Opinion: District health boards were established in January 2001 under the Public Health and Disability Act 2000. They were a relatively new approach to the provision of healthcare, both in New Zealand and internationally.
Before DHBs there was a structural separation in the statutory responsibility for community (including primary) and public hospital health services. What made DHBs different was that their role was to be integrative; that is they were to be responsible for both community and hospital care for their geographically defined populations.
This was innovative and world-leading. However, with the coming into force of the Pae Ora Act 2022, the 2001 Act was repealed, with DHBs abolished.
DHBs were replaced by Health New Zealand – Te Whatu Ora. Being a highly centralised and vertical organisation, unsurprisingly it developed a hierarchical top-down operational culture. This left a vacuum. It was the absence of a local statutory voice for geographically defined populations.
This is important because overwhelmingly community and hospital healthcare was provided within geographic areas for their populations. Local government (city and district councils) are also statutory bodies responsible for geographically defined populations. Increasingly these councils are now having to consider their role in the health of their populations.
Historically local government had statutory responsibilities in population health (such as food and water safety). But involvement in the provision of health services was largely left to the health system itself.
The Pae Ora Act did provide for some involvement. It required new entities called ‘localities’ to be set up. Limited consultation with local government over their establishment was required. However, progress was extraordinarily slow with only a handful of the planned 80 established. By mid-2023 it became clear that localities would be little more than unempowered geographic maps. They are now on hold as the Government works out what to do with them.
Localities did provide an immediate need for local government to consider its role in the new health system. However, in the context of the abolition of DHBs and no comparable replacement, the Local Government Act is much more relevant.
In 2002, the year after the formation of DHBs, the Act was amended to change the purpose of local government by including the promotion of community wellbeing. Local government became statutorily responsible for improving the social, economic, environmental and cultural wellbeing of their communities.
Accessibility to comprehensive community and hospital health services is situated within the core of community wellbeing. This statutory responsibility is not about local government becoming a provider of public health services. Becoming a provider risks the formation of isolated silos and increased fragmentation in the health system.
Instead, in the context of promoting community wellbeing, the role of local government requires advocacy for access to the range of health services their populations need. Several councils are at different stages of recognising this necessity.
The most prominent example was in 2023 with the Dunedin City Council’s private and public advocacy to resist a government decision to reduce the level of services for the planned new Dunedin Hospital. The advocacy focused on the capacity for the new hospital to provide sufficient services to meet its population’s health needs. This advocacy was largely successful, although recent reports of a budget blowout might require a resurrection of this campaign.
A voice for communities’ health needs
The Kāpiti Coast District Council is becoming increasingly proactive about health services accessibility for its population. Even before the decision to abolish DHBs, its mayor K (Guru) Gurunathan formed a committee to advise him on the consequences. (Coincidentally its first chair was local resident Karen Poutasi who subsequently became, briefly, chair of Te Whatu Ora.)
Under current mayor Janet Holborow, this has now become a formal advisory committee to the council thereby strengthening its status. The committee has sub-groups covering access to services, mental health, youth health, public (population) health, and hospital transportation.
Already the advisory committee has successfully recommended that the council urge the Government to reconsider its repeal of anti-smoking legislation, promote measles vaccinations for potentially affected children, and support a petition calling for the retention of Kenepuru after-hours’ services.
Its most ambitious initiative is to develop a compelling case for Te Whatu Ora to establish a polyclinic providing a range of primary, after-hours and less complex non-surgical hospital services.
Kāpiti’s council is also close to finalising a health strategy for its population. It is a higher level document intended to provide a framework for addressing health needs in the district.
One of the most important strengths of a health system is to have the opportunity for voicing the health needs of communities. DHBs did this as well as they could, although the voicing was rarely public because of the level of central government control.
Local government stepping up to this voicing and advocacy role based on its community wellbeing obligations should be welcomed by Health Minister Shane Reti. It would help him in two areas that are presently challenging him.
First, he is keen to devolve decision-making within Te Whatu Ora closer to where healthcare is provided. This is admirable but not easy to put into practice. Local government engagement provides an opportunity to help progress this objective.
Second, for good reason, Reti does not support top-down controlled localities as intended by the former Labour government. At the same time, he wants to enhance local engagement in health services. An expanded local government role in the health system offers a way through this difficulty.
It now falls on local government to fulfil this voicing role through advocacy on behalf of their populations and, where necessary, more publicly than DHBs were able to.
