My last Otaihanga Second Opinion post (8 December: link at end of this post) was the first of a two-part blog series based on an address I gave in November to Kapiti U3A (Third Age).
The subject of my address was deliberately provocative – How did our health system get into this poop and how might it get out? The first post discussed how it got the poop while this post discusses how it might get out of it.
Before looking at getting the health system out of the poop we first must establish what should not be done.
A magic bullet didn’t assassinate President Kennedy in 1963; nor will it get our health system out of the poop
Restructuring the recently restructured system (in 2022) is not the way to go. There is no magic bullet and certainly not a structural one.
Given the tumultuous chaos the health workforce has already been put through, it doesn’t deserve to suffer more destabilisation.
Aligning legislation with health moralities
Instead, what is needed is a shift to a culture that is engagement based, empowering and relational.
Health moralities need to be aligned
In order to function effectively, health systems require two aligned ‘moralities’ – internal and external.
Internal moralities reside within the ethos of its workforce reinforced by their professional colleges and associations. This is a rich strength that health systems benefit from.
External moralities define the overall parameters, including distinguishing characteristics, of health systems, beginning with legislation. The Health and Disability Commissioner Act, including its requirement for informed consent, is a case in point.
Legislation governing how the health system should be structured and why is a critical external morality. The starting point is an act’s purpose clause.
Pae Ora Act’s purpose clause nebulous and misplaced
The Pae Ora (Healthy Futures) Act 2022 was the legislation that radically restructured the public health system through vertical centralisation. Its purpose clause is characterised by brevity, nebulousness and misplaced focus.
The purpose of the Act is to provide for the public funding and provision of services in order to:
- protect, promote, and improve the health of all New Zealanders; and
- achieve equity in health outcomes among New Zealand’s population groups, including by striving to eliminate health disparities, in particular for Māori; and
- build towards pae ora (healthy futures) for all New Zealanders.
The first purpose is uncontestably correct and uncontestably vague on its own. Similarly, so is the third purpose with its apparent tilt towards population health.
It is the second purpose which has serious credibility issues. Health inequities and disparities are overwhelmingly driven by social determinants of health such as low incomes, poor housing, limited educational opportunities, social and community contexts, and healthcare access.
While “striving to eliminate” health inequities and disparities comprise one third of the Act’s overall purpose, these social determinants are overwhelmingly outside the control of the health system.
Eliminating them requires government actions; legislation and policies. Health systems can mitigate social determinants.
This was the case with the successful clinically developed and led health pathways between community and hospital health care under the former Canterbury District Health Board in areas such as acute health demand and Māori.
But health systems can’t eliminate social determinants driven inequities and disparities. Unfortunately, the Pae Ora Act’s purpose clause encourages an expectation that it can.
How might the Pae Ora Act purpose clause improve health system external moralities
Consequently, in order to improve the external moralities of our health system, the purpose clause of the Pae Ora Act should be amended to include the following:
- Mitigation rather than elimination of health inequities and disparities.
- Explicit recognition of role of social determinants of health on health status, inequity and disparity. This includes recognition of the importance of population health in the context of prevention.
- Placing at a systems level adherence to healthcare provision being patient-centred.
- Integration between care in communities and care in hospitals, including clinically led and developed pathways between them.
- The culture within Health New Zealand (Te Whatu Ora) to be relational based on engagement with and empowerment of its health professional workforce.
- Emphasis on Te Whatu Ora’s role to provide national cohesion rather control of healthcare provided locally.
- Explicit responsibility of Te Whatu Ora for the wellbeing of its workforce.
Patient-centred care
In the context of a more relevant purpose clause, the starting point for the above-mentioned cultural shift required to start to get the health system out of the poop should be by putting the patient first through what is known as ‘patient-centred care’.
Patient-centred care should be the yardstick for health system decision-making
Health professionals are familiar with this term but usually in the context of treating the individual patient in front of them.
Patient-centred care should also be given a systems purpose, making it the yardstick of decision-making.
Every non-clinical decision, before proceeding further, should be assessed on whether it advances or hinders patient-centred care.
Restore subsidiarity into health system decision-making culture
Incorporating the principle of subsidiarity in the culture of the health system goes to the heart of ensuring patient-centred care.
Subsidiarity principle should be restored
This democratic principle underpinned our universal health system from its establishment under the Social Security Act 1938 to its abolition under the Pae Ora Act 2022.
Most healthcare innovation, service design, configuration, and delivery is done locally by health professionals. Good clinical sense also makes good financial sense.
An increased level of greater local decision-making is important for continuous quality improvement. It is the core of sustainable systems improvement.
Consequently the subsidiarity principle should be incorporated into Health New Zealand’s culture, including its strategic and operational functioning.
Integrated care
The passing of the Pae Ora Act meant a loss of the legislative requirement for integrated care between community and hospital. This was to the detriment of patient-centred care.
Focussing horizontally between care in communities and care in hospitals significantly improves patients’ access to and the quality of their healthcare.
It also plays a significant role in constraining acute hospital admissions (keeping people out of hospital).
Health pathways pioneered integration between community and hospital healthcare
The internationally recognised pioneering work of the former Canterbury DHB in developing health pathways between community and hospital based care is instructive.
It demonstrated that horizontal integration is where the most significant healthcare improvements can be made from within the health system.
This success included mitigating some of the impacts of the external social determinants of health such as by bending the curve of rising acute hospital admissions.
Health workforce leadership
Culture is the most decisive driver of system effectiveness. Patient-centred care can’t be achieved without the right culture.
Health professionals provide best leadership for health system improvement
No sector in New Zealand has such a large concentrated critical mass of intellectual capital. It is the best resource Te Whatu Ora has to draw upon. Those who do the job know best how to improve it.
It should therefore ensure that decision-making is distributed as close to the workplace as practically possible.
This involves workforce empowerment, including what is known as ‘distributed clinical leadership’ (as distinct from formal clinical leadership positions).
Workforce shortages
Top priority needs to be given to address the severe workforce shortages crisis. Health New Zealand has a formal workforce strategy whose vagueness defines it as the kind of strategy you have when you are not having a strategy.
Lack of strategic planning to address workforce shortages a major failing of health system leadership
In the past and for good reason there has been a stronger emphasis on retention than recruitment.
There is a relationship between the two; stronger retention benefits recruitment when natural attrition occurs.
But this has changed since salary increases were severely constrained from the 2010s, not by DHBs, but by both National and Labour-led governments. This is compounded by the aging of the workforce.
Workforce fatigue (and burnout) the logical outcome of absence of recruitment strategies
There is not a single labour market in Te Whatu Ora’s health professional workforce. They vary from medical specialists to nurses to (and between) the numerous critical allied health professional groups.
The reality is that, depending on the occupational group, Health New Zealand has to compete domestically in a wider private labour market (such as scientists) or internationally in an Australian labour market (especially in the case of medical specialists compounded by their significantly longer and similar training requirements).
Consequently, it needs to engage directly with the applicable unions to develop recruitment strategies targeted at the specific occupational groups and their different labour markets.
External social determinants of health
As discussed earlier external social determinants of health, the biggest of which is low incomes.
Social determinants of health are the biggest driver of health demand (including acute demand) and cost
They are the biggest driver of health demand and cost. Health consequences include increasing chronic illnesses and acute hospital admissions.
From the early 2010s more and more the operational accounts of DHBs were in deficit. By the time of their abolition in 2022 all were in deficit.
Rising acute hospital demand most consistent driver of health demand
The most consistent factor behind these deficits was acute hospital demand (as measured by discharges) increasing at a higher rate than population growth.
Te Whatu Ora can’t resolve the causes of these social determinants of health. But it does need to recognise and act on the importance of mitigating them.
It should also advocate for government to make the necessary policies and legislative changes to eliminate them. Neither Health New Zealand nor the Health Ministry can do the latter.
Devolving decision-making within Te Whatu Ora
The regions and districts within Te Whatu Ora should be empowered to make decisions relevant to the design and provision of local hospital and community services.
Former health minister Shane Reti understood importance of devolving decision-making but minimal progress since he lost the portfolio
Drop the top-down control and command culture inherent in vertical centralisation and go relational.
This should be drilled down further by its regions and districts being empowered to have a proactive engagement culture with its health professionals.
As part of this devolving is recognition that the greatest relevant experience and expertise over how to improve hospital and community health services rests with this workforce.
Engagement culture critical to health system getting out of the poop
We need an engagement culture that empowers the workforce to be in the engine-room of decision-making.
This devolved engagement culture would better enable improved healthcare within hospitals, between hospitals, within communities, and between communities and hospitals. Collaborative networks are a critical part of this.
Local government
The Local Government Act 2002 requires local government (city and district councils) to improve community wellbeing. Accessible and comprehensive quality healthcare is integral to wellbeing.
Even if wellbeing wasn’t explicitly referred to in the Act, it is implicitly the reality of what councils must do regardless. Councils are also already responsible for public health matters such as water sanitation and food safety.
Councils need to enhance their role by providing a statutory voice for the health status needs of their populations. Several are already doing this.
What would Mark Twain say?
New Zealand now has a system largely devised by business consultants were also the main beneficiaries. But insufficient work was done in advance on how the new system might work.
Lester Levy hasn’t provided anywhere near the leadership necessary to get out of the poop
Health New Zealand was left to build a plane while flying it or build a house without an architect’s plan and building consent.
Lester Levy’s leadership both as Commissioner and Chair has not advanced its ability to complete the building of the plane (or house).
The tragedy of the latest ‘health reforms’ is not just that they threw the baby out with the bathwater.
They also threw the bath out. If our health system is to be protected and enhanced, the baby at least needs to be retrieved.
When in the poop look to Mark Twain for insight
It is depressing. However, I would like to share something my father once said to me not long before he died.
First, if you come up with an idea or turn of phrase that you want to impress people with, say Mark Twain said it. His rationale was that no one would ever know. He got that right!
Add a drop of whiskey when the glass is half empty
Second, when things seem bad, say that Mark Twain once said that while the glass is almost always half full rather than half empty, if in doubt put a small drop of whiskey in it.
But Mark Twain would have also added another pearl of wisdom: listen to prominent American psychiatrist ‘Samuel Shem’ (a pseudonym). He said, “If you don’t take the temperature, you can’t find a fever.”
Changing the health system’s culture to engagement, empowerment and relational enables it to take the temperature first as the starting point for it getting out of the poop.
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.
Any health or educational program aimed at equalizing average outcomes across different demographics is fatally flawed. This can easily be shown with a simple thought experiment. Imagine (for example) that Maori rates of obesity are reduced by 10% over the next 5 years, and that non-Maori rates of obesity are also reduced by 10 %. Surely this is a great result! But not if our objective is “equity”, because the “inequity” has not been reduced. Programs fixated on “equity” introduce a perverse incentive to NOT improve outcomes for non-Maori. Yet obesity is by no means exclusively a Maori problem.
Your ideas sound good, although I would like to see extra income from the unhealthy choices that people make (alcohol, tobacco, sugar, etc.), also put into the health system. I don’t know how realistic it is to raise tobacco taxes without causing other problems, and I wouldn’t want to trigger significant cost-of-living increases, so I wouldn’t target essential items. There will be differences over what we think is essential, so I would want science, not people’s feelings, to be the primary method of decision-making.