Abstract
When our President made his kind offer to me to provide material for his column in Australasian Psychiatry it was clearly one I had to accept. The problem I now confront is producing something that is up to the expectations of a wide and knowledgeable Fellowship, so here goes.
Following on from Jonathan's previous article (1) which outlined the challenges and directions he saw appropriate for our College, I thought it would be useful for me to give a brief description of the Colleges’ involvement with Health Policy issues in New Zealand. Central to this briefing is my strong belief in the development of clinical governance.
In a very informative publication, Warner (2) uses the expression psychic prison when discussing health service system [re]organisation. He calls on the wisdom of Gareth Morgan (3) and Karl Popper (4) to define this prison, the trapping of organisations and the actions they pursue by ancient memories or believed history. He further observes that the pace of change of personnel in the modern era intensifies the memory loss and increases the resorting to ‘believed history’ and ‘fantasy’ to offer the organisation comfort. The Japanese proverb: ‘visit the past to know the present’ is apposite to the debate. Warner suggests we also need to add ‘don't let yesterday interfere too much with today’.
Under the delightful heading ‘re-organise and be damned’ the concept of the zone of delusion is raised. In part Warner is referring to the thinking that re-organisation in itself is innovative and will be the answer to system problems. Such is delusional when the change is not part of the bigger picture. Another delightful term, from whom I cannot recall, is that of mural agnosia (the inability to read the writing on the wall). It may well be that in order to be in the ‘zone of delusion’ mural agnosia is a prerequisite.
My reason for this discourse is that the presented thoughts resonate so closely with my experience of health policy generation in New Zealand. The particular roles that have helped me develop these insights are as a member of the Mental Health Commission Advisory Board and as Chair of the Council of Medical Colleges in New Zealand (CMC).
There have been a number of reports to the College regarding the New Zealand Mental Health Commission. In brief it was set up following (yet another) incident driven inquiry. It recognised a primary problem in policy, planning and subsequent delivery of service. This was partly because of lack of shared direction (the system did its best to ensure the work of enlightened people such as our Immediate Past President were not successful), partly because of severe lack of resources and also from a lack of leadership. My work with the Commission has revealed how much key agencies such as the Ministry of Health and the Health Funding Authority operate in Warner's delusional zone.
It was clear that the Council of Medical Colleges would need to take strong collective steps to help move to a more productive way of operating. The first step was about getting our own house in order. I think it fair to say that many of the individual member colleges were to some degree trapped in the ‘psychic prison’. It was important to shape a CMC that was about maximising collaborative efforts of vocational colleges; that supported the input to health policy of medical colleges as arbiters of standards in particular areas. For such an enterprise to be successful it remained crucial that the individual colleges have a strong commitment to the setting of standards and curricula. They provide training and evaluation of competence in that area of practice and have processes to maintain the standards. They need fair and transparent mechanisms to deal with those who bring the body into disrepute. We saw that colleges must represent standards that promote maximal health for consumers, not interests of college members. We noted, therefore, the need for clarity in the separate roles of colleges, medical associations and medical worker union groups.
One key area of our activity that I will elaborate on was the setting up of relationships with the key health governance bodies. Their operation, especially in policy creation, had moved to one where the senior doctor felt extruded. The loss of those organisation's institutional memory seemed to be a planned event. The attitude appeared to be one that saw the colleges as ‘bad objects’ who would immediately capture any process for their own ends and thereby disadvantage the customer (be that patient or wider community), the so called professional capture.
The Council of Medical Colleges worked hard to re-establish links. We wanted to provide one point of contact, coordination of activity and consensus opinion. The usual experience of consultation was by way of large documents that required rapid feedback on ‘options’. This did not reap the key advice and knowledge colleges could offer. We have been moderately successful in shifting to having involvement at the initial end of the policy process. We can offer much more helpful inputs at that level, sometimes saving hours of redundant work. If such a status was to be accorded colleges, it was crucial we were able to offer assurance to the policy formers that we would not use the information from initial discussions in the media or even across college fellows to pressure decisions. The principle of ‘no surprises’ was one each side had to commit to.
Though it is still early days, I see this new order bringing a potential that was not previously available. If vocational colleges are involved earlier and can share in health policy formation as partners than I suspect those awful occasions when colleges, or sections of them, have to go on the attack against the health governance bodies will greatly diminish. These wars have heavy casualties. The credibility of the governance and policy groups in the public's mind is reduced. The retaliations reduce the college credibility. Best solutions that give most health for available dollar are seldom found, therefore the patient and their family miss out. Often the issues raise internal conflicts in all involved organisations. Blaming, scape-goating and the like are common. There is incentive to project and externalise, not work together to seek best outcomes.
If in the end this sounds a bit like an ad then I suppose that is the case. I hope that I am not misreading the writing on the wall. The usual complaint I have from others is not my misreading, but the incorporation of too many issues so things get complicated. That is the world I think we are in. It is complex, there are hundreds of simple solutions and all are wrong. Only by using creatively the strengths and perceptions of many groups will we really make a difference. If medical vocational colleges do not make a difference to the health policy and delivery systems than we will never reduce the zone of delusion, we will leave people trapped in the psychic prison.