What should we do now on health?

Thank you for the opportunity to be with you tonight. There is much to think and discuss about the important and urgent needs in our public health system. There is also much noise made about the system. The two are not always connected. I will try to avoid the chatter in favour of things that matter in what I have to say tonight.

It is important to say first that we do not have bad health services in this country. The huge number of health services provided to people every day are typically soundly based in clinical terms, delivered in a caring and sensitive manner, and reasonably cost efficient. There are over quarter of a million people involved in some direct or indirect way in that delivery and they are typically skilled, dedicated and hard working. We all owe thanks to them.

But there are real issues. The noise I referred to does not come from nowhere. They may be amplified and exploited but the issues are genuine. They are not all the same and they matter a great deal to our sense of individual, whānau and community wellbeing.

Health services substantially deal not with health but with ill health – its avoidance and treatment. It is commonly accepted that the huge majority of things and behaviours that cause ill health lie outside of the health services system. Our approach to reducing ill health is seriously deficient in that we continue to accept many aspects of our society that exacerbate ill health and do not promote wellbeing.

If you ask those active in social services in any area to identify what is needed to have a healthier community (which Te Whatu Ora has done in its “locality” planning), they will with remarkable consistency identify the need to work together across a broad range of services and to control the activities causing the ill health issues. We largely know what the problems are and our response should start with those.

Heart disease, cancer, you name it, does not start in the health services system and the best thing we can do to help the health services system is to control the things driving demand. The opportunities for this are vast from accident prevention to alcohol harm, to violence, to drug use, to nutrition, to housing, the list goes on.

Yet we are often far too reticent about these things, in the face of opposition which is often commercially motivated and always self serving. Our public health knowledge is good but we give far too little resource and commitment to actioning that knowledge. We even have great examples (like anti-smoking) but fail to learn the lessons.

The current reforms make minor adjustments to this but they are an abject failure in really shifting the outcomes. That requires a determined reallocation of resources to attacking causes of ill health. We know the rough order of potential positive impacts. Yes, we should research more on causes, study more closely the health and economic returns from action on them. But this must not hold back the overriding need to action the knowledge we have.

Can I give just one example from the past week. A research report said that over half of all New Zealand workers are exposed to cancer-causing agents or activities in the workplace and identified the causes. The equity impacts are those we have come to expect on Māori and Pasifika workers.

But we have no dedicated public agency responsible for occupational health in a gap between WorkSafe, ACC and the Ministry of Health. Screening and data collection are inadequate and so we allow workplace practices to continue that we know are generating suffering and health service costs down the line.

I may have missed it but I have not seen any other calls for action on this. The public debate is too focused on the negatives in our performance on handling ill health and too little on stopping it happening.

So that is the first big priority. To reach pae ora (healthy futures), we have to do the great majority of change not amongst those activities dealing with the effects, but amongst the causes. This will mean challenging many vested interests. Mostly it will be a matter of forcing costs to where they are being created. This will require an unprecedented level of political fortitude.

But anyone who tells you they want a more healthy community without being prepared to stop, control or properly allocate costs to those activities causing ill health is lying and beneath contempt. They are collaborators in harm.

There will still be plenty of ill health issues for our health system to respond to, that is part of the human condition. But it will be far less when you take away or even limit the need to repair and respond to deliberate acts of harm. Or at least make the perpetrators pay the full costs of their activities.

You might think I am trying to avoid or deflect from the issues facing the current health system reforms. That is not my intent. I turn to those now but warn you in advance that the theme of courageous action will not go away.

We are in an age of instant gratification. The politicians, bureaucrats and consultants promoting the pae ora reforms did not go out of their way to make this clear, but any structural reform of this scale was always going to be disruptive, costly and slow to bear fruit. So it is. It will be years before anyone can confidently say that the reforms are a success or a failure. We should treat with derision or at least deep suspicion anyone who confidently asserts success or failure one year into the reform.

There are broadly two measures of success for this reform (if one cuts through the countless pages of analysis, description and promotion):

• Are we getting more and higher-quality health services delivered for an equivalent cost, and

• Is the geographical and ethnic and income distribution of those services equitable?

It is harder to find but I, and I think many of us, would add to this:

• Are those delivering health services well trained, resourced, supported and paid?

I have to say that while I was involved in trying to implement the reforms, and since as I listen to and discuss with those still involved, I developed some doubts about many aspects of the reform package.

But the last thing those working within and interacting with the system need is another major reform. There are some changes I would do but ,the more I reflect, the more I think the priority has to be to do the best we can with what we have created now.

I have suggested a number of structural changes (for example, to establish better clarity and control for physical capital investment) and revision of timelines (for example to allow the localities concept to develop under less pressure). But this bureaucracy’s reputation is not for flexibility, a reputation it justly deserves. There is simply not going to be the kind of pivot one might expect when a plan meets reality.

The much bigger threat politically is a reversal of direction for unrelated reasons, which would be very unhelpful to the positive changes that are going on.

Frankly, there are not any perfect such systems and the best option (leaving aside my major shift in emphasis in public health matters) is to do our best to make this new structure work. I think there is plenty that can be done to make it work better and to do a pretty good job on the three measures I have identified.

To name a few things we could be acting on:

• We do not have a clear “model” or set of principles on which we think and act about health services as a whole. What we call a “public” system is overwhelmingly a private system funded by public health money, along with ACC money, insurance money and user payments. The crafters of the current reforms really did not address this. We need to find a common way of understanding this and make our funding arrangements in line with this, simplifying it for providers, funders and users alike. At present we are dominated by ad hoc renegotiations of services and funding. This can only be effectively done cooperatively and respectfully without threatening any of the existing participants. It does not require further structural reform but without it the outcomes will be suboptimal at best.

• Aligned with this, we need to sort out an understanding on matters such as aged care. The current issues of staffing and funding and service availability are real, but small alongside the future known requirements for aged care. These will not be effectively dealt with in an ad hoc, negotiated framework. Again, involving all interests a model of what we as a society want in aged care is the place to start, with funding, staffing, investment and other issues flowing from that.

• Mental health is a major issue with no easy solutions. A common agreed pathway is required, amongst providers, users and communities, which we do not currently have. It will not be a single “solution” but a set of responses from prevention to care and rehabilitation. As with all these matters giving this a genuine priority and working in partnerships is required.

• Many people working in the health services system and their union and professional organisations feel they have inadequate involvement in key decisions and implementation of decisions. There has been a reticence from leadership to create actual involvement. These groups are very important in this sector; they are key to successful operations. There is a big difference between involvement and consultation, and it is deeply felt. We would all benefit if this changed – and with it the models of management and governance being applied.

Whichever area you take, my perception is that really good and effective practices are already in preparation or existence across the system taken as a whole. Many people involved feel that the sheer fact of major change has encouraged and enabled an increase in this, which is great. It is vital that such expectation is not stilled. The task for the leadership of the system is not to invent or reinvent but to nurture and support these practices, cut through silos and barriers.

The Te Whatu Ora structure is not perfect but it can deliver this. The issue is not so much structure as leadership. Leaders at all levels must see their commitment as being to the kaupapa not the institution or its chains of command.

We need real courage and initiative from all leaders to promote change not as some inevitable drag or as negative, but as positive and celebratory of what is already being done. Most importantly, those in leadership positions must genuinely commit to devolving power and information, seeing themselves as a support function not as commanders. One of the main faults of the reforms to date is that hierarchical structures with familiar faces are being constructed or replicated to the detriment of the cause.

Some of the most promising innovations are taking place in the communities which themselves have access and equity issues, not only Māori or Pasifika initiatives but also Asian and other ethnicities. One can also see initiatives from within communities defined by interests other than ethnicity, for example, disability or gender identity. We should welcome and nurture and resource these. It is far more likely that they will find the route to equity of access, involvement and outcomes than someone from above and unaffected.

Te Whatu Ora and the ministry must be prepared to take this stand without needing to control and to shift resources even where some existing structure or provider is affected. Again, courage and initiative are to be rewarded above obedience to the old ways.

I don’t comment much about Te Aka Whai Ora because I had limited involvement, although I greatly appreciated the involvement I had and learned a great deal from it. I think its most important contributions are, first, the degree to which it can establish genuine mana motuhake for kaupapa Māori health services with an appropriate level of resourcing to do this.

Right now, its resourcing is well below the necessary level that must be built, ideally alongside the more broadly framed actions of Whanau Ora. But also, second, the critical role it has in monitoring and guiding actions from the wider system. This potential is huge. It can derive great strength from the iwi Māori partnership boards being established, which have, in the legislation, great potential strength in constructing and calling out faults in equitable health services for Māori. This will translate through Te Aka Whai Ora’s oversight of equity in Te Whatu Ora and the ministry. The leadership of this must again be courageous and assertive. If it is, it will have a real impact. It must not be quiescent but assertive in this unique opportunity.

Turning back to Te Whatu Ora itself, there is a tendency for the leadership to see its role as representing the political and bureaucratic position to those working in, interacting with and accessing the health services system. In my view, this is wrong and sells short the potential of the reforms. If this were the whole intent of the reforms, there was no need to establish separate Crown entities, associated boards, et cetera. It could all have been done with a government department.

Te What Ora is rightly subject to the Government Policy Statement and its Government approved Health Plan. Funding is rightly tightly controlled by the ministers. There must be a line for public guidance or even instruction from ministers where this is justified. But beyond that normal and prudent oversight, there must be more flexibility for a Crown entity to make its own operational decisions. Hopefully this will come with maturity.

The leadership can and should be assertive about what it needs to do and what it needs to do it. It must be a strong advocate for what its clinical, care and other professional staff know. All that takes is confidence and courage.