Was Covid-19 and lockdown the catalyst for a new future for healthcare or did it just expose systemic inequity? In the latest of a series on the country’s future infrastructure needs, Tim Murphy looks at how the long push to shift health’s focus from hospitals to the community might have received a nudge forward during Covid-19.
In March 2020, when hospitals and even GP clinics emptied and large numbers of people ‘saw’ their doctors over the phone or internet and had their prescriptions applied for and dispatched electronically, it was possible the healthcare system touched on its long-promised future.
Governments, medical professionals, health systems academics and economists globally have debated and made relatively small steps over decades at implementing services that are customer-centric, more accessible and delivered by new technologies.
How to put more control over how we access health services into our own hands and via broadband connections into the closest towns and regional centres?
How to use technology, not just for the phone consultations that dominated the detached weeks of lockdown, but for true innovations in telehealth, data, gene therapy, robotics and even gamification of therapies?
The complexity of the health system has limited progress on these goals. But each new study of our future health highlights the need for such advances.
Newsroom has talked to health professionals, academics, primary and hauora providers, technology and telehealth experts for this article.
Some hope the fundamental change forced on the country so suddenly by the Covid-19 pandemic will help change attitudes and remove some of these barriers for good. Some are sceptical that even a pandemic could spur the system and its vast infrastructure spending into a new approach.
Overall, the feeling seems to be optimistic that the planning and funding systems might now be freed up enough to focus on community-based and technology solutions in a meaningful way.
Experts we interviewed emphasised New Zealand needed to view ‘infrastructure’ needs beyond bricks, mortar, vertical and horizontal facilities and physical hardware.
First, according to Simon Royal, chief executive of the National Hauora Coalition, a Māori-led Primary Health Organisation, New Zealand needs to re-assess its healthcare philosophy to put equity at the centre of all discussions.
Before reshaping or spending up on physical infrastructure, big issues like the funding tensions between publicly-owned secondary and tertiary care and mainly privately-owned primary care needed to be addressed.
Citing Scandinavian health systems that put equity at the front of their allocation of resources, Royal said decisions over new models of care were as important as new facilities.
He also added another lens to ‘infrastructure’ needs. “Infrastructure has to be thought of as how do we capture data and what’s the relative importance of data and data analysis in helping us to determine what we should invest in. That’s a whole area of real importance to Māori. It is the infrastructure upon which so many investment decisions are made, in politics, healthcare, natural resources, addressing climate change. Decisions are going to be made on the basis of data.”
Hauora Māori encompasses Māori organisations and their models of care and the kaupapa of Hauora is not just conventional primary health care services. The NHC, for example, says everything it does “is centred on enhancing and enabling the strengths of whānau so they can achieve their aspirations.”
The country has to settle on its approach to wellbeing before any big spending decisions are made. Kelvin Keh, of UniServices at the University of Auckland said: “We need a clear idea first of how we want to look after our population in the next 50 years, because the investment in infrastructure has to be secondary to that answer.”
Richard MacGeorge of the New Zealand Infrastructure Commission, Te Waihanga echoes the need to get the thinking right first: “We are bringing wellbeing more into the way we are thinking about infrastructure. There’s an assumption that health has to be carried out in a healthcare facility. But what is the role of the hospital going to be, say, in 2050? Is the current model going to be continued for the next 20 or 30 years or is it likely there will be some fundamental change?”
Associate Professor Tim Tenbensel of the University of Auckland’s School of Population Health says such change has not been easy to achieve. “For 20 to 30 years, all governments and all health systems have had an absolute mantra that we need to move things out of the hospital and into the community. But in that time, we’ve not seen any real movement in any high-income country…. There might be a tipping point that we reach in the future but it is hard to see that right around the corner.”
The economic, social and political effects of the pandemic might have opened up possibilities. “We may be at a point where the neoliberal influence is less important in policy. Will that mean people take a more long-term view?”
The current position
The country has about 90 publicly or community-owned hospitals.
Latest analysis by the Ministry of Health, from September 2019, estimates we need to spend $14 billion for buildings and infrastructure for the DHBs (excluding repairs and maintenance) in just the next decade – with a further $2.2 billion for information technology services. Many of our hospital facilities are old or not fit-for-purpose.
Rebuilding or refurbishing would be costly, but there are also concerns over the country’s capacity in our construction sector to pull that off.
The ‘Simpson’ review of the health and disability sector, convened by Heather Simpson, the former chief of staff to Prime Minister Helen Clark and unveiled in June, 2020 said: “This level of investment may be daunting, but it also presents an opportunity. The health and disability system could look at replacing ageing facilities with ones designed and planned for the future.
“New facilities can use technology to support new ways of delivering specialist services, embrace the shift of services closer to home and be a great place for the future health workforce to work in.”
Tim Tenbensel says it is not particularly original to suggest that many things now handled by hospitals could and should be provided in the community.
His University of Auckland colleague Kelvin Keh says: “We are geared to episodic care. We build hospitals and GP clinics that we go to and that’s ingrained into our psych. During Covid we were no longer able to go to those things. It disrupts it entirely. It was a stress on the system because it was implementing a number of things at the same time, but it also shows some of the resilience of the system. We could change.”
Keh says episodic health care is no longer seen as the gold standard. “Care for a person can come in many forms, and comes outside of a clinic environment as well. There’s a lot of recognition of community and family playing a big part in looking after a particular individual.”
How care changed during Covid lockdown
As the pandemic impacted New Zealand, hospitals cancelled elective surgeries and outpatient services to clear capacity and resource for a possible Covid-19 related influx of patients. GPs’ clinics had to put restrictions on walk-in consultations to protect patients and staff, and some set up community Covid-19 testing facilities in carparks.
Dr Samantha Murton, president of the Royal NZ College of General Practitioners, says in the key Covid-19 months GPs took more than half a million swabs to test for the virus.
Ranjna Patel, a director and founder of Tamaki Health, one of the country’s largest primary care providers, said 4000 patients usually go through the firm’s 48 Local Doctor and White Cross clinics from Whangarei to Christchurch daily. But during the lockdown in March to May, Tamaki Health converted substantially to virtual consultations. “It was phenomenal. We realised that’s what people needed.”
Tamaki had already developed a web-based consultation system named Bettr, and advanced its training for doctors in virtual consultations, catering for its own high-needs communities, and with around 15 percent in total from rural areas. At post-lockdown levels of demand, the company believes 30 percent now and up to 50 percent of consultations can be via telehealth methods.
Tenbensel, from the University of Auckland, says a Health Research Council-funded project into the state of primary care took the opportunity during lockdown to survey patients across the country who undertook tele consultations. “Basically, most were just by telephone. The other thing we know is that as soon as things went back to normal in June and July, then things went back to normal.” The ‘old normal’.
But he is encouraged that the movement for ‘health to the homes’ will have been accelerated by the Covid-19 experience.
Simon Royal says New Zealand showed during Covid lockdowns the same attitude as after the Christchurch earthquake and Edgecumbe floods: that, in a crisis, a complicated government system could move at speed. “We effectively operated as an agile business really … we responded to the immediate needs, moved in rapidly, shifted government agencies and broke down silos.”
Telehealth and technology
While the lockdown spurred change, telehealth and new technologies offer innovations far beyond phone or video consultations with doctors or nurses.
Dr Ruth Large, chair of the National Telehealth Leadership Group and an emergency physician at Waikato DHB, says New Zealand achieved perhaps five years of telehealth activity in the few months when Covid was causing lockdowns.
Before lockdown about 5 percent of total consultations were conducted remotely; that rose to around 75 percent during lockdown, with around 5000 practices involved nationwide, and about 500 activated on the national electronic prescribing system in April and May alone. Previously, a physical signature on a prescription was required for most patients going to a pharmacy.
Non-attendance rates at appointments were much smaller, patients did not need to travel, health providers could remain in their home town and there was evidence of less need for bricks and mortar facilities. “What can we do to stop patients coming in in the first place,” Large said on a national health webinar, “especially if they have the burden of chronic illness”.
Outpatient work was mainly by phone rather than video. Online consultations and communications raised issues such as patients’ privacy (a proportion of households had shared email addresses, affecting who could see what), and the lack of an integrated patient record and data on the volume of consultations.
“With telehealth, it’s not okay to say the internet is slow for video,” Large says. “It’s a must-have for rural communities and those who are disadvantaged.”
Once video availability increased, the kind of health service provided could expand beyond simple appointments to diagnosis. “Very few of your final diagnostic bits come from the ‘laying-on of hands’. Most come from talking to your patient.”
The Simpson report suggests major improvements can be made to the health sector’s IT ‘backbone’, saying the many distinct systems and hundreds of applications will never be unified, because of the diverse data needs of different disciplines (lab testing, pharmacies and prescriptions, radiology, for example).
Professor Robin Gauld, co-director of the Centre for Health Systems and Technology and Dean of the business school at the University of Otago, is an advocate for a drastic revamp in the way health’s IT systems serve individual patients. The logistics are complex, but he points to a company like Air New Zealand and the aviation industry for inspiration.
Gauld hopes Covid has “really galvanised the reason for us to think, to have the political, professional and managerial will to put the patient in the hot seat.”
The Simpson report quotes analysis suggesting every hour of every weekday there are around 2000 people waiting in a queue, physically, for an appointment somewhere in the system.
“Assuming there is three hours of time per visit (which is conservative),” it says, “this amounts to 11 million hours of time per year that patients are just travelling or waiting. The magnitude of this time cost alone demonstrates why future service planning should prioritise reducing travel and time costs by offering virtual options where possible.”
There’s a push for the health and education sectors to work more closely to ensure broadband services which have been successfully networked to most of the country’s schools and education facilities – and marae and other community centres – are also extended to clinics or co-located health and education centres.
Simpson recommended short to medium-term capital funding dedicated to digital investments to accelerate “systems that better support new ways of working.”
Beyond online consultations
At UniServices, Kelvin Keh adds another element to the digital thinking for health. “One of the more important things about healthcare is the route [can be] through education, not always through health. In things like non-communicable diseases like obesity or diabetes, we have healthcare solutions for these but education is one of the most effective tools in that.”
That can extend to ‘gamification’. An example: UniServices was involved in developing a tool for young people’s mental health. “The challenge was to package the key messages in a way that can be consumed in a format that will go down a lot better than posters or the stock standard content,” says Keh.
“We did a pilot for teenage kids…. to help moderate depression. The solution? A role playing game, a digital intervention, a game where the user plays and, as you play, it teaches you about resilience.”
The game, Sparx, featured in the BMJ medical journal. “It was designed for teenage kids but open for everyone. It could be used side-by-side with going to see a counsellor, or you could just play the game, because with that particular demographic, going to see a counsellor has some stigma attached to it. Playing a game, no one else needs to know. It doesn’t always have to be super high-tech to be effective.”
That’s just one type of digital innovation.
Problems of access can be addressed to stimulate wider use of personalised, home and community healthcare. Eighty-one percent of New Zealanders own a smartphone but being able to afford to buy data is a challenge for many.
The health ministry, with the Department of Internal Affairs and the country’s telecommunications providers, is piloting ‘zero-rated’ data to consumers for five websites. So, there is free access to certain healthcare online services. “Approaches like this have shown a considerable impact, as well as return on investment overseas,” says the Simpson report, advocating a permanent and expanded use of zero-rated data for New Zealand.
What might hospitals provide in 20-30 years?
If changes in policy and the system of funding health services can be achieved, and investment in technology and community-based services become a reality, what role would hospitals play in such a decentralised health system?
Simpson summarises: “While changing models … should support more care being delivered in the community, hospitals would still play a key role for patients with complex conditions and those who are acutely unwell … The challenge for the health and disability system is to make the changes required to ensure that hospital demand is stemmed to the greatest extent possible.
“The hospital of the future should be better supported by technology, be focused on caring for more complex patients and provide virtual and outreach specialist advice,” it says. “The expectation is that it would also be better integrated into the community so that people could access specialist expertise without needing to visit hospital.
“As some services move out of the hospital, the services that remain are likely to be more highly technical and cater for increasingly complex and frail older populations.”
UniServices’ Kelvin Keh comments: “Essentially the healthcare infrastructure of today will not be able to cope with the burden in 50 years’ time, given the increased lifespan of our populations and associated chronic conditions.
“I expect we will see more forms of personalisation where services are tailored to particular demographics to enable better outcomes. This will likely be a mix of services within clinical settings, at home and in the community.”
Tim Tenbensel says there is much which should be provided in the community, with a more preventive focus like the community-based mental health services. “If not addressed, we are going to continue to have hospitals used in ways that may not be ideal.”
One example he cites is emergency departments, where simply having better community facilities might not move demand from hospitals. “In the short-term it doesn’t necessarily work that way and part of the reason for that is the co-payment issue [where ED is free but primary care centres charge]. It’s not the main reason people turn up to ED but it is still a pretty big reason.”
Figures are not available for what percentage of people attending emergency departments do so because of prohibitive costs at their local or after-hours GP clinics, but anecdotally, as late as November 2020, RNZ reported “Expensive GP visits blamed for pressure on EDs” as a doctors’ union warned of breaking point at some hospitals.
The health ministry’s latest statistical snapshot shows 13.3 percent of adults found themselves prevented from visiting a GP (not ED) due to cost in the 2019/20 year, similar to the figure in 2011/12.
Ranjna Patel believes the Covid-19 crisis has made bureaucrats more willing to consider different approaches, something which had been lacking in the past. Funding for telehealth has been allocated. First, in March, the Government committed $20m to improve video conferencing and telehealth consultations, and in September topped that up with $7.1m more for DHBs and $3.4m for GPs.
What is needed, Patel says, is follow-through. For example, a funding increase for mental health in primary care 15 months ago had only ‘landed’ about two months ago for providers to access.
She says the time is right to think again about big infrastructure spends on hospitals. “The thinking has got to be: ‘Who has what competencies?’ You cannot be building bigger hospitals when there are things they [patients] do not need to go to hospital for.”
Simon Royal of the National Hauora Coalition, a former district health board executive, says there has to be an ambulance at the bottom of the cliff in having a hospital system for emergency and complex care.
“But hospitals burn money. People who don’t work in the health system have no idea of how much money we just burn in the hospital system.”
It’s bigger, too, than ‘health’
For the health system to truly change how it serves the people it will need to achieve public support, political courage, professional flexibility, major technological investment and integrations, and a radical shift to decentralising, personalising and putting patients’ needs first.
Even then, as Royal highlighted at the start of this story, it will first need to address fundamental issues of equity in the way the system is designed and funded and even the way we define ‘health’.
The concept of ‘hauora’ is broader than conventional western definitions of medicine, bringing in all that contributes to the wellbeing of a person or whānau. The NHC’s submission to the Simpson review says the country needs to put aside the narrow view of health in favour of holistic Māori models.
It says there has been significant underfunding or Māori PHOs/providers, and they are prejudiced against by a DHB funding model limiting care across multiple DHB districts, which Māori providers encompass.
A new model should see an independent statutory hauora agency, Māori-led and with a central national presence working with each rohe, or district, with solutions for their populations. The hauora agency could set up a commissioning model to invest in frontline activity on the ground and provide wraparound services for whānau.
In the meantime, before such an agency was established, the NHC advocated direct contracts between the Ministry of Health and Māori providers and stronger equity targets to holds DHBs and PHOs to account for improving Māori health.
Royal says: “We need this in order to break down the artificial silos between different government agencies, which persist despite the evidence of links between housing, income, education and health (to pick a few areas as examples.)”
Pouring more money into the same old structure is not the solution. “Right now, our systems in that regard are quite archaic, in the way they deal with Māori. They are simply not fit-for-purpose, both at a primary care level and secondary and tertiary services. If you are talking seriously about addressing inequality and reducing downstream fiscal costs, this [new models] is the stuff you need to invest in.”
The way ahead
Covid-19 has highlighted the potential for the long-debated shift of resources and services in health away from capital-heavy hospitals towards community and technology solutions. The complex health system was able to respond, in emergency conditions, and experts hope some of that innovation and impetus will continue for lasting change.
If an approach is taken that recognises health services are one element of caring for the community’s overall wellbeing, and addresses the inequity challenges identified by hauora Māori, the benefits for patients in access and cost of care could be significant. A re-targeted investment of taxpayer funds into a mix of hospital, community care, technology and hauora Māori services could finally deliver more efficient spending – if not lowering the total expected need for investment, it could achieve better outcomes for New Zealanders.
Te Waihanga’s paper “Infrastructure under one roof” looks at the role infrastructure can play in improving New Zealanders’ wellbeing. The paper, which is here, is part of Te Waihanga’s work on a 30-year infrastructure strategy to be presented to the Minister for Infrastructure in September 2021.
Read earlier articles in this Newsroom content partnership series with Te Waihanga: