‘One plan to rule them all’ a tempting but fantastical approach to health system

Conducting a review of the whole of New Zealand’s health and disability system is an epic, hero’s journey.

There are so many potential pitfalls and, in such a comprehensive attempt, a variety of health system creatures are likely to be offended or unwelcoming.

But it is true that often our heroes fall short, the journey lays bare their weaknesses. Who among us is as brave as we need to be when the
moment of reckoning comes?

There’s not a lot of bravery in the review’s official recommendations.

Regarding the neutered proposal of a Māori Health Authority, clearly the majority of the review panel pushed for more bravery.

While I wouldn’t expect a Māori Health Authority with expanded commissioning powers to be able to make an enormous dent in health inequities in the next five to 10 years, it is hardly likely to do worse than the status quo.

Overall, it seems everyone’s pet organisational solution is somewhere in the recommendations. Plenty of new organisations and functions have
been recommended, yet few, if any, old ones have been discarded. That, in itself, seems a peculiar strategy to address system complexity and
fragmentation.

The report’s answer is that designers of the system will be able to clarify the roles and responsibilities of each agency. I suspect the health minister might well read that as a “hospital pass”.

The hero’s journey certainly requires preparation. In the final report, this amounts to the preparation of plans.

To quote the report: “There is currently no single national document that combines the health and disability system’s expected population health
outcomes that details how different parts of the system will work together.” This is true. It is also true for all substantial domains of public policy, and it is also true in every other health system in the world.

Chapter 4 then proceeds to outline an elaborate fantasy, summed up in a diagram on page 54 – an alluring graphic of concentric circles of planning, with the New Zealand Health Strategy sitting at the centre – “one ring to rule them all”.

There is no doubt that, in areas such as capital spending for hospitals, and health workforce development, more coordinated planning is long
overdue.

Where this renewed faith in planning is rather alarming is its application to the vital but highly complex task of improving population health outcomes. Here the onus is on the “refreshed” DHBs to be held accountable for improved health outcomes and equity.

Chapter 7 further elaborates that non-government providers of Tier 1 (primary and community care) services within a district “would be
jointly accountable to the DHB for agreed locality outcomes”.

We have seen this vision before. The mantra of planning for population health outcomes was central to the creation of DHBs in 2000. As the report makes clear, the reality fell well short of expectations. It’s certainly true that the 2010s were not propitious times for any major health policy objective.

But we can look at the experience of the 2000s, when funding and goodwill were relatively plentiful, and see clear indications of the limitations and unintended consequences of the dream of planning.

As early as 2005, it was abundantly clear the capacity of DHBs to plan services according to population needs was severely constrained by the
absence of data, and the lack of mechanisms to link analysis of health needs to decisions about what services to fund.

DHBs held the accountability, but not the tools for the job. This is still the case today, notwithstanding some pockets of improvement in data.

Adequately measuring utilisation of community-based services including primary care was a problem then, and still is today. The Ministry of Health and DHBs quickly focused on measuring and monitoring more mundane, process-based indicators (because that is what they could do),
even though it did not produce much real intelligence about the system.

But there are even more fundamental problems with this data-driven vision of one plan to rule them all. We simply do not have population health
outcome indicators that are sensitive and reliable enough to underpin this elaborate planning approach, and we are nowhere near attaining these.

Let’s take a promising indicator: ambulatory sensitive hospitalisation for children under five. We are still a long way from knowing and understanding whether improvements or deteriorations in these rates can reasonably be attributed to the actions of DHBs and providers of health services, as distinct from an unusually cold or warm winter.

How could such data be confidently used to underpin planning?

Then there is the issue of a workforce capable of managing and analysing any data that exists. My guess is, no more than 100 people in
the country have the requisite skills.

In short, the idea of holding DHBs accountable for improvements in health outcomes is an unsustainable fantasy. Those working for DHBs, who
have been developing population health data, know this only too well. How on middle earth will holding people accountable for things they do not control, counteract the culture of risk-averse management?

I’m not saying that governments should walk away from the moral imperative to address inequities of health outcomes. The most pressing issues for 21st century governments are complex, multisectoral, multidimensional, “wicked” problems, such as climate change and population
health.

But planning-based, rationalist tools and accountability mechanisms are a very poor fit for these policy challenges.

Most contemporary scholarship, and a great deal of government practice around the world, now emphasises experimentation and high-level collaboration between government and non-government stakeholders to deal with such problems.

Unfortunately, the Heather Simpson-led review has been blinded by the precious allure of rational planning, and has downplayed or ignored alternative thinking about policy and governance. What are the chances that whoever is in government after September will also succumb to the power of the ring?

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

Shelley Campbell, Peter Crampton, Lloyd McCann, Win Bennett and Sharon Shea believe they have the best recipe the Government and the sector could have for improving the trajectory of Māori health

In the final report of the Health and Disability System Review Panel, we argued strongly the proposed new Māori Health Authority must incorporate fully empowered health service commissioning. We believe that, of all the various changes proposed by the review panel, this innovation will have the greatest chance of significantly improving the trajectory of Māori health.

In reality, what would fully empowered Māori commissioning look like? In short, it would look like any other office on The Terrace populated by health experts, only in this case they would be Māori health experts.

The Māori commissioning function would be fully integrated within the machinery of the national health system, working in close collaboration with other policy and commissioning agencies.

But, most importantly, it will be Māori-led, it will have a meaningful budget, and it will be resourced and supported to succeed.

The resources of the review’s secretariat were not deployed to work up the details of this option, so it is important the right range of people, agencies and stakeholders now have input into fleshing out the details of this proposal in order to transform Māori health outcomes.

Māori commissioning is one of the most important recommendations to come from the panel; the challenge now is to ensure the concept is fully manifest through the implementation phase.

Shelley Campbell is Waikato/Bay of Plenty Cancer Society chief executive; Peter Crampton is a University of Otago Māori health researcher; Lloyd McCann is Mercy Radiology and Healthcare Holdings Ltd chief executive and head of digital health; Win Bennett is a former planning and funding boss for several DHBs; and Sharon Shea is a consultant and interim Bay of Plenty DHB chair