Political opposites Ian Powell and Heather Roy take the temperature of the country’s unitary health body
Aotearoa New Zealand’s health system was restructured effective from July 1, 2022 with the coming into force of the Pae Ora (Healthy Futures) Act.
There are three main features of this restructure – the abolition of the district health board system by replacing the 20 DHBs with a new national body called Te Whatu Ora; the establishment of the Māori health authority Te Aka Whai Ora; and the establishment of the Public Health Agency as a directorate within the Ministry of Health. The Ministry of Health is significantly downsized as a consequence of the establishment of Te Whatu Ora.
The main focus of this paper is how best Te Whatu Ora can achieve quality healthcare and wellbeing which is equitable, comprehensive, available, accessible, and cost-effective. In our view it can best achieve this by putting patients at the centre as the starting point.
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The establishment of both Te Aka Whai Ora and the Public Health Agency are not the subject of this document. Both are positive initiatives. But both could have functioned, as established, without abolishing DHBs. Neither are magic bullets, however.
The Māori Health Authority’s major focus is on community healthcare and wellbeing in the context of inequities. Expectations are high on what it might achieve which may create problems. It has the potential to improve accessibility to healthcare services providing that it is practically focused.
To be really effective an advocacy role will also be important. Advocating for government policies and legislation to address the effects of social determinants of health will benefit all susceptible New Zealanders, not just Māori.
The establishment of the PHA recognises the importance of the health system focusing on population as well as personal health. This importance was highlighted by Aotearoa’s pandemic response, particularly from March 2020 to September 2021. Its expertise in advising on how best to address social determinants of health will be critical.
As a separate directorate located within the restructured Ministry of Health, it must not be allowed to be marginalised. The culture within which PHA operates will need to be conducive for it providing frank advice and the opportunity to forward this to relevant cabinet ministers.
The writers come from different and often conflicting places on the political spectrum. But this is not a compromise paper. Instead it reflects our pragmatic, shared understanding of the best way forward for Te Whatu Ora given the nature of the health system New Zealand now has.
Disestablishing DHBs and replacing them with a unitary Health New Zealand is not the system we would have put in place. One of the successes of DHBs was their ability to understand and, subject to funding and other central government constraints, address the needs of their defined local populations. A centralised healthcare system is most unlikely to consider nuanced local populations’ needs and we are concerned this loss of understanding will impact best patient care.
But, given the structure that now exists, we want to constructively promote and encourage for debate how HNZ can do the best for both patients and the health of populations. How can HNZ best address the key challenges of the healthcare and wellbeing of New Zealanders in this new system?
In other words, as a consequence of it assuming the planning and funding functions previously held by the Ministry of Health and the DHBs, Te Whatu Ora needs to be sharply focused on ensuring the best possible patient-centred care (both access and quality).
Patient-centred care leads logically into adapting the principle of subsidiarity to the new system. Subsidiarity is a little-used term in New Zealand. But it is widely known in Europe as the basis of the relationship between the European Union and its member states. The basic premise, in summary, is that decisions should be made locally unless it makes better sense to make them nationally (or regionally). However, ‘national’ is the ‘higher authority’.
Patient-centred care and subsidiarity are followed by integrated care between communities and hospitals, a culture based on high engagement through distributed leadership, ensuring sufficient workforce capacity, external social determinants of healthcare, and localities. They are followed by major capital works, medicines, and generalism and sub-specialism in specialist medicine.
This paper deliberately does not discuss funding as an issue to be addressed by Te Whatu Ora. Obviously funding needs to be at a level sufficient to ensure the wellbeing and safety of both New Zealanders and the health workforce. However, it is not discussed in this paper because it is too early to assess the adequacy of health funding in the July 1, 2022-June 30, 2023 Budget.
Further substantive discussion at this point would distract from the key challenges now facing HNZ. But we have a capacity and capability concern. HNZ must ensure that the new system has the capacity and capabilities, including workforce, to operationalise the Budget’s increased health funding. These requirements currently do not exist, at least not sufficiently.
However, while not discussing funding other than the above introductory comments, it will be important that Te Whatu Ora develops its strategies and actions through an investment lens. Investment in the health workforce is an investment in improving the capabilities for innovation and systems improvement which enables a more effective spend of the health dollar.
Investing in greater access to new and proven medicines is an investment in improving the quality of people’s lives, and reducing current costs to the health system, especially in relation to chronic conditions. Further, the International Monetary Fund has long-recognised that investing in health is good for the economy of developed countries.
Patient-centred care
Our starting point for Te Whatu Ora should be patient-centred care, which is broader than, but includes, patient outcomes. The extent to which care is enabled to be patient-centred, the better the outcomes for patients.
Patient-centred care means treating a patient with dignity and respect and involving them in all decisions about their health. It is linked to patient’s rights to timely access to quality healthcare. The principles include:
- treating patients with dignity, respect and compassion;
- communicating, coordinating and, where applicable, sharing patients’ care between appointments and different services over time, including between primary and secondary care;
- tailoring care to suit patients’ needs and what they want to achieve;
- supporting patients to better understand and learn about their health;
- empowering patients find ways to get better, look after themselves and stay independent; and
- involving patients in their healthcare decisions at all times.
To achieve patient-centred care requires sufficient workforce capacity and capabilities to work in an integrated manner. But it is more than just how patients are treated by health professionals. It is also about how community care providers, hospitals, and the Government create and support policies to put patients, rather than organisations, at the centre of care.
Principle of subsidiarity
The principle of subsidiarity goes to the heart of ensuring patient-centred care. A major problem confronting Te Whatu Ora is the loss of this principle. This was a central feature of the Social Security Act 1938, which established Aotearoa’s universal public health system, and continued through changes over time to the ways in which healthcare was delivered, to the New Zealand Public Health and Disability Act 2001.
Subsidiarity underpins the relationship between central and local government in New Zealand. This includes the health system from the implementation of the 1938 Act up until the Pae Ora Act. This principle recognised that healthcare was primarily delivered locally rather than nationally or regionally, largely through general practices and hospitals.
Consequently a statutory point of decision-making was established at the more local level. Local structures changed over the years from hospital boards to area health boards to Crown health enterprises (later renamed hospital and health services) and finally to district health boards.
Area health boards and district health boards had a wider public health and community healthcare responsibility than the other hospital based structures. But, in all cases, these different structures were local statutory points of decision-making.
The Pae Ora Act involves a significant shift in the point of statutory decision-making by removing it locally and centralising it. But healthcare, including by hospitals, will continue to be primarily locally delivered. From a system of statutory decision-making that was both vertical (health ministry to DHBs) and horizontal (between hospital and communities), we now have a decision-making system that is much more vertical.
The challenge for Te Whatu Ora is that most healthcare innovation, service design and configuration, and implementation are done locally by health professionals through what is, in effect, continuous quality improvement. This goes to the core of sustainable systems improvement.
If it is to enhance its ability to achieve its objectives, Te Whatu Ora will need to adapt as part of its culture to the principle of subsidiarity. Adapting subsidiarity to its strategic and operational functioning should be, as much as practically possible under the Pae Ora Act, on the basis of policy.
Part two of this series, published tomorrow, identifies a structural weakness that may stifle healthcare improvements
