Servant becomes master

BY NICOL HORRELL

OPINION: The Southland District Health Board's vote to reverse its two earlier decisions not to support Brian Rousseau's determination to have only one district health board-appointed PHO for Otago and Southland is disappointing, to say the least.

Mr Rousseau's classic "divide and conquer" tactic – having reached some sort of accommodation with Southlink Health, the region's independent practitioners association and the New Zealand rural GP network – provided sufficient pressure on the board to finally achieve the result he wanted. Which brings into sharp focus the contradiction in terms these highly paid public servants portray.

Somewhere along the line the servant-master relationship has been reversed.

Mr Rousseau's comments after the meeting that one PHO for Otago and Southland was in the best interests of the community should be particularly worrying for the community and Maori; reinforcing the top-down, we-know-best attitude that has dominated this whole exercise.

The contemptuous and dismissive attitude the DHBs have shown to the nine legally constituted independent PHOs they intend to disestablish has left many people feeling hurt, angry and disenfranchised.

In political terms, the cumulative effects of the power play we have seen during recent months are corrosive and will have fallout for the Government. If this was a test case for the rest of the country, the process needs a major overhaul.

Few people would disagree that a review of primary health care is timely. The Health Minister's request, for PHOs to reorganise themselves to reflect the fact we are in the worst recession since the 1930s, as a cost-saving measure was not unreasonable.

Mr Rousseau's single-minded approach to torpedo all the existing PHOs seems to be at odds with government policy and the minister's statements.

He presented the boards with legal advice, warning them they could not enter into discussions with or allow PHOs to reorganise themselves, for fear of breaching the Commerce Act.

It gets better. They were also advised that an explicit unilateral policy decision by the Otago and Southland DHBs to contract with only one PHO (and form a monopoly) would not breach the act.

If the DHBs don't renew contracts with the existing PHOs, they will no longer be competitors in the absence of contracts with the DHBs, leaving the new monopoly PHO free to acquire the assets of the exiting PHOs without the act applying.

This advice, especially in the minds of the public, must be seen for what it is – convenient, questionable and certainly not within the spirit of the act.

Part of the motivation for only one PHO appears to have been to stop 13 Dunedin general practices moving to another PHO – a move that Health Minister Tony Ryall offers his support for ("Clinicians should be free to choose their PHO", August 26).

This makes the Southland board's U-turn even more surprising. It could have offered some semblance of choice by simply warning that the Southland PHO might lack critical mass but allowing practices in Otago and Southland to make their own decision.

Are Mr Rousseau and the boards at odds with government policy, or are they leading it? Was this move about efficiencies in the delivery of primary health care or does it have more to do with control and money by vested interests and cash-strapped DHBs?

We appear destined to have a Dunedin-based PHO, where a small group of well-paid clinical and professional directors who will make "one-cap-fits-all" policy for a large and varied geographical region.

The DHB's plan to amalgamate is also to be fast-tracked to create another Dunedin-based entity after a token round of public consultation. Which provokes the question: why the rush?

DHB amalgamation currently requires widespread public support and a legislative change to accommodate such a move. A referendum at local body elections in October next year would provide an ideal vehicle to get an accurate public response at little additional cost.

Regional co-ordination of tertiary services across the region makes perfect sense and is already happening. In general, people don't mind travelling if an operation or procedure is available when they need it. However, I would have thought that reducing elected representation, and with it the opportunity for the public to have any influence on their performance, would have been the last item on any efficiency priority list.

Any early amalgamation encourages everyone, from planning and funding staff to medical specialists, to be based in Dunedin.

There are huge efficiencies to be gained in the health budget by cutting out the double and triple handling of everything by a top-heavy administration. There is no good reason all the DHBs in the South Island could not share the administration accessed by an integrated computer system.

This would create real savings, significantly reducing administration staff; creating a centralised bureaucracy increasingly remote from the people it is supposed to serve, whose first priority will be its own survival, will certainly not.

Let's not give away our democracy, and with it any checks and balances, to the "we know best" and "the ends justifies the means" attitudes that prevail at the moment.wNicol Horrell is chairman of the Waiau Health Trust.»

» Nicol Horrell is chairman of the Waiau Health Trust

- © Fairfax NZ News