While the health system is facing serious pressures, even crises, Ashley Bloomfield says relentless negativity is contributing to the problem
Ashley Bloomfield, the former director-general of health and one of the faces of New Zealand's Covid-19 response, says constant catastrophising about the state of the health system is wearing down staff morale and undermining public trust in hospitals and medical professionals.
In an address at the Health Leadership Symposium last week, Bloomfield argued New Zealand was not alone in experiencing workforce shortages and mounting pressure in its health system. He cited articles from the United States, the European Union and the United Kingdom as examples of a global phenomenon of health vacancies.
"Health care systems have not adapted sufficiently to keep up with the rapid technological developments and the transition to an ageing and more frail population. It took from the Stone Age to the 1970s to realise a 20-year increase in average life expectancy globally. We have seen a further 20-year increase since the 1970s," he said in the speech.
Bloomfield, who is now the director of the Public Policy Impact Institute at Auckland University and co-chairing of efforts to rewrite international health rules, also spoke to Newsroom about his view that the health system is not failing – a position he acknowledged was "not commonly heard or necessarily popular at the moment".
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He was careful to make clear this wasn't an effort to dismiss or minimise the challenges facing the system.
"Having spent my career in the healthcare system, I can't remember a time when we had enough of everything we might need: people, money, leadership, coordination and so on. Because it's such a complex system, there are always challenges, there are always difficulties, there are always setbacks, there's always more we can do," he told Newsroom.
"The circumstances at the moment are unique because we're coming out of the tail of a pandemic, but the challenges and the issues are not ones that have just arisen out of nowhere, nor are they just because of the pandemic."
The goal of the speech was to put these challenges in the global context, to remember that "it's not all bad" and keeping the focus on the future with a sense of hope and building on the successes of the Covid-19 response.
"We showed what we can do if we have that focus and use the inherent advantages we have as a country because of our size, the nature of our system, the relationships, the relative simplicity of political decision-making here in New Zealand," he said.
‘If it's just about crisis upon crisis and failure upon failure, the risk is we lose a sense of agency that something can be done about it. The risk is paralysis.’ – Ashley Bloomfield
Some of the most important health outcomes are still improving in New Zealand. Life expectancy has continued to increase, even through the pandemic, when other countries fell backwards. Māori smoking rates are falling, with one fifth of the Māori population no longer smoking today when they were a decade ago. Mortality rates from cancer and cardiovascular disease are falling too.
On staffing, the number of doctors has doubled since 2000, the retention of New Zealand medical graduates is the best in a quarter of a century and the public nursing workforce has risen by 23 percent over the past five years.
Then again, the latest performance measures from Te Whatu Ora, released on Tuesday, show mounting pressure on the system. Avoidable hospitalisations for those under five were up 35 percent in the June 2023 quarter as compared with the June 2022 quarter. The number of people waiting more than four months for their first specialist assessment is up to 51,000, from 35,000 a year ago. Times to treat cancer patients and emergency department visitors have both slipped as well.
Though these are all "imperative" to fix, Bloomfield said, they don't show the system is failing. So what would?
"It would be when the system is in a spiral where it's not delivering care to the majority of people. The contention I make, and it's an approach I tried to use during Covid, is it's not a failure if things don't go right, it would be a failure if we didn't review and learn and adjust as a constant cycle," he said.
"Building on that kind of approach, I would say it would be a failure if the system kept going down and wasn't saying, 'Okay, what is the problem? What do we need to do differently?' And we do see, in the system, a lot of examples of that continuing to happen."
There's a cost to the continual negativity as well, Bloomfield believes.
"If it's just about crisis upon crisis and failure upon failure, the risk is we lose a sense of agency that something can be done about it. The risk is paralysis," he said.
"We've got to be really careful that we're not just undermining trust and confidence in the system by the public. They need to have trust and confidence – it's a really important part. Most days, I have people who just in my everyday work or life, say, 'Oh yes, I had this interaction with the health system and gosh the people were fantastic and gosh the care was amazing'.
"Now, again, that's not to dismiss or try to paper over the waiting lists and the problems that there often are and the quality failures that happen at times. But people's experience of the healthcare system is actually a really good one and we need to hold on to that and maintain trust and confidence. Again, if we go back to the Covid experience, trust and confidence in the response was so important for us to be able to be effective."
If you go back 20 years, Bloomfield said, the media coverage and narratives from stakeholder groups would look very similar today.
"This is much less a reflection on where the system is at at any point in time and much more a reflection of the deep complexity of the health system."
In his address, he also mounted a defence of public servants working in managerial or so-called back office roles, who are often the "scapegoat of convenience". He cited the International Civil Service Effectiveness Index, which ranked New Zealand's public service second in the OECD in its 2017 and 2019 reports (no more surveys have been conducted since the start of the pandemic). Quarterly surveys by the Public Service Commission also show trust in the public service remains around 10 percentage points above pre-Covid levels.
In his time in Wellington district health boards, Bloomfield witnessed a policy capping the number of administrative or backroom staff to ensure resources went to the frontline.
"What I observed in, let's say, Hutt District Health Board when I was chief executive there, was that the people working in those operational leadership roles – tier three, tier four in the organisation – had an enormous span of control. They were probably the busiest, hardest-working people in the organisation," he said.
"They were the people in charge of making sure operating theatres ran and at the same time, all the outpatient clinics were functioning across a whole range of specialties. These people were essential, and most if not all of the clinicians recognised the importance of having the right people in those roles and how busy they were."
It can be a "false economy" to balance frontline staff against back office staff, he said, because the frontline doesn't work without the administrative support.
Critics also take aim at managerial staff in ministries and government departments, which Bloomfield said was unfair.
"Folk who over many years have come in to work in the ministry, often coming form a slightly critical perspective of the Ministry of Health have, to a person, actually been impressed with the quality of both the people and the work that's done there and have gained a better understanding of the complexity of the political interface that the ministry works in."
