For several years, I have subscribed to the New York Book Review which was a literary delight. Its overall political orientation is not mine, but that adds to its intellectual appeal rather than diminishes it.
Unfortunately, I have a backlog of unread issues and I only recently read an article published on August 19, 2021 that brought my attention to a subject I knew little about.
The author was Edward Chancellor who writes on financial matters. He is currently the author of a book on the history of “interest”; a topic that I thought would be impossible to make interesting, but, if this published article is any indication, it just might succeed. The title of the chancellor’s paid item is Waiting to deflate.
Chancellor begins his account (actually a review of two recent books on why people go mad in crowds and financial bubbles) with a three-volume book published as early as 1841 by Charles Mackay titled Extraordinary popular delusions and madness of the crowds.
Mackay begins with the “Tulip Mania” (1634-1637) in the Netherlands during its financial “golden age” when contract prices for some bulbs of the recently introduced fashionable tulip rose to extraordinarily high levels until a dramatic collapse. It then takes the reader through a journey of witch mania, alchemists and the like.
‘Tulip Mania’ in 1630s Holland led to financial crash
Chancellor acknowledges that Mackay was not a “rigorous historian” (he made a living as a poet, songwriter and journalist) who resorted to “outlandish legends”. Nonetheless, he argues, Mackay can still be read for “enjoyment and instruction” in light of the many fads that followed. The two books reviewed take the fads further up to and including ISIS and recent financial bubbles.
For me, the interesting point was when mistakes happen because individuals become too influenced by what other people think. The more a group interacts, the more it behaves like a real mob and the less accurate its assessments become and the more errors there are. This is described as “imitative behavior” which can lead to the installation of delusional beliefs.
In the Chancellor’s words, “manias are diseases of the mind. Popular delusions occur when attractive but baseless stories spread contagiously from person to person. We can see this right now with extreme anti-vaxxer views, especially when linked or led by the political far right.
Completely false and unsubstantiated claims that Covid vaccines are killing New Zealand children or that the disease is spreading among the crowded unvaccinated protesters currently occupying the grounds of Parliament is due to electromagnetic emissions (rather than the Covid-variant). 19 Omicron) are examples.
But there are also non-extreme examples in health policy decision-making. This is where collectivized interactions, including public assertions by people in positions of authority, become increasingly false, reaching the level of popular delusion.
It is not within my competence to judge whether these are “diseases of the mind”. But it is within my competence to identify instances where these imitative interactions have led to a high level of delusion about Aotearoa New Zealand’s healthcare system.
“Models of care”
The misuse of the terminology “models of care” is one example. Real models of care are examples of exciting complex innovations stemming from engagement between healthcare professionals with relevant expertise and experience.
Models of care broadly define how health services are delivered. They describe the best care and service practices for an individual, population group or cohort of patients as they progress through the stages of a condition, injury or event.
But the terminology has been captured and misused by those far removed from the specific model of care. When used by the Ministry of Health or other central government agencies, they are more likely to be simplistic, meaningless soundbites used to justify an ill-considered decision.
Worse still, when voiced by outside business consultants. Originating from their keyboards or whiteboards, they have as much substance as one of Baldrick’s clever blueprints from Blackadder.
What’s the difference between a business consultant and Baldrick’s clever plan? Very little!
It’s no surprise that Ernst & Young (EY), currently ensconced in the engine room of healthcare restructuring decision-making, cites new models of care as part of its message. Both disappointment and some surprise that the Minister of Health lets himself be taken in.
District health boards
The government and EY consultants repeatedly peddle a line that the existence of 20 DHBs means New Zealand has 20 different health systems, which is the cause of so many problems. But repetition is not a truth as “old English” would say.
The truth is that we have a national public health system which is provided locally by DHBs mainly in doctors’ surgeries and hospitals. DHBs are required to be knowledgeable of their geographic populations but are under considerable central government control, including funding and policy implementation.
Minister Little blames DHBs for severe shortages of manpower, including medical specialists and nurses. But responsibility for workforce planning currently rests with the Department of Health at the national level (which will be transferred to the new Health New Zealand in July).
Additionally, the government controls the funding DHBs can spend, and labor makes up the majority of their costs. The government reprimands DHBs for overspending, even when the Department of Health is responsible for the overspending (witness the 2020 Department-EY brutal attack on Canterbury DHB senior management.
Central to the government’s reasoning for abolishing DHBs in July is the so-called ‘postcode lottery’, according to the health minister. This occurs when a patient in one geographic area receives state funding for a particular drug or treatment while a patient with similar clinical needs in another area does not.
The sin of DHBs, however, is not to cause postcode lotteries but to identify the extent of their existence. Before the creation of the DHBs in 2001, there was no local structure responsible for the health of the geographical populations.
The DHBs, with their unique focus on the hospital and the community, have allowed postcode lotteries to be better identified and understood. Having identified a problem, DHBs are now blamed for it.
The reasons for postcode lotteries are complex but include central government funding (levels and allocation) and rurality. But DHBs are the convenient scapegoat.
Edward Chancellor’s description of highly imitative collectivized interactions growing ever more false to the point of illusion (perhaps arguably “diseases of the mind”) has unfortunate resonance with regard to the system of New Zealand health.
This is especially the case when the imitative interactions come from the political and bureaucratic leaders of the system as well as some of the business consultants they hire. This is certainly the case with the misuse of the otherwise laudable terminology of “models of care”, attacks on DHBs for things beyond their control, and “postcode lotteries”.
Charles Dickens said it all
It’s the sign of a good writer when he can use an applicable quote from a novel. Chancellor does it well by quoting Charles Dickens’ epitaph to a crook in Little Dorritt:
You really have no idea how human bees will swarm to the beat of any old pewter kettle: therein lies the complete manual for governing them. When they can be made to believe that the kettle can be made of precious metals, that is all the power of men like our late lamented.
I can’t say better than that.
Ian Powell was executive director of the Association of Salaried Medical Specialists, the professional union representing senior doctors and dentists in New Zealand, for over 30 years until December 2019. He is now a health systems commentator , labor market and political living in the small river estuary community of Otaihanga (the place by the tide). First published at Second opinion of Otaihanga