Exclusive: The sacked health chair offers some forthright advice to his successor on addressing extensive waste, resolving recruitment, retention and pay anomalies, and partnering with the wider health sector.
Opinion: Te Whatu Ora is at the very beginning of its journey towards Pae Ora healthy futures. While not chair, I will be on that journey along with the rest of our population. It is very important to us all, and to later generations, that this journey is a success and does not take longer than is absolutely necessary. I share these thoughts as a private citizen, though all are matters I have advocated from within.
The initial period has been one focused significantly on getting governance and senior management structures established for the largest corporate entity we have. Not only is this amalgamating a large number of organisations and their separate systems and processes, but it is also and necessarily a shift to a much more efficient and modern corporate structure. That is not fully done but the path is set. That now has to be promptly completed and management systems activated around accountable performance targets.
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There remains extensive waste, both pre-existing within each part and resulting from duplication (multiplication) across the system. The plan for eliminating this has to be put into action now along with the disestablishment of many hundreds of overhead roles. This is capable now of creating room for a shift of hundreds of millions of dollars from overhead to front line expenditure. There will be future waves of such change but the first big shift must happen now.
We have not yet been able to resolve recruitment, retention and pay anomalies across the wider health system with something like a quarter of a million roles. Much faster progress is required on pay equity, pay parity and other outstanding claims. This will require more government funding now but it will substitute for more funding later in rectification and costs being met in care standards and staff stress.
Equally important is that the historical relationships with staff, their professional organisations, and (critically) their unions must be swiftly enhanced. The immediate need is for genuine partnership to do this together not in negotiation, arbitration or even consultation. Together means together in partnership.
One fault in the Pae Ora structure is that the property/physical infrastructure functions should have been more clearly separated out into a body providing and maintaining infrastructure to the operating body and required to meet its clinical and other service demands. This would have focused governance, planning, financing and delivery much more efficiently.
It would also have freed operating and clinical management and governance to clarify and press for their needs and options. It is an area in which private or social finance and/or delivery could have a useful role. This separation, while not an immediate option, should be addressed promptly by the Government.
Training and occupational regulation needs a lot more funding and attention. Te Whatu Ora will need to own this and force the shifts in thinking we need. At present, progress is slow. This again may mean taking risks, including political risks, by openly pressing for the right actions.
I am concerned about the relationship between Te Whatu Ora and the wider or “primary” sector. It has been very hard to shake this away from a very transactional set of relationships that Te Whatu Ora inherited, especially from the ministry. Those relationships, even in transactional terms, are clumsy and poorly structured and delivered.
I would like to see much more partnership with social and private agencies, with personnel switching between the roles. It may be that in time the locality frameworks being developed will provide a base for that, but many such agencies are national in nature and these frameworks will not carry the resources (in their early years at least) to play this role.
Te Whatu Ora has to be promptly and inclusively taking the lead, often relinquishing control to get to an effective funding and delivery position. It does not have the resource to do it all itself and cannot command if full energetic commitment from others is wanted. I know the best people in Te Whatu Ora know and want this, but they need to be allowed to and encouraged (or more).
I think an early issue is to shift more funding to kaupapa Māori health services. If no new money is made available, Te Whatu Ora must lead by shifting existing funding across to direct or co-management faster than has happened so far
There are groups who feel they have not been heard in the process so far – a number of multi-ethnic communities, disabled communities, LGBTQI, and even groups such as women’s health advocates. There are many others – we are a complex and diverse society. I know from talking with them that a wide range of groups feel this way. One wrote to me saying “your people say we are hard to reach but it is your people who are hard to reach”.
Our current systems do not meet these diverse needs. Again, the best people within Te Whatu Ora know this and want it to change. To access and benefit from health care, our services, our systems, our feel and look, have to meet these aspirations. This has to be led from the top and has to include a real shift of spend and taking risks. If Te Whatu Ora waits for Manatū Hauora to develop policy or for staff reluctantly transferred from prior roles to activate around new targets, it will fall short.
Training and occupational regulation needs a lot more funding and attention. Again, working this through the thicket of bodies and rules is working against a fast or far enough outcome. Te Whatu Ora will need to own this and force the shifts in thinking we need. At present, progress is slow. This again may mean taking risks, including political risks, by openly pressing for the right actions.
Finally, and without apology, the issue of Māori health equity. I won’t bang on about the facts. The Pae Ora legislation gives Māori voice and influence within a Crown structure. That is not enough to satisfy Māori aspirations in terms of the putea or mana motuhake. But it is a start, as are the Iwi-Māori partnership boards.
To me this is a very exciting area for progress in our health system. There are really great people working on it and Te Aka Whai Ora has a really good and appropriate board. I think an early issue is to shift more funding to kaupapa Māori health services. If no new money is made available, Te Whatu Ora must lead by shifting existing funding across to direct or co-management faster than has happened so far. This will help not only Māori but also the many working-class tangata tiriti who currently choose to access kaupapa Māori health services.
