The most important lesson from the Covid pandemic is the failure of the current health structure to deliver the national public health campaign demanded by the crisis.
There was a time when the country could have delivered such a campaign through a high quality, dedicated public service. We can do it again – in fact it’s the only possible way forward to deal with any national health crisis such as the Covid pandemic or our mental health emergency.
When the Department of Health was abolished in favour of a slimmed down Ministry of Health dealing with a devolved health structure of hospitals and primary healthcare providers, the main driver was to create “competition” and improve “efficiency”. This would be provided by bringing in “private sector disciplines” through contracting of services to the public and private sectors.
The Ministry of Health was deliberately populated with non-health sector lawyers and administrators whose main job was to develop and monitor contracts for health services.
Politicians since then have tinkered to create more “efficiencies” with smaller hospitals closing and local health services diminished. As part of this push Aotearoa New Zealand’s first woman Prime Minister, Jenny Shipley, wanting a bigger role for the private sector, brought in “hospital part charges” and fought hard to ration health services. For the most part she failed on these initiatives through grassroots public fightback campaigns.
When the Clark Labour government came to power in 1999 it retained the contracting model because they said it was important for Māori healthcare providers to obtain funding for devolved delivery of primary healthcare. Māori providers often argued the contracting model was a liberating model from a stifling “one size fits all” bureaucracy.
Māori should have been delivered services based on the Treaty of Waitangi rather than Māori desire to provide primary health services being used as an excuse for allowing fat private sector profits to be made from privatising public services. The contracting model was NEVER developed to provide for Māori alternatives – it was developed to provide government health contracts to the private sector. Māori were a convenient excuse for the attempted wholesale privatisation of public services in health.
Despite supposed benefits for Māori health, the opposite happened and the eyewatering cost to Māori has been revealed just this week. Peter Crampon from Otago University has costed the “making of policies to address service failures and then failing to properly implement them”. He has calculated the underfunding and under-provision of primary health care for Māori and says “The dollar equivalent cost of poor health and deaths for Māori over an 18 year period that may be attributable to failed policy implementation is in excess of $5 billion a year”.
Meanwhile our Ministry of Health is dominated by bureaucrats who are expert at writing contracts but far below par when they have to respond to a national health emergency such as the pandemic. They are making it up as they go along.
Among the myriad of failures was the Ministry’s assertion they would replace private security guards at MIQ facilities with directly employed guards. As far as I’m aware that idea has been quietly dropped in favour of continuing with private security guards because key Ministry bureaucrats prefer contracting – it’s in their blood – irrespective of the health issues involved.
National have been right to point to the numerous failures as our “not fit for purpose” health system has tried to deal with a national health emergency. The health system has also been an utter failure to deal with our other national health emergency – mental health care.
The holes in the pandemic response are obvious but National and Act proposals to hand over more of the response to the more “efficient” private sector, such as allowing employer groups to run MIQ for their areas of the economy and a dedicated, purpose-built, privately-run MIQ facility, would make things worse. (“Efficiency” was one of the weasel words of the 1990s – it sounds sensible but simply means the private sector will pay people less to do the same job and will pocket the profit for doing so – in general Māori health providers have been as poor employers as any other private health provider)
Private provision of health care can never result in a high-quality primary or secondary healthcare system for everyone. The US is the example National and Act would like us to follow – the pinup example of healthcare failure – the worst health outcomes for the greatest expenditure.
As Minister of Health, Andrew Little has the ball in his hands and he is punting it in the right direction.
Covid has shown us that we need a single national health structure to deliver health services as announced by the government in the 2021 budget.
For a small country with the same population as Sydney our ongoing insecurity has led us to mimic the failed health structures of other countries.
The Ministry of Health – more a “contractocracy” than a health delivery system – has to go and the neoliberal zealots who have run it and our various DHBs must follow.
Rebuilding a quality healthcare system, for primary and secondary care, needs dedicated public servants and billions in extra funding to make up for the underfunding over the recent decades of decline. (The sort of billions the Reserve Bank has printed this year and given to the private sector banks who have used it to make the housing crisis worse – like pouring jet fuel on a fire and hoping it won’t explode)
We have all suffered one way or another from healthcare failure. The holes are being plugged in an ad hoc way now as we face this national pandemic – and it shows.
A single national health service alongside a dedicated Māori national health provider is the best direction to head.
Don’t let the buggers steal your ball Andrew Little.
Everything worked really well in the 1970s.
It all goes to show what a gang of self-serving liars and saboteurs can do if given the chance.
Afktt, Looking back the 70’s do seem to have been halcyon days, but a word of caution lest we keep the rose tinted glasses on too long. The 70’s had many problems, many that were just as real for those suffering from them as the ones we see today. Today’s problem seems to be despite endless increases in resources the problems are just getting worse.
Some charities seem to have become businesses in their own right, requiring poverty growth to survive.
I am appalled when we get donation request letters ‘telling’ us how much we are expected to give, a figure normally derived automagically from a formula based on our last donation.
Five main reasons why everything is now so much worse overall than in the 70s:
1. Population overshoot has increased enormously.
2. Energy has been squandered to the point of near exhaustion.
3. Resources have been squandered to near exhaustion.
4. The pass/fail education system has been replaced by an everyone-,passes system (however little work they do or however little knowledge they acwuire). This has been accompanied by a dumbing-down of the quality of broadcasting and a focus on consumption.
5. Rapid, and increasing degradation of the environment, both locally and globally -especially via covering of pasture with duburbis, excessive CO2 emissions and plastics everywhere.
Sure, almost everyone has a screen device, and smoking is no longer ubiauitoys. And there are more advanced medical techniques etc. Homosexuals are not persucuted the way they were.
But overall the decline is very noticeable. And it is governmet policy to continue to drive the quality of life DOWN.
But
Thanks John, an excellent overview of how we got here.
Like you I hope Minister Little can keep focused on the end goal. It seems to me over and over again we see the failures originating from the new look public service under the control of lawyers, accountants, and business management graduates.
Anaru Little needs to take out Jacinda for things to change for the better for Maori if you can believe what he says, he’ll do.
2023 maybe?
Oddly enough, the Public provision of health care hasn’t resulted in a high-quality primary or secondary healthcare system for everyone either and outside of maybe the Nordics with their massive sovereign wealth funds it hasn’t really delivered anywhere else that I am aware of.
I’d much rather receive the incredibly high US healthcare standards than go to Middlemore. I accept that there’s a cost to this but that’s what’s missing from the article. Healthcare costs are outrageous and NZ can’t afford the standard of care that people want.
Healthcare Insurance may well be an ugly model but at least it rewards those that look after their own health rather than penalising them by forcing them to carry the cost of those who do not.
Health insurance only rewards them who can afford to buy it which is why the USA is only ranked 4 places above nz at 37 and us 41st in the WHO’s world rankings in 2014.
Our total healthcare system is dysfunctional.
It is this bullshit re health insurance that comes from the USA .
Ask yourself why Insurance companies now offer Trauma care and cancer care policies ?
Why because our health system is so dysfunctional it is profitable for them to do so.
I have been banging on about this for 7 years only now is middle class nz beginning to give a shit.
Our health system is worse than the USA Slovenia Cuba and Brunei then us.
Think about that.
Our Meds funding is below Mexico in % of GDP.
Ideas to fix long term illness and health welfare funding.
1 Create a Medicare agency including accidents and long term illness ( long term being anything outside of your sick leave entitlement).
2 Place a Medicare Agency social worker in every Doctors surgery ( Why because of the increased workload because of idea 5 6 7 and 9 ).
3 Fund ALL MEDICINES through the Medicare Agency ( Pharmac funded or otherwise).
4 Fund all long term illness welfare funding through the Medicare agency ( i.e. 80% of Minimum wage benefit).
5 Remove all Long term Welfare illness funding from Winz.
6 Remove all the relationship rules and limits for all long term welfare illness benefits.
7 Remove the requirement for 2nd opinion doctors reports as the ACC social worker can discuss it directly with your doctor at the clinic.
8 Create the agency within the New remodelled Agency of compassionate care to cut double agency costs.
9 The Agency organises specialist appointments and where an operation in a public hospital can’t be done in a timely manner arranges it in the private sector at Governments cost.
This should be arranged before leaving the Doctors surgery/clinic.
10 All medicines on a Prescription ( Funded or Unfunded) should count towards the 20 count, including any repeats, to get Free meds after 20 Prescriptions.
11 Remove restrictions on diagnostic and maintenance testing that patients require for effective medication dosing purposes.
12 All ACC SOCIAL WORKERS at a doctors surgery issue a patient with a medicines swipe card to swipe at a pharmacy.
If a medicine is unfunded ACC pays all but the $5 pharmac fee, if it is Funded the Patient pays the $5 fee.
Why the card ?
This is to keep track of the total number of medicines prescribed in any given year and the total cost involved .
This means all costs will be available from one agency and not as now spread over multiple Dhb’s who have no idea whatsoever of the total dollar cost of unfunded medicines prescribed each year .
13 Dr visit fees and unfunded Medicines then be funded by a medicare levy, which replaces the current acc levies, we all pay to the Medicare agency including beneficiaries.
https://thedailyblog.co.nz/2021/09/01/guest-blog-ian-powell-funding-general-practice-in-new-zealand/
This is point 14 added to my list of things to add to the new medicare agency.
The medicare agency buys up retiring doctors clinics whose staff are not interested in buying the current clinic they are employed in . The Medicare agency overtime builds a nationwide health Hub GP clinic network that runs on the low cost funding model.
Then point 15 :
The new medicare agency charges Pharmac with the responsibility of building OUR OWN MEDICINES PRODUCTION FACILITY.
I have been told in NZ in 2019/20 $115 billion was spent on Medical research, approximately 1/3rd of our total GDP so why are we buying generic’s and importing them ?
When we could be producing our own at a much lower cost.
https://thedailyblog.co.nz/2021/06/27/guest-blog-ian-powell-lets-manufacture-our-own-pharmaceuticals/
Point 16:
Labours ; Social insurance policy
Why cant this Social insurance which currently apparently is only going to cover short term Unemployment.
Why cant it cover also any unfunded medical care or Unfunded medicines you need and also any GP costs ?
The Green party are looking at these ideas.
What are you saying about the
‘incredibly high US healthcare standards
the health system in the US is appalling, people who can’t afford health care are sometimes put outside under a tree to die.
How does health insurance reward those who look after their own health? Please explain.
Health insurance is for those who have money so no matter their state of health they will get private care.
We did have a good health system, if you had a hernia you got it fixed and that and many things do not get fixed anymore, it has gone downhill over the past 40 years and it need not have.
What are you saying about the
‘incredibly high US healthcare standards
the health system in the US is appalling, people who can’t afford health care are sometimes put outside under a tree to die.
How does health insurance reward those who look after their own health? Please explain.
Health insurance is for those who have money so no matter their state of health they will get private care.
We did have a good health system, if you had a hernia you got it fixed and that and many things do not get fixed anymore, it has gone downhill over the past 40 years and it need not have.
https://hswn.org/2021/09/02/decisions-behind-the-mask/?
“Under funding of Medicines by Pharmac” Facebook group Ideas from Group discussions
Ideas to fix long term illness and health welfare funding.
1 Create a Medicare agency including accidents and long term illness ( long term being anything outside of your sick leave entitlement).
2 Place a Medicare Agency social worker in every Doctors surgery ( Why because of the increased workload because of idea 5 6 7 and 9 ).
3 Fund ALL MEDICINES through the Medicare Agency ( Pharmac funded or otherwise).
4 Fund all long term illness welfare funding through the Medicare agency ( i.e. 80% of Minimum wage benefit).
5 Remove all Long term Welfare illness funding from Winz.
6 Remove all the relationship rules and limits for all long term welfare illness benefits.
7 Remove the requirement for 2nd opinion doctors reports as the ACC social worker can discuss it directly with your doctor at the clinic.
8 Create the agency within the New remodelled Agency of compassionate care to cut double agency costs.
9 The Agency organises specialist appointments and where an operation in a public hospital can’t be done in a timely manner arranges it in the private sector at Governments cost.
This should be arranged before leaving the Doctors surgery/clinic.
10 All medicines on a Prescription ( Funded or Unfunded) should count towards the 20 count, including any repeats, to get Free meds after 20 Prescriptions.
11 Remove restrictions on diagnostic and maintenance testing that patients require for effective medication dosing purposes.
12 All ACC SOCIAL WORKERS at a doctors surgery issue a patient with a medicines swipe card to swipe at a pharmacy.
If a medicine is unfunded ACC pays all but the $5 pharmac fee, if it is Funded the Patient pays the $5 fee.
Why the card ?
This is to keep track of the total number of medicines prescribed in any given year and the total cost involved .
This means all costs will be available from one agency and not as now spread over multiple Dhb’s who have no idea whatsoever of the total dollar cost of unfunded medicines prescribed each year .
13 Dr visit fees and unfunded Medicines then be funded by a medicare levy, which replaces the current acc levies, we all pay to the Medicare agency including beneficiaries.
https://thedailyblog.co.nz/2021/09/01/guest-blog-ian-powell-funding-general-practice-in-new-zealand/
This is point 14 added to my list of things to add to the new medicare agency.
The medicare agency buys up retiring doctors clinics whose staff are not interested in buying the current clinic they are employed in . The Medicare agency overtime builds a nationwide health Hub GP clinic network that runs on the low cost funding model.
Then point 15 :
The new medicare agency charges Pharmac with the responsibility of building OUR OWN MEDICINES PRODUCTION FACILITY.
I have been told in NZ in 2019/20 $115 billion was spent on Medical research, approximately 1/3rd of our total GDP so why are we buying generic’s and importing them ?
When we could be producing our own at a much lower cost.
https://thedailyblog.co.nz/2021/06/27/guest-blog-ian-powell-lets-manufacture-our-own-pharmaceuticals/
Point 16:
Labours ; Social insurance policy
Why cant this Social insurance which currently apparently is only going to cover short term Unemployment.
Why cant it cover also any unfunded medical care or Unfunded medicines you need and also any GP costs ?
The Green party are looking at these ideas
Five main reasons why everything is now so much worse overall than in the 70s:
1. Population overshoot has increased enormously.
2. Energy has been squandered to the point of near exhaustion.
3. Resources have been squandered to near exhaustion.
4. The pass/fail education system has been replaced by an everyone-,passes system (however little work they do or however little knowledge they acwuire). This has been accompanied by a dumbing-down of the quality of broadcasting and a focus on consumption.
5. Rapid, and increasing degradation of the environment, both locally and globally -especially via covering of pasture with duburbis, excessive CO2 emissions and plastics everywhere.
Sure, almost everyone has a screen device, and smoking is no longer ubiauitoys. And there are more advanced medical techniques etc. Homosexuals are not persucuted the way they were.
But overall the decline is very noticeable. And it is governmet policy to continue to drive the quality of life DOWN.
But
There’s a lot to unpack here.
John I would have thought NZ’s response to the pandemic has been exceptional, taking into account there has been no playbook. The public health units have done an excellent job contract tracing and training up hundreds of new staff very quickly. 9/10 if it was a medical student assignment.
If the virus had run rampant our hospitals would have struggled certainly, not enough ventilators and staff and space, but it would have been unrealistic to have that capacity on standby. Who would have predicted the scale of covid?
Our hospital staff have been exceptional in not only treating the patients but stopping the infection within the hospitals. Also our epidemiology/micro experts have given outstanding advice in the face of huge worldwide criticism.9/10. Genome sequencing10/10. Unbelievable. We just get better with time. Vaccination rollout ramping up to 90,000/day-exceptional from all those gp practices and pharmacies and other providers.9/10
So back to the new Health Authority (and Maori Health Authority) that starts 1 July 2022 (10 months less Christmas Holidays less Covid admin time-so maybe 8 months). This has the potential to go badly wrong! Where is the planning at?I bet it has barely started. Who is doing this planning and is it clipped on to their current job description? Where do all these fresh faced new health planners/administrators come from? What experience will they have? Do they just re-employ the same tired old DHB planning and funding staff or do they have to all re-apply for their jobs? Why will the DHB CEO’s go out of their way to help when they lose their jobs and get massive redundancies in 10 months? The CEO’s found out about the new authority the day before the public! Strap yourself in folks.
The solution: Keep the Maori Health Authority but with a realistic timeframe for implementation of about 3 years. High focus on health promotion and prevention and training Maori healthcare workers.
Keep the local DHB’s and set up a team of 4 highly skilled audit staff within each DHB. The lead auditor shall be a listening skills expert. One medical expert, one planner and one health systems analyst. They audit each service within the DHB’s with the aim to achieve 80-90% efficiency. No service can operate at 100% efficiency. They report on needs of staff, whats holding them back from higher efficiency etc.
The Key part: If a service is rated 90% efficient or more, then any shortfall of treating patients is allocated with extra beds and extra staff and extra funding.
OP Read Ian Powell’s posts with Business Consultants setting up the New Health Authority I have no confidence what so ever That it is going to improve anything when consecutive govts blatantly underfund health care in all sections of our health system.
You only have to look at Pharmac and the bullshit excuses and pitiful amounts its budget is increased year on year.
It will be more of the same bullshit business oriented cost before people’s needs model.
Same old bullshit neo liberal crap.
You only have to read Ian Powell’s tdb blog posts to see what the Health bureaucrats in Wellington did to demolish the Canterbury District Health Boards patient oriented model to figure out the direction where this health authority will go.
The only one I have even a smidgeon of confidence is the Maori health authority at least they are patient oriented.
Same applies to energy too
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