New Health Minister Dr David Clark has announced a highly significant and wide-ranging review of health and disability services. It includes district health boards but goes beyond them to include primary health organisations (PHOs) and the wider primary sector. The draft terms of reference are broad and open to public consultation, a positive approach that compares well with past government initiatives.
The chair is Heather Simpson (the rest of the review group is yet to be appointed). Given her role as the highly influential senior adviser to Helen Clark in her different roles, especially as a three-term prime minister, this appointment is open to political attack.
But it must be remembered that in a previous life she was an academic health economist. Further, she was centrally involved in the construction of the current legislation that created DHBs and replaced the commercial business model that had previously governed our public health service. She knows the principles our current Act is based on more than most, and no one, including political opponents, criticises the quality of her brain cells.
This doesn’t mean ASMS will not have differences with some of the things her taskforce proposes. We may well do. But whatever that might be, it is likely to be considered, and not lacking in intellectual grunt.
The review deserves to be welcomed, but with caution, depending on which way the review and the Health Minister’s expectations go (hence the cartoon).
New Zealand’s public health system, compared with universal systems around the globe, performs very well. It punches above its weight. But there are difficulties, much of which are due to sustained under-funding in a sector affected by continuing and increasing demand (especially acute and chronic). The Government advises us that it intends to address this during its occupancy of the Treasury benches. It is off to an encouraging start, but one year of reasonable funding does not make up for eight previous years of under-funding.
Relational community and hospital continuum of care
There are processes and leadership culture that also constrain the effectiveness of our system.
There is too much focus on primary and secondary care as somehow something being organically separate, leading to narrow constructs of ‘primary-led’ and ‘shifting services’ from the former to the latter. The focus is structural, rather than relational. Instead, the emphasis should be relational based on the continuum of care between community and hospital.
The most mature example of this is the several hundred health pathways between community and hospital (broader than just primary and secondary) at Canterbury DHB. These have been developed and agreed through effective clinical leadership (not just doctors) in both community and hospital. As a result, the outcomes are much more robust, despite serious workforce capacity issues (shortages) amongst specialists at least.
Centred on distributed clinical leadership, good relationship-based networking and patient-centred care, they have led to considerable gains both in the quality and accessibility of patient care and financial performance. This includes the unparalleled experience of bending the curve of increasing acute demand.
This doesn’t mean that we don’t have disagreements with Canterbury DHB over engagement; we do. But this experience confirms the importance of this low transaction cost relational approach instead of the high transaction cost contractual and structural approach. Critical to its success is the leadership culture developing these pathways (distributed clinical leadership), its networking approach and the focus on patient-centred care.
The Minister’s review needs to focus on improving processes through a relational lens (sometimes called alliancing). This is not just through the networking approach between community and hospital, but also between DHBs sub-regionally, regionally and nationally. Clinically developed and led networks between public hospitals have achieved proven success in Scotland and New South Wales. We have made some progress in New Zealand but are way short of realising the potential.
For this to happen, however, we need to increase the capacity of the health professional workforce. This includes specialists who face (through leadership neglect from government to DHB) a crisis as they suffer worsening chronic shortages, burnout, presenteeism and retention loss. The review should consider making explicit in the legislation an obligation on DHBs to ensure workforce empowerment and the wellbeing and health of those they employ.
Avoid the structural focus please, minister
But there are some alarm bells. Dr Clark has intimated in a couple of public utterances on a more structural approach; specifically, the number of DHBs.
Further, medical sociologist Professor Peter Davis has argued that we should go back to the short-lived structures of four regional health authorities of the mid-1990s when the government of the day tried to run our public hospitals as commercial businesses competing with themselves and the private sector. These four authorities controlled the funding for this competitive model that subsequently collapsed under its own ideological absurdity.
I suspect Professor Davis is not proposing a return to this failed business model. It would be contrary to his own previously articulated views on this failed attempt to create a commercial market in a universal public health service. But, simplistically, he seems to be advocating for reducing our 20 DHBs to four, presumably based on the four regional groupings of DHBs we currently know as Northern, Midland, Central and South Island.
There are several problems with this approach. DHBs are responsible for defined populations. These four populations are too big and dispersed for a DHB to have an effective operational focus in both community and hospital care. It is too big an ask.
Look at how difficult the relatively new Southern DHB (the result of a top-down driven merger between Otago and Southland) is finding addressing the health needs of the most geographical dispersed defined population of all our 20 DHBs.
If the objective is to improve integration in the continuum of care between community (why would it not be otherwise), then smaller is better. Where there is more than one general practice voice or PHO in our 20 DHBs, it has proven very difficult to achieve the gains that have been made in the Canterbury DHB (which has the added advantage of one GP voice to engage with; Pegasus). Creating four mammoths will severely impede this objective.
Structure is not the determinant of clinical collaboration between DHBs. There are already good examples of this happening now. One that hits me in the eye is the very small West Coast DHB and the very large Canterbury DHB, separated by a huge mountain range. There are longstanding historical roots to this collaboration but in recent years it has qualitatively advanced beyond Canterbury specialists doing lists or clinics on the Coast. Services on both sides of the Alps function in a more integrative way than before, with an encouraging Transalpine feel emerging. A big brother-small brother relationship would not have allowed this.
This is still a journey but the road map is good. But it is being achieved under two DHBs rather than through a merger (although they share some senior management functions). If it had been a merger, it most likely would have fallen short. What has been important is that by having its own DHB, the West Coast and its senior medical officers (SMOs) have had a greater voice which has benefited all.
Our current four regional boundaries are somewhat artificial. Largely historical, they do not neatly capture natural clinical synergies between DHBs. For example, while Whanganui DHB has a need to consider a close relationship with its near neighbour MidCentral, particularly vulnerable smaller services and sharing critical mass, in respect of patient referrals its clinical synergies are further north in Auckland and further south in Wellington.
Merging DHBs does not of itself save money, or at least not enough to be worth the considerable hassle and disruption. Didn’t the top-down driven merger of the former Otago and Southland DHBs into the new Southern DHB work well financially with its sustained high level of debt? The politically driven failed attempt to merge by stealth the three lower North Island DHBs – Wairarapa, Hutt Valley and Capital & Coast – led only to uncertainty and a level of havoc.
The practical outcome of this review focusing on the number of DHBs will be a distraction from what is really needed to improve our public system. It would create uncertainty over the future for many working in DHBs, particularly the smaller and medium-sized ones, even greater than the poorly judged Health Benefits Ltd initiative of the former Government. The political risk of such an approach, with the next election in 2020, is high.
Only policy wonks with their heads in the clouds and their feet well away from the clinical front line would contemplate going down such a short-sighted direction.
National and local health systems
A feature of all universal health systems is the tension between their internal
local and national systems. All health systems struggle with getting the balance right between what works best locally, regionally and nationally. Arguably, universal health systems are too dynamic to get the balance right.
But it is not the struggle that is the issue. Instead it is the quality and robustness of the struggle; the better this quality and robustness, the better for our system overall.
The reality is that we have defined geographic populations with variable diversity of needs as part of a national system. Each depends on and interacts with the other. It is logical, given its defined population, for example, to speak of a Northland health system. Conversely, it is illogical to speak of a northern health system comprising the three quite diverse metro DHBs in Auckland and the Northland DHB.
In this context, the review would be better placed to consider how the operational role of the Ministry of Health might be better refined to facilitate (perhaps even direct) DHBs to focus on clinically-led, relational-based networking within and between DHBs, and across the community-hospital continuum.
Review must not become rationale for procrastination or delay
There is also a risk of the Government allowing shorter term exigencies to either be dumped in the bucket of the review’s scope or continuing to be ignored.
These include the crisis facing the DHB specialist workforce referred to above, and the lost opportunities caused by the failure to advance distributed clinical leadership. Both of these were glaring omissions from David Clark’s first Letter of Expectations to DHBs in April. It is imperative that if the Minister is to be genuinely rather than rhetorically transformational, that he focuses on addressing them post haste.
Ian Powell is the executive director of the Association of Salaried Medical Specialists (ASMS). This opinion article was first published as a column in the latest issue of the ASMS magazine The Specialist. The Chris Slane cartoon featured on the cover of the latest issue.