Building tension as policy bakers seek perfect recipe for health sector cake

Imagine you are a contestant on My Kitchen Rules, and you are asked to invent a new variety of cake for which there is no recipe.

There’s quite a bit to get your head around, depending on how experienced you are generally as a cake maker. So, think about the range of skills you will need. You’ll need to envisage your ideal cake, and this requires some experience of knowing what sort of cakes people like, what ingredients are compatible, and which mixes to avoid.

So quite a lot must go right to pull off whatever cake the Transition Unit, Mr Little and the rest of Cabinet are concocting

You’ll need experience in cake-making techniques, sifting, mixing and getting the icing the right consistency. Finally, you’ll need some way of knowing whether you have the right amount of ingredients, and be able to make adjustments.

Over the next year or two, the Government will be creating some sort of new health system cake.

The word “commissioning” is on many lips as we await early indicators of the Government and health minister Andrew Little’s thinking around a Māori Health Authority, the role of the proposed Health New Zealand, and/or regional authorities or super-sized DHBs.

While there is a discernible appetite in the health sector for a new type of cake, we shouldn’t underestimate the size of the challenge. Health policy reform is monumentally difficult to pull off in most settings in most times. In a recent book on health policy reform, which I co-edited, we looked at the experience of reform in 12 countries, and even in countries that managed to “pull it off”, successes typically involved high stress, some tears and even the odd flesh wound.

By “pulling it off” I don’t just mean passing legislation, I mean the whole nine yards of seeing a major change through and achieving the policy objectives that motivated reform in the first place. “Policy capacity” refers to the competencies and capabilities that are needed to make and implement policy decisions.

There are three main areas of policy capacity – political, operational and analytical. In any policy area, there are very different ideas of what constitutes a good cake, so it is always worthwhile assuming that any proposal for major change will generate some level of opposition. This opposition may come from groups that know their interests will be adversely affected.

It could come from stakeholders who don’t agree with the policy objectives. It could come from those who have no problem with the ends, but object to the ingredients chosen. Or it could simply come from fear of change and the unknown. Political capacity is the ability to overcome such opposition.

There are two divergent routes to political capacity.

The first is to prevail despite the presence of opposition. The second is to win over opposing voices by bringing them into a broader coalition.

The design of New Zealand’s political system with its single house of Parliament, and no states or provinces to make things messy, makes the first strategy very tempting.

In other political systems with more institutional checks and balances, building a winning coalition of support is generally a much more effective strategy, despite the convolutions and compromises involved. However, the institutional free kick, that governments get in New
Zealand, often does not lead to beautiful cakes because of what actually happens later in the kitchen.

This is where operational capacity comes in. This refers to the competencies of our publicly funded health system to turn policy reform decisions into practice.

Creating commissioning entities such as a Māori Health Authority or Health New Zealand, and then having them fulfil their roles, will require people and organisations that can coordinate governmental and non-governmental activity.

Our sous chefs in the Ministry of Health and DHBs have well-developed skill sets in stipulating, managing and monitoring contracts. But the soft managerial and leadership skills that involve building trust and building workable coalitions locally are skills that are in relatively short supply in government agencies, but probably more readily available in the Māori health and social service sector after 10 years of whānau ora.

Even when there is ample political and operational capacity, the cake might be a flop because our sous chefs mightn’t have the right equipment for measuring ingredients, or the experience to make adjustments on the fly.

Epidemiological data and health service utilisation data are hugely important pieces required to underpin commissioning of health services for populations. Yet it takes a lot of resourcing and effort to put this information together, and there remain large information gaps due to limitations in data sharing and IT compatibility issues.

Analytical capacity also requires intelligence about what communities, whānau, patients and service users want and need – and we do not
yet have sophisticated systems for gathering this information and plugging it in to decision-making at the local or national level.

Policy capacity also requires political, operational and analytical resources to be available at all levels of the system, from individual managers, to networks of organisations at the local level, to the whole national health system. The interim report of the Health and Disability System Review Panel noted how these resources are spread too thinly.

So quite a lot must go right to pull off whatever cake the transition unit, Mr Little and the rest of Cabinet are concocting. If there are weaknesses in our health policy capacity, then there may need to be some trade-offs between going for an ideal that is extremely challenging to implement, and something that is less of a stretch given the skill sets and resources we have.

I’ll certainly be tuning in to future episodes of My Health Policy Kitchen Rules even though the tension is already killing me.

Tim Tenbensel is associate professor, health policy, in the School of Population Health at the University of Auckland