Historic health shake-up: will it end era of distrust?

This morning’s announcement is truly a historic event. The changes proposed go significantly beyond what had been recommended by the Health and Disability Review Report last year.

The big news is the abolition of District Health Boards, and their replacement with a single national organisation, provisionally known as Health New Zealand, which will have four regional divisions, and a district or locality branches at local levels.

The creation of a Māori Health Authority with commissioning powers is the other major innovation. Again, the scope of the MHA goes beyond what was recommended by the Simpson Review, and aligns more closely with the ‘dissenting’ view supported by the majority of the Review panel.

The third major initiative is the creation of a public health agency within the Ministry of Health, which will give public health—the focus on prevention, promotion and protection of health—a much higher profile in government decision-making.

Broadly, these reforms are likely to be widely welcomed by health sector leaders. While DHBs were meant to foster the development of community-based, primary health care services, and move the system towards prevention and earlier care, this did not happen, especially in the past decade. Most DHBs have been hospital-focused and risk averse in facilitating new models of health services that are suited to addressing widespread inequities and the needs of people with long-term, multiple and chronic health conditions.

The new structure aims to address this by shifting the hospital-focused centre of gravity through HNZ and the MHA. We have seen the broad outline, and it has been painted in bold strokes. But as is always the case in any health system reform anywhere in the world, the devil is always in the detail.

Many big questions remain. How much disruption will these changes create? Can we move smoothly to a new structure in the tight timeline of 15 months?

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?
 

Some will see these reforms as a return to the days of the Health Funding Authority in the late 1990s. There are similarities, and important differences. The structure of the 1990s stimulated many new initiatives, but was not so responsive to local conditions and needs.

The biggest challenges for the government and the health sector, however, are long-term. 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 hardwire collaboration and trust as well.