In April this year, health minister Andrew Little announced a major restructuring of New Zealand’s public health system to take effect in July 2022.
Central to its implementation are business consultants EY whose senior partner Stephen McKernan heads up the government’s transition unit.
His restructuring involves three main changes. Two of the structural changes are establishing a new Māori health authority and public health agency. Both are good initiatives subject to their underpinning values and cultures along with resourcing.
The third is high risk – replacing the 20 district health boards (DHBs) responsible for the funding and provision of health services to defined geographic populations with an even more centralised additional new national bureaucracy. This is poorly thought out and grossly irresponsible in the midst of a threatening pandemic.
But much more important than structure is the values and culture that Andrew Little’s centralisation experiment is expected to be driven by.
These will be the maker or breaker of the new system. The best insight to date of what its values and culture are likely to be is the government’s new health system indicators framework.
There are 12 national initial high-level indicators. Some are still in development – access to primary mental health and addiction services; participation in the National Bowel Screening Programme; percentage of people who say they can get primary care from a GP or nurse when they need it; and the percentage of people who say they felt involved in their own care and treatment with their GP or nurse.
Cloud and haze
Some are arguably noble in aspiration such as the percentage of children who have all their age-appropriate schedule vaccinations by two years; rate of hospital admissions for children and adults (45-64 years) for an illness that might have been prevented or better managed in the community; percentage of under-25-year-olds able to access specialist mental health services within three weeks of referral; acute hospital bed-day rate; and access to hospital planned care.
As heart-warming as these may appear, the most likely outcome is fudged nebulous results partly because of the generalised nature of the wording and partly because the abolition of DHBs are likely to lead to more aggregated results (possibly national only) thereby weakening their usefulness.
Further, some are able to be manipulated by, for example, the way hospital admissions and bed-day rates are coded.
Two further indicators help define the values and culture of Little’s health system – the annual surplus or deficit at financial year-end and the variance between planned budget and year-end actuals. But this excludes consideration of whether government funding is sufficient to meet the pressures on the health system.
Because they are the most measurable, these indicators are the ones that the government can use to be be judgemental about health system performance. The system can be held to account but not the funders of the system (ie, government).
They tell you little about the financial performance of the health system when funding does not cover increasing acute admissions and chronic illnesses (both big cost drivers) driven by external social determinants of health such as overcrowded accommodation and low incomes.
There are also glaring omissions from the indicators framework that speak volumes about the values and culture of the Labour government’s system. A huge omission is the exclusion of unmet patient need (denied access). We desperately need measures of what the health system doesn’t achieve, what doesn’t get done, and of those who did not receive the treatment they need. But the government’s indicators are about numerators (what got done) rather than denominators (estimated number of cases in the community).
For example, as an anaesthetist recently advised me, if we do 1,000 hip replacements we might be doing well, but if we estimate there are 5,000 people out there who should be offered it, we are underperforming.
Another omission is the severe workforce shortages which are having a detrimental effect across the health system and fatiguing health professionals who are the prime driver of health system improvement. Workforce wellbeing through effective retention and recruitment should be an indicator.
Further, there is nothing about the allied need to improve workforce engagement. Most of the expertise and experience necessary for health system improvement is possessed by its marginalised workforce. Strengthened engagement through distributed leadership with the most effective driver of innovation should be an indicator.
One of the biggest drivers of hospital operating costs – and a contributor to DHB deficits – is acute patient demand. This is because acute demand is increasing at a faster rate than population growth. Through its clinically-led engagement between hospital and community, Canterbury was the most successful DHB in addressing this driver. There should be, but isn’t, an indicator on first slowing the rate of increase, and then reducing, acute demand for hospital treatment. The same can be said for rising chronic illnesses. Their omission smells of avoidance of political accountability.
It is difficult to go past access to cancer treatment as an indicator of how well the health system is performing. This is because of the prevalence of cancer as a cause of sickness and death affecting the spectrum from community to hospital. But it is excluded from the new indicators. The fact it can be counted would suggest its exclusion is political.
Shorter stays in emergency departments (six hours maximum) was a successful target under the previous National-led government because it led to hospital-wide system improvements change such as combating bed-blocking). But this is excluded as an indicator. Like access to cancer treatment, shorter ED stays are more measurable and therefore more likely to expose system failures.
The indicators framework suggests a new health system that will have some noble rhetoric but vulnerable to being overly subjective and able to be fudged to the point of being hazy and vague. They are weak on government accountability and distortionary on financial performance.
Rather than improve health system performance they are more likely to rationalise increased top-down centralised decision-making.
At best they are like a child’s school report progress as “could do better” or “has improved”.