changes decided on would take time to implement. Strong governance and leadership would be needed through any transition period, Dr Clark said. Postponing elections would create “unnecessary uncertainty”.

In 2017, the 209 DHB board members – 140 of whom were elected – and four commissioners were paid almost $6 million for 30 days of work each year, according to data gathered by the Herald.

By comparison, up to $60 million went on the salaries of 231 chief executives and their senior executives.

But the issue isn’t so much cost as effectiveness. Once elected, board members are often surprised to find they’re highly constrained in how much they can do.

Starting with the minister’s letter of expectations, board members receive a lot of direction. The Ministry of Health tells them how many cases most of their board’s various services can care for, and what they will get paid to provide.

Mrs Gill says she understands why, in 2001, the Labour Government wanted to go back to the old hospital board days, when community people on boards actually decided the health needs of their communities.

But that’s no longer how it works. Board members have a small amount of control on discretionary spending, she says. Waikato DHB would not be free to initiate another scheme like its lifestyle innovation Project Energize, a big success for the region.

The system is wrong, for many reasons, Mrs Gill says. “When people vote, they don’t know what the hell they are voting for.

“The people who stand say, ‘I’m going to stand on the platform where I’m going to get more health services for Taumarunui’. Well, it’s just not going to happen.”

She wanted to work inside the system, and point out it’s wrong. “I’m not standing again,“ she says, ”not because I think I’ve been useless. [It] sounds silly, [but] I think I have made a difference in some of the things I have said.

“But I just can’t see the ability as a board member to make a huge difference. It is just really limited.”

WHICH RAISES another problem facing DHBs: the level of interest in being a board member.

Of a board’s 11 members, seven are elected and four appointed by the minister. Two board members should be Māori.

University of Otago health policy researcher Robin Gauld says the initial rush of interest from people wanting to stand when the DHBs were established has diminished over time.

In 2001, 1084 candidates stood; by 2004, the number had almost halved to 518; and, in 2007, 428 people stood for 147 places. By 2016, the last time DHB elections took place, 363 candidates vied for 133 positions.

The shortage of candidates is perhaps not surprising. State Services Commission guidelines list the desirable traits in a board member; there’s a lot to live up to.

The list includes: a wide perspective on, and awareness of, social, health and strategic issues; integrity and a strong sense of ethics; financial literacy and critical appraisal skills; strong reasoning skills and an ability to actively engage with others in making decisions; and good written and oral communication skills. Ideally, these skills will have been honed through governance and manage-ment experience at senior levels.

For Māori board members, there are additional challenges. In her 2013 Massey University doctoral thesis on the experience of Māori DHB board members, Joy Panoho points out, despite the intention that DHB boards would all have two Māori members, the legislation requires only that the minister “endeavour” to ensure at least two Māori members. Not all boards meet the requirement.

In a media release, Dr Panoho explains the Māori directors she interviewed felt burdened by the responsibility of being the sole advocate for Māori health on their boards, being “a walking Treaty workshop”.

“Many felt there was little cultural or historical understanding of the damage to Māori health brought about by the process of colonisation. Māori directors have valuable grass roots experience that is an important strategic tool for DHBs. This experiential capital is as valuable a resource contribution as, for example, a law degree or an accountancy degree.”

Dr Panoho’s interviewees recognised that, without the legislation, there would be little or no Māori representation.

“All participants recognised the importance of having a seat at the table, even though progress was, at times, hard to measure,” she writes.

“Most felt, overall, they were having a positive impact and there was an opportunity to change attitudes and help turn Māori health statistics around.”

Professor Coster, who was appointed to the boards he chaired, says health boards are richer for having the community perspective provided by elected members. But he has concerns about the board structure.

The quality of representation achieved through elections is the problem, he says.

“I’ve met some wonderful board members whom you are delighted to work with, and others where you go, ‘I think they’re a waste of space.’”

He cites board members with a penchant for disappearing in the middle of board meetings for an hour to conduct their own business. “I find that disrespectful of the process, having been elected by the public.”

Board composition requirements leave little leeway to ensure sufficient board members have health expertise. Given boards are dealing with multimillion-dollar budgets, that’s a problem.

And it’s a problem likely to get worse if the Health and Disability System Review recommends fewer DHBs.

Unlike local government, where councillors often come up through community boards, gaining more experience and expertise as they move up, health representation is very specialised, Professor Coster says.

He’s happy with 11 members per board but would like to see the balance between appointed and elected at six and five (or vice versa), and the 20 DHBs reduced to six.

“You are dealing with stuff like mental health, and this is something that has to be taken very seriously. It would be nice to have, I think, a few more people with expertise in the right areas on these boards.”

Board competency is a perennial issue.

In 2015, the New Zealand Health System Independent Capability and Capacity Review, commissioned by the Ministry of Health, noted the DHB board structure “presumes competence in governance and leadership, including from elected members”. But this appears to be lacking in practical day-to-day execution, the review team said.

It suggested reducing the number of board members to nine. The current mix did not respect the leadership requirements to competently operate large, complex organisations.

It warned that where boards lack competence, executive managers can have too much influence on decisions.

But, in suggesting the number of board members should drop to nine, the review also recommended a convoluted system to ensure a public voice on boards. This would see the minister appoint six of the nine members; the remaining three would be rotated onto the DHB board fora staggered six-monthly term from a community advisory board. Advisory boards would consist of 12 members, elected by the community every three years.

How did it get so complicated?

At Victoria University’s Health Services Research Centre, director Jackie Cumming says boards’ historical community emphasis has been replaced by accountability to the minister. This affects the degree of openness, Professor Cumming says.

She notes that DHB elections can be damaging to groups that fail to gain representation.

Community councils were proposed to improve public input, but have been slow to develop. Some are doing okay, while others are “terrible”, she says.

Some are also picking up bad habits. The Hawke’s Bay DHB Consumer Council meetings include items with the public excluded.

The councils are intended to provide input into service delivery, but Professor Cumming says the way the system works “is a bit of a joke”.

“We have no way of knowing if something is impacting on service delivery; we have to take [DHBs] at their word.”

The fact new money often comes with the minister dictating where it should go makes a nonsense of the community being able to have a say in it, she says.

While the problem of naivety and lack of skills in elected board members is often cited, Professor Cumming says these characteristics are just as likely in the members appointed by politicians.

If I think I was going to end up back in the compliance and financially driven model, I would have little interest in going back – Richard Thomson

DUNEDIN BUSINESSMAN Richard Thomson has been both elected and appointed, and also sacked, three times, from roles on health governance boards.

His first ousting was in 1990, when the then health minister Simon Upton dumped area health boards altogether in advance of the rollout of National’s market-driven health reforms.

Then, in 2009, National health minister Tony Ryall sacked Mr Thomson as Otago DHB chair, holding him accountable for fraud by senior staff at the DHB. Mr Thomson could stay on the board in spite of the minister, thanks to having been elected onto it in the first place.

Six years later, as an elected member of the Southern DHB board, he was sacked along with his fellow board members by National health minister Jonathan Coleman over the board’s financial struggles. He wasn’t out of the picture for long. New commissioner Kathy Grant appointed him a deputy commissioner. (The other deputy, Dunedin accountant Graham Crombie, died last month.)

Mr Thomson is careful choosing his words when asked which system he prefers. He says the elected model enables people to stand up for public opinion. “That may or may not be a good thing,” he adds.

But the DHB with its 11 members is an unwieldy body for both management and the public to engage with, he reckons.

The commissioner system has been much more satisfying for him personally, in terms of real engagement. Mr Thomson attributes that to the Southern DHB’s team approach. It’s a dynamic that has worked well, he says; commissioners have held regular public meetings.

“We take the view that, if we don’t engage with our public or staff, we have no hope of making meaningful change.”

And, while the DHB does not have board meetings per se, it has continued to run the board committees.

Mr Thomson is animated about the potential for changes that would not have been possible in previous board incarnations.

However, time is running out. The legislation that set up the Southern DHB commissioner expires this year. There will be elections for a new board in November.

Will he stand again?

“I think if I believe we can continue work we are doing around trying to transform the system, I would have some enthusiasm. If I think I was going to end up back in the compliance and financially driven model, I would have little interest in going back.”

Putting it more passionately, he says, “It would break my heart to go back to that kind of approach.”

University of Auckland health policy researcher Tim Tenbensel is more exasperated. Elected boards are just not having any effect, Dr Tenbensel says.

They have already disappeared from similar jurisdictions such as Australia and Canada.

If boards were making decisions that really mattered to people in their area, people would be at the meetings, Dr Tenbensel says.

“You can tinker with the structures, maybe give elected board members particular areas of interest but, ultimately, what do they have control over?”

Is it worth the time and money worrying about secrecy in boards, and tying ourselves in knots trying to find the right democratic structures, when DHB boards can do little of their own accord, other than deciding on the contractor for a local development?

If elected boards are to remain, a reset will be needed.

Democracy needs openness to breathe. Boards’ risk-averse, batten-down-the-hatches lack of transparency has to go.

Relationships may never run smoothly between DHBs and the media, but access to information should be the norm.

“Beam them out,” says Professor Cumming – in other words, livestream DHB board meetings. This, she says, would be a great start. “Give people more of a chance to see what is happening, and they might be more inclined to have a say.”

The justice select committee last year used Facebook to livestream hearings on cannabis legislation and the Treaty of Waitangi has livestreamed hearings held for the kaupapa inquiry into health services and outcomes.

Many of the country’s councils routinely livestream meetings; Taupo District Council got the ball rolling in 2010. Some use internal video systems, others use YouTube to broadcast and archive meetings.

Figures quoted in 2017 for the small Westland District Council show an initial set-up cost of $16,700 and an annual cost of $3700 based on one meeting per month.

At Auckland City Council, meetings are streamed; in February, viewer numbers ranged from 0 to 152. It’s not possible to say how many of those watched the meeting “live” or later, or for how long. But even a handful of viewers compares pretty favourably to the empty chairs seen at most DHB meetings. Broadcasting also has the effect of lifting councillors’ game and providing media with the opportunity to cover meetings.

Bigger questions dog the whole matter of board effectiveness. Professor Cumming says these include, “what is the place of the board meeting; does everyone contribute; how much time is spent on strategic versus operational issues?”

Technology will increase the channels for informed citizens to give feedback and input. Nearly all DHBs – with the exception of Lakes – have some form of social media.

And surely the onus lies with the elected representative to ensure views are heard, not with the individual citizen to battle to be heard.

Dr Tenbensel considers elected representatives in smaller towns might have more impact but, with huge boards like Auckland’s, he wonders whom the elected representative is actually representing.

Democracy is a precious thing and, even if it is a remnant from a quaint time of local hospital boards, no element of democracy should be dismissed lightly.

Professor Gauld says locals may not show up to vote in the DHB elections, but politicians know they will rally around if their local health services are threatened.

Elected boards, no matter the quality of the governance, are a symbol of communities taking a “last stand against the marketisation of New Zealand health care”, he writes in the book Democratic Governance & Health, co-authored with Miriam Laugensen.

He also notes the current model allows governments to claim victory for local successes while it also deflects to the DHBs any blame for failures and controversies.

That would be hard to give up.

The DHB board table is also of value to Māori, as seen in Dr Panoho’s research.

Enough time may have elapsed since the market-led reforms that the public will end its affair with elected boards, or be happy with another avenue of transparency and ac-countability such as livestreaming of meetings or regular public forums as the Southern DHB uses.

Professor Cumming sees no sign of people’s interest in health services abating. With the growth of long-term illnesses, and as people have fewer episodic interactions with health professionals, interest in what is happening with services, and why, can only grow. Primary care and mental health services are set to have an impact on a much wider group of people and their families.

Accountability will be called for and, as Professor Gauld points out, politicians have been happy to have that at arm’s length.

When I catch up with Mrs Gill a few months after our initial chat, I find her more upbeat about boards.

She explains that not long after we first spoke, she attended a presentation to all of the Midland region boards by Heather Simpson, the health economist chairing the Health and Disability System Review.

“Her opening salvo was ‘there is nothing in the legislation preventing boards making significant decisions about the health of their people’, which is amazing,” Mrs Gill says.

“I was heartened by that.” Heartened to the extent she is now concentrating on some projects she wants to see through before she finishes her term.

Much is riding on the review. Ultimately, Professor Coster says, the public will decide in next year’s general election whether they are happy to support any proposed changes arising from its recommendations.

“Where that lands is anybody’s guess.”

This feature and a related report were written with the support of a Voyager Media Awards nib senior health journalism scholarship awarded to Barbara Fountain in 2018.

DHBs should routinely not be holding three-quarters of their meetings with the public excluded – Gregor Coster

To measure DHBs’ preference to stay out of the public gaze, I looked at how much time in DHB board meetings is spent with the public excluded.

The plan was to take 12 months of board-meeting minutes for each DHB and use the recorded meeting start and finish times, and the time at which the meeting excluded the public, to come up with an average length of meeting and an average length of time with the public excluded.

I would then allocate a score to the exclusion time as a percentage of the entire meeting, scoring the most open at 0 and the most secretive, 100.

Tracking down the minutes is the first challenge. If you were an organisation wanting to engage people in your decision-making, a big red button with the words “decisions here” could be a winner. But on many DHB websites, to get to meeting times, agendas and minutes is a “click fest”, typically starting with the “About Us” button.

Even with the minutes, the plan to score DHBs falls to pieces because, as with so many DHB data, there is no consistency.

Only one DHB, West Coast, provides the time a meeting starts, the time at which it excludes the public, and the time at which it finishes.

Specifically, over the year, the average length of a West Coast DHB board meeting was just over three hours, broken down into one hour and 22 minutes open to the public and one hour and 42 minutes with the public excluded, during which time board members also took a 30 to 40-minute lunch break.

Being generous, I don’t count lunch break, and come up with a score of 43, putting West Coast towards the “open” end of my scoring system.

As to the rest of the DHBs, information is patchy. Counties Manukau gives no indication of the length of its meetings. Waikato, Lakes, MidCentral, Tairāwhiti and Taranaki mention only the time when meetings start.

Auckland and Northland sit for a total of about four and a half hours, but don’t indicate the time at which they close the doors to the public.

The remaining DHBs give meeting times ranging from one hour to 165 minutes; I assume this is just the public part of the meeting.

Despite suspicions that key decisions are made away from board meetings, few DHBs reported, when asked, that board members meet regularly outside the scheduled board meetings: a training day here, a planning day there.

Former DHB board chair Gregor Coster suggests, as a yardstick, DHBs should routinely not be holding three-quarters of their meetings with the public excluded.

But long and detailed conversations with the public excluded should not be automatically viewed as suspicious, Professor Coster says.

Complex and thorny issues need long debate, he says.

As a board chair, he always sought consensus, feeling it was important boards acted as a single team and everyone was in agreement with decisions made.

There is little relationship between the size and cost of a communications team and the number of media releases produced

Counties Manukau DHB’s communications team cost $1.093 million in staffing in 2016/17. That year it produced five media releases, eight fewer than the year before.

Annual figures supplied to the health select committee last year show huge variation in the use of media releases by DHBs as means of communicating with media and the public. They also show little relationship between the size and cost of a communications team and the number of media releases produced.

As part of its annual review of DHBs, the health select committee seeks answers to more than 160 questions, including the number of PR and/or communications staff, contractors and consultants used and how many media releases were released in the financial year and previous years. Given the size differences, it is difficult to make direct comparisons between DHBs. A lack of consistency in data exacerbates the problem. For example, some DHBs specifically state they include or exclude regional public health communication costs. Others don’t.

Counties Manukau DHB was not the only one sitting on five media releases; Hutt Valley produced the same number but at a staffing cost of $182,847.

South Canterbury also produced five media releases (with a staffing cost of $80,000), but explained the low number was due to a good working relationship with local media. Presumably, the DHB communicates by talking to reporters rather than through emailed statements.

Included in the Counties Manukau total is a salary of $212,000 for a “media relations” staff member. Not included in the total, but also supplied by Counties Manukau, is another $351,059 for the then busy communications staff of innovation centre Ko Awatea. The subsequent ditching of the sector quality and innovation conference, the APAC Forum, run by Ko Awatea, and controversy over building costs has seen the centre’s communications merged with the DHB’s. Also excluded was $375,1999 in outsourcing.