The author of the acclaimed book Things That Matter talks to Gareth Shute about health policy in the lead-up to the election – about the obesity crisis, the social investment approach and the kind of place New Zealand wants to be.
Dr David Galler has worked at the intensive care unit of Middlemore Hospital for 25 years. In that time he’s experienced firsthand the effects of changes in government health policy. His book, Things That Matter, largely concerns itself with personal stories from his life as a doctor and is threaded through with heart-rending experiences of dealing with patients who come close to death or families who’ve had to let a loved one go. Yet the book also makes a passionate plea for New Zealand to improve our approach to healthcare, especially when it comes to those who are most vulnerable.
As a starting point, it seemed worth asking Galler what policies he believes would have the biggest impact if they were enacted after the next election. However, Galler resisted this way of looking at it – he believes this type of piecemeal approach is exactly what is wrong with the current approach to healthcare. If healthcare is not tied to a larger vision, he said, then policies in other areas can counteract what we are trying to achieve. For example: if our housing policy leads to household overcrowding then there will be more people with infectious diseases turning up in hospitals; or if we don’t target our food regulations to encourage healthy eating, then diseases connected to obesity will rise and place a new burden on our healthcare system (as has happened over the last couple of decades).
The Spinoff: When you think about government policy for the next election, what do you think are the most important areas?
Dr David Galler: Oh, I think the really big thing is having a sense of purpose – what is it that we’re trying to create? That’s the thing that’s been missing in the debate. You can look at policies individually – their upsides and their downsides – but what we want is cohesion across our policy and implementation regime. You want them to be supporting each other for a purpose that is clearly defined. Instead what we currently have is a chaos of social policies because they cancel each other out or create problems that require new policies to clean up the consequences. We end up going around in circles and we wonder why we aren’t making progress over the big issues.
What would you suggest instead?
I was recently speaking at a conference in Vancouver together with a First Nations group that represents three disparate Native American communities that live throughout the province of British Columbia. They have a definition of health and wellness that’s quite different from Western definition, though similar to Māori, who view health and wellness in a holistic sense. Physical, spiritual, mental and family wellbeing are a package deal. What’s interesting about the First Nation’s approach is that they relate that definition of health and wellbeing to a vision that all the people of the First Nations should all be able to reach their potential. Health contributes to that, but so do a whole lot of different things. The danger when you don’t have a vision is that you have a clash of policies and implementations, so you take two steps forward with one policy and two steps back with another.
Look at child poverty. The government in 2013 was delivered a plan by Jonathan Boston’s expert advisory group commissioned by the children’s commissioner to tackle child poverty. The group actually defined the level of poverty in New Zealand according to an internationally recognised definition. They set a goal that they reduce that level of poverty by 30-40% below the current rate and they outlined the evidence-based interventions that need to be sustained over time in order to do that. A thing like child poverty is one of those wicked issues – there’s no single solution to it. You need to look at the evidence for how it’s going to work and focus your interventions over a long period. You also need some good measures to tell you that you’re making progress against it. One of their recommendations was a universal child benefit and on the basis of that, the government dismissed the whole thing.
What the government tends to do is implement some of the weaker recommendations because they don’t clash with their ideology and they’re less politically sensitive. The most effective health-related interventions – a tax on sugary drinks for example – carry with them a challenge to the existing ideology and they also carry with them some political risk. What we tend to get is less effective recommendations and they occur without the package of the other ones. The government will point to them with a big smile on their face and say – “look what we’re doing about such-and-such” – but the reality is that they’re just piddling around at the margins.
In the latest budget, $3.4 billion is added to the healthcare sector (1.8 billion will go to the DHBs, while another 1.4 billion is to cover the increase in pay for aged-care workers). Looking at the healthcare section of the National Party’s website, they start by saying that over their time in office they’ve increased the number of elective surgeries by nearly 50,000 per year and have added 6100 doctors and nurses. They’re all about finding efficiencies and removing unneeded back office staff.
Much of that output stuff can be challenged, but they’re probably not even the measures that you want anyway. When it comes to the obesity epidemic, the demand for key care services in the hospital are largely driven by what are to-some-extent reversible and to-some-extent preventable problems. Demand is going through the roof. This place [Middlemore Hospital] has never been busier. Constantly full – the whole place bulges. That demand is outside of health to fix. We’ve got 200,000 people living at deprivation levels 9 and 10 in Counties Manukau and 40,000 of those are children.
The Greens’ child health policy does talk about taking a holistic approach and they have comprehensive plans for increasing heart health among New Zealanders and combating the diabetes epidemic. But each of these involves a dozen new sub-policies, which would be hugely expensive to implement. With a growing number of retirement aged people over the coming decades, how could we ever afford to put all those policies in place?
The counterfactual is that what we’re currently doing is totally unaffordable. Our DHBs are currently running at a deficit. They might say we’ve got a rock star economy, but when you look at our GDP per capita, it’s actually well below the OECD average, because we’ve just relied on immigration to bump up the numbers.
Do you think the system would work better financially if we take earlier intervention?
We have to.
It doesn’t seem to be a popular approach politically.
I think they don’t know how to do it actually. I think if politicians were a bit more confident about what to do and how, then they would be more inclined to do it. I think if government was willing to show the kind of leadership that is necessary, things would head in a different direction. They don’t want to make the hard decisions – they don’t want to do it.
Boyd Swinburn along with other academics went to the Minister of Health, Jonathan Coleman, with a plan to fight obesity and he immediately showed them the door. So he’s rejecting evidence-based policies on the basis of his own politics and his view of the world. This is the part of the problem that we have woodwork teachers like Gerry Brownlie and free marketers like Coleman who are making non-evidence based decisions.
Do you think doctors are a group like teachers, where they’re all seen as all being left-wing so it’s assumed they’ll always be asking for more money for schools and hospitals? Do you think that causes a communication gap?
Well, there is a demand for services so that demand does need to be met. At the same time, we do need to reorient our attention to primary and secondary prevention. Primary prevention is really around the way we live our life, the food that we eat, our environment and so on. Secondary prevention is the active management of existing disease to keep people well and out of hospital. But we also need to treat people who are sick.
There are all sorts of issues in all those baskets. Certainly in the emergency care unit of the hospital what we want is really good, high quality services. Yet value is a complicated thing because while you can look at it in financial terms, but you really need to look at it in terms of the triple bottom line – which is social and environmental outcomes as well. You have to look at all those costs.
To be fair to the National government, if you asked most people about the new health policies that have been put out by Labour and the Greens so far then you’d probably find that they could only name single policy items without much sense of a holistic framework (Labour has yet to finish updating their 2014 policy for the current election). One of the recent Labour proposals is “a clear time-frame for industry to reduce sugar content in all processed food”. The Greens have long proposed a sugar tax and labelling foods with a traffic light system, so you can see whether a particular food items is healthy or not. On the surface, these sound just as one-off as the National policies.
But are they one-off? What you need to do is look at the entirety of the policy. The problem is that politicians release policies one by one and they tend to be reactive. But what we want to do is actually look at the basket of policies and how they contribute to the outcome that we want. When it comes to food regulation, there is an enormous amount of opportunity to improve the standards of food that are available to people and the government are simply blocking that. The government strategy is just the free market and individual choice. My question is: is that what New Zealand wants? Because the free choice of individuals and the free market has got us to where we are today and where is that likely to lead us? We are the third fattest nation in the OECD and we have the third highest rate of childhood obesity.
Is part of the problem just being able to talk about obesity in a political context? The counterargument is always that obesity is a self-control issue. It’s difficult for politicians to bring up the fact that some populations in New Zealand are genetically predisposed to obesity, especially given that it has a connection to race.
Well, Gareth, I’ll tell you, there was no obesity epidemic before the 1980s, so I say – there may be all sorts of genetic predispositions to all sorts of things, but that is not the issue here! The issue here is the cheap, ready access to very high sugar and high fat foods to a population that has very little money, while the cost of decent food is much greater. And it’s against an advertising regime that just pushes this down their throats left, right and centre. This is not personal choice. This is David versus Goliath when it comes to personal choice – it’s not an even playing field. Far from it. Why do you think all the pokies are in South Auckland? Why are there so many liquor stores and shitty fast food outlets where the poor people are? Is that personal choice? This personal choice argument is crap actually. It’s complete bollocks.
One thing we haven’t covered so far that you discuss in your book as being tied to health is housing policy and the inequities there. What would you say about that?
We can learn from the past. We discovered in the early 90s that when the housing benefit was removed, we reached the tipping point for the meningococcal epidemic. The number of adults in a house increased because the benefit was removed and a child’s chance of getting meningococcal disease has been clearly linked to the number of adults living in a house. That’s proven scientific fact.
We also know that when Counties Manukau in the early 2000s put a lot of its money into Housing New Zealand to clad damp houses in South Auckland, the numbers of children being admitted in winter with paediatric respiratory disease dramatically decreased. There are very clear links between things like housing and wellness. So we need to recognise those and actually set a goal for what we’re trying to achieve and a strategic plan to deliver on that goal, along with measures to tell us if we’re progressing towards it.
Instead, we don’t have a strategic approach at all. I look at it and I just see gross mismanagement really. I just see a bunch of silo-based decisions being made that have a whole series of unintended consequences and tend to counteract other policies and directions being taken in other areas. It’s social chaos – that’s what we’re seeing. We shouldn’t be surprised with what we’ve got.
One thing that the National government has done is make the B4 school checks free for children and they’ve also added a diabetes checklist to this so that “95% of children identified as obese in our free B4 School health checks will be referred to a health professional for support to improve their family’s lifestyle through better nutrition and more physical activity”.
But what’s a health professional going to do? Tell them not to spend their five dollars they’ve got that day for food at KFC? It’s complete bullshit. It’s so disingenuous. It’s just one of the things that politicians do where they’ll have a policy that is virtually meaningless and very ineffective, then they’ll say that’s their solution to a big problem. It’s more complicated than that.
Bill English’s social investment approach is quite interesting. I actually think it’s a good idea, in the sense that he’s starting to look at vulnerable families and how can we actually customise the resources available to these families and deliver them in a way that is meaningful to those families, with our approach changing as their circumstances change. It’s a transformative model of service delivery. But they’re talking about it and it not doing it.
I think the best example of transformative service delivery is the alcohol and drug treatment courts. It actually looks at recidivist criminal offenders whose offending is driven by alcohol and drugs. That is a truly transformative model of service delivery and Bill English’s social investment could be really good at dealing with vulnerable families if it took a similar approach.
But the other side of this is – what are the drivers of vulnerability and what are you doing about those? They’re not looking at that, so it’s just classic government policy. They have a whole lot of policies that have consequences, like creating vulnerability to health issues. And then they’ll introduce some intervention to deal with the vulnerable. You see what I mean? They haven’t got an overarching strategy about reducing vulnerability – their policies aren’t linked up in any way. Instead, they just piss around at the margins and it will ultimately be really ineffective in dealing with the big issues.
What I’m saying is – we deserve better. We are a proud country. We’re lucky as hell to be who we are and where we are. What we have is incredibly precious, in terms of our geography, our relatively small population, our natural resources that are available to us. What worries me is that we are eroding those at an incredible rate and we are allowing that to happen. The argument is – at least we’re not as bad as “x” – but why can’t we be the best? And we should be.
You’re talking about a holistic agenda, but the whole way politics is run now via short articles in our daily newspapers and two-minutes pieces on the evening news, so you can’t blame politicians for trying to get an easy-to-understand talking point. Plus our community is more gentrified than it used to be and I’m not sure people believe in the social safety net in the same way that they used to…
I’m not so sure about that. I have more faith in the people in our community to tell you the truth. I truly believe that there is an enormous amount of goodwill towards others in this country. It’s a question of re-discovering that and not driving people into their political camps. The discussion needs to be on the issues and values that we want, rather than the National Party has got this policy and the Labour party has this policy and the Greens have got this policy. I’m not sure if that’s necessarily helpful, it just hardens people’s positions.
I think New Zealanders are very kind people – they’re very equitable and fair, generally speaking. I don’t think we marshal that power in the way we probably should. We’ve left it to the media to report the way that they do. We leave it to the politicians. As soon as you start getting political, you drive people into their entrenched political camps. My sense is that we need to talk about the issues and not the politics. We need to have a frank discussion about how we want New Zealand to be.
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