GUEST BLOG: Ian Powell – The New Zealand Health Charter – worthy or satirical?

What should we make of a document that is “worthy”? Worthy means having adequate or great merit, character or value. In the context of a document, it may mean deserving of praise.

However, in the context of the health system, particularly one in which business consultants have been influential in its design, another word comes into play – satire. That is, the use of irony, sarcasm or ridicule to expose the document as being far from ideal, or worse.

Charters in health systems are not novel. They can also be global. The World Federation of Public Health Associations, for example has a global health charter which was developed with the World Health Organisation.

This global charter provides insights into the direction of public health and guidance for both ‘services’ (protection, prevention and promotion) and ‘functions’ (governance, advocacy, capacity and information).

Public health associations’ global health charter

However, this charter is about addressing the health status of populations rather than around the quality, comprehensiveness and accessibility of the diagnosis and treatment of patients.

The ‘New Zealand Health Charter: Wow!

So, will the New Zealand Health Charter – established under the Pae Ora (Healthy Futures) Act 2022 that now governs Aotearoa New Zealand’s health system – be worthy of acclaim or satire?

It is one of the main features of the Act introduced by Minister of Health Andrew Little. At least one health union (Association of Salaried Medical Specialists) has placed high hope on it being a gamechanger for a better health system.

Health charter one of the features of Andrew Little’s Pae Ora Act

Section 56 of the Act declares the Charter’s purpose is to support the achievement of the ‘health sector principles’ outlined in Section 7. With a particular emphasis on equity and (but not confined to) Māori, these principles include access to services; engagement to develop and deliver services and programmes; choice of quality services; and protecting and promoting people’s health and wellbeing. All highly laudable, although abstract.

Section 57 then goes on to affirm the Charter is a statement of the values, principles and behaviours that both Health New Zealand (Te Whatu Ora) and the Māori Health Authority (Te Aka Whai Ora), along with other health entities, are expected to demonstrate. Those working in the health system are similarly expected to demonstrate them, both collectively and individually.

The Act’s Section 57 states that Health New Zealand and the Māori Health Authority are responsible for facilitating the making of the Charter. They have engagement obligations with other health entities, organisations and workers involved in delivering publicly funded services, organisations they consider representative of the interests of workers who work in the health system (presumably health unions), and Māori health professional organisations.

The Charter comes into official being when, after this process, it is endorsed by the health minister. Section 58 of the Act requires it to be reviewed at least every five years by Te Whatu Ora and Te Aka Whai Ora.

Helen Clark’s old turf

It will not be Aotearoa’s first health charter. Back in the day – 14 December 1989, to be precise – a health minister by the name of Helen Clark officially announced a national health charter. This was the time of area health boards, which were relatively new organisations.

These boards marked a significant shift in healthcare provision able to cover both hospital and community care. In effect, they were precursors of district health boards, which came into being in 2001.

However, area health boards were soon replaced by a competitive business model-driven health system under the National government elected less than 12 months later.

But this 1989 charter gives an indication of what a charter might look like, even if worded much differently to represent the health system 33 years later. It begins with an objective as a charter should.

This objective was to “…maintain a nationwide public health system with the overall goal of protecting and improving the health of New Zealanders”. It meant that the provision of essential healthcare should be “universally acceptable” (rather odd wording today but made sense for the time).

Next, the Clark charter went to principles, including respect for individual dignity, equity of access, community involvement, disease prevention and health promotion, and effective resources use. All commendable and an advance on the system that preceded area health boards.

Finally, there were a series of healthcare goals, including a strong population health focus. They included:

• reducing smoking;
• improving nutrition;
• reducing alcohol consumption;
• reducing preventable deaths and disabilities from motor vehicle crashes;
• reducing the prevalence of high blood pressure;
• reducing hearing loss among under five-year olds;
• reducing avoidable illness and death from heart disease and stroke;
• reducing both the incidence of invasive cervical cancer and the cervical cancer death rate; and
• reducing the skin cancer incidence and mortality rate.

All commendable, with a noticeable emphasis on prevention and protection (population health) rather than treatment (personal health). Unfortunately, after 1990, area health boards were focused on preparing for their abolition, which occurred on 1 July 1993.

There was no opportunity to assess the charter’s effectiveness. While it is impossible to know, it is reasonable to assume the extent to which it might have been operationalised is arguably the extent to which the health system might have been in a much better space than it is now.

Contrasting 2022 with 1989

What does this mean for the Health Charter under the Pae Ora Act? The years 1989 and 2022 could not be more different times.

On the one hand, surgery has become much less invasive, allowing shorter hospital stays for planned surgery; treatments have dramatically improved with new medicines; emergency medical specialists have become the cornerstone of emergency departments; and general practice has achieved specialist status through vocational registration.

On the other hand, social determinants of health, such as low incomes, poverty and unhealthy housing, have worsened thereby increasing the demand for, and cost of, healthcare. Successive governments have neglected the wellbeing of the health workforce to the extent of creating severe shortages that have left it reeling in a state somewhere between crisis and carnage.

The culture and design of the health system is also fundamentally different. In 1989, it was recognised that a level of statutory decision-making should reside locally where the large majority of healthcare delivery occurred. Business consultants had minimal involvement in the design of area health boards (as was also the case with DHBs).

Now we have a health system with a vertical structure and significantly increased centralisation. Decision-making is more top-down and, with the abolition of DHBs, further removed from the point of delivery. Further, in contrast with the 1980s and early 2000s, business consultants were instrumental in the design and the decision-making culture of the new system.

Embed with workforce and integration

For a health charter to be meaningful for 2022 and beyond, it needs to have embedded recognition of the centrality of the health professional workforce to the quality and accessibility of the health system.

This workforce is the dominant source of innovation and continuous improvement. It needs to be empowered. But this is obstructed by worsening severe shortages.

To be meaningful, a health charter today needs also to embed the importance of enhancing the integration of the patient journey between community and hospital care. The more this is done, the better the health of the population and the less the pressure on the health system. It also means improving the cost-effectiveness of the health system.

However, in what we have seen to date of the design of the new health system and its leadership culture, these are the least likely things to either appear or have prominence in the forthcoming charter.

Consequently, the most likely description for it will be a satirical one. If I am wrong, I will eat my keyboard (metaphorically, that is).

[This is an amended version of my column published in NZ Doctor on 12 October 2022]

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