I’m Sorry I Haven’t a Clue is a famous BBC radio and television show, billed as the antidote to panel games and launched in 1972. A parody of panel shows, it features two teams of two comedians each being given “silly things to do” by a compere.
The show is still going strong, and is now being replicated in the restructure of primary and community care in Aotearoa New Zealand.
This restructure is part of the Government’s wider restructuring of the health system including the abolition of district health boards (DHBs) which are the statutory points of connection between central government and the local design, configuration and delivery of health services.
Objectives and functions of Pae Ora Bill
The Pae Ora (Healthier Futures) Bill presents very different objectives and functions for primary and community care than does the current New Zealand Public Health and Disability Act 2000 it is replacing on 1 July.
DHBs will be replaced by a new national monolith, Health New Zealand (HNZ), which will have greater legislative discretion for exercising authority than the DHBs and Ministry of Health presently have. The health ministry will continue but in a much reduced role.
The requirement for integrating health services between primary and hospital care is removed, and direction is transferred to a significant degree from legislation to Health NZ (and, to a lesser extent, to the Māori Health Authority).
DHBs work under specific legislative directions, including to promote the integration of health services from community to hospital. There is no equivalent of this in the bill. Collaboration between DHBs and preschools and schools, for health promotion and disease prevention, also has no equivalent in the Pae Ora bill.
Health NZ’s laudable objectives, but…
Whereas DHBs have 12 legislated objectives, Health NZ will have three. These can be summarised as:
- designing, arranging and delivering services
- encouraging and maintaining participation in health improvement and service planning, and
- promoting health and preventing, reducing and delaying ill health, including a collaborative focus to address determinants of health.
These are laudable, but equally important is what is not there. This includes new supposedly pivotal ‘localities’ that are to have a direct relationship with primary care. Currently DHBs working through primary care organisations have this direct relationship.
DHBs are statutory bodies with all the importance that this status brings. DHBs are central to the current act. In contrast, the new localities will not have the same statutory status. Further, in the replacement bill, they are not even referred to in Health NZ’s 17 functions (although HNZ will be required to “develop and implement locality plans”).
There are three underlying fundamental faults of the Labour government’s approach to its health restructuring:
- Misplaced belief that structural more than culture change can drive health system improvement.
- Failure to comprehend the critical role of statutory points of connection (ie, DHBs) between central government and local healthcare provision.
- Unhealthy reliance of external business consultants as its advisors even though much more expertise resides within the health system. This is most pronounced in the government transition unit whose director is EY business consultancy senior partner Stephen McKernan.
The net effect is a series of consequential failures, a big one of which is the development of ‘localities’ which are supposed to be a pivot for primary care, largely delivered by general practitioners.
The new localities
Localities and locality planning were proposed by the Health and Disability System Review Panel, chaired by former political operative Heather Simpson. But this was in the context of a smaller number of DHBs continuing and providing local support, including resourcing and population-needs analysis.
Heather Simpson’s review advocated localities supported by DHBs
EY senior partner and government transition unit director advocates localities without DHB support
To get some insight into the aspiration held of localities now, one has to go to the explanatory statement before, but not part of, the Bill. It states that:
New Zealand will establish localities to plan and commission primary and community health services effectively and engage with communities at the appropriate level. This will reduce system complexity and enable consistency, a population health focus, and meaningful community and consumer participation in the planning, delivery, and monitoring of health services.
Localities are to have a much lower status in primary and other community care than DHBs presently have. Localities will be based in geographic areas determined by Health NZ for the “purpose of arranging services” in primary and community care. They will be required to have locality plans, but these will be developed by Health NZ rather than the locality.
The plans are to set out, for at least three consecutive financial years, the locality’s “priority outcomes and services”. Although there are consultative obligations, including with communities in the locality, it is Health NZ that does this rather than the locality.
The Transition Unit, led by EY senior partner Stephen McKernan, last month issued an update describing a locality as “essentially a place-based approach to improving the health of populations, as well as a mechanism for organising health and social services to meet the needs identified by whānau, community and mana whenua”.
However, this implied bottom-up enabling runs into conflict with the top-down direction of the new governing legislation through HNZ, which is where the real power resides.
Eighty localities will cover the country, the first nine being Ōtara/Papatoetoe, Hauraki, Eastern Bay of Plenty, Taupō/Tūrangi, Wairoa, Whanganui, Horowhenua, Porirua and West Coast. The complete rollout is intended to take two years.
Localities appear likely to comprise about 30,000 to 50,000 people. This is the population of a number of smaller DHBs up to the size of Whanganui at least. These residents will see their current decision-making rights transferred to Health NZ, leaving them relegated to consultation at best.
MidCentral DHB Chief Executive Kathryn Cook helped develop DHB supported localities working as networks predating Simpson review
Horowhenua, currently part of MidCentral DHB, is interesting. Under its about-to-depart chief executive Kathryn Cook, MidCentral was proactively into localities for primary and community care well before they became a glimmer in the eyes of the Simpson review.
In fact, the way Simpson’s review was written suggests that MidCentral’s localities were the model for what it was recommending.
DHB support will be gone
MidCentral’s localities, of which Horowhenua was one, functioned more as networks than as formalised structures. They comprise, along with the DHB, a range of non-government organisations including iwi, community groups and general practices.
These localities work on a relational rather than contractual basis in order to ensure participants’ transaction costs are low. This is made possible by the resourcing support, including staff, provided by the DHB.
The abolition of DHBs will mean in effect splitting MidCentral in half, between hospital and community healthcare, and changing the accountability relationship of its localities to a more distant and centralised Health NZ.
West Coast is another DHB split in half, with its community and primary care becoming a locality. But primary care is significantly integrated with general practice on the Coast. Owing to recruitment and retention problems on the Coast, its DHB stepped in to directly employ GPs.
Despite ups and downs, this close relationship between general practice and hospital care has been a positive. To begin with In it saved primary care on the West Coast. This close relationship is reinforced by the expansion of rural hospital medicine specialists who come from a grounding in general practice.
As it stands now, this West Coast integrated whole will be split in two, without an understanding of how the line between hospital and community will be drawn.
General practices will be working as part of localities. All we can say at the moment about them is they are going to be very late in establishment and will probably be like local networks, distantly determined and controlled by Health NZ.
Yet another problem (if there wasn’t enough)
But there is another problem. The Bill provides for localities to be established and controlled by Health NZ through its regional offices. The intention back in April last year was that there would be four, presumably in Auckland, Hamilton, Wellington and Christchurch.
But around three weeks ago serious opposition was raised by the Māori Health Authority (supported by HNZ) about the difficulty of effectively performing its functions locally with such a low number as four. Eight appears to be alternative number suggested.
Within a very limited context there is understandable merit in this opposition. But it has been strongly resisted by the Transition Unit’s (and EY’s) Stephen McKernan. In a wider context and with help from Blackadder’s Baldrick, this development is discussed further in my previous Otaihanga Second Opinion post: A health restructuring transition without a transition plan.
The net effect: I’m sorry I haven’t a clue
The net effect is that with the new health system only a month and a half away, those responsible for ensuring that the system does what it is supposed to in providing healthcare don’t know who they will be accountable to and where they will be.
If a member of the public or GP were to try to knock on the door of a locality on or after 1 July, they would either find nothing on the other side of the door or no door at all. So what does this and other failings mean this directionless context which will continue well beyond July?
If the movers and shakers of this restructuring haven’t got a clue, then other than parody in action, I’m sorry but neither do I . All I can see is a leadership vacuum creating further uncertainty for those responsible for the provision of healthcare services plus control from a far greater distance and knowledge base than now.
[This is a revised version of the author’s column published by NZ Doctor on 9 May]
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