Executive summary / He whakarāpopoto

The Health and Disability System Review is charged with taking a system-wide approach to what needs to change to ensure the health and disability system of the future achieves better and more equitable health and wellbeing outcomes.

The canvas is huge. The health and disability sector employs more people than any other sector in the country and it impacts on the lives of every New Zealander.

The interim report does not provide specific change recommendations. It indicates the direction of change the Panel believes is necessary in key areas and points to questions which still need to be answered to arrive at final recommendations due in March 2020. This report reflects the messages received from meetings, submissions, analysis of the current state of the New Zealand system, and what is known about local and global trends that will impact on the system in the future.

Overall New Zealand has a good health system. Outcomes and spending are in line with other OECD countries, and the system has a dedicated staff who work hard to provide the best care for patients. There are many good examples of innovation in service delivery and initiatives achieving sustainable improvements in patient outcomes.

But it is clear that there is room to do better. The system is already facing many challenges and demand pressures are increasing. On the other hand new technology and new ways of working offer many opportunities. For the system to produce better and more equitable results in the future, significant changes will need to occur.

Panel members visited DHBs, met with key stakeholder organisations, held workshops and wānanga around the country, and conducted an online submission process open to all.

Key themes clearly emerged:

• The current system is overly complicated and very fragmented from a consumer’s perspective, which leads to a lack of confidence or trust in the system
• Leadership is lacking at all levels and this partly results from a lack of clear decision making frameworks with confused accountabilities and little effective enforcement
• There is reasonable consensus around strategies in many parts of the system but little evidence of consistent implementation
  Concern about the inequity of outcomes is widespread
• Māori, as Tiriti/Treaty partners, have not been well served by the system and in the future mātauranga Māori and rights under te Tiriti o Waitangi/the Treaty of Waitangi, must be fully implemented
• There is recognition that the health and disability system alone cannot eliminate all differences in health and wellbeing outcomes, because most of the differences arise from social determinants
• Consumers want the system to work better for them. They need the system to respond to what consumers value and need, rather than being designed primarily around provider interests
• Disabled people want more control over their own lives, and more flexibility and inclusion from the system
• The way people work in the system is not leading to the most productive results. Healthcare organisations do not cooperate well, many professionals resist collaborating across disciplines, there is a lack of flexibility in employment arrangements, and a general resistance to change at many levels
• While consumers report facing barriers to access within the system, it is clear these do not simply relate to monetary costs. Time, transport, or lack of culturally appropriate services are often as, if not more, significant barriers
• Rural communities face particular challenges and need solutions designed specifically for them.

Directions for change

Combining the information from submitters with analysis of the current state of the system, and consideration of previous reviews, shows there are a number of areas where change could lead to more consistent and equitable results.

The interim report, in each of its sections, indicates the direction of change the Panel believes needs to be taken to formulate recommendations for the final report.

Some of the common threads running through Panel thinking include:

Leadership focus and culture change

The system needs to work in a collaborative, collective, and cooperative way. Culture and attitudinal changes are needed. These changes need to be led from the centre and applied consistently throughout the system with a common set of values and principles guiding the behaviours of all parts of the system.

Mandates need to be clarified, accountabilities clearly defined, and enforced.

Placing consumers, whānau and communities at the heart of the system

The system will need to be driven more by what consumers value and need most, with more choice about how needs are met.
The system will need to be much more focused on preventing ill health and promoting wellbeing. A more deliberate population health approach will be needed at all levels if future demand is to be managed, equitable health outcomes achieved, and the system is to be financially sustainable.

Within Tier 1 (the broad spectrum of self-care, home and community services), more emphasis on community health hubs, offering a broader range of services in localities that suit consumers, will be essential, and funding systems will need to reflect more emphasis on prevention and wellbeing, and less on throughput.

Developing an effective Tiriti/Treaty based partnership within health that delivers a health and disability system that works for Māori

Te Tiriti o Waitangi / the Treaty of Waitangi must be fully incorporated to provide a framework for meaningful and substantive relationships between iwi, Māori and the Crown. This will provide a positive flow on effect linked to leadership, governance and decision making, and assist in strengthening Māori provider, workforce and service development.

Integration, planning and longer term thinking

At the governance level there needs to be more deliberate and longer term, national, regional and local level planning which engages communities effectively in planning and decision making.

At the operational level the system needs less duplication and more collaboration and integration, with hospital and specialist services operating as a comprehensive network.

Workforce strategies need to effectively address projected shortages, so the workforce of the future better reflects the community it is serving, is trained appropriately and is able to achieve better work/life balance.

Data systems which are of better quality and more integrated both within and between Tier 1 and Tier 2 (hospital, specialist and diagnostic services), are a prerequisite for implementing models of care which effectively use technology and best practice to provide better care and access for customers.

Major facilities and equipment in the system need to be managed within a national asset management plan, with transparent decision making, within a longer term capital funding path which encourages system-wide over local prioritisation.

Moving towards final recommendations

Clearly this summary cannot do justice to the breadth of input and analysis incorporated into the body of the report. It does however point to the direction of the work the review will be focusing on during the next phase of its deliberations.

The interim report details a number of questions which need answers before recommendations for action can be finalised. The process now will be to engage again to develop that detail.

The challenge and opportunity now is to build on the foundations of the existing system and leverage the commitment of those involved, and the service and innovations delivered, to create a more responsive, equitable and adaptable health and disability system.