Health Minister David Clark (Photo: Hannah Peters/Getty Images)

End to DHB elections, new agencies proposed in major health system review

The Simpson report into the health and disability sector has finally been released, proposing major changes to the way the health system is organised and governed. Alex Braae reports on the most important bits.

What’s all this then?

About two years ago, Heather Simpson was tasked with leading a massive review into the health and disability sector, with pretty much every aspect of it on the table. This morning the report was finally released.

And what are the biggest changes being proposed?

The biggest proposals for change relate to District Health Boards, and how people get onto them. Currently, there are 20 DHBs around the country, and the Simpson report proposes that number be reduced to between 8-12 over a period of five years. It also proposes a move to fully appointed boards, rather than the existing combination of election and appointment. DHBs would also be expected to take into account the effect their actions would have on other regions, rather than the current situation in which they’re solely responsible for their own patch only.

Wait, we have DHB elections?

We do, but not a lot of people vote in them. They’re bundled in with the rest of the local elections, and often seem to end up more as an exercise in random selection than democratic oversight. The lack of interest in DHB elections arguably makes it less problematic to lose them, though what comes afterwards will need close scrutiny. The report proposes that new DHB members be “appointed against a transparent framework to ensure board members’ experience covers an appropriate range of governance and health sector competencies, and reflects te Tiriti partnership”.

The Green Party expressed caution about the review’s recommendation to end DHB elections, calling it a risk to local democracy. The party conceded that the current system could be improved to increase perennially low voter turnout. “The proposed replacement of DHB elections with appointed boards must ensure communities can still have a say in health decisions that affect them,” Julie Anne Genter, the party’s health spokesperson, said in a statement.

What else would be set up as a result of these proposals?

The report has proposed that a new Crown Entity called Health NZ be set up – that name is probably a working title so it could still end up following the government’s style guide and get called KiwiHealth. This would have accountability over DHBs, and would in turn be accountable to the health minister. There would also be a Māori Health Authority established, “to include specific provisions for commissioning Māori health services”.In her introduction to the report, Heather Simpson admitted that the remit of the Māori Health Authority is still up for debate. “In the end there was no consensus on the extent to which the Māori Health Authority should control the funding and commissioning of services for Māori,” she said. “But while that is a significant difference, and is a debate which is sure to be ongoing, it should not detract from the rest of the recommendations.”

Did this review have anything to do with that whole global pandemic thing we just had?

Not as such – it was commissioned well before Covid-19 had appeared. However, health minister David Clark said “one of the key lessons of Covid-19 was the importance of a strong public health service. That is what this review has been all about.” It’s likely that, at the very least, it steeled commitment to emphasise in the report commitment to public health.

Will there be a change in the philosophical underpinning of the health system?

One of the points made repeatedly in the report was that there needs to be a shift towards “a greater focus on population health”. What this means in theory is a greater focus on keeping people healthy in the first place, rather than simply treating illness as it comes up.

There is also a strong focus on equity in the report, as currently different groups see widely diverging health outcomes and service provision. The report calls for improvement to primary and community services (described as ‘Tier 1’ in the report) as the most effective way of ensuring more equitable outcomes. As one key paragraph in the report’s introduction notes:

“Planning and funding these services must be driven by the needs of each community, not just the population numbers, so higher deprivation localities have more funding to allocate. Similarly, services need to be designed to work for the population they are serving, so Māori communities need to have access to a wider range of kaupapa Māori services.”

What about the disability sector?

With an ageing population, the number of New Zealanders living with disabilities is likely to increase – and already, a quarter of New Zealanders have some form of disability. Their needs are diverse, and the report says change is needed to ensure that “disability is no longer treated as an exception or managed separately. The increasing number of disabled people have the right to expect equitable outcomes from the system.”

What’s not included in the report?

There’s minimal mention of oral health and dentistry, which is interesting as it is part of the health system which operates largely outside of everything else, even though many DHBs do have very limited dentistry departments. ACC and Pharmac were both also outside the scope of the review.

Will the government do anything with this report, or will it just sit on it?

The health minister, David Clark, hedged on this, though said that cabinet has “accepted the case for reform, and the direction of travel outlined in the review, specifically changes that will reduce fragmentation, strengthen leadership and accountability and improve equity of access and outcomes.”

What does that mean in practice? Basically, that over the coming months cabinet will decide on specific recommendations and whether to implement them. With the speed that government normally moves at, that means you might still have to get your heads around candidate lists for DHB elections at least one more time.

Heather Simpson: why is that name familiar?

Simpson is best known for being a critical aide to Helen Clark when she was prime minister. So critical she earned the nickname “H2”?

Can I read the full report anywhere?

You can read the final report in full here (PDF).



The Spinoff is made possible by the generous support of the following organisations.
Please help us by supporting them.