Will the proposed health changes make a difference in Auckland? The short answer is – no; unless, the proposed commissioning (contracting and funding) powers get to be located at the level of the region rather than the centre, and unless those same powers stretch right across the funding spectrum to include not just hospital services but all those services delivered in the community by health providers and NGOs, many of which – such as Plunket and midwives – operate autonomously.
Auckland is host to competently-run public hospital services that, partly as a result of COVID, are increasingly working, with Northland, as a regional network – as envisaged in the proposed health changes. Auckland is also host to two of the most significant networks of providers of general practice services, with ProCare run on professional lines with 200 practices and Tamaki Healthcare a corporate with nearly 50 clinics. Again, these are consistent with the proposed health changes.
With the abolition of the District Health Boards (DHBs), the centre of gravity in Auckland and Northland inevitably moves to the regional level. Furthermore, as the management of COVID in Auckland shows, organizing a regional system from Wellington can produce unforced errors and shortcomings that, with media amplification, very easily become an embarrassment to central government.
The argument for a regional presence in Auckland, advised by local stakeholders including Maori and Pacifika, is therefore a strong one. But it would be a missed opportunity if it were left to the current regional actors in hospital and primary care services, competent and well-tested as they might be.
If we had a properly-resourced regional commissioning agency, it could make quite a difference to the shape of hospital services. We might use hospital facilities more efficiently (including at weekends), such as expensive theatre time, equipment and beds, instead of building and buying new capacity. The trend towards fewer in-person outpatient and other visits in favour of contacts conducted virtually would hasten. There could be a greater blurring of some technical roles and a determined attempt to work with the educational sector on more flexible personnel. Much more “hospital work” could be done at home and with family doctors. These is the potential.
But by far the greatest possibility comes with non-hospital services. Under the existing model, rather than the “health” in the DHB moniker leading to a liberation and empowerment of non-hospital services, it instead disguised the fact that these services were overshadowed by the almost exclusive focus of management on effectively running their resource-intensive hospital services. By putting hospital services exclusively back under management control as they were in the 1990s, the non-hospital sector has “got out from under” and has a better chance of flourishing.
There are three challenges that primary and community care need to meet: integration of care between the current multiplicity of providers and funders; “levelling up”, so that we can bring up levels of service provided to lower socio-economic and other disadvantaged groups to match those currently enjoyed by more affluent suburbs; and keeping people out of hospital with sound after-hours cover, prevention of treatable hospital admissions, and early intervention for a range of conditions like diabetes that threaten to get out of hand. A regional commissioning agency prepared to add payment-for-performance criteria to standard methods could, over a period of years and with central government support, make a difference in these areas.
There will still be an important role for the new central health agency, Health New Zealand. For example, we might finally get a seamless IT and digital infrastructure that can replace our current patchwork with a national system that serves in real time anybody, anywhere, regardless of condition and provider. We will also, with Health New Zealand, have a coordinated national programme of capital investment, workforce development, specialist networks, and screening services across the spectrum.
There is a good chance these regional and national initiatives could draw bipartisan support.
What will we not get with the proposed health changes? We are unlikely to get marked improvements in life and health expectancy, particularly for the most disadvantaged. That requires vigorous public policy on housing, income maintenance, education, job safety and security, and public hygiene and environmental standards. It also requires a public health response that goes well beyond the proposed public health agency to tackling the drivers of disease from the food and beverage industries in the consumption of tobacco, alcohol, sugar, saturated fats, salt, fast foods and so on.
Also, with the proposed health changes, we will not get an end to shortage of service and unmet need. The demand for health care is hard to satisfy, and we will never have the supply to meet it fully. That is something that will not change, no matter who is in charge.
Emeritus Professor in Population Health and Social Science, University of Auckland.