Continuity Amid Chaos: Health Care Management and Delivery in New Zealand
ed Robin Gauld
University of Otago Press, $49.95,
Snakes and Ladders: The Pursuit of a Safety Culture in New Zealand Public Hospitals
Peter R Roberts
Institute of Policy Studies and Health Services Research Centre, $35,
Borderland Practices: Regulating Alternative Therapies in New Zealand
University of Otago Press, $24.95,
Both during and after my time as health minister, I experienced a steady stream of honours and graduate students seeking interviews as input to research essays and theses. The quality of the projects varied widely, some being little more than exercises in applied ideology. What it revealed, however, was the veritable industry unleashed in academia by reforms to the health system. The three books under review here are more or less readable fruits of this industry.
The least readable is Continuity Amid Chaos: Health Care Management and Delivery in New Zealand. Here we have 17 contributions of largely descriptive prose consuming 300 pages that offer, according to the editor, “insights into the ways in which a range of different health-care services in New Zealand are managed and delivered, and how those involved have responded to the continual restructuring of the health system”. I cite the editor’s summary since it accurately describes the terrain.
But “insights”? The book is written by insiders who seem to have no clear idea of their audience. There will be nothing new here for their peers. This is the stuff that fills dreary presentations at conferences. Talking to these busy people is always far more rewarding than reading the acronym-ridden commonplaces that spill out into their prose. For the general New Zealand public this sort of stuff is impenetrable. And for the overseas reader? Well, the problem is that it’s local and also unreflective.
Which leads one to ask, what market did the publishers think they were reaching? Maybe there are dreary diploma courses in which unfortunate students have to be able to cite some literature in describing the health system. If so, a gap has been filled. The only other “market” I can think of is future health systems archaeologists. Like a time capsule buried for future retrieval, this book captures a wealth of turn-of-the-century jargon, acronyms, diagrams and accounts of what people saw themselves doing. In 50 years it will be a splendid dig for scholars studying the history of social service delivery. It will stir no debate today.
The same cannot be said for Snakes and Ladders: The Pursuit of a Safety Culture in New Zealand Public Hospitals. This book grew out of a master’s thesis in public policy at Victoria University and explicitly sets out to influence current debate. It is an exploration of the limitations and risks of an approach to the pursuit of hospital safety based on identifying errors, imposing rule-based procedures and meeting shortcomings with attributions of blame. In place of it, Peter Roberts proposes a paradigm shift that would value a pervasive awareness of safety by collecting information, so as not to apportion blame but to overcome errors, and seek to understand the motivation of teams of professionals in a way that builds trust.
The thesis was written against the backdrop of ongoing reform and restructuring of hospital management, and a number of high profile cases involving the alleged failings of practitioners, notably in Northland and Gisborne (the Parry and Bottrill cases for those inclined to attach blame to individuals).
In its broad thesis, few will quarrel with the view that the huge complexity of modern hospital care and the degree of professional specialisation involved does not lend itself to mechanical or retributive management systems. As Roberts repeatedly underlines, the reporting of much information that can add value to learning from experience is, in effect, voluntary. (Knowing about near misses and learning from them is vital – and anonymous reporting the best way of guaranteeing that you find out about them.)
Anyone acquainted with New Zealand health and management bureaucracy will scarcely be surprised by Roberts’ sustained defence of the professionalism of clinicians, even if at times he seems to place them beyond the reach of external scrutiny. But if blame is out for health professionals, it is definitely still in for other groups. The blame culture is diagnosed as being rooted in “deeply ingrained societal attitudes led from Parliament”. (Phyllida Bunkle is uniquely named in this regard.) The retributive command and control paradigm is favoured, we are told, by “politicians and many bureaucrats”. The unqualified mention of politicians seems to reflect an animus directed by the author at the unenlightened whose number include the media and those members of the public who have fallen so far as to consider themselves mere consumers.
The most interesting question the book raises is why its author felt moved to elaborate his views by way of a thesis. Roberts attributes his motivation to a realisation that “bad public policy was more dangerous to his patients than the flesh-eating bug”. This is a great line for the dust jacket, but a careful reading of the book discloses a deep irony about the vehicle Roberts has chosen to influence the debate.
Snakes and Ladders is explicitly written for the policy community (and indeed published by its nerve centre, the Institute for Policy Studies). The public may not be ready for the paradigm shift, Roberts suggests, but policy makers need to be. This is the urgent message of the closing chapters. The prizes and endorsements the book has attracted suggest the establishment is already converted.
This extraordinary faith in the power of policy may go some way to explaining Roberts’ need to buttress his undoubted clinical experience with all the trappings of academic formalism. This book is an unflinching route march through heavily academic terrain. Fully two-thirds of the text is a survey of the literature. Bracketed references sprout liberally throughout the text, at times completely arresting the momentum of the argument. Even the smallest observations often find their parentage somewhere in the academic prairies.
This is standard grist to the academic mill but whether it represents a sound publication strategy is another matter. Theses are the means by which academic novitiates win their spurs from scholarly superiors. They have to prove they’ve covered the ground. (The pressure to do so makes one wonder whether academia doesn’t begrudge emerging researchers the possibility of original insights!) And herein lies the great irony: Peter Roberts brings a wealth of practical and professional insight to his chosen subject. And it is the triumph of form over substance, and standardisation over unique insight that he argues against. Yet here is a policy-tuned analysis that conforms in every respect. Even Roberts’ insistence that we should break with linear, reductionist ways of thinking is belied by the neatly tabular way in which paradigms are classified and programme logics described.
Here, surely, was someone who could have written an equally compelling piece of advocacy based on practical, clinical insights (and still drawn on the fascinating survey results recorded) without feeling the need to locate that analysis within the conceptual production industry that so much academic reflection submits to. It is as if the only way Roberts feels he can communicate authoritatively is vicariously through conceptual, research-based filters.
I found myself searching, often in vain, for Peter Roberts’ own practical wisdom as against the drafting of research insights in support of paradigmatic policy shifts. Even when the author’s ideological preferences are near the surface they are quickly referenced – in this case, variously, to Boston and Kelsey. Everything is academically “earthed”.
Those with a nose for these things will enjoy the familiar board game reproduced on the front cover in which the snakes and ladders have been artfully labelled – the good climb upwards through teamwork, collective mindfulness and internal morality; the bad slide down on the back of protocols, control and dreaded individualism. If this is the purgatory of public hospitals, one hates to think what snakes are lurking in private hospitals – beyond Roberts’ study. Does he believe they have any ladders at all?
In the end, survey data (largely collected in intensive care units) is interpreted both in the light of what Roberts regards as a failing paradigm and what it can tell us about a better one. That much is convincingly done. But for this reviewer, a culture change is not just a question of storming the heights of policy. Neither is it a question of locating the forces of resistance in what he terms “media-political mythology”. Policy has ultimately to be explicable and persuasive in a democracy. Politicians and journalists have long ago been stripped of any authority. The defenestration of doctors and other professionals is a more recent affair (which probably explains Roberts’ passion). But it has happened nonetheless.
The cult of blame is part of a much wider social phenomenon that has evolved in a society in which information is much more widely held and the currency of castes, be they political, professional or religious, greatly debased. Conservatives (of all stripes) may regret this turning of the wheel, but they would be foolish to believe that any corrective will spring fully armed from the world of policy.
The same levelling forces that have rattled the gates of the professions have often embraced alternative, and sometimes completely counter-cultural, belief systems. This is the territory into which Kevin Dew steps in his Borderland Practices: Regulating Alternative Therapies in New Zealand. This book, too, started its life as a doctoral thesis but the gestation period was much longer than in Roberts’ case. The result is much more readable. The ropes and pitons left behind in the academic ascent do not intrude as they do in Roberts’ book. Dew’s peak was not conquered yesterday and the result is altogether more discriminating and thoughtful. If publishers are considering re-jigged theses, this is the presentational standard to which they should be aspiring.
Dew’s book is about the relationship of alternative therapies to the medical mainstream in New Zealand and the people who inhabit and police this shifting “borderland”. Along the way there is some fascinating history on how orthodox medicine found centre stage and stayed there. Three particular skirmishes are recounted in some detail: the outcome of the Commission of Inquiry into Chiropractic of 1978 (a case of outsiders being brought inside the pale); the rise to acceptance of acupuncture from within the ranks of the medical profession (a case of internal deviancy being accepted); and, the expulsion of Mat Tizard from the medical register for disgraceful conduct following claims he made about chemical poisoning and his ability to treat it using electro-acupuncture.
The dissection of each of these cases is fascinating. Dew exposes the deft way in which the commission on chiropractic managed to endorse the discipline’s effectiveness in a limited scope of complaints, without buying into its more esoteric claims. Similarly, he highlights the way medical practitioners who adopted acupuncture stressed the practice rather than the philosophy. Amusingly, we learn that one doubt doctors had about chiropractic was that it had only spread in countries influenced by America. (Surprisingly, Dew does not explore the possibility that acupuncture’s acceptance within the mainstream might have something to do with western respect for an ancient and sophisticated culture that has embraced western medicine without letting go of techniques widely accepted by Chinese patients and physicians as effective).
Dew’s verdict on the Tizard case is likely to arouse sharp disagreement. For my part, he adduces insufficient evidence to support his verdict that it was all part and parcel of the medical profession using its power to suppress someone who threatened its hegemony. His conclusions on the causes and uses of standardisation and limits on clinical freedom will be less controversial (and resonate with Roberts’ diagnosis). They are, to my mind, somewhat bald: standardisation techniques (such as quality assurance programmes and protocols) are cost control tools driven by fiscal pressures; doctors embrace them to maintain their legitimacy.
Notwithstanding Dew’s remarkable claim that there has been a global trend to cut health expenditures since the 1970s, my hunch would be that a bewildering proliferation of interventions and technologies has forced health administrators to say something about outcomes to justify the inexorably rising costs of healthcare driven by even faster rising (and frequently unrealistic) public expectations.
But, unlike Roberts, Dew lets doctors do some of the talking on these normatively charged issues, rather than staying in the world of abstract paradigms. Seven doctors whose practices have in different ways embraced alternative elements are interviewed. Their range of views is fascinating and provides the element of individual practical wisdom missing from Roberts’ account. Here we find a first-hand account of the struggle working doctors have reconciling the objectivism and rationalism science demands with the individuality and differentness of the patients they are trying to help.
Only in the closing pages does Dew touch – and then only fleetingly – on the great political conundrum that lies submerged beneath so many health debates: how to reconcile a taxpayer-funded health system with increasingly plural – and not always commensurable – views about what treatments are legitimate. The problem is far from being merely budgetary (safe ground to which, one senses, Dew would happily hew).
At the base of any public or social democratic health system resides the fundamental claim that human well-being can be collectively known and stated. And in terms of our experience of pain and suffering that seems so intuitively right. The difficulty is that, along with that assumption, goes the claim that we can actually secure it. And that is where the problem starts – because if we are going to claim we can deliver the outcome, any democratic system of accountability must have a way of testing that. When something as individual as a sense of well-being is at stake, informed as it often is by powerfully divergent belief systems, it is idle to believe there will not be contested versions of what should and should not be provided.
It is only a short step from here to deciding that we can’t determine all this bureaucratically and that if we want to respect differences and choices – without breaking the bank – some sort of market for vouchers is where the logic leads. But before anyone embraces this heresy they would have to explain what they would do faced with bad choices.
If there is one immutable law in political cultures such as ours, it is that no government can ever admit that it will stand indifferently aside in the face of suffering caused by illness. (The fact that that may be the effect of its policy choices is another matter.) So the risks always end up being shouldered by taxpayer-funded services. As long as they are, outcomes will be contested and the effectiveness of expenditure will always be in the public, political arena. And there is no escaping the arc lights of popular debate in a society that feels ever more entitled to challenge claims of expertise, whoever makes them.
If Kevin Dew avoids these issues, he more than does justice to his chosen terrain. This is a book that can – and should – be read by a wide audience.
Simon Upton is a former Minister of Health.