Health system restructure: Five issues to think about
The restructuring of our health system announced by Health Minister Andrew Little has raised issues we’re going to be analysing and discussing for some time.
One central agency, Health New Zealand, to work with a new Ma¯ ori Health Authority, will replace 20 District Health Boards (DHBs).
I’ve identified five broad issues that are important to get our heads around.
Efficiency
It’s a word I dislike. It has connotations of people working harder for less or of cutting corners to save money.
I accept that spending taxpayer money on any public service should be well-directed to achieve the most benefit. I reject the idea that competition is the best path to achieve efficiency.
The logic, imported from the business world, is that competition creates lean, efficient systems that somehow work to benefit the whole. That idea applied to the health system has been proved to be plainly wrong.
It’s not efficient to have duplicate layers of high paid senior managers replicating tasks throughout the country. It’s not efficient for hospitals to use different IT (information technology) systems or compete for staff and resources.
A siloed mentality is not good for sharing information about what works and what doesn’t.
Co-ordinating a national plan to address a national health issue is needlessly more difficult. The government found this out when it came to the Covid threat.
Co-operation, sharing of information and co-ordinated planning that’s responsive to the concerns of patients and staff can be “efficient”. Or, as I would prefer to say, just better run.
Prevention
If we want to talk about cost, it’s not sensible to have an excessive amount of the healthcare dollar spent on last-resort medical care rather than on prevention.
The DHB structure did not seem to encourage a bigger picture, preventionfirst, approach to the health of all citizens.
Health New Zealand should be able to better implement sciencebased, culturally appropriate, nationwide strategies to encourage healthier lifestyles and target early diagnostic care before patients end up in hospital.
Accountability
We’re a small country. Our media and many of our non-government organisations focus on what happens nationally. Our democracy is centred on Parliament.
The focus on what gets decided in Wellington puts the decision-making there under enormous scrutiny.
In contrast, the personnel, politics, agendas, ideologies and skills of DHB members would be a complete mystery to most of us. We know some of that stuff about our politicians, and we learn more all the time because of media scrutiny.
We don’t know much about government bureaucrats either (Ashley Bloomfield excepted), but a centralised health structure puts a more intense spotlight on the relationship between elected government and the bureaucrats. Failure to meet targets has a clear accountability trail.
A centralised system will also empower staff and their unions big-time. Their voice was diluted by the divided DHB structure.
I’ll back staff to raise the issues that need to be raised and propose practical solutions.
Scarcity
Modern healthcare is a scarce resource. Operations, treatments, accurate and early diagnosis, medicines and vaccines are costly.
New Zealand is competing for medical staff, medical equipment and medicines with the rest of the world.
Demand is always going to be greater than supply.
New Zealand is competing for medical staff, medical equipment and medicines with the rest of the world.
Moving to a more centralised structure puts faith in a handful of knowledgeable people to make better decisions about the management of healthcare scarcity than the previous DHB structure.
We need to accept that Whanga¯ rei Hospital can’t offer every treatment or surgery. More centralisation in Auckland, requiring travel, is likely.
The trade-off, however, must be more local doctors and healthcare providers focused on prevention, early diagnosis and building relationships of trust with their communities.
The new decision-making structure must get the balance right for Northland.
Managing healthcare scarcity shouldn’t be confused with how much taxpayer funding goes to health. A government can give more money to DHBs as easily as providing more money to Health New Zealand.
Our levels of taxation and the portion distributed to the health system is a whole other political issue.
Separatism
National Party leader Judith Collins has called the decision to establish a Ma¯ ori Health Authority separatist.
It’s not clear exactly how the authority will operate, but it’s misleading to say this is a race-based initiative. It would be more accurate, I think, to say that it’s about bringing a different cultural perspective to the national provision of health.
It’s about enabling more Ma¯ ori cultural values - in some sense, these are idealised - to be applied to health practices, particularly when delivering to Ma¯ ori.
The Ma¯ ori Health Authority might be seen as a centralised think tank for addressing the statistically worse health outcomes of Ma¯ ori.
At a basic level, our attitude should be, give it a go, see if it works.
We need, however, to be careful how far we go in attributing failures in the health system to conflicting cultures. I would argue that the major divide in the health of New Zealanders is based on poverty, regardless of ethnicity or culture.
And the most separatist thing about the health system is that you can bypass the public health sector and get private healthcare if you’ve got the money. If there are concerns about fairness and equity, that’s where attention should be focused.
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