Health system reform – Expert Reaction

The government has committed to reforming our “complex and fragmented” health system after a long-awaited review proposed a major shake-up.

The Health and Disability System Review, chaired by Heather Simpson, recommends halving the number of District Health Boards and ending elections for DHB members. It also proposes a new Crown Entity, Health NZ, to focus on finances and operational work, as well as a Māori health authority.

The SMC asked experts to comment on the report.

Professor Robin Gauld, Director, Centre for Health Systems and Technology, University of Otago, comments:

“Most people want change now, not in 5 years. It would be better to enact changes straight after next election.

“The removal of elected board members was to be expected as the model has really not delivered. One question I have is why 8-12 DHBs? It would be better to rename these as ‘local health networks/services’ or something similar. What’s intended is a local integrated system, hence the suggestion to remove Primary Health Organisations. This is a good move to build vertical integration. DHBs have been very hospital focused and bring a legacy of underperformance and silo activity, and have worked separately from PHOs. It’s also not entirely clear how the DHBs will work more closely with one another, and we need to really break the silos. Governance also needs to be clearly agnostic of Tier 1 and 2, and independent. There is a high risk that we will still have considerable inequity across the country and problems with coordination.

“The proposed Health NZ is like the Health Funding Authority of late 1990s. This was a good model, but did not feature DHBs, just hospitals and managers. This would be preferred. The Simpson model potentially adds complications.

“A Māori Health Authority is a good move. We had proposals from iwi in the early 1990s for such, to work alongside the Regional Health Authorities then in place. This Māori Health Authority seems more constrained in terms of scope, which could be a concern.

“We need to sort out IT right now, not over time. Bringing in Air NZ’s team would be useful; they have also overseen complex system changes behind the scenes in order to bring services/schedules to customers via their app.

“What about GP fees/patient charges? For the new networks to work there should be a full capacity to have a provider team across the spectrum of care, free of charges. It’s time to think about full funding of GPs.”

No conflict of interest.

Dr Rhys Jones, Public Health Physician and Senior Lecturer, Te Kupenga Hauora Māori, University of Auckland, comments:

“The NZ health & disability system is racist to the core and complicit in (re)producing health inequities.

“Establishing a new Crown agency, reducing the number of DHBs, and creating a Māori health authority with limited powers is not going to change that.

“So it seems the review’s recommendations will fail to realise the transformation that’s needed to achieve equity in our health and disability system. This represents a failure to honour Te Tiriti and give full expression to Indigenous rights.

“This conclusion is supported by the presence of an ‘Alternative View’ on Māori commissioning, buried on page 173 of the report. (Note that this was authored by a majority of Panel members and all members of the Māori Equity Advisory Group).

“They argue that the review does not go far enough, that the proposed scope of the Māori Health Authority is too limited, and that the vision should be far more ambitious.”

No conflict of interest declared.

Kate Waterworth, Post-graduate lecturer in Critical Disability Studies, AUT University, comments:

“The Health and Disability System Review (Hauora Manaaki ki Aotearoa Whānui) recognises that the health and disability system as it currently operates in Aotearoa NZ is inequitable, fragmented and inconsistent. They describe personal stories of Māori and disabled people who have experienced poor healthcare service delivery and live with the consequences of that – in terms of their experiences of poor health and wellbeing – and recognise that such issues can be related to big picture issues such as institutional racism or poor co-ordination between and within healthcare delivery systems. The panel makes suggestions in terms of the organisation of DHBs as well as national funding and planning arrangements to attempt to address these long standing issues.

“In relation to their discussion of issues for disabled New Zealanders the panel has made recommendations directed at improving equity – through better understanding of issues and experiences of disabled people, through better processes for the provision and sharing of information, through improving access to disability support services and attention to funding mechanisms. They have also suggested that the system acts as a model to the rest of New Zealand by becoming a leading employer of disabled people in New Zealand. These recommendations are an important starting point for improving the healthcare experiences (and health outcomes) of disabled New Zealanders.

“It is however important that our entire health system becomes adept at facilitating access for disabled people (not just disability specific services) – for example that a woman with a spinal cord injury can easily access a mammography or that someone with an intellectual impairment experiencing an acute mental health event can receive care individualised to their needs and circumstances.

“The panel have recommended that their suggestions for overall health system change take account of population health and equity issues, and they noted that the current system is rooted in traditional understandings of ill-health and treatment. These traditional medical understandings have led to disability issues being relegated to the side-lines of our health systems. It is important for system change to include opportunities to shift broader understandings of disability as being part of the typical human experience in order for health care systems and providers to recognise their obligations to provide appropriate high quality services to all.”

No conflict of interest.

Associate Professor Tim Tenbensel, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, comments:

“This is basically a call to go back to the reforms introduced in the early 2000s – focusing on the health of populations, address inequities between Maori and non-Maori, and creating a broader vision and focus that goes beyond hospitals – but this time do them properly. The way to do this for the Report is  through more and better planning. This was also an emphasis of the 2000s reforms.

“While most stakeholders and commentators in the sector agree with these directions of travel, the Simpson Report has delivered recommendations that strengthen and expand the roles of DHBs in community-based services, while centralising some responsibilities for hospitals. There is also a clear view that elected members of DHBs is an idea whose time has passed.

“Based on the Simpson report and the Minister’s press conference, the key points of interest are:

  • Setting up two new agencies at the national level – Health NZ and a Maori Health Authority
  • Consolidation of DHBs from 20 to 8-12, and the removal of elections
  • Restructuring local primary health care (tier 1) services in a way that strengthens the role of DHBs, provides more scope and involvement for local NGOs, and is intended to weaken the dominance of general practice (primary medical care) in primary care

“The overall message is that accountability for driving the health system, and for health outcomes, lies with government, and not with non-government entities such as Primary Health Organisations (PHOs). Government agencies should have more control and room to manoeuvre to plan what services across the health and disability sector should look like at the local level. There is considerable faith that these organisations will be able to engage in longer term planning and to deliver on those plans.”

No conflict of interest.

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

“The focus on community and better responsiveness within the Health and Disability System Review is heartening. In 2008 the World Health Organisation’s Commission on the Social Determinants of Health reviewed the global evidence of what causes health and illness. It concluded that most of health and equity is created in the places we are born, live, work and play – our communities. It is pleasing that there is recognition of this evidence.

“The Review acknowledges the current health system is fragmented and still struggling with how to effectively deliver services, programmes and interventions locally, to diverse communities. We have still not addressed institutional racism, and we have not done well in tackling the social determinants of health, such as liveable incomes and healthy housing.

“It is however good to see culture change featuring prominently. Health organisations such as DHBs and hospitals are substantial assets to their communities which hold enormous potential to provide leadership and support for local collaboration and collective initiatives as well as role-model through their own behaviour, effective action on inequities and the environment.

“Whilst the recommendations in the Review are welcome reading, there remains a big risk that it is in their implementation where efforts will fall over. Our policy system has been dogged with systemic implementation failure in our past attempts to reorient the health system. Top-down initiatives and structures have so far failed to create or support real change within communities – despite intention.

“Action on the social determinants of health requires approaches that join up sectors, as well as join up communities. 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 failed in achieving long-term integration of services and programmes within communities. Likewise, devolution of service provision and decision-making to communities has so far most often led to its devaluing, rather than a strengthening of control and voice.

“Long-term concerted attention needs to continue to ensure that the top down changes called for in this Review have real benefits for the wellbeing of local communities. The real challenge in the implementation of the recommendations is that real power is going to need to change hands.

“Leaders at all levels (not just the top) 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 within the context of their lives.”

No conflict of interest.

Professor Jim Mann, Professor of Human Nutrition and Medicine, Department of Medicine, University of Otago, comments:

“I have not yet had time to read the report properly but the executive summary and a scan of the full report leave me extremely concerned about the status of public health.

“I note that the Director of Public Health would be able to report directly to the Minister and that is a positive move. But with the disestablishment of the Health Promotion Agency and the delegation of population health responsibilities to a range of bodies also responsible for clinical service, I fear for future action in relation to the prevention of non communicable disease.

“In the post Covid era there will clearly be emphasis on communicable disease but where does responsibility lie for obesity, diabetes, coronary heart disease and cancer which are likely to cause far more premature deaths and disability? What is the role of the Public Health Advisory Committee? This sounds like a poor substitute for an independent body which so many of us believe is needed.

No conflict of interest declared.