GUEST BLOG: Ian Powell – Epiphanies and health system improvement

Decades ago, when an impressionable young student at Victoria University, I participated in a student association meeting to debate a resolution that the two chaplains rooms (Anglican and Catholic) be removed from the student union building.

With such a topic it was no surprise that the turnout was high and the debate passionate. It was quite an experience to witness. The resolution was defeated although I voted in favour.

Among many quality speeches, the one that stood out for me was from a student who may have seconded the resolution . What impressed me was the articulate, intelligent and precise delivery of his argument that New Zealand was a secular society and why that was a good thing. This underpinned his support for the resolution.

What in God’s name are you students up to?

Epiphanies twice

This student had an epiphany while at university becoming a socialist and drawn to unionism. After graduating in economics he quickly became a prominent union leader in the private sector. This included being elected to the then Federation of Labour national executive.


This was quite an achievement for a former student; back then few students went on to work for unions (at least in the private sector), let alone become union leaders.

Then, in the ‘Rogernomics’ era which started in the mid-1980s,  he had a second epiphany with a sudden realisation that the future lay with market forces rather than the union movement. He started up his own consultancy and then became a successful professional director. The rest was lucrative history.

I recall a meeting with him soon after this epiphany.  I had started working for the Association of Salaried Medical Specialists and was confronted with the double-whammy of the anti-union Employment Contracts Act and the National government’s intention to introduce a competitive business market into the health system.

He was advising the transition unit for the latter on employment relations. His advice was that the various consultation requirements negotiated by health unions were a roadblock to the ability of health bosses to manage.

Epiphanies thrice

More recently he had a third epiphany which was, in part, a healthier lifestyle. From advocating hard-line employer positions the tone shifted to a softer line. Compassion and the need for equity now feature more in his public discourses.

My own encounters with him beginning as a student were occasional only. But, despite differences over the years the contact was always friendly. He was never personal and respected those who were not on the same page as him.

Now that student chairs the interim board of Health New Zealand (HNZ) which comes into force on 1 July replacing the district health boards (DHBs) and assuming some key functions of the health ministry.

As much as I disagree with the undemocratic and poorly thought-out decision to abolish DHBs, Minister of Health Andrew Little’s decision to appoint Rob Campbell to this role is one of the few sensible decisions he has made.

The Spinoff (13 March) provides interesting insights about Campbell in an interview prior to his appointment as interim chair of HNZ: Rob Campbell paradox.

Having commended Campbell’s appointment, hopefully without unintended faint praise, a recent interaction with him reveals concerns about his approach to health system improvement.

Rob Campbell: a good appointment as HNZ interim board chair notwithstanding


A revealing interaction

On 23 May BusinessDesk published an article by me: Distracted health leadership means leadership neglect. My argument was that in 2017 the Labour led government inherited four crises in the health system – severe workforce shortages, infrastructure, top-down managerial leadership culture, and medicine supplies.

But the government’s preoccupation with restructuring led it to neglect these crises thereby allowing them to get worse.

On 27 May Rob Campbell responded on LinkedIn:

Yes, “four inherited crises”. To which we should add embedded inequity for Maori, Pasifika and other groups.
Simply putting more money into a structure which is incapable of effective response to these crises would be madness.
Pae Ora [the new health legislation restructuring the health system translated as healthier futures] is this Government’s response which builds on many studies and many more lived experiences about the options. No doubt it will have imperfections but it provides a structure which is capable of meeting those crises.
Whether we can use it to do so will depend on the skills, goodwill and determination of all those working in and around the structure.
Those who stand back and only scoff will not solve the crises.
Within the old system, people have found many ways to innovate and create, to patch up and make do, to work around and above the limitations and shortages. That is what we will build on.
Pae Ora, the national health service and our Maori partners, are a pragmatic response from within to deep crises as will be very evident to all as the careful, equitable and financially responsible changes take effect.

Campbell begins by saying that there was a further inherited crisis: “embedded inequity for Maori, Pasifika and other groups.” I would put it differently.

Unmet need has continued to grow, including disproportionately for Māori and Pasifika, primarily due to the increasing impact of social determinants of health and the four crises I referred to have made mitigation of their impact by the health system more difficult.

However, discussing this aspect further takes one down a semantic what comes first – chicken or egg – debate. Best say no more on this.

Fourth epiphany required

But the rest of his response is disappointing. Essentially it blames the existing structures (primarily DHBs) for the crises in the health system, including unmet need. No evidence for this is provided; it is simply declared.

The prime drivers of unmet health need (and consequential inequities) are the social determinants of health, such as low incomes, poor housing and limited educational opportunities.

But these driving determinants are external to the health system. Only government action through targeted legislation and policies can address them. At best the health system can only mitigate their effects.

DHBs can’t be blamed for the failure to address these social determinants. Nor can DHBs be primarily blamed for the failure to mitigate their effects on the health system. To begin with central government determines the funding that DHBs receive.

Further, central government is primarily responsible for the failure to address severe workforce shortages, infrastructure neglect and restricted medicine supply. This has been made more difficult by the top-down leadership culture of central government towards DHBs.

Time for an epiphany Rob

Time for an epiphany Rob

Just has Campbell scapegoats existing structures for the crises of the health system, he also looks to legislated restructuring to solve them. But, contrary to his brief reference to “many studies”, the overwhelming experience is that restructuring does not deliver sustainable health system improvement.

As is often stated, cultural change trumps structural change in improving health systems all the time. It is an ABC that business consultants often ignore. Time for a fourth epiphany Rob! Come on; you can do it. I say this in a non-scoffing way!

Ian Powell was Executive Director of the Association of Salaried Medical Specialists, the professional union representing senior doctors and dentists in New Zealand, for over 30 years, until December 2019. He is now a health systems, labour market, and political commentator living in the small river estuary community of Otaihanga (the place by the tide). First published at Otaihanga Second Opinion

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