Burwood Hospital, Christchurch. (Photo: Health.govt.nz)

‘All my dreams have come true’: Doctors and experts react to the end of DHBs

In a set of sweeping health reforms announced today, district health boards will be abolished and a new Māori Health Authority will be established. Here, doctors and experts react to news of the biggest change to the health system in a generation.

Lester Levy, professor of digital health leadership, Faculty of Health, AUT (with a multi-decade background in health management and governance)

All progress is a result of change, but the problem is that not all change leads to progress. Ineffectual change is wasteful, disheartening, damaging and regrettably all too common. Professor John Kotter, an acknowledged global thought leader on organisational change, revealed that in 70% of the circumstances where substantial change was unmistakably needed, it was either not initiated or failed. 

In my view, the health reforms proposed by Minister Little and his colleagues are the type of change that have all the potential to result in unparalleled progress for healthcare in New Zealand. There are three crucial elements that give me confidence that these reforms can make a transformational difference. Firstly and most critically, they firmly address the underlying root problems rather than the symptoms; secondly, they are bold and comprehensive rather than the more customary tinkering; and thirdly, the disposition of the minister and his colleagues is calm, thoughtful, compassionate but unquestionably resolute. 

The one unease I  do have about this reform process is that when it comes to effective change the primary source of success is not strategy but implementation. The only thing that stands between the future path the minister and his colleagues have so clearly laid out and a successful outcome is the efficacy of implementation. 

It is understandable but regrettable that the focus of the discussion following the announcement of the reforms has primarily been on structures. This misses the point that the fundamental essence of these reforms is not simply rearranging the prevailing  institutional arrangements, rather it is system building. Admittedly, structural recalibration is not an inevitable requirement of a systems approach, however, in the case of New Zealand the existing institutional arrangements are so deeply fragmented that structural change is clearly warranted.

Developing a  health system is vital, as it is the model with the greatest potential to resolve some of the most intractable healthcare problems currently faced in New Zealand, of which health inequalities and inequities are unquestionably front and centre. There are others of course, such as the astonishing scale of growth of the non-communicable diseases such as diabetes and heart disease. These most common and costly health conditions in New Zealand are the most preventable, yet the current institutional arrangements and priorities have not enabled health prevention to anywhere near the level required.

The characteristics of a health system are that all the components unequivocally share a common purpose, goals, objectives and set of priorities. There is and can be can only be one strategy. This alignment is in stark contrast to the existing arrangements where frequently these are not only different, but sometimes are even in conflict. 

A health system ensures consistency of access and quality of care by measuring what really matters – and that is the outcomes of clinical care. There is much work to be done in the clinical outcome space but health systems can and do facilitate that. There is indelible proof that the fractured set of current institutional arrangements has not adequately advanced this critical part of the health value equation.

Financial sustainability is another steep gradient that health faces and a health system approach will introduce a much more refined approach to this issue, particularly by placing the spotlight on more precise and coherent allocative efficiency and effectiveness of all resources. This will inevitably lead to the reformed system delivering far greater value than currently.

In my view these health reforms are well conceived, soundly constructed, genuinely necessary and, with disciplined and outstanding implementation, will make the difference everyone would like to see.

Glenn Colquhoun, GP and writer

I’ve been wandering around Mt Cook all day today … as well as writing nursery rhymes in my head for a new book of children’s poems. Both seem incongruous things to do … but good ways of maintaining my own mental health working in the New Zealand lack-of-a-health-system at the moment. It’s late afternoon. The light is hitting the high peaks and the moon is beginning its traverse.

In between thinking of rhymes for “worm” I’ve been mulling over the announcements on the changes to our health system as I wander. I’m wanting so much to be cynical. I’ve figured out that at any one time I’m about 17 people … and three or four of the tribe have been super disrespectful and moany most of the day. You know how it goes; but, but, but … what about … what about … bastards … yeah, yeah, yeah …

But I have to say two or three of me are just truly deeply happy. Like, the sky-has-opened-and-rays-of-light-are-lifting-me-up-to-heaven happy. And those guys are winning the internal dialogue hands down right now.

Shit it’s mad out there. Bunkered down in medicine. It really is. Truly utterly mad. And so hurtful to large swaths of disbelieving patients. I have one permanently angry Glenn hanging about me all the time now. So anyone who says it needs to stop … and we need to start working together gets a vote of confidence from me. Even saying the words, “national health system” moves me. Beyond words, to be honest.

The seven other mes left (one is walking … one is looking around … one is writing) are cautious and sober and watchful. I suppose the most consistent thought rising up among them is, “I hope they don’t stuff it up”. Except it doesn’t come with the word “stuff” in it. There are so many vested interests in health and I reckon they’ll all want feeding. That’s gonna be hard to deal with.

I remember so clearly the “redesign” of the Child, Youth and Family Service to Oranga Tamariki only to see nothing appreciably change on the ground in that organisation. Overnight its managers went from saying, “Of course we’re not broken” to “We’re so sorry things were broken … but we’ve fixed things now. So don’t worry about it.” Hmmmmm.

There will be so many health managers scrambling for jobs with the DHBs going belly-up and I can imagine that many of them will see themselves as a fit for the new world. But they presided over the old world and helped to make it just that. They protected the status quo when they should have yelled long and hard it was stone-cold-sober broken.

So I’m super wary of the old becoming the born again new. It’s going to need political and economic courage and lots of new thinking to skin the health cat again. It needs people who can say, “What are the challenges in health and how can we meet them if we start again from first principles?” It doesn’t need those who will say, “What are our current solutions and how can we re-bore them?” Or, “How can we manage this lot and this lot and buy some compromise?” Or, “What can we sell to the minister, public, etc?”

And I worry about politicians. They come and go so much and are such a temporary, insecure basis for big change. I reckon the health system belongs to all of us. It should be a national treasure … built on good principles … and thinking. But what can you do?

The cornerstones of making the changes stick … and the health system work (for most of me) are:
1. Getting the right people in the right jobs. We need a blend of those who know what it is like in the trenches of medicine, those who know what it is like to be sick, those who know lots about economies, and those with some truly fresh, blue sky ideas (not those who helped to create and maintain the current mess).

2. Truly focusing on prevention, prevention, prevention of poor health in our communities. That will pretty quickly mean addressing rising inequality in our society. Heaps of us middle class people might have to suck it in a bit for that. That’s the real sticking point. The politicians aren’t to blame for that. That’s on us. We are their curare.

In my experience there are two New Zealand’s at least, and too many of us don’t really want to look at that for too long. Everyone talks about the prevention of ill health … but I rarely see the kind of brave political decisions that might drive the measures needed for such forward.

Buuuuttt … they said national health service … so I guess for a while I’m helpless in their arms …

David Galler, intensive care specialist at Middlemore Hospital

Never before have I been so moved, excited and inspired by an announcement from the government. It is as if all my dreams have come true.

I know that feeling will be shared by many of my colleagues and I hope the public at large. 

Those of us who have been working on the frontlines know that these reforms are long overdue and we congratulate those in the Transition Unit for their work and our ministers of health for taking these bold and necessary steps. The word transformation is much overused but not here. 

The intent here is clear – these changes are focused on an agreed outcome for all in a courageous approach to reconfigure our resources to better align and coordinate services to improve their reach to all New Zealanders and especially to those who are missing out now, Maori in particular.

These changes will begin immediately but the emphasis here is not on structure, it is on functions, those of a truly National Health Service based on equity and good outcomes and the promotion of health and well being.

These are changes I support wholeheartedly and I hope you will too.

Gabrielle Baker (Ngāpuhi, Ngāti Kuri), health policy expert

For the last three years I’ve been having conversations about the possibility of a Māori Health Authority. There is close to unanimous support that the current system of 20 DHBs and 30 PHOs doesn’t work. And there is widespread Māori support for a Māori Health Authority of some kind. So, I should feel thrilled to hear ministers give so much visible support for it – more than Heather Simpson and a minority of her peers did in their Health and Disability System Review report last year. But Māori seldom benefit from these disruptive changes, so it is important to keep a critical eye on what is being proposed. Just about everyone has already said it: the devil is in the details.

The things I’ll be watching over the next few weeks and months are:

  • The establishment of an interim Māori Health Authority as an independent department agency within the Ministry of Health. The jargon in that sentence is a red flag to almost anyone. Me included.
  • Keeping the accelerator on all Māori health activity. When under threat it might be human nature to retreat. But if DHBs and other health professionals decide to stay away from Māori health because it will soon be someone else’s problem, there will be devastating consequences. I want to see the current work in Māori health ramp up, not be set aside until the dust settles. 
  • The balance of a national authority with mana whenua and mana motuhake at a regional level. Its all well and good to have a fancy national organisation but if it is used to reduce the influence of Māori communities it’s failed before it’s begun. 

Jacquie Kidd, associate professor nursing and health equity, AUT University

“Overall the announcement is very welcome and, if fully realised, will address the pervasive health disparities experienced by Māori. 

“This new structure must fully engage with whānau to ensure that trust is carefully established and nurtured, and that national health agendas do not overtake those of hapū and whānau.” 

Tim Tenbensel, associate professor, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland

“Many crucial policy questions have yet to be addressed. How will funding be allocated in this new system? Will there still be a role for primary health organisations? How will these new organisations work out exactly who is responsible for doing what?

“This proposed model requires a much more collaborative, problem-solving approach in which health sector organisations work effectively together. For the past 20 years in many parts of the country, relationships between organisations have been driven by distrust – something that has been hardwired by broader public sector reforms in the 1990s, which emphasised competition, hands-off relationships and compliance monitoring. The system has been driven by accountability, but ultimately that accountability has focused on trivialities.

“The challenge for the new health system will be to hard-wire collaboration and trust as well.”

Kate Waterworth, post-graduate lecturer in critical disability studies, AUT University

“This announcement does make reference to the issues that disabled people experience as health system users. At this point, however, any specific response to disability issues is deferred until September 2021. Disabled people have traditionally been neglected as a focus of political attention. Minister Little refers to an outcome of this neglect – that there is poor data held nationally about disabled people’s experiences and outcomes of healthcare service use. This lack of visibility appears to have delayed important decision making in this space.

“I look forward to hearing Minister Little’s announcement in September to hear his specific response to disability issues within the health system. I hope that this will address issues of access and quality of health service delivery, of health outcomes (including life expectancy) and of the complex interactions between the experience of disability and broader social and political systems.

Debbie Ryan, principal, Pacific Perspectives consultancy

“The change acknowledges that a system that has had a focus on regional and local action has been less effective at addressing national issues. This is shown in persisting and worsening disparities in health and service outcomes for smaller populations, including Pacific across a range of indicators.

“The creation of localities as the unit of health service delivery across NZ has enormous potential to increase local input into how health services are provided in all communities. This is potentially a game changer for smaller rural communities.

Carol Atmore, Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago

“The creation of localities as the unit of health service delivery across NZ has enormous potential to increase local input into how health services are provided in all communities. This is potentially a game changer for smaller rural communities.

“As with all these things, the devil will be in the detail. How will localities be defined, and by whom? Who will lead them? How will the final locality plans be developed? How will the Health NZ and Māori Health Authority commission services to meet the locality plans?”

Michael Baker, professor of public health, University of Otago

“Many of us will look at these reforms through the ‘Covid-19 lens’ of how they would support better preparedness for outbreaks and pandemics, and improved detection and management of such events. A second test is whether this model can deliver the changes needed to reduce the huge burden of long-term conditions such as diabetes and smoking-related diseases. A third key test is the need to take vigorous action to improve health equity, particularly improved outcomes for Māori.

“This health reform has potential to meet these health challenges but its success will depend on implementation and resources. As we have seen with the Covid-19 response, a key need is to build sufficient public health infrastructure to meet current and predicted needs.

“I would personally have favoured a more independent stand-alone public health agency combined with the national public health service and health promotion agency to provide a strong voice for public health across Aotearoa New Zealand. However, these reforms go a long way to achieving that need.”

Arindam Basu, associate professor School of Health Sciences, Education, Health & Human Development, University of Canterbury

“The administration is simplified by doing away with 20 different organisational elements – the abolition of DHBs – but such centralisation also carries with it the potential to become a complex monolith, and risks losing the efficiency that each individual unit might provide in a federated system.”

Selah Hart (Ngāti Kuia, Ngāi Tahu, Ngāti Kahungunu ki Wairarapa), CEO of Hāpai te Hauora

“In order to have a truly national health service that focuses on achieving Pae Ora, as Minister Little described this morning, we must understand that the current system has a bunch of invisible walls, that have further perpetuated inequities, called bureaucracy. We know that initiatives which are community led, owned and resourced can mobilise with immediacy. If there is a need, the community rally together to enable a quick response, much like the iwi and hapū up and down Aotearoa did in the face of a global pandemic. However, let’s remind ourselves that while a pandemic is at play across the world, the Indigenous health burden of disease and death has not become any less prevalent. I would assume it’s worsened.”

“A Māori health authority, the first one ever formed by the Crown, is about 181 years too late but let’s rejoice for a moment, because if we get a true Tiriti-based partnership from this, we might start to create a pathway for a healthier nation, with a specific focus on the most underserved communities.”

“While the announcement today did not talk to the detail, I hope that the resourcing, decision making and most importantly, the funding, is placed where it is most needed. Of particular interest to me will be ensuring there is strong Māori public health leadership capability sitting in support of the Ministry of Health, Health NZ, and the Māori health authority. From where I sit now, it seems likely the MHA will be focused on how we fix people when they are sick or in need, instead of creating environments that enable all members of society to live flourishing, well lives.”

“Prevention is the winner in the game of health. If we get that right, everyone will reap the rewards.”




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