Letter to National

Dear Mr. Key

Congratulations on winning the election. I know you are probably too busy right now to read blogs, but I also know that there is at least one National health staffer who reads MacDoctor Moments, so I thought I’d just get my oar in early and let you know my opinion. After all, that’s what blogs are for, aren’t they?

I’m not going to tell you how to run the country. Wouldn’t have a clue anyway. But I can give you my opinion of the broad things you need to do to health.

First up – you do NOT need to change the DHB system. Please.

We all said the same thing to Labour when they took the reigns in 1999, but they thought they knew best and wasted vast resources on changing things to suit their ideology. You, however, seem like a moderate sort of bloke, so I ask that you resist the urge to change things yet again. We have far more important fish to fry.

And, yes, I know there are a lot of resources wasted by having a ridiculous number of DHBs. I suspect the optimum number is more like 9 or 10 rather than 21. If you concentrate on breaking down barriers between the DHBs, they will probably naturally amalgamate. At any rate, it is something you can just chip away at gradually, rather than revising the whole system now that we’ve become used to it.

Your real problem in health actually stems from government, rather than health management. It is the “pocketisation” of healthcare funding (This is my own, made-up word – feel free to use it as your own). Pocketisation is the packaging of the massive health budget into smaller and smaller parcels. Governments do this in order to dictate where money is spent, so they know that they are getting good value for their money. Authoritarian governments tend to take this to extremes, getting involved with the minutia of health care and dictating exactly where the money is spent.

There are two major problems with this. The first is that each pocket of money develops its own bureaucracy. It has people to administer it, people to do surveys for it, people to provide quality assurance for it and, of course, its very own set of forms to fill and criteria to be met when applying for it. This is the chief cause of the massive increase in health bureaucracy – every little pocket of health funding needs to justify its existence by providing paperwork to show it is doing its job.

The second problem is that each pocket automatically becomes too prescriptive in its criteria. People lose out on funding every day because they don’t quite meet the criteria to access that funding, even when it is clear that they are the very people that the funding has been set aside for. This is because medicine is vastly more complex than health bureaucrats imagine. People do not get sick in nicely defined categories. People are annoyingly messy. This is why diagnosis does not equal certainty, treatment does not equal recovery, patient satisfaction does not equal good treatment and, conversely, complaints do not mean bad treatment. Everything in medicine comes in tones of grey, metaphorically.

Excessive prescriptiveness also has the effect of balkanising medical funding. It is not unusual for a disabled person to have to access funding from half a dozen sources. All of them need to be convinced that the patient is “theirs” (meets their rules). It is no wonder that many disabled people do not access all their available funding. Why would they want to jump through a new set of hoops for an extra $10 a week or a bathroom rail that they could just get a friend to install? I have seen elderly patients stuck in precious hospital beds for weeks while the various “pockets of money” decide who will pay. It seems to have escaped them that all of their funding comes from the same source – the taxpayer.

So what is my advice? Gradually amalgamate your pockets into larger pools with less prescriptive criteria. I say gradually because it takes time for people to get use to the changes, and you don’t want the needy to lose out. Pay close attention to the complaints of people who claim they are “slipping through the cracks” – they usually are. It is important you plug these holes rapidly. However, do not use the method of the previous government which was to produce a new pocket. Rather reset the criteria of an existing pocket to meet that need. At the same time, don’t forget that that pocket may now need extra cash. Almost certainly, somewhere else will need less (unless this is a “new” – previously unmet – need).

I am sorry if this seems a little theoretical. I am reluctant to give concrete examples because the problem is endemic to health and I don’t want you to latch on to one or two examples while not tackling the rest. As you go through the entire funding system, just ask yourself “could these safely be joined together?” You’ll soon get the hang of it.

Oh, and take lots of advice from the people who know – health workers on the frontline and, of course, those much maligned users of the health system – patients.

Good luck (you’re gonna need it)

MacDoctor

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