Published in The Post, 20 August 2024
Health has been in the headlines recently, for all the wrong reasons. It would be easy to shrug your shoulders and assume that it’s all too complicated and that nothing much can be done. But there are quite practical things that can be done that would go some distance to giving us greater confidence that the system is working as it should.
- Maintain health funding in real terms, say 9-10 per cent of GDP. Aside from the pandemic and a major restructure, we are still to an extent suffering from static or declining health funding in real terms through the 2010s. Maintaining and increasing health funding are necessary both to meet the requirements of an ageing society and to reassure the public of good faith. How to do it? We are too reliant on income tax and should expand our social security/social insurance funding system as many other countries do. Extending ACC from accidents to illness would do this.
- Empower “the sleeping giant” of primary health care. General practice and primary and community health have so much to offer, and yet are the poor relations in a hospital-oriented system. Medical graduates should not be expected to take a drop in earning power to enter general practice, and the same goes for allied health professionals. Their principal job should be to keep people sufficiently healthy and robust so that they do not end up knocking on the door of the nearest hospital. They should be equipped and incentivised to that end.
- Reform medical training. In many other places there are four-year medical school programmes with graduate entry, in contrast to New Zealand’s six-year, school-entry system. Introducing this would increase our output by half, and likely change the calibre of entrants with a greater chance of finding those with an interest in general practice. It is also rather extraordinary that our doctors can leave so soon after training. We should consider a bonding system for repayment, particularly for newly-minted specialists who decide to leave. That repayment could fund a replacement training position.
- Use associate health professionals more. Many of the waits in our system are due to a scarcity not of doctors but of associates such as anaeshetic and medical imaging technologists. In my view this deserve more attention from the authorities than it gets. We should also be using nurse practitioners more, we might allow dental therapists to work outside the school system, and we should look at physician assistants. All of these can increase graduate productivity.
- Enhance the “back office” enablers. A large part of the future of health care is digital, virtual, remote, online, and AI-enhanced. These enablers could in time amount to 30-50 per cent of all health care contacts, with major productivity pay-offs. This opportunity requires careful management to ensure patient satisfaction and care effectiveness, but we are just starting.
- How about a seven-day a week health system? It is striking that much of the health system operates on a five-day week, with hospitals and practices at much lower ebb on week-ends. And yet it as at week-ends that people can find the time to attend to their health care needs. It should be possible to find ways of stretching the availability of hospital and practice facilities, if only to offset the cumulation of “out-of-hour” visits at emergency and urgent departments, both acute and non-acute.
- Improve productivity and performance. The government has introduced performance targets. If followed through with resources and appropriate management, this has potential. And yet we do not have a measure of productivity in our health system, unlike the UK for example. With care the use of such measures can help. For example, surgeons in the UK are trialling a “high-intensity theatre” approach with two parallel teams that can hugely increase throughput.
- Expand the role of the Health Quality and Safety Commission (HQSC). Would you not like to know how effective your local practice, rest home, or hospital was, using accepted metrics respectively of, say, immunisation rates, occurrence of bed sores, or rates of hospital-acquired infection? It is startling that we require public ratings on food outlets but not health facilities, at least not that you as a patient or consumer would know. The HQSC could do a useful job here.
- Shift the balance of Te Whatu Ora from Wellington to the four regions. The system cannot be run from Wellington. There are four well-established regions. These should be the energy focus of the system. They could be integrated care systems with a board, defined budget and managerial responsibility and accountability, encouraging coordination and efficiency. We could have a central executive of these four regional leaders chaired by the CEO of the Ministry of Health.
Find and back your clinical leaders. There will be clinical leaders coming forward in primary and community care and in the hospital system prepared to take risks and advance a progressive agenda for the health system. We should back them.
There is talk of “deals” between central government and cities. We need one for health. We need a new social contract, one that secures the funding, but in return expects changes that improve the quality and performance of our health system.
Peter Davis, Emeritus Professor of Population Health and Social Science, the University of Auckland, and former elected member at the Auckland District Health Board.
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You talk about extending the ACC type service/system to cover illness. The Woodhouse report, which prompted the development of ACC, recommended that the service be extended to include cover for illness. Certainly, expanding the service to cover illness would be great but funding it would be a challenge.
You talk also of some bonding of medical students/graduates to keep them practicing in NZ. There was a scheme whereby medical students could get supplementary funding (a bursary) while studying in exchange for a commitment to work where directed by the Health Department. It must have been in the late 1960’s that one beneficiary of the scheme refused to work where directed by the Department – the case went to court and the practitioner was released from the requirement to work where directed by the Department. That was the end of the scheme. Any universal bonding scheme must not restrict young doctors wanting to pursue specialist careers from gaining international experience.
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Thanks for your comments (from quite some time ago). If we were to extend ACC, I would see it as focused on delivering a solid underpinning to non-hospital services, particularly primary care. In Australia they have a medicare levy which is 1% of incomes (?), which pretty much does that job. There are other approaches, like getting those commercial products that affect our health adversely to pick up the tab for the work the health system has to do via some actuarially-determined levy (as ACC does with accidents). As for bonds, well that is never going to happen! But I think it ridiculous that we are producing health professionals courtesy of a major taxpayer subsidy, and they can just go overseas no questions asked and without any responsibility either to reimburse some of that subsidy (depending on who long they stay in NZ) or are required to return. Yes, there are student fees, but the last estimate I saw suggested that they amounted to about a third of what it really costs to produce a fully-trained NZ medical graduate.
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All really great ideas especially like the ACC one
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Agree with al of this but the one that would have the most impact is immediate better funding of primary/community health. I am involved in a national NGO deliverer and we are starved of funds – can’t compete with hospital pay. Yet the primary system in totality if it was funded so it worked to capacity would take immense pressure off secondary/tertiary.
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I agree, but this sector has to organise itself and show ambition. In the early days the GP leaders opposed Labour governments trying to bring down costs in primary care. Remember they took Bassett to court. I think they are more open to it now, particularly as they realise that there is a greater threat from corporates than from the government. One thing would be to remove the funding control from the DHB structure. With the four RHAs the funding was dictated from the RHA with a funding/delivery split, and that at least provided the opportunity for conversations to be had in an independent fashion about the interface between community and hospital. I am a metrics person. Could one follow up patients admitted to hospital with a preventable condition and see whether their provider could have avoided that admission, with help? When I first had contact with the hospital board back in the 1970s and 1980s I remember a thing called the extra-mural hospital. Could that not be an area for cooperation?
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Hi Peter
I have some questions:
Regards
Jane
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On the first. Yes, I have heard that. But I find it hard to believe that people of goodwill in the health system cannot work something out, and there are years in which that can happen. I guess the university halts its sense of responsibility once graduates leave, but then it is up to the colleges to address this.
On the second. We need a measure of productivity. It has to be quality-adjusted, so that it’s not just increasing output without taking account of quality improvement at the same time. The NHS has suffered under a regime of austerity for a long time, so I don’t think we can attribute that to productivity. But I did argue in my piece that the government of the day has to act in good faith by underpinning an acceptable level of funding, and then work on various measures for raising performance – rather than using cost cutting and austerity as the starting point for those initiatives.
On the third. While on Auckland DHB it was obvious that the digital infrastructure was in a bad way: the immunisation register was close to collapse, all digital systems were past their use by date and mostly no longer supported by the original vendor, and in the community none of the digital systems were interoperable. Because of cost-cutting capital investment in such things as digital infrascructure are raided for clinical tasks.
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