Kiwiblog

The ODT reports that Tony Ryall has set just six targets for DHBs (I presume on top of don’t run out of money). They are:

1. cut emergency department waiting times so 95% treated within six hours
2. deliver faster treatment for cancer patients – all those needing radiation treatment to get it within six weeks by July 2010 and within four weeks by Dec 2010
3. carry out more elective surgery – an extra 4,000 operations per year
4. more immunisations – 85% immunised by July 2010, 90% July 2011 and 95% July 2012
5. better help fro smokers to quit – 95% of smokers in hospital to be given advice and help to quit
6. better diabetes services

What were the targets from the previous Government:

1. 13 health priorities
2. 61 objectives
3. additional subset of 13 health objectives
4. 10 health targets measured through 18 indicators
5. 25 other indicators of DHB performance
6. 4 hospital benchmark indicators assessed through 15 measures
7. an outcomes framework with 9 outcomes, measured against 39 headline indicators

Sounds like doctors may have more time to see patients and be spending less time reporting on priorities, objectives, indicators and outcomes. Also sounds like we may have a few less administrators.

I saw in the Herald that a Tim Dare has responded to the excellent op ed by Dr Shaun Holt on the bureaucratic PC ethics approval system for the most basic of health experiments (the example was honey on a rash).

Now when Dr Holt did his original op ed I noted he provided an actual example of how the system was nonsense, and that he spoke from first hand knowledge, being a Doctor.

So before I even read Tim Dare’s response, I crolled down to the end to find out whether he was someone with a vested interest in defending the status quo. And indeed:

Dr Tim Dare is head of the department of philosophy at the University of Auckland and chairman of the Health Research Council ethics committee.

Interesting. Dr Dare is chairman of the HRC ethics committee (which makes him the ultimate vested interest) but he is also (to quote Rob Muldoon) one of those doctors who makes you sick, not well

But what does he say:

Dr Holt is moved in part by his experience as a former ethics committee member and researcher. He recently sought approval for a study looking at whether honey helped treat a common childhood skin condition.

“Only 15 children were required,” he reports, “and all the caregivers had to do was to apply the honey, cover with a dressing and see if it seemed to help.”

The ethics committee refused permission, he says, raising more than 40 objections. He gives as an example of its obstructive approach a requirement for Maori consultation.

This is misleading. I was a member and chair of New Zealand’s busiest health research ethics committee for seven years. Some very difficult applications, such as those requiring the development of new policy, took a long time. But the vast majority were dealt with at the meeting following their receipt (within two or three weeks), as required by national guidelines. Even allowing time for letters following that meeting, few were still open six to eight weeks after receipt.

He says this is misleading, but nowhere does he dispute that Dr Holt was refused permission and had over 40 objections to overcome to what appears to be the most simple of experiments.

And rather than quote actual statistics on turn-around, we only get told ” the vast majority” and “few”. I prefer hard numbers. But the issue is not just about time to make a decision, but the hurdles that applicants have to jump through prior to application.

Delays beyond that were often because researchers took time responding to committee requests for clarification or amendment.

So it is their fault. Again no statistics on this.

Dr Dare turns to Dr Holt’s proposal and comments:

Dr Holt’s account of the treatment of his own proposal is also less than complete. Ethics committee minutes are publicly available. The minutes for Dr Holt’s study before the Auckland committee (to see them, run NTX/08/09/085 through Google) indicate that the committee deferred a decision on Dr Holt’s honey project because they were concerned about its validity.

They seem concerned the study did not have enough participants and that parents were required to change dressings and wash the affected area during the study without an indication how Dr Holt would know whether it was the honey or the washing that made the difference. There is mention of Maori consultation, but it is not given as the primary reason for deferral.

These are very ordinary concerns about research validity: one of the legitimate roles of an ethics committee is to ensure that health therapies cannot claim to have been shown effective unless the research is rigorous and sound.

Note that the committee did not decline approval: they deferred a decision. Dr Holt chose to not clarify or amend his study.

It was good of Dr Dare to provide the Google reference as it does provide the minutes of the meeting. But I think the minutes prove Dr Holt’s point. Look at the changes that were demanded for such a simple study:

• Study, as it stands, is a pilot and this needs to be stated in the title, and then reflected in the design, the research question(s) and the PIS and consent form. Alternatively, the researcher may choose to power the study, after consulting a statistician
• Guidelines NAFG to be consulted.
• Part 1: Provide positions/qualifications/organisations of co-investigators
• A3.1: Insert information regarding washing the MC lesion every 2 days (same as PIS).
• A1.2: Explain what type of honey will be used and the justification for using this.
• A3: Study Design: It is planned to dress 1 MC with honey, cover it then, for the next four weeks, wash it every 2 days wash it, dress it with honey and cover it while the other MC is left untouched. Clarify how the researcher will determine which of these interventions is causing any effect seen.
• A3: Randomize over two chosen sites, and include an osmolarity control.
• A3: Explain how participant compliance with study design will be monitored between visits
• A4.1: Explain how the 15 child participants will be assigned in respect of each locality
• B10: Grounds for exclusion to be ‘factual’ not left to doctor.
• B11: Provide worksheet. What information is being collected and why?
• B12: Explain why a dressing known to cause allergic reactions will be used, rather than a non-adhesive dressing, and explain how the cause of any adverse reaction will be ascertained.
• B12: If removed from the study what treatment will be offered to the child?
• B16: Clarify ‘safety reasons’.
• D5/6/7: Data to be kept until age of majority plus 10 years (Health Act – Children)
• E: Researcher to explain how interpreters are accessed, if used
• Section F: Consultation needed from Tauranga Maori Health Providers. Honey is food – are there cultural implications?
• Locality Assessment Cannot be signed by PI. To be redone.
• Pt 4 Declaration: 2: Cannot be signed by PI. To be redone.
• B11: Provide worksheet?
• Provide an information sheet/consent form for children under 15.
• A8.1: Provide itemised budget that justifies the $900 payment to doctors. Without such detail we are unable to assess whether the payment to doctors might act as inappropriate inducement to recruit and retain.
• D4: The committee is concerned that having the initial approach made by the GP increases the potential for conflict of interest and coercion of the participant, given the payment per participant that is proposed.

Hell I would have given up at this point also.

An article full of revelations appeared on Monday by Shaun Holt on medical ethics in NZ. He explains:

As an experienced medical researcher and an ex-member of an ethics committee, I am likely to know about the ethical requirements of medical research. Last year I submitted an application for a simple study to see if honey could help treat a common skin infection in children that is otherwise very difficult to treat. Only 15 children were required for the study, and all the caregivers had to do was to apply the honey, cover with a dressing and see if it seemed to help.

Sounds about as simple as you can get. It is 1,000 miles away from let’s not treat this women for cervical cancer so we can see how effective the treatment is.

In order to apply to the ethics committee, I had to consult a Maori health provider to make sure there were no cultural issues if any Maori children took part and see a justice of the peace to sign a statutory declaration.

The application itself needed around 9000 words to complete and over 350 pages had to be submitted. For a study which could not be any simpler and had almost no chance of causing any harm, the application process took longer than doing the study would have.

This is the first stage of distress. Consulting a Maori health provider should not be mandatory – common sense should apply. And God forbid how you need 350 pages for such a simple study. Think of not only the cost to the healthcare system, but also the research that never happens due to such bureaucracy.

The study was rejected by the committee and around 40 points were raised, most of which were either wrong or not relevant to the ethics of the study. For example, I was told to consult at least two more Maori health providers and to have systems in place for interpreters, even though the study was to be undertaken by a few GPs who would ask their own patients with this condition if they wanted to take part.

Almost enough to make you weep.

It is no surprise he writes:

Medical researchers are hugely frustrated by the quality of the ethical reviews of their proposals, the work required for an application and the time taken for the responses and approvals. One of our leading orthopaedic surgeons has said the greatest impediment to medical research here is the growth of the ethics committee process.

We owe Dr Holt our thanks for speaking up. Hopefully the powers that be  will take note.

Hat Tip: MacDoctor

Phil Goff is upset that Tony Ryall may have caused a $350,000 primary health conference to be cancelled.

I think Mr Goff should keep campaigning in defence of taxpayer funded conferences.

Inaugural Health & DIsability Commissioner Robyn Stent writes in the Herald that then Health Minister Annette King changed the law in 2004 to allow the storage of body parts or bodily substances without the consent of the patient they came from, if it is for the purpose of approved research.

I’m all in favour of embryo research, but only if the parents give consent. It is shameful that Annette King nationalised their embryos to allow embryos to be stored without parental consent.

Poneke is in Brisbane and has discovered it has the buzz of prosperity:

On the surface, the prosperity can be seen in the world-class infrastructure of roads and electric rail lines that Auckland in particular has not been able to achieve despite decades of talk; the very high standard of housing, commercial buildings and public facilities; the wages that really are stunningly higher than at home; the many job vacancies in the papers even on the Saturday after Boxing Day. Australia has not had a single quarter of negative growth this year while we have had three (though the Aussies fret about it and fear recession might still happen). I could go on.

MacDoctor shares some first hand experience of emergency clinics:

An article in the Weekend Herald (not yet online) entitled “High cost stopping Kiwis visiting the doctor” tells us that over two thirds of New Zealanders over 20 have avoided visiting a doctor because of the cost. I didn’t need any research to tell me this is true, because these people pitch up to emergency departments throughout the country with the line, “I couldn’t afford to go to my GP”  or it’s alternative “I owe my GP too much money”. …

I view these two excuses with a great deal of cynicism. Many who use these lines are drunk or have nicotine stains on their fingers (or both). They drive up in expensive cars and sport MP3 players (many are genuine iPods). They typically arrive not long after the GPs have all closed for the evening, or over the weekend. These are the “milkers of the system”  - They know how to work the health system to their advantage and they use Emergency Departments like a GP clinic. …

I suspect most of the two thirds of New Zealanders who said that they do not go to a doctor because of cost, are really saying that they would rather spend their time and money on something other than their health. It has nothing to to with lack of access and much to do with lack of interest. Until we, as a society, start to see that health is important and worthy of investment, this problem will not go away, regardless of the amount of money governments may throw at it.

Hear hear. I think all bar the very poorest should pay something towards their healthcare.

Bernard Hickey recommends a Kim Hill interview with JJ Joseph – a man who used to beat his wife. It’s a very moving interview that shows people can turn their lives about.

And finally Lynn Prentice at The Standard manages to link Bernie Madoff’s ponzi scheme to National’s planned repeal of the EFA. The hilarious part is:

based on recent experience of their autocratic, arrogant, and undemocratic behavior in the house, we will probably see some opaque, badly written, and badly thought through legislation pushed through under urgency.

What does he call the EFA if not badly written and badly thought through? And he ignores of course that unlike Labour, National has said it will consult all parties over the replacement legislation. It was Labour that tried to use bipartisan electoral law to screw over its enemies.

From Monday’s Dom Post:

Just 67.5 per cent of category 2 patients including those suffering serious head injury, moderately severe trauma and suspected heart attacks were treated within the recommended 10 minutes.

Fewer than half of patients categorised as triage 3 those with fractures, breathlessness, bleeding or other conditions requiring urgent treatment but not considered life-threatening were seen within the recommended time of 30 minutes.

This result was “the worst performance bar one since they started recording data in 2001″, Mr Ryall said.

During their nine years in office Labour increased health spending from $6.1b to $11.6b. That is an extra $5.5 billion, yet still barely half of emergency patients get seen within recommended times.

Idiot/Savant is sceptical of the planned policy to have maximum waiting times for A&E. He claims that in the UK, the response to such targets was:

The policy is based on UK Labour’s attempts to improve quality in the NHS by introducing these sorts of absurd targets, and Ryall claims that policy was a success, having led to a reduction in the number of patients waiting for than four hours from 23% to 3%. But that success was an illusion. As noted in Adam Curtis’ documentary, The Trap, faced with pressure to improve their statistics, NHS managers created a new and unofficial post, the “Hello Nurse”, whose sole purpose was to greet new arrivals to A&E so they could claim for statistical purposes that the patient had been “seen”. Faced with a similar target aimed at reducing the number of patients waiting on trolleys in corridors, they simply removed the wheels from the trolleys and reclassified them as beds.

I’m not sure whether to be appalled or impressed by the ingenuity – reclassifying trolleys as beds!

The targets were met, but the underlying performance didn’t change one iota. Mangers being managers the world over, the same is likely to happen here. It’s a general problem with this sort of empty managerialism and obsession with statistical targets: the statistical goal – measured patient “waiting time” – ends up taking the place of the real goal – patient care. And doctors and nurses end up spending all their time filling in performance spreadsheets rather than doing what they’re supposed to be doing: seeing patients.

Idiot/Savant arguments would be stronger, if the status quo had not failed so badly. Under Labour we have had $3.5 billion of exra funding for health, no targets for A&E, and the result has been 20% of people waiting for more than eight hours.

Why does he think throwing more money at it, without targets will work? Can he cite an example in the world where it does?

As I said yesterday, the benefits of targets are it creates transparency. DHBs can cost what the cost will be to meet the six hour target. Dedicated funding can be applied for. If the Government refuses, then people can hold the Government accountable.

Rather than clinging to the dead 80′s cult of managerialism, National should target the real problem: lack of resources. The reason people have to wait so long in A&E is because hospitals cannot afford to employ enough medical professionals to deal with demand.

And without a target to aim for, how on earth can one calculate what it would costs to have the extra staff?

The reason they are parked on trolleys in hospital corridors is because there is not enough space. But solving these problems would cost money, which National would rather give to the rich in tax cuts. It’s just a question of priorities – and National clearly rates redistributing wealth to those who need it least well ahead of ensuring that every kiwi has decent access to healthcare.

And now we just get the blind slogans, instead of intelligent analysis. Idiot/Savant is not stupid. He has read National’s fiscal package. He knews that the tax cuts are being funded almost entirely out of changes to KiwiSaver. Not from less spending on Health.

In fact National has pledged significant funding to train up more doctors, to set up 20 new surgicial wards etc etc.

The Herald editorial is supportive of the policy:

It is also all the more reason to welcome Health Minister Tony Ryall’s plan to impose maximum patient waiting times on emergency departments, and to hold district health boards and their management accountable for meeting them. His initiative is sure to attract criticism. Such targets are always something of a crude measure, if only because they fail to give sufficient recognition to quality of care, which should, ideally, be hospitals’ paramount concern.

The target are no silver bullet, but frankly we should be debating why we have never had them before, not be surprised that these minimum measures of accountability are being introduced.

But Mr Ryall can be excused for starting at this point. There is a sense that, while the Labour Government increased the health budget by more than $3.5 billion, too much of this was swallowed with little discernible increase in efficiency. There were neither quantitative nor qualitative improvements. At the very least, targets incorporated into performance agreements will lay the foundation for better results by increasing accountability in emergency department operations.

Indeed. The status quo has seen massive funding and little way to judge how well utilised that funding was. Now that is great if you are Minister of Health, but not good for patients and taxpayers. This si why I said Ryall’s policy was brave – it actually creates an accountability for him as as Minister that was previously lacking.

The Herald reports:

Health Minister Tony Ryall will impose maximum patient waiting times on hospital emergency departments. …

The Herald reported yesterday that a consensus is emerging – in talks among senior physicians and health officials – that the maximum time should be six hours and that no patient should be left waiting in an emergency department corridor. Recommendations are expected to be made to Mr Ryall within weeks.

This is a very brave move by Tony Ryall. Under Labour we saw billions thrown into health, but very little measurable improvements for that money. This means that Labour could talk about how much it cared, but never be measured on success.

Tony is putting in place measures that will introduce better accountability. DHBs will have to front up and specify what resources they need to ensure they can see all A&E patients within six hours. The DHBs can be held to account for that, and also the Minister and central Government an be held accountable if they fail to adequately fund the DHBs.

He cited Britain’s success in reducing emergency department waiting times through a target maximum wait, set in 2004, of no more than four hours from arrival to admission, transfer or discharge. Within several years, he said, the proportion of patients waiting in emergency departments for more than four hours fell from 23 per cent, to 3 per cent.

In New Zealand, Health Ministry data from one large emergency department and two of medium size indicated that while the majority of patients were seen within several hours, up to 20 per cent at one of the hospitals spent more than eight hours in the emergency department.

Looks to be a good plan.

The final legacy of Labour’s healthcare policy. The Capital and Coast District Health Board has a $70 million budget blowout (funny how the Minister has not sacked them even though he sacked the Hawke’s Bay one for a far far smaller sum).

The DHB has said if it does not get bailed out, it may be unable to pay staff wages. I can’t imagine staff will work without getting paid somehow.

MacDoctor blogs on how Labour is placing ideology above patient care. He explains:

There is excess capacity in the private health system. There is also an ability in the private health system to provide even more excess capacity at relatively short notice. Most surgical clinics have been constructed to allow rapid expansion of wards and theatres, particularly if resource consents are streamlined.

There are thousands of people on elective surgical waiting lists who are waiting many months to years for operations. Most of them could have already had their operations if the private sector was allowed to properly partner with DHBs. Currently, most private sector “public” operations are done under limited contract – often 1 or 2 surgical sessions at a time. There is absolutely no incentive for the private hospital system to “flex up” as the huge demand is being dealt with in a piecemeal fashion.

This is bad enough for Mrs. Smith who has waited three years for her hip operation and can barely walk. It is life-threatening to those who need cardiac surgery or radiotherapy. I am certain that, if Saturday sees the return of a Labour government, the brand new radiotherapy clinic in Auckland will have a few patients sent to it by the DHBs – the ones who have waited well beyond a safe waiting time. There will, however, be no concerted plan negotiated between the DHBs and the new clinic to maximise this new resource, because Mr. Cunliffe is apparently nearly out of his comfort zone.

This means, to put it baldly, people will die because of his ideology.

He also dispels the myths around using the private sector more:

I hear objections to using private health care occasionally from my colleagues. Their objection is that, if you move these patients out of the public system, hospital doctors will eventually have insufficient variety of work to maintain their skill sets (”I’m in charge” Cunliffe puts it as “sucking capacity out of the public system – a nonsense phrase, if I have ever heard one). Apart from the dubious ethics of essentially denying people timely care in order to maintain a doctor’s skills (or non-existent theoretical hospital capacity), this objection does not hold water. Most of the surgery dealt with by the private clinics is low complexity. Private clinics usually lack ICU beds and so cannot deal with the very complex. What maintains your skills better – 10 routine hip replacements or three complex revisions? Removing a dozen easy appendixes or a couple of complex appendix masses?

He concludes:

So let’s stop this whining about privatising medicine and use all of our resources, both private and public, to get the medical care that people need. National’s thoughts on this are very promising, particularly the multiyear funding guarantee which will enable both public and private resources to expand capacity with confidence. Yet another reason to vote for the three-headed hydra.

I note that the Herald uses the word “Elite” meaning “private”. I realise this is probably due to space constraints in their headline, but it is hugely insulting to those people who are having to mortgage or sell their homes in order to get the surgery they desperately need. I think we need to get past the place where we see private medicine as the domain of the wealthy and see it as a normal and valuable part of the entire health system.

This should be an op ed in a newspaper.

National has pledged to fund 20 new elective surgery theatres and train 800 additional surgeons, anaesthetists and nurses to staff them.

And what is Labour’s response:

Minister of Health David Cunliffe said the National plan was an “unworkable imitation of current Labour Party policy” and questioned where National would find the additional medical staff given the shortages.

The only way to build 20 theatres would be through privatisation, he said.

This sums up everything wrong with Labour. They would rather have 20 less operating theatres, than have the private sector involved. Their concern is not the health needs of New Zealanders, but their anti private sector ideology.

And I won’t even try and comprehend how you privatise an operating theatre that currently doesn’t even exist!

In the 1999/2000 years $6.8 billion was spent on Vote Health. In 2008/2009 Vote Health was forecast to be $12.6 billion. Now some of this is to over inflation and population growth but it is still a huge amount of extra funding. And what has been the result?

The Press editorial notes:

Heart disease is a leading cause of death in New Zealand and there have been longstanding concerns about the level of cardiac surgery services, writes The Press in an editorial. Yesterday’s report into cardiac surgery confirmed that these concerns were justified. The report found that this nation lagged behind comparable nations in heart surgery rates, with Australia’s level of service being 85 per cent higher and that within New Zealand there were significant regional variations.

Australia’s level of service is 85% higher.

And not only is this an election year when the Government must defend its health record, but another critical report, issued by the Ministry of Health yesterday, said that eight patients who died in 2006 and 2007 while awaiting heart surgery at Wellington Hospital had avoidable delays in their treatment.

Eight actual avoidable deaths, as oppossed to Helen’s invented 60 deaths in Iraq.

It is worth noting that a total of 16 people died while waiting for cardiac surgery during those two years, so that figure of eight being preventable represents half of them.

National has pledged to lift the number of annual places in medical school from 365 to 565, over five years. This would be the biggest increase ever.

We are currently one of the biggest importer of doctors in the world, and producing more doctors locally is sensible. And the student loan abatement for staying in NZ, along with lower taxes, should help keep them here.

MacDoctor proposes an alternative billboard for National

National has released a policy to incentivise doctors, nurses and midwives to stay in New Zealand, and even No Right Turn likes it.

Policy details are:

• Voluntary bonding with student loan debt writeoffs
• Will apply to those willing to work for three to five years in hard to staff communities or specialities
• A maximum annual write off of $10,000 per annum
• $30,000 written off (if at maximum rates) after year three and then $10,000 a year for the next two years if they stay on.
• Will apply to anyone who graduated from 2005 onwards
• Will be extended to other health professionals over time
• Cost is initially $3 million in year one expanding to $9 million in year three which covers 100 doctors and 250 nurses and midwives.

Jim Anderton released National’s draft health policy yesterday, and look at the headlines:

Nats plan spending spree on health

Surgery boost promised in Nats’ health policy

Seriously you can’t buy headlines that good.

The policy details, as leaked to date, are:

• over $100 million a year of taxpayers’ money on new health projects
• a spending spree on new operating theatres – building 20 operating theatres over three years. Capital cost $165 million over four years.
• Training an extra 750 health workers. Cost around $20 million a year.
• Giving a 30 per cent health insurance rebate, up to $500 a year, to those aged 65 or older. Cost $40 million a year at first.
• Gradually increasing medicines funding to match Australia’s per-head level. Initial boost of $20 million a year.
• Prostate cancer testing programme for men over 50 with a close family history of the disease. Not costed.
• Developing a dental assistance programme for over-65s. Not costed.
• Giving an extra $15 million to hospices.
• more state-funded use of private hospitals
• a star-rating system for district health boards
• the number of bureaucrats would be capped
• losses of health workers overseas would gradually reduce because of tax cuts
• voluntary bonding would be offered in return for student loan debt write-offs in hard-to-staff places and specialties
• will maintain the Government’s budgeted health spending projections – “not a dollar less than Labour”.
• maintain the current universal GP subsidy system, including the fees review process
• fund Plunketline
• funding 12 month access to breast cancer drug herceptin

This is only the draft policy of course, but I can’t wait until the final policy is released. More theatres, more medical staff, more medicines funding and a rebate for over 65s who have private health insurance – all going to be damn popular.

UPDATE: National has now released the official policy, or at least part one of it.

The NZ Herald reports on the successful Counties Manukau District Health Board which has had a 37% increase in elective surgery rates since 2004, and an 18% increase in total patient numbers – without an increase in facilities.

This shows that a combination of good governance, good management, good staff relations, and dedicated staff can make a real difference. It is not just about throwing money at the problem. Sure the DHB will have had funding increases which will have helped, but that is just part of the solution to improving health productivity.

The NZ Herald reports the Association of Medical Specialists:

“We got nowhere with [former minister] Pete Hodgson on that. It was like beating our head against a brick wall,” Mr Powell said.

“When David Cunliffe came along, it felt as though there had been a change of Government.

Treasury has been warning for some years about the lack of productivity or lack of increased outputs (let alone outcomes) in health despite the massive increases in funding.

Tony Ryall has pointed out that the number of first specialist appointments in 2007 was in fact 10,000 lower than in 2001 when records begun.

Note primary Y axis starts at 340,000 to align starting point with health spending.

The graph above shows both the level of first specialist appointments (a slight downwards trend) and the level of funding (in real terms) for Vote Health. Health spending has gone up 33% in real terms in six years, yet less people are seeing specialists for first appointments.

A good Minister will sometimes step in when regulations strange common sense.

This was very much the case when Kataraina Pewhairangi was ruled ineligible to donate part of her liver to save her 10 month old baby,  because she was not 21.

David Cunliffe made a very good call. Let us hope the operation is successful.

David Fisher puts his investigative skills to good use in the latest issue of The Listener. The article will not be online for a week or so, so I really recommend people interested buy a copy.  Some key points I noted:

• The e-mail between Hausmann and CEO Chris Clarke in January 2006, discussing details of the contract Hausmann was tendering for, was only accessed by Board Administrator Deborah Houston as she was filling in for his PA. Hence there may have been many more e-mails like that.
• King’s appointment of Peter Hausmann was at whim, and while legal (she can appoint anyone she wants) failed to follow best practice by having the potential appointee go before an interview panel.
• The Cabinet Appointments and Honours Committee staff alerted King’s office to the extent of Hausmann’s conflicts of interest
• A senior Ministry of Health staffer wrote a letter describing Hausmann’s appointment as posing a “huge risk”.
• Peter Hausmann asked for an inquiry not just into his own actions, but for a full review of the Board’s performance and governance. The Ministry of Health advised there was no need for this, and that it should be into Hausmann’s conflicts only as they believe “these are prima facie serious matters”.
• Pete Hodgson ignored the Ministry advice, and by making the review so much wider, meant the review took much much longer to complete, which in itself led to greater dysfunction.
• Ray Lind recorded several conversations with staff and board members, without telling them at the time.
• These secret recordings were only discovered when PWC audited the e-mail system and found Lind had e-mailed himself a copy – the e-mail had been deleted but was on the backup tape.
• Hausmann had access to the RFP months before his ten competitors did, and at least one of them complained about the lack of time to respond when it went public
• The e-mails to and from Hausmann regarding the RFP were deleted from the DHB’s e-mail system. This is arguably illegal under the Official Information Act.
• The only backup tape which had the e-mails was May 2005, and of the 12 backup tapes given to PWC, it was the only one damaged.
• DHB Management were severely criticised by the Audit Office for another (Wellcare Education) contract they gave to Hausmann’s company.
• An e-mail from Hausmann, after he was appointed to the Board, was sent to a senior manager extensively advocated on behalf of Wellcare Education, which Hausmann’s company’s owned.

The failings of both King and Hodgson, but also Lind and Clarke seem numerous. Deleted e-mails, official advice ignored, preferential treatment, secret recordings, appointments without interviews, to name a few.

What Annette King has yet to answer is why she appointed Hausmann? She says she just met him and as impressed with him.  But why did she ffail to follow best practice? She says she was not legally obliged to do so.  Fine, we know that.  But the question is why did she not have an interview panel as normal?

And has Pete Hodgson explained why he ignored the advice from Ministry officials who had no political interest in the outcome? Did he talk to King before making that decision? Did he talk to Hausmann, Clarke or Ray Lind?

And why did DHB management not once, but twice, fall over themselves to give preferential treatment to Hausmann?

A good thing may emerge from the sacking of the Hawke’s Bay District Health Board just a couple of months after they were elected. A questioning of the whole DHB structure.

Up until these events, people like myself who advocated DHBs should not be elected, were a very quiet minority. A month ago Matthew Hooton wouldn’t have been able to joke that he thinks Cunliffe should sack all 23 DHBs.

But by showing how DHBs are there to do as the Minister tells them, and that they have little control over important stuff such as funding, the Emperor’s new clothes are displayed.

So we see the Dom Post today saying:

Before Labour formed the government in 1999, health spokeswoman Annette King promised to return democracy to public healthcare, writes The Dominion Post. She argued people were agitating to get back around health board tables so they could have a say in what services their public hospital should provide.

Enter, in 2000, 21 district health boards, each with its own government-appointed chair.

The boards are a cruel hoax. Just how cruel was underlined last week when a King successor, David Cunliffe, sacked the board Hawkes’ Bay voters elected just months earlier and installed a “commissioner” instead. …

The need for a commissioner in the Bay reinforces the health management trick perpetrated on the public. Since DHBs were born, this Government has pretended that their seven-elected, four government-appointed members are those who decide local healthcare priorities. It has also deflected criticism of government funding and priorities their way.

What it has deliberately downplayed is the fact that it, via the Health Ministry, still pulls the strings by setting board budgets and circumscribing their activities. It has also glossed over the reality that, though communities go through a three-yearly charade of half-heartedly electing board members, they serve at the minister’s plea sure. That brutal fact has now come home to Hawke’s Bay voters. …

Mr Cunliffe’s strong faith in his own ability will be no more than self-aggrandisement unless he has the courage to tell the prime minister Labour’s fatally flawed health board model needs fundamental, albeit gradual, overhaul. He won’t. National, if it forms the next government, apparently plans no change, either. Because the electorate doesn’t trust it over public healthcare, it will tread lightly. …

They are indeed a charade and a hoax. The Minister should appoint the DHBs (and there should be less of them) and the Government should be accountable to the publci for their performance.

Marc Ambinder at The Atlantic blogs on the numbers showing how tough it will be for Hillary Clinton to pull back Obama’s lead. He finds that even a rosy scenario has Clinton only reducing Obama’s lead by 60 – 80 delegates.

Colin Espiner blogs on the latest polls.

Keeping Stock blogs a quote from Helen Clark on the sacking of the Hawke’s Bay District Health Board:

“But my view is that I don’t really care what the rights and wrongs of what was going on within the board are – I don’t believe that you can run a decent health service for the people of Hawke’s Bay while that is going on.”

I should think the PM should deeply care about the rights and wrongs.  The members of the DHB whose reputations are affected by this sacking certainly care.

Russell Brown comments on his blog on the context around the photo of him at the Hero Debate.

Whale Oil has a video on Labour’s health problems.

Paul Walker has a hilarious video on economics.  Yes seriously it is funny.

Michael Laws in his column (and he is on a DHB) describes the true nature of DHBs:

Every piece of legislation that governs DHBs essentially says the same thing.

Your arse is mine. The minister drives policy and everybody else, whether elected or not, is simply there for show. Kevin Atkinson and his Hawke’s Bay DHB forgot that simple truth. They were never in charge; they were elected/appointed to do the minister’s bidding.

But by having some of them elected, it gives the illusion of local control, and gives the Minister scapegoats.

Expecting Cunliffe to “sort out” health would be like asking Winston Peters to sort out the Middle East. It’s not a case of where you would start so much as a case of the complete system is stuffed. Just like the Middle East. You would need a neutron bomb and the sure knowledge that only starting all over again would have any impact.

That’s a fair call. The demand for health is unlimited, so there will never be a truly sorted out health system.

Ministers don’t have that luxury. Instead they get the dubious privilege of managing all the major and mini crises until some other poor bugger gets allocated the portfolio. So they don’t need stroppy DHBs who think that their primary aim is to expose health contract corruption, run deficits and generally deliver way more health services than they are funded for.

Ouch he used the c word.

The truth is that until New Zealand has just four or five DHBs, with the necessary economies of scale and integrated services, and until the public health sector starts paying internationally competitive salaries, then no remedy will be possible. Health ministers know this. But one of their sacred cows is letting the locals labour under the illusion that they are really running their own health services. Reducing, combining or even co-ordinating the current DHBs is essential but too politically difficult.

Illusion is the right word.