Health system restructuring too often is driven by top-down decision-making based on misleading snippets of information about other health systems and disregard for the importance of an engagement-based leadership culture.
At worst, they commence with establishing new structures instead of first designing the sort of health system that was needed.
An example of design coming first was the Public Health and Disability Act 2000 shepherded through Parliament by then minister of health Annette King.
Part of the design was to replace the previous system that was premised on running the public health system as competitive commercial businesses.
The design required removing the coverage of the system by the Companies and Commerce Acts.
Another key element of the design was to address barriers arising out of the formal separation between community (including general practices) and hospital care by an integrated whole of population health approach. King also recognised that district health boards (DHBs) required greater engagement with health professionals through what was called clinical leadership.
This was further extended to distributed clinical leadership by subsequent ministers David Cunliffe and Tony Ryall.
The structural change that followed this design was the formation of DHBs responsible for ensuring the provision of both community and hospital health services for geographically defined populations.
Soundbites not design
When health minister Andrew Little announced the abolition of DHBs last April effective July next year, he went straight to structural change rather than design.
There were soundbites but they don’t constitute design.
There was nothing to suggest DHB abolition in Labour’s election manifestos of 2017 or 2020. When in opposition under Little’s leadership, Labour had defended DHBs from criticism including that of the health ministry.
The Health and Disability System Review led by Heather Simpson didn’t hold DHBs responsible for its identified problems in the health system.
The Simpson review did correctly identify the lack of national cohesiveness as a problem but its main solution was national structural change.
It did recommend a reduction in the number of DHBs but still saw the continuation of their responsibility for geographically defined populations as central to the effectiveness of the health system.
In short, minister Little’s announcement was a left-field decision developed very late in the process without engagement that caught everyone outside the inner circle by surprise. There was no mandate for it or even an earlier narrative justifying it. There was no design to explain it.
The closest Little got was to assert that abolition of DHBs would enable the establishment for the first time of a national health system and that the restructuring was consistent with the National Health Service (NHS) in the United Kingdom. But Little’s advisers neglected to inform him that the NHS in the biggest part of the UK (England) is presently moving closer to our DHB integrated care structure through the formation of ‘integrated care organisations’.
This English trend is influenced by both exigency and the influence of the King's Fund, an influential independent think tank focussing on the health system in the United Kingdom. The Fund has a strong focus on the benefits of integrated care – between community (including primary care) and hospital.
A considerable influence in the King’s Fund’s thinking and advocacy was innovative work on an integrated care initiative based on distributed clinical leadership that started to get traction in 2007 in one of NZ’s largest DHBs – Canterbury. It concluded that Canterbury’s initiative had transitioned from fragmented care towards integrated care with measurable success. This was both within its hospitals and, through clinically developed and led health pathways, between them and community care.
The Welsh experience
Andrew Little should have been encouraged to look at Wales where the NHS already has similarities with our DHBs scheduled for abolition.
Wales has seven Health and Wellbeing Boards (generally referred to as health boards) serving a population of over 3.1 million. Rather like DHBs, their role is to improve the health and wellbeing of their population and reduce health inequalities for their geographically defined populations.
Cardiff & Vale University Health Board provides an interesting insight. It covers the Cardiff and Vale of Glamorgan area with a population of around 445,000 (Canterbury’s population is around 578,000).
Early in the covid-19 pandemic in 2020, clinical staff at Cardiff & Vale realised they would have to make rapid changes to prevent the widespread cancellation of elective surgery. Rather than using the traditional model of senior managerial oversight of projects, health professionals took much greater direct responsibility for decision-making, within a team working model, which provided a different form of oversight and challenge. In other words, leadership was widely distributed.
The result was a quick reorganisation of surgery within the health board’s hospital network by creating covid-free ‘green zones’ and making substantial changes to how services planned and delivered elective operations (including pre-assessment and establishing dedicated and self-contained clinical teams to deliver surgery pathways rather than sharing staff with other services). The result was significantly better patient outcomes including much greater access to treatment than would have otherwise been the case.
What is most revealing is where the innovators at Cardiff & Vale got their inspiration from. They were very explicit. They had been investing in system-wide approaches to improvement, building on the model from Canterbury DHB for the last five years.
NZ’s government is ditching critical statutory structures without having developed a design for the sort of health system it wants.
The country (UK) the health minister is citing as an example to follow has already ditched (Wales and Scotland) or is moving to ditch (England) its structures replacing it with something similar to what the Government is ditching.
A classic case of ships passing in the night but only one has a navigation system and it's not ours. Go figure!
