Last April Minister of Health made a major health system announcement comprising three central features to take effect in July next year. It confirmed the establishment of the Maori Health Authority as proposed by the Heather Simpson convened review of the health and disability system but with stronger powers than the review recommended. Second, a new crown agency is to be established responsible for public (population) health.
I support both of these decisions. They are not restructuring as such but structural adaptations designed to help better address needs of equity and preventative wellbeing. National responsibility for both Maori and population health presently resides within the Health Ministry. But the Ministry isn’t considered fit-for-purpose to give them sufficient focus. The new public health agency was not proposed by the Simpson review but had been advocated for some time. Neither announcement from the Minister came from left-field.
What are DHBs
Regardless of one’s view of these two decisions the aspiration is to sharpen the health system’s focus and performance rather than restructure it. It is the third central feature that involves restructuring – the abolition of district health boards (DHBs) and their replacement by a new national large health bureaucracy (in addition to the health ministry) currently labelled Health New Zealand with four regional offices.
DHBs are the statutory authorities responsible for ensuring the provision of health and disability services, from community to hospital based, for geographically defined populations. This includes funding and planning services consistent with a health needs analysis of their populations. DHBs don’t function simply as localised entities. They are part of a national health system with a high level of central leadership both politically and from the Health Ministry.
DHBs are consistent with a long tradition of local government, both internationally and in New Zealand, based on the principle of subsidiarity (this is a principle that the many policy wonks that make up this government appear to have forgotten). In essence and in a political context, the principle is that a central authority should have a subsidiary function, performing only those tasks which cannot be performed at a more local level.
Design or structures
When considering the effectiveness of a health system there are two alternative starting points – design or structures. If the starting point is the former then the chances of an improved health system are greater; if it’s the latter the chances are low. Once design is worked out any structural change to better enable the design can follow.
An example of design coming first was then Health Minister Annette King’s Public Health and Disability Act 2000. Part of its design was to replace the previous system premised on running the public health system as competitive commercial businesses with public hospitals run by state-owned companies to a system based on a cooperative and public good ethos. King’s design involved removing the coverage of the system by the Companies and Commerce Acts.
Another key element of the design was to address barriers arising out of the formal separation between community (including general practices) and hospital care by an integrated whole of population health approach.
The structural change that followed this design was the formation of DHBs responsible for ensuring the provision of both community and hospital health services for geographically defined populations.
In abolishing DHBs Little went straight to structural change rather than design. There were soundbites but they don’t constitute design. There was nothing to suggest DHB abolition in Labour’s election manifestos of 2017 or 2020. When in opposition under Little’s leadership, Labour had defended DHBs from criticism including that of the Health Ministry. There was no public discourse from government or anyone else prior to the April announcement.
Heather Simpson’s review didn’t hold DHBs responsible for its identified problems in the health system. It did correctly identify the lack of national cohesiveness as a problem but its main solution was national structural change. The review did recommend a reduction in the number of DHBs. But it still saw the continuation of DHBs responsible for geographically defined populations as central to the effectiveness of the health system.
Little’s announcement was a left-field decision developed very late in the process without engagement. It caught everyone outside the inner circle by surprise. There was no mandate for it or even an earlier narrative justifying it. There was no design to explain it.
Where’s the opposition
The decision to abolish DHBs and replace them with a new centralised national bureaucracy in which decision-making will be further removed from health professionals and communities was both abrupt and drastic.
But there have been few voices expressing public concern or opposition. Some of this is due to the clever nature of the Health Minister’s April restructuring announcement. As another former retired union leader observed to me, it had a bit of something for many – those who didn’t like DHBs, those who liked the Māori Health Authority, and those who liked the new public health crown agency. This had an obscuring effect.
Further, in effect, DHBs had become the scapegoats for unpopular or poorly thought out government decisions because they (rather than government or the health ministry) still had to publicly front them. DHBs have been the statutory fall-guys for political decisions and actions.
The new Public Service Act in 2020 brought DHBs under the direction of the Public Service Commission (replacing the State Services Commission). This meant that DHB staff including chief executives became public servants. The effect is a silencing consequence.
DHBs themselves are silenced despite the considerable level of experience and expertise they have within their ranks. This is compounded by Board chairs and deputy chairs, along with several other board members, being government appointees. Even elected members are bound by strong controls. Central government control is not new but is strengthened by the 2020 Act.
Contrast this with the vigorous critical response from local government to the Government’s water management where the accountability of councils is to those who elect them. On the other hand, DHBs responsibilities are to the Public Service Commission and Health Ministry on behalf of government.
There is a naïve belief that abolishing DHBs is a move to a much cherished national public health system based on the erroneous claim that we have 20 different health systems. Many find this attractive. But it is a badly misplaced conclusion.
The public health system since 1938 has always been national with a significant degree of central control including through legislation, funding and policy decisions. It is a national system strengthened by a strong focus of local governance and provision consistent with the principle of subsidiarity.
Among many in the health system there is a sense of inevitability of DHB abolition reinforced by a first time majority government under MMP. There is also an associated high level of cynicism. Many see it, with justification, as another moving of the ship’s deckchairs.
Distinguishing soundbites and substance
While it appears that the Health Minister has been very clever with his intention to abolish DHBs, it is important to distinguish between soundbites and substance, and the ability of people to make this distinction.
The main problems facing our public health system include the lack of an effective strategy to address external social determinants of health, severe workforce shortages, equipment and facility rundown and shortages, lack of a strong workforce engagement culture (most of the intellectual capital to generate systems improvement exists with its health professionals), and leadership capabilities at a national level.
Nothing in Little’s abolition of DHBs will address these problems post-next July. Instead abolition will distract the attention that they should be given. To cap it all off, he is doing this at a time when the country is being whacked by a deadly pandemic likely to be made worse by the increased pressures on the hospitals and the rest of the health system arising out of the Government’s decision to move away from zero tolerance of community transmission (the elimination strategy) not to be confused with zero tolerance or automatically equated with lockdowns.
The cleverness of the Minister’s announcement is too clever by half. Many in the health system already know this. It is only a matter of time before many of the public also know it.