The big Little revolution

A: Andrew Little became health minister in November 2020, following re-election of the Labour Party to government in the October general election. Mr Little in­dicated he would be going further with reform than was recommended by the Health and Disability System Review Panel led by Heather Simpson. On 21 April 2021, he announced major chang­es to the system, including the ditching of DHBs and the creation of a powerful Māori Health Authority.

Legislation to enact the changes is expected to be in place by next April.

B: Back-office functions, such as a contract management system and national data and digital functions, will be carried out by a new central agency, Health New Zealand.

C: A New Zealand Health Charter will articulate shared values, standards, expectations and ways of working, to act as a common foundation across disciplines and loca­tions. Contractors as well as employees will be expected to sign up to this.

The new central agency Health NZ will provide clinical leadership to the sys­tem and facilitate clinical networks, and have a key role in fostering an innova­tion culture within the system.

A national consumer forum will be established to act as the umbrella organisation for consumer and patient voices, bringing together multiple existing local groups and non-govern­mental organisations.

D: DHBs come to an end on 1 July 2022, when all DHB staff will be transferred to employment in the new agency Health NZ on their current terms and conditions.

No decision has been made on the fu­ture provision of disability services. Officials’ advice on alternative models for disability governance is due to be delivered this September.

E: DHB boards have been chosen via election and ministerial ap­pointment, but are to disappear. Current DHB boards will continue to meet until July next year.

“Etiquette” from Mr Little’s Cabinet paper is outlined: “Giving effect to this system model will require steps to en­sure collaborative working arrange­ments and positive behaviours between the ministry, Health NZ and the Māori Health Authority. Roles should be de­signed to be aligned and complementa­ry, limiting areas of duplication and with clear protocols for managing day-to-day issues.” Advice is being sought on the role of ESR (the Institute of Environmental Science and Research) and where surveillance capacity should sit.

F: Funding does not feature strongly in official papers to date. G: For front line general practice, the big change will be a new contract with Health NZ. Beyond the core services that are required to be provided, potentially additional contracts could be entered into according to needs identified in a locality plan. Practices will not be required to contract with a PHO to receive funding. Some PHOs, or remnants of them, may remain.

H: Health NZ, a new central agency, will take responsibility for the day-to-day running of the health system. It will take over all functions of DHBs, holding public as-sets including hospitals and employing health professionals and other staff. It will plan and commission health ser-vices for the whole population. It will monitor sector performance and also take on the roles of current shared ser-vices agencies. The Health Promotion Agency is to be split, with its delivery function be-coming a shared service of Health NZ and the Māori Health Authority, and its research function going to a new Public Health Agency in the ministry. Hospital and specialist services will be planned nationally by Health NZ and will be managed through regional networks.

I: There are 20 existing iwi-Māori Partnership Boards, but their role, scope, composition and decision rights vary. They are self-governed and designed by iwi; they are not Crown agents. Under the proposals, they will be strengthened to act as a decision-making voice for iwi and Māori in each locality. They will have influence regionally through their relationship with the Māori Health Authority.

J: 1 July 2022 is the date Health NZ and the Māori Health Authority come into existence.

K: Kaupapa Māori services will be commissioned by the Māori Health Authority and there is an expectation these services will be available throughout the system.

L: Localities will be networks of healthcare providers offering primary care and community services. They will include GPs, practice nurses, nurse practitioners, pharmacies, physiotherapy, kaupapa Māori ser-vices, midwifery, district nurses, public health services and optometry. A district may have more than one locality.

M: A Māori Health Authority will lead commissioning of kaupapa Māori services and work in partnership with Health NZ – as a co-commissioner – to commission care across New Zealand. It will have approval rights for all relevant strategies and plans at the regional and locality level, including primary, community and hospital services, and an ability to exercise a veto in sign-off. It should act as a conduit to represent the advice and direction of iwi in regional decision-making.

The Ministry of Health becomes “chief steward” of the health system and lead adviser to the Government on matters relating to health. It will set and review the key parameters and settings in which the system operates, including legislative and regulatory settings and the ongoing design of the system model. The ministry will man-age continuous review and oversight of the system, and support the accountability of organisations to the minister.

N: A national hospital plan will set detailed requirements for access, thresholds for treatment, common service specifications, standards and models of care, and expectations on cost, to be applied and monitored in all regional networks.

O: The health minister will have specific powers to set national objectives, approve system level plans and closely monitor Health NZ performance, including ap-pointing Crown Monitors to the Board and observers to any Health NZ-run or contracted services.

P: The Ministry of Health is to develop a new strategy for Pacific health.

A new Public Health Agency will be established as a business unit of the ministry. The agency will be responsible for monitoring environmental threats to public health and will develop advice on the appropriate system response to risks. The director of public health will continue as a statutory role in the ministry and will be a key leader in the agency and the national public health service within Health NZ. This includes providing professional support and oversight for the medical officers of health. Health protection officers and medical officers of health will be part of Health NZ. The Public Health Agency will also support the overall health system to improve environmentally sustainable practice.

A national public health service comprising the 12 regional public health units will sit inside Health NZ.

Q: The Health Quality & Safety Commission will be the “centre of excellence” for consumer engagement and will build capacity and support in the use of evidence-based models.

R: Health NZ will have four regional divisions. They will have two distinct but aligned arms – one for commissioning primary and community services, and one for providing hospital and specialist services. These arms should have separate internal management lines within Health NZ, both reporting to the national executive.

S: The timeline gives September 2021 as the date for legislation to be introduced, an interim Māori Health Authority and Health NZ to be established and ministerial committees appointed. Then by September 2022, it is expected the new entities will be fully operational.

The Ministry of Health will retain its statutory functions and current accountabilities, including the monitoring of DHBs and management of some national con-tracts during the transition period, but some functions and staff can be gradually transferred to the interim entities over the transition period (September 2021 to July 2022). This will enable interim entities to commence early implementation activities and enable a smooth transition once legislation has been passed. The transition will also pose issues as to the timing and scope of the necessary re-structuring of the ministry to reflect its new role. This does not commence until early 2022, to avoid any risk of disrupting the COVID-19 response.

U: Health sector unions will be looking for delivery on prom-ises of pay parity and general improved salaries and conditions.

V: “Our vision is to build a system which achieves pae ora | healthy futures for all New Zealanders” – Health reform white paper, Our health and disability system.

The Ministry of Health will continue to both secure and monitor Vote Health funding.

W: Population Health and Wellbeing Networks – this is the working title for the district offices of the new central agency Health NZ’s four divisions. Each will have locality commissioning teams with responsibility for particular defined areas.

X: An expert advisory committee on public health will be established and supported by the Public Health Agency within the Ministry of Health. The ministry is developing advice about the form and membership of this committee.

Y: Yahoo – A system built on strong primary and community care in the expectation that GPs, practice nurses, nurse practitioners, pharmacists, midwives, physios, Māori and Pacific community providers, aged-care service providers, dentists, community mental health service providers, and more, will capture some of the funding – not just the work – that is expected to be moved out of DHBs and into the community with new changes.

Z: The DHB system established by Labour in 2000, has passed its zenith and it is now downhill to Health NZ.

We hold the documents so you don’t have to! Our coverage of the Little reforms references a number of documents which we have gathered together on our website