Restructuring the health system: what’s needed

Lyndon Keene | Health Policy Analyst

In summary • All DHBs will be replaced by one national organisation, Health New Zealand (HNZ), which will be responsible for running hospitals and commissioning primary and community health services. It will have four regional divisions. • A new Ma -ori Health Authority (MHA) will have the power to commission health services, monitor the state of Ma -ori health, and develop policy. • A new Public Health Agency will be created. • A “strengthened” Ministry of Health will monitor performance and advise Government on policy. • The emphasis will be “squarely on primary and community health care”. • The changes will be phased in over three years.

The new structure is potentially a game changer. It could enable a closing of the shameful health status gap between Ma -ori and non-Ma -ori, facilitate more consistent access to services nationwide, see better integration between hospitals and community service providers, reduce unmet health needs, and go a long way to meeting the Government’s wellbeing goals. Or it could do none of those things. To ensure it does achieve its goals, there are at least five ‘musts’ to be included in the missing detail.

Responsible investment policy

The bold and politically high-stakes ambition proclaimed for this new system will need equally bold investment. Current funding levels are not meeting the needs of many people, so divvying up current funding levels between the MHA and HNZ, no matter how it was done, would perpetuate high levels of unmet need. The essential goal of health equity between Ma -ori and non-Ma -ori must go hand-inhand with a goal to significantly reduce universal unmet need. The aim must be to improve the health of the whole population while improving the health of the most disadvantaged faster. Greater investment to address entrenched health workforce shortages must be a priority. As the Health Workforce Advisory Board has pointed out, the United Nations High-Level Commission on Health Employment and Economic Growth has sought to draw attention to the social and economic benefits of investing in the health workforce, locally and globally. “The Commission hoped to change the mindset of political leaders, policymakers and economists who view health employment as a burden on the economy (as it is considered to be inefficient, resistant to gains in productivity and an expense to be stringently controlled). The Commission wanted to shift the focus of health employment as ‘consumption’ to health employment as an ‘investment’.” In New Zealand, evidently there is still a lot of shifting to do.

Community voice

DHBs have failed to respond well to their local communities because they are primarily accountable to the Minister of Health. The background papers on the restructuring outline the plans for national, regional, and local “consumer forums” that will connect with HNZ, MHA and Ministry of Health. The system will “work towards a single mechanism” for two-way communication, so communities can see how their voice is being heard and acted upon. So far so good, assuming the process is well implemented, including being resourced to provide high quality forum facilitation and coordination. But to have a meaningful say on how services are designed and delivered, communities will also need access to comprehensive and relevant information, including local measures of unmet need for hospital care, as well as primary care, and data to identify service pressure points and assess where improvements are needed. Having to rely on Official Information Act requests for such information, which is then subject to political risk assessment and can take many months, won’t wash.

Clinicians’ voice

The planned channel for community voice is not replicated for clinical voice. Aside from some “engagement with the health sector” as the new system is established, there is no indication of a clear ongoing means for front-line health professionals to have a say in how services are planned and run. This is a significant oversight that must be corrected.

Globally, health systems employ many of the highest achievers in the labour force, yet their skills and knowledge are so often overlooked by policymakers and management when attempting system improvements. One can only imagine what might be achieved if 95% of employeegenerated ideas were put to practical use, as reported by one of the world’s leading car manufacturers, instead of just 10%, as reported in a health system study that appears to be typical of systems around the world, including New Zealand. The evidence shows securing greater engagement is a cultural change too important to be left to chance. It requires deliberate government policy and strong commitment. Get it right, and the elusive goals of systemic clinical leadership and integrated care will become more achievable.

Cultural competency and safety

First and foremost, as the MCNZ comments: “It is hoped that Ma -ori specific cultural competencies will be developed in a framework of self-awareness so that doctors