Te Aka Whai Ora loss unhinges future of reforms

We always knew localities were the problem child for the health reforms

"I think the crux of it is warranted variation versus the unwarranted variation. Some variations absolutely warranted local solutions, local needs. Others, as Margie has said, [are] unwarranted, and we could actually do better without [them]. And getting those two elements really clear, I think, is the kernel to the answer to your question because we don’t want to drop warranted variation.”

That was Te Whatu Ora board chair Dame Karen Poutasi answering a question at a recent health select committee meeting. The question was about how Te Whatu Ora ensures that, in its process of rationalising service delivery, it doesn’t ditch priorities deemed necessary to local communities by the old district health boards.

It begs the question, who decides what is warranted and what is not? And, as of last month, there was one less voice in that discussion with the “unwarranted” Te Aka Whai Ora consigned to the health reform vaults, where it keeps company with many now forgotten agencies and forgettable acronyms.

The concept of Te Aka Whai Ora was not universally loved, obviously. But for all those who felt it was an unwarranted intrusion on the healthcare landscape, many others were prepared to give it more than 19 months to prove itself. What I expect is most frustrating is that it has been ditched without a clear direction of what comes next.

The extent to which Te Aka Whai Ora was woven into the health system is demonstrated by the amendment bill required to extract it. It takes 42 clauses to delete Te Aka Whai Ora from the pae ora legislation and, ultimately, the sector. That extraction, from the triumvirate that was the Ministry of Health, Te Whatu Ora and Te Aka Whai Ora, leaves the reform infrastructure destablished. Essentially, though, the smallest of the three, Te Aka Whai Ora, was the system’s conscience. And that is a loss. Watch out for increasing tension between the two left behind.

Health minister Shane Reti talks of wanting to paint a new vision for Māori health that will be outcomes-focused, driven by need and with decisions made closer to home. Sound familiar? It’s what we heard in the run-up to the current changes. Dr Reti’s vision retains two elements of the current reforms – the Hauora Māori Advisory Committee and the iwi Māori partnership boards – declaring the Government will support both to do “more” but at the same time stripping them of some unique qualities.

While current members of the Hauora Māori Advisory Board were appointed by the minister, the future was to see them appointed by Māori, namely the iwi Māori partnership boards and other Māori groups; instead, they will continue to be ministerial appointments.

Localities are not totally written out of the picture, but they have been significantly delayed – some might say they have been pushed even further into the too-hard box. But iwi Māori partnership board involvement has been downsized; instead of being intimately woven into localities and their plans, they now have the more nebulous function of “developing priorities for improving hauora Māori” by working with Te Whatu Ora. And none of this considers the lack of detail regarding current support and resources for the boards, let alone what they can expect in the future.

As for localities, we always knew these were the problem child for the health reforms – for a start, no one knew quite what they were, how they would work or be funded. The minister is allowing the prototypes to continue for now, and I expect some will flourish despite the puzzling environment they find themselves in. But at their heart, these prototypes are about generating variation – finding different ways in different areas to cater to local health needs within local resources. For a system antipathetic towards variation, the day will come when someone makes a call on the degree of warranted or unwarranted variation at the local level. Some localities will fall.

Te Aka Whai Ora was, in part, a response to the Waitangi Tribunal claim, Wai 2575, findings on outcomes for Māori in primary care. With its departure, Māori health policy expert Gabrielle Baker says it’s time another key recommendation, the review of primary care funding, was acted upon. She will get no argument on that account from the wider primary care sector. But the delay in addressing funding has disproportionately affected Māori and Māori health providers. In the meantime, it is worth reminding ourselves, yet again, that the health system can stumble on doing the best it can with the resources at hand, but alone it can never deliver a healthy community.

The social determinants of health – where we live, what we eat, what we know, how we move about and the work we do – continue to be the key to 80 per cent of our health and wellbeing. Even as I write it, I know "social determinants" is so unsexy. Not only that, dealing to this multi-headed beast sitting in a policy pit is a huge proposition.

But, in recent weeks, we have witnessed such a crescendo of activity and proposals that so ignore this awkward creature, it beggars belief. From ditching Smokefree legislation, pushing to bring back dangerous guns, cutting expenditure on cycle and walking paths, proposing cuts to school lunches, vacillating on the security of safe water supplies to repealing fair pay legislation and making roads bigger and faster, the pit is getting rather mucky.

A colleague talks of politicians’ propensity to “speak things into being”. You can't speak into being health equity for Māori, better health services for rural communities or a safer world for the next generation. You actually need to get into the policy pit and get down and dirty with social determinants. With the loss of Te Aka Whai Ora there’s one less stalwart on that perilous journey.