Surprise and delight at bold reforms

Veteran ASMS member David Galler casts his mind back to when Auckland Hospital resembled “Italy before Garibaldi” in this Q & A with Senior Communications Advisor Eileen Goodwin.

What’s your reaction to the health reforms?

I tuned into the announcement and found myself strangely moved by it – not just by its aspiration but more by the tone with which it was delivered. My immediate reaction was surprise and delight. Surprise because I didn’t expect the aspiration to be so bold, and delight from the clarity of the rationale for change and the intent expressed for what these reforms are in place to achieve.

Do we risk over-centralising health?

The question presumes that health is not over-centralised now, and that the status quo delivers for those populations covered by the existing district health boards. It clearly doesn’t, and there is unwarranted duplication and variation in every aspect of what district health boards do, which contributes to the distress felt by our workforce. The current approach is heavy on a lumbering over-centralisation, micromanagement and an intolerance of innovation. Any reform will be hard pressed to match that! I see the structures announced as enablers for services to be shaped and continually improved by the professions and the public to customise different solutions.

What’s one good thing in the current system that you fear might be lost?

In response to the constraints and problems that exist within the current model/approach (I hesitate to call it a system), a range of highly functional and successful clinical networks have arisen linking patients and clinical staff across the regions. It would be a tragedy if these were lost and not used as a basis for learning to achieve the aspirations of the current reform.

What does this mean for a big urban area like Auckland? Don’t the Auckland DHBs already collaborate?

What I hope for is change that sees the expertise of all staff working within the metro area networked across all the hospital sites to ensure an equity in access and service provision that doesn’t exist now. Often the past is a reliable predictor of the present, and what will repeat in the future without critical appraisal and change. When my specialist career began, Middlemore, Auckland, Greenlane and National Women’s hospitals were part of the Auckland Area Health Board chaired by Papatoetoe GP Frank Rutter. In those days, Auckland Hospital was (and perhaps in some ways still is) like Italy before Garibaldi – not a unified country but a collection of city states each protected by high walls with professors in high heels patrolling the ramparts pouring burning oil on anyone who came near them. So, no surprise when I started as a specialist at Middlemore that every tile in the place was cracked and every loo leaked. There had been no investment into that place for a very long time. But despite it, I was amongst like-minded friends and we worked hard and we worked well together. Not long after came the deficit switch, which saw the Northern Regional Health Authority absorb Auckland Hospital’s massive debt, but not Middlemore’s, leading to a long period of austerity. The population we served missed out on many services available to a population 14 km up the motorway. For years we had no CT scanner whilst Auckland had two, one ultrasound machine when Auckland had many, and so it went, and so it still goes. It is remarkable that today a population of 650,000 people with the most complex health needs in the country has less access to services than populations in the more Pa -keha - cities of Te Whanganuia-Tara, O tautahi and O tepoti. In those days, as it still is today, there are no inpatient acute services in important specialty areas, and instead of addressing that directly, the tendency is for them to become increasingly centralised. A truly regional service means staff who have traditionally been bound to one institution liberated to work across other sites.

What will this mean for the themes you have been outspoken about, particularly food and obesity?

There are several potential benefits for communities like those in South Auckland who have been abandoned to the market, and in particular, fallen prey to the fast food, alcohol and tobacco moguls, to suffer high rates of preventable harm from obesity-related complications of diabetes. These include better access to a wider range of services, and a better coordinated approach to public health.

What is your advice for the Health Minister as he embarks on this reform?

1) Keep a focus on the end game. 2) Learn from our collective success in managing the Covid-19 pandemic – transparency, clear communication, embracing the views of experts and the public, not just those of the bureaucracy. These will build strong relationships and trust among the professions and public. 3) Establish a set of relevant metrics for improvement to measure key aspects of the reform process and outcomes. 4) Your portfolio traditionally concentrates on the provision of health care services, but these will never keep pace with demand without a more holistic approach to keeping people well. This can only be achieved by addressing more broadly the many societal determinants of health that are continually formed by policies from across all of government. Dr Galler recently retired as an ICU specialist from Middlemore Hospital after 31 years