The government has announced sweeping changes to the health and disability system.
The changes include replacing the 20 DHBs with a national body – Health NZ – charged with planning services nationwide, establishing a Māori Health Authority, and creating a dedicated agency for public health.
The SMC asked experts to comment on aspects of this morning’s announcement:
General comments
Associate Professor Tim Tenbensel, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, comments:
“This morning’s announcement is truly a historic event. The changes proposed go significantly beyond what had been recommended by the Health and Disability Review Report last year. The big news is the abolition of District Health Boards, and their replacement with a single national organization, provisionally known as Health New Zealand, which will have four regional divisions, and a district or locality branches at local levels.
“The creation of a Maori Health Authority with commissioning powers is the other major innovation. Again, the scope of the MHA goes beyond what was recommended by the Simpson Review, and aligns more closely with the ‘dissenting’ view supported by the majority of the Review panel.
“The third major initiative is the creation of a public health agency within the Ministry of Health, which will give public health – the focus on prevention, promotion and protection of health – a much higher profile in government decision-making.
“Broadly, these reforms are likely to be widely welcomed by health sector leaders. While DHBs were meant to foster the development of community-based, primary health care services, and move the system towards prevention and earlier care, this did not happen, especially in the past decade. Most DHBs have been hospital-focused and risk averse in facilitating new models of health services that are suited to addressing widespread inequities and the needs of people with long-term, multiple and chronic health conditions.
“The new structure aims to address this by shifting the hospital-focused centre of gravity through HNZ and the MHA. We have seen the broad outline, and it has been painted in bold strokes. But as is always the case in any health system reform anywhere in the world, the devil is always in the detail.
Many big questions remain. How much disruption will these changes create? Can we move smoothly to a new structure in the tight timeline of 15 months?
“Many crucial policy questions have yet to be addressed. How will funding be allocated in this new system? Will there still be a role for Primary Health Organisations? How will these new organisations work out exactly who is responsible for doing what?
“Some will see these reforms as a return to the days of the Health Funding Authority in the late 1990s. There are similarities, and important differences. The structure of the 1990s stimulated many new initiatives, but was not so responsive to local conditions and needs.
“The biggest challenges for the government and the health sector, however, are long-term. This proposed model requires a much more collaborative, problem-solving approach in which health sector organisations work effectively together. For the past 20 years in many parts of the country, relationships between organisations have been driven by distrust – something that has been hardwired by broader public sector reforms in the 1990s, which emphasised competition, hands-off relationships and compliance monitoring. The system has been driven by accountability, but ultimately that accountability has focused on trivialities.
“The challenge for the new health system will be to hard-wire collaboration and trust as well.”
No conflict of interest.
Māori health
Shelley Campbell, CEO Waikato Bay of Plenty Cancer Society and member of Hei Āhuru Mōwai Māori Cancer Leadership Aotearoa, comments:
“As we reflect on the announcement of these reforms, it is remarkable that the support for an empowered Māori Health Authority, which can commission, comes not just from Māori but from a broad sweeping range of health professional bodies and groups. Our aspiration is that discussions on Tiriti rights to date make way for a Te Tiriti-inspired health system.”
Conflict of interest statement: Member of the Health & System Disability Review panel who supported the alternative view, CEO Waikato Bay of Plenty Cancer Society, Co-Chair of Te Aho o Te Kahu advisory council, and Co-Chair of the Māori Bowel Cancer Screening Programme.
Associate Professor Jacquie Kidd, Taupua Waiora Centre for Māori Health Research and School of Nursing, AUT University, comments:
“I applaud the government for their courage in planning such profound changes to the health system. In particular the announcement of a legislated Māori Health Authority that has the teeth to monitor Māori health outcomes is significant. The announcement also included reference to decision making in partnership with HealthNZ, which embodies Te Tiriti o Waitangi in terms of tino rangatiratanga and ōritetanga. Overall the announcement is very welcome and, if fully realised, will address the pervasive health disparities experienced by Māori.
“Our research with remote Māori communities has highlighted the importance of local solutions to health issues, and (along with many other studies) has documented the widespread mistrust of the health system by whānau. This new structure must fully engage with whānau to ensure that trust is carefully established and nurtured, and that national health agendas do not overtake those of hapū and whānau.”
No conflict of interest declared.
Dr Heather Came, Head of Department Public Health and Research Associate with the Taupua Waiora Centre for Māori Health Research, AUT University, comments:
“I spent the morning at a DHB as we listened to announcements about the health reforms. Some people were celebrating while others were deathly quiet. I have worked through many health sector reforms; for those of us at the bottom it is usually just a new logo on the business card; the real impact of the changes hits the health sector leadership. I thank the outgoing health leadership for their service.
“He tangata Tiriti ahau. I am a person of te Tiriti o Waitangi. I desperately wanted the health reforms to address the recommendations of the Waitangi Tribunal WAI2575 front and centre. Our health outcomes data shows the existing legislation, policy and structures have largely failed Māori. Something had to change.
“I was hoping for a te Tiriti-compliant Māori-led health system, Māori-led health governance and clear commitments to increased investment in Māori health. I am hopeful for the Māori health authority, but I want to know it will be resourced well and be able to exercise tino rangatiratanga. The success of the authority is a life-and-death matter. District health boards and primary health organisations have not delivered the public and population health gains we hoped for. Minimising duplication of services is strategic and overdue.
“I hope we are entering into an era where the art and science of public health is central, and the era of the for-profit clinician is fading. Covid-19 has shown we need to invest in public health infrastructure. We need public health thinking about keeping people well; at every level of the health system. This will extend the lives of New Zealanders, improve quality of life, and save us millions of dollars in health care costs.”
No conflict of interest declared.
Pacific health
Dr Debbie Ryan, Principal, Pacific Perspectives, comments:
“The opportunity for a system reset is welcome. The change acknowledges that a system that has had a focus on regional and local action has been less effective at addressing national issues. This is shown in persisting and worsening disparities in health and service outcomes for smaller populations, including Pacific, across a range of indicators, such as long term conditions and child health, despite 20 years of policy commitment to equity, closing the gaps and health for all New Zealanders.
“The differential impact of COVID-19 on Pacific communities during the past 12 months, the measles epidemic of 2019 and the persisting rates of rheumatic fever in Pacific children highlight a health system where ‘we are not all in this together’. This needs to be acknowledged as a fundamental starting point for change. High level strategies and policy commitment have not been sufficient to improve Pacific health. Pacific communities remain engaged in working with the health sector to achieve health and wellbeing for our families, despite the repeated failure of implementation of poorly-designed programmes, which have not included understanding of patient experience or adequately monitored and evaluated performance.
“The COVID-19 response has shown how an end-to-end approach that included Pacific leadership at a political and policy level, Pacific expertise and analysis of data to support decision making and the mobilisation of Pacific providers to work with Pacific communities can overcome barriers to access and ensure that those who are most in need get the care they require.
“I strongly support action to address Māori health and the commitment to Te Tiriti o Waitangi. I hope that the system changes will demonstrate a commitment to addressing inequities in health and service outcomes for Pacific whānau.”
No conflict of interest declared.
Public health
Professor Michael Baker, Professor of Public Health, University of Otago, Wellington, comments:
“I very much welcome this health sector reform which has much potential to improve public health in Aotearoa New Zealand. The establishment of a dedicated national Public Health Agency is particularly welcomed, as is the creation of a coordinated national public health service, and a Māori Health Authority.
“Public health has suffered from years of fragmentation and erosion of its core capacities. We are facing huge health, equity and sustainability challenges. The country was poorly prepared for the Covid-19 pandemic. Transformational change is needed.
“Many of us will look at these reforms through the ‘Covid-19 lens’ of how these reforms would support better preparedness for outbreaks and pandemics, and improved detection and management of such events. A second test is whether this model can deliver the changes needed to reduce the huge burden of long-term conditions such as diabetes and smoking-related diseases. A third key test is the need to take vigorous action to improve health equity, particularly improved outcomes for Māori.
“This health reform has potential to meet these health challenges but its success will depend on implementation and resources. As we have seen with the Covid-19 response, a key need is to build sufficient public health infrastructure to meet current and predicted needs. One example is the requirement to attract and retain a sufficient critical mass of public health science expertise so that New Zealand can keep ahead of pandemics and other global health threats.
“These new public health structures will also need sufficient critical mass and mandate to influence key health determinants such as housing, social welfare, and tax policy. They will need to be able to affect actions by other organisations such as the Ministry of Primary Industries to improve problems like campylobacter contamination of fresh chicken, which is causing an unacceptably high burden of illness and deaths in New Zealand.
“Some key bottom-line public health requirements should be enshrined in law. Key examples would include regular comprehensive reporting on the health of the nation and mandated review of government policy and legislative proposals from a health and equity perspective.
“I would personally have favoured a more independent stand-alone public health agency combined with the national public health service and health promotion agency to provide a strong voice for public health across Aotearoa New Zealand. However, these reforms go a long way to achieving that need.
“Myself and colleagues have been advocating, based on evidence, for a dedicated public health agency for several years to support improved response to events like the 2016 Havelock North waterborne campylobacteriosis outbreak and the 2019 measles epidemic, and also to support a more effective Covid-19 response.”
No conflict of interest.
Associate Professor Arindam Basu, School of Health Sciences, Education, Health & Human Development, University of Canterbury, comments:
“This is a significant overhaul of the governance architecture of our health system. In particular, abolishing DHBs to establish a unified NHS-UK style centralised system, with parallel arms for Māori health and public health systems, may have important implications for costs.
“In an overhaul of this magnitude, any comment now is premature in terms of the eventual overall performance of the health system – in terms of costs to care, access to care, and quality of care. However, there are opportunities and challenges worth considering.
“On the opportunity side, the administration is simplified by doing away with 20 different organisational elements – the abolition of DHBs – but such centralisation also carries with it the potential to become a complex monolith, and risks losing the efficiency that each individual unit might provide in a federated system.
“I greatly appreciate this change has been made while keeping in mind the perspectives of the providers (the doctors and the caregivers) and the patients. Hence, with this change I believe access to care will be significantly improved for everyone.
“The establishment of the Māori Health Authority is definitely a welcome move as such a structure will help to mitigate the existing inequitable access to care for Māori.
“Equally, the newly created National Public Health Authority replacing the current 12 Public Health Units is likely to improve the coordination of the services. In particular, for the current and future pandemics, such a structure will make backward and forward contact tracing very efficient.
“Overall, as a public health researcher/academic, I welcome this move, and look forward to it. Having said that, how the cost to care will play out for payers and patients is a space to watch.”
No conflict of interest.
Disability
Kate Waterworth, post-graduate lecturer in Critical Disability Studies, AUT University, comments:
“This announcement has a welcome emphasis on Te Tiriti o Waitangi, on hauora Māori, and on equity.
“A number of aspects of the announcement are pleasing, including the emphasis on equity and access issues, attention to seeking views of communities and iwi, and acknowledgement of significant issues with health system performance in offering healthcare services that work for Māori, Pacific, Disability and Rainbow communities.
“This announcement does make reference to the issues that disabled people experience as health system users. At this point, however, any specific response to disability issues is deferred until September 2021. Disabled people have traditionally been neglected as a focus of political attention. Minister Little refers to an outcome of this neglect – that there is poor data held nationally about disabled people’s experiences and outcomes of healthcare service use. This lack of visibility appears to have delayed important decision making in this space. Minister Little also acknowledges that disability is not just a health issue, rather is a complex experience that spans social areas (that include education, welfare, transport etc). Health itself can also be considered more broadly as being able to live a good life and when further information is released in September I would hope that the interactions and influences of health and the health system with broader social systems will also be explored.
“Broader aspects of these reforms, if well managed, may have significant positive benefit for the disabled community – Māori are more likely to experience long-term health conditions or disability and so the establishment of a Māori health authority, with decision making powers and community influence may offer important opportunities for more suitable and effective services. Minister Little also mentioned placing value on the health and support workforce. A more valued workforce, including support workers, is more likely to be able to work effectively in partnership with patients and their family/ whānau.
“I look forward to hearing Minister Little’s announcement in September to hear his specific response to disability issues within the health system. I hope that this will address issues of access and quality of health service delivery, of health outcomes (including life expectancy) and of the complex interactions between the experience of disability and broader social and political systems. Each member of the disability community has the right to experience good health and access to health care services. At present this is sorely lacking – for example men with intellectual disability have a life expectancy of approximately 20 years less than men without. This is stark and shocking and must change. I hope further reforms will facilitate this. This will require bold decisions in September.”
No conflict of interest declared.
Rural health
Dr Carol Atmore, Head of Department, Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, comments:
“The creation of localities as the unit of health service delivery across NZ has enormous potential to increase local input into how health services are provided in all communities. This is potentially a game changer for smaller rural communities.
“As with all these things, the devil will be in the detail. How will localities be defined, and by whom? Who will lead them? How will the final locality plans be developed? How will the Health NZ and Māori Health Authority commission services to meet the locality plans? Once these things become clear then the opportunities and fish hooks will become clearer.
“The health system is perfectly designed to produce what we currently have, and what we currently have doesn’t meet the needs of Māori in Aotearoa NZ, or of many rural communities. So I’m optimistic about the potential the new system can bring, but there is a lot of work to be done to bring it to life. The issue of primary care funding needing to be increased has not been addressed yet, and this will be a key part of getting the future system right as well.”
Conflict of interest statement: Practicing General Practitioner in Dunedin, Fellow of Royal NZ College of GPs