Dr David Galler offers seven lessons from past reviews of the NZ health system that should inform the thinking currently under way
Reviews of New Zealand’s health services have almost invariably proven controversial, arousing particular opposition from groups with vested interests. And once complete, they seem to have achieved little more than a reshuffling of a few more deck chairs on the ship of health.
Now another review is under way. Why should we expect this one to be any different? The best way may be to learn from what’s gone before.
On the whole New Zealand is an enlightened country. Never was this more evident than in two momentous decisions. The first was in 1893, when we became the first self-governing country in which women had the right to vote in parliamentary elections. Then, in September 1938, Michael Joseph Savage made a commitment to universal health coverage through legislation. Interestingly his attempt to establish what would have been the world’s first national health system was stymied at the last moment by the interests of doctors represented by the British Medical Association and as a result, effectively and forever privatising General Practice.
What lesson could we draw from that? Call it Lesson 1:
No matter what recommendations might follow this latest round of consultation, their implementation will be challenged by groups wedded to the status quo. In the controversial area of health it has been groups of doctors who have wielded most influence.
Decades later, in the early 1990s, powerfully moved by Margaret Thatcher’s neoliberal ideology, NZ embarked upon a set of market-oriented health reforms. These were a direct challenge to the values espoused by Savage, creating a furor amongst the public and that part of the medical profession dedicated to public practice. Eventually the then National government was forced to temper their commercial and competitive basis, but despite that New Zealand’s swing to embrace market-driven economic theory and practice changed forever how many of us view and value the public funding of health and social services.
Looking back, New Zealand’s response was one-dimensional and unsophisticated, turning our attention exclusively to reducing short-term financial costs while paying little attention to outcomes. As a result, and by stealth, New Zealand redefined the inherent value created by social services like education, health and others, solely in terms of their cost, the revenue they generated and, in some cases, their saleable value.
This unfortunate legacy, a kind of enduring myopia, continues today and is in effect a barrier and brake on the many efforts we have made since then to become the fair, equitable and progressive nation many wish New Zealand to be.
A few years later, in keeping with other nations debating the same issue, New Zealand’s Core Services Committee was established to advise on what specific health services the state should be responsible for and which should be funded by individual citizens. It soon became apparent that there was no easy answer to that question so instead the Committee recommended New Zealand adopt the following principles: ability to benefit; value for money; a fair use of public money; and that the decisions made were in line with our communities’ values.
Because little more was done in practical terms to define how best to assess our performance against those principles, apart of course from cost and the volume of activity done, it’s hard to assess what tangible benefits by way of health gain these reforms actually delivered.
The most recent round of reforms in 2001 created the District Health Board (DHB) model. New Zealand, a nation of only 4.5 million people, has 20 DHBs, each responsible for the provision and funding of all services for people within their geographical region, with some purchased from other DHBs that provide specific regional or national services. However, from the outset, the absolute number of DHBs has been debated, driven by a tension between the need to ensure equitable access to quality services and the political necessity for those services to be delivered locally.
Past attempts to network services and change existing patterns of service configuration will meet opposition from members of the public fearful of losing local services and the politicians that represent them.
There is much to learn from existing clinical networks. Culture trumps structure every time because structural change can help or hinder doing what we know is best; ultimately it is how people are prepared to work together that will determine the success of any changes made.
Many patients, especially those with long term conditions, feel abandoned and struggle to turn their lives around to become well despite attending outpatient clinics and visiting their family doctor. Yes, we can write scripts and tell people what to do in the millisecond of their lives when they are with us but in reality we have very little influence over the difficult choices and changes in lifestyle that so many people need to make in the places where they live and work in order to become well and stay well.
Living well with a long term condition is more about choices and changes in lifestyle than it is about healthcare and medicine. In that regard, we have much to learn from others who recognise the place, power and influence of those with lived experience of the same condition combined with the effective deployment of care coordinators who stay close to their clients to personalise and customise the interventions needed to help them get well and stay well.
Despite a growing burden on our health services from preventable disease no previous review has systematically addressed primary disease prevention. Late last year, the Health Coalition Aotearoa was established to do just that by providing evidence based approaches to inform policy and practice to reduce harm from alcohol, tobacco and unhealthy diets. Whether this government will have the courage to accept this gift to the nation and implement the kinds of changes I know it wants to make is uncertain.
This review must address the whole of the system and that includes developing a comprehensive, systematic approach to primary prevention.
Although this latest consultation will shape the nation’s health services for the future, its success might lie in the enduring truths of the past. For many first nations – Māori in NZ, the First Nations Health Authority (FNHA) in British Columbia – health and wellness is a state of being that encompasses more than just the physical health of an individual – it includes the health of the mind, spirit and family. Health and wellbeing in turn, contributes to a higher purpose by creating the conditions for individuals, families and communities, to be self-reliant and productive, able to start and staff their own businesses, ultimately allowing them to reach their potential for themselves, their communities and the nation.
This more holistic approach, to align our efforts around a clearly defined purpose, is mirrored in the Living Standards Framework being developed by the NZ Treasury for this year’s Budget and opens the door for a more sophisticated approach by the public to how they might respond to the questions posed in this review.
So here’s hoping that this latest review of New Zealand’s health services will be bold, systematic and comprehensive in its scope and recommendations.