Taking Action
Influencing Policy as a Member of the San Francisco Health Commission
Catherine M. Waters
“In every community, there is work to be done. In every nation, there are wounds to heal. In every heart, there is the power to do it.”
—Marianne Williamson
I was appointed as a Commissioner to the San Francisco Health Commission by the Mayor of San Francisco, Gavin Newsom, in 2008. I replaced a nurse, Dr. Catherine Dodd, who had 1 year left in her term when she was appointed as the Mayor’s Deputy Chief of Staff for Health (Figure 71-1). Commissioner Dodd recommended me to the Mayor’s Office to complete her term. I was told that other candidates, mostly physicians, were being considered also for the position. In the span of two weeks, I was notified by the Mayor’s Office that I had been appointed, and I was sworn in at City Hall the following week. I am certain that the synergy of various nursing connections and networks was an influential factor in my appointment.
After completing my 1-year term, I was reappointed by the Mayor in 2009 to a 4-year term. The reappointment required that I testify before the city’s Board of Supervisors for approval. In my televised testimony, the Board of Supervisors queried me about my commitment to the citizens of San Francisco and whether or not my views were independent of the Mayor’s views. I emphasized that the Health Commission is an independent, autonomous body that provides health advice to the Mayor on behalf of the residents of San Francisco.
In addition to my service on the full Health Commission, I am a member of the Joint Conference Committee that oversees San Francisco General Hospital and Trauma Center, a member of the Community and Public Health Joint Conference Committee that oversees community programs and public health prevention activities, and a liaison to the San Francisco Health Plan, the program that provides health access to low- and middle-income San Francisco residents.
Applying My Nursing Background in Commission Activities
I bring expertise to my work as a public servant from my background as a doctorally-prepared registered nurse, a university faculty member, a nurse scientist, and a citizen. My community-based participatory research and teaching, which focuses on health-promoting lifestyle interventions in collaboration with public and private community partnerships, informs my policy work and decision-making on the Health Commission. Making decisions and having debate about the multifaceted issues that come before the Health Commission requires the application of diplomacy, democracy, politics, and the art and science of nursing. During my tenure, the primary focus of the Health Commission has been on deciding where spending reductions have to be made within the Department of Public Health. Diplomacy and democracy are about differences, which are bound to diverge when different viewpoints and demands are expressed freely between competing interest groups or individuals for limited funds and resources.
The Health Commission hears arguments from disparate sides; I listen with diligence and in earnest from a nursing perspective. How do I prioritize and decide which programs that serve as the safety net for vulnerable populations take precedence over other programs that serve vulnerable populations? As a nurse, how do I in good conscious vote for the reduction and elimination of programs that I know may prove to be detrimental to the public’s health, particularly to populations who are the most vulnerable, but often, who have no voice, no power, and no leadership? I try to give voice to these stakeholders who often cannot speak for themselves. There is no magical formula to determine budget cuts that are difficult, painful, inevitable, and indispensable. I use principles of public health nursing, my professional expertise for the past 15 years, to guide me in policymaking and decision-making. Prior to public health nursing, my expertise was in oncology nursing.
Public health nursing contributes to population-focused health through effective partnerships with communities and populations to identify specific public health needs and concerns, address those issues at multiple levels, and use the political process to assure healthy communities via an ecological approach (American Nurses Association, 2007). The central principle of public health nursing is to achieve the greatest good for the greatest number of people by working with the population as a whole and as an equal partner (Levin et al., 2008). Adhering to this code of ethics requires being guided by a moral compass and philosophical and ethical values in order to help people live more healthful lives in the context of mutual respect, fairness, and justice.
I believe I have a moral obligation and duty to do the greatest good for the greatest number of people and engage in actions that cause the least harm to the fewest number of people. During this economic downturn, some people would question my use of morality and dismiss it as naïve, but morality has a place in policymaking and decision-making, especially when it involves the safety of the public’s health. Ideology may not be a prudent course of action during this time, but making sure that every person has a fair chance for a healthy life and an equal opportunity for quality health care is not about ideology; it is about the inherent and inalienable right to life, liberty, and the pursuit of happiness, which is not possible without good health. As a society, we have little to gain and everything to lose under a disparate health care system.
Overview of the San Francisco Health Commission
As the governing and policymaking body of the Department of Public Health, the San Francisco Health Commission (referred to as the Health Commission), is mandated by the City and County Charter to manage and control the City and County hospitals, to monitor and regulate emergency medical services, and to oversee all matters pertaining to the preservation, promotion, and protection of the lives and the physical, mental, and environmental health of San Francisco residents (Health Commission, 2008).
The Commission’s Scope of Work
The Commission considers issues including approval of the budget of the San Francisco Department of Public Health; estimates of revenues and expenditures; budget modifications; fund transfers and reappropriations; accepting and expending grants and receipt of gifts; entering contractual agreements; and reviewing proposed rates, fees, and other similar charges. The Health Commission also considers policy matters relating to health needs of the public, including program additions, deletions, or modifications and the closing and building of hospitals in San Francisco. All declarations of policy are made in the form of a resolution, and if approved, the Health Commission forwards the resolution to the Mayor for submission to the Board of Supervisors.
Infrastructure
The Health Commission is composed of seven members from diverse backgrounds and is led by a president and vice president. Health Commissioners are appointed by the Mayor and approved by the Board of Supervisors and serve 4-year terms. The Health Commission conducts all of its business in a public forum; however, it may meet in closed session. Members of the public are encouraged to attend the meetings and address the Health Commission. Public comments are heard prior to the vote on action items. Four Joint Conference Committees compose the Health Commission. One reviews financial reports of and approves contracting services for the Department of Public Health. Another provides oversight for the Department of Public Health programs and its citywide contractors that deliver services on behalf of the Department of Public Health. The remaining two committees provide oversight of health care delivery services for the City and County of San Francisco’s two hospitals, Laguna Honda Hospital and Rehabilitation Center and San Francisco General Hospital and Trauma Center. In addition to the Joint Conference Committees, the President of the Health Commission appoints one Commissioner to be a liaison to three governing bodies needing Health Commission representation.
Difficult Decisions
Some of the issues that I’ve been involved in have been challenging. I had to consider whether to vote to eliminate services (that would prevent ophthalmologic problems for persons with diabetes, reduce clinical hours during the week and eliminate a weekend day of clinical services for persons seeking urgent care, and eliminate integrated behavioral and medical services for persons living with the human immunodeficiency virus and acquired immunodeficiency syndrome) in order to budget for mandated cost-of-living allowances for health care personnel. These health services programs were implemented to prevent complications, such as blindness, emergency department overuse, and stigmatization, in these populations. Why would we dismantle services that were designed to save lives, improve quality of life, and decrease health care costs?
The Health Commission cannot spend money that it does not have. However, I feel an obligation to advocate for the public to do the greatest good for the greatest number of people and cause the least harm to the fewest number of people. The Health Commission’s budget principles dictate that it will develop a budget to maximize revenues; minimize the impact on vulnerable populations—those with the lowest income, severest illness, disproportionate health disparities, and are homeless; and preserve its core functions (i.e., primary care, emergency care, and protection of the public’s health through education and infectious disease control). Using these budget principles, I voted in favor of a wait-and-see approach to see how the overall budget would unfold before approving cuts in services that might harm the most vulnerable populations. In waiting for a thorough assessment of the fiscal impact of decisions to reduce and eliminate services, it reflects my belief that the balance sheet should reflect the Department of Public Health and its partners’ values, not the other way around.
The Balance of Power
The balance of power in San Francisco’s local government is similar to the balance of power in the United States federal government. The Health Commission falls under the executive branch because its members are appointed by the mayor. The powers and duties of the Health Commission are in accordance with the City and County Charter. The Board of Supervisors composes the legislative branch and approves the appointments made by the mayor. Serving as the judicial branch, the San Francisco City Attorney Office provides legal services to the mayor, Board of Supervisors, and Health Commission. The Health Commission recommends programs to be funded, eliminated, or reduced; the Board of Supervisors determines expenditures for those programs; the mayor considers implementation of the expenditures recommended by the Board of Supervisors; and the City Attorney’s Office provides advice about the legality of expenditures.
The Public’s Trust in Nurses and What It Means
According to the 2008 USA Today/Gallup poll, rating the honesty and ethics of workers in 21 different professions, for the seventh straight year, nurses are the most trustworthy, honest, and ethical of health care professionals (Saad, 2008). The public values and trusts nurses—a trust that is an honor that brings with it responsibility and commitment to serve the public. I believe it is my moral obligation and duty to ensure the delivery of services to assure the welfare of the public, to be honest in delivering information, to develop trusting partnerships, and to recognize the status of people who are inextricably bound to their social context. With this responsibility comes internal vigilance and being a part of the decision-making process in a discriminate and participatory manner. It is a fata morgana, a mirage, to believe budget cuts will not have a negative impact on the health of vulnerable people. In a decent, democratic society, there are certain obligations that are not subject to trade-offs or negotiations. Health care is one of those obligations.
I believe nurses know better than anyone where the system works and where it does not work, and they know how to improve quality of care and serve clients more effectively and efficiently. Despite it being difficult to prioritize resources among people who are all at-risk, I have learned to articulate my viewpoint, defend my position, face controversy, build a consensus, and debate issues of vital importance with diplomacy. Admittedly, this can sometimes be a slow and fragile process, especially if the process is conducted democratically and diplomatically.
Summary
All of the Health Commissioners do not always agree, but we engage and dialogue to find common ground with each other, the Department of Public Health and its partners, and the public to develop a common agenda and vision. The debate can and should be nuanced, principled, and spirited. Arguing over ideas is different from suppressing, changing, or ignoring opinions. Transparency and inclusiveness of decision-making and negotiation, action in the face of uncertainty, and accountability are fundamental to the success and maintenance of democracy in public health.
There are many health needs in San Francisco, but there are limited funds and resources available to address them. We cannot do everything that would be desirable to eliminate health disparities. This is the time to set priorities and consider inescapable trade-offs and opportunity costs with creative and innovative practices. This is an appropriate time to rethink how the Department of Public Health does business—moving from a model of “more quantity of services” to “quality of care and value of services” with more focus on outcomes. Difficult decisions must be made because of the fiscal reality.
For a list of related websites, please refer to your Evolve Resources at http://evolve.elsevier.com/Mason/policypolitics/
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