Health system changes no small task

The long-awaited Final Report of the Health and Disability Sector Review (the Simpson Report) has finally seen the light of day after a two-and-a-half month Covid-19-related delay.

Essentially, the report is recommending a return to the policy settings of the early 2000s, with the clear message that it needs to be done better this time. This message was telegraphed in the interim report released last September.

Minister David Clark has already indicated his broad support, and most of the recommendations are likely to be well-received in the health sector. That said, we can expect the devil in the detail to have ample room to create mayhem if and when such recommendations are implemented.

The proposed changes to DHBs (reducing the number by around half) are nowhere near as far-reaching as many commentators hoped or feared. The recommendation for a new crown agency (Health NZ) with wide ranging responsibilities for health service delivery reflects the views of many submissions to the review. The changes to the ways that hospital services are planned will be broadly welcomed by most stakeholders.

The recommendation for a Māori Health Authority is also strongly supported by many in the sector, although it will create some political headaches for government in terms of its status and its relationship with other agencies. But while all these moves have wide sector support, if not handled adeptly they run the risk of adding further fragmentation and complexity to an already fragmented and complex system.

Journalists interpret these recommendations, and the government response to them as a ‘massive overhaul’ of the health system. The Minister of Health has described them as the most significant changes in a generation. It is true that if implemented, they would constitute the largest structural changes in 20 years, but let’s not get too carried away. The scale of change is nothing compared to what we saw in the early 1990s when National attempted to start with a blank sheet of paper. It also pales in comparison with the early 2000s when Labour under Helen Clark consigned National’s (by then heavily amended) reforms to the dustbin of history.

By and large, the report recommends a ‘reset’ of a ‘population health’ focus rather than a ‘big bang’ approach to change. It reflects a widely held view that health sector policy has been in a state of drift since around 2005.

It makes much more sense to view the proposed changes as a reboot of Labour’s health policy agenda from 20 years ago. Each of the following themes of the Simpson Report were also highly prominent in the early 2000s:

· A health sector based around the health needs of local districts and their populations.

· A commitment to embedding Te Tiriti o Waitangi into the health sector.

· A focus on addressing structural inequalities in who gets access to health services, and in health outcomes of different groups in society.

· A shift in understanding primary care from a focus on general practitioner services to a much broader range of community-based services.

Taken together, this population health focus emphasises the health of all citizens, not just those who actively seek out health services. Internationally, New Zealand is known for being a pioneer in developing population health policies. Unfortunately, we are also known internationally for having a system in which many people with high health needs cannot access the services they need. They main reason is that most people have to pay significant fees for primary care services (unlike in most countries we compare ourselves to).

The other strong line of continuity with the 2000s is the means to achieve these population health goals. The language of the Simpson reports (both interim and final) are peppered with references to holding health sector organisations accountable, and the importance of strategic planning by District Health Boards.

Sure there are also some important differences. The Simpson Report concludes that some features of the reforms of the early 2000s were not fit-for-purpose. These include elected membership of DHBs, but also the creation of Primary Health Organisations (PHOs) as a vehicle for enhancing more responsive and accessible primary health services.

In 2000, when Labour reinstated elected membership of hospital boards (i.e. DHBs), there was much celebration from many quarters. However, it soon became clear that elected members had little chance to influence DHB governance when the signals from central government were so much stronger. Through no fault of their own, the role of elected members is largely symbolic under current legislation. Instead, the Simpson report advocates for community involvement at a different scale, based on new mechanisms for community representation that have evolved in recent years.

The status of PHOs is a very intriguing feature of the report. PHOs are non-government organisations made up of primary care practices, and through which primary care funding is channelled. New Zealand has been an international pioneer in establishing such organisations. During the past 17 years, they have developed some significant capacity in creating new types of primary care services.

But the Simpson Report is of the view that they have not lived up to their original purpose, and are not sufficiently accountable for the public funding they receive. The report recommends changes that would most likely threaten the existence of PHOs, or transform them into very different beasts. If these recommendations are taken up, primary care interest groups will almost certainly fight them.

Although these changes do not amount to a major restructure and most of the ideas have been kicking around for some time, I wouldn’t underestimate the effort needed to implement them, and the challenges in putting flesh on the bones. For example, the creation of two new national agencies also creates the potential for significant battles over bureaucratic turf, as happened in the late 1990s between the Ministry of Health and the HFA.

It is no surprise that Labour plans to bring its A team (including Jacinda Ardern and Grant Robertson) plus the Department of Prime Minister and Cabinet to steer implementation, if it is in a position to push ahead after the September election. They will definitely need to bring their A game.