Getting the health system culture right; aligning moralities

In order to function effectively health systems require two aligned ‘moralities’ – internal and external. ‘Internal moralities’ reside within the ethos of its workforce.

This characteristic spirit is manifested in attitudes and aspirations through what is often referred to as professionalism. The spirit of this culture is reinforced by the colleges and associations that health professionals belong to..

‘External moralities’ define the overall parameters of health systems, including distinguishing characteristics. They  begin with legislation.

It is from these two moralities that health systems get their two cultures. The first (internal morality) is the culture of those who actually provide healthcare, predominantly health professionals, along with enabling managers and support staff who work with them.

Health moralities critical to strengthening health systems

This culture is a source of underpinning strength to health systems providing that the wellbeing of those who provide healthcare is protected.

The second (external morality) is the overarching culture of the health system. This starts from the legislative framework governing why and how the system should be structured and why.

When these moralities are aligned, then the outcome is a ‘business-as-normal’ proactive engagement culture which provides the basis for a well-performing health system.

Both the Health Practitioners Competence Assurance Act and the Health and Disability Commissioner Act are good examples of where ‘external morality’ is consistent with the ‘internal morality’ of Aotearoa New Zealand’s health system.

The former establishes regulatory authorities to protect the safety of the public. Examples are the medical, dental and nursing councils.

The latter is responsible for resolving complaints about patient care, including within an informal consent framework.

Culture and legislative purpose clauses

The same cannot be said for the Pae Ora Act which governs New Zealand’s health system. Its purpose clause (3) goes to the heart of its culture.

There is already a strong hint when comparing its word length with what it replaced (Clause 3 of the Public Health and Disability Services Act 2001). The previous Act’s purpose clause had over 330 words. In marked contrast, Clause 3 of the Pae Ora Act has only 65 words.

Pae Ora Act: its culture is shaped by both what’s in and not in its purpose clause

Specifically the new purpose clause states:

The purpose of the Act is to provide for the public funding and provision of services in order to:

1. protect, promote, and improve the health of all New Zealanders; and
2. achieve equity in health outcomes among New Zealand’s population groups, including by striving to eliminate health disparities, in particular for Māori; and
3. build towards pae ora (healthy futures) for all New Zealanders.

Brief, nebulousness and misplaced focus

The outcome therefore is that we have health system governed by legislation whose purpose is characterised by brevity, nebulousness and misplaced focus.

This is an inevitable consequence of having, for the first time since 1938, health legislation shaped more by structural than cultural change.

The first purpose of the Pae Ora Act is uncontestably both correct and vague. Similarly, so is the third purpose with its apparent bent towards population health.

In the absence of foresight by the legislative designers, these faults hardly surprising given the lack of understanding of our political leadership about how health systems work and its excessive reliance on external business consultants.

It is the second purpose which has serious credibility issues. Health inequities and disparities are overwhelmingly driven externally by social determinants of health.

These include low incomes (the most important), poor housing, limited educational opportunities, healthcare access, and social and community contexts.

While “striving to eliminate” them is one third of the Act’s overall purpose, these determinants are outside the control of the health system.

Eliminating them requires government actions; both legislative actions and policies. Health systems can mitigate but not eliminate.

Compare this with the more realistic expectations of the purpose clause in the previous 2001 legislation in respect of health disparities. One purpose was to:

to reduce health disparities by improving the health outcomes of Māori and other population groups:

Health systems can reduce health disparities but they can’t eliminate them. Consequently the legislation governing the health system sets it up to fail.

Defaulting to a vertical control culture

The most critical issue facing the health system today is longstanding neglect of severe workforce shortages.

Such is their severity that these shortages cover the full range of health professionals from doctors to nurses to over 40 allied health occupations (such as scientists, audiologists, psychologists, anaesthetic technicians, podiatrists and physiotherapists).

To get to first base in order to resolve this critical issue requires a major cultural change of the leadership of Health New Zealand (Te Whatu Ora).

Former health minister Andrew Little must take ultimate responsibility for dogmatically allowing a culture of control to be the logical outcome of this legislative restructuring

By failing to give a clear steer on the purpose of the health system, the Pae Ora Act defaults to allowing a new vertically centralised leadership culture to emerge in the way it has –  a culture of control.

What about the health sector principles and the health charter

The Pae Ora Act also includes ‘Heath Sector Principles’ (Clause 7) Pae Ora Act health sector principles and a ‘New Zealand Health Charter” (Clause 56) Pae Ora Act Health Charter.

The former puts equity ahead of accessibility and quality. But without these being at the forefront, it becomes the kind of equity you have when you are not having equity (potentially shifting the focus to equalising inequity or creating inequity for all).

Further, rather than focussing on the health of the whole population, including (expressly) Māori health, the principles focus first on followed by other population groups.

This distinction may appear semantic but it contributes to how Te Whatu Ora messages its focus. Consequently it gives an unhelpful and unnecessary divisive message for those who chose to interpret it that way.

More important, however, is that these principles ignore or downplay critical issues like workforce wellbeing and the importance of an engagement culture.

They are subordinate to the purpose clause and have to be applied in the context of the overarching consequential vertical control culture.

The latter (Health Charter) is enabled by the Pae Ora Act rather than contained within it. It has just been released by Minster of Health Ayesha Verrall: The New Zealand Health Charter.

Dr David Galler: retired intensive care specialist, member of original Health Quality & Safety Commission and former President of Association of Salaried Medical Specialists. Did good work on Charter but…

The Charter has much to commend it. It deserves a fuller separate analysis. Dr David Galler, who was brought in to complete the drafting, deserves much credit for this.

But, as with the health sector principles, the Charter has to be applied in a prevailing vertical control culture and risks being stymied as a consequence.

Rewriting purpose clause

To align the Pae Ora Act with the ‘internal morality’ of the health system its purpose clause requires rewriting. This rewriting should include the following largely interdependent components.

First, changing the role of the health system towards health inequities and disparities from the unachievable elimination to realistic mitigation.

Improving the integration of care provided in communities and hospitals can be effective in mitigating the impact of social determinants of health.

Second, explicitly recognising the role of social determinants of health on inequity and disparity.

This should include the role of the Act’s new health entities (primarily Te Whatu Ora) to advise governments of the ongoing impacts of these determinants on people’s health status.

Third, requiring the culture within Te Whatu Ora (and the other new health entities) to be relational based on engagement with and empowerment of its health professional workforce.

Fourth, ensuring that Te Whatu Ora has explicit responsibility for the wellbeing of its workforce.

This includes ensuring the right staffing levels to ensure patient-centred care and to prevent ongoing fatigue and burnout.

It also means being accountable for ensuring access to and provision of education and research, along with achieving quality improvements.

Fifth, placing at a systems level adherence to healthcare provision being patient-centred.

While patient-centred care is usually seen as being relevant to the treatment of individual patients, it should also form part of a systems approach.

In other words, all decisions should be subject to whether they potentially promote or hinder patient-centred care.

Sixth, changing the emphasis of Te Whatu Ora’s role to providing national cohesion, instead of control, of healthcare provided locally.

This means empowering the districts of Te Whatu Ora with the delegated authority to take responsibility for decision-making over matters relevant to both the community and hospital based healthcare and the wellbeing of their populations.

Seventh, integrating between care provided in communities in communities (such as general practices, not-for-profit providers and rest homes) and care provided in hospitals.

This includes clinically led and developed pathways between them. It also means better enabling the development of local integrated care facilities (polyclinics) providing a mix and range of primary and lower level (less complex and associated diagnostic) hospital services.

The above seven points are obviously not the draft wording of a new purpose clause for the Pae Ora Act. But the health system could start to be turned around if the essence of each one were to be captured in a sentence or two for inclusion in a new clause.

Nothing ventured; both nothing gained and everything to lose!