On 23 February I had a lengthy article on the Heather Simpson review of New Zealand’s health and disability system published online by the Democracy Project.
The essence of my article was that the Simpson review’s proposed major overhaul of our health system’s structures (district health boards and nationally) guaranteed that the two main weaknesses it identified would not be fixed; arguably worsened. Specifically, social inequities would not be reduced and increased national cohesiveness would become top-down centralised bureaucratic decision-making stiffing local innovation and needs. This recommended massive structural overhaul is both a big threat to New Zealand’s public health system and high political risk.
Instead I advocated that the Government should put structural change to one-side (experience shows that restructuring doesn’t improve health systems) and instead focus on potentially positive process improvements likely to lead to improved and sustainable cultural or relational transformational change that were also identified by the Simpson review – locality planning (most likely in local government boundaries such as the Kapiti Coast) and a national health plan (largely hospital services).
Locality planning and national health plan
Locality planning would help address the social determinants of health (poor housing for example) that are external to the health system but significant drivers of illness and costs. It could also identify specific unmet health need in communities (a conservative estimate is 9% of the population) and how those affected might best access diagnosis or treatment.
But this requires DHBs to know their populations well. Dismantling the existing 20 DHBs and replacing them with a much smaller number of distant larger city based ‘mega’ DHBs will make this task much more difficult.
The same requirement of DHBs to know their populations well also applies to the recommended national health plan which would largely be about what, how and where public hospital services should be provided, from Lakes District Hospital in Southern DHB to Auckland City Hospital in Auckland DHB.
Northland DHB is much more likely to understand the services that should be provided at Whangarei Hospital than a ‘mega’ DHB based in Auckland. The risk of simplistic and ill-informed desktop decisions being made that reduce or remove hospital services outside our larger cities would be high.
Creating a new national bureaucracy instead of reforming the existing one
My article discussed the Simpson review’s recommended creation of a new national health bureaucracy to be responsible for the funding and provision of health services. The Government’s position appears to be fixed despite the Simpson review’s justification for its recommendation being not well argued and based, in part, on incorrect international examples.
It would be sensible to instead first consider whether the capabilities necessary to perform these functions might be better located in the existing Ministry of Health. This would have the advantage of being more integrated into other health decision-making and less costly.
But the Government is uninterested in considering this. It has formed a negative view of the Ministry. This is understandable and predates the current Ministry leadership but some failings on the operational side of the overall successful response to Covid-19 have reinforced this negativity. Nevertheless an open mind is called for.
Indications of Government listening
On the positive side there are indications that the Government is now seriously rethinking creating a small number of ‘mega’ DHBs. This is a recent significant political development. I would like to think that it has accepted the points made in my Democracy Project article last week!!
Certainly there have been a number of informal messages to Government from those it respects that structural change doesn’t drive health system improvement. There have also been friendly messages warning of how disruptive and de-stabilising such large-scale restructuring would be to the health system.
But there is a compelling alternative or supplementary argument against running with this Simpson review recommendation. It’s called political risk. If one drives or walks through the middle of Whangarei you will see a digital billboard saying every two minutes “Save Our DHBs”. The sign belongs to National Party deputy leader, health spokesperson and medical practitioner Dr Shane Reti.
Imagine similar signs in all those electorates in our smaller to medium cities and rural towns. Suddenly the political risk to the Labour Party in the next election in 2023 becomes acute. Then imagine if Dr Reti and his colleagues were to add the following words to their digital and other billboards – “and save our hospitals”!
Ian Powell was Executive Director of the Association of Salaried Medical Specialists, the professional union representing senior doctors and dentists in New Zealand, for over 30 years, until December 2019. He is now a health systems, labour market, and political commentator living in the small river estuary community of Otaihanga (the place by the tide). First published at Otaihanga Second Opinion.