The health reforms were so big it seemed sensible to sit back and wait and collect what different people were saying about them.
Firstly, below is a comprehensive response from a CDHB staff member who has been involved in health for decades. I have agreed to keep their name confidential.
Here is what they wrote:
Andrew Little appears convinced the announced restructuring of the health system will achieve major improvements in equity, consistency, and health outcomes. However, there is absolutely no explanation of how this will happen.
The announcement of health reforms was accompanied by the usual positive PR support to justify why the changes needed to occur. However, the response has been muted with a lot of commentators saying the devil will be in the detail. Having spoken with a wide range of people associated with health, one thing that is clear is that many people are terrified to speak up and express an opinion / view or even raise questions out of fear of being identified as “not supporting” the reforms.
If you listen very carefully to the announcements, Little said the reform was “about doing better with what we have”. However, it is not realistic to think significant improvement will happen without additional funding. This does raise the interesting question of where, and whom, the Minister got his advice. The transitional health authority overseeing the implementation of the reforms is led by none other than by Stephen McKernan (an EY partner – his analysis incorrectly identifying that there were 500 to many nurses at Christchurch Hospital gives you some feel about the confidence of the analysis that he has previously provided) and a team made up with a large number of consultants. This perhaps explains the comments from the Minister that there are too many IT and HR departments and that is where the savings will come from.
Already around the country (and including Canterbury) hospitals are full to over flowing – the biggest issue being a lack of resources and not fit for purpose facilities. In that context the recently announced health reforms have now become a structural reform that will distract the health sector, which is already under enormous pressure from continuing to provide the care that their communities need.
While the rhetoric about a “not fit for purpose” system has grown momentum and has been perpetuated, most of the barriers to DHBs working have been due to lack of effective policy development (a core function of the MOH), lack of capability, a failure of leadership in MOH/ Treasury and some DHB’s. Health continues to be used as a political point scoring football; siloed funding from central government and a lack of investment – most of these actually sit outside of the domain of DHB’s!
DHBs are some of the largest organisations in NZ, e.g., ADHB alone is the same size as the NZ Police Force. CDHB and West Coast DHBs together are the same size as the NZ Police Force. To think that combining IT and HR systems is going to provide a magical fix is naïve – these require massive investment and are multi-year projects of significant complexity
There is already a connected patient record called “HealthOne” across the whole South Island covering a population of just over 1.0m people, which connects General Practice, Community Pharmacies and Hospitals with clinical information. This has been in place for a number of years. The only reason it hasn’t been further rolled out has been the lack of capability in central agencies (MOH / Treasury), and political will. Single information systems don’t require a structure change to make them happen – it just requires a government to mandate standards. The 5 South Island DHBs are already on track to have “one signal” hospital-based IT systems. All 5 DHBs will be on that system later this year – the only DHBs in the country to have made this happen.
This was led by the old leadership of the CDHB a number of years ago to connect the whole of the South Island with the same system. This enabled clinical records to be available no matter where you were being treated. This is the sort of strategic leadership you might have normally expected from central agencies and government.
Central bureaucracies have been tried before in NZ. RHA’s (Regional Health Authorities / National Health Board) being just two recent examples. They didn’t work because they lose relevance to local communities and become clumsy and inefficient. That is why DHBs were created – to become the vehicle for local service integration. There are NO health systems in the world that work in effective control and command structures – and there is a very good reason for that. They just don’t work.
It is hard to fathom why NZ is trying to follow the NHS (the Minister made explicit reference to the NHS) when the NHS is now mandating Integrated Care Systems be established to better reflect the needs of communities. They are adopting the equivalent of DHB’s which in NZ we are about to get rid of. The concept of a single commissioner running all of the hospitals from the centre is a complete fiction.
So, by changing structures, NZ is going to achieve a different set of outcomes, using the same people. This ignores the fact that the NZ Health System is already internationally regarded as one of the most efficient and cost effective health systems in the OECD. What has been very clear in NZ is that there is a lack of capability / competency in bringing strategy to reality. Too often those with the capabilities and competencies have already left. Central agencies have been so many times the biggest barrier to change, innovation and outcomes.
Health interests and needs of the Southland community are totally different that the Northland community. That is why you need different responses and ways of delivering care. Central bureaucracies are very effective at driving everything to the lowest common denominator, and so often cause more harm than good.
The direction of the proposed policy appears to be based on a shallow understanding of international health systems which are being used as a justification and the desire to “command and control”. Culture and integration come from local relationships based on partnership and trust NOT mandated from a remote central agency.
If you think this splendid defence of the essence of devolved responsibility in health is wrong, then read these commentators.
Firstly, read what Ian Powell, former Executive Director of the Association of Salaried Medical Specialists for over 30 years, had to say:
Andrew Little claimed that the restructuring follows the United Kingdom health system known as the National Health Service (NHS). His business consultants have poorly advised him. The NHS is not the model to follow as it is in a mess and was so before Covid-19. Further, there are attempts to reform the NHS by moving to new ‘integrated care systems’ which have strong similarities with our DHBs. The British government is presently looking to introduce legislation to give effect to this. As New Zealand moves closer to the UK system, the UK moves closer to ours!
The Government is going down the path of basing health decision-making on increased centralised bureaucracy. This further removes communities and health professionals in DHBs from decision-making. Instead, decision-making will become more top-down from Wellington (sometimes via the four regional branches) and consequently more wrong decisions made. In this context local innovation will be a casualty. Canterbury DHB’s successfully health pathways between community and hospital would not have got off the ground in Little’s new system.
Abolition of DHBs will not lead to a reduction of bureaucracy. It will just reposition it. The Health Ministry will be downsized to policy but two new bureaucracies also requiring their own policy brains will be established. Hospitals will still require management structures. In the absence of DHBs locality networks will also require some level of management support.
In hindsight it is now clear that the Government was complicit in the Health Ministry and Ernst & Young’s hatchet job on Canterbury DHB last year and that this heralds the kind of leadership culture that we can expect from the restructured system. It would not be surprising if the word Stalinist becomes used to describe its decision-making over time.
The biggest beneficiaries of the abolition of DHBs will be bureaucratic centralists, business consultants who stand to make a killing, and the National Party who have been given a potential electoral game-changer. The biggest losers are patients with a new structure conducive to enabling service reduction, health professionals more likely to be further marginalised, a fatigued workforce with a further removed decision-making process, and local innovation.
Here’s the article:
Kathy Spencer was Deputy Director General in the Ministry of Health, a General Manager in ACC, and a Manager in the Treasury. She has also worked as a Senior Adviser to a Minister of Health and a Minister of Revenue. Her comments are summarised in the final paragraphs of her article:
Instead of being diverted into legislative change, organisational charts, and shuffling people from one organisation into another, the effort and energy should be focussed on solving the most important problems.
- Identify the highest priorities for improving access and outcomes for Māori; set a target of removing the disparities within two years; commit to everyone being able to see a GP within seven days for a routine appointment.
- Recruit GPs to parts of the country with poor access. Bring them in now, through the quarantine system, while NZ is a particularly desirable place to live.
- Develop a unified IT system across the health sector so health records are readily available wherever people are treated.
- Get visibility back by reinstating regular public reporting on the system’s performance, including access to GPs, timeliness of specialist appointments and planned surgeries, satisfaction with disability support services, and reports on how the large injection of funding into mental health is being used.
These are the areas that need actioning, not a major restructure that will take everyone’s focus off the end game.
Brian Easton – Economist
I rather liked this summary of centralisation by Brian Easton:
You almost certainly know of such failures in your locality, but the most recent spectacular one has been at the Canterbury DHB where a first-class leadership team was unaccountably destroyed. Some of the factors driving the disaster seem to have been the failure of the centre’s funding of the earthquake-hit DHB, its responsibility for the new acute services bloc new building which suffered severe cost overruns (which were then dumped on the DHB) and the appointment of powerful advocates of the central government agenda to overcome the sustained resistance by the previous Board and its executive team to this agenda.
It is likely that such things will happen again under the new regime. Despite its brilliant handling of the Covid Crisis, there is little confidence that the Ministry of Health is one of our better government agencies (at a time when there is much pessimism about the quality of the public service generally). I have wondered whether a covert purpose of the re-disorganisation between the Ministry and the Health New Zealand is to improve the functioning of the ministry. If it works, it will be welcome.
The failure to acknowledge that the centralisers will make errors – grievous errors – is why the designers think there is no need to build the public’s involvement into the new system. It is unnecessary if you never make mistakes,
If one never acknowledges mistakes, one never learns from them. There have not only been poor appointments to DHBs but some of the appointments to the ministry itself (and of ministers) have also been poor quality. Not to mention that what happens when a minister takes over who is unsympathetic to the principles underlying the system and systematically undermines them, as has happened. Should we design a system so heavily dependent upon such people at the centre?
When mistakes happen, you won’t even be able to picket your local DHB.
Bryce Edwards– Political Scientist
The mental health example doesn’t bode well for the just Announced health changes. After much hype about a brave new future mental health across the country would appear to be going backwards. I think when people really step back and understand what has been proposed there will be a lot of very disappointed people
Nuffield Trust UK –
This summary is interesting and scary. Central bureaucracies don’t seem to ever learn. These articles give an international perspective as to why the new direction towards health in NZ is likely to fail and be more costly, the impact of “optimism” bias and consultants. When systems fail, the consultants who recommended the structural change are nowhere to be found.