Just what the doctor ordered?
Another Government, another set of plans to reform the health service. Bridie Witton examines what the latest $9.5 million review means for patients.
Robin Gauld has been pushing for years for our health system to become more patient-focused. So he might be expected to be pleased with the latest reform proposals announced this week.
After all, patients and their care were supposed to be at the heart of the Heather Simpson-led review.
So what will the review, which has cost $9.5 million and been two years in the making, mean?
‘‘It means almost nothing,’’ says Gauld, associate professor of health policy at the University of Otago. ‘‘It’s more bureaucratic admin.’’
The Health and Disability System Review proposes creating a new independent Crown entity, to be called Health NZ, to oversee district health board operations, cutting the number of DHBs from 20 to between 8 and 12, and charging those boards with ensuring equitable health outcomes.
It has other recommendations and comments: we should provide more healthcare in the community rather than hospitals; services should be more consistent so quality of care isn’t dictated by postcode; and we need good IT systems.
But as far as DHBs being in charge of equitable outcomes, Tim Tenbensel, associate professor of health policy at the University of Auckland, is not convinced.
‘‘It’s a fantasy. We know DHBs don’t control the things that have an impact on health outcomes. It [the review] has huge fishhooks in it.’’
Gauld agrees, but goes further. He would like to see all DHBs gone in what he calls the de-bureaucratisation of health.
‘‘We have hospitals, and we have general practices, so we don’t need DHBs,’’ he says. ‘‘My preference would be a group of hospital managers working to support a network of clinical leaders.
This would form ‘‘a total customerfocus with patients, and building them together with health professionals who are charged with all the decisions about how services should be funded’’.
Readers with long memories could be forgiven for thinking we have been here before, many times.
DHBs were the creation of the LabourAlliance coalition in 2001, which in turn followed the National-NZ First coalition combining four regional health authorities into one national purchasing agency, the Health Funding Authority, only three years earlier.
‘‘The proposed Health NZ is like the
Health Funding Authority,’’ says Gauld. ‘‘This was a good model, but did not feature DHBs, just hospitals and managers.’’
Cutting DHBs by roughly half would see a number of smaller, rural DHBs merged with their neighbours.
Likely candidates for amalgamation include the West Coast DHB, which has the smallest population but the largest geographical area in New Zealand.
It has a reliance on locums, and has a shortfall of senior doctors.
‘‘People die waiting for diagnoses because they don’t see the same doctor twice,’’ says Westport GP Martin Smith, who worked at a West Coast DHB general practice for seven years.
He welcomed a system overhaul and has spoken out previously about patients needlessly suffering while waiting years for orthopaedic surgery.
DHBs have always been management organisations, and New Zealand’s high hospital admission rates for children with preventable diseases, such as whooping cough, rheumatic fever and measles, shows it has not had an impact on public health.
The idea behind DHBs with elected members was to ensure a closer link to communities.
But it just hasn’t worked, says Anna Matheson, senior lecturer in public health policy at Victoria University, and the members, who are paid between $16,000 and $26,000 a year, have very little influence on health policy.
Their leadership is panned in the Simpson-led report. ‘‘Leadership within the DHBs also needs to change,’’ it says. ‘‘At the governance level, the review concludes that the effectiveness of elected over appointed boards is not compelling.’’
Instead, it calls for members to be fully appointed by the health minister, and measured against a transparent set of competencies, including financial and governance experience, as well as tikanga Ma¯ ori and disability sector knowledge.
Tenbensel describes the role of elected members, who are voted in during local government elections, as symbolic.
Veteran board members have suggested boards may become too political if chosen only by the health minister.
But the idea that elected members will speak out against DHB policy is misplaced, Gauld says.
And since voter apathy is rife during board elections, it is questionable whether they can be thought of as the voice of the people.
‘‘Elected board members aren’t there to represent the people or challenge; they are there to implement policy,’’ he says. ‘‘They are effectively muzzled.’’
The result is that boards have ended up favouring their own providers rather than supporting community groups, Matheson says.
Yet communities are more stable than the policy environment, which changes with a new government. ‘‘So you get Ma¯ ori and Pasifika community organisations working off the smell of an oily rag with no DHB funding.’’
She calls for workforces that work locally with people to be valued, and for more collaboration.
‘‘Whole-of-government and intersectoral action have been with us for a long time. But not only have they failed to achieve their aims across government, they have failed in achieving long-term integration of services and programmes within communities,’’ she says.
Still, the culture change described in the report is heartening.
‘‘DHBs and hospitals are substantial assets to their communities, which hold enormous potential to provide leadership and support for local collaboration and collective initiatives.’’
Indeed, encouraging citizen involvement in the health system also posits a new set of issues, Tenbensel says.
‘‘With a patient voice, there is a bias towards those who are better off.
‘‘They often have very valuable things to say, but you don’t get the bus driver from Ma¯ ngere.’’
One of the panel’s big recommendations was to set up a Ma¯ ori Health
Authority to sit alongside the Ministry of Health and Health NZ, and advise on all aspects of Ma¯ ori health policy.
A Ma¯ ori agency was a key recommendation in a 2019 report from the Waitangi Tribunal’s inquiry into Ma¯ ori health outcomes.
So the focus on improving Ma¯ ori health through a new agency is a move in the right direction, Gauld says
Although it doesn’t go far enough. ‘‘It is quite constrained and doesn’t give self-determination.’’
The extent to which the authority would control funding and commissioning of services is still to be worked through, and divided the review panel.
Under the proposal put forward by Simpson, the Ma¯ ori Health Authority would take on all the functions of the Ma¯ ori Health Directorate, currently part of the Ministry of Health.
It would have oversight on all things Ma¯ ori in the health system, but overall funding would stay with Health NZ.
But some panellists were concerned this would limit its role, and mean it functioned as more of an advisory group than an independent Ma¯ ori entity.
Tenbensel says it isn’t clear where the Ma¯ ori Health Authority and Health NZ would overlap, and where each agency would begin and end.
But since New Zealand’s health system has a shameful record of failing Ma¯ ori, any serious impact won’t just come with a new agency, Matheson says.
‘‘If you are not dealing with institutional racism in the whole system, there is little that an underresourced Ma¯ ori Health Authority will be able to do.
‘‘I think culture change is really important, and probably more crucial than the structure.’’
The report also recommends disability services be managed in primary and community health.
This change is needed to ensure that ‘‘disability is no longer treated as an exception or managed separately. The increasing number of disabled people have the right to expect equitable outcomes from the system,’’ according to the report.
But critics say this will medicalise disability.
CCS Disability Action, the largest pan-sector support and advocacy organisation, goes as far as saying the report is ‘‘at odds with years of consultation with disabled people and wha¯ nau’’.
Chief executive David Matthews has called for the establishment of a Disability Authority, akin to the Ma¯ ori Health Authority, and says disability support is not health service.
‘‘We need a separate Disability Authority governed by disabled people and their wha¯ nau.
‘‘In the review there is no mention of any guaranteed disability representation at either the DHB or Health NZ level. Frankly, that is just not good enough.’’
Any focus should be on ensuring disabled people have the same opportunities as other New Zealanders.
‘‘That the proposed new entity is named Health NZ does not fill me with confidence that the review understands this,’’ Matthews says.
‘‘Instead, we are likely to see an even narrower focus on just meeting health-related needs in these healthdominated authorities.’’
Tenbensel says there is a lot of concern for people already in the health system, never mind those outside it who need care.
Many who need to access health services aren’t doing so. ‘‘The whole point of the review, and what people have been saying for a long time, is that we need a health system designed for people where the health needs are.’’
Since the Government has accepted the report wholesale, the Cabinet will decide on specific recommendations, and whether to implement them in the coming months.
But if any recommendations are enacted, it could be about five to 10 years before they would be noticed by patients.
And what the steps towards achieving equity of health outcomes will look like, particularly for Ma¯ ori and Pacific people, is still unclear.
‘‘I think the ‘what’ is really good, but what is missing is the ‘how’,’’ Tenbensel says.
The report describes restructuring at the top end of the health system, but getting there is a different task, says Matheson.
‘‘I don’t know how long it will be. It’s theoretical at this point.’’
And the report itself is not good value for money, according to Gauld.
Review representatives travelled to the United Kingdom, Norway, the United States and Canada to gather international evidence, and more than $5.5m of the budget went towards consultant and contractor costs.
‘‘Consultants are really expensive, you are looking at $500 an hour,’’ Gauld says.
‘‘Most of the work wasn’t actually done by the panel.’’
There will still be a tension between Health NZ and the amalgamated DHBs, with differing national and local views on priorities and decisions, he believes.
But ultimately, reshuffling how things work at the top has no real bearing on the patient. ‘‘It is quite a rehearsal of ideas that have been in place in New Zealand over the years. That is why it is a bit confusing.
‘‘It is time for a rethink on how the business model works.’’