By Peter Byard Davis, City Vision elected member of Auckland DHB. This post was originally published by The Spinoff.

It is a privilege as a member of the Auckland District Health Board to observe professionals at work steering and managing one of New Zealand’s largest and most complex organisations. But the agenda of our most recent meeting brought to mind another image – Landseer’s ‘Stag at Bay’, a magnificent beast encircled and facing danger.

So, we have a key large-scale and complex public sector anchor institution staffed by highly competent and committed professionals that is beset by a series of challenges that have accumulated and are coming to a head. This is what we are faced with:

The hospital is full. This is not just the usual winter peak, but exacerbated by a higher-than-expected additional set of acute admissions. There is basically 100% occupancy with cutbacks on beds for “planned” (elective, discretionary) care to provide extra resource.

Provider of last resort. The hospital remains the backstop for frailties and fragmentation in our primary and community care system. There is always the Emergency Department, and rightly so. But a significant proportion of admissions would benefit from early community intervention.

Industrial relations. There are multiple strikes, threatened, actual, potential involving nurses, midwives, salaried medical staff. In some cases such actions will coincide. This against the backdrop of a once-in-a-century health crisis where the government has asked for public sector pay restraint and senior management staff have not sought any pay increase.

Supply chain. Global supply chains are being disrupted by cascades of lockdowns around the world. This is affecting the health sector as much as any other.

IT infrastructure. Operating systems are kept going long after their “use by” date (25 years in the latest instance). Staff have become proficient in fix-ups and work-arounds that are part of “normal” practice, but that clearly hamper the smooth and efficient management of care.

The drum beat of negative media coverage. The organisation has, with regional partners, and alongside “normal business”, handled a Covid pandemic, staffed the borders and regional facilities, established a comprehensive contact tracing and vaccination system practically from scratch and is making good progress – but this does not make for positive front-page stories and headlines.

Cultural transformation. Directorates throughout the organisation are undergoing actions and debates “to eliminate institutional racism, racism and discrimination, unconscious bias, social injustice and unfair health care treatment at all levels” (to quote just one).

The Holidays Act. DHBs are setting aside several billion dollars in reimbursement for a flawed piece of legislation as they painstakingly work through staff records going back a decade. This is a public policy failure we could do without that, like “leaky buildings”, undermines confidence in our regulatory system and for which nobody has been held to account.

Health reform. We will have a new system. Nobody is sure how this will work. The senior staff have to prepare for an organisational turnaround of unknown dimensions over the next year.

And then the corona came back into the community. Via a person returning from Australia. And an ADHB nurse was in the cluster of those infected. She carried out a number of shifts. Patients and staff were traced and checked. Some patients were moved elsewhere. This was a scenario recently practiced and enacted by staff for just such an eventuality. And level four restrictions have an impact on what work the hospital can do and under what conditions. More risk and complexity.

And yet. And yet.

Our record of patient surveys carried out over the last two years show a steady 86% of inpatients rated their experience very good or excellent, and 90% of those in outpatients. Any public-facing organisation would be happy with statistics like that.

The Auckland DHB can also demonstrate progress on streamlining and strengthening services that might otherwise be underpowered, understaffed, and working at less-than-optimal capacity: extended hours in clinics, extended hours in theatres, formalising Saturday operating, more all-day lists, standby lists for late cancellations, reviewing of pre-admission blood tests to pre-empt unnecessary repeats. This is an organisation dealing with the urgent, but also preparing for improvements in “normal business” in the future.

It is a matter of some wonderment to observe senior professionals going about their business as they steer a great anchor public institution through “the slings and arrows of outrageous fortune”, and all this without public acknowledgement. At the same time the University of Auckland, another key anchor public institution, has, against all odds, gained 2,000 more students, achieved efficiencies, adjusted to online delivery, and is likely to maintain, if not increase, the surplus that it is required as a public body to report. Again, little acknowledged.

We need our anchor public institutions to work well at times like these. Fortunately, they are willing and able to do so – even without the recognition they otherwise surely deserve.

Cervus Lacessitus Leo. The stag at bay becomes a lion.

Sir Edwin Landseer’s Stag at Bay