The Health and Disability System Review was charged with recommending system-level changes that would be sustainable, lead to better and more equitable outcomes for all New Zealanders and shift the balance from treatment of illness towards health and wellbeing.
The challenge is clear. New Zealand has a diverse population with a history of experiencing significantly different health outcomes.
An indigenous Māori population whose ability to encompass te Ao Māori and participate in whānau and cultural connections are prerequisites to good health.
Increasing populations of Pacific peoples and a growing Asian population.
More disabled people, an ageing population, and a rural population that often feels they are invisible to urban decision-makers. As well, New Zealand has a level of intergenerational poverty which, perhaps more than anything else, negatively impacts on health outcomes.
On the positive side, New Zealand has, by world standards, a very good publicly funded health and disability system which can evolve into being more effective and more sustainable.
On the other hand, the health and disability system is under serious stress. Financially, it has had difficulty managing within the resources provided to it for some years. From a workforce point of view staff are feeling more and more stressed, facing increasing demands and significant shortages in supply, and the public hear more about deficits than they do good news stories.
In August 2019 the Review published an Interim Report that identified areas where submissions, and the Review’s own analysis indicated that change was needed.
These were grouped around four key themes.
Since the Interim Report, the Review has continued to talk with a wide range of stakeholders and conducted its own more detailed analysis in many of these areas and arrived at a set of final recommendations.
The recommendations range from legislative change, to structural and culture changes. The changes cannot happen all at once. To realise the benefits of a new system would require a determined change programme over a number of years.
This executive summary discusses some of the Review’s proposals under the themes previously identified.
Improving the equity of the health outcomes achieved in New Zealand requires first that we acknowledge that current inequities are not acceptable, that we understand better what is contributing to that inequity, and the health and disability system becomes more determined to operate differently so that inequities are addressed.
The system must understand the needs of individuals, whānau and communities in much more detail and must design and deliver services to address the identified needs. It also requires that the costs and benefits of service design to consumers are given much more weight relative to those of providers than has been the case in the past.
Analysis by the Review points to improvements in the way primary and community (Tier 1) services are organised as having the biggest potential to improve the health outcomes of those currently disadvantaged. The Review proposes working towards a much more networked Tier 1 environment where the full range of primary and community services are planned with the community, where services are digitally connected so information flows as required, and where more of the services have an outreach element making it easier for whānau to stay connected to the system.
Planning and funding these services must be driven by the needs of each community, not just the population numbers, so higher deprivation localities have more funding to allocate. Similarly, services need to be designed to work for the population they are serving, so Māori communities need to have access to a wider range of kaupapa Māori services.
Disabled people have not been well served by the existing health and disability system. Their health outcomes are worse and the way the disability support system operates is complex and confusing. The Review found that there is wide unexplained variability in the way assessment processes work around the country, and this should be addressed. The Review proposes that disability support becomes an integral part of Tier 1 service planning, funding and provision.
Home-based support, in particular, should be assessed by need rather than having eligibility determined by diagnosis. Needs assessment processes need to be more streamlined and less repetitive.
Consumers, whānau and communities are not, however, only concerned with their immediate wellness. Communities need to have a part in the decision making about the design and delivery of treatment services at all levels.
Tier 1 and Tier 2 services need to be well integrated and the Review proposes improved care management, within Tier 1 networks, and better digital information flows. Priority should be given to moving Tier 1 services currently provided in hospitals into communities.
The Review also proposes a much more transparent planning and reporting system. It stretches all the way from the New Zealand Health Outcomes and Services Plan (NZ Health Plan) which takes a long-term look at what outcomes we should be trying to achieve and how and where services will need to be developed, through five year district and regional strategic plans to funded annual DHB plans which describe what primary and secondary services communities can expect to see locally and that ensures regular reporting back to communities on health outcomes.
The further work of the Review reinforced the view that the health and disability system needs more active leadership at all levels. The Review concludes that this cannot be achieved through any one action or decision, but would require a clearer definition of functions and structures, more collective responsibility and more deliberate upskilling throughout the sector, from kaiāwhina to DHB board members.
The Review proposes that a new agency is created, provisionally called Health NZ, which is accountable to the Minister of Health for leadership of health service delivery, both cinical and financial.
Leadership for hauora Māori is also strengthened with the creation of the Māori Health Authority (provisional title) to sit alongside the Ministry of Health (the Ministry) and Health NZ, to not only be the principal advisor on all hauora Māori issues, but also to lead the development of a strengthened Māori workforce and the growth of a wider range of kaupapa Māori services around the country.
Leadership within the DHBs also needs to change. At the governance level the Review concludes that the effectiveness of elected over appointed boards is not compelling. The Review recommends that all board members be appointed by the Minister of Health against a transparent set of competencies ranging from financial and governance experience through to tikanga Māori and specific health and disability sector knowledge. The Review also concludes that the number of DHBs needs to be reduced within the next five years, to between 8 and 12 DHBs.
Providing effective leadership is, however, about much more than creating new organisations or changing governance structures. Effective leadership is as much about the culture of the sector as it is about the structure. Health NZ is not envisaged as an organisation that just tells DHBs what to do. It is designed to be an organisation that is responsible for working with all parts of the delivery system to ensure it is operating effectively, fairly and sustainably.
The Interim Report highlighted the lack of a collective culture in the health and disability system. The Review addresses this in a number of ways.
A legislated charter setting out the common values and workforce behaviours expected throughout the system is a start but will need to be reinforced by active management.
As noted above, New Zealand is a country of different cultures. Cultural safety for all and an absence of racism must be a given.
Interprofessional teamwork happens brilliantly in some places but in others it is still largely non-existent. Yet, if the system is to focus on keeping people well and treating patients with complex comorbidities as the norm, no single part of the system will be able to work on its own and be effective.
The culture needs to change at the organisational level as well. Currently, DHBs are only accountable for what happens in their own district. The Review proposes this should change and while each DHB must take responsibility for their domicile population, they should also be expected to consider how their planning and delivery impacts the overall system. This should be reflected in their formal accountabilities.
Along with these changes, the focus of the health and disability system needs to move. Despite primary health care strategies and numerous reviews of the system recommending more focus on keeping people healthy rather than simply treating illness, the structure, funding streams and accountabilities built into the system have not made this culture change happen.
This Review proposes that population health functions, which would underpin a shift to a health and wellness focus, need to be strengthened. The Ministry needs to lead with more focus on capacity and capability, planning and outcomes used to measure performance need to be population focused, and the funding and accountability for improving these measures need to be firmly managed by DHBs.
The fact that Māori health outcomes are significantly worse than those for other New Zealanders represents a failure of the health and disability system and does not reflect te Tiriti commitments.
Designing a health and disability system that will produce better results in the future requires a recognition that change has to happen right across the system.
A system which doesn’t reflect mātauranga Māori or enhance rangatiratanga will not be effective at improving health and wellbeing for Māori. As a first step the Review recommends that, in line with recommendations of the Hauora Report (Wai 2575) te Tiriti principles in key health legislation are updated.
As noted above, the Review proposes to create an independent Māori Health Authority. As well as the functions referred to above it would be expected to monitor and report on the performance of the health and disability system as it impacts on Māori. The Māori Health Authority would identify the issues which need to be addressed and develop and test solutions.
The Māori Health Authority would also need to partner with other parts of the system; no one part of the system can improve equity on its own. The Māori Health Authority would need to partner with Health NZ to develop commissioning models that will work for Māori, whether for general, taha Māori or kaupapa Māori services. It would need to work with DHBs and iwi to develop partnership arrangements that can co-govern service networks and work with communities and providers to develop better need and outcome measures.
Governance in other parts of the system needs to reflect te Tiriti partnerships. The Review proposes that the Health NZ board have equal numbers of Crown and Māori members so that the way the delivery system functions incorporates different world views.
While improvements in leadership and governance will assist Māori, perhaps the most immediate concern is to ensure the next generation of Māori have better lives and health outcomes
More effort must go in to identifying unmet needs across the board, but especially for Māori communities. Health outcomes will not improve if the health and disability system waits for whānau to turn up to be ‘treated’. The system has to reach out with the explicit aim of preventing illness. For example, providing more flexibility to ensure Well Child / Tamariki Ora services meet whānau needs, rather than always expecting the community to adjust to the ‘rules’.
To achieve this there will need to be significant new investment. Funding for Māori communities needs to better reflect need and be protected from being diverted to broader treatment programmes. The Review proposes increased ethnicity and socioeconomic deprivation weighting within the population-based funding formula, formal ringfencing of Tier 1 funding within DHB budgets and a requirement to disclose indicative budgets to communities and report on expenditure against those budgets and outcomes.
The Interim Report highlighted the lack of structured planning within the current health and disability system. The Review is convinced this is a fundamental flaw and proposes a properly integrated planning system is legislated for which requires the system to cooperate and plan within an agreed framework.
The first requirement is to have a clearly articulated NZ Health Plan that looks ahead at least 20 years. Health systems take a lot of time to turn around and investment that is needed is often large and complex. Without a long-term plan there can be no certainty that the enablers: an appropriately trained workforce; buildings and facilities that are suitably equipped and fit for purpose; and data and digital systems that enhance integration, patient safety, efficiency and effectiveness, can be in place in a timely manner to produce an effective system.
Workforce development is a key constraint in our current health and disability system. In line with worldwide trends New Zealand is experiencing growing clinical workforce shortages. Our system will not be sustainable unless we change models of care and use the workforce differently. While the Review does not recommend immediate changes to workforce regulatory structures it notes that there are large numbers of different bodies involved in workforce training and regulation. Unless they work effectively together to promote and achieve relevant workforce plans then, in future, some tighter oversight may be required.
The New Zealand system is too small to duplicate expertise and effort unnecessarily, and when significant investments are needed, it is important they are made in the right places at the right time so that health outcomes and equity are improved for all New Zealanders.
The current system for planning and delivering capital projects is not cohesive or effective. While the Government has recently introduced improvements, such as establishing a health infrastructure unit and changing the capital charge regime, the system still encourages duplication and spreads scarce expertise too thinly.
The Review proposes a more streamlined prioritisation process coming from the New Zealand Health Plan. This process, along with improved governance from appointed national and regional boards should reduce time wastage and duplication of effort and give the Government more confidence the right investment decisions are being taken and can be kept on track.
Planning for the level of digital technology needed to support an effective health and disability system is lagging behind in New Zealand. The quality of data, the ability to transfer data securely, and the interconnectedness of the various systems operating around the country are all barriers. Having an agreed plan and an ability to enforce decisions regarding issues such as interoperability standards, would be a benefit from adopting the Review’s recommendations.
The health and disability system must act and be managed as a single integrated system comprising public, private and non-governmental organisation (NGO) providers. District health board strategic plans need to complement each other and be consistent with the New Zealand Health Plan. This does not mean that all health and disability services have to be delivered in exactly the same way. In fact, the Review proposes that there be less reliance on national contracts, especially for providing tier 1 services, because services must be more responsive to local communities.
That flexibility must be operated within a framework that gives New Zealanders the assurance that they know what to expect from their health and disability system, they understand the rationale for where and how services are being delivered, and they have confidence that where they live is not unfairly disadvantaging them in accessing quality services.
The Final Report discusses all these and many other issues in more detail. It does not repeat the analysis presented in the Interim Report but has applied the same structure to help readers make necessary connections.
Each chapter concludes with a set of changes which the Review proposes need to be taken to build the most effective health and disability system. Some of these changes would require government policy decisions, others are or would be within the control of the system itself.
Very few of the Review’s recommendations are stand alone. The lesson from past reviews and attempts to change the health and disability system is that it can not be done piecemeal.
The Minister of Health commissioned the Review; the key recommendations are directed to Government. These are decisions the Government needs to make to allow the system to evolve into one which has the promise to change both the way New Zealanders view their health and disability system and in the level and equity of the outcomes it achieves.