"Equity in health" a speech delivered by former Te Whatu Ora chair Rob Campbell

You cannot divide, dictate, cut, restrict, ignore and instruct your way to a healthy health service.

It is an honour to be able to spend this time and share some thoughts with you on the vital issues on your agenda of “reimagining the future of nursing”.

In these times where the deficits in health equity, in the scope of and access to healthcare, and in the wider building of healthy communities, are so clear we must have real clarity on who we are as promoters of health equity and what we must do to protect and promote it.

The deficits are real but they should not dominate our thinking. What should dominate our thinking is promotion of healthy futures and how we work together for those futures.

Whatever role we may have in that there is none more important than that of the nursing profession.

The university of which I am chancellor - AUT/Te Wananga Aronui o Tamaki Makaurau - is the largest provider of education to health professionals across a wide range of skills.

Our work is fully committed to excellence and equity in that process.

I am speaking today personally and not in an official role, though obviously I hope that what I say might resonate with many of our team and students.

I cannot help but reflect with sadness and concern on how far issues of equity have slipped down the leadership agenda at the minister’s offices, at Manatu Hauora and at Te Whatu Ora over the past year.

Trashing Te Aka Whai Ora was the symbol. A mindless piece of destruction in its own right but an even worse indicator of what is to come.

We have lessons to learn aplenty and it is important that we do learn.

So I will share with you some thoughts – not from any real expertise, but from quite short health sector experience and empathy with the huge tasks ahead of you. My wider governance experience also tells me something about what went wrong and what can best be done from here.

I did not stop being concerned about equity and excellence in our health care system when sacked by the previous government for warning of the dangers ahead, some already evident at the time. One day some of them might even accept that I was right.

You cannot divide, dictate, cut, restrict, ignore and instruct your way to a healthy health service.

It need hardly be said but here goes is my summary:

“Nurses are fundamental to any possible genuine pae ora/healthy futures. Such futures and the equity they require must have nurses, their interests and their capabilities actively at their core”.

You are at the centre of this, not just as objects of either deficit or change but as subjects, as drivers of solutions. Or solutions will not occur.

This is true also of the many kaimahi, paid and unpaid, in kaupapa Māori social and health services. They are not simply objects and costs but the subjects, drivers of and integral to solutions.

Any serious discussion on equity in health has to see nurses, not solely of course, but centrally as the key to solutions, as drivers of solutions.

The inequities are real. And they grow deeper as those with the ability to pay private services do access those services – meeting their needs while weakening service for others. If you are “wealthy and sorted” like the prime minister the problems do not loom large or not at all. But for others they do, nurses included.

So much of this is so clear but we should not allow the inequities to be lost sight of.

It was right, for example, that the Pae Ora legislation should emphasise equity for Maori in health services because the evidence is so abundant that it exists, and that special focus is necessary to address it.

Just this week Lady Tureiti Moxon said: “In health services, we didn’t ask for anything more than anybody else. But we didn’t ask for anything less, either. We didn’t ask for bad health, or not being diagnosed in time. We didn’t ask to die young. But here we are”.

So true.

This idea that nurses are central to the answers to equity in health is not unique to Aotearoa. I was struck by the wording of a July article in your journal Praxis: “Nursing is inherently a caring profession and, if we are truly advocates for the people we serve, it is also a political one……will we bow to the political pressures that are divisive and competitive and force us not to care?….nurses always choose to care despite the challenges”.

As I am sure you are aware that very core of “caring” is seen and often exploited as a weakness, and the expectation of managers becomes that of submissive service. But properly understood in unity and activism it is force far more powerful than government austerity and dictation and it carries the future of health with it.

This is a global recognition. I recently read a publication of the National Academies of Science, Engineering and Medicine in the United States entitled “The Future of Nursing 2020-2030. Charting a Path To Achieve Health Equity” from a high powered group which recognised that nurses “live and work at the intersection of health, education and communities”. That alone, they noted, makes nurses central to any achievement of health equity.

The publication identifies the outcomes which are required to give effect to health equity which are largely about educating and empowering nurses aligned across public health, health care, social services and public policies. It will all be familiar to you, but it is far from what is happening either there or in Aotearoa.

It should be what we are doing, but what we have is a system based on division and separation, controlled from above, subject to “push me/pull me” swings of political motivations not healthcare.

I still believe that what I referred to on taking up the Te Whatu Ora role as “equity, excellence and efficiency” should still be the goals. These are complementary, not in conflict. The aim is the best, most equitable, services we can afford. This is something we can only achieve by those most involved working together for their patients and communities.

As it happens the Pae Ora (Healthy Futures) Act, which is the governing law though it hardly seems to be, supports this view.

It is worth reminding ourselves that the purpose of this Act is:

“To provide for the public funding and provision of services in order to:

(a) Protect, promote, and improve the health of all New Zealanders; and
(b) Achieve equity in health outcomes among New Zealand’s population groups, including by striving to eliminate health disparities, in particular for Māori; and
(c) Build towards pae ora (healthy futures) for all New Zealanders”

As to how this should be achieved there was plenty of room for debate on detail but the basic formula of setting national standards of operations and service and of financial accountability, localising specific primary service availability and accountability to community levels, rationalising major hospital delivery of service, and development of a dedicated Māori health service was well supported by health research and the views of the various professional bodies.

The behaviours which should underpin this were to be agreed in a Charter to cover management, staff, contractors and funded service providers, later developed in the form of Te Mauri o Rongo, which is, I remind you, still officially in place.

The guiding pou of the Charter are:

• wairuatanga/purpose and commitment;
• rangatiratanga/supporting people to lead;
• whanaunagtanga/working together;
• te korowai āhura/safety and support in work.

There are some grand words in this, some poetic expression. The basic principles are that we can only do this together, so we will.

Read it again. You will not find much that you recognise from today’s relationships within Te Whatu Ora or between it and its funded sector.

There is not point in me reiterating problems for nurses or your colleagues. You all know them better than me. Let’s just agree that we are a very long way short of where we need to be.

With the benefit of some time and distance I think I can reflect usefully on a few aspects of what went wrong:

1. Some of it was in the process of developing the legislation

• It was dominated by Ministry people who thought they knew best and consultants who were sure that they did.
• It failed to take a holistic view of all of the public and private parts of the health system and plan for their integration.
• It did not identify and articulate the key physical and information technology base which was required and provide for it, leaving a mixture of grand scale plans in both areas of infrastructure imposed on top of messy and inadequate basic existing facilities.
• There was no establishment of a clinical “senate” or equivalent where the clinical people could evolve, express and advocate for united views on key priorities leaving the initiative with managers.
• There was inadequate time provided for the transition, and no plan embedded into the legislation to develop understood change programmes.

2. Some of it was in the structure developed

• The role of Te Aka Whai Ora was not sufficiently supported by funding or clarity of its goals.
• Key components of the structures and scope of entities such as the IMPBs and “localities” were inadequately identified and supported;
• The Ministry retained far too much influence and had no idea how or what its role as “steward” of the system really entailed. Along with that there was confused “oversight” from the Ministry, Minister’s office and Prime Minister's office and various advisors to each.
• The transition left far too much of the previous district structures and management in place for the new structure to change so it was faced with a disestablishment task as the start of its establishment.

3. Some mistakes were made by Board, management, and Ministers

• The Crown Entity structure was ignored by Ministry and Ministers in favour of direct management involvement bypassing the Board.
• The position of Chair should have had initial executive powers given the passing over of old structures and senior executives.
• The Board was not sufficiently assertive and open about the challenges and defects either with staff or public.
• The Board spent too long working with executives and processes which should have been more thoroughly disrupted more quickly.
• Management failed to adopt the required processes working with unions and professional organisations in favour of retaining historical hierarchical and transactional practice.
• In summary Te Whatu Ora became an organisation which was not seen as working for health service workers and its communities because it wasn’t.

All of these issues have been intensified under the new regime imposed during 2024.

The organisation appears to have the transparency; the breadth and depth of vision; and the flexibility and responsiveness of a concrete wall.

Those leading this are doing and saying what they are told rather than what they should. I do not believe for a second, to give just one example, that Te Whatu Ora did not know how many nurses they were hiring, nor that they were having to pay such nurses.

I still think that, with all of its inadequacies, a good framework for building equity in health is provided in the Pae Ora legislation.

But it would be naïve to think that there is any intention to head in that direction.

You may, in your work, have found differently but from my knowledge and experience there is simply no path to equity, excellence and efficiency in health services which does not have at its core a robust public health service.

No backing away from that. We have been told and will be told more often that this or that aspect of health service can be provided more efficiently by private interests. But:

• In almost all cases this still involves public funding, underwrite or backing where community equity interests are met if at all in some residual fashion limited in time and scope;
• Each private initiative weakens a comprehensive public service even it appears to have initial benefits;
• Quality regulation remains an ongoing issue for the public interest.
• Any really serious approach to equity in health starts well before contracting out or privatising specific health services.

It starts with how our education, housing, income and taxation, and other economic activities are conducted. If the social and commercial determinants of good health are not being promoted any health service will face increasing demand for repair and rehabilitation.

Given this there are two imperatives for those who wish to preserve what we can and to build understanding for a better future in our communities even while many aspects of equity in health are frayed:

• In Defence: to work cooperatively across all parts of the health system from research, to education , to public health, primary and hospital care to articulate the issues and solutions which have the greatest possible commonality across health services. Only a fully combined and integrated response from all professional and union organisations can be effective. There is only danger in promoting or even accepting sectional or selective interests; and
• In Progress: to promote community and iwi based health services which exist or might be built as core public sector provision is weakened or closed down. If no alternatives are proposed and promoted then “for profit” will not only take but define the spaces.

There is a further danger which I think is not far off. Do not think that initiatives such as the new Ministry of Regulation intends to limit itself to “tape” of any colour impacting only businesses.

I have no doubt at all that occupational regulation will be looked to as a target. You can already see some of this around roles like nurse practitioners and pharmacists. I’m not taking a view on these specifically but across the board of clinical roles it is certain that both public and private health service managers will be promoting blurring of lines across what they see as restrictive work practices.

Both unions and professional organisations will be posed as holding back efficiency.

It is very important not only to be prepared for this but to be ahead of the game where technology or other changes impact traditional qualifications or accreditations. If you don’t identify, adapt and promote changes then the managers and investors will.

This requires close involvement with educators as well but is more important than ever.

I think it is important too, to keep mounting campaigns for positive progress wherever we can.

It can’t all just be about defending what we have when we don’t have enough.

I think a good example (this is just a personal view not on behalf of anyone) is paid placements for nurses.

We know it is very hard for nurses to get through training on the same basis as other students, but facing the additional costs of equipment, travel, and losing pay from other work in order to take part in required placements, is often intolerable and nursing students often find it a step too far.

Not only do the public and publicly funded health services have a responsibility to provide placements but also either pay themselves our secure funding for these costs.

It is a good example of where the whole system needs to work together. A trained workforce is a fundamental requirement of a public health service, a cost which must be met, and not by those just getting prepared to join. Nurse trainees are doing us all a favour, but that is not a reason to exploit them.

So just simply, if I may, the key to having nurses meet the kind of health equity challenges I described in opening, that Tureiti described, that Praxis described, that the US study described requires:

• Educational availability and funding for nursing that is integrated with and paid for from within the funding for public and private health services;
• Curricula and availability of specialist training on the same basis to meet specific needs and ongoing innovation in nursing and integrated with other health professional roles on bases driven by the clinicians;
• Fair payment and other working conditions across whole sector;
• Full recognition of Māori health equity requirements and processes developed and met by Māori.

I may seem to have been quite light on how vital Māori health equity is. I’m reticent to be speaking on this in any detail as tangata Tiriti but that does not mean I am not fully committed in allyship to that cause. I understand as I am sure you do that Māori need to chart and drive their own mana motuhake not have it explained by those like me.

I think we also share how important this is to be integrated as well as independent with the full public health system.

Right now my view is that the IMPBs are a key focus and catalyst for health equity and must have full attention and support from us all. The more focus they have the better.

Other groups of course have very special needs and areas where equity is denied. I am always bemused that such attention is seen as divisive or separatist.

Things like the Women’s Health Strategy which managers and politicians tried to avoid and certainly have failed to implement are a good example.

The special needs of migrant groups, of Pacific peoples, whaikaha, and others are all areas where communities will recognise their own need to be part of nursing’s challenge and share the need to lead and create with nurses. These communities are our allies.

So that’s it really: be assertive, be innovative, be positive, be open and active across all issues. You are the centre of how we will create health equity and I thank you for all that you have done and will do in that cause.