Developing the New Zealand Health Plan – by elitist desktop analysis?

One of the most important features of the Pae Ora (Healthy Futures) Act 2022, which came into force on 1 July, is the requirement to produce a statutory document called the New Zealand Health Plan.

The Plan is important in that it will state what, where and how healthcare services will be provided in the communities (including general practices) and public hospitals which make up Aotearoa New Zealand’s health system. Both the Plan itself and the process for developing and implementing it are prescribed in the statute.

Pae Ora Act establishes the New Zealand Health Plan as its first function

Section 14 of the Act outlines the functions of the new additional national body, Te Whatu Ora (Health New Zealand). The very first function, hitting the reader right in the eye, is to jointly develop and implement the Plan along with Te Aka Whai Ora (Māori Health Authority).

Section 14 of the Act outlines the functions of the new additional national body, Te Whatu Ora (Health New Zealand). The very first function, hitting the reader right in the eye, is to jointly develop and implement the Plan along with Te Aka Whai Ora (Māori Health Authority).

Government Policy Statement and Health Sector Principles

To better understand the Plan’s context, two other parts of the Act should be considered. The first is the Government Policy Statement on health (GPS) and the second, Health Sector Principles.

The Plan must give effect to the Government determined GPS. Section 34 of the Act says a GPS must be issued at least every three years. Its purpose is to set priorities for the publicly funded health sector and set clear parameters for developing the Plan.

On the other hand, the Health Sector Principles are specified in the Act’s Section 7. They include:

  • equitable health sector ensuring Māori and other population groups have access to services in proportion to their health needs;
  • engagement with Māori, other population groups, and other people to develop and deliver services and pro­grammes that reflect their needs and aspirations;
  • providing Māori with opportunities to exercise deci­sion-making authority on matters of importance to Māori;
  • providing Māori and other population groups with choice of quality services, and
  • protecting and promoting people’s health and wellbeing, including by adopting population health approaches and focusing on the effects of social determinants of health and climate change.

Omission of enhancing integration of healthcare

These principles are laudable, although very general. However, in contrast with the predecessor legislation, there is no reference to enhancing integration between community and hospital healthcare.

This is unfortunate because of its capability to improve the quality of patient care and constrain rising acute demand which, prior to the pandemic, was a major cause of deficits and cancelled planned surgery.

This capability was certainly the experience of the former Canterbury District Health which progressed integrated care more than any other DHB. This was largely through its successfully clinically developed and led heath pathways between community and hospital.

David Meates, Chief Executive of Canterbury, the DHB that advanced integrated care the most

Unfortunately, the inward-looking leadership culture that prevailed at the higher levels of the Ministry of Health delayed the spreading this initiative to other DHBs.

Further progressing integrated care was also make difficult because of the effects of worsening health professional shortages due to sustained underfunding throughout the 2010s.

As for the Plan

The Plan itself is outlined in Sections 50 and 51 of the Act. Its purpose is to provide a three-year costed plan for the delivery of publicly funded services by the two new statutory organisations.

The Plan must contain an assessment of population health needs; identify and prioritise improvements in health outcomes (including measurable outcomes); and describe how health entities will deliver service and investment changes to achieve these improvements.

The devil is in the approach and detail

Again, as with the Health Sector Principles, these are laudable. However, the devil is in both the the approach to the development of the detail and who controls the detail.

Bureaucratic centralism and desktop analysis

The culture that led to the replacement of district health boards with Health New Zealand is best described as bureaucratic centralism. Arguably, the most significant change to the health system from 1 July is that decision-making has moved much further away from the provision of healthcare services and much closer to the national centre.

One of the bedfellows of bureaucratic centralism is desktop analysis. That is, an intelligent person in Auckland can best decide the configuration of healthcare services, both hospital and community, from Northland to Southland.

The underlying assumption is that an intelligent person of this type has more insight than the collective experience and wisdom of health professionals, health managers and communities in Northland to Southland and the districts in between.

Will desktop analysis drive the NZ Health Plan?

It is an interesting that the idea of a national health plan had its geneses in the Health Ministry in the mid to late 2000s when Stephen McKernan was Director-General. At the time, when I was working for the Association of Salaried Medical Specialists, I thought it had merit.

It is an interesting that the idea of a national health plan had its geneses in the Health Ministry in the mid to late 2000s when Stephen McKernan was Director-General. At the time, when I was working for the Association of Salaried Medical Specialists, I thought it had merit.

Recently I learnt from a respected former DHB chief medical officer that when it was being promoted in his DHB once one drilled beneath the soundbite the understanding behind the initiative was superficial.

There was little understanding of what the healthcare needs of geographically defined populations were. It was he who coined the term desktop analysis and I’ve plagiarised it ever since.

However, this geneses didn’t survive McKernan’s departure as Director-General. It was picked up on in the Heather Simpson led review of the health and disability system (2020) and followed through by the Government’s health restructuring transition unit headed by Ernst & Young senior partner Stephen McKernan.

Stephen McKernan: considered to have promoted desktop analysis approach to earlier version of health plan in 2000s; now EY senior partner chairing health restructuring transition unit

Elitism at its best!

I have simplified desktop analysis above. But, the critical point is that decision by desktop analysis increases the risk of the services provided at, say, Gisborne Hospital being arbitrarily downsized in the name of rationalisation in a national health plan.

Te Whatu Ora now controls the public hospitals. Owing to this direct relationship along with their size and scope, it is more likely that planned changes to their configuration will appear before change happens in the provision of community healthcare, including through general practices.

But, for community healthcare services, control is still there. Localities established under the Pae Ora Act can be expected to play a big role in community-based healthcare. Localities can enable structural changes to primary healthcare, in particular, which appears to be a target of Minister of Health Andrew Little.

The mechanism could be the locality plans that localities are required to have. The Act specifically gives Te Whatu Ora responsibility for determining both the localities and their locality plans.

Rob Campbell, Chair of Te Whatu Ora: the ball is in your court Rob; just saying!

If, on the other hand, Health New Zealand makes the break to an engagement culture that is substantive rather than formalistic consultation, and recognises that the real expertise about health system improvement resides with those at the clinical and diagnostic workplaces and in communities, then health professionals will have reason to feel relieved.

If the culture of Te Whatu Ora is the same as that which created it, then health professionals in both community and hospital healthcare have much to fear for their patients and the health of the wider public.

If, on the other hand, Health New Zealand makes the break to an engagement culture that is substantive rather than formalistic consultation, and recognises that the real expertise about health system improvement resides with those at the clinical and diagnostic workplaces and in communities, then health professionals will have reason to feel relieved.

As a starting point business consultants should have no role in the Plan’s development; not just Ernst & Young for obvious conflict of interest issues. The ball is in Te Whatu Ora’s court (if government allows it to hit it to the engagement culture court, that is).

[This is a modified version of my column published by New Zealand Doctor on 3 August]

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