Improving equity and wellbeing for Māori requires immediate improvements in the way the system delivers for Māori, a growth in the range and distribution of kaupapa Māori services, enhancements to rangatiratanga and mana motuhake.
All recommendations proposed by the review are designed to improve the effectiveness and the equity of outcomes for Māori, but this chapter has focused on the particular structural and cultural shifts necessary.
The Review proposes the following changes
Te whakauru i te Tiriti o Waitangi ki te pūnaha / Incorporating Treaty of Waitangi into the system
- Te Tiriti o Waitangi sections in health legislation should be updated to ensure they reflect recent interpretations of te Tiriti principles.
- An independent Māori Health Authority should be established, as kaiarataki for hauora Māori, reporting directly to the Minister with the following functions:
- advising the Minister on all aspects of Māori health policy
- partnering with all other parts of the system to ensure mātauranga Māori and other Māori health issues are appropriately incorporated into all aspects of the system
- monitoring and reporting to the Minister on the performance of the health and disability system with respect to Māori health outcomes and equity
- investing in kaupapa Māori health services and providers
- developing and leading the implementation of the Māori health workforce strategy
- developing or supporting innovative Māori-specific population health initiatives.
- Reflecting the Te Tiriti partnership in the system through 50:50 Māori–Crown representation on the Health NZ board and ensuring DHBs and other boards also reflect the te Tiriti partnership.
Te whakararau i te mātauranga Māori ki te pūnaha / Embedding Māori knowledge systems in the system
- The Māori Health Authority should develop and implement policy on mātauranga Māori.
- Mātauranga Māori should be embedded into all health and disability services. Additional investment should be made in kaupapa Māori health services and providers, and DHBs should be required to ensure kaupapa Māori services are provided for in all locality planning.
Te whakawhanake i te ohumahi hauora / Developing the Māori health workforce
- The Māori Health Authority should work with Health NZ to ensure that the whole workforce, organisations and services deliver culturally safe, competent and effective services to Māori.
- Equity clauses in health legislation should be updated.
- The Māori Health Authority should:
- work with other parts of the system to ensure the programme to combat institutional racism is delivered effectively
- develop the Māori health workforce by ensuring it has a detailed Māori health workforce plan and invests in its implementation
- develop Māori health provider development strategies to ensure there is an appropriate Māori workforce and the range of services to meet the health and disability needs of Māori whānau and communities
- ensure funding provided for increasing innovation of Māori providers, supports the development of more specific population health initiatives for Māori
- review the terms of reference of the Māori Provider Development Scheme, the National Māori Workforce Development Fund and Te Ao Auahatanga Māori Health Innovation Fund, and update both the scope and the size of these funds.
Governance and Funding
The New Zealand health and disability system can and should be simplified. Changing a system's structure can be very costly and disruptive, divert attention from delivering care and can impede innovation. Therefore, whilst significant change is recommended, wherever possible, the Review's recommendations focus on making the system's current arrangements work better.
The Review proposes the following changes
System-level stewardship and leadership is strengthened
- The Ministry of Health should be the chief steward and chief advisor to the Government on health and disability strategy and policy.
- A Māori Health Authority should be established to lead strategic policy with respect to Māori health, to act as kaiarataki for hauora Māori and to ensure the system is committed to achieving equity of outcomes for Māori.
- A new crown entity, Health NZ, should be established to lead delivery of health and disability services across the country. A Charter for Health NZ would be developed that sets out shared values and aims to guide the health workforce culture and behaviours.
- Health NZ should be governed by a board of eight members and a Chair, with 50:50 Crown-Māori representation, with board membership drawn from DHB board members in each of the regions.
- Leadership should be built at all levels of the system, and deliberate actions taken to shape the system culture and capabilities, and provide leaders with the accountabilities, information and tools to lead.
District health boards are refocused and accountable
- DHBs should be accountable for both improving the health outcomes and equity among their local populations and contributing to the system’s effectiveness.
- All DHBs should be required to operate as a cohesive system subject to Health NZ leadership. Health NZ would oversee a reduction in DHBs from 20 to between eight and 12, and DHB regions to no more than three.
- All DHB Board members should be appointed by the Minister of Health against a transparent set of competencies, including financial and governance experience, tikanga Māori and specific health sector knowledge. The composition of Boards should reflect te Tiriti/the Treaty partnership. DHB Board members should have on-going training and professional development in the capabilities they require to govern effectively.
- DHBs would be expected to engage effectively with Māori, and build their services capacity and capability to engage with, and understand the perspectives of Māori.
Consumers, whānau and communities are engaged
- Local communities, iwi partners, consumers and whānau, clinical experts and other stakeholders should have meaningful opportunities to influence planning, and be engaged throughout the life of strategic plans to understand priorities, implications for services and outcomes achieved.
Integrated planning connects the system
- The New Zealand Health Strategy should set the overall parameters for all planning in the health and disability system.
- A New Zealand Health Outcomes and Services Plan (the NZ Health Plan) should be developed to guide the long-term strategic direction for the system, outcomes to be achieved, and how different parts of the system would work together. The Ministry should have overall responsibility for coordination of the Plan, and lead on system outcome measures. The Māori Health Authority should lead on Māori outcome measures. Health NZ should lead on services planning.
- Each DHB would develop a District Strategic Plan based on the population health needs of its district, include locality arrangements for Tier 1 services, and be guided by the direction and outcomes for the NZ Health Plan. DHBs would also collaborate regionally, and develop regional strategic plans that take a collective view of priorities.
Funding arrangements drive an efficient and effective system
- The predictability of funding for baseline services is maintained through legislation establishing minimum annual increases, determined by a formula reflecting increasing population, needs and costs. Vote Health appropriations should be simplified to support a single integrated system through having a single appropriation for Health NZ and DHBs.
- The transparency of financial reporting should be improved by requiring regular reporting on revenue and expenditure by DHB, population groups and services.
- The stability of individual DHB annual revenue should be improved by smoothing population revision impacts and changes to ways IDFs are managed.
- New initiatives funding should routinely be for a specified term.
- A dedicated performance support function should be established within Health NZ to drive changes in system effectiveness and efficiency.
- Investment aimed at rebalancing the system should be managed through Health NZ to ensure DHBs with unsatisfactory performance, have their access to additional funding more closely supervised.
- The population-based funding formula should be improved to better reflect needs. This would require an investment in improved information across all health care settings as an input to an improved formula.
- Funding for Tier 1 services should be ring-fenced so that it cannot be diverted to other areas.
Improving population health must become the driver of all planning within the system. A proactive approach to promoting and protecting health is required, with an explicit focus on equity.
Core health protection competence and capacity within the system needs to be strengthened to ensure the system has sufficient resilience to cope with the increasing frequency of incidents that threaten population health.
The Review proposes the following changes
Population health drives the system
- Population health would drive all strategies and outcome measures and targets are predominantly population rather than treatment based.
- The Ministry should have a strengthened leadership role and capacity for population health.
- The Ministry should increase work with other government agencies on policy that impacts the social and commercial determinants of health
- The Māori Health Authority should have population health expertise to focus on improving the health and wellbeing of Māori. It would be the key source of Māori population health intelligence for the system. The Māori Health Authority should be proactive in reporting on Māori health and disability issues and providing advice on Māori population health priorities.
- Health NZ should build a strong population health intelligence function to support population health being embedded into service planning, delivery and performance.
- The functions currently performed by the Health Promotion Agency should be transferred to the Ministry, Health NZ and the Māori Health Authority.
- DHBs should provide greater focus on population health through allocating resources, strategic and locality planning, service delivery and population health management functions.
- The funding for population health would be devolved to DHBs rather than being managed through a central appropriation and separate contracts.
The system is prepared and resilient
- Core health protection competence and capacity will need to be strengthened as will connections between the Ministry and other agencies with responsibilities for public health functions.
- The system’s emergency preparedness needs to be better connected, use data and be capable of rapid deployment. The system needs to have sufficient resilience to cope with the increasing frequency of emergencies and outbreaks.
There is an authoritative voice on population health
- The Director of Public Health and medical officers of health should have the authority and independence to advise the Minister and DHB boards directly about urgent or significant population health matters.
- A Public Health Advisory Committee should be mandatory. It should provide independent advice to the Minister and be a public voice on important population health issues.
To make a difference, particularly for individuals and communities who are currently missing out, Tier 1 needs to become more useful to consumers and their whānau, simple to access and easy to navigate. Services need to be commissioned in a way that enables them to be designed for the wellbeing of the people they serve.
The Review proposes the following changes
DHBs have the resources and authority for Tier 1
- DHBs should be fully accountable for planning and organising Tier 1 services on a locality basis for their population.
- Where a rohe is a defined locality, the plan could be the shared responsibility of the DHB
Tier 1 services are connected as a network and jointly accountable for outcomes
- Tier 1 services receiving public funds should be connected as local networks, managed by the DHB. Services within the network should be jointly accountable to the DHB for health and wellbeing outcomes of the locality’s population.
- A mix of service types and business models should be a part of the network, with NGOs and kaupapa Māori services playing a vital role.
- Contracts for Tier 1 services should, over time, have common requirements that facilitate working in a connected way. These include digital connectivity and data provision for measuring performance and outcomes.
- The default timeframe for contracts should be longer-term to provide greater financial certainty and stability for service providers, encourage investment and a sense of shared ownership of the network and the population served.
Tier 1 services reflect local populations and needs
- Each network should be made up of a mix of publicly funded Tier 1 services that address local needs and include guaranteed services with a strong focus on prevention and wellbeing. This should include outreach services, behavioural support, population health services, care coordination, home-based support and medicines optimisation.
- DHBs should be responsible for ensuring the mix of services is accessible to the population. This would include more services being delivered at home, marae, or schools, at times and locations that reflect the community’s needs, and with transport options that ensure reasonable access.
- If accessibility and availability of services cannot be achieved by existing providers, DHBs should bring in new providers or provide them directly.
A commitment to culturally safe services, including options for Māori whānau to access kaupapa Māori services
- DHBs should engage with Māori in locality planning to ensure that tangata and whānau needs are considered and prioritised in models of care.
- DHBs should include provision for kaupapa Māori services in locality planning.
- DHBs should ensure mātauranga Māori is embedded in all services with the Māori Health Authority providing support and guidance.
A locality approach drives commissioning of Tier 1 services
- DHBs should have the flexibility to commission Tier 1 service delivery models that reflect their population’s aspirations and needs.
- There should be no requirement to contract primary care through the national PHO services agreement. Similarly, Well Child / Tamariki Ora and maternity services should be planned and organised at the DHB level.
- Health NZ should develop detailed commissioning guidance for a range of Tier 1 services, including a range of contracting options for general practice.
- Health NZ should have responsibility to ensure consistency in commissioning and contracting protocols.
Equity and prevention is the priority for future funding
- Tier 1 investment should prioritise prevention and addressing inequities by initially expanding service coverage in areas of highest need.
- The first priority should be preventive services and services that ensure children, Māori and Pacific peoples achieve optimal outcomes. Investing in a wider range of mental health services must also continue to increase
- Priority should also be given to introducing medicines optimisation services (eg, for people living with chronic conditions) and new models of care for frail older people and older people with complex health needs.
Equity and ringfenced funding for Tier 1
- Tier 1 funding should be ringfenced, at least in the medium term, to ensure funding is not diverted to other services.
- Each locality should have an indicative budget based on the age, ethnicity, and socioeconomic deprivation of its population, which is transparent to the public. This would ensure services address local needs.
Better health, inclusion, and participation of disabled people must be a priority for action across the whole health and disability system. Increasing numbers of people are living with impairments, and more disabilities are being recognised. The system needs to be able to respond to disability becoming more of a norm and must be focused on a nondisabling approach to service design and delivery.
The Review proposes the following changes
Strong focus on improving equity and health outcomes for disabled people
- Health NZ and DHBs should engage with disabled people including tāngata whaikaha and their whānau as part of the planning and design processes, nationally and locally using a range of inclusive practices.
- The disability support system should move away from relying on diagnosis for initiating eligibility for assistance, towards providing assistance to live well, according to an individual’s need
Better data collection, analytics and meaningful engagement of disabled people
- Increased capability and use of data analytics to ensure better disability data collection and sharing that would underpin planning and services delivery.
Improved information, advice and early intervention
- Health NZ should have overall accountability for ensuring that nationally consistent information and advice about disabilities, and disability-related supports and services is available and accessible through different channels; this should be linked into the Tier 1 networks.
- Well Child / Tamariki Ora or other health checks could be extended to support early diagnosis and early intervention with improved information sharing and care planning across the health and disability system.
Accessing disability support services is an easy process for disabled people and whānau
- Health NZ should ensure there is a consistent needs assessment framework in place and used across the country.
- Assessment and reassessment processes should be streamlined so that those who require more service coordination support receive this in a timely manner, the need for regular reassessment is reduced, and people gain more freedom to manage their own support.
- Service coordination support should work more closely with other agencies to ensure disabled people receive more joined-up services.
- Over time, needs assessment and service coordination services should be integrated into Tier 1 service networks.
Disability support commissioning and funding transitions to Health NZ and DHBs
- Health NZ should develop a consistent commissioning framework for disability support contracts that aligns with the Tier 1 framework and supports the integration of purchasing of these services. The framework should specify core components that should be nationally consistent, while allowing DHBs the flexibility to contract for services that best meet their population’s needs.
- Funding for disability support services should, over time, be devolved to DHBs so that it can be managed with Tier 1 services.
- Health NZ commissioning rules should aim at building a better trained and more secure disability support services workforce.
- Health NZ commissioning rules should specify that the majority of services should be supplied by workforces on a secured salary basis and that salary rates should be consistent.
The system is a leading employer of disabled people
- Health NZ should lead a programme of work to engage and support the system to become a leading employer of disabled people in New Zealand.
While changes to models of care should support more care being delivered in the community, hospitals will always be needed to treat complex conditions and acutely unwell patients. It is expected that for the foreseeable future, growth in demand will continue to outstrip population growth.
Tier 2 must be organised as a cohesive network of providers, with streamlined planning design and funding arrangements.
The Review proposes the following changes
Hospitals and specialist services operate within a national plan, and have clear regional and local plans
- The NZ Health Plan should provide a system-wide view of Tier 2 services and identify national and specialist services, where these would be provided and how equitable access would be ensured for all New Zealanders.
- Regional and district strategic plans would provide more detailed service plans for short- medium- and long-term timeframes.
- Health NZ should fund most secondary Tier 2 services using a population-based funding formula. Where there is agreement that services would be provided nationally funding should be via a top slice negotiated on a three- to five- year basis.
- Where a region agrees that a lead DHB would provide services for other DHBs, this may be funded via a regional top slice.
- The IDF process should be streamlined so that service changes are incorporated more quickly and there is greater transparency of IDF flows.
Hospitals and specialist services operate as a cohesive network
- Hospital and specialist services should be delivered through a network that works closely with Tier 1. Boundaries between DHBs and care settings should become less distinct.
- The majority of Tier 2 services should continue to be delivered in each DHB, but complex services should be led by agreed providers consistent with the national services plan or regional agreements.
- Rural services planning should recognise the unique challenges of geography and distance. Service delivery should be integrated (and may be delivered from the same facility) with Tier 1 services and be routinely supported by using telemedicine and telemetry links with Tier 2 service providers.
- Service development should be clinically led and use local and international evidence to systematically determine investment and disinvestment decisions.
- Enhanced integration and seamless transfers of care should underpin service design. Technology should support enhanced access to specialist advice, and admission and discharge planning should routinely involve a care management focus from both Tier 1 and Tier 2 perspectives.
- Tier 2 services should be delivered for extended hours to improve efficiency and consumer access and clinical rosters should routinely include virtual sessions as well as face-to-face sessions.
- DHBs should have transport plans to better support patient and whānau transfers where required. Air ambulance services should be nationally managed and road ambulance services should be managed to consistent national standards.
Effective performance management systems are focused around high-quality, cost-effective service delivery
- Health NZ should work collaboratively with the sector to address unwarranted variation and drive sustained, better-quality care and better value for money.
- The Health Quality & Safety Commission should continue to monitor and improve the quality and safety of health and disability support services; and help providers across the health and disability system to improve the quality and safety of health and disability support services.
- Health NZ should enforce the open and collaborative sharing of hospital cost and performance data and improve the quality of reporting and analysis.
- DHBs should have robust systems in place to routinely provide data specified in the OPF that can be consolidated into a meaningful national view, and provide additional information when required.
The people who make up the health and disability workforce are the backbone of the system. The proposed system-wide changes will also better support the workforce to work to its potential, to release time to care and to work in more team-based and flexible ways.
The Review proposes the following changes
- The Ministry should lead the development of a workforce plan with input from unions, employers, Health NZ, the Māori Health Authority, the Health Workforce Advisory Board, TEC, the NZ Institute, regulators, professional associations and other training providers. The Ministry should also work closely with stakeholders to develop specific workforce plans for Pacific peoples, disabled people and rural communities.
- The Māori Health Authority should develop and lead the implementation of the Māori workforce plan and manage the associated funding.
- The Workforce Plan should take a 10- to 15-year view. It should incorporate plans to increase the representativeness of the workforce, increase accountability for being a good employer, gather better workforce data and a present system-wide view of required workforce competencies.
- The Ministry should work with TEC, Health NZ, the NZ Institute and other regulatory authorities and training establishments to ensure training is consistent with achieving the goals of the NZ Health Plan and accompanying strategies.
- Training providers should be encouraged to develop shorter-term training modules and micro-credentials; provide more development opportunities to kaiāwhina; offer more online training courses; deliver more training in rural locations; support more Māori, Pacific and disabled students; and develop more learn-as-you-earn pathways.
- Where there is a guarantee of employment on the completion of training, the workforce plan should stipulate the numbers of available training places.
- The Ministry should work with the Ministry of Education to promote clinical and non-clinical health and disability careers and increase the uptake of science, maths and health-based subjects in secondary schools, with a particular focus on increasing the numbers of Māori, Pacific and disabled students.
- All parts of the health and disability system should be cooperating to develop more learn-as-you-earn options and shorter cumulative training courses to encourage more non-traditional participation, and particularly to facilitate more participation from rural trainees.
- The regulatory system should support the NZ Health Plan and associated workforce strategies. It should be encouraged to move towards more interdisciplinary, flexible, consumer-focused and competency-based approach to regulation, over a profession-based focus.
- The effectiveness of voluntary changes by regulatory bodies should be reviewed after five years.
Strategic employment relations
- Health NZ should manage strategic employment relations, drawing on better data and aligning with the workforce plan and the NZ Health Plan.
- The tripartite accord should be reinvigorated and commit all parties to working constructively to achieve the long-term objectives of the system, fostering more effective dispute resolution and developing a clearer strategy on relative salary scales and employment terms and conditions
- The workforce should reflect the community it is serving, and all parts of the system should be accountable for implementing specific Māori, Pacific and disabled workforce strategies.
- Health NZ should prioritise developing better and more consistent workforce intelligence from all parts of the system.
- The system should be encouraged to become disability confident, drawing disabled people into a wider variety of roles and supporting them to thrive.
- Employers should be expected to adopt best-practice staff recruitment, onboarding, development and retention practices, including more flexible learning options and developing staff in leadership roles.
- Commissioning and contracting policies should be used to encourage more secure employment and, therefore, more opportunities for career development, particularly for the workforces involved in home-based care and other outreach services.
Digital and Data
To enable a data-driven, digitally-enabled ecosystem that supports modern models of care, investment is needed. People need better access to, and control over, their own data and stakeholders need safe and secure ways of sharing information. More central leadership in areas such as standards and data governance is critical, as is the building of digital literacy across the system.
The Review proposes the following changes
Connected and shared health systems, data and information
- A national reference architecture should be defined and agreed to support consistency across the system.
- National standardised datasets and interoperability standards should be agreed and implemented so that data flows across the system and supports better clinical outcomes, empowered consumers, and data-driven decision-making.
- The Ministry should be responsible for determining data policy, strategy and setting standards; Health NZ should be responsible for implementation and ongoing stewardship.
- Health NZ should invest in data collection, research and analytics capabilities to understand need, prioritise resources, and measure benefits using clear data ethics frameworks.
- Researchers, decision-makers and innovators should have secure access to public datasets provided by Health NZ to inform the development of new products, services, care models and treatments.
- The Ministry, Māori Health Authority and Health NZ should ensure high levels of trust in privacy and security of data are maintained.
- Consumers should be able to control access to their own health data and information. Changes to the Health Information Privacy Code (HIPC) should be considered to facilitate this.
- A pragmatic approach to use existing databases such as the National Health Index (NHI) and Health Practitioners Index (HPI) should be adopted and enhanced to drive interoperability. A change to the HIPC should be considered to narrow the meaning of the word ‘assign’ to enable health care organisations to use the NHI more.
Tier 1 services connected as a network
- Consumer data should be shared across Tier 1 within provider networks if approved by consumers.
- Providers within networks should have collaboration tools to enable delivery of consumer-centred shared care.
- A Tier 1 standardised reporting dataset should be developed over a two- to three-year period.
- Consumers should have the tools to manage their own health and navigate the system.
- Virtual (telehealth) services should be established to provide consumers with greater access to services.
- Services should be built that enable seamless interaction between Tiers 1 and 2 and supports long-lining of specialist Tier 2 services into Tier 1 networks.
A commitment to ensuring equitable access to services
- The Māori Health Authority should partner with the Ministry, Health NZ and DHBs to ensure that Māori interests are represented and that Māori-specific issues are addressed in the design of digital standards, services and data strategies. These approaches would also extend to Māori population health analysis and capabilities.
- Digital standards and service models should be designed to meet the access and equity needs of other groups, including older people, people with chronic or complex conditions, Pacific peoples and others with specific cultural needs, and disabled people.
- Services should be designed to reduce inequities using methods and data that is representative and unbiased.
Strong leadership and system-wide digital literacy, capability and maturity
- Decision-making capability of executive-level leaders should be strengthened by building improved data and digital literacy and capability, and encouraging enhanced partnerships with clinicians, consumers and digital leaders.
- The workforce should have the capability, tools and resources needed to effectively transition to and deliver modern models of care.
- Consumers should have trusted, flexible access to a range of services via accessible, inclusive digital channels.
- A long-term plan should include modern ways of working with data and digital technologies as core to enabling a sustainable, adaptable, future-proof health and disability system.
- The Ministry and Health NZ should set governing principles and responsibilities regarding expected behaviours for those developing, deploying and using data-driven technologies.
Clearer decision-making and procurement and investment processes
- Core national digital infrastructure criteria should be more consistent and should be centrally sponsored.
- Procurement and contracting models should support agility and speed to value by differentiating between types of products and services, and applying only as much process as is needed for the level of risk involved.
Facilities and Equipment
The state of current assets and the lack of integrated forward planning for investments has left the system with a significant challenge. While additional investment is needed, for it to be most effective changes are proposed in how capital planning is linked to outcomes and services planning, how investments are prioritised and how projects are managed.
The Review proposes the following changes
- Health NZ, through the Health Infrastructure Unit (HIU) should be responsible for developing a long-term investment plan for facilities, major equipment and digital technology derived from the NZ Health Plan.
- Health NZ should develop a prioritised nationally significant investment pipeline so that unless a project has been prioritised, a business case is not developed.
- Each DHB should have a longer-term rolling capital plan based on a prioritised, robust pipeline that would deliver the medium-term and longer-term service requirements in their area.
- The HIU should develop central expertise to provide investment management leadership to support and speed up business case development and standardise the way capital projects are designed and delivered.
- The Capital Investment Committee should continue to provide independent advice, both to Health NZ with respect to prioritisation and to Ministers with respect to business case approval.
- Programme and project governance should be streamlined and standardised to ensure expertise is used strategically and project and programme governance is strengthened.
- The National Asset Management Plan should be developed and regularly refreshed so it can form a basis for ongoing capital planning.
- There should be further work on refining the capital charge and depreciation funding regime for Health NZ and DHBs to ensure that a significant rebuild or new development in one DHB is properly accounted for in the system, but does not starve the DHB of capital for business-as-usual capital replacement.
- More financial and governance expertise on DHB boards, together with system and district accountability, should ensure better long-term asset management decision-making. More explicit asset performance standards and a strong central monitoring function from the HIU would reinforce this.