It would be easy to misinterpret "industrial engineering" as the science of designing and manufacturing giant machines that crash loudly while emitting great gouts of steam.
Although that description is in some ways close to the truth, retiring Clutha Health First chief executive Ray Anton explained the discipline has more to do with the cogs of human interaction, and the machines of corporate business.
Mr Anton (67), who graduated as an industrial engineer from the University of California Berkeley in 1977, formally retired from the Balclutha rural health facility this week, although he will remain in an acting capacity until his replacement assumes office in January.
His tenure concludes a life spent in healthcare, analysing and improving management systems, while steering, innovating, encouraging and advocating to improve the lot of staff and patients alike.
Born in Iraq, and spending a happy childhood in Lebanon and the United States, Mr Anton began his post-university career in the US as a healthcare management consultant, a path from which, since, he has rarely diverged.
"I started as a consultant, essentially running around with a clipboard.
"After a year out in Saudi Arabia working for their Ministry of Defence, I returned to the US and continued working with hospitals, establishing management engineering departments, doing time and motion studies, and developing systems and processes to increase efficiencies and quality of service, in part by listening to and implementing staff suggestions.
"That’s the essence of industrial engineering as it relates to healthcare."
His work led to a position with global giant KPMG, as a management consultant focused on healthcare.
"A contract was given to KPMG in New Zealand in 1988, and I and a team of US consultants came over and worked in Hamilton, Rotorua and Dunedin to establish costing systems, to see where health funding was being spent.
"We modified the budgeting system here in Dunedin in conjunction with the local team, which included a lady who eventually became my wife, Susan."
The couple were married in Dunedin at the end of that year, before returning to the States.
However, the family draw of Otago proved too strong, and they returned in 1995, where he took up a role at the Southern District Health Board.
"Family drew us back to Dunedin. Susan was born in the old Balclutha Hospital and her family was in Dunedin. We eventually had our youngest child [of four] in Dunedin."
Mr Anton said he worked at Dunedin Hospital for six years, but found it "stifling".
"It was difficult to move and manoeuvre in a politically-charged environment, difficult to actually make decisions — slow decision making — which left me disenchanted."
The opportunity to take up a fresh position at the recently created Clutha Health First rural hospital was a welcome escape.
"It was a [DHB] contracted hospital, but with the innovation that the GPs, led by Dr Branko Sijnja, would share facilities and collocate with the hospital in a loosely collaborative fashion.
"Initially, that was about collocation only. We built a GP practice that had five independent surgeries, each with its own administration and register of patients, adjoining the hospital. We were essentially functioning as a landlord."
Over time the GPs decided it made more sense for them to collaborate as a single practice, eliminating duplication.
"So we took down walls and reshaped the surgery, to include an after-hours area for them to share collectively.
"We started buying supplies for the whole facility through the DHB, with the economies of scale that entailed, benefiting all our practitioners.
"Gradually we moved towards a more collaborative model, and the shared practice started to grow."
However, by 2010, growth and the related financial side of the practice were becoming challenging for its GP overseers.
"As a hospital, we relied heavily on the fact that the general practice existed within the facility, as this is the first point of contact for the public, before they can access secondary hospital care.
"The GPs were struggling to provide after-hours service, which raised the risk of patients being dumped on the hospital, which was not in a position to take them on.
"So, at that point, we offered to buy Clutha General Practitioners Ltd."
This was unusual for a secondary healthcare provider, and regarded as something of a radical innovation at the time, he said.
"Primary-secondary integration is not the norm in New Zealand, although the DHB always talks about seeing closer integration of services.
"The prevailing system, where we split and silo primary care from the hospital is a mistake; it’s actually a disaster for this country.
"My experience from the US was that primary-secondary collaboration was key to a better journey for the patient."
Splitting primary and secondary care led to an "adversarial" approach to healthcare, Mr Anton said.
"A patient’s care is 90% of the time held in primary care. But when they’re really sick, 10% of the time, they need secondary care, and from the patient’s perspective, that journey from primary to secondary needs to be seamless for the best outcome."
Collocation led to a more collaborative approach, where both types of practitioner viewed each other as colleagues working in one facility, for the patient’s benefit.
"We need to think of ourselves as one system, because we are."
It had further benefits for both patients and staff, he said.
"A consequence of the closer integration of services was the upskilling of GPs and nurse practitioners to deliver specialist services that could speed the process of diagnosis, then access to appropriate secondary care, for example in the area of breast care and assessment.
"Our experience has shown this can save up to 80% of referrals, and related costs, time and stress for patients, as well as providing professional development and job satisfaction for staff."
As his tenure drew to a close, he was confident he had left successor Sharon Mason — chief executive of Buller District Council — a "steady ship" ready to weather the perennially "choppy waters" of New Zealand health care.
"We have a fantastic team. They are passionate, energetic, innovative risk takers, who care about our community. I’m leaving behind a positive environment in healthy financial shape for Sharon."
Key challenges he would pass on to his successor centred on recruiting and retaining staff, exacerbated by ongoing discussions about delivering pay parity between Te Whatu Ora staff and rural health providers such as Clutha Health First.
"Te Whatu Ora staff will be paid 20%-40% more than their professional equivalents in rural health care. Inevitably, this will make it harder to recruit and retain clinical staff.
"This flies in the face of Te Whatu Ora’s professed aims of providing health equity for all New Zealanders. It will simply further drain rural resources to the cities.
"It’s undermining and, I’m sorry to say, it’s a result of incompetence and an inability to grasp the bigger picture."
He believed politicians should adopt a lighter touch when it came to health care.
"They don’t know what they’re doing. They should tax New Zealanders, fund healthcare, then get out of the way and let businesses run and deliver health systems for their communities."
Following his final handover in January, he expected to take a partial step back from healthcare to enjoy his retirement.
However, he hoped to continue to be able to contribute to positive change in the rural health sector through his work on the board of advocacy body Hauora Taiwhenua.
"I’ll remain involved in the sector in a governance capacity, while stepping away sufficiently to spend more time with family in Melbourne, and to travel more widely."
