This morning, Heather Simpson’s long-awaited review of the health and disability system was released. It’s not the revolution many were hoping for, but it’s still regarded as a step in the right direction.
The health and disability system review released this morning has detailed research, but only a few key recommendations: the creation of a new crown entity called Health NZ, the consolidation of DHBs from 20 down to between eight and 12, the removal of DHB elections, and the creation of a Māori health authority. These changes are to be implemented over the next five years
Minister for health David Clark said the review confirmed what many were already saying: healthcare workers and clients are both struggling under the current system.
“It sets out a path towards a better, more sustainable health system with clear lines of accountability,” he said in a press release. “One that is more responsive to the needs of local communities and that better tailors services to the way that people live their lives.”
The Māori Health Authority
One way the review proposes responding to the needs of the community is with the establishment of a Māori health authority, which would monitor and report on impacts the healthcare system has on Māori, and then develop and test solutions to problems it finds.
Matt Tukaki, executive director of the New Zealand Māori Council, said this morning that the council welcomed the review. “It’s a brutal look at the system but also a pathway of opportunity towards closing the gaps when it comes to the health inequities between Māori and non-Māori,” he said.
The New Zealand Nurses Organisation (NZNO)’s Kerri Nuku said in a statement that NZNO members have long advocated for the population health approach the review focuses on, especially its approach to community health.
“We especially welcome the proposed structural changes, particularly the Māori health authority. These changes echo the recommendations of the Wai 2575 Health Services and Outcomes Inquiry and will better reflect Te Tiriti and ensure obligations under Te Tiriti are reflected across the whole health system,” she said.
Whānau Ora said the proposed authority was a welcome suggestion, but that it “must have the teeth” to actually achieve its stated goals. “The best intentions will only ever remain intentions in name, unless the Māori health authority holds central appropriation of funds, iwi/Māori are supported in 50/50 governance arrangements to oversee commissioning; and a mātauranga Māori commissioning frame is applied which builds on the Whānau Ora commissioning model,” said spokesperson Helen Leahy.
Kate Waterworth, a lecturer in critical disability studies at AUT University, noted that Simpson’s review acknowledged the current system was inequitable and inconsistent.
She told the Science Media Centre, “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,” she said. The review also suggests hiring more disabled people so real-world experience is incorporated into the system.
It’s important “to include opportunities to shift broader understandings of disability as being part of the typical human experience”, said Waterworth, “in order for healthcare systems and providers to recognise their obligations to provide appropriate high-quality services to all”.
Another change to better represent Māori will be visible in the proposed new DHB boards, which will be appointed by the minister for health rather than elected by the public. The appointments, the review said, should be 50% Māori.
David Galler, an intensive care specialist at Middlemore Hospital and author, said an elected position wasn’t necessarily the best way to keep a board accountable to its community. “One of the most interesting things they could do is make board meetings totally open to the public; total transparency in how they conduct their business.”
Dr Bryan Betty, medical director of the Royal New Zealand College of General Practitioners (RNZCGP), said the appointments were “probably a step in the right direction, so long as the balance is right”.
Julie Anne Genter, Green MP and the associate minister for health, said local democracy was a core value for the Green Party, but the current system of DHB elections was flawed. “The proposed replacement of DHB elections with appointed boards must ensure communities can still have a say in health decisions that affect them, if it goes ahead,” she said.
“Voter turnout for DHB elections is notoriously low, so we agree that the current system could be improved. It is vital that local voices are heard and that health services match the different needs of different communities.”
DHBs distribute funding to PHOs, which in turn distribute funding to the services under their umbrella: places like publicly funded GPs and dentists. “A slight concern we have is that the PHOs were established to create a counterbalance to the focus on hospitals in DHBs,” said Betty. “Losing that and bringing that back into the DHB fold could be a potential problem.”
On the whole, he’s encouraged by the report’s focus on structuring to support community services, he said. “A lot of our feeling was that [the current system] didn’t allow innovation, or community-delivered services. There’s an inherent inequity in the system, particularly in terms of Māori and Pasifika,” he said.
“We’re really encouraged by the fact that it’s acknowledged that in order to get equitable outcomes, there needs to be a real focus on the services in the community, and away from the tight hospital focus.”
Galler said the proposed shift away from PHOs made sense. “What we want is a system that is well aligned and functioning in a coordinated fashion,” he said. “Dealing with lots of different PHOs doesn’t necessarily help that.”
Referring to the proposed timeline of five years for the DHB restructure, Robin Gauld, of the University of Otago’s Centre for Health Systems and Technology, told the Science Media Centre that “most people want change now, not in five years. It would be better to enact changes straight after next election”.
He said the vertical integration of Health NZ and the Māori health authority was a good move, but that further detail was needed on how the restructure would allow entities to work together. “DHBs have been very hospital focused and bring a legacy of underperformance and silo activity, and have worked separately from PHOs,” he said. “It’s also not entirely clear how the DHBs will work more closely with one another, and we need to really break the silos.”
It’s not yet known which DHBs and PHOs would be absorbed should the review’s suggestions be enacted, but Clark was adamant in a press conference earlier today that job losses were not currently on the agenda. The review indicated hiring more healthcare workers, particularly those best able to represent the community’s needs. “Our health and disability sector could be employing more disabled people,” he said. “[It] could benefit from people who have direct experience of disability.”
Galler said that the review was detailed, considered, and should be taken as a whole strategy, rather than in parts.“Without an absolute commitment to a comprehensive strategy, the changes made here won’t be as successful,” he said. “It’ll be moving deck chairs on the Titanic.”