Patients and doctors on Health NZ’s ’14 levels of governance’ list

The “14 layers of management” at Health NZ Te Whatu Ora, criticised by the government for being bureaucratic, cover the patient and the nurse or doctor providing care.

Prime Minister Christopher Luxon announced last week, along with Health Minister Dr Shane Reti, that the National Health Service Board would be dismissed and replaced by a commissioner, with Lester Levy as chairman.

The board was reduced from seven to two people after several members resigned early or refused to return after their terms ended.

However, Luxon and Reti argued that “significant challenges” arising from the merger of DHBs under the previous government’s health reforms had led to budget overruns of about $130 million a month, with the organisation on track to run a deficit of $1.4 billion by the end of the year.

Luxon said the reforms had led to a lack of performance monitoring, limited oversight of financial and non-financial performance and “up to 14 layers of management”.

“If you’re a doctor or nurse working on the front line, with 14 levels of contact between the CEO and the patient, you hear a lot of mumbo jumbo from management but you’re not clear on what’s expected of you,” he said.

“We’re not achieving health outcomes against the five goals that we have. We’re not managing the budget within the monthly deficit that’s building up, and we’re certainly not getting a clear organizational model when you have 14 levels of management between the CEO and the patient and 2,500 additional back-office staff. So those are the three things that we’re focused on fixing.”

Asked about the 14 layers, Reti said the organizational chart he saw was “just mind-boggling. I can’t name the different layers of signposts, trackers, boundary spanners—God knows what else—from A to B.”

He said he would ask Levy to send over the chart and that there should only be six levels of management.

“Six… because that’s the advice we got from the experts who help us manage change. An organization this size should have about six levels between the CEO and the patient.”

However, the list of management levels provided by Reti’s office included not only the chairman, the board of directors, the chief executive officer and their chief of staff, but also the patient and the “team member” himself—the doctor or nurse.

• 1. Chairman and Board
• 2.CE
• 3. Chief of Staff
• 4. National Director of Hospital and Specialist Services
• 5. Regional Director of Hospital and Specialist Services
• 6. Group Operations Director
• 7. General Director
• 8. Service Manager
• 9. Manager
• 10. Assistant Manager
• 11. Team leader
• 12. Team leader
• 13. Team Member
• 14. Patient

The spokesman said the list was team-specific and due to privacy reasons no further details could be provided at this time.

“In response to the subsequent criticism that patients are not part of the system and should not be here, I reject that. They are an absolutely crucial part of the system and deserve their place,” the spokesman said.

However, if we take into account the “CEO-to-patient” layer barometer developed by Reti and Luxon, the graph presented shows only 10.

Labour’s health spokeswoman Ayesha Verrall said it appeared as if it had been “created to confirm what the Prime Minister said last week”.

“If you take that approach, even at the first few levels, there are going to be people who are treating patients. So, for example, the team leader or the shift manager is probably going to be directly involved in care. So they’ve thrown a bunch of front-line roles into the chart and said, ‘This is a bloated management structure.'”

She added that the 2,500 “back office” workers, whose numbers the government says have increased since 2018, also needed further investigation.

“It occurred to me that we had an increased number of frontline workers, so we needed more managers to support them during this period. And there were also programs that we had in the health system, like Healthy Homes, which were really important for health, but they didn’t have to be run by nurses or doctors.

“But the bottom line is that the increase has led to a budget blowout that didn’t hit the books until March 2024. How the hell could six years of job growth only have become apparent in recent months?”