Policy goes back to the future

Over the summer, it was clear that prime minister Christopher Luxon knew that health could turn into a significant electoral liability in 2026. It prompted his appointment of a self-professed “Mr Fixit”, Simeon Brown, as health minister. Fast forward six weeks, and I doubt I’m the only commentator to have had the phrase “back to the future” flash through my mind during Mr Brown’s major policy announcements in the first week of March.

Most attempts to turn a new page in health policy take us to places where we’ve been before. The larger, familiar cycle follows changes of government and their policy emphases since 2000. When Labour is in government, there is an emphasis on reducing inequities and expanding access through increased health sector funding. Under National, we have a focus on pressure points such as ED, managing within budget and reducing bureaucracy in a more constrained funding environment.

Labour pulls the big levers of sector restructuring, only to find that they are very rubbery and that the dots that need to be joined and rejoined add more complexity to an already complex beast. New consultations, collaborations and processes proliferate. Traction is slow and invisible to the electorate. National seeks to simplify. Traction on smaller problems can be achieved faster, but the inherent complexity of health is underplayed.

To me, the most striking feature of Mr Brown’s tenure so far as health minister is an emphatic return to a very specific style that marked one of his National Party predecessors, Tony Ryall, who was at the helm from late 2008 to 2014.

Mr Brown’s political communication style, emphasising “fixing things”, “the basics”, “performance”, and less bureaucracy was as familiar as a warm bath or a cold shower, depending on your perspective.

In terms of substance, among the many echoes from the Ryall era were the emphasis on targets and managing performance, the (welcome) focus on integrating primary and secondary care, promoting care closer to home, and contracting with private sector hospitals to deliver more publicly funded surgery.

Another major part of Mr Ryall’s ministerial style was to engender fear of the ministerial phone call when the target indicators didn’t look good. Engendering fear was not former minister Shane Reti’s style. Reading the tea leaves, senior managers can expect to see a return of the dreaded phone (or video) call or equivalent.

There is one notable departure from the Ryall playbook. In a 7 March speech, Mr Brown portrayed health sector unions and colleges as part of the problem he was fixing rather than as potential allies he may need to smooth the waters. Mr Ryall made sure that he didn’t alienate the most powerful of these groups.

So, where might we be headed next if we have been somewhere like here before? There’s a neat image, based on mathematical models, known as the Lorenz butterfly effect (see image). It depicts a complex dynamic in which history doesn’t repeat but regularly rhymes. Trace the single line in the picture and you’ll alternate travelling in circles on the left, then the right, but without ever returning to a previous point.

In terms of consequences for the health sector, what is likely to play out as we travel around the right wing of the butterfly? We know that health targets have positive effects initially, as they focus minds on process and flow improvement. This phase lasts up to two years when it is usually followed by a phase in which services hit ceilings of improvement within their control, gaming takes hold and resources are diverted from untargeted services.

Better integration between primary and secondary care, and “empowering primary care to keep people out of hospitals”. How to do this? The emphasis in the early 2010s was on supporting more collaborative problem-solving between DHBs and PHOs, and service and funding design. There was momentum in the early 2010s under the better, sooner, more convenient business case process; by about 2015, this energy had foundered on the rocks of funding stream inflexibility (both perceived and real). Most of the obstacles to better integration are still firmly in place.

Then there’s the electoral consequences. Even while the flatlining of government per capita spending on health was beginning to bite, Mr Ryall neutralised health as a potential advantage for Labour in the 2011 and 2014 elections. This time around, Labour and the left are in a stronger position than in the early 2010s. If the aim is to stem the bleeding and take health out of the headlines, having a minister who has demonstrated skill in shaping the health policy narrative might just work for National.

But even if successful in the short term, by 2027, Mr Brown may have moved on. After all, between January 2000 and January 2025, New Zealand had 10 health ministers (an average of 2.5 years).

In the plot of Back to the Future, Marty McFly time travels in a DeLorean car back to the 1950s to prevent his mother from marrying his father’s obnoxious rival, Biff.

If the current minister could really time-travel back to 2009/10, I wonder which of the many slow crises that have manifested since he would seek to prevent. Workforce shortages across the whole sector, and primary care in particular? Demand for health care services that is increasing faster than population growth?

I popped into my own DeLorean and retrieved a piece by my longtime colleague Toni Ashton and me in 2011: “Policy settings that are concerned only with getting the right services to the right people at the right time are inherently shortsighted if they fail to tackle the long-term causes of increasing demand for future health services.”¹

Or, to put it another way, there’s little point in being effective at fixing potholes if the road sits on top of an underground stream with an ever-increasing water flow.

Tim Tenbensel is professor of health policy at the University of Auckland