The Roster Te Rārangi: Edition 6

System review: A Roster special edition
Here's your guide to the changes hovering on the horizon for health and disability system services, policy, decision-making, monitoring, structures and culture. Health minister David Clark says the Cabinet accepts the case for reform made, and the direction indicated, in the Health and Disability System Review Panel’s final report, released on 16 June. Dr Clark highlights “changes that will reduce fragmentation, strengthen leadership and accountability, and improve equity of access and outcomes for all New Zealanders”.

New appointments due soon
Prime minister Jacinda Ardern is to lead a group of ministers driving the changes. Dr Clark says he will appoint a ministerial committee to provide ongoing expert advice. An implementation team, administered by the Department of Prime Minister and Cabinet, will lead the detailed policy and design work. Decisions will be made in coming months in what Dr Clark envisages as a reform programme taking many years.

DHBs: Fewer and unelected
Slashed from 20 to between eight and 12 in number, DHBs will remain responsible for the health of people within their boundaries, but have an eye on the national health picture, the reviewers recommend. DHBs would fund the likes of general practice, maternity care, community pharmacy, under-18s’ dental care, mental health support, disability needs assessment, children’s health, palliative care, population health and aged residential care. Board members would all be government appointees (no more DHB elections), with a spread of knowledge of areas such as finance, governance, tikanga Māori and the health and disability sector.

Slow death for PHOs
The 30 primary health organisations (PHOs) throughout the country could be in for a slow, five-year death if the report is picked up in its entirety. It recommends DHBs commission and fund general practice care directly rather than through PHOs, with an end to the national agreement negotiated by Ministry of Health, DHB, PHO and provider representatives. DHBs would also take over PHOs’ contracts for population data analysis and management services. At General Practice New Zealand, which has PHO members, chief executive Liz Stockley says PHOs have taken the lead in primary care development and shouldn’t be allowed to wither.

The funder-contractor
A new organisation, tentatively called Health NZ, is proposed to lead DHB activity as the funder and contracting party. Health NZ would develop new commissioning approaches, drive “consistent operational policy”, and lead service delivery. It would be accountable for the system’s finances, would push clinical and financial continuous improvement, and lead industrial relations. It’s proposed to be governed by an eight-member board (plus chair), with 50/50 Crown/Māori representation. Health NZ would appoint managers in the regions to facilitate DHBs’ collaboration, and hold DHBs accountable for outcomes, services, finances and consumer assessments. Its initial priority would be the performance of hospital and specialist services.

Ministry minus a chunk or two
The Ministry of Health would downsize with the loss of its funding and contracting responsibilities to Health NZ. But the ministry should build its public health expertise, the reviewers say. It would become largely a strategic planner, legal and regulatory adviser and monitor of the system’s performance, and would still lead work on the health spend in the annual Budget. Gone would be the ministry directorate that provides advice and guidance on Māori health. That job falls to the proposed Māori Health Authority (see below). The ministry would develop a set of long-term outcomes and performance measures.

Authority or partner?
The Māori Health Authority is portrayed in the main review report as an advisory, monitoring, reporting and partner organisation. The authority would work with others in the system to embed Treaty principles and mātauranga Māori. It would partner with Health NZ on commissioning models; with DHBs and iwi on co-governing of service networks; and with communities and providers on need and outcome measures. Some scope is seen for the authority to invest in Māori health workforce innovations. Panel chair Heather Simpson has given New Zealand Doctor her take on the reason for not separately funding services for Māori.

The dissenting view
A majority of panel members did not see the Māori Health Authority in the way described above. They were seeking an authority that controls the funding and commissioning of health services for Māori. The review’s Māori expert advisory group chair, Sharon Shea, says this debate is still alive. The granting of a partnership role, says the dissent view in the report, reduces Māori input to little more than an advisory role with a small and marginal budget.

Stability for DHBs, NGOs
The reviewers are all too aware of the DHBs’ financial deficits, and they want to see guaranteed increases in the health budget, as happens with social development and education. The review recommends a formula be used to set minimum annual funding increases, to account for total population and changes in population demographics (eg, age and ethnicity), costs of products and services, and costs of wages. This would facilitate commitment to multi-year contracts with non-governmental organisations (NGOs), helping them become more stable and better able to plan.
(Image: Dieter Spears, Inhaus Creative)

Public health stays with DHBs
The review is calling for an increased focus on prevention, maintenance of wellbeing, and influencing the broader determinants of health. The work of public health units would continue to be the responsibility of DHBs. “A stronger line of sight” is proposed between medical officers of health to the director of public health at the Ministry of Health, to enable “more coherent responses to emerging issues”. The Health Promotion Agency is recommended to be absorbed into the ministry.

Training and working differently
The ministry will need to come up with a 10 to 15-year workforce plan, the reviewers say. One aim is to ensure health workers better represent the country’s population. A wide range of education organisations would be involved in talks to ensure training is consistent with Health NZ’s plan. Cultural competence and safety are seen as core requirements of the entire workforce. The health workforce will also need to develop skills in working as teams, change management and project management, person and whānau-focused services, new technologies and leadership.

Networks with accountability
Networks of primary, community and home-based services, managed by the local DHB, are envisaged. Networks would consist of NGOs, businesses and directly provided services, working together to meet a population’s health needs, and would be accountable for agreed health and wellbeing outcomes. DHBs could target resources to particular communities and populations if this was based on evidence and was equitable. Dedicated investment would be needed to support this change, says the report.

Closing the tech gaps
The reviewers were told of health technology skills shortages, eg, design thinking, user experience design, data science and artificial intelligence. New roles such as data scientists and user researchers will be required. Key aims should be: connected and shared health systems, data and information; primary and community care services connected as a network; commitment to equitable access to services; strong leadership and system-wide digital literacy, capability and maturity; and clearer decision-making, procurement and investment processes.