It’s a shambles of our own making, but it’s still one we can turn around, argues health sector expert Dr David Galler.

Trust and confidence in the public health system is at an all-time low. Not a day goes by without another story highlighting its alleged failings, eroding what little trust and confidence the public has left in it. 

It would be wrong to blame all of that on the current government but, make no mistake, if it continues on its current path, we risk losing forever what was once a jewel. To know how to get out of this mess in health, we need to understand how we got here and to understand how best to secure the future of public healthcare as a viable national asset.

That can be done but will require a political commitment that the health of the nation is a national asset worth protecting – or better still, to shift decisions about our health system to an independent group to decide – leading to a commitment across government to address the social and economic causes of ill health and understand the benefits of building a world-class public health system.

The alternative is an inexorable drift towards privatisation and more unequal health outcomes.

Where we are today

The pressures on our health system have been compounding across many election cycles and are the result of a lack of vision, a long history of confusion, lost opportunities, poor judgment and serial mismanagement. The mess is now evident for all to see, with public worry about “health” reaching epic proportions, perhaps only exceeded by the white-hot anger and contempt many in the health sector (individuals, specialty groups, healthcare organisations, NGOs, unions) feel towards those responsible for how we have ended up in this position. 

In the eyes of many, this downward trend in the fortunes of our publicly funded health system has become a death spiral that if left to run its course will leave no future for publicly funded healthcare in New Zealand. Whether by accident or design, this death spiral will inevitably lead to more and more privatisation of services and the entrenchment of a two-tier system delivering very different outcomes.

The crisis has now become so marked that different groups from across civil society are meeting formally and informally to discuss what must be done to secure the future of a public health system for all New Zealanders. We in the health sector have had enough of this shambles and want to see a smarter, more collaborative approach by governments to invest in the future of this service.

For years successive governments have chosen to tinker at the margins, spending more and more to tidy up the consequences of their neglect instead of systematically addressing their causes and in doing so, exhausting our most precious resource, the energy and goodwill of our workforce. 

We have been unwilling and unable to implement the recommendations of review after review, choosing instead to muddle along in a chaos of public policy. As a result of that drift, we’ve neither planned nor invested in how we will provide services into the future.

Workforce training, recruitment, retention and growth has been haphazard and grossly inadequate and as a result we haven’t built the relationships within the sector necessary for the new models of care needed to meet an exploding demand for services triggered by an ageing population, increasing economic inequity, and new and effective treatments.

Overwhelmed with work, much of it from complications of preventable conditions, actively promoted by commercial interests, the pressure on our small and already stressed health workforce has steadily risen to become intolerable. 

Being under-appreciated and treated poorly by a system that values short-term costs and profits over people, health workers continue to leave the country, become burnt out, leave health altogether, or go into the private sector for a better, less chaotic life.

Because that workforce is small and always at the edge of its capabilities, further losses add to the pressure on those who remain and their ability to treat people and the range of life-altering conditions they suffer from diminishes. 

Members of the public who need help to maintain the quality of their lives either don’t get it or are forced to wait for long periods of time before they can be seen. As a result, many suffer, cannot work and are forced into the welfare system. The toll on them and their families is immense. 

The private system has helped some but that too is changing. Up until the 1980s and early 1990s, New Zealand had a much smaller private health system existing in relative harmony alongside our public sector, with people choosing to “go private” for very specific reasons: the belief by some that if you pay for a service, it must be better; choice of time, facility, place and who you wish to be treated by; and for anonymity.

But now people go private just to be treated at all. So now, those with insurance and the desperate who can raid their savings seek care in the private sector, where queues and long waits have also become the norm. 

That demand for services in the private sector attracts more disaffected health workers out of the public system and so the death spiral continues round and down the gurgler until it is spent, leaving the public sector on its knees, only able to treat those with imminently life-threatening conditions. 

So, how did we get here?

Experts with long memories point to the neoliberal reforms of the 1980s as the game changer for how New Zealand came to view the funding and provision of health and social services, heralding a fundamental change in the role of government and their willingness to fund public services with a shift to a user-pays philosophy.

Once seen as an investment and an expected function of government, the debate over health came to centre on cost – what specific services should be state funded and what should be paid for by the individual. Hence, spending in health (and social services) was quite suddenly redefined simply in terms of the direct financial cost to provide those services or the short-term profit that could be made from their sale.

In 1990, the American state of Oregon led this debate about affordability by formally constructing a list of conditions highlighting what would and would not be covered by their local funding mechanisms. 

In New Zealand, that debate was managed by the core health services review chaired by Sharon Crosbie. She presided over heated discussions in packed town halls, where many of the attendees were hostile and deeply sceptical about the government’s motives. As time went by, it became obvious that the New Zealand public was not prepared to follow the Oregon experiment, instead choosing to opt for a principle-based approach to determine what the state should provide. Those principles included transparency, fairness, need, equity and the ability to benefit. So far so good.

However, as sound as that was at the time, the Ministry of Health never established a means to assess our performance against those principles, losing the opportunity to deliver on what we had agreed was important. 

In parallel with the introduction of the neoliberal reforms the world became increasingly interconnected through globalisation. While there were many advantages of that, lower prices and higher standards of living for some, few were willing to consider and mitigate its harms largely caused by a rise in corporate influence and power, wealth concentration and a rapid and ongoing rise in inequity. 

Without controls or systems to monitor the impacts of those forces, new threats to the health and wellbeing of our people emerged. Increasing poverty, poor housing, greater access and targeted marketing of cheap supplies of tobacco, alcohol and unhealthy foods, often referred to as commercial and social drivers of health, radically altered the health landscape contributing to a massive and ongoing rise in long-term conditions most marked in specific population groups, notably in Māori, Pacific and our poorer communities. The huge increase in demand for services this created was unmatched by planning and funding and an equal unwillingness to address its causes. 

Blinded by ideology, wilful neglect, general incompetence, a lack of courage and short-term thinking fuelled what has now become a death spiral for many of our public services, cheered on by those who profit by it. It’s a shambles of our own making but it’s still one we can turn around. 

These same forces that have wrecked our services have wreaked havoc elsewhere, nowhere more so than in the English NHS. Lord Darzi’s recent report commissioned specifically to address the dire state of their health service has made a series of recommendations that mirror many of those made by the recent Simpson Review. That should give us greater confidence in pursuing what we already have discovered for ourselves. Important themes have also emerged for how to repair the mess we are in and to inform strategies to improve the nation’s health and healthcare system. These shouldn’t be a surprise to anyone, so what can we do together to implement them?

Please, no more reviews

We already have a wealth of information to set and take charge of the agenda to resuscitate and rebuild a health service we can be proud of. But because so much damage has been done over such a long period of time that rebuilding process will be long, require investment, a public commitment to create a service that works for all New Zealanders and a plan to deliver on that over time. The success of that will always depend on regaining the trust of our health workforce and the local communities that rely on them. 

The case for investment is backed by an overwhelming volume of evidence clearly showing that appropriate funding for health and health services improves productivity and decreases costs elsewhere in our economy. Further, both commonsense and evidence both point to the extra value created by funding a connected system of care centred on the needs of the people and the communities they serve, and set in a wider context where government policies quite deliberately promote health and wellbeing, not the commercial interests of corporations whose products diminish that. 

Reviews and reports from the past, most recently the Simpson Review and that led by Lord Darzi, point to establishing a system with national oversight, where we work together to agree on the outcomes we want to create, but one where we direct our efforts and resources to support health and wellbeing interventions locally, where people live and work. 

We are fortunate to have examples to learn from where communities have intervened to influence issues that impact on their health and wellbeing: the success of community-led initiatives like the Covid vaccination programme in South Auckland, efforts to improve the built environment in specific neighbourhoods, better transport options, the numbers and placement of liquor stores, and in establishing school and community gardens et cetera. 

Empowering and supporting communities is at the heart of any successful health service where local people can seek help from a wide range of service providers who understand their needs, have access to their records and can make a genuine connection with them.

Those community care providers become part of a networked system to extend their ability to manage people and help people manage themselves at home, supported through their relationships and connections to a wide range of specialists from local, regional and national hospitals who provide medical, nursing and allied health advice. The great Sir Muir Gray, the iconic Glaswegian professor of public health from Oxford University, described this model of connected healthcare more than 40 years ago. 

The Simpson Review and the Darzi Report take us away from the centralised command and control approach that we have grown so used to. Away from an all-powerful minister and commissioner, to create and support a devolved decision-making model to assist those closest to where services are delivered, our workforce and the communities they serve, in the clear expectation that they will find the most appropriate ways to deliver on the outcomes they value.

In this new outward-facing approach, the role of the public servant will change. They will become a dynamic link between healthcare professionals and government decision makers and work to benefit both by putting good policy into practice and good practice into policy. 

Instead of enforcing edicts from on high and managing up to a perpetually unhappy minister and government, they will be out and about building close working relationships with providers across the system to ensure that they can be successful in meeting the needs of those they serve. 

Public servants will walk alongside service providers to understand the nature of their work; to assist them in removing barriers to their success; help them develop real time measures of their performance used for improvement which in turn will cascade up to contribute to system level measures; and in that relationship of trust, public servants, those lucky buggers, will also challenge providers to develop new models of care. It’s an exciting prospect that I know many will relish.

This is my hope, so what chance of that?

Not much, if history is anything to go by. 

But hope exists and it’s a powerful source of energy when turned into a plan.

And that energy exists in the collective action of the public, our health professionals and their unions, in their societies and colleges, it lies in our communities and in local government organisations, in all those groups who have had enough of the tinkering and cost cutting and lack of vision.

We are at the edge now; we need to act together. It’s time for a better and more sophisticated way to plan and deliver a publicly funded healthcare system that brings health and wealth to all of us.   

My message to the public, local government, our health professionals, our professional societies and colleges and unions is to put aside our individual fights and join together to demand a more sophisticated approach to investing in a publicly funded health service for the future and for all New Zealanders. This might be our last chance.