Amanda Cameron acameron@nzdoctor.co.nz

He's part Jamaican.

He won't tell you which part, but you can guarantee it's not the hair.

Tony Ryall made a risqué remark about his Jamaican heritage the first time I met him four years ago when he was in Opposition.

Now that he's health minister, will he think better of it? No, I find he's still happy to make ribald reference to his ancestry.
And he's still wearing those shirts and ties.

His wife, he says, came up with the "stripes on stripes on stripes" look.

It's the same wife, one assumes, to whom he exclaims every morning "imagine being minister of corrections" in a set-piece joke he tells audiences about the health minister being "the best job in Government".

The fact he really does enjoy being health minister is no joke, though.

It was obvious to key health sector players that he wanted the job when he was National's health spokesperson and, now that he's got it, he wants to keep it.

It's one of the reasons he's widely regarded as having made a success of the job so far.

"The general feeling around the sector is that he's doing a damn good job in difficult times," NZMA chair Pete Foley says.

"He's smart, he's well informed, he engages, and he's clever.

"He's smart in that he's intelligent...but he's clever in that he's engaged with lots of people in the sector in a way that they see themselves as allies rather than foes."

Dr Foley's comments are typical of those made by the medical leaders the health minister regularly seeks out for their opinions.

It's an approach that earns him kudos with the leaders after the Labour-led Government left them feeling shut out for nine years.

They love that he's accessible, listens to them, and acts quickly if he thinks there's an important problem.

They love his emphasis on clinical leadership.

And they mostly seem to think he's taking the health system in the right direction.

Even his critics grudgingly acknowledge he's doing a good job.

And the public likes him. The most popular MP after the prime minister, Mr Ryall gained a net approval rating of 60 per cent on Kiwiblog this month - 20 per cent more than the next on the list, Bill English.

The New Zealand Herald ranked him Politician of the Year in 2009 after his first year as health minister, and the New Zealand Listener named him the most powerful and influential New Zealander in health/education/social issues. A year later, Herald chief political commentator John Armstrong says Mr Ryall still hasn't made any major blues.

It seems the minister can't put a foot wrong.

Mr Ryall calls the gongs "very kind" and believes people often win "best newcomer" because they suddenly get noticed.

If so, he is a case in point. Mr Ryall has just celebrated 20 years in politics. At nearly 26 and a member of the notorious "brat pack" (with Bill English, Nick Smith and Roger Sowry), he was one of the youngest new National MPs elected to Parliament when he took the East Cape seat off Labour in October 1990.

After promotion to the Shipley Cabinet in 1997, and various ministerial roles in the dying days of that administration, came nine years on the Opposition benches, first as law and order spokesperson, then as health spokesperson.

That gave him a lot of time to meet people in the health sector, learn what they think, and find out what's happening here and overseas, he says.
"That all builds a flavour of what you want to do."

Mr Ryall is relaxed and confident during the 40-minute interview at New Zealand Doctor's offices he has squeezed in before yet another medical centre opening.

A tape recorder sits on the table between us. He says his staff told him to bring it. They say he reads every piece of media correspondence from his office and can spot a spelling mistake at 50 paces.

"If I look at the people in my first nine years in Parliament, none of them (like Simon Upton, [Bill] Birch...and Mrs Shipley) ever had the opportunity to be the Opposition spokesperson before they became ministers."

Nine years in Opposition also gave him time to reflect on his predecessors' mistakes.

"One of my missions is to ensure New Zealanders can have confidence in a National Party Government running the health system. Because that confidence was shaken with some of the events in the early 1990s with those changes [towards privatisation], and people felt it was not well explained, and it looked like change for change's sake.

"And what I want to ensure is that New Zealanders trust the National Party to deliver what they want in their health service without anything like ideological change."

Is he ideological? He says not.

"Ideological is always used in a pejorative way...I consider myself as having very clear principles in the sense I come from a known set of views tied up with reward for effort, low bureaucracy, Government doesn't always have to do it, cut through the nonsense. This is the set of attitudes associated with conservatism.

"We just do the business."

Indeed, they do.

Since becoming health minister two years ago, Mr Ryall has ticked off a handful of key vote-winning moves and ushered in the beginnings of profound changes to the health system.

He points to "dramatically" shorter waiting times for surgery and cancer radiation treatment, and the decision to fund Herceptin, as his top achievements to date.

He has also overseen a sharp reduction in the number of PHOs, the first DHB merger, and some revolutionary steps towards delivering more secondary care in the community, but he doesn't mention any of these.

As one sector observer comments, the health minister has overseen an awful lot of structural change in the sector for someone elected to power on a promise of no structural change.

"He's been very clever...He hasn't done it by ministerial directive but made sure that 'the minister's wishes' are known...There's no paper trail necessarily."

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This hands-on, hands-off approach is well known in the sector.

The minister is notorious for phoning or visiting DHB staff at all levels, from executive management to juniors, to question aspects of their work.
Green Party health spokesperson Kevin Hague says this approach has had a destabilising effect, leaving people scared to make decisions and questioning whether their authority is still intact.

"It's tied to his lack of trust in the people who report directly to him and I think it's had a whole lot of ripple effects which have had quite a profound overall effect," he says.

Mr Hague is referring to what he says is the health minister's unwillingness to trust virtually anyone who worked in senior positions under the last Government. He says this is leading to an extraordinary loss of experience, knowledge and momentum.

He cites this month's resignation by widely respected Auckland DHB chair Pat Snedden as the latest casualty of the health minister's mistrust of Labour appointees, following the resignations of former director-general of health Stephen McKernan and former Capital & Coast chief executive Ken Whelan.

The Ministry of Health has also lost some good people, such as National Health Committee secretariat manager Margaret Earle, who was one of the deep thinkers available to the minister, Mr Hague says.

"He doesn't trust appointed advisors...Instead, he has a small ring of confidants on whom he leans for advice, who unsurprisingly have their own agendas. Some of this advice has been very poor."

Mr Hague doesn't want to name names, but it's clear Mr Ryall still relies on the advice of many of those he built relationships with while in Opposition.

No one seems to know exactly who's in the minister's trusted inner circle, however. Even Dr Foley, who says he can meet the minister any time he wants, claims not to know.

The usual suspects - Association of Salaried Medical Specialists executive director Ian Powell; RNZCGP president Harry Pert; General Practice New Zealand executive director and National Health Board member Bev O'Keefe; and ProCare Health chief executive Ron Hooton - confirm they are in regular contact with the minister.

Mr Ryall himself names former Treasury secretary and now National Health Board chair Murray Horn, professor of medicine and Health Workforce New Zealand executive chair Des Gorman, and Waikato DHB chair Graeme Milne as among those from whom he seeks opinions.

NZMA GP Council chair Mark Peterson says Mr Ryall calls him occasionally about various matters. "I'm not sure how he chooses whom he talks to...but he's got a lot of people's cellphone numbers," Dr Peterson says.

The minister is a prolific texter, by all accounts, and says he invites people to keep in touch and speak frankly with him by note, text or email.
As he explains it, there is a real risk when you are a minister that "people only tell you what they think you want to hear".

My Ryall says: "I try to move beyond the normal bureaucratic advice stream in order to talk to people who are doing stuff directly."

Sceptics have labelled the minister's approach to seeking advice as "policy making by Blackberry" (New Zealand Doctor, 7 April 2010).

"That's complete rubbish! We don't make policy by Blackberry," Mr Ryall responds. "We have a very considered policy-making process in this Government, but it is not as long and tedious as the previous one.

"One of the big messages from the health sector in the previous election was 'we are happy to be consulted but does it have to take three years?'

"So we have a much shorter consultation process. [It's] much better to get a round table of people together to sit for an afternoon to nut the business through rather than [have] endless papers and discussion documents. In the end, if we can get all the players together who have all the understandings of things in the room, you can deal with stuff."

The problem is, not everyone agrees the minister really does get "all the players" together.

One health heavyweight who has not spoken to Mr Ryall since he became health minister is Bupa chief executive and former Waitemata DHB chief executive Dwayne Crombie.

According to Dr Crombie, New Zealand Aged Care Association's chief executive, Martin Taylor, is the minister's preferred source of advice on aged care.

"He's open to advice, but has preconceived ideas about whom he'll listen to. There are some people whose views or politics he doesn't like...If you're part of the inner sanctum, you can put anything on the table and he's prepared to push for it and push quite hard.

"I don't see him as getting a broader triangulation."

Another sector insider says the danger of the minister's approach is that he listens only to those who tell him what he wants to hear: "Sometimes you think, 'I hope he's getting another opinion about that area as well'..."

Not that this approach seems to have done Mr Ryall any harm.

There are a few grumbles, but everyone seems relatively happy with the health reforms at this point and, for the most part, he has managed to keep health off the front page.

Mr Powell believes Mr Ryall's well-earned nickname of "Teflon Tony" in health circles is partly due to his good relationship with the sector and partly to his latching on to a few key initiatives strongly supported and driven by senior health professionals, such as cancer treatment and emergency department waiting times.

That and the fact it's still early days for a new health minister and a new government - a fact Mr Ryall himself acknowledges.

"It's a combination of the new Government, drawing a line under the previous Government and being very clear what our agenda is, what we focus on, and we try to deal with the negatives as quickly as we can from a political point of view...The momentum of new government makes it easier to achieve things and easier for the public to see you are making progress."

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Mr Ryall's ability to keep a lid on health is likened by several people to that of former Labour health minister Annette King, one of New Zealand's most popular and effective health ministers.

He deals with problems quickly and shuts things down before they have a chance to boil over, Herald chief political commentator Mr Armstrong says.
In addition, he astutely judges what the public will and won't accept, and has been careful to frame the reasons for the health reforms as practical rather than ideological.

"He knows the limits of how far you can push before you go over the edge and get a backlash," Mr Armstrong says. "He saw Simon Upton come a cropper...and Ruth Richardson waving the flag for privatisation and saw how that derailed the 1990 National Government."

For example, he assumes Mr Ryall's hand was heavily involved in the mysterious disappearance of some of the more radical recommendations from the final version of the Horn report, prepared by the Ministerial Review Group, led by Dr Horn.

Mr Ryall wants to see more flexible use of the private sector in health, but has been careful to ensure Labour and its allies, who are suspicious a right-wing agenda is operating, can't nail him down to anything specific, Mr Armstrong says.

As far as he can see, the only political mistake Mr Ryall has made so far is letting DHBs make cuts to home help for the elderly - a vulnerable, articulate population that will change their vote at the drop of a hat.

Indeed, attacks from Opposition MPs in Parliament seem to slide right off him. That might not be important from the public's point of view, but debating-chamber wins have an important psychological impact on the various political parties, Mr Armstrong says.

Labour health spokesperson Ruth Dyson says, politically speaking, Mr Ryall's ability to stick to what she calls "slogans" such as "Better Sooner More Convenient" without deviating from the script, is an attribute.

However, Ms Dyson says, the health sector finds this approach "quite shallow" and his refusal to give "any sensible answers" in the House indicates he's "not really on top of his job".

Ironically, the fact the health minister is a politician at all seems to count against him in health circles.

NZMA's Dr Foley: "The only thing I don't like about him is that he's a politician, and all that might mean. At the end of the day, surviving as a politician is as important as, or more important than, improving the health system."

Another sector insider points to the Labtests affair as an example of what a good political operator Mr Ryall is: "He was told by several leaders at the time of the disaster that was looming. He didn't act and we had the fiasco...Has any of the mud stuck to him? Not a bit."

Whether there's any mud to come remains to be seen.

Mr Ryall moved fast in his first year as health minister in order to see results before the 2011 election, Mr Armstrong says.

Asked whether he worries that making rapid changes without long consultation and analysis will eventually backfire on him, Mr Ryall answers: "There's always the risk of being blindsided. But there is a lot of goodwill about...and some stuff may not work but at least we're giving it a go...I've been remarkably impressed in the health service...it's just impressive the level of commitment and the speed at which various groups and organisations have got in there and started changing things to help us meet those [six health] targets."

And there he is, the consummate politician, selling the good news again, as he does unremittingly. Indeed, the flashy ties, the bright smile and the slick messages are all reminiscent of a salesman and, like any good salesman, he neither over-promises nor under-delivers. However, the promises are driven more by politics than by policy, according to his political rivals.

And some in the sector think of the minister as a short-term, operational thinker rather than a long-term, big strategy thinker. Mr Hooton comes to his defence, however. "I think he's consistently taken a long-term approach...He wants to be minister of health for a long time. You can cherry-pick some things, Herceptin, for example, that were done for electoral points, but I haven't really seen all that much of that."

Mr Ryall, who is never without his Breast Cancer Foundation pink ribbon, must know health professionals understand the Government's decision to fund Herceptin was a political one. But he continues to justify it in terms of the scientific evidence and "bringing New Zealand into line with many other countries".

Green Party health spokesperson Mr Hague believes the minister considers how a proposal will affect voters before he considers how it will affect health, citing how he shackled himself to elective surgery as a priority while in Opposition and is still tied to it, even though, in Mr Hague's opinion, there are more important issues to address.

The minister just "doesn't get" public health and the social and environmental forces that shape patterns of disease, Mr Hague says. He gets the concept of educating individuals but doesn't understand people don't necessarily make rational choices about their health, he says.

Mr Ryall explains the Government's approach to public health and the health system in terms of what he calls New Zealand's "cultural legacy".

"I don't think New Zealanders like having the Government tut-tutting, particularly on food...[but] we've put a huge investment into smoking because that is an area the public wants dealt with...And they don't like to think some people get something others don't when it comes to the public health system. So I subscribe to operating within that legacy."

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Trying to distil the minister's own personal cultural legacy proves difficult. He's unwilling to give too much away but happily reveals the straightforward biographical details.

The eldest of three boys, he says he had a safe, happy and secure childhood in the Bay of Plenty, first in Kawerau then Whakatane, where his hard-working parents owned a garden centre and his father worked for Tasman Pulp and Paper.

Having done well in maths and economics at school, he studied finance and accounting for four years at Massey University before getting a "proper job" in banking in Wellington. He worked at that "proper job" for two-and-a-half years before being selected as a National candidate in his home electorate at just age 24.

What sparked his original interest in politics? The same thing that motivates most health workers, he says - the opportunity to help people. He first became interested in politics at school, joined the Young Nats at just 15, and helped run an election campaign while at university.

He denies any notable formative life experiences - "I think everything you do in life is formative" - but does reveal his mother was very ill when he was in the seventh form at school and he had to step up and help run the family business for some time. It's not a tale he will dwell on, however. "I didn't have an epiphany or life-changing moment...no. Very boring."

In fact, he says, he quite enjoys the attention he gets because of his eccentric shirts and ties exactly for that reason. "It's really quite fun because I am a reasonably boring person, actually. I've led a rather conservative life. So it's really quite nice to be noticed on the clothes thing."

His wife enjoys it, too, he says. Kara has a great colour sense with a background in interior design and textiles and helps him choose the shirt-and-tie combinations that now have their own Facebook page.

The family home is in Tauranga but they live in Wellington during the school term so that he can spend at least some time with Maisie, 13, and Llewellyn, 9, although he expresses some regret he cannot spend more time with them. "I'm not sure you can be a great father in this job. I do my best."

He cycles a few times a week, wouldn't mind retiring to a vineyard in the Wairarapa (as a cycling mate has), but says, if he wasn't a politician, he'd probably be a partner in an accounting firm in the provinces.

No, he doesn't want to be the prime minister and, no, he and his family don't have private health insurance. "This really annoys the lefties," he beams.

He volunteers the fact he's registered with the Western Bay of Plenty PHO and that his GP has just told him he must lose weight. "So I'm focusing on nutrition and physical activity."

And there it is again.

You've got to admire the guy. He never lets up.

"It's difficult to separate the man from the politician," Dr Foley observes. "And I know the politician more than the man...But, if he wasn't the minister of health and I wasn't in my position, I'd be happy to have him around to dinner...I find him very easy to get on with."

Ms Dyson won't comment along those lines, saying whether she likes the health minister or not is irrelevant. Dr Crombie is the only person interviewed for this article who does not find it easy to relate to Mr Ryall.

"He doesn't engage you on an emotional or personal level," says the aged care group executive. "He's very much a career politician. It's kind of interesting, because you might get a less competent person whom you'd crawl over hot rocks for."

Whatever you make of the man, the politician is in the pink.

Sector leaders variously come up with a few qualms. Maybe, they say, he put enormous pressure on the primary care sector without enough resources to get change. Maybe Better Sooner More Convenient has not gone as smoothly as he might have hoped. Maybe he has sidelined the ministry and left it a bit directionless, is more an operational than a big thinker, and underestimated the political drive needed to get the agreement with senior hospital doctors, In Good Hands, implemented. And maybe he has underestimated the effects of slicing hospitals' backroom budgets.

But he's enormously popular with the public and with most health leaders and that's quite an achievement in the vexed portfolio that is health.

Maybe it's those Jamaican genes. Maybe it's those shirts and ties. Or maybe he's just damn good at his job.