The Corporate Creep

Most doctors have stories about pointless ‘business’ meetings we’ve attended. For example, I once  dropped everything for  a meeting where the only item on the agenda was a name for the meeting. (That’s right, it was a meeting about what to call the meeting.)

We’re adept at the subclinical eyeroll when managers use corporate babble. “Your work in this space has  really shifted the dial”, someone gushes, unconvincingly. “We’ll shift the paradigm in no time to establish core efficiencies and reach the goalposts faster.” Really?  It’s enough to make me break out my bullshit bingo* card.

Recently I sat in disbelief listening to a non-clinician solemnly lecturing a group of seven experienced paediatricians on the fact that ‘a child is surrounded and supported by its mother and father’, in explanation of some new branding they were very proud of.  

Bruising as they are, these are minor injuries in comparison to the main reason we don’t like business meetings: they don’t work. 

My colleagues pause urgent clinical work to attend management meetings, because they’re one of the few tools we have to advocate for better resources. But as a locum doctor who periodically  returns to various hospitals to cover the same stretched services, it astonishes me how often I hear the same pleas repeated, often to a new manager, months and years later – because nothing has changed. Essential roles remain vacant. An electronic health record, accessible to all involved in a patient’s care, remains a pipe dream. 

So let’s talk about ‘the business of health’. Here’s a fact for you: it wasn’t always a business. In the 1930s NZ displayed the forward-thinking values we’ve always bragged about, and passed laws enshrining free public health care, administered by Area Health Boards. It wasn’t until 1991, after the rise of Rogernomics, that the Government decreed that the health system would follow “free market”  principles.

Thirty years on, we have watched the rise and fall of Crown Health Enterprises (intended to make a profit), District Health Boards (intended to not make a loss), and now the single mega-entity of Te Whatu Ora Health NZ (boasting a “strategically aligned Entity Performance Framework”) Meanwhile the culture of framing healthcare as a business transaction, has metastasised throughout the health system. The same people are in charge, they’ve just swapped titles. And we still talk every day about targets and ‘business cases’ for resources.

While we can’t blame the business model entirely for inadequate health care in Aotearoa, it has caused damage. When I asked colleagues for examples they came up with so many that I can’t begin to cover them in this column. But I can frame them under a few broad categories.

 

The impossible targets category:

Every week, clinicians receive emails detailing their failure to meet government targets. Unfortunately, those targets haven’t been accompanied by the resources needed to meet them.  Regions are shamed for being “in debt” when the measures they are reporting against don’t adequately consider the need that exists within their community. Achieving zero seclusion in psychiatric units is a wonderful aspiration – and almost impossible to achieve when wards are badly designed and overcrowded and nearly 30% of psychiatrist positions are vacant. GPs are urged to do more, when they are already spending huge hours doing unpaid paperwork after a day of back-to-back appointments in which they have 15 minutes to try and resolve complex medical needs, knowing that a referral to a specialist is likely to be rejected or put on hold for months.

 

The Bad Language Category:

If the culture of business has spread like a cancer through health systems, so has its language. When did we move from ‘healthcare’ to ‘health service’? When did ‘patients’ become ‘clients’ and how did that change how we related to each other? One colleague reports that she found the term ‘revenue generating units’ in place of patients, on government documents. The language creep is frankly, getting offensive.

Even more dangerous are the apparently bland terms. The current Government is pushing through changes, mostly cuts, citing ‘efficiency’. Efficiency is a laudable goal in principle – it’s about using resources (like time, staff, and equipment) in the best possible way to minimise waste.

Efficiency is measured by setting targets – time on surgical wait lists, for example. Financial penalties are imposed for not ‘achieving’. Government funders, inspired by big business, employ a moving goalposts approach – encouraging further ‘efficiency’ by offering less resource for increased targets the following year.

But what if we’re using the wrong language? Where efficiency is about ‘doing things right’, productivity is about ‘doing the right things’ – achieving the outcomes needed for each person by using the right resources at the right time.  And then there’s efficacy – making sure that the resources we apply actually have the intended effect. 

In rural practice, efficiency is often wrongly conflated with productivity. Engaging local community members to deliver a vaccination programme may seem less efficient than, say, sending a team out from Wellington. But as the Covid experience taught us, in the end it’s way more productive and efficacious – because those community members already have the relationships and local knowledge to do the job, even if they need training at first.

 

The Cosplay Category:

I didn’t realise that the hospital ‘business meetings’ I’d taken part in weren’t normal for actual businesses until I was (inexplicably) invited to sit on an external sustainability panel for a major bank. Sitting in that boardroom, with senior bank managers expertly moderating discussion and then having actionable points emailed to us to sign off on just a week later, I realised that most of us sitting in hospital ‘business meetings’ are just cosplaying. 

You know the one. Doctor goes to medical school to learn how to heal people. Doctor then lands in a meeting where they have to construct a business case so that they can be allowed to er, heal people. Doctor tries to mitigate unsettling experience by putting on a funny nose and using magic words.

It would be easy if it was just us who had no clue how to make a ‘business case’- after all, we have no experience even though most of us can pick up pointlessly long words with ease. But the crazy thing is that even the ‘business minds’ seem to make it up. 

 One colleague writes: “I’m dismayed that Health NZ spends vast resources preparing what I think of as ‘faux business documents’ – which superficially have the form of those used by big corporates – but which are populated with such inaccurate and meaningless data that they serve no purpose whatsoever.”

It gets worse – another colleague told me that specialists in her field spend hours every week filling in a ‘risk register’.  However, nothing in the document seems to be used for anything. When she tried to translate the jargon-y bits by adding another column to clarify the real-life risks to patients’ lives,  the column was quietly deleted. It’s hard not to conclude that if having a list is the indicator to be measured, some people will stop at the list.

A recent proposed restructure of a mental health service in the Wellington region drew backlash from clinicians, patients and families after they pored through hundreds of pages of  “change program” business jargon but did not understand what was being offered. The people designing the program could not say  roughly how many people in the region had serious mental illnesses needing specialist care. Unbelievable. Or unfortunately for clinicians who deal with this stuff every day, all too believable.

 

The Losing The Point Category:

Let’s talk about outcomes. The way the health system is funded doesn’t weigh all ‘outcomes’ fairly. For example, surgical procedures are seen as more ‘valuable’ for a service to offer, as they attract more funding. It’s really strange to me that a funder would ‘price’ one type of healthcare as more valuable than another, when all are needed to keep people well, but I guess that’s why I don’t have a business degree. Over time, this has led to some pretty weird imbalances.

For example, under this system, medical clinics and community services are underfunded or not funded at all, even when they are an essential part of post-operative care. Statistics show for example that stroke patients who undergo urgent clot retrieval (some of the most expensive and specialised surgeries available), are then neglected. Most never see a stroke specialist again after discharge, they wait six weeks or more for speech therapy, they lose their job and income. 30% have depression or anxiety and their suicide rates are twice as high as the general population – but can’t see a psychologist in public.  That just seems daft.

Another word on outcomes: it’s usually the outcomes outside health that matter the most. Here is a tradie who can go back to work; here is a child who can finally learn at school. Are these counted as measurable outcomes, to be supported with resources? Take a wild guess.

 

The I’m Too F-ing Tired Category:

I’ve mentioned that most doctors don’t have the lingo and cultural knowledge to write ‘business cases’.  We also don’t have the time – as one colleague says, it’s bonkers to expect us to write a proposal in our ‘spare time’ to prove we are overworked and need more staff.  It becomes a catch-22 – we are too tired and we don’t know how, if we do there is almost zero chance anything will happen, but if we don’t we will become more exhausted. Unsurprisingly, navigating bureaucracy is an often-cited factor in burnout and resignations. Or more cynically, “It’s a way of keeping us overworked and then blaming it on us.”

 

Okay! I get it! What should we do?

Here’s the solution: all doctors should study for MBAs.

Just kidding. 

 

I think we need to reconsider the model for health, especially doctrines like ‘business drives greater efficiency’ or ‘one size has to fit all’. 

 

I also agree with Sir Ashley Bloomfield who this week has proposed a bipartisan approach to health policy – one where all political parties agree to set a plan for the next ten years instead of tearing down and rebuilding every time there’s a change in government.

 

Yes. That would be super nice. But.

 

The Government is further entrenching itself in an ‘efficiency’ drive when it comes to health. The new Director-General of Health and Chief Executive, Ministry of Health

announced last week, Audrey Sonerson, does not come from a health background. In her previous role leading the Ministry of Transport, Sonerson oversaw the increasing of speed limits on roads near schools and the lowering of emissions standards on cars so that preventable air pollution will affect millions of people with chronic respiratory issues. She also removed the clean car discount, further contributing to climate change with its massive threat to health and life.

 

Tellingly, in announcing the pick, Deputy Public Service Commissioner Heather Baggott stated:

“I have no doubt her leadership and skills are what the ministry needs right now. I am confident Ms Sonerson will quickly get on top of the presenting challenges. She has strong financial acumen and a relentless focus on efficiency, effectiveness and performance.”

 

Hmm. Relentless focus. With unswerving optimism, let’s hope she focuses on the right things. 

 

* Bullshit bingo: I got taught this method to get through meetings when I was a registrar. Before the meeting agree with your fellow players what 5-8 jargon phrases you’re all listening out for. The winner is the person who hears all the phrases, mentally ticking them off while appearing incredibly attentive, and does a pre-arranged signal for ‘Bingo’.