The madness of health system restructuring in a pandemic

Three main pillars were described in the ‘health reforms’ for New Zealand’s health system announced by Minister of Health Andrew Little in April. The ‘reforms’ are being lined up to take effect in July next year.

Two of these pillars make good sense and have the potential to help improve the health system’s effectiveness including addressing the biggest driver of demand and cost – external social determinants of health. They are establishing a Māori Health Authority and a new public health agency.

These organisations’ effectiveness will be influenced by how the system functions at an operational level, and here is where the third pillar comes into play – disestablishing the 20 district health boards (DHBs). They are to be replaced by a new second additional health bureaucracy, Health New Zealand.

The abolition announcement was a complete surprise to the health sector. It was not part of the narrative around the review of the health and disability system, led by Heather Simpson, nor of the lead-up to Mr Little’s announcement. Simpson recommended both that Health NZ be created and DHBs continue although the number would be reduced.

What are DHBs?

DHBs arose out of the Public Health and Disability Act 2000. They were established to replace the failed market experiment in the 1990s to run the health system as competing commercial businesses. The Act rejected business competition and promoted cooperation (including integration between community and hospital care).

The 2000 Act expressly requires DHBs to be responsible for the health and wellbeing of people in specified geographic areas (described as “resident populations”). Aside from the short interlude of area health boards (late 1980s to 1993), for the first time the one structure, DHBs, took statutory responsibility for primary, community and hospital care.

DHBs being responsible for geographically defined populations and for promoting the integration of all community – including GP and aged residential care – and hospital health services has been a strength of our public health system. This includes the obligation to “regularly investigate, assess, and monitor the health status of its resident population”.

Structurally, this gives New Zealand’s public health system significant advantages over many other modern health systems, including those of Australia and England where, for different reasons, community and hospital care are much less integrated. It also made the health system better able to implement a pandemic vaccine rollout.

Narrative failure

There was a failure to develop a narrative to justify abolishing the DHBs. Instead, soundbites were produced based on an embellished claim that New Zealand has 20 different health systems, as well as a factually inaccurate assertion that abolishing DHBs was consistent with the National Health Service in the United Kingdom.

The reason for this failure was that the decision to abolish DHBs was made late in the process. It appears to have gained traction when business consultants Ernst & Young (EY) got into the engine room of decision-making. (The reforms’ Transition Unit is led by EY senior partner Stephen McKernan.)

DHB abolition was never part of Labour’s election campaign in 2020. Instead it was disingenuously kept secret right up to the April announcement. The combination of this lateness and the failure to engage with the health sector in advance of the decision greatly affected its robustness.

Rushed law-making is scrambled and, therefore, flawed law-making.

‘Localities’ and ‘locality plans’ lacking in detail

The Pae Ora (Healthy Futures) Bill has been referred to a select committee. The Bill establishes Health NZ to “lead system operations, planning, commissioning and delivery of health services, working with the Māori Health Authority”.

After its own establishment next July, Health NZ will also establish new bodies called “localities” to “plan and commission” primary and community health services. Apart from covering geographically defined populations, localities are undefined. What they are and how they will work is omitted.

Instead, without context, we are left with vacuous statements like engaging with communities “at the appropriate level”. It will be left for Health NZ to determine, further down the track and with the agreement of the Māori Health Authority, what these localities will be.

This is alarming because the purpose of localities is to arrange primary and community health services covering all of Aotearoa. Currently this is the responsibility of DHBs.

Health NZ will then develop “locality plans”. As well as including nationally determined decisions such as a national health plan, locality plans will set out the priority outcomes and services for the locality.

Potentially, these locality plans are important. But it is clear they will be directed and determined by Health NZ. This signals a much more centralised system than we currently have.

No one seems to know what localities and locality planning mean or look like. The Bill recognises this problem by ignoring it. Both were recommended in the Simpson review but with only a brief explanation.

Consequently there will be no identifiable local structure to take responsibility for primary and community health services next July when DHBs are abolished.

The madness of poor leadership

So, DHBs are to be abolished in new legislation that is vacuous on primary and community care and virtually silent on hospitals (other than public hospitals being run by Health NZ).

Replacing existing structures with new ones that have not been worked through demonstrates poor political leadership and governance irresponsibility. Before leaving the health system we have, we should know much more about what we are going to.

What makes it even more irresponsible, if this were possible, is to do this in the midst of an out-of-control pandemic overseas. Whether or not the newly discovered and quickly running rampant Omicron variant is more deadly than Delta remains to be seen. It is certainly more transmissible.

Two things are certain, however. First, if Omicron gets beyond our border isolation and quarantine facilities (as all earlier variants have eventually done) into community transmission both our general practices (and other primary care providers) and hospitals will be overrun.

Second, at not too long after DHBs have been abolished (if not before), a new variant more deadly or transmissible than delta and omicron will emerge in New Zealand. It is a question of when, not if.

Aotearoa will need to continue to reach communities for booster vaccinations and potentially new vaccines for newer Covid variants. Existing DHBs are better placed to do this than a new, much more centralised structure led by newbie bodies with key parts that will still to have be worked out after it comes into force.

These DHBs will know their populations much better than Health NZ, particularly in the absence of any alternative such as the currently vacuous new localities. Since the arrival of delta in the country the vaccine rollout has been very impressive and protective.

Especially when central government implementation constraints have ceased, DHBs have been critical to this in penetrating deep into diverse communities and working with non-government providers.

Conscious of public safety, accessibility to healthcare, and the wellbeing of health professionals and other staff, a responsible government would put the abolition of DHBs on hold at least until there is a better understanding and consensus over what any workable and robust replacement might look like.

The reasons for discontinuing the abolition of DHBs are as self-evident as the United States Declaration of Independence was to Thomas Jefferson.

[This is a revised version of my column published by New Zealand Doctor published on 15 December 2021]

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