Was Health New Zealand A Mistake?

Should we celebrate or commiserate on the upcoming two year anniversary of DHB amalgamation.

On 30 June 2022, the 20 District Health Boards were formally disestablished and were replaced by Health New Zealand/Te Whatu Ora.

The health board structure was 21 years old when it was scrapped. 

If it was a person it might have been it's third year at university, voting in student body elections for the guy promising free beers, rather than requiring its own local board elections which tended to attract even less voters (and zero free beers).   

I was never a fan of the old model - we were a nation of less than five million so having this many districts doing the same thing seemed like a bureaucratic mess of duplication and redundancies. 

Even while working within multiple different health boards, I questioned whether we needed things like twenty different communications teams across the country doing essentially the same jobs. 

Our system was based on England’s NHS model, a nation with a population ten times the size of ours, and provided both a competitive structure and uneven outcomes.  

In New Zealand, these uneven outcomes were identified by health targets and made public by the Ministry of Health on a regular basis. 

The combination of a semi-competitive model paired with clear data and limited narration meant under-performing regions could be identified, and their twenty separate leaders could be scrutinised. 

It was not a perfect model, but it was an amended and evolved version of the English model. We had smoothed out some edges, but others were a part of the structure. 

During my first stint at the Ministry of Health, working as the media handler for the National Health Board division which oversaw reviewing each District Health Board [DHB] and its investment needs.

I was responsible for releasing this data, finding the bullet point outcomes, massaging some of the wording, and fielding questions from the media about our findings. 

These inevitably included very reasonable ones around postcode lotteries, whether the targets could be gamed by individual DHB’s to give a more glowing picture than was entirely accurate, and whether anything could be done to make the system better. 

They made some fair points, and when the last government scrapped this structure I was cautiously optimistic that things would actually get better.

Then they scrapped health targets.

Not great, I thought, but they had a solution that they believed would lead to much better outcomes - both financially and health wise - and wouldn't require them anymore. 

We are now only a few days away from the second anniversary of Health NZ/Te Whatu Ora, has it been worth it? 

Are we any closer to the promised improved outcomes that were meant to spring from a centralised model, or is our health now even more bogged down by bureaucracy and delivering worse outcomes?

The second element of that is hard to answer, the first is more clear. 

The sneaky, slightly cynical genius of removing health targets while also going through a large structural change, is that clear objective data now harder than it once was. 

A layer of public accountability was removed when we arguably needed it the most. In spite of this, there are public metrics we can use to gauge its successes. 

Unfortunately for my previously strongly held view that this change was needed, the reality is that they don't show a system finally hitting its stride. They show health outcomes that have not improved, with many going disconcertingly backwards.

The Annual Update of Key Results 2022/23: New Zealand Health Survey, released in December of last year, shows that our health system has gone backwards across a number of metrics.

The key issues exposed, in my opinion, were:

• There was an increase in unmet need for professional mental health support

• Time taken to get a GP appointment was already too long, and this has only gotten worse

• Visits to the GP decreased and visits to the emergency department increased

• Waiting times in emergency departments across the country have continued to increase.

The main retort put forward by defenders of the current system is that these issues already existed and were exacerbated by COVID. 

The problem with such a defence is that it only highlights the poor timing of these changes in the first place. As soon as a global pandemic was announced, a major restructuring of our public health system should have been shelved. 

In the abstract, a more interconnected health system may appear beneficial during such a national crisis, but in reality a Wellington-centric and a quite dictatorial model with reduced community engagement proved detrimental to decision making and public trust. 

Significant extra funding was invested into our public health system during COVID, but too often it ended up in the hands of highly paid multinational consultancies and not reaching where it could have been of greatest use. 

Community health NGOs had to fill in the service gaps left by Health NZ [HNZ] and Ministry of Health [MoH], while lamenting a lack of support or contact from HNZ and MoH. 

We needed community connections and local leaders. What we got was Deloitte Touche Tohmatsu Limited. 

District Health Board elections often resulted in shockingly low voter turnouts, but they balanced regional and democratic demands. 

During a time when people on the ground and community leadership was key, we were instead focused on centralised efforts. The small way in which regular people could have their say on how their local public health services were run was gone. 

There will always be a modicum of distrust whenever central government interferes in people's lives, even appropriately, but elected local health boards could have helped mitigate a bit of this. 

At a bare minimum it would have helped make the system feel less authoritarian at a time when that was a growing fear. 

The new centralised model was meant to bring us a slick commercial outlet, in a good way. Instead it brought a slick commercial outlet, but in a bad way. 

Another benefit of a post-DHB world, economies of scale, was both largely overstated and not fully followed through on.

A system with 20 versions of the same leadership roles inevitably resulted in duplication of work, but the previous government was fearful of the mass redundancies amongst senior executives that would stem from a centralised model. 

In any other setting, if you merged twenty consumer-facing organisations this would result in a lot of management roles being unnecessary. You'll still need consumer-facing workers, the people who do the actual work that matters, but there will be a lot of well paid mid-managers who are doing the same job for no benefit to anyone other than themselves. 

Centralising backroom functions like HR and comms sounded… sound, but without mass redundancies it would only result in moving roles from across the country over to Wellington. 

This ended up being the case with the post-merger health services, economic benefits from job losses were touted but the actual job losses were seen as too harsh. 

If you're not going to make job cuts, why promise the economic benefits from said job cuts in the first place? It's one or the other. 

Another economic argument for this new model was around economies of scale. 

On the face of it, having twenty different individual organisations negotiating against each other for things like PPE is a bit mad. 

That's an easy argument to make, but it's also disingenuous - that simply wasn't happening. 

Economies of scale had already been considered and reached - with the Ministry of Health managing large service and employment contracts at a national level, and cross DHB cooperative agencies negotiating on behalf of multiple DHBs as collectives for things like catering and other services. 

I've watched a bit of (admitted melodrama) Shortland Street and they've made much out of hospital-level staff cutting deals that, in real life, they wouldn't know the first thing about. 

In one episode I saw, a mid-tier hospital exec was being blackmailed by a dodgy pharmaceutical saleswoman who wanted them to use a shady Chinese provider. 

I laughed at the idea that a mere cog in such a large and complex machine would be entrusted with such power. 

If Shortland Street was real life, this argument would have held water, but it's not and the scale was already there. 

Any new economies would require cuts to either jobs or services - we didn't get enough of the former and too much of the latter.   

So if there were no economic benefits and no community benefits (quite the opposite in fact), what was meant to be better?

A big change the previous government did commit to was a separate Maori Health Authority, one with commissioning power. 

There's a lot of arguments for and against such an entity, as well as questions around some of the people involved in leading it, and so I've decided to do a deeper dive in a separate post that will be out next week. 

This is something I have a very personal and complex relationship with - a battle between philosophy and my own whakapapa, practical and emotional considerations that influence my complex and well earned view - it would be doing you a disservice to not acknowledge all of this before making my views on it more clear. 

I'll always be upfront about my biases, even when they are uncomfortable to share publicly (see my previous post ‘It'll End In Tears, Just Not Theirs’ for a similar example). 

One thing I can give away here is that, whether due to a lack of time or a lack of purpose, it wasn't able to achieve anything concrete in its very limited lifespan. Its board was also largely stacked with people who have either a direct or relatively close financial relationship with Te Pati Maori president John Tamihere. 

Maoridom may be small, but the board lacked anyone I would consider a JT-sceptic - of which there are many within Maoriom more widely. That always concerned me. 

It also continued a theme amongst the previous government's multiple centralisation initiatives. 

Community leadership and a multitude of voices on what are essentially local issues were replaced with political appointments. 

Worse than that, we got a partisan with zero previous health experience steering the entire centralised public health service. Someone who was later fired for partisanship and now moonlights as a highly partisan commentator. 

It's not ‘polite’ to criticise another commentator's commentary, but when that commentary largely consists of rewriting history to make himself a heroic whistle-blower, it is awfully hard not to. 

It's also hard not to judge the outlets that run said content, but that's a different rant for another time. 

In spite of all this - poor leadership, questionable selection of leaders, over-hyped economic benefits, reduced democratic and community voices, and even poor timing - it appears that this centralisation effort will outlive the many others also implemented by the last government. 

Te Pūkenga is gone. The proposed water infrastructure entities have been scrapped. 

Yet, Health New Zealand still lives. Its future seems secure, largely because unwinding this complex beast would be too hard this far into the project. 

At the start of this column I questioned whether DHB amalgamation was worth it, while acknowledging that I once thought it was both inevitable and necessary. 

After two years, the answer is clear.

It wasn't.