Changes for how health is delivered
If the ideal health system for a small country were being created from a blank canvas, there is no doubt it would be closer in design to the blueprint Andrew Little has outlined than the hodgepodge that currently exists.
However, the blueprint goes a lot further in two important respects from the Heather Simpson review of the health and disability system on which it is based.
One is easily addressed — getting rid of the 20 district health boards to have a national health service run by a single authority, Health New Zealand, which will commission health services.
The other is the proposed commissioning and veto powers for the Ma¯ori Health Authority and is likely to be the most contentious issue within the blueprint.
Little and the Cabinet not only rejected Simpson’s view that the Ma¯ori Health Authority not have a significant function in commissioning health services and want to commission services for Ma¯ori, they also want it to co-commission services alongside Health NZ for the whole population.
The Cabinet paper approving the blueprint sets out the expanded role.
It says the Ma¯ori Health Authority will be the lead commissioner of health services targeted at Ma¯ori and that it will “act as co-commission for other health services accessed by Ma¯ori, working jointly with Health NZ to approve commissioning plans and priorities”.
Little says in the paper that in terms of national service planning, it is his expectation that the Ma¯ori Health Authority should have a colead role in relation to national planning and in designing the key operating mechanisms that the system will use.
“This would require the Ma¯ori Health Authority to jointly agree national plans and operational frameworks [eg the commissioning framework], with clear approval rights including an ability to exercise a veto in sign-off.”
The design of the Ma¯ori Health Authority is not spelled out because it will be designed by Ma¯ori.
But there are already calls for it to follow the design of Whanau Ora — a social service delivery model set up by the Ma¯ori Party and National in which the government funds three private commissioning agencies which in turn commission providers.
The persistently poor health outcomes for Ma¯ori have demanded a new focus on Ma¯ori health in the reforms.
It should be relatively easy for the Government to say that what is happening now is not working and that a Ma¯ori Health Authority is required. The emphasis should be on its ability to work with the system, not separate to it.
The real debate will be around its powers, the lines of accountability, to what extent it will duplicate the general health system and most importantly, the transparency of the authority.
What does an autonomous and independent agency funded by the government look like?
If the authority’s proposed powers actually make a big improvement in health outcomes, it would be worth supporting.
But it must be transparent enough for anybody to see how their money is being spent and what the outcomes are.
Those questioning it should prepare to be labelled racist for even asking the question. But the answers are more important.
Transparency across the whole system is absolutely vital to
But it must be transparent enough for anybody to see how their money is being spent and what the outcomes are.
measure the success of the reforms.
Simpson wanted limited powers for the Ma¯ori Health Authority.
Her expert Ma¯ori advisory group offered an “alternative” view. The Government has gone with the alternative.
The other Simpson recommendation that was rejected was to cut the number of DHBs. But that debate is not going to get legs.
It makes sense to have none, rather have a halfway house between a national system and a fragmented regional system.
The failures of the current system have been laid bare in Covid-19. While New Zealand has performed well, it has been in spite of the structural deficiencies.
The 20 district health boards had their own public health units and operated as silos — even hiding PPE in the early days from the national inventory to protect their patches.
The system incentivises focus on individual performance of silos and duplication rather than have a good sound healthy system as a whole. Change is needed.