The appointment of a health outsider to the chair of Te Whatu Ora was opposed by the Prime Minister from day one, but health minister Andrew Little carried the day. It wasn’t an encouraging start, writes Ian Powell.
Comment: If one sees the sacking of Rob Campbell as a question of whether Health Minister Ayesha Verrall’s decision to do so was the right one, or an over-reaction, then it is easier to comprehend.
It's finely balanced for me. I hold the latter view although a severe reprimand would have been justified. It was, however, within her lawful prerogative.
However, if the objective is to better understand what was behind his sacking, then this is the wrong question. It has to be seen in the context of the health restructuring pursued by former and recently demoted health minister Andrew Little, particularly the ramifications of the decision to abolish district health boards which he drove.
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Labour went into the 2020 general election committed to implementing the principles of the Heather Simpson review of the health and disability system.
This included continuing with DHBs as a bedrock of the system. Six months later, without any prior public or health system consultation, and with no previous experience of this system, Little announced their abolition to take effect less than 15 months later (1 July 2022).
Given that DHBs were responsible for ensuring the planning and provision of the overwhelming majority of healthcare in New Zealand this was an extraordinary decision, especially in the midst of a pandemic and with an exhausted workforce.
Compounding the situation was that the government opted not to use those with expertise in the health system to advise them. They were marginalised.
Instead the Transition Unit established a few months earlier to implement the Simpson review was dominated by business consultants; somewhat akin to asking Wayne Brown to write a book on etiquette. Prime responsibility for this approach rested not with Little but with former Prime Minister Jacinda Ardern.
The core of the problem
In this context the ‘health reforms’ were confronted with many challenges with the main three (excluding funding) being:
1. The contradiction between decision-making becoming increasingly centralised and vertical, on the one hand, and the reality that overwhelmingly the provision of community and hospital healthcare is local as well as being the main source of innovation.
2. Healthcare is a public good, not a market commodity. The increasing demand tap for planned, chronic and acute care can’t be turned off by the health system. Only government policies focussed on external social determinants of health such as low incomes and housing can do this.
3. The impact of worsening severe health workforce shortages, through political leadership neglect, linked to the failure to appreciate the centrality of workforce to access, quality, innovation and system improvement.
This is the context in which Te Whatu Ora (Health NZ) with Rob Campbell as its chair found itself on 1 July 2022 when the new Pae Ora Act came into force. The neglect of pressures that had led the health system to be in a state of crisis in 2017 when the Labour led government took office continued unabated as it allowed itself to be distracted by restructuring.
To use an aerial analogy, the ‘health reforms’ required a new aeroplane to be built between April 2021 and July 2022. This was the task of the Transition Unit. It failed partly because it lacked the right expertise and partly because of lack of time. When Campbell and Te Whatu Ora turned up on the runway expecting to fly the plane, they found that they had to build it while flying it in rising turbulence (ie, increasing pressures largely due to workforce shortages).
Campbell’s appointment
Campbell’s appointment was not without internal cabinet dissent. Little pushed hard for it but Ardern was not supportive (whether this was due to opposition to Campbell or preference for someone else is unclear). But such was Little’s influence at the time that he prevailed. While not that big an issue, it wasn’t an encouraging start.
When his appointment was announced I was surprised. He had no background in the health system. But, having some acquaintanceship with him over the years and with the qualification that it would depend on the circumstances, I thought it was an innovative appointment. How important that qualification turned out to be.
Campbell’s lack of health system background certainly didn’t help. He suffered from what many others in similar circumstances have also suffered from; lack of sufficient appreciation of the complexity of the health system – providing a universal public good through highly integrated and interdependent community based and hospital care without being able to control healthcare demand, much of which is 24/7 acute.
Campbell behaved as an intelligent person who unfortunately does not know what they don’t know but believed that they do. He focused blame on the structures that had been dismantled in such a ‘gung ho’ manner that blame appeared to be transferred to those working in them.
This included discounting the benefits of having a significant level of statutory decision-making at that local level. But what he was saying was consistent with the government’s position.
An evolving Rob
But there was another side to Campbell. He was intellectually curious, a free thinker and genuinely interested in how the system worked and might be improved. Over time he actively got out and about visiting health professionals in their workplaces, both in the community and hospitals. He was impressed; he learnt and evolved. But the more his evolution progressed, the more he came into conflict with political masters.
On December 12 there was a revealing long interview with Campbell by RNZ’s Kathryn Ryan. Campbell handled himself professionally. He reaffirmed and articulated his support for the restructured health system.
But some of his observations would have caused considerable government irritation. He fully acknowledged more than once the severity and effects of workforce shortages. He was not supposed to do this even though he was right.
Further, he also acknowledged that the effectiveness of DHBs had been affected by health ministry constraints. Again Campbell broke a government messaging taboo. But again he was right.
Getting confessional
One could be forgiven for thinking that LinkedIn was Campbell’s preferred means of communication. He was prolific. Often he would comment on what I had published; sometimes he was so quick it felt like it was before I had written it. Social media is high risk and it was also a platform where he was getting a little confessional.
On December 19, in a response critical of a post by me, he said: "To be clear. I don’t much blame the DHBs as such. They were doing what they thought right within the structure they had. I think that the leadership and monitoring and support from the Ministry was a much greater problem. With the new system some better opportunities open up, but whether they work or not is totally up to leadership and culture (funding will help too!) at all levels and locations in the health service environment." [emphasis added]
His statement was largely correct but it was not what he was politically supposed to say. The government line was blame health system failures on DHBs and that its structural change would drive improved health outcomes and equity.
Then there was a further LinkedIn comment on December 31 with an added tone of contrition: “My inbox stays busy from within the health system (please don’t stop). Tired, committed, skilled health workers of all kinds. Asking for help to help them help others. We do not do the things we know we should do, know how to do. Or at least not comprehensively or fairly. I got locked into the blame game this year. That was wrong…”
Inevitably this evolution brought Campbell into increasing conflict with government positions even though he was right on the issues. Specifically, on the advice of public health experts he supported a Green Party bill on alcohol protection; criticised the Immigration Service’s restrictive policy in respect of recruiting overseas nurses; and criticised the excessive use of business consultants in the health system.
Recently he and Ayesha Verrall inadvertently expressed reported opposite views on how Middlemore Hospital’s emergency department would cope with the coming winter pressures; Campbell was much closer to the mark.
Monitoring plus governance
The sacking also raises important questions about the governance role of crown entity boards. In general the role of these boards is to monitor management. But the board of a newly established crown entity does need to have a monitoring-plus role. Further, the health system has never had a structure like this before. It was completely unchartered territory without a compass.
This is relevant to Te Whatu Ora and its specific circumstances – those in which it was created and inheriting a management workforce that largely felt marginalised and unconvinced by the rationale behind the restructuring.
But, from the perspective of the board and Campbell, this required not just monitoring but also creating and leading. The downside is that it also creates a great risk of overreaching, especially in social media.
By the time of Campbell’s sacking, Andrew Little’s restructuring was in serious trouble. Its health workforce was characterised by exhaustion and demoralisation. Much of Te Whatu Ora’s management at both national (formerly health ministry) and district (formerly DHBs) workforce were unenthusiastic about the new structure and struggling to adapt to the uncertainty of its more vertical decision-making. Those closer to the ‘clinical frontline’ were finding decision-making more difficult to comprehend and less responsive than before.
As the pressures on the health system continued to get worse the new structure was proving not to be the ‘magic bullet’ that Andrew Little had implied it would be. The only ones who appeared to be enthusiastic were those working in the isolated bubble of the upper echelon of management.
Work in progress and an own goal
In this context Rob Campbell’s performance can best be described as work in progress. It was both work in progress in the right direction in terms of the health system and in the wrong direction in terms of his political masters.
To some extent he was mirroring the experience of the senior management of the former Canterbury DHB in 2020; the closer he got to constructively engaging with health professionals the more he became a political liability.
More than anything else, it is the seriously flawed nature of the government’s restructuring both at its core and its implementation that was responsible for his sacking.
Well before his recent controversial LinkedIn post the government had concluded Campbell had to go. But how?
His own goal gave government a straightforward and lawful way out. His sacking was an overreaction but an inevitable one.
