Steve Liddle
The heart of the disputes between the Christchurch, Southern and other DHBs and the Government is not just the ability to allocate health resources rationally but an inability to respond to the needs of citizens.
According to figures released by Parliamentary Services last week Government has spent more than $15 billion on health in the last year and more than $74b over the past five years. But what do these raw figures mean?
In 2015-16, health spending was S14.7b and for 2016-17 it is an estimated $15.24b. But a more meaningful figure, when assessing relative spending and affordability, is the percentage of expenditure of GDP. For the same years, Treasury-supplied figures put spending at 5.3 and 5.6 per cent of GDP respectively.
Over the past two decades there has been increasing criticism of the funding model becoming dominated by the Government's insistence that budget targets rather than health needs are met. If there is underfunding, as many senior doctors are now saying, how has it come about?
Information deficits about health needs have occurred. Non-disclosure clauses in health professionals' contracts ensure information is kept in-house.
What has been more effective, however, is an ethos confusing silence with discretion and institutional loyalty. This results in a self-censorship that paints raising issues publicly as unprofessional and best left to management.
The refrain from the health minister and ministry is there is enough money to meet needs, that inefficient use of the money is the problem. Senior doctors in the UK are increasingly publicly critical of funding that has too readily incentivised management with bonuses and shamed health professionals with labels of incompetence.
Many pressures can coincide to prevent professionals from challenging inadequacies. Last month there were 86,000 vacant posts in NHS England. A doctor reported understaffing in her large hospital as no "dry statistic", with 30 per cent nursing vacancies on her ward and 50 in the one next to her.
She instanced grim ward jokes featuring health department spin doctors explaining away "the latest headlines about NHS understaffing".
Underfunding is also criticised for being self-fulfilling. A run-down public system can be used as an excuse for more expensive private systems, originally designed to provide choice.
In New Zealand, despite increased spending, the reality is that in the face of sinking-lid budgets management seldom successfully go to government with the underfunding word - either as single DHBs or an association.
Lack of effective channels may be one reason. More likely is the devolution of responsibility that incentivises CEOs to meet budget targets at the expense of other DHB needs and then labelling them as incompetent if they do not do so. This tactic was used in the health ministry's "Pearl Harbour attack" on Christchurch's DHB last month.
Last Friday Health Minister Johnathan Coleman fronted to Radio New Zealand's Checkpoint programme to reassure listeners that Southern DHB problems were being worked on and that the "cot-case" DHB, when all others were managing well, had enough money. Chief executive Chris Fleming had assured him, he said, that unacceptable delays in operations were being addressed.
He repeatedly assured listeners the situation was not a matter of money, though a "flood" of feedback - including from staff at the ICU unit, senior doctors and Dunedin GP Daniel Pettigrew - disagreed with this diagnosis.
In the UK sinking-lid budgets have declined to 7 per cent of GDP. Think tanks and professional bodies are arguing for an increase to 11-12 per cent of GDP. They are also contesting directives demanding continual "efficiencies" as counter-productive to effective care.
Doctor associations object to the type of thinking that sees efficiencies as incompatible with funding desperately needed to meet increased demand.
In a model involving such closed logics as: "reduction of policy-induced deficits is only your responsibility", and "to be judged competent you must make continual savings", responsibility for the health service's failures shifts from government to CEOs and boards.
When interviewed recently the Prime Minister repeated expectations that DHBs meet targets, as if reported deficits are related only to management failures and nothing to do with meeting citizens' health needs.
His Government needs to change such damaging thinking.
Steve Liddle is a researcher and independent journalist based in Napier. Views expressed here are the writer's opinion and not the newspaper's. Email: editor@hbtoday.co.nz