Bruce Bisset’s HB Today column of 13 September offered his view of the candidates and the stakes. I don’t always…
What are DHBs?
According to the Ministry of Health (MoH) DHBs are “responsible for providing or funding the provision of health services in their district”. Boards, led by a chairman, are comprised of anywhere between 7-11 members, seven of who are publicly elected and four who the health minister of the day may appoint.
The New Zealand Public Health and Disability Act 2000 requires DHBs to “improve, promote and protect” the health of all members of the community they serve by promoting the integration of health services and by seeking the best arrangement and delivery of health and disability services to meet the needs of its community.” Boards are also expected to show a sense of social responsibility and foster participation from all sectors of the community in health improvement.
DHBs are Crown entities. As such they do not work in isolation as the government of the day determines the outcomes it expects from the health sector. So although some board members are elected by the public, they are responsible to the minister first, then to the people who voted them in. Board members are held accountable by the MoH through mechanisms such as an annual plan and a regional services plan.
The latest figures show the 20 DHBs have a combined budget of more than $13 billion. According to the MoH this represents 75% of the government’s total health spend. Health boards are one of the largest employers in any region, with 60,000 people employed by them across the country.
However, despite the importance of health boards economically and (literally) in terms of life or death responsibilities, the voting public just doesn’t seem interested in them … they’re an afterthought in already-low turnout local elections.
And who can be elected to what could be argued is the most important board in the region? The answer– as with councils – anyone who votes, and it doesn’t even have to be their DHB.
To run what often is the largest business in any given region across New Zealand, the MoH says candidates “don’t need to have experience as a director to stand and [they] don’t need any particular qualifications”.
The MoH does suggest a list of ‘generic skills’ that a board member should have which includes financial literacy and critical appraisal skills, strong reasoning skills and a “wide perspective on social, health and strategic issues”. Any board member unfamiliar with their obligations is expected to undergo training and keep a record of it.
Once on the board, members are paid for their work with fees varying from $16,320 to $26,520 per annum, not including board associated costs and an extra $2,500 per annum for every committee they sit on. The board chair and deputy receive a higher fee.
Currently 18 out of 20 DHBs have the maximum number of board members. Southland and Waikato’s DHBs have been replaced by commissioners at a cost of around $3,000 a day each. Canterbury DHB has a Crown monitor sitting alongside the board members.
Are DHBs worth it?
Earlier this year a team from Lincoln University – David Sheard, Gregory Clydesdale and Gillis Maclean – published a paper on their research into the Canterbury District Health Board. The paper examined how healthcare provision was governed and looked at the CDHB for answers.
The team posed questions at the end of their study that they felt should be asked in future research:
“First, is public input necessary at the level of governance? Second, is there a better alternative structure to facilitate public participation? Third, do voters understand the skill set needed at board level and whether the background of those elected meet those needs? Finally, given that healthcare management is now a highly specialised area, is the desire for public participation a reflection of effectiveness or ideology?”
They are questions worth asking, considering the half billion worth of debt the country’s DHBs have racked up. Managing public health is such a specialised area that universities offer master’s degrees in it. So, is the man off the street up to the task?
Former associate minister of health Peter Dunne echoes these questions. He says it is time to look at new models where the “focus is on providing the best service, in the fastest time, in the most cost-effective manner and in the place of best convenience for the patient”.
So, why have boards racked up so much debt? Does the problem lay with central government and the Health minister of the day, or with inadequately-qualified local governors?
At the time of publishing, the DHB debt, to the end of June 2019 was expected to blow out past $500 million. The New Zealand Council of Trade Unions Working Paper on Health No. 22 reports the MoH has set aside $139 million under capital for DHB deficit support in what the Council says is “an acknowledgement of the ongoing financial stress in the DHBs.” However, it estimates that $234 will be paid out for this purpose after an additional $95 million already provided during the yea
Hawke’s Bay DHB
A Crown entity, the HBDHB is the region’s largest business. With a budget of nearly $557 million and a staff of almost 3,000 (2,926, according to the HBDHB’s latest annual report) the board serves a population of 165,610 people.
Hawke’s Bay’s population tends to be older than the national average, we have more Māori residents than the national average and proportionally more people in the more deprived segments of the population … all factors contributing to higher healthcare costs.
Going into this year’s election, the HBDHB’s 2018-19 underlying operational deficit came in at $12.1 million – $7.1 million more than the planned $5 million. According to the latest board report, these figures would be revised as “more and better information becomes available”. However, advice from the MoH is that the HBDHB’s financial performance would be evaluated on the operational deficit of $12.1 million and against the planned $5 million.
How did we get here?
Retiring HBDHB member Barbara Arnott believes the government got it wrong 20 years ago when it came to creation of health boards. She believes back then the government should have funded DHB capital expenditure – such as new builds and facilities – and left boards with a budget to spend on the healthcare of their respective populations. While it hasn’t worked out that way, Arnott is adamant that the health sector needs DHBs in the regions.
“I’m not sure what the future is,” she says. “[But] I’m under no illusion that you need people on the ground to advocate for the people. I believe in democracy really strongly. I believe that you need people who live in the area to at least oversee management to make sure that the people are getting the best deal they can.”
And she has nothing but praise for the DHB staff who are doing just that, saying all the staff have got one purpose when they come to work – to do the best job possible for the people they are serving at the time. She says for this reason more empowerment needs to be given to the people who actually do the work.
“This board has tried its very best to manage its budgets without risking patient health. And there comes a time where you can say we cannot make any more savings.” She says if the board continued down this path the risk is that part of our population – albeit a small part – would not get the services they need.
“The government needs to take away the feeling that we just can’t manage our budget,” she says, noting that the Board she has been a part of and the management she has worked with over the last nine years have been incredibly prudent. Not only delivering health services, but also building capital from funding that did not come from government. (Arnott noted that the government recently released some money for the radiology department “and we are always grateful for that”).
“We posted a deficit last year which we strove not to,” she says. “We strove to make savings. But we have been making savings for the last seven years. You can’t keep on making savings because [then] you are constraining people at the other end such that they start not to be able to do their jobs.”
Put simply, Arnott thinks there is just not enough money spent on health. “I think genuinely we’re underfunded. I think health is underfunded.” She says health hasn’t kept up with the expectations of New Zealanders or the needs of the over 65 or the needs of the equity issues facing the Bay’s Māori and Pasifika population. “Our funding doesn’t go far enough,” she says.
Health Minister Dr David Clark says current DHB deficits are a result of underfunding over the nine years of the National Government.
“This Government doesn’t accept that deficits are inevitable, nor do we accept DHBs cutting services to manage their financial position,” says Clark. “We’re focused on ensuring that New Zealanders get the health services they expect and deserve and ensuring DHBs are on the path to sustainability.”
Clark noted some DHBs managed to post small surpluses, break even or only post small deficits while maintaining services, showing that “it can be done”.
He says his Government is committed to funding health better, and Budget 2019 included an extra $2.8 billion for DHBs over the next four years, adding that it’s “a record $695 million increase in funding” for DHBs this year.
“But I do want to acknowledge, once again, that after years of underfunding, it will take time to get them all back on the path to sustainability,” says Clark.
Despite the post-election problems that a new board will have to deal with, 25 people from across Hawke’s Bay are vying for a place on the HBDHB. The candidates are as follows:
Hayley Anderson, Ana Apatu (incumbent), Kevin Atkinson (incumbent), Paul Bebbington, Garry Brian, Annette Brosnan, Garth Cowie, James Crow, David Davidson, Peter Dunkerley (incumbent), Hine Flood (incumbent), Trish Giddens, Leona Karauria, Rizwaana Latiff, Anna Lorck, Graeme Norton, Umang Patel, Jacoby Poulain (incumbent), Heather Skipworth (incumbent), John Smith, Gerraldine Kelly Tahere, Hinenui Tipoki-Lawton, Claire Vogtherr, Julia Wilson, Jason Whaitiri.
Eleven candidates responded to Bay Buzz by deadline. This is what they had to say about the state of health in Hawke’s Bay and why they are standing to run the biggest business in the region.
Anderson says everyone in Hawke’s Bay should have access to good health care. “We know the most vulnerable and Māori and Pasifika miss out.”
She says she comes to the role with experience – from being a frontline nurse at Hawke’s Bay Hospital and the chief executive of Hastings Health Centre, to being on the board of Hawke’s Bay Primary Health Organisation (PHO) and Te Matau ā Māui Health Trust.
Anderson says she is supportive of a representative board with the right mix of skills to govern effectively and with accountability. “My experience in health tells me that local governance; consultation, planning, funding and decision-making matters to people.”
“We must put people at the heart of health. Everyone needs to live in a warm, dry home with clean water, nourishing food, employment and safe social connections. This requires greater cross-sector collaboration, community and public health support.”
As a current board member, Apatu wants to emphasise that the HBDHB needs to keep the focus on supporting people to be well.
“We need to be more in charge of our own healthcare and wellbeing. We need to better work together to address housing, employment, education,” she says.
“We have a clear mandate from our community to not keep increasing resources with our hospital services but to ensure we have better preventative and primary healthcare closer to our communities.”
“Equity of care for those that need healthcare the most delivered in the most effective way is the most pressing thing we are facing as a board in a financially constrained environment,” she says.
“We need to listen to our community and be brave to make changes. I am excited by the calibre of Māori leadership in our community and the opportunities this brings.”
Napier City councillor Brosnan believes with her governance experience she will work well within the DHB to bring about positive change for Hawke’s Bay health.
“I think I would add value to the DHB,” she says. “I really want to delve into some of the challenges that we’ve got in the health sector and look at the opportunities for improvement.”
She says DHBs are driven by where the money comes from – central government. “This is why DHBs are important,” she says. “By having elected members on a board, by the way, it does provide an opportunity for community members to contact someone who is approachable and like them to be able to voice concerns and have those concerns heard. And so if nothing else that provides a way for that communication.”
Brosnan says she is keen to promote the transparency and communication channels between the Napier City Council and the DHB. “I think that will be increasingly more important, especially with the introduction of our new drinking water regulator.”
Crow wants to look for ways to create healthier, happier communities. “In the past 18 months I have seen calls by nurses, doctors, specialist technicians and even patients for better treatment under the DHB’s governance. This speaks to a need for genuine focus and attention on those who care for our community and some new approaches to achieving this.”
He believes his 16 years business experience will help to address the board’s financial woes.
“There may exist a possible need to reassess how DHBs are funded or structured, or for increased budgets to meet rising demand,” he says. “But a primary concern for any DHB should always be the impact of this higher workload on the health status of staff and how this affects day-to-day patient care.”
He says a top-down solution needs to be looked at if institutional racism is to be addressed properly to “cater to our over-represented Māori and Pasifika communities”.
Long-serving board member and retired pharmacist and CEO, Dunkerley says he is standing again to ensure the plans the HBDHB have advanced over the last term are put into action. “Particularly given our ageing population and the need for equity for our disadvantaged residents,” he says.
Dunkerley says change is needed in the healthcare sector. “There needs to be more care delivered out of the hospital which will ensure that the main hospital services are available for the people who really need them,” he says. “[This] has the advantage of providing care nearer to people’s homes and places of work. That change is a critical part of the board’s plans.”
Is the health board model the best way to go? He says it is what we have to work with, despite its challenges. He says he is not convinced a different model health board will deliver better results. “The problems will be the same and managing them logically and sensitively will always be the best course.”
Latiff is running for the HBDHB because she wants a more truly representative health board for Hawke’s Bay – both with women and the ethnic community she is a part of. She says the needs of this community are vastly different and often not addressed. “The board and upper management do not reflect the demographic of people who are involved in the DHB,” she says.
With more than 30 years’ experience in health systems across the globe, Latiff – a nurse and midwife – has been involved with the DHB since 2004. “I have seen the many changes with the DHB. Some I agreed with, some I didn’t,” she says.
She does believe the DHB model needs to be re-examined. “We don’t want people in Wellington to be telling us what we need in Hawke’s Bay. And that is across the board.”
From personal experience, Lorck says she knows the health system and its challenges well: “One of our five daughters has a life-long condition, diagnosed from age six, we’re in and out of hospital, from paediatrics and Starship to now adult clinics, seeing nurses, specialists and GPs.”
She wants to see a community-led health strategy, “transforming how we deliver greater access to affordable healthcare, including well-resourced mobile services and clinics into our most vulnerable areas with more nursing teams on the ground. … I’d love to see every HB teenager leave school with a health plan so they’ve got the tools and support in place to keep active and stay well.”
Prevention-minded, she says to relieve increasing pressure and costs we’ve got to “help people stay well, active and out of hospital.”
Regarding governance, “We do need democratically elected members, but at the same time best governance requires having the right mix of experience, skill sets and board structure. Ultimately the public must have trust in those representing them and know that they are there to always serve in the best interests of HB.”
With 40 years in business, Norton comes to this election having chaired both the HB Health Consumer Council and the Health Consumer Council of New Zealand. He believes the HBDHB has a “track record of designing really good plans and never getting them done”.
In order for the DHBs to achieve what they need to do the 150-year-old biomedical system must change. “By now we should have moved to something which is underpinned by wellbeing,” he says.
Norton says it is primary care’s job to support people to be as well as they can be. “So, 8,760 is the number of hours in a year that my multiple long-term conditions live with me. One [hour] is four 15-minute appointments with the GP.” Consequently, he says, the patient should be in charge of their health, not the primary care practitioner.
“Because I’m the one who’s likely to have the most impact on how well I live. Many of us, we don’t need a GP, we need a coach. Yeah, somebody to support us to do the right things, not to tell us what to do. Because we know, lots of us have become experts in their own condition.”
As medical director at Napier’s City Medical 24-hour health service, Umang Patel says he is focused on reversing the “ambulance at the bottom of the cliff model” and instead will focus on health promotion, prevention and improved access to care.
“I am standing because I want to improve the health and wellbeing of all people of Hawke’s Bay and reduce inequalities in health outcomes. The current ways of thinking have not delivered the health outcomes our communities and whānau need or deserve.”
He says while previous board members have brought with them considerable business and financial expertise it is not clear whether this has translated to improved health equity, access to care, reduction in disease burden and progress in other patient and community focused outcomes.
“Simply throwing money at the problem is not the right answer as we have deep inefficiencies and waste in the current system. Health promotion and prevention and patient/whanau education need to be at the forefront of any care delivery model. Investing in this line of thinking will lead to tremendous savings, as the old saying goes, an ounce of prevention is better than a pound of cure. Healthy individuals lead to healthy families and to communities.”
Incumbent Poulain says the HBDHB needs to move towards a system that’s more decentralised and more responsive to the needs of the Hawke’s Bay community.
“We need to put the resources into the hands of more diverse providers and increase the competition.” As an example, she suggests not tying patients to one GP practice. A patient could go to any GP and if they are not happy with that doctor, they could go to another. Consumers would be using their dollars to vote for their best healthcare, and this competition would provide them with better care.
Poulain wants to change the system so that board members could spend more than one to two days a month overseeing the region’s largest business. The healthcare system needs more attention than that from the eyes of governors.
As a councillor, Poulain said she gives the Hastings District Council two days a week of her time. “It is a bit out of whack when the revenue stream is about 10 times as much as the local councils. The time and attention we put to [the DHB] is tokenistic. But the model is driving that not the desire.”
Pharmacist Wilson is standing so better health decisions can be made. “The main thing is to get better community healthcare set up,” she says.
Wilson says with the ageing population only going to increase over the next ten years, it will be her generation that will be dealing with it if the right decisions are not made at a board level and if money is not spent wisely by DHB management.
She says although the DHB might be a closed governance system and people cannot interact with them like they can with local councils, she wants people to know that she is a part of the community and as such people can approach her. “I am a member of this community, and I will work for them. I’m really here for Central Hawke’s Bay.”
The DHB might be the most important board in the Bay. Consider that as you vote this year.