The hundred and one recommendations

In One Hundred and One Dalmatians, a litter of 15 puppies is kidnapped. Villainous Cruella (what chance did she have?) wants to turn their spotty fur into designer coats.

By the end of the story, the puppies have been rescued by their dogged parents, who save another 84 captive dalmatians to boot, producing the sum total 101 of the title. The recent Planned Care Taskforce report, Reset and Restore, has 101 recommendations, 30 of which are earmarked for implementation to start next month.

By all accounts, the taskforce has done a good job in drawing up recommendations in a relatively short time. But the 101 recommendations face two significant challenges – the villainy of workforce shortages and the problem of spots and how hard they can be to change.

First, it is worth reiterating that Planned Care, in capitals, is not just about surgical waiting lists. It is, as the report defines, “a continuum for the investigation and management of non-acute symptoms and conditions”.

In other words, from the time a patient visits the GP, through requesting diagnostics, to the referral for first specialist assessment, to the first visit to surgery, to follow up – that is planned care.

This report has great ideas. You can sense the enthusiasm as they are bullet pointed. Some of them, like greater access to diagnostics and wider use of clinical pathways, have been around for years but have only relatively recently gained traction as the sector has come under greater stress.

Why did it take so long? It is 13 years since health minister Tony Ryall, part of a National government, cried “devolution”.

You can argue it has taken so long because it required sector managers and health profession leaders to ditch outdated patch protection and siloed care, that is, to change their spots.

Yet those who have a hankering to do so are hampered by the twin villains of “workforce” and “funding”, each inextricably linked to the other.

The lack of attention to the primary care workforce crisis, which has been approaching on the horizon for the past few decades, is verging on criminal, given the problems it now presents for the entire health system as it looks to restructure.

These twin problems loiter between the lines of Te Pae Tata Interim Health Plan 2022. Some might scoff at the high ideals and lack of detail in the plan, but it’s a start. And starting with the existing funding envelope seems the only option. The reforms are about better reaching those in need, and it is widely accepted that the current primary care funding model fails to do this. So, until that is addressed, adding more money will perpetuate current failings.

Like the planned care recommendations, Te Pae Tata has a strong reliance on people changing their spots, even more than that, their world view. The Government and its health leaders have been clear from day one that the key thrust of the health sector changes is achieving equity in health outcomes for Māori. All staff and contractors are required to understand the place of Te Tiriti o Waitangi in building a more responsive, effective health system.

That might yet prove to be an easier cultural divide to span than the ongoing divide between privately owned primary and publicly owned secondary services.

In the book One Hundred and One Dalmatians, Mr Dearly, owner with his wife of the missing dalmatians, was a financial wizard granted lifelong tax exemption and a nice house in central London after wiping out government debt. Money definitely makes it easier to get the job done.

There is a lot riding on the 101 recommendations and the 30 tagged to be early off the block. We’ll get an early sense of how well the system is really prepared to change its spots.

Recalling National’s earlier “devolution” plans – the word was later dropped for the less aggressive “integration” – I dug out a cover story from 9 September 2009 featuring Mr Ryall, Che Guevara-style.

Back then, deputy director-general Margie Apa laid out plans for an expression-of-interest process seeking organisations with sufficient capability and capacity to be early adopters of the Government’s plans for devolution and integrated family health centres.

These early adopters, which were to be in the first wave of activity covering 15 per cent of the New Zealand population by the following June, were to be large enough to demonstrate critical mass and the ability to deliver large-scale change over time, Ms Apa said.

The NZMA GP Council chair at the time, Mark Peterson, wrote of devolution: “GPs are generally welcoming of the chance to have better access to diagnostic services that they have until now been unable to request. They also welcome the chance to use some of the different skills they have developed during training.”