Elitism not what the doctor ordered

There is no reference to enhancing integration between community and hospital healthcare

One of the most important features of the Pae Ora (Healthy Futures) Act 2022, which came into force on 1 July, is the requirement to produce a statuto­ry document called the New Zealand Health Plan.

The plan is important in that it will state what, where and how healthcare services will be provided in communi­ties (including general practices) and hospitals. Both the plan itself and the process for developing and implement­ing it are prescribed in the statute.

Section 14 of the act outlines the functions of the new additional national body, Te Whatu Ora – Health New Zealand. The very first function, hitting the reader right in the eye, is to jointly develop and implement the plan along with Te Aka Whai Ora – Māori Health Authority.

To better understand the plan’s context, two other parts of the act should be considered. The first is the Govern­ment Policy Statement on health and the second, health sector principles.

The plan must give effect to the statement, which is determined by the Government. Section 34 of the act says a statement must be issued at least every three years. The statement is to set priorities for the publicly funded health sector and set clear parameters for developing the plan.

On the other hand, the health sector principles are specified in the act’s Section 7. They include:

• equitable health sector ensuring Māori and other population groups have access to services in proportion to their health needs
• engagement with Māori, other population groups, and other people to develop and deliver services and pro­grammes that reflect their needs and aspirations
• providing Māori with opportunities to exercise deci­sion-making authority on matters of importance to Māori
• providing Māori and other population groups with choice of quality services, and
• protecting and promoting people’s health and wellbeing, including by adopting population health approaches and focusing on the effects of social determinants of health and climate change.

These principles are laudable, although very general. However, in contrast with the predecessor legislation, there is no reference to enhancing integration between community and hospital healthcare. This is unfortunate because of its capability to improve the quality of patient care and constrain rising acute demand which, prior to the pandemic, was a major cause of deficits and cancelled planned surgery.

The plan itself is outlined in Sections 50 and 51 of the act. Its purpose is to provide a three-year costed plan for the delivery of publicly funded services by the two new statutory organisations. The plan must contain anassessment of population health needs; identify and prioritise improvements in health outcomes (including measurable outcomes); and describe how health entities will deliver service and investment changes to achieve these improvements.

Again, as with the health sector principles, these are laudable. However, the devil is in both the detail and who controls the detail.

The culture that led to the replacement of DHBs with Health NZ is best described as bureaucratic centralism. Arguably, the most significant change to the health system from 1 July is that decision-making has moved much further away from the provision of healthcare services and much closer to the national centre.

One of the bedfellows of bureaucratic centralism is desktop analysis. That is, an intelligent person in Auckland can best decide the configuration of services, both hospital and community, from Northland to Southland.

Elitism at its best!

That, obviously, is an oversimplification. But the critical point is that decision by desktop analysis increases the risk of the services provided at, say, Gisborne Hospital being arbitrarily downsized in the name of rationalisation in a national health plan.

Te Whatu Ora controls the public hospitals. Owing to this direct relationship, it is more likely that planned changes to their configuration will appear before change happens in the community.

But, for community healthcare services, control is still there. Localities established under the act can be expected to play a big role in community-based healthcare.

Localities can enable structural changes to primary healthcare, in particular, which appears to be a target of health minister Andrew Little.

The mechanism could be the locality plans that localities are required to have. The act specifically gives Te Whatu Ora responsibility for determining both the localities and their locality plans.

If the culture of Te Whatu Ora is the same as that which created it, then health professionals in both community and hospital healthcare have much to fear for their patients and the health of the wider public.

If, on the other hand, Te Whatu Ora makes the break to an engagement culture that is substantive rather than formalistic consultation, and recognises that the real expertise about health system improvement resides with those at the clinical and diagnostic workplaces and in communities, then health professionals will have reason to feel relieved.