I was embarrassed and outraged by the news about the state of the hospital where I work, writes Dr David Galler – for this systematic betrayal of the very people we are here to serve and of the staff that works so hard to help them. And it goes to the fundamental question about what we choose to value
Counties Manukau Health in South Auckland, serves a population of more than 600,000 people with at least one third of them, including 40,000 children, living in significant poverty. Likened by some to Baragwanath, the main hospital of Soweto, Middlemore is New Zealand’s busiest and, like Baragwanath, a place reknowned for its hard working staff and good culture.
Although we serve a diverse population, the majority who live in our district carry some or all of the cards of the South Auckland full house – a six card hand of obesity, diabetes, heart disease, hypertension, chronic kidney disease and gout. Add to that poverty and poor quality overcrowded housing and you will better understand why every day upward of 300 people will visit our emergency department seeking help. Of that number 60% will be admitted to the inpatient services for an average of 2.3 days, to be stabilised, diagnosed and treated before being discharged into the same environment which led to many of their health issues in the first place. Both the number and the acuity of the patients we are seeing have been rising fast for some time.
We have known about the drivers of that demand for a long time. They were obvious during the long period of underinvestment in health and social services in the 1990s and were obvious again (to anyone with a pulse) 20 years later during the recent National government’s nine years of neglect. Another round of endemic poverty, low wages and rising inequity; homelessness, grossly inadequate housing with people sleeping in cars; no action to limit access to cheap, high fat foods and sugary drinks in the face of a rising incidence of obesity and the expensive, life threatening complications of diabetes related complications; alcohol and drug misuse and addiction; a run-down mental health system with high rates of depression, suicide and more.
In the same way as it was in the 90s, this recurring pattern of co-morbid disease and its complications has been exacerbated by significant under funding for acute hospital services so it’s no surprise to me that hospitals such as mine are now overwhelmed with work.
The ideology behind that – to reduce government expenditure and privatise costs to individual New Zealanders – extends across other areas of the social sector that traditionally rely on government funding. So with a change to a government with different priorities and an opening of the books, it seems like a new problem emerges every day.
Only now is the public starting to see and appreciate the herculean task facing this new administration as it seeks to right our listing ship whilst at the same time charting a different course. Clearly the massive extent of the clean up needed will take time and will not be possible for the coalition government in one three-year term at the helm. So to those of you who want a better and fairer New Zealand, I say, be patient.
One of the latest emerging problems is the news that the buildings at Middlemore Hospital have become rotten and infested with a toxic black mould. I found out in the middle of a late-night ward round from a Radio NZ journalist who phoned seeking comment – I had none, because it was news to me. The next morning, the rest of our staff and all of New Zealand heard the story and over the next few days there followed a confusion of detail about the extent of the problems and who knew what when.
Although I was too tired and busy to think deeply about it at the time, I was overcome with embarrassment and a sense of outrage for this systematic betrayal of the very people we are here to serve and of the staff that works so hard to help them, to promote good health and keep people well.
In medicine when people are inadvertently harmed by what we do, we follow the principles of open disclosure: to make a heartfelt apology or an expression of regret for the harm caused and to support those harmed; to investigate how the harm occurred; and put in place interventions to reduce the likelihood of the same thing happening to others. This approach would have been a useful one to follow here but got lost under the watch of the last government’s well used umbrella of commercial sensitivity – who’s to blame, who will pay, there’s no more money, say nothing.
We are now more than a week down the line and the news cycle has moved on but questions still need to be asked:
- How did this happen?
- Do we have more surprises in store? And what’s the extent of this problem across the public sector?
- What will we learn from this and how will we prevent this from happening again?
So how did this happen?
I see two big answers to that. The first has been well described and relates to the circumstances that led to the ongoing catastrophe of leaky homes and which in my view are a direct consequence of the second and more fundamental question about what we choose to value.
Brian Easton’s 2010 paper Regulatory Lessons from the Leaky Home Experience is worth reading. It is so much more relevant today than it was then, when the crisis was emerging. He describes how a series of factors came together to create the problem we have now and which will continue to cost us millions and millions of dollars for a very long time.
They included the rapid innovations in building materials of the 1980s and 1990s – specifically, the introduction of monolithic cladding that was not water tight as advertised and the accepted use of untreated timber; a significant shift in public policy, effectively downgrading the importance of engineering in favour of cost accounting; a change in the building code to set performance criteria rather than specifying how things ought to be built; the demise in the late 1980s and 1990s of institutions that may have protected us; “the light hand of regulation” leaving standards to be based solely on normal market practices; and to make matters worse, no consideration put into what redress there might be for the house owner if performance standards were not met.
But was this just a freakish conflation of circumstances that led to a perfect storm? I don’t think so, says Easton: “When Marcellus in Hamlet says, ‘something is rotten in the state of Denmark,’ he was not referring to the buildings, he was referring to the governance.”
The leaky home saga should not have been a surprise to us – the Canadians went through a similar experience earlier and it is said that many here knew of that and the problems we were running into, but they were discouraged from speaking out.
But there is deeper problem at play here and it speaks to the concept of value and what we value. Value is defined as outcomes/costs, but what are the costs we really value? Value for money is one, and a term commonly used by hard-pressed politicians and bureaucrats always needing to do more with less.
Let’s reflect on the outcomes that value for money alone has delivered in two specific instances both characterised by a concentration on short-term costs instead of valuing a longer term investment.
First, the disastrous Compass food deal. Worked up under the umbrella of commercial sensitivity, this was signed off by Health Benefits Ltd (HBL) on behalf of the previous government contracting the UK multinational, Compass Foods, to supply inpatient meals, and meals on wheels, for all 20 DHBs, for an eye watering 15 years. Picked up by only six DHBs, the three Auckland metro DHBs, supported strongly by Lester Levy Chair of both Auckland and Waitemata at the time and a previous Board member of Health Benefits Ltd; Tairawhiti; Nelson-Marlborough; and Southern DHBs. As I understand it, these six now carry the liability for all 20 DHBs for the duration of the contract.
In late 2014, our sustainability group at Counties Manukau argued against that contract: the food was terrible, the duration of the contract ridiculous, but our main objection was because the deal in effect cut our local suppliers out of the economy created by the biggest employers in our regions and did nothing to promote their wellbeing.
We argued that if we properly assessed social and environmental costs as well as fiscal costs, the contract with Compass could have been turned into an opportunity to promote healthy eating and put money into the pockets of the local community instead of becoming the liability that it now so clearly is. That could have been easily achieved by ensuring that where possible all food was sourced locally, our food waste composted rather than sent to landfill and that compost returned to the suppliers to grow more food.
A second example: the leaky and mouldy buildings at Middlemore – and elsewhere across the public sector? As it stands, capital investments in health follow the guidelines of the Capital Investment Committee which provides advice to the director general of health and the ministers of health and finance to ensure that government objectives are appropriately prioritised and met. As well-meaning as this might be, in the end it has always come down to money and short term costs.
If social and environmental costs were factored into those decisions, and we paid attention to those long term returns from what are in fact long term investments, we wouldn’t be in the dreadful state we are in now but in a much better place.
The benefits of this approach has been elegantly demonstrated in a recently published paper by a group of experts from Harvard University. They examined a subset of green-certified buildings over a 16-year period in six countries including the US, China, India, Brazil, Germany and Turkey. In that time period these Green Buildings saved $7.5bn in energy costs and $5.8bn in climate and health costs.
In the US alone the health benefits derive from avoiding an estimated 172–405 premature deaths, 171 hospital admissions, 11,000 asthma exacerbations, 54,000 respiratory symptoms, 21,000 lost days of work, and 16,000 lost days of school.
So here I am writing, in this windowless room deep in the heart of a leaking and mouldy building, where good people are working hard to look after the critically ill. It is what it is, and we need to come clean about all of that and deal with it, but we cannot go on as we have in the past – there is a better way and for those of us who care about the future of this country and it is by standing up for what we really value.
Dr David Galler is an intensive care specialist at Middlemore and the author of Things that Matter: Stories of Life & Death
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