Published on stuff.co.nz, 24th September 2019
OPINION: The interim report of the health and disability review panel confirms much of what we already know:
OPINION: The interim report of the health and disability review panel confirms much of what we already know: while the New Zealand system performs adequately by international comparison, it is overly complex and lacks national coherence, its performance is not well monitored and enhanced, primary care and population health lag, digital technologies are underdeveloped and at odds with each other and there is a lack of responsiveness to Māori and Pasifika. And, overall, the system needs “future proofing”.
So, the health and disability system “ain’t broke” – but it still needs fixing.
Take complexity and national coherence, for example. We have 20 district health boards, 30 public health organisations (PHOs), 80 hospital facilities, thousands of other agencies, and multiple funding streams – all for a population of fewer than five million. We somehow muddle through, and our health statistics are internationally competitive, but this system seems wasteful and not tenable over the long haul.
Emblematic of this lack of strategic direction is a recent news item that DHB deficits are set to expand to about $500 million for the year, a substantial sum on a total annual health budget of about $20 billion. Perhaps this is to be expected after a decade of a funding squeeze, and the current Government is to be applauded for its allocations to health.
But hospital services seem to be the main beneficiaries at a time when we should be reorienting to primary health services and social care in the community.
This approach is already working overseas. For example, Denmark – a country of a similar population size – has reduced the number of hospitals over the past 20 years from 98 to 32. This involved moving to a greatly expanded primary care system. In other words, the hospital of the future is likely to be devoted to dealing only with those conditions – mainly acute or life-threatening or highly complex – that cannot be addressed outside its walls.
This is also consistent with health and demographic trends. We are getting to the stage where we are reaching the biological maximum of people’s lives; this means that the returns to increasing life expectancy are declining and we need to concentrate on improving the quality of people’s lives. This requires different skills and resources that lie in the primary, community, intermediate and social care sectors.
It is also more consistent with the Māori world view in emphasising less the Western medical model of active intervention at time of medical need and more the nurturing of well-being.
So, how might we progress this agenda?
Complexity and coherence. We could return to four regional health “boards” (Northern, Midlands, Central, Southern), with the chief executives of these boards meeting regularly as an executive chaired by the director-general of Health. This would provide the necessary strategic and operational oversight to the system. A remodelled Ministry of Health and Social Care would retain its policy role for the sector.
This executive should oversee the national screening and other population health programmes, a Pharmac extended to all health technology assessments, and a Quality and Safety Commission that should take on a broader, public and more active mandate on the performance of the health system.
In addition, the executive should have power to oversee and manage the digital commons of our health system. This would equate to the UK’s NHS Digital; that is, centrally harnessing and co-ordinating health IT platforms and initiatives for the benefit of patients and clinicians.
The key substantive development should, however, be devolved – in primary, community, social and intermediate care. This is the “sleeping giant” of the New Zealand system. These sectors need joining up and knitting together. We took great initiatives in the development of primary health organisations, but have not progressed since.
The UK is introducing primary health networks to service populations of about 50,000. We should do something similar with, say, primary health and social care organisations, which would be enhanced practice networks, the principal objective of which would be to nurture the health, well-being and social care needs of their designated practice populations and to keep them out of hospital.
There are elements of all of these operating at present, but we need to bring it together.
A major part of that would mean committing to more functional alliance arrangements between hospital and non-hospital sectors across the country, under the aegis of four regional health boards.
As for “future proofing” – the Australians have financially underpinned their primary health care sector with a Medicare levy; that looks a lot like an ACC-style social insurance scheme. We could do the same with a modification to current arrangements.
And central government needs to look again at the primary care funding formula in order to facilitate new and more efficient models of care while retaining continuity of care.
Dr Peter Davis is Emeritus Professor of Population Health and Social Science at the University of Auckland.