When Chris Fleming was appointed as the Southern District Health Board’s chief executive in 2017, he was told it was a role which offered opportunities and challenges.
After an eventful five years Mr Fleming might be entitled to feel that there have been more of the latter — as we speak Dunedin Hospital is trying to get back to normal after having to stop performing all but emergency surgery due to overcrowding, illness and staff shortages, particularly of nurses.
"It is frustrating, but it’s also complex," he says, perhaps unintentionally summing up the health system in one short sentence.
"In the last two years we needed to recruit 580 nurses both to meet normal turnover and to achieve safe staffing, and if we had taken 70% of all the graduates from Otago and SIT for two years that would have been about 280.
"Where do the other 300 come from, particularly with the borders closed and demand from right around the country?"
After five years wrestling with such problems at southern, and 30 years of working within the health system, Mr Fleming has had his fill.
The Government’s health reforms, which in three weeks will do away with his current employer, were the final motivation for a long-discussed return to his native Waikato and a complete change of direction: Mr Fleming, his wife and son are to take over two branches of Paper Plus.
He expects that he will still be called upon as a consultant in the sector and is optimistic about the reforms, despite the personal and professional upheaval they have occasioned.
"I have obviously decided to do something different — the reforms helped me think about where I want to be for the next decade, I came to a personal conclusion as to where that was and I didn’t come to that conclusion because I thought ‘Oh jeez, Health NZ’.
"I actually do believe that the mantra HNZ has of nationally planned, regionally delivered, locally tailored, if they can make that become more than six words on a piece of paper, but action that affects the way we live, then I think it is the right thing."
When Mr Fleming arrived at the SDHB its deficit was about $30 million, and as he leaves it is about the same, although as a percentage of overall DHB debt the southern slice is hugely reduced.
While not overjoyed about running a large deficit, Mr Fleming notes that in any publicly funded health system there will always be a tension between patients who want more services, health professionals who want to provide more services and the Government’s ability — or willingness — to pay for them.
"We always try to prioritise access to health services over the fiscal parameter but it is a difficult challenge."
Uncertainty remains over many aspects of the reforms, especially how health localities are to function.
Mr Fleming has managed services in the largest and one of the most rural of the 20 DHBs, and trying to maintain healthcare in its most far-flung corners has been a strain — the lengthy and often bitter row about maternity services in Southland and Central Otago being a shining example.
During its final meeting the SDHB considered a future services plan for those regions, something Mr Fleming hopes will be template for all health planning in Otago and Southland.
"In Dunedin all the infrastructure planning has been done in exactly the opposite way to how it should have been done.
"When I arrived here we were going to replace the clinical services block, that was $300 million, and then the obvious question was where do you replace it and then it doubled to $600 million and then to a billion, and now to $1.47 billion and a whole new hospital.
"Nobody did robust service planning to identify the needs for this particular community and then built a business case for that. Why didn’t people do that? Because of the scarcity of available capital.
"Health NZ’s infrastructure unit is the first time there has been a dedicated structure motivated to try and get that right, but it will come at an eye watering price."
One attribute which Mr Fleming has needed in his time in the South is a thick skin.
As the public face of the organisation, it is he who takes the flak when things go wrong, even if it is not his fault or — as was the case with disastrous and harmful backlogs of ophthalmology and urology patients — the problems started before his watch began.
He is philosophic about the vitriol he has attracted, particularly online, about his job performance.
"I reckon my family suffers more than me: when people go ‘that bloody Chris Fleming’ they don’t know me, they’re not talking about me as a specific individual, they are talking about my role and the decisions I am having to make as a chief executive of the organisation.
"So, it doesn’t really bother me, but it does bother my family at times if they see it as mean or targeting me, but it’s just part of the job."
One patient has lingered in Mr Fleming’s mind though, long after their individual crisis slipped from the headlines.
Stephen Hoffman, who was "Patient B" in a damning health and disability commissioner report released in 2019 concerning the SDHB’s urology department, made several scorching comments about the SDHB and its leadership, and has continued to cross paths with Mr Fleming since.
"The things he said back then, that hurt me a lot, but not because of what he said but because I knew what he was saying was true," Mr Fleming said.
"At the end of the day there were many Stephen Hoffmans caught in the crossfire: it does hurt, but it also poses the challenge of how can you make sure that you don’t allow that to continue and that you do actually get a sustainable improvement."
Although Mr Fleming downplays the stress of the role, he does later confess that the job has given him a few sleepless nights.
"One of the things that has kept me going in health for 30 years, in a perverse way, is that every night when I go home I know I haven’t done enough," he said.
"We achieve a whole lot of really great things in our workforce, we screw up from time to time, but no matter how well we are going there is always more that we could do, more that we could improve."
In his final months as chief executive Mr Fleming has allowed that frustration fuller expression, becoming more outspoken about the need to repair or preferably replace the partly dilapidated wards at Wakari and increasingly forthright about what for months he has warned was a looming crisis in the aged-care workforce.
"I don’t there has ever been a moment in time where funders, providers and unions have been in so much agreement about the problems and issues of aged care," Mr Fleming said.
"We have to fix the remuneration for nurses, we have to address the immigration settings and we have to enhance the number of people who are going through training programmes."
Of course, Mr Fleming’s years have not been entirely negative.
On the plus side of the ledger, among others, he cites the southern health system’s impressive response to Covid-19, the increasing engagement with Maori, the introduction of the healthcare home model in primary care, improved clinical governance and the Government agreeing to the SDHB’s expensive and ambitious digital strategy, as well as the progress to date on the new Dunedin hospital.
"I am a bit disappointed that the only thing I am going to see of the new hospital is a few piles. Hopefully I get invited back down for the opening."
