Can we really get rid of the postcode lottery or will local input recreate it?

Many aspects of the Government’s reforms to our health and disability system merit commentary this month, but I can choose only one. It’s the unsolvable tension between national consistency and local control and influence in a health system.

This tension – and the cyclic fashionability of devolution and centralisation – has justifiably been a prominent theme in general media commentary on health minister Andrew Little’s reform plans.

Similarly, any health policy wonk who has been around a while, and even some who haven’t, know this is an inevitable and irresolvable tension.

In the electoral arena, governments engaging in health-system reform must appear to choose whichever is not the status quo – either the devil or the deep blue sea. And that also means oppositions cast their lot accordingly.

The National Party passed up the opportunity to reform the health system in the 2010s, so our major parties have swapped sides on the question of centralisa­tion and devolution.

Central to Mr Little’s fram­ing of the case for health-structure reform was the phrase “getting rid of the postcode lottery”.

This is a stock standard rhetorical technique in moving towards centralisation.

This framing makes political sense. For an audience outside the health sector, it is difficult to sell a major structural reorganisation, with all its attendant disruption and uncertainty in the near future, without touting a major benefit.

Sector insiders and leaders may see all sorts of wonder­ful possibilities under the new structure, but such nuances count for nothing in the court of public opinion.

Populaiton health and wellbeing networks may well have significant scope to shape health services

However, the term “postcode lottery” in health originated in the UK’s NHS. Clearly, having a unified organisation responsible for health delivery does not get rid of this particular problem. Former Association of Salaried Medical Specialists executive director Ian Powell has argued on the Stuff website that greater centralisation will simply make it impossible to know the extent of postcode disparities.

The writers of the Cabinet paper outlining the health and disability system reforms know full well that the relationship between health-system structure and geographic variation in access and outcomes is not at all straightforward.

The word “postcode” appears only once in the paper; it notes that “the lack of robust collective accountability has contributed to fragmentation, misalignment of decision-making, and postcode variation in access and outcomes”. This leads me to suspect addressing postcode variation was not top of the list of rationales for these reforms as far as the Transition Unit in the Department of the Prime Minister and Cabinet was concerned.

The link between health-system structure and variation takes a lot of untangling. So there’s a significant political risk in raising public expecta­tions about reforms’ capacity to reduce geographic variation.

Geographic variation in health outcomes persists in all health systems, however they are organised and however they are funded. The reasons for this are more to do with variation in the social determinants of health rather than anything about health services.

It’s much more reasonable to link the structure of a system to geographic variation in access to health services. For example, we know residents of Northland have only a 30 per cent chance of getting access to bariatric surgery compared to their counterparts living in Counties Manukau.

But will having a regional division of Health New Zealand covering Auckland and Northland be able to address this? The roots of the disparity lie in the history of local health services, the physical capacity of hospitals, and the availability and work practices of bariatric surgeons.

This problem is more likely to be on the agenda under the Health NZ structure than under the DHB system, but that doesn’t necessarily mean it is more likely to be solved. After all, nearly 10 years after the merger of Southland and Otago DHBs, major disparities in access to urology services continued to occur between Southland and Otago.

When it comes to primary care, there will always be pronounced disparities of access as long as the location of practices is primarily determined by market forces, as it is in New Zealand and most comparable countries.

But we cannot declare the proposed reforms are unequivo­cally about centralisation. In fact, the reform proposal lays out a road map for more significant degrees of local input and influence. The proposed population health and wellbeing networks may well have significant scope to shape health services, particularly if they cover smaller geographic units than DHB districts.

For example, Locality A might opt for a fully integrated primary healthcare and mental health counselling service, while Locality B across the river might choose nurse practition­er-led services. So, at a fundamental level, the proposed reforms could increase variation in access to services if they are implemented fully.

That would be the inevitable consequence of local control, experimentation and community responsiveness.

Would that constitute a postcode lottery? And, if so, would that be a problem for a future govern­ment to get rid of?

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