• Health Reforms Long Overdue

    The Government’s (that is, Andrew Little’s) far-reaching health reforms have been – predictably and rightly – well received by most health professionals.

    I judge them – and welcome them – on the basis of my own experience in chairing a Primary Health Organisation over a period of some years. My experience led me to the conclusion that the problems of the health service were the consequence of flaws, not only in the organisational structure of health service delivery, but also in the funding arrangements.

    The decision to entrust the country’s health policy to a national body and to abolish District Health Boards is long overdue and gives us a chance to end the “postcode lottery” produced by the different standards and piecemeal levels of achievement in different parts of the country. It allows the possibility of a national policy, applied across the whole country, and one that does not depend on the vagaries implicit in having a range of district health boards, each one of which has its own local priorities, levels of expertise, and differing sensitivities to the presumed (and often widely varying) needs of their local communities.

    The variability created by having twenty District Health Boards was not, however, the only cause of difficulties. Problems also arose as a result of a confusing set of funding arrangements. Funding came originally, of course, from the government, that is the Ministry of Health. The total funding for the region, – that is, funding to cover both primary and secondary health care – was paid initially to the DHBs. They then had to allocate a proportion of the funding to primary care – that is, to general practitioners – and the remaining proportion they then retained for secondary care, – that is, for hospitals, the sector which they themselves administered.

    This unnecessarily complicated system of funding inevitably gave rise to uncertainty and suspicion. The primary sector would always suspect that they were being underfunded by the DHBs whose priority was, naturally enough, the funding of the hospitals for which they were responsible.

    But this was not the only cause of tension between the DHBs and the primary health organisations. Performance standards in primary health care were set by the Ministry, which looked to the DHBs, as the funder, to ensure that the standards were being met. The DHBs in turn would in turn monitor the performance of the primary health organisations, and would react strongly if they felt that the standards were not being met – and since they held the purse strings, this was a constant source of tension between the two sectors.

    The primary health organisations found themselves having to serve two masters – first, the Ministry, that set the standards, and secondly, the DHBs, who controlled the funding. The DHBs also found themselves in a difficult situation, having to account to the Ministry for meeting the required standards, but having to delegate to another body or bodies the practical responsibility for the work needed to meet the standards.

    The reforms seem likely to cut through these unnecessary and confusing complexities, so that funding will be provided directly to those bodies that will be responsible for delivery, and those bodies will have a direct line of accountability and reporting to the body that both sets the standards and holds the purse strings.

    The second major reform – the establishment of a Maori Health Authority – is also strongly to be welcomed. Anyone with any experience of health service delivery to a population containing a substantial proportion of Maori will have learnt that the take-up and effectiveness of health care provision is greatly improved if the delivery of that service is seen to be in Maori hands. The learning of that lesson is long overdue and should at long last lead to the improvement of shamefully bad Maori health statistics.

    Bryan Gould
    22 April 2021