Opinion: Moose was my flatmate’s dog. An inappropriate name, I thought, for a gentle, long-haired German shepherd, but in her mild-mannered way she did not seem offended. Moose was an indoor dog, on one condition: she stayed in her basket. Occasionally, she strayed. And my flatmate would be heard exclaiming: “Moose, back in your basket; get back in your basket.” To which Moose quietly complied, but with an air of ‘so be it’.
A similar command – “get back in your box” – has been rattling around in my head for a while now, getting steadily louder as the months go by.
I suspect it started when the disestablishment of Te Aka Whai Ora Māori Health Authority was announced and Māori health leaders and experts were essentially told to get back in their box. Public health experts got their own taster when politicians criticised them for making submissions on public health matters, such as fast-food outlets: “Get back in your box.”
Health Minister Simeon Brown’s ironically named consultation paper Putting Patients First implied that health professionals do the opposite. It sought to weaken the regulation of health professionals by their own professional bodies in the service of political imperatives – we want it and we want it now. Dissenting regulators were told “get back in your box”.
By the cancelling and rejigging of contracts, NGOs and others who fail to meet the coalition Government’s determination to remove equity-based objectives in health services have been forced, if they want to stay in the game, to fit into smaller boxes.
The Healthy Futures (Pae Ora) Amendment Bill quite bluntly puts te reo back in its box – in brackets in case there are any doubts.
The catchcry “healthcare for ALL New Zealanders” demands that Māori, Pacific peoples and other minority ethnicities fit back into the ubiquitous Pākehā box, after years of gradual acknowledgement that treating everyone the same does not produce equity in health outcomes.
Iwi Māori partnership boards have been boxed in by the amendment bill, which downgrades their role from strategic commissioning and Treaty partner, to a conduit between local Māori communities and the Hauora Māori Advisory Committee, not to the top table at Te Whatu Ora – Health NZ. Get back in your box.
The bill calls for Te Whatu Ora “employees, board members, the chief executive, contractors and secondees” to be politically neutral, without defining what that means, so potentially silencing staff when it is professionally appropriate for them to speak.
And, likewise, the Public Service Commission’s revised code of conduct seeks similar restrictions.
In its submission on the code, the New Zealand College of Public Health Medicine stated that medical professionals must be able to advocate for patient safety and public health without fear that doing so may be misinterpreted as political activity or a breach of their employment obligations.
The college notes that the proposed code conflates criticism of politicians or political parties with criticism of policies. The former should be avoided, but it may be entirely appropriate for a public servant to comment on policies. Again, back in your box.
By their nature, health targets create a box for the sector to sit in, which risks a lack of attention to matters outside of the box and ignores the evidence that targets are open to gaming. So, targets are more of a jiggery-pokery box.
Industrial action by public services has seen an elevation in the “get back in your box” response as Cabinet ministers have turned the wider concerns of health and education professionals about the state of their sectors into a simple demand for more money.
Closer to (primary care) home, rumour suggests the current flexible funding pool is likely to become less flexible, and primary health organisations and their practices are likely to receive more direction about how they should spend their money.
The letter of expectations from Brown raises the issue of primary health organisation cash reserves and the legacy of former health minister Tony Ryall, who deftly transferred $12.5 million of reserves out of primary care into other areas of health to balance the Budget.
It’s highly probable Brown will endeavour to constrain primary health organisations in how they spend their reserves, and that there will be a reduction in the variety of projects undertaken. Get back in your box.
Government rhetoric on the value of primary care extends as far as primary care doing what it’s told without complaint.
Boxes can be dark places. For years, we have acknowledged the problems arising from professional siloes, both for clinicians and patients. Boxes have their place, but they are being used in a punitive fashion to control open discourse, inhibit innovation and hamper the goal of equity in health outcomes.