Health Boards: Patient wary of Dr Clark's new cure

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The health system is under the knife again. GEOFF CUMMING looks at whether the Government has got the diagnosis right.

Want to help run a public hospital with a multimillion-dollar budget?

Hundreds of people have responded to advertisements for candidates to join hospital and health service boards.

These are the agencies known as crown health enterprises until 1998, when National changed their name.

The call for nominations, which closed on Friday, is a chance to get a foot in the door of Labour's back-to-the-future health system - one under which the boards that run hospitals and community health services are publicly elected.

The recruits, to be named in May, will be appointees and will join the directors of existing boards to prepare them for a return to the public fold.

The call for wannabe directors is a stepping stone to the most radical surgery on the health system since National's unpopular "reforms" of the early 1990s.

Twenty-two district health boards will replace existing health and hospital services boards with the passing of the Public Health Services bill, due late this year.

And the Health Funding Authority, which negotiates contracts with hospitals and other care providers, will be absorbed into the new boards and the Ministry of Health.

The first district health board elections will be held with the next local body polls in October next year.

It may seem a way off, but putting an element of democracy back into health administration is already causing convulsions in the system.

Critics cite the hard-won gains made in the running of hospitals and community health agencies since National axed area health boards in July 1991.

They believe that better financial discipline and improvements in governance and monitoring could be lost when locally elected representatives start balancing unmet local health needs against strictly limited central finances.

Concerns within the system are provocatively expressed by octogenarian obstetrician Sir Frank Rutter, who chaired the Auckland Hospital Board for 14 years until 1986.

From the Papatoetoe surgery where he still works part-time, Sir Frank summed up the last fully elected board as "dreadful."

"It had five members who were hospital staff ... and to think these people were entrusted with $650 million a year.

"It was just nonsense. They had no medical knowledge of any significance, and there was no long-term vision about where the board was going."

The financially troubled board evolved into the Auckland Area Health Board - which was sacked in 1989 by the then Health Minister, Helen Clark.

At the time, she lamented that the board - which included her husband, university researcher Dr Peter Davis - was "paralysed by special interest groups."

The restructuring Helen Clark's Government is now setting up has some similarities to the old area health boards, with a majority of publicly elected members and a responsibility for finances as well as providing services.

But Health Minister Annette King says checks and balances will prevent "capture" by local interests and avoid budget blowouts.

The new district health boards will be required to act in an efficient and businesslike way, she says.

Hospitals will continue to be run by managers - "the board members won't sit around running the hospital as area health boards did."

Financial disciplines will remain, and hospital funding will be guided by data on disease incidence, expected growth in acute admissions and other information.

"Hospital priorities will be influenced by the range of services they provide and the Government's intention to reduce waiting times to a standard level throughout New Zealand," says Mrs King.

Another big departure from the old area health boards is that the new boards will finance GP and other primary services.

This has raised concerns that the primary sector will wither while small local boards grapple with the needs of hungry hospitals.

Dr Tom Marshall, chairman of the country's biggest GP grouping, Procare, says boards will buy secondary [hospital] services from their own facilities.

"We worry there will be greater temptation to spend on things they own rather than on our services."

Procare's chief executive, Mark Wills, believes the Government's plan to "ringfence" primary funding should ensure that the sector does not suffer.

But he is worried that ringfencing could restrict the two sectors' ability to work together, hampering the goal of "integrated care" of patients.

Mr Wills cites examples such as community-based asthma education programmes and information-sharing between pharmacists, GPs, hospital doctors and nurses about their interactions with a patient.

Such advances could be lost as present arrangements are dismantled and the logistics of the new system are thrashed out.

He says doctors are tired of continual change in the health system and want an explanation of why another upheaval is needed.

"The common complaint is that patients aren't benefiting from any of these changes.

"Right now, we're on the cusp of delivering some real advances in preventive care and it's, 'Oh no - let's not abandon this now'."

Mrs King says bringing primary and secondary sectors under one roof will improve integration rather than hindering it.

"The idea that GPs will become the poor cousin ignores that they are the poor cousin now."

She says the Government's goal is to channel more resources into preventive care in the community rather than to hospitals.

Primary sector needs will be identified for the first time to help local representatives make decisions about their health areas while aiming at national health goals.

Separate subcommittees of each board will deal with each sector to ensure all get a fair share.

Support for change comes from an unlikely quarter.

Alison Paterson, who chairs the Crown Health Association, representing existing boards of directors, says the Government's policy direction - including the change in legal structure and integration between services - is clear.

The level of management expertise in hospital and health services is "hugely better" than in 1992, she says, and the boards' governance role is now well established. District boards will inherit this set-up and gain expanded responsibilities.

"Including elected representatives on boards will allow local populations to feel ownership of these additional responsibilities," said Ms Paterson.

But former minister Wyatt Creech says health professionals are worried about a structure weighted in favour of hospitals. He says having 22 health boards for a population the size of Melbourne will produce "a shemozzle."

He accuses Mrs King of misrepresenting the present boards which, he says, do reflect community concerns and interest groups.

And he say hospitals should be run in a businesslike way.

"We are talking about organisations with budgets of hundreds of millions of dollars. Running big organisations requires people with the right skills."

But at least one long-serving administrator is confident the next wave of change will have little impact on services.

"You can change things at the top, but at ward level things grind on and we cope."