Health NZ, the Maori Health Authority, And Why Structural Integrity Matters

A failure of leadership, commitment, and vision, in two parts.

This week's culling of the Health NZ board was an early step along the difficult and painful path towards a public health sector structure that might look close to the (pre-amalgamation) model we spent heavily to ‘improve on’.

I've written previously about the decision to coalesce our public health system into a centralised model so I won't repeat myself again. In short, there are arguments for this model but I believe they are outnumbered by the many issues.

To me, the most compelling argument against Health NZ is that it replaces local and democratically elected voices with bureaucrats.

This is not to besmirch all bureaucrats, as one I always tried to balance my role as a mere cog in a vast machine with my duty as a mostly decent person who believes that the well-being of others should come before all else (even the health of my bank balance).

The issue is the Wellington-centric model - one which replaces elected local health boards and their community focus with often-careerist public servants whose careers are made or broken by the patronage of the Public Service Commissioner.

While King Charles the Third is our Head of State, the Public Service Commissioner [PSC] is our Head of Service.

During his reign as PSC, Peter Hughes was infamous amongst public service watchers for only tapping his chosen acolytes to lead government departments.

You could be a world class leader, the Michael Jordan of c-suite, but unless you showed sufficient fealty to Hughes there would be a ceiling to your public service career.

This ‘boys club’ created within Wellington a combination Game Of Thrones / Succession vibe, one where palace intrigue inevitably overrode the best interests of the public they are paid high six figures to serve.

I have worked for a half dozen public health leaders, closely, and while the vast majority of these people were highly capable and thoughtful, one wasn't.

This person was like Saddam Hussein when he was found in a specially designed hidey-hole after the fall of Baghdad - a despot determined to die on the throne.

For me, this one bad apple threw into question the validity of the entire hierarchy itself. We can vote out a government riddled with infighting, see the Bolger–Shipley Government, but we can't vote out a public servant who does the same.

The leadership of Health NZ was only part of a much bigger problem, one that leads me back to the demise of the Maori Health Authority and how our public services are designed and how they fail.

The Maori Health Authority - A New Model, With Old Issues

The Maori Health Authority was meant to be different. It was the brainchild of many public health academics and activists, but none more so than Prof Sir Mason Durie.

I have had the pleasure of talking at length with Sir Mason, and have heard in-person his vision of devolving vital services to community based services rather than relying on an inflexible public service to successfully provide multiple models of care.

His Pae Ora model for Maori health does make culture and ethnicity and important part of his care model, which inevitably leads to criticisms that it is inherently divisive, but I believe the best way to understand the founding and demise of the Maori Health Authority one needs to look beyond its ethnic underpinning and delve deeper into the actions it sought to undertake and the people tasked with leading the authority.

If you strip back the politics and posturing, the Maori Health Authority bears many similarities with Whanau Ora - it was designed to commission services, rather than provide them directly, and therefore relied on non-governmental providers to undertake the actual work.

It sought to fit in somewhere between the Ministry of Health, the policy and regulation arm of our public health service, and Health NZ, the direct provider of public hospital and specialist care.

In theory, such an organisation wouldn't be bogged down by the politics of Wellington or by a public health system that struggles to evolve.

It would be pure, outcome focused.

I've been to dozens of patient engagement forums for various DHB’s and have heard countless stories of people getting lost or ignored by our monolithic public health system.

The most common issues raised are around communication between clinical staff and patients or their families during times of heightened emotions.

In theory, the Maori Health Authority would be involved in both policy and in improving outcomes (and communication) at the front-line, but what necessitated it being a separate entity was its commissioning function.

The authority could trial community initiatives that wouldn't be expensive but had the potential to be beneficial.

This was meant to be the ace up its sleeve - it could fund non-governmental providers and create alternative services almost like Charter Schools but for healthcare - instead it hastened the Authorities demise.

Why?

There is a great Homer Simpsons quote that requires no context but helps articulate something complex, it goes:

“Marge, I agree with you ‘in theory’. In theory Communism works. ‘In Theory’.”

The theory behind the Maori Health Authority was never the issue, rather it was the real world flaws and the imperfect nature of real world leaders that meant - like Communism - it was doomed to fail.

Both are perilously top-down hierarchies, and both are capable of being manipulated for individuals personal gain.

I do not, and could never, question the intellect and academic rigour of Sir Mason - in that space he is beyond reproach by the likes of me - but the flaw in both of the services he played an architectural role is that it requires a level of integrity which is uncommon.

The Maori Health Authority would provide funding to community healthcare providers, while also being led by several people with very close connections to the community healthcare providers that would be bidding for said funding. Or people in the then-government.

Chairing this new board was Tipa Mahuta, a seasoned board member and leader of good repute, but also the younger sibling of Labour stalwart Hon Nanaia Mahuta.

This isn't something Tipa can control, we can't pick our family and siblings are still individuals first and foremost, but it adds a complicating factor that a controversial new entity doesn't need.

You can't pick your family, but you (hopefully) do pick your spouse, and at the same time that questions were being raised about the overly close relationship between the Whanau Ora Commissioning Agency and Te Pati Maori, the Chief Operating Officer of the Whanau Ora Commissioning Agency (and wife of Te Pati Maori President John Tamihere, and daughter of Sir Mason Durie) Awerangi Durie was also on the board of the Maori Health Authority.

Both have strong CV’s, but as choices to lead a politically controversial organisation they raised more concerns than they resolved.

Between these questionable selections of leaders and a lack of coherent role, the Maori Health Authority days were numbered from day one.

Why Structural Integrity (And Care) Matters

The two biggest changes to the health system of the past government - Health NZ and the Maori Health Authority - have now been scrapped entirely or are facing severe cuts.

They were very expensive follies, but ones that typify an era in our public health leadership which has resulted in almost two billion dollars being lost and a system facing an uncertain future for no quantifiable gain.

It wasn't meant to be this way, these were supposed to be transformational changes that (with time) paid for themselves.

Some will argue that the Maori Health Authority was not given enough time to prove its concept, but when you contrast both to the NZ Super Fund - which initially faced partisan push-back but also had a clear value proposition and is now highly regarded across the political spectrum - you see the seams.

The argument for Health NZ, that a centralised model will provide greater consistency of outcomes, is also an argument against the Maori Health Authority.

The opposite is also true - if there are tangible benefits to a more community based approach then why move to a centralised model at all? Why turn community decision making over to Wellington?

Implementing both at the same time, and not saving one by abandoning the other when it was clear they were incongruous, showed a lack of overarching philosophy or conviction.

This is akin to adopting the metric system, but only on weekends. Complex ‘simplicity’.

More than any other factor, this is why the Maori Health Authority is no more - it was abandoned by absentee parents who brought it into the world but were unwilling to raise it once actual parenting was needed.

Health NZ cannot be so easily disestablished, the horse has bolted, but its bloated structure and lack of public accountability were always going to catch up with its leaders - and this week they finally did.

“Dig Up, Stupid!”

Health NZ is under new(ish) management but our public health system is in far greater crisis than at any time in modern history.

The decision to appoint Prof Lester Levy, the former chair of multiple DHBs and someone who successfully implemented the centralisation of many non-clinical business services across the Auckland region, makes a lot of sense but comes with an equal sense of foreboding.

As Levy himself stated:

"The organisation has become too large, it's quite bureaucratic and we want to turn it into an organisation that's highly focused on the delivery of health services to patients, their families and communities. So we want to power up the front-line and we want to have less bureaucracy, less management, less administration, less complexity."

I think it is overly generous to say it "has become" too large, that implies that it spiralled in an unforeseeable fashion. More accurate framing would be that Health NZ as originally designed was always too large and too bureaucratic.

Cuts are inevitable, and necessary, but they will not improve health outcomes. The reality is we as a nation have spent billions to take our public health services backwards.

That is the tragedy of both Health NZ and the Maori Health Authority - two well funded, well-intentioned, but poorly structured and executed, efforts to make our nation healthier have failed to improve the health of anyone.

Our health system now finds itself in poor health after bad life choices, its recovery will not be quick or painless.

Nothing has improved, and we are now in for a long winter…

Happy Friday!