Published in The New Zealand Herald, 5th July 2020
The Health and Disability System Review (known as the “Simpson” Report after the chair, Heather Simpson) was recently published. It draws substantially on submissions from the sector and has been a couple of the years in the making. It is the most substantial review of the sector for about 30 years.
The “Simpson” report has made little impact in Auckland, yet in many respects it presents an opportunity for the region. Firstly, the pandemic has forced health services in the region to operate in novel and more coordinated ways. There is an openness to change. Secondly, the region has flourished as a single “super city” for a decade now. There could be synergies with this structure. Thirdly, primary and community health services are becoming increasingly stretched for Auckland’s lower socio-economic and ethnic minority communities. A combination of health risks – obesity, poor housing, insecure employment and so on – together with inadequate health infrastructure and the incursion of barebones and semi-predatory practice operators means that the most disadvantaged are also in danger of receiving sub-optimal care in the community with the hospital sector picking up the pieces. On these three grounds Auckland stands out as being the one major area in the country that could make the most of the “window of opportunity” offered by the “Simpson” report.
But what are the major recommendations of the report – and are they likely to be implemented?
Its major recommendations, that are likely to be implemented in one form or another, are:
- A new crown entity, Health New Zealand, for central co-ordinating, initiating and planning.
- A Maori Health Authority that has an advisory, planning and advocacy function associated with the Ministry of Health, but without a separate health system budget.
- Fewer DHBs, without elected members.
- Networks: local primary and community health organisations, hospitals and specialist services.
- A recognition of the need for monitoring and enforcing efficiency and effectiveness in the performance of hospital and related services.
- An encouragement to workforce development and training to move towards a competency-based approach to regulation rather than a profession-based focus.
- A data-driven, digitally-enabled ecosystem.
- Improvements to the management of asset and capital expenditure and planning.
It is hard to disagree with any of these proposals, and the pandemic has brought their necessity into sharp relief. But how will they affect Auckland? What potential is there in the report to enable Auckland to try something more clearly tailored to its requirements as a regional health system?
Firstly, there is the impact of the pandemic that has forged the makings of a regional system.
Second, the ten-year existence of a single city, Auckland Council which has within it 21 ready-made communities of interest of 85,000 each that could provide the basis for primary and social care practice networks and community input. As with the Council, these could provide the “step down” from a single regional health authority. There is also the potential for the Council’s regulatory functions in health-related areas to find synergies with the otherwise free-standing Auckland Regional Public Health Service.
Finally, the primary care system in the region is on a cusp with the middle class enjoying high-quality services but low-income and other disadvantaged populations increasingly dealing with barebones corporate and other practices that are struggling financially and professionally to provide adequate levels of care for these otherwise poorly-served groups. Indeed, in the recent pandemic thirty general practices just shut up shop. What other anchor medical specialty dealing with 90 per cent of patient encounters would find itself in this predicament? Quite aside from the sub-optimal service received by these groups, the DHB essentially acts as a provider of last resort through avoidable hospitalisations and late presentations for acute and emergency care because the first line of defence is simply not working well enough. On top of this add a growing and ageing population, chronic illness, and multi-morbidity.
Essentially primary and community care needs to move to a regional system of “health maintenance”, the function of which would be to work closely with specialists and social agencies to keep people out of hospital. This would require a transformation of existing umbrella organisations to a single regional commissioning and active management entity based on a model of leveraged primary care, like the Kaiser Permanente in the United States. Family doctors would need to be recognized as a core specialty with matching salaries, and require physician assistants, and work with multidisciplinary teams.
This is the potential for the region. In other words, the “Simpson” Report is best seen as a starting point for what could be a process of intelligent, long-term reform that could gain bipartisan and stakeholder support. It is a window of opportunity that Auckland should use to the full.
Peter Davis, Emeritus Professor of Population Health and Social Science, University of Auckland, and elected member, Auckland District Health Board.