Monday, October 11, 2010

Against elected DHBs

The Herald reports that the Auckland District Health Board has had a clean sweep by candidates with names at the top of the alphabet. Over on Kiwiblog, DPF takes this as an argument that we shouldn't elect DHBs. And I agree with him. But its not just a question of farcical elections, where no media coverage combined with an election method which produces large fields results in an unmanageably large decision space and a virtual lottery between candidates. There are deeper philosophical reasons as well.

Fundamentally, elections are about representation and accountability. We elect people to make decisions on our behalf, and to make them accountable to us for those decisions. A corollary of this is that those people need to be able to make decisions that they can be accountable to us for - where there is no power or discretion, there is no point in election. Unfortunately, neither of these criteria is satisfied when it comes to DHBs. Legally, they are accountable to the Minister, not to us. If they advocate on behalf of their electors, they can be sacked. And their decision-making power is mostly an illusion. Both their strategic and annual plans must be signed off by the Minister. More importantly, their funding, and what it is spent on, is dictated by the Minister. A DHB has very little discretion on how their money is spent. Instead, they are effectively elected managers, all accountability with no responsibility.

The result of this is to insulate the real decision-makers - Ministers - from accountability. They can underfund health, then say that cuts are the DHB changing priorities. They can refuse to provide enough money for doctors and nurses, then blame the DHBs for the resulting strikes. They can fail to fund enough operations, then point the finger at the DHBs for waiting lists. DHBs get to carry the can for every Ministerial decision. Except the good ones, of course - when the Minister announces tagged funding for another thousand hip-ops, they take the credit. But when that funding is never increased, demand exceeds supply, and people hang around in pain for months or years, its the DHB's fault.

Ending this charade and replacing DHBs with appointed management bodies would allow us to place the blame for health decisions squarely where it belongs: on the Minister. It would allow us to hold them accountable, and prevent them from hiding behind a bunch of poor saps who get to helplessly implement whatever deranged scheme the Minister has come up with. But since Ministers write the law, the chances of such a change are about zero.