Beatling on: He may be a dreamer

It’s sobering that the Dutch story is the only example of blueprint health-policy change in the four countries over a 70-year period

Imagine you’re a health minister. It’s easy if you try. No opposition to scare you. Your limit is the sky. Okay, back to reality – what do governments really need to think about when they want to reform the health system? How far should they go? And how fast?

New Zealand’s experience over the past 30 years has oscillated between “big-bang” changes – both large scale and fast-paced (the early 1990s and 2001) and the small-scale and slow-paced pattern of incremental change since then. We know that big-bang changes have the advantages of coherence and not being weighed down by compromise. They have the disadvantages of being highly disruptive, generating widespread opposition due to many interests being disaffected, and they are easily reversed (as in 2001).

So the conventional wisdom since about 2003 has been to let it be and for governments to pursue relatively small-scale, incremental changes. However, incremental changes can produce policy incoherence (take Very Low Cost Access funding as a case in point), and result in arrangements that are frustrating to most or all stakeholders. Such is the tenor of New Zealand health-policy commentary in the late 2010s. Given these two unappealing choices, are there any alternative strategies to policy change?

Well, we political scientists can help. At the end of January, a new book Remaking Policy by the eminent Canadian scholar Carolyn Hughes Tuohy appeared on my doorstep in its 717-page glory. This book takes a broad international and historical sweep of health-policy reform in the US, UK, Canada and the Netherlands. It should be essential reading for any government, but no one will have the time, I suspect. So, let’s boil it down to 800 words.

The key insight of Tuohy’s book is to distinguish between the scale and pace of health-policy change. She argues there are two other, neglected, patterns of health-policy change. Both President Obama’s Affordable Care Act and the Conservative–Liberal Democrat coalition’s changes to commissioning in England are examples of what Tuohy calls a “mosaic” strategy. This seems to offer the “worst of both worlds”, stitching together a diverse range of piecemeal and incoherent political compromises, yet still subject to high levels of political conflict.

The opposite to the “mosaic” strategy is the “blueprint” strategy, which involves large-scale change unfolding at a modest pace. This really does seem like the “best of both worlds” – significant, coherent policy change, achieved with low levels of political conflict.

The clearest example of this is the fundamental change in the Dutch health system that was first mooted in the late 1980s but took until 2006 to fully realise. The details of the Dutch system are very different to our tax-based system. From the post-war period to the millennium, about 70 per cent of the population were covered by “sick funds” – smaller non-government insurance organisations based on a particular geographic location of occupation. The remaining 30 per cent (generally the better off) had private insurance, which was less regulated than social insurance. In effect, the Dutch reforms of 2006 merged the two systems, requiring all citizens to take out insurance, and blending the social and private schemes into a single, competitive system, with government regulation of premiums and benefits.

What’s important for Tuohy, though, is not the content but political strategies that are heavily shaped by conditions beyond the control of governments. Why would any government want to adopt a mosaic approach?

Basically, this approach may have been the best on offer. Coalition governments in the UK were in uncharted waters requiring all sorts of odd compromises. The US political system’s fundamental design principle is to prevent concentrations of political power.

Obamacare – anaemic as it appears from afar – was still a significant political achievement. New Zealand’s political institutions are the exact opposite of the US in most respects, which means that we are less likely to try the mosaic strategy.

On the other hand, the blueprint strategy seems to mesh with the brief given to the Simpson review – come up with a model that describes where we should be in 10 to 20 years. So could this approach work in New Zealand? Well it’s sobering that the Dutch story is the only example of blueprint health-policy change in the four countries over a 70-year period.

According to Tuohy, it requires a distinct set of political conditions, the most important of which is “established systems of cross-party collaboration”. The Dutch are the experts at building coalitions of support between multiple political parties. This is very different from our New Zealand tradition of “winner-take-all” party politics, which has been only slightly tempered by MMP. Boiled down, this means that any blueprint strategy would require support from the National Party, otherwise it is unlikely to survive a future change of government.

Oh, and did I mention that, after a dozen or so years, the Dutch reforms have not delivered the very thing that their proponents expected – better control over rising healthcare costs? Never mind that – remember it’s not only the substance but the strategy that matters. At least they have taught the world how to make major health-policy changes without disruptive conflict.

You may say I’m a dreamer, but I’m not the only one.

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