A culture of control over healthcare management threatens mental health services (and beyond)

Thank goodness for investigative journalism. As Aotearoa New Zealand’s health care system becomes less and less transparent, the work of investigative journalists becomes increasingly important.

This is especially true when it gives voice to those who know what’s really going on but don’t feel safe speaking about it.

An example is Alex Spence, who is a senior investigative reporter at the
New Zealand Herald. He previously spent 17 years in London, including working for Times.

On 3 September Spence published a powerful piece on Health New Zealand’s (Te Whatu Ora) dubious plans to scrap community mental health services in much of Wellington (Wellington, Hutt Valley, Porirua, Wairarapa and Kapiti): We don’t need this nonsense, say exhausted staff mental health.

“bull***t”

Spence reports a “backlash” from psychiatrists, psychologists, nurses and social workers in the busy service, who believe these planned management reforms could put more pressure on an overburdened and increasingly dangerous state system.

The plans include dismantling the central regional triage and crisis response teams as part of a wider restructuring (which, laughably, is part of the redundancies). But they can’t unravel what these directly affected healthcare professionals are assessing:

… the most pressing problem is the desperate shortage of qualified and experienced clinicians capable of supporting patients with severe mental illness.

Spence reports that these health experts warn that the “reforms”:

…can exacerbate staffing pressures, pushing already overworked and stressed clinicians to leave or reduce their hours. The staff turnover in the service is already unbearably high.

Like similar mental health services in Aotearoa, this specialist service has suffered from years of poor planning, under-funding and under-staffing.

This comes at a time when “…numbers of people are seeking help for severe and complex mental illness and acute mental distress”.

Unsurprisingly, one of the affected health care workers clearly states to Spence, “We don’t need these lies. We just need the resources to do our jobs.”

Spence reports on the seriousness of the consequences of scarcity and lack of resources. These include excessive workloads, inability to support highly vulnerable patients, unsafe conditions for patients and staff, and staff illness. Attempts to resolve these issues with Te Watu Ora were unsuccessful.

Instead, the new health care bureaucracy has proposed a plan that both ignores and reinforces this cruelty.

Chop half an apple

Sarah Dalton, executive director of the Association of Employed Medical Professionals (ASMS), gets it right with her answers:

Instead of (health authorities) saying, “We know we’re really short-staffed, so we’re going to have to see what services we can safely limit or how we’re going to deal with that,” they’re saying, “Let’s just do a review services or care model review’.

Which, very roughly, is (as if to say): “We need a whole apple, we only have half an apple, let’s try to cut it in a different way and break it up, and can it turn into a whole apple? It will never turn into a whole apple. It’s just a horrible half-apple that’s now mush.

This is well supported by her analogy of an apple and half an apple. I would just add that half an apple starts with a rotten core that survives as an extended part of the “ugly mush”.

Work duties are not fulfilled

A final decision on the management plan is expected to be made in October. But there is one thing that Te Wathu Ora doesn’t seem to have appreciated; its obligations to consult and engage with its employees.

The strongest of these can be found in the national collective agreement negotiated by the ASMS, which covers senior doctors, including psychiatrists, employed by Health New Zealand. For context, it begins with a strong statement about employee well-being:

The parties recognize that the well-being of employees is important and can affect the effective and efficient delivery of health care services, patient outcomes, patient safety, the ability of employees to meet accepted professional standards of patient care, and the clinical practice of employees.

Accordingly, under the Health and Safety at Work Act 2015, the employer and employee agree to take reasonable steps to protect employees from harm to their health, safety and welfare by eliminating or minimizing risks arising from work and to promote welfare employees – being.

Then, more specifically (clause 2), it clarifies the relationship between senior doctors and managers in matters related to the design, configuration and delivery of services:

Managers will support staff to lead in service design, configuration and service delivery best practices.

There is no ambiguity. The planned restructuring of mental health services in the wider Wellington region is clearly embedded in the design, configuration and delivery of services. There is also a “best practice” threshold that psychiatrists know best, not managers.

In other words, the role of leadership is not to manage, but to support psychiatrists in a leadership role (along with their fellow psychologists, nurses and social workers).

There are other obligations, but the most prominent in this issue is clause 43.3:

Before an employer undertakes any review that may affect the provision or quality of clinical services, it shall consult with and obtain the approval of the Association as to the purpose, scope, process and scope of such review and shall have due regard to the Association’s Advice.

Obviously, this did not happen in substance, if not even technically. There is a reason for this clause and the others discussed above in the collective agreement (I should know, I was a defense attorney).

Time to end the culture of control

If proposed changes in how health services are designed, configured and delivered are not proactively led by health professionals, they will almost certainly not only fail, but lead to worse outcomes for patients.

The application of Te Whatu Ora’s culture of top-down control is not limited to the mental health of the population in the Wellington region.

It’s not limited to mental health either. It is built into the design of Te Whatu Ora and is applied across all health services.

This culture of control is the biggest obstacle to its ability to address the growing threats and challenges to the health care system.

Te Whatu Ora needs to realize this and recognize that its culture of control is harmful to patients and the health professionals who work for it.

The leadership of this cultural shift must be insisted upon by the Board of Health New Zealand, led by Chair Dr Karen Putasi. It is not yet time to do so; its overdue.

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