Thinking something doesn’t make it so: The big gap between idea and actuality

All up, the Community Services Card solution is likely to create an enormous amount of work, with only marginal improvements in equitable access to primary care

Making good on promises is something that each of us struggles with sometimes. Whether it be New Year’s resolutions, decisions to spend more time with family, taking on additional responsibilities in a job that is already full – we often fall short, for a myriad of reasons.

It is no different in the world of health policy. Most people working in the health sector know intuitively that what governments decide to do, and what ends up happening, can be miles apart.

If we are to learn from experience, then it is crucial to understand why implementation doesn’t meet policy expectations, or has additional unintended consequences.

In the past 25 years, many examples of health policy decisions have led, once implemented, to results far short of policymakers’ expectations. These include the National Bowel Cancer Screening Programme; integrated family health centres (IFHCs); partial community governance of PHOs; and the purchaser– provider split of the 1990s.

In explaining these shortfalls, it is tempting to be cynical and suggest governments are more interested in promising than delivering, or that government agencies are poor at carrying out instructions. The reality is far more complex and multifaceted.

Clearly, electoral politics can be a significant factor. Policy platforms are designed to maximise a party’s chances of winning an election or, at the least, to minimise chances of losing. Opposition politicians and the party operatives who craft policy platforms often have limited experience of the intricacies of governing.

A second reason implementation often falls short lies in resistance to the policy “on the ground”. Most PHOs and most GPs didn’t want partial community governance of PHOs and actively resisted its implementation.

A third reason amounts to “the devil being in the detail”. Some potential pitfalls – former US defense secretary Donald Rumsfeld’s “unknown unknowns” – become apparent only when implementation starts in earnest.

A final, and less obvious, reason is that central government agencies, including the Ministry of Health, often do not have the capacity to think through and provide guidance about implementation.

With the implementation of purchaser–provider splits in the 1990s, DHBs and PHOs in the 2000s, IFHCs and district alliances in the 2010s, the common denominator has been: “We (central government) give you the framework, but don’t ask us how to do it – you have to work that out yourselves.”

This is a major reason we have the intricate mess of DHB and PHO boundaries that are not contiguous.

As University of Otago health policy academic Robin Gauld argued in 2008, the ministry did not have a handle on issues emerging from simultaneously restructuring the health system (creating DHBs) and introducing the Primary Health Care Strategy (creating PHOs).

When the public sector was re-engineered in the 1980s, a central principle was for ministries to focus on the provision of policy advice, rather than on operational matters. The jargon of the time (Treasury’s, at least) was the need to avoid “provider capture”.

Essentially, a central message of the State Sector Act was that it wasn’t the job of the Ministry of Health to think about implementation.

So, with all this in mind, let’s consider the chances of implementation success for the proposed changes to Very Low Cost Access to primary care.

Back in 2015, the Primary Care Working Group, chaired by GP Peter Moodie, produced a report on general practice sustainability. A key focus of this report was the VLCA scheme and its blunt and inaccurate approach to targeting low fees for high-needs patients. Among other things, the report recommended the resurrection of the Community Services Card as a targeting mechanism, alongside targeting residents of deprivation 9 and 10 census areas.

During the 2017 election campaign, both parties ended up adopting the CSC recommendation. Instead of pursuing the deprivation 9 and 10 option, National promised to extend eligibility to Housing New Zealand tenants and those receiving accommodation supplements. Labour decided to match this.

This pretty much guaranteed the resurrec­tion and extension of the CSC, regardless of the election result. In this case, central government agencies had no chance to work through the im­plementation issues beforehand.

Implementation of the CSC option is likely to be in­furiatingly complex. It will involve extensive changes to the Health Entitlement Card Regulations, and complex negotiations between the Ministry of Health, the Min­istry of Social Development and Housing New Zealand about transfer and privacy of data about clients.

It’s also unlikely that it will effectively improve access to primary care for those who face the largest barriers.

Since the 1990s, we have known that about a quar­ter of those eligible for CSCs do not have them, and that those who don’t are more likely to be Māori and Pasifika.

All up, the CSC solution is likely to create an enormous amount of work for public officials, with only marginal improvements in equitable access to primary care.

If political parties and government agencies gave sufficient time and energy to implementation analysis, they could realistically anticipate many shortfalls and unanticipated consequences.

A health policy environment that minimises impulsiveness and maximises consideration of implementation would be a worthy goal.

Tim Tenbensel is associate professor of health policy at the University of Auckland. Dr Tenbensel acknowledges the contribution to this article of Masters of Public Policy student Rose Boele van Hensbroek, who carried out a detailed analysis of the VLCA change