What worked under threat

Undoubtedly, the health system needed further improvement, but in reality, it always will. Successive governments have struggled to meet the requirements of a fullyfunded health system, so compromises have had to be made. Treasury has struggled to grasp the cost-benefit equation of health, not understanding that society loses everything else without health and wellbeing.

Equity is a significant issue, and the evidence from the Waitangi Tribunal process (WAI 2575 Inquiry) is that funding formulas in health have not appropriately taken into account the real impacts of ethnicity and deprivation on health.

Still, the required solutions are much broader than the health system itself. The Heather Simpson review was putting the system on the right path, taking the best of what we had and addressing deficiencies. However, the current reforms will take us in a different direction and risk the very things that have made the New Zealand health system one of the best-performing in the world.

Despite the rhetoric over the past two years, the New Zealand health system stacked up well against comparative systems both in cost and outcomes, including equity and efficiency.

We have fewer hospital beds per head of population than most systems in Europe, except for England, which is similar. Prepandemic, we had more timely access to general practice, diagnostics, and community services than anywhere in Britain’s National Health Service (NHS).

Compared to the NHS, we have better access to rehabilitation services (including community-delivered services) for the elderly, for people post-operatively and also after injury.

In the NHS, people wait weeks to months in a hospital bed to access community support or long-term residential care which frequently they will have to pay for.

In terms of equity, many systems in Europe do not capture ethnicity data, so we cannot easily compare. In the NHS, it is patchy, but the mortality gap related to socio-economic deprivation ranges up to 25 years in Scotland and Wales.

Despite being free, access to general practice care in the NHS is challenging and certainly not timely, which is probably why the population attends the emergency departments at a much higher rate than in Aotearoa New Zealand.

General practice in Aotearoa is more sophisticated, more organised and has access to a broader range of supporting services. New Zealand-based companies lead the world in digital innovation in health. New Zealand’s population-based funding approach to health gave us the flexibility to innovate in a way that fee-for-procedure systems will not.

Local systems with devolved accountability for their populations made progress on addressing the real drivers of health need. Certainly, it was patchy, but with some stand-out performances that illustrated that in Aotearoa we did have the solutions in our hands, but they were not consistently delivered.

Let us remember that the term ‘‘postcode health’’ was actually coined in the NHS, and they continue to struggle with the enormous variability.

DHBs were created to support the health and wellbeing of local populations through an integrated health and social framework that enabled services to be designed and delivered to reflect local population needs.

While planning and service delivery was local, in reality many decisions were in the hands of the central agencies. External analysis established that despite old and failing infrastructure, DHBs managed comparatively efficient models.

Infrastructure is clearly an area that requires a centrally planned programme of repair/replacement, not predicated, as it was, on forced competition between DHBs for limited capital, and not one that creates long-term debt, which must be paid by cutting operational expenditure. That one policy setting contributed largely to ‘‘postcode’’ health. If your DHB had new capital infrastructure, it had less to spend on services.

With the disestablishment of DHBs from July 1, it is important that Te Whatu Ora creates a framework to ensure that in localities hospitals, general practice, aged care, disability services, mental health, NGOs are all working in an integrated way with iwi and local populations, to meet both the increased health needs and workforce pressures of an ageing population.

Almost ironically, the NHS is currently seeking to emulate the fundamental principles of an integrated approach to health and social care through integrated care systems that also started on July 1. The policy hopes that will be a vehicle for achieving greater integration of health and care services, improving population health and reducing inequalities.

The NHS now needs to deliver joinedup support for the growing numbers of older people and people living with long-term conditions. Evidence consistently shows that the wider conditions of people’s lives exert the greatest impact on health and wellbeing. This is what DHBs were also established to achieve.

In all public service delivery, there is a tension between local and centralised decision-making. Evidence is clear that the best way of addressing inequity is through empowering local decision-making and leadership.

It is critical that in moving to a new model, we do not give away the local decision-making capability, local leadership, and the opportunity to create a powerful collective model that has a better chance of managing the escalating demand on our health system through earlier intervention and enhanced social services for our most vulnerable populations.