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Māori as Tiriti / Treaty partners have not been well served by the health and disability system. Despite many good examples of kaupapa Māori services proving their effectiveness, the system overall has not delivered Māori health and wellbeing outcomes that are fair.
While issues relating to Māori health are addressed throughout the report, key issues include:
Recognising the Tiriti / Treaty relationship
The Panel believes a health system tailored to meet the needs of all New Zealanders must:
- fully incorporate te Tiriti o Waitangi / the Treaty of Waitangi to provide a framework for meaningful and substantive relationships between iwi, Māori and the Crown and recognise the importance of considering the heterogeneous realities of Māori and kaupapa Māori aspirations
- better meet its obligations regarding the health of Māori communities and embed rangatiratanga (authority, ownership, leadership) and mana motuhake (self-determination, autonomy).
Embracing mātauranga Māori
The Panel recognises that the New Zealand health and disability system has evolved with a strong western medical tradition. The inequities which have arisen for Māori from this system cannot be fully addressed without ensuring that going forward the system also embraces the Māori world view of health.
The Panel recognises that progress has been made in incorporating mātauranga Māori into many of our practices but there will need to be an ongoing and deliberate policy to ensure that practice continues to grow and that kaupapa Māori services are more readily available.
Governance and funding
The function of the health and disability system is to improve the health and wellbeing of the population it is set up to serve. Too often in the past, the way the system has been designed or managed appears to have been driven by the interests of the system rather than the interests of those most in need of help. Inequitable outcomes have been the result.
The Panel is strongly of the view that priority for change must be given to areas that will most benefit those who are currently least advantaged.
A more cohesive system with consistent and effective leadership
- The Panel believes that while the shape of the particular structures within the health system are important, they are not the key reason for the lack of effective performance.
- If New Zealand is to develop a system that operates effectively with equitable outcomes throughout, it must first operate as a cohesive, integrated system that works in a collaborative, collective, and cooperative way. Behavioural and attitudinal changes are needed. These changes need to be led from the centre and applied consistently throughout the system.
- To this end, the Panel believes a clearly defined set of values and principles that appropriately reflects the diversity of cultures and Māori as tangata whenua should guide the behaviours and operation of the entire system.
A clearer decision-making framework
- The Panel believes a clearer decision-making framework is needed across the system that allows decisions to be made in a timely manner, made at the appropriate level, and enforced effectively.
- Decisions should support the best use of available resources across the whole system, rather than being driven by the interests of a region, discipline, or organisation. Governors should be responsible (and held accountable) for both local and system-wide impacts.
Collaborative long-term planning
- The Panel strongly believes that the lack of mandatory longer-term integrated planning throughout the system makes it impossible for communities or government to have confidence in the effective performance of the system. Planning needs to be strategic and undertaken within a system-wide framework.
- Effective strategic planning will require more systematic community and stakeholder engagement, both within the health and disability sector and intersectorally. Such engagement will be necessary in both the development and implementation of plans. Iwi and Māori must be fully involved.
A system that is less complicated
- The Panel recognises that the health and disability system will always be complex, but believes the objective should be to make it less complicated with fewer, not more, agencies.
- The Panel believes that if the system is to be reoriented so it purposely focuses on the needs of the community it is serving, communities need more effective avenues for guiding the direction of health service planning and delivery. The Panel has not formed a definite view on whether DHB elections are an effective or an essential way of achieving this.
Access to enhanced analytical and back-office functions
- The population and geographic sizes of the current DHB regions vary significantly, yet all DHBs are mandated to perform the same range of functions. The Panel believes that before deciding the solution is to have fewer DHBs, it is worth considering whether the system as a whole should provide more analytical or back-office functions to smaller DHBs in other ways.
More funding alone is not the answer
- The Panel recognises that there will always be worthwhile ways to spend more money within a health and disability system and that the relatively slow growth in expenditure in recent years has added to stresses within the system.
- Projected changes in demographic and disease profiles mean demand for health services will continue to grow strongly, which, along with recent adjustments in staffing costs, will require further increases in the overall funding envelope over time, even with improvements in efficiency.
- The Panel recognises however, that increasing funding alone will not guarantee improvements in the equity of outcomes. The Panel’s initial focus is, therefore, on how the system could operate differently to make better use of whatever financial resources are available to it.
- The Panel also recognises that previous funding levels have not been the sole cause of the system continually running financial deficits and believes accountability mechanisms need to change to hold the system more accountable for staying within future funding paths.
For the system to be more effective in the future, population health needs to be recognised as a foundational element for the entire system. This requires that capacity is both increased and better integrated across the system, and that the system operates more effectively with other sectors.
Population health is fundamental to the system
- The Panel believes that the focus of the system needs to be much more on the population, not just the individual who presents for treatment.
- Communities need to be more actively engaged in needs analysis and system planning. Greater emphasis on intersectoral work is also necessary to properly address the wider determinants of health.
- A continued focus on the basics, such as clean water, immunisations, and the provision of robust emergency preparedness capacity able to react immediately at the local level, will become more, not less, important as issues such as climate change and antimicrobial resistance, have an increasing impact.
- The Panel is well aware of ongoing debates about the desirability or otherwise of recreating a standalone Public Health Agency and consideration of which functions are best undertaken nationally, regionally, and locally. Further analysis and input from stakeholders is needed before we reach a view on this.
Strengthening the role that Tier 1 services play in the system is critical. This view has been espoused for over 20 years, but progress has been limited. Equity is a priority and New Zealand needs to be more ambitious with Tier 1 services, as there is good evidence that enhanced Tier 1 service delivery can improve equity and support health and wellbeing for Māori and others for whom the current system is not working.
The system is very fragmented with 1000s of provider organisations operating under different pricing and access arrangements. In many instances, service delivery arrangements have not considered the burden of chronic disease, comorbidities and mental health issues that now exist in communities. Nor have these arrangements kept pace with how New Zealanders expect to be able to access services or the health information for themselves.
System designed for the consumer and their whānau not the provider
- The measures of value and cost the system uses needs to reflect much more what consumers and whānau value, not simply what the system deems important.
- Services should be established where they best suit the community (now and into the future), rather than allowing the location of services to be determined by the preference of providers alone. More services also need to be available for longer hours.
- The system needs to be better integrated so patients can move more readily through it.
- Refocusing the system on promoting wellness rather than principally treating sickness also requires changes in attitudes and for health promotion and behavioural health services to be a much more integral part of the system. A bigger role for Population Health services will be essential in this.
Multidisciplinary collaborative teamwork the norm
- A more determined effort is needed to embed more collaborative approaches to service provision, particularly if we are to address the equity issues experienced by Māori, Pacific peoples, disabled people, people living in rural communities, and other vulnerable populations. The sector needs to be less dominated by standalone service providers and be more driven by community-focused, integrated service provision hubs. A culture of collaboration between providers should be encouraged.
- The approach of general practices and community pharmacies being largely funded on the basis of throughput is unlikely to be appropriate in areas where the emphasis needs to be on encouraging behavioural change and early intervention.
- Different approaches need to reflect not only different business models but also different cultural perspectives.
Enabling Māori to provide better services for Māori
- Māori must have the right to access and develop services that appropriately recognise whānau rangatiratanga and are culturally appropriate. This will require both more Māori providers and more Māori involvement in the governance, planning and development of the system.
Learning from rural communities
- For Tier 1 services to be effective, they need to be designed to support the community they are serving. The Panel observed positive examples of rural communities using technology and more flexible working arrangements to provide more comprehensive service coverage. We believe many lessons can be learnt from these examples and applied to make urban services more effective and efficient.
Clarity of mandate and accountability
- The system gives both DHBs and PHOs responsibilities for promoting health and wellbeing for their populations. This sometimes leads to a constructive working relationship between the two and sometimes leads to neither accepting real accountability. Achieving more integration and more effectiveness will require either fewer layers of accountability or that the system is clearer about where accountability for producing results lies.
Changing funding mechanisms
- Dependence on funding mechanisms that incentivise throughput needs to be reduced, and the first priority for change needs to be improving services to the populations for whom the current system is not working well.
- Similarly, the lack of any systematic process for determining which services qualify for public funding and which do not needs to be revisited.
- The current mix of funding regimes, which leads to a plethora of different charging regimes for consumers, needs to be rationalised so the imposition of charges in some parts of the system does not distort the ongoing development of more holistic services.
Better data management
- All data generated across Tier 1 services should be covered by system stewardship agreements. These agreements would facilitate shared decision making and more coordinated service delivery and give consumers greater confidence that all providers can access their relevant information.
Better health, inclusion, and participation of people with disabilities must be a priority for action across the whole health and disability system. Increasing numbers of people are living with disability, and more disabilities are being recognised. The system needs to gear its ability to respond to disability becoming more of a norm.
Living well and prevention
- A focus on living well and preventing the exacerbation of disability should be a priority. This will require more integration both within the system and across other parts of government. Promoting living well for everyone, with and without disability, and preventing different abilities and health conditions from becoming disabling, need to be the focus.
- All people with disabilities have health conditions and/or health care requirements at some time. The Panel believes disability needs to be much more visible at a system level, so the health outcomes of disabled people are properly focused on.
- Better data collection and information use, greater inclusion and participation of disabled people through all levels and parts of the system, and better service and workforce development are fundamental.
System leading by example
- The Panel’s view is that, as the largest employer in many regions, the system should lead in employing people with disabilities. Boosting employment of disabled people overall may be the single biggest contributor to improving wellbeing of disabled people. Bringing their skills to the workforce in health will also make the sector more responsive, adaptive, inclusive, and reflective of the community.
Whānau and carer support
- Disabled people are members of families, whānau, and communities. Addressing whānau and carer needs should be an integral part of all aspects of disability service assessment and provision.
More joined-up information, advice, and services
- The Panel believes that delivering a transformed disability support service using Enabling Good Lives principles may improve the future for many disabled people, but this will require focused leadership and change.
- There will continue to be a large number of people with disabilities for whom other parts of the health or wider government system are the main point of contact. Interface issues across the system and historical boundaries that no longer seem relevant need to be addressed and greater flexibility introduced.
The need for high-performing Tier 2 services will continue to grow for the foreseeable future, as the burden of chronic disease grows and the number of people living longer with multiple comorbidities increases. This will include the need for both hospital-based services and specialist services delivered in outpatient, community, and virtual care settings.
- The Panel is strongly of the view that a nationwide long-term health service plan needs to be developed and refreshed regularly. This plan would address which services should be provided nationally, regionally and locally.
- Further analysis is needed to determine the level of specificity this plan should include, but it needs to be able to inform and guide investment and disinvestment decisions across workforce, digital technologies, facilities, and other infrastructure.
- The Panel believes that continuous quality improvement needs to become a much more prominent driver of service design and delivery. Achieving this will require more transparency and sharing of information about variation in performance, quality, and outcomes with providers and consumers. Clinical leadership, in both design and implementation, will be essential, as will be the need to respect and incorporate cultural values and consumer input.
- The system will need to become more transparent and evidence-based, leveraging international thinking where appropriate, to improve decision making regarding what and where new investment and disinvestment should occur.
A networked system
- It will be essential, in the future, that all hospitals and specialist services operate as a cohesive network on behalf of the patient and the system, with clearly differentiated responsibilities as appropriate.
- For the system to become more responsive to consumer expectations, hospitals and specialist services will increasingly need to function on a 24/7 or extended hours basis for a wider range of services.
- Rural Tier 2 service delivery models will need to be supported by enhanced remote access to specialist services, enabling a wider variety of planned services to be accessed locally. The system also needs to be designed to reduce the need for patients to travel to outpatient clinic appointments and to better support generalist-led models of care for rural communities.
Workforce pressures are significant and need to be urgently addressed by ensuring both better planning for future supply and more flexibility in training to prepare for different roles. Workforce practices will need to provide better work / life balance in the future.
Changing skill mix
- The types of work and the balance of demand for different skills is changing rapidly, yet our training methodology is very rigid. The Panel believes the sector needs to be both more open minded about how services might be provided and more flexible about the range of qualifications needed to perform various tasks.
- We need to improve communication between tertiary education providers, professional bodies, the Ministry and DHBs in order to undertake more effective workforce planning and supply management. This will need to be centrally driven.
- Growing the workforce is not just a tertiary education issue. We should be actively influencing secondary school students to attract them into the health workforce and support them to be successful. Taking a strategic approach to growing our kaiāwhina workforce over the next 5 years will be a key to achieving a step change in the ways in which we are able to deliver services.
- Our digital and data capability needs to be invested in significantly, both in terms of building the skills of our current workforce and also creating new roles to support changed ways of working.
Being a good employer
- The system could have a significant impact on the health and wellbeing of our entire population both by being a good employer and by ensuring the system workforce properly reflects the population it is serving.
- Leveraging the system’s ability to create employment opportunities for those who have traditionally found it hard to find employment (particularly those with mental health conditions and disabled people), and growing the Māori and Pacific workforce is a must.
- Changing demographics along with increasing comorbidities, and technologies, will continue to increase the demand for all parts of the system to act in more multidisciplinary, collaborative ways. The need to be able to provide services where they are most needed by consumers and in ways which are most accessible, will also require flexibility on the part of the workforce. Ensuring such behaviours are the norm rather than the exception will be essential.
- There are currently many different employers within the system and employees working for multiple organisations. While the Panel believes that the system should continue to consist of a variety of different business models it will be important that there are explicit measures in place to ensure conflicts of interest are properly managed.
- The presence of multiple employers, managing multiple employment contracts, with significantly different conditions can create constraints to optimising the effectiveness of the workforce and the efficiency of training, from a whole of system perspective. These impacts will need to be managed more effectively.
- Existing workforce strategies promote a strategic relationship between our key unions and the employers but there is little evidence of this being an effective partnership. Building a more collaborative workforce will require unions and employers to buy into different ways of working.
Digital and data
Advances in digital technologies have huge potential to enable an information-rich, data-driven, people-powered approach to health care and to support the health sector in achieving better outcomes. New technologies such as genomics, artificial intelligence, and digital medicine are already transforming healthcare services, and other digital technologies, such as mobile, social media, cloud services, and analytics are changing the way healthcare services are delivered and consumed.
Good data needs to be one of the foundations of the health and wellbeing system. It enables consumers and providers to access and share information, plan, and make decisions about appropriate care. It can also help consumers to take control of their own health and wellbeing. For organisations and government, good data supports better decision making and planning, drives research and innovation, and enables monitoring and measurement of outcomes.
Robust and accessible data
- The system is becoming increasingly dependent on data and digital solutions. The Panel believes that the system needs to be better informed at every level by robust and timely data that is readily accessible to all who work in the system and all who use the system. Better data and more use of digital solutions is not only a necessity but it also provides an opportunity to free up clinician time to focus on more caring and to support those people who wish to use technology to help take greater control of managing their own health and wellbeing.
Strong leadership to drive data standards and other mandates
- The Panel believes that implementation of data standards, data stewardship, identity management, and interoperability must be accelerated. This will require strong national leadership, but will be essential for improving effectiveness and supporting collaborative and team-based working.
Digital literacy and new ways of working
- The Panel supports digital development at every level of the system. Training in new skills and ways of working will need to be embedded in an overall workforce strategy and development plan. New roles, such as for data analysts, will be required, and the system will need to make these roles attractive, as demand will be significant across the economy.
Facilities and equipment
A significant volume of health capital investment will be required over the next 10 years to address issues associated with assets that have not been adequately maintained and/or are not fit for purpose. Investment will also be required to support new models of care and to accommodate demographic pressures including a reorientation toward Tier 1.
The Panel heard considerable frustration with current processes, including concerns about convoluted decision-making processes, the impact of the capital charge regime, and a lack of capacity and capability in the sector to manage and deliver major health capital investment projects.
Managing to a system plan
- The Panel is of the view that future major capital investments decisions should demonstrate consistency with the long-term health service plan and follow a consistent decision-making process for facilities, major equipment, and digital technology.
- Capital planning should not be based on a one-year budget bid process. A longer-term rolling plan should be developed that is based on a prioritised, robust pipeline that will deliver the medium-term and longer-term service requirements.
- Links between system planning and local and district planning should be strengthened, and health infrastructure planning should be considered more routinely alongside local government, education, and transport planning.
- The Panel believes that asset management planning processes must be strengthened to ensure that sufficient investment is made to maintain current infrastructure and replace major equipment, while also future proofing for new models of care and capacity growth.
Delivery of major capital projects
- The Panel is of the view that processes for developing and approving business cases need to be streamlined so decisions are made in a way that minimises the time and expense incurred in progressing proposals that are unlikely to be accepted.
- The current distributed model for the design and delivery of capital projects is ad hoc, is expensive, and may not be sufficient or appropriate to meet the scale of investment required.
- Other jurisdictions have centralised these functions, and work is under way in New Zealand to explore such an option. The Panel believes there are potential gains to be made in this area and supports more work being done.