Barely a day goes by without some worrying story about shortcomings in our health system appearing in the media. In a career of working with and observing the health system, I have come to expect a regular diet of stories of this kind. But, over the last year or so, the sheer volume and intensity of coverage has increased markedly.
In 2019 I was elected for a three-year term to the Auckland District Health Board (ADHB). For the next few months until the arrival of COVID-19, from my perspective – as a director on the board – the ADHB ran like a well-oiled machine.
This continued even in the tumult and uncertainty of a health system struggling with a pandemic of almost unprecedented dimensions. As Board members we were supplied with routine performance information on a regular and timely basis, and we had a steady flow of reports from management. Indeed, my respect for management increased once we were grappling with COVID – a crisis for which we had no playbook.
It is also worth noting that, quite aside from the onslaught of COVID, we were grappling with a nine-year reduction in the real level of health spending under the previous government and we were having to absorb record population growth as the country advanced from four to five million in the space of just 17 years, much of it through barely controlled immigration, and much of it in Auckland. Also we had experienced a poorly administered Census in 2018 which brought into question some of the data on which we were asked to make decisions. Yet we did well.
The health system restructure
On July 1st. 2022 the DHBs were disbanded and replaced by Te Whātu Ora – Health New Zealand. I was now an observer on the outside and starting to wonder – is the health system really as bad as the media, commentators, health advocates and ordinary people are now making out, despite the fact that health spending at 9.74% of GDP is the highest it has ever been?
Yes, there is the aftermath of COVID which has greatly stressed the system and produced a backlog (as it has in every other developed country). This is particularly evident with waiting lists, immunisation, emergency departments, and access to primary care (i.e. family doctors).
Aside from the aftermath of COVID, which is too easily forgotten, there are some other factors.
First, the 20 DHBs have been abolished and we now have a single entity. That means that anything that does go wrong is sheeted back to that one entity, and ultimately to the government of the day.
Second, we have almost no data and we have no targets. As a DHB member I had a dashboard of key information and performance data at my fingertips. Where there is no authoritative data, the media understandably go for personal stories, professionals, commentators, and advocates. And without targets we have no performance levers, just plans from the centre that may or may not deliver.
Third, towards the end of the Delta wave of the pandemic, there occurred a mood shift in public opinion to the disadvantage of the government. This has been reflected in the polls and the media.
Finally, many of these issues are endemic to the health system in New Zealand, particularly given the tendency with the swing of the political pendulum for government funding to oscillate between feast and famine. This uncertainty on funding makes long-term investment hard to plan.
Hence, during my time at the ADHB we faced the legacy of almost all the IT systems being beyond their use-by date, lacking interoperability, sustained only by workarounds, and in need of urgent replacement. This included the national immunisation system which was described by senior staff as being “on its last legs”. And this just before a massive vaccination programme under Covid!
What can be done
Covid was not entirely a setback. There are features of the health system that could and should be working better than before COVID. These include the use of digital and virtual methods to increase access and reduce unnecessary person-to-person contact, greater flexibility in the deployment of the health workforce, more joined up IT systems, greater regional integration (at least in Auckland), and so on. These all greatly advanced under the urgency of Covid conditions.
Emergency Departments? There are well-established interventions, much of which revolves around ensuring accessible primary care and after-hours services, outreach of skilled clinicians able to give advice to paramedics, families, and hospital staff, faster hospital workflow, and successful triage.
What about the state of the workforce? Yes, we could do with more doctors and nurses, but according to OECD figures New Zealand’s level of nursing was similar to a group of OECD developed countries with 10-12 nurses per 1,000 population (above Denmark, Sweden and Canada, and below Australia, the US and Germany) and 3-4 doctors per 1,000 population, again close to Australia. What we could really do with more of, aside from general practitioners, are paramedics, physician assistants, nurse practitioners, and other allied professionals who could extend clinician productivity.
And we also need to tackle inflexibility in work practices. Why did it take so long to agree non-RN vaccinators under Covid? Why can school dental nurses not be dental nurse practitioners? Why are we so short of anaesthetic technicians? Why are more GPs not open on Saturdays? Why do public hospitals downshift so dramatically at weekends? All worth a look, and more.
Where to from here
We have just gone through a big restructure, but is there anything we could do with the structure of the system to improve things? One approach would be to make more of the four current regional groupings (as originally proposed in the Simpson-led review), empowering them as commissioning and coordinating agencies for health services, starting with primary and community care as at present and progressing to other services, including outpatients and specialist services, elective surgery, midwifery, and well child services.
With data publicly available, and clearly specified targets in areas such as waiting lists, we could start to get discernible, publicly noticeable, and reassuring movement in each region. And we could put primary care – that is, family doctors and their teams – in the box seat with the mission of keeping people out of hospital along the lines, for example, of the US non-profit, Kaiser Permanente, where the centre of gravity is the family doctor fully enabled with a team of colleagues and assistants, with direct access to specialists and specialist, screening and preventive services, with hospital admission very much as a last resort.
Health always has its discontents, and we cannot expect to be unaffected by such turmoil post-COVID. But with patience and goodwill, and a bipartisan commitment to long-term funding, data, enforceable targets, and evidence-based planning, the problems we face are eminently fixable.
Peter Davis is The Helen Clark Foundation Chair and former elected member of the Auckland District Health Board.Read more