A politician in a right pickle

No matter how well a system is structured, how lean and efficient, without a fit-forpurpose workforce, it fails

Former health minister Andrew Little has never struck me as someone who cares too much about what people think of him, which for a politician is both a blessing and a curse.

Because we all know it is easier to get people on side if you can say the right things at the right time and mean it. And mostly, I think, Mr Little did. But sometimes, he could not help himself. A word here, a sigh there, and he was in a right pickle.

Mr Little could talk up primary care, no trouble, but he didn’t really understand the sector’s low self-esteem and how the simple ongoing broken promise of funding reform ate at its heart.

It’s hard to argue with his thoughts on general practice. The following is from an interview reporter Martin Johnston had with Mr Little:

Mr Little sees primary healthcare as constrained by small, owner-operator general practices.

He speaks favourably of hubs, where patients have access not only to GP clinics but also to nurse practitioners and the services of allied health practitioners, such as physiotherapists and podiatrists.

He also notes traditional general practice ownership has become less popular among young doctors, who commonly don’t want to own a small business, and says this contributes to the GP shortage.

“Given that primary care is reliant heavily on State funding, then I think the State does have an interest in the way they set themselves up to provide care for communities,” he adds.

Asked how the State can influence private and trust-owned practices to change, he says it is through locality planning processes, and funding and incentives to drive health to better meet community needs.

“I don’t expect the State to be a big owner of primary care practices. But I think the State, through its funding role, can incentivise and encourage more effective business models to provide better care.”

There’s the rub again, funding. And for the whole of Mr Little’s tenure, any critical comments were amplified by the lens of exhaustion wrought by COVID-19 on primary care.

Ultimately, like so many health ministers before him, here and abroad, he inherited a health portfolio with a huge overarching challenge – workforce.

You can blame it on poor planning, on blind faith, on professional guilds keeping closed shops but the fact remains, no matter how well a system is structured, how lean and efficient, without a fit-for-purpose workforce, it fails.

And the past 30 years have seen a dramatic failure to do anything much other than tinker with workforce programmes and, in the area of general practice, to pretty much ignore the coming disaster of both GP and practice nurse retirement.

While Mr Little was far too late on the scene to have significant influence on workforce, he committed to tackling another key issue – the inequity in health outcomes. And that meant tackling institutional racism and the bias that has seen decades go by without any real improvement in health outcomes for Māori.

Mr Little took on board the findings of the Waitangi Tribunal’s Kaupapa Inquiry into Health Services and Outcomes. His Pae Ora (Healthy Futures) Act 2022 gave the Māori Health Authority, Te Aka Whai Ora, a greater leadership role than had been envisaged by Heather Simpson, chair of the major review destined to be known as the Simpson report. Under Mr Little, iwi Māori partnership boards have been introduced as te Tiriti partners.

Māori providers and iwi are suffering the same workforce issues as the wider sector and the expectations wrought by the reforms are testing the capacity of providers and policy-makers.

I have enjoyed referring to the current reforms as the big Little revolution, because there is no doubt Mr Little has opened doors that will not be shut, no matter what opposition parties suggest.

But, in the meantime, with all the will in the world, general practice and wider primary care cannot significantly change models of care or breadth of healthcare delivery while the funding model for general practice fails those with high needs, and while various primary care NGOs are burdened with multiple contracts.

Change is promised but not until localities are in place. And, so, we wait.