Right now, our health system is in desperate need of critical focus on priorities and a more disciplined approach to execution. Members of the Health and Disability System Review Panel and Māori Equity Advisory group examine the areas the next elected government should be focusing on.
Comment: It is hard to remember an election in New Zealand which took place in a more uncertain and troubled global and local context. Now is a time for leadership and vision to bring us together to address critical economic, health, social and cultural issues.
We must expect and demand nothing less from our leaders and we must be prepared to consider new solutions and fresh thinking.
Health was always going to be highly politicised in this election year. Health sector groups compete to amplify their own legitimate concerns around workforce, resourcing, risk and pressure across the system. This noise confuses the public and dilutes prioritisation, focus and investment as officials jump between responding to various issues and crises. At times it appears like policy and decisions are driven by news cycles.
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Perhaps more concerning has been the narrative around Māori and Pacific leadership as the cause of social unrest and division rather than the antidote to improving long-standing unfairness in health outcomes for these marginalised populations. Attacks on the legitimacy of the new government agency, Te Aka Whai Ora (the Māori Health Authority), are one example of negative framing of Māori leadership.
The government elected in October will need to produce evidence-informed plans and policies that back up their election rhetoric and promises.
A long-term vision for the health system which all parties sign up to is vital if we are to improve access to quality health services and drive fair health outcomes for New Zealanders. Some countries like Denmark are leading the way in signing cross-party leadership collaboratives where 20-25-year health plans are agreed, developed and implemented.
The Health System Review panel (2018-2020) led by Heather Simpson spent two years reviewing the history of New Zealand’s health system and performance and comparing this to other similar health systems around the world.
There are some significant differences between what the panel recommended, and the reforms that were implemented. Most notably the panel recommended less structural change (moving to eight-12 DHBs not to one single entity) and envisaged a stronger focus and investment in comprehensive primary and community care.
It is too early to expect this massive reform (arguably one of the largest in New Zealand’s recent public sector history) to have delivered any real change and anyone trying to sell the view that a series of short-term sprints or bringing doctors in from overseas will fix our health system woes simply lacks knowledge about the complexity of the system.
We should now however expect to see signs that the health system is heading in the right direction. It is complex, but not impossible to fix, especially if we engage with the notion that we have the leadership, great local innovation, and some proven service models right here in our own backyard.
If we heeded the evidence that emerged from the Health System Review, health leaders and decision makers would focus on these six critical areas.
- Hold new leadership to account for delivering on culture and behaviour change in the health system. Any call to ‘restructure the restructure’ doesn’t make sense because embarking on further structural changes (particularly in a short period of time) would be catastrophic in terms of expense, uncertainty, health service delivery and staff morale. But the focus needs to shift from the centre and development of capability in Wellington out to those delivering services. If changes are to be made within the new health entities, we should aim for stronger prioritisation and clarity about leadership roles, decision making rights and commissioning models. Questions around what services should be provided nationally, regionally and locally to deliver best care and outcomes are not new and are fundamental to resourcing and workforce decisions.
Leaders need to join up the various components of change across the system and make more transparent the timeline and master plan for this change to better engage clinical leaders and health service providers. It is critical that a plan is communicated and then progress against this plan is tracked with the focus on delivery and performance. It is essential that Te Whatu Ora commissions services across the full spectrum from community-based to tertiary care and does not become by default a large hospital board. Te Aka Whai Ora must continue to focus on capability to deliver high quality commissioning and Te Manatῡ Hauora must put a spotlight on overall system policy and strategy. This includes speedier decision-making and clarity on monitoring roles across they system.
- Strengthen primary health care. The system’s leaders and stewards must develop and implement a sophisticated primary health care strategy and a sustainable funding model that builds real capability into more accessible community-based health care, where service models reflect local need. They need to review the investment gap that exists for general practice and related services and consider a mix of ownership models that are truly fit to meet the needs of priority populations. NZ will be unable to shift services out of hospitals into communities until we build this early intervention and prevention capability into primary care, as is occurring in the most responsive health systems around the world. This includes investing in sustainable and ‘large-scale’ te ao Māori-inspired models of care.
- Integrate health and social care more effectively. Care must be integrated and funding models simplified at a community level for those with high and complex care needs. There should be a refocus on wrap-around care and support services that work on doing whatever it takes to get people into longer-term affordable housing and employment while connecting them back into communities and support systems. Bold policies are needed to develop state-provided care for low-income communities, such as dental care and optometry.
- Implement the health workforce strategy. Leaders must move quickly to implement the new health workforce strategies. Lack of action has caused apathy and the drain of healthcare talent and the morale of the very people we need to champion change of front-line services. Both the composition and the skills of the workforce must be considered as important and these must be augmented with a new unified digital health strategy and delivery to complement face-to-face services. Te Whatu Ora, Te Aka Whai Ora and Te Manatū Hauora need to create more opportunities for health workforce leaders who want to be agile to work in new ways, and to prioritise leadership roles with authority so they can try, and model, new ways of working. The cultural safety and competence of the entire workforce must be boosted.
- Monitor and report on population health outcomes through the lens of fairness. This approach has an impact on many New Zealanders including economically marginalised populations like Māori, Pacific, poor etc who have the highest healthcare needs. Fairness is a unifier. When we take fairness as the lens through which strategy and service delivery are viewed, all New Zealanders stand to gain. As an example, the Rongoā Māori services funded by Te Aka Whai Ora and ACC are being accessed in approximately 40 percent of cases by non-Māori. The gap in mental health services is significant and affects all New Zealanders and what we want here are fairness-based interventions and approaches providing benefit for all. Fairness is not a zero-sum game as some have tried to argue. Fairness has the potential to be a great unifier at a time when unity is desperately needed in health and more broadly.
- Strengthen and sustain Māori leadership. After a standing start, Te Aka Whai Ora is the innovative and agile building block in the system for improving services and outcomes of communities with high unmet needs. Year two must be focused on execution-excellence including fine tuning technical knowledge and skills to deliver on strategic intent. Building on this new leadership and capability, the emerging Iwi Māori Partnership Boards must be empowered to be active and influential players in the system, not just commentators or monitors.
Te Aka Whai Ora and Te Whatu Ora must research and showcase the services and approaches that are proven to work and actively share and scale these across the country. There is a further opportunity for Te Aka Whai Ora to become a broader system integrator, driving collaborations between agencies that have an impact on the social determinants of health (housing, education, sport, employment etc). Te Aka Whai Ora must not be positioned as an ‘equity backstop’ but as a leader and valued partner in innovative new ways to commission, monitor, drive policy and system-wide practices to ‘turn the fairness dial’ and ensure the voices of whānau are elevated to inform system and service design and delivery that will make a sustained difference. This is the way to turn the tide from intergenerational unfairness to fairness (as a steppingstone towards wellbeing).
Shelley Campbell (Ngāpuhi, Ngāti Hine) served on the Health and Disability System Review, which advocated for the development of a Māori health authority, and is the CEO for Wise Group. She is a lecturer on Ngā Manukura (Clinical Leadership training programme for Māori Nurses and Midwives) and the Leadership for Māori in Public Health programme.
Professor Peter Crampton (Pākehā) is a public health researcher at the University of Otago. He served on the Health and Disability System Review, which advocated for the development of a Māori health authority. He is a member of the board of Te Tāhū Hauora (Health Quality and Safety Commission) and is a member of the Public Health Advisory Committee.
Sharon Shea (Ngāti Ranginui, Ngāti Hine, Ngāti Haua, Ngāti Hako) served as the Chair of the Māori Expert Advisory Group that supported the panel of the Health and Disability System Review, which advocated for the development of a Māori Health Authority. Sharon also served on the boards of Te Aka Whai Ora (the Māori Health Authority) and Te Whatu Ora (Health New Zealand) for 2.5 years. Sharon is the CEO of Shea Pita & Associates Ltd (an indigenous consultancy firm) and Manawaroa Ltd (a health and wellbeing provider).
Dr Lloyd McCann (Cape Coloured) served on the Health and Disability System Review, which advocated for the development of a Māori health authority, and is the CEO for Tāmaki Health.
Dr Win Bennett (Pākehā) served on the Health and Disability System Review, which advocated for the development of a Māori health authority.
