Healthy democracy?

The nation's health is back in your hands. WARREN GAMBLE examines how big a part the public will really play because of the Government's return to having elected health boards.

You have finally dug out the local election voting papers that have been sitting around for the past fortnight.

Your pen flicks down the lists of mayoral hopefuls and aspiring councillors before running into an altogether different body.

For the first time in 12 years you have the chance to elect representatives to the authority that could have the most bearing on your life - your health board.

After the closed doors of National's crown health enterprises (say Ches) and hospital and health services boards (HHS), the Labour Government has emerged with a new entity, DHBS (district health boards).

A central plank of Labour's election policy, the 21 boards were set up at the start of the year with appointed members.

They will not only administer the hospitals, but have responsibility for primary care services - funding of general practitioners - as well as disability and some mental health services.

When the votes are counted next weekend, the boards will have seven elected representatives with four to be appointed by Health Minister Annette King.

There must be at least two Maori members, and the minister's appointments will be targeted to fix imbalances in representation.

But how do you know who will give you the biggest bandage for your health bucks and will they have a real voice?

Some centre-right commentators argue that the boards are a sop to democracy because the Government holds all the strings - allocating funds and holding them to Government health strategies. The minister will even appoint the chairman and deputy chairman of each board.

But supporters from the centre-left say the boards will be able to exercise their influence on local decisions, and the new transparency allows public involvement, which makes the calibre of those elected crucial.

Despite initial worries that there would not be enough candidates, particularly with the boards mired in multimillion-dollar deficits, there is no shortage of choice.

A total of 1083 candidates are competing for 147 seats across the country. In only one constituency, the Queenstown-Lakes seat of the Southland board, is the election not contested.

At the other extreme, the North Shore seat for the Waitemata board has a whopping 50 candidates for three seats. In Auckland there are 69 candidates for seven seats. The centre-right Auckland Citizens and Ratepayers Now is running a ticket, as is the centre-left Peoples Health First, a grouping of Labour, Alliance and the Greens with unions and community groups.

But the bulk of candidates are independents, largely from community organisation backgrounds.

Election officials in Auckland have even banned honorifics from voting papers to treat untitled candidates equally.

The inclusion for the first time of a candidate profile booklet at least offers some basis for a decision, including occupations.

But for some it is not enough. Business Roundtable executive director Roger Kerr will probably not exercise his newly returned democratic right.

"I don't think I will be voting because it will be just such an uninformed choice," he said. "I don't know the people, their views, I have no idea of their competence or the constituencies behind them. How am I to judge that?"

He does not believe that a return to "politicising" health through elected boards will give consumers greater say.

One who does is Gary Taylor, a member of Auckland's transition health board and a former chairman of the old Auckland Area Health Board.

Taylor says that in Auckland's case, the board's new responsibilities mean it will be running a $1 billion operation.

He believes the appointments process will be critical to achieve the right skill mix to govern such a large and diverse organisation.

Taylor, who is not standing for election, says he favours a more even mix of elected members and appointments, a 6-5 split instead of the 7-4 makeup.

"If one was critical, I would have to say with four appointments and a requirement for two Maori to be on each board there is going to be quite a lot of pressure on Maori accountants."

Among the skills needed are business and financial experience, governance and strategic thinking - recognising that boards are responsible for big picture decisions, leaving management to chief executives.

Taylor welcomes the presence of health professionals on boards, as long as they do not entirely dominate.

He says "redemocratising" health will bring more transparency to the crucial task of setting funding priorities.

But high-profile women's health advocate Sandra Coney is not so sure.

She believes there are too many boards, running the risk of hugely complex contract rounds, inconsistent or duplicated services and lack of expertise leading to poor decisions.

She favours a system resembling the four regional health authority model but with elected boards.

Coney, the executive director of Women's Health Action, is also dubious about greater public involvement. Meetings of the Auckland transition board this year had attracted few members of the public.

The culture of board managers and appointed members used to working in a business model will also have to change if a public voice is to be heeded.



Coney says boards need strong, informed people willing to stand up to managers and the Government.

"There is the potential to be quite overwhelmed. It's easy just to turn up and tick what your officials want, but that's not going to be very helpful to anybody."

Annette King's brief for board members is a mix of governance, health, community services, disability support and business skills.

King has also warned that the Government does not want "single issue people or advocates for any one group in society."

The Medical Association, which represents half of the country's doctors, is disappointed at the continuing upheaval and cost of health changes in a sector suffering from "restructuring fatigue".

But with the new system in place the association is concerned how the 21 boards will function. The potential problems reaching agreement on regional and national issues could undermine the worth of the changes.

"We struggled with four regional health authorities, if we now have 21 mini-RHAs then we are going to be in difficult," said chairman Dr John Adams.

Strong leadership will be needed from the Ministry of Health.

Adams says more responsibilities and inadequate funding means board members have to oversee complex health priorities. That means health professionals, particularly doctors, should be well represented.

The chief executive of the Mental Health Foundation, Alison Taylor, believes directly consulting the public on issues would be a better way to engage the community than elected board members.

She has concerns about the boards' ability to objectively award contracts when providers are up against non-Government and community organisations.

And she echoes concerns about the number of boards, particularly the potential to create an administrative nightmare for groups that have contracts with several.

It all makes for a daunting task when the successful candidates start earning their fees (which range from $15,000 for rural board members to $48,000 for urban chairman) from December 10.