Personal Views: Doctors playing at politics
Authors: Harry McNaughton
Journal: BMJ (2004)

In 2003 the New Zealand Ministry of Health funded an update of the New Zealand stroke guideline (available at www.stroke.org.nz). As part of the launch of the guideline the minister of health hosted a parliamentary function. As a co-editor of the guideline I was invited to speak for five minutes on its main points. What follows is my description of the experience of trying to get an important message across to a political audience in a short space of time.

The minister of health is in the front row. Maori greetings, responses, and waiata (songs) are completed. Caterers' trays jingle in the background. How do you say, in five minutes, something that will make a minister sit up and act? Did I miss this bit of the medical curriculum? “Ten easy ways to convince politicians and civil servants”? Perhaps not.

This launch represents the work of dozens of clinicians, consumers, and voluntary organisations putting the case for better service delivery for people at risk of stroke and better management of stroke patients. We all know how relatively easy it is to write the guideline, but how difficult it is to get it implemented. Getting on to the minister's radar screen would be a good start.


We are not trained in the dark arts of politics


So, a big breath, and: “Ladies and gentlemen.”

I miss out the greeting in Maori after advice from a Maori colleague: “Unless you feel totally confident you'll sound a complete prat.”

“In the next five days 100 New Zealanders will have a stroke.” I run through the grim outcome statistics. Is the audience looking a shade uneasy now?

“But, yes, there is a treatment that can make a substantial difference to these outcomes—not a drug but an organisational change to services. Organised stroke services, including stroke unit care for all people with stroke... fantastic evidence... will reduce costs in the long run.”

The unease has turned back to comfort. They've heard this before—in a briefing 30 minutes ago. I look the minister in the eyes and launch phase two.

“The only problem is that `organised stroke services' were recommended in the 1996 stroke guideline. Successive ministries of health have let down the people of New Zealand by failing to implement those recommendations. In that time 1500 preventable deaths from stroke have occurred, and potential savings of tens of millions of dollars have been missed.”

The minister momentarily goes slack-jawed but rapidly readjusts the fixed smile and stares back. The other ministry people start fidgeting and tap meaningfully at their palmtops.

Minutes tick by. Get to the bottom line: money for implementation. A one-off payment by the health ministry of $NZ1000 (£370; $670; €540) for each new stroke patient this year—the cost of a magnetic resonance image or a couple of days in hospital.

And then it is over. Friends in the audience give a thumbs up and there is scattered applause. The minister is impassive.

Suddenly, without realising it at first, I am hit by a blanket defensive pattern. The minister and sidekick, smiling, ask 10 surefooted questions then intercept the hovering media people and smother them with the party line: “Yes, better stroke services are what we want. Yes, the ministry is working with `the sector' to deliver best outcomes for stroke patients. But, no, the ministry doesn't have a big pot of money. The district health boards are now the funders of health services, so you will have to ask [all 22 of] them how they are going to deliver better stroke services.”

I have visions of Lawrence Dallaglio, superbly skilled at slowing down play, killing the ball, and kicking the goals that count. I check my face for sprig marks: no worse than usual.

The ministerial party disappears for another function. The media people start asking questions. I babble, knowing the game is lost. The reporter seems to have got the wrong end of the stick and repeats a few things the minister has said. “But, but...” I stammer, and they are gone. It will sound even worse on the radio the next day. I grab a glass of red wine, accept some well meant congratulations, then wander outside to catch my train home.

Can any lessons be learnt from this? Possibly. Firstly, these people are professionals, well coached and with a clear game plan. A nice turn of phrase and a bunch of randomised controlled trials won't usually be enough. Pushing funding and responsibility out to the district health boards is an effective defence against calls for national action. Secondly, we're amateurs. We are not trained in the dark arts of politics and media relations, and apart from some gifted individuals we get taken to the cleaners every time. But you have to play this game. Luck plays some part, and maybe in the end you do score some points in the war, even if you lose many of the battles. You have to be seen to mean it and be prepared to take the public hits to make progress in the back rooms where, eventually, the deals get done.

And yes, even rugby world champions lose sometimes.