Health and disability sector review – Expert Reaction

Our health sector is overly complicated and fragmented, according to a panel charged with reviewing the way healthcare works in New Zealand.

The Health and Disability System Review Panel today released its interim report, having delivered it to the Minister of Health last week.

The Panel’s broad view is intended to encompass issues of culture, structure, strategy, procurement, governance, and the Treaty of Waitangi. Recommendations will be made in the Panel’s final report, due by 30 March 2020.

The SMC gathered expert comments on the interim report, feel free to use these comments in your reporting. 

Dr Rhys Jones (Ngāti Kahungunu), Senior Lecturer, Te Kupenga Hauora Māori, University of Auckland, comments:

“First, by way of context, it’s important to note the absence of a Treaty-compliant approach in undertaking this review. The Expert Review Panel was not constituted in a way that prioritised expertise in Māori health and equity, and the review process did not reflect a genuine partnership approach. This is disappointing given that the purpose of the review was underpinned by a goal of achieving equity, and in view of the significant and unacceptable inequities in health outcomes for Māori (and Pacific) peoples.

“The report rightly notes that our public health system has failed to deliver on the guarantee of equitable health and wellbeing inherent in Te Tiriti o Waitangi. While detailed recommendations are not provided, key directions for the New Zealand health and disability sector are signalled. They include an expectation that the health system must ‘fully incorporate te Tiriti o Waitangi / the Treaty of Waitangi to provide a framework for meaningful and substantive relationships between iwi, Māori and the Crown’. The report also recognises that such a system must embed rangatiratanga and mana motuhake.

“However, these principles do not appear to extend to full decolonisation of the health and disability system. Rather, in terms of structure, governance, leadership and culture the panel appears to be indicating a modified version of the status quo. They note that the system needs to work in a collaborative, collective, and cooperative way, and that culture and attitudinal changes are needed. The Panel believes the system should be guided by ‘a clearly defined set of values and principles that appropriately reflects the diversity of cultures and Māori as tangata whenua’.

“What appears to be missing from the report is an unequivocal expectation of equity in the health and disability system. This is a critical omission. The report notes that normalisation and acceptance of inequalities in health for Māori are demonstrated by the health system’s failure to respond, despite overwhelming and consistent inequities in Māori health outcomes. Yet it does not articulate a clear expectation of equity in its key directions, and therefore implicitly perpetuates this normalisation and acceptance. If we are to achieve equity in health outcomes for Māori, that has to be a non-negotiable starting point across the entire system. From there, mechanisms are required to hold all health sector organisations to account for delivering equitable outcomes.

“The recommendations of the review also need to be much stronger in relation to addressing racism. It must be recognised that structural racism underpins the poorer health outcomes experienced by Māori, and also explains why the health system has failed to respond to this inequity. There needs to be a more explicit emphasis on dismantling racism at all levels, and every aspect of the proposed health system reforms must be fundamentally anti-racist and pro-equity.

“So while there are some positive changes signalled in this review, the report does not provide the direction that’s required to achieve equity for Māori. That direction involves full recognition of rights under Te Tiriti o Waitangi, fundamental and decolonial transformation of the health system, a non-negotiable expectation of equity, and ensuring that anti-racist, pro-equity measures are centralised in all aspects of the health and disability system.”

No conflict of interest.

Dr Anna Matheson, Senior Lecturer in Health Policy, School of Health, Victoria University of Wellington, comments:

“There are no surprises in the interim review. This is all stuff that we have known about for a long time and has also been highlighted in the recent Inquiry into Mental Health and Addiction. The review shows we are still struggling with how to effectively deliver services, programmes and interventions locally, to diverse communities, we still struggle with institutional racism and we have not done well in tackling the social determinants of health, such as liveable incomes and healthy housing.

“The review finds that the whole health system requires strengthening and better integration. Emphasising the importance of improving the speed, responsiveness and accountability of relationships between health system leaders, the workforce and communities.

“Approaches to integration such as whole-of-government and intersectoral action have been with us for a long time. But, not only have they failed to achieve their aims across government, they have for the most part, miserably failed in achieving long-term integration of services and programmes within communities. Likewise, devolution of service provision and decision-making to communities has frequently led to its devaluing.

“The review states that health system change will be difficult to achieve. The real difficulty here lies in the necessity for power to change hands. Leaders at all levels need to empowered and joined up, barriers to both individual and organisational collaboration need to be identified and removed, and more value needs to be placed on workforces who work locally with people in the context of their lives.”

No conflict of interest.

Professor Tony Dowell, Professor of Primary Health Care and General Practice, University of Otago, Wellington, comments:

“It’s important that constructive work has been undertaken and that a large number of submissions and themes have been incorporated. This is an appropriate assessment of some of the major challenges facing the sectors, and importantly a recognition that cross sector working is essential.

“There’s relatively modest acknowledgement of the work being done currently by the sector. I would like to see a more appreciative enquiry approach.

“There is recognition that social determinants are important, but little detail on how government strategies might or should interface with report recommendations and address major social problems.

“I support the call for changes in attitude and culture to be ‘led from the centre’. This will require resourcing and a clarification of what the centre means – e.g. Ministry of Health, district health boards, etc. Will there be changes in the MoH/DHB/PHO [Primary Health Organisation] nexus? And if not, why not? For the population size, the current system is unwieldy and confusing (and probably inefficient).

“A focus on population health is welcome, but there needs to be a recognition that firstly a lot of excellent work is already being done, particularly in primary care settings. I support a ‘continued focus on the basics’.

“I also support the need for clarity of mandate and accountability for Tier 1 services, but we need details as to how ‘fewer layers of accountability’ would be achieved. Current public health approaches need to incorporate systems science, complexity and appropriate implementation strategies.”

“I support the need for simplification of funding streams. Although I agree that a focus on teamwork is appropriate, I recognise the constructive work that has been done on interprofessional working within sectors, e.g. primary care. I would welcome more resourcing and clarity about intersectoral working.

“I welcome a focus on disability services.

“Regarding Tier 2 services – there’s a recognition that the hospital and specialist services should operate more cohesively. We will need detail of how that would be done within current structural settings.

“On the workforce – I question whether there is sufficient recognition of the rapidly changing workforce environment and adaptation that has already occurred, e.g. incorporation of changed nursing roles, new behavioural and navigator roles. I support the call for the workforce to include those with ‘mental health conditions’ and disabled.

“There’s recognition of the potential benefits in harnessing future technologies e.g. digital. The panel will need to be detailed in its recommendations as to how much it wants to have a strategic approach to digital or allow a multiplicity of independent initiatives to develop.

“There are helpful sections in the report describing challenges in particular sector areas such as Maternity care. It is important that there are clear recommendations as to how any structural change might be supported, and in particular how integration with other primary care services will be achieved.”

No conflict of interest.