health & science

A case for fewer DHBs in health system shake-up

An interim report from a broad review of the country’s health and disability system makes a case for a significant overhaul, which could include amalgamating DHBs. Laura Walters reports.

A damning review of the country’s health and disability system describes it as a “confusing monolith”, and raises many of the same issues discussed for decades.

The report raises again the possibility of doing away with some of the country’s 20 district health boards.

Fragmentation and duplication are key issues raised in the report's discussion of DHBs, primary health organisations (PHOs), NGOs and other services.

While there are examples of professionals working in a flexible and cohesive way, much of what the review found was a system that does not primarily serve consumers’ values and needs, and does not have enough focus on prevention and wellness. This results in inequitable outcomes and the so-called "postcode lottery" of healthcare. The review also found a lack of leadership and accountability across the healthcare sector.

The interim report of the Health and Disability System Review makes a case for widespread change.

The degree of concurrence around what people wanted the system to achieve and how they wanted it to behave was described as “distressing” by review panel chair Heather Simpson - Helen Clark's former chief of staff .

"The reality is that these views have been being expressed, and supposedly agreed with, for decades. Yet the system changes have been only marginal at best.”

Simpson said this level of consensus on the challenges facing the system and the changes people wanted to see might seem like a good thing.

“But the reality is that these views have been being expressed, and supposedly agreed with, for decades. Yet the system changes have been only marginal at best.”

The challenge was not to reinvent the wheel, with many strategies already in place, but to provide a reality check on where the system was at, find examples of success and failure, and pose key questions on how the system should look and behave, going forward.

Calls for fewer DHBs

The report looks at a range of themes, including: governance and funding; Māori wellbeing and equitable access and outcomes; population health; primary health and prevention; disability; workforce; technology and data; and facilities and equipment.

A core finding is that the fragmentation and duplication makes for a complicated system, leading to a lack of confidence and trust in the system. It also leads to a lack of accountability and leadership.

Questions posed in the report signal possible directions of change, including: “Is the best way to achieve more efficiency and more equitable outcomes within available resources to have fewer DHBs, DHBs with different functions and/or more sharing of resources at regional or national level?”

There are currently 20 DHBs, which serve populations ranging from just over 33,000 to almost 600,000. There are also 32 PHOs, or networks of GPs and other primary health care providers (which don’t necessarily line up geographically with the DHBs); and 2200 NGOs working in the health sector, of which less than half receive government funding.

University of Auckland professor of general practice and primary healthcare Felicity Goodyear-Smith said for a tiny country, the system is complex and fragmented, which contributes to inequity and inefficiency.

“The reality is that the world is rapidly changing. Changing demographics alone will increase demands on the system making it unsustainable unless it operates very differently in the future."

Goodyear-Smith said while the report did not contain any surprises, this was the first time such a comprehensive review had been carried out, which presented an opportunity for the health and disability system.

“We could make some courageous changes that could make some big differences.”

The report was correct in its conclusion that the same approach was no longer viable, especially as demand increased, she said.

In the report, Simpson says: “The reality is that the world is rapidly changing. Changing demographics alone will increase demands on the system making it unsustainable unless it operates very differently in the future.”

“Consumer expectations are changing. New technologies, climate change, increasing comorbidities, and growth in antimicrobial resistance etc are happening whether the system changes or not. But their impact on system performance for the least well off will be hugely different, depending on what actions are taken now.

“When we project forward and consider the demographic, technological, societal, cultural, and environmental changes that are rapidly overtaking us, it is clear there are challenges ahead.

“Continuing with the current model of care, based largely on a western medical model, employing more and more medically qualified staff focused on treating illness, rather than promoting wellness, will not only be ineffective in achieving the equitable outcomes we desire, it will not be sustainable. The numbers of staff required will not be available and the cost would be prohibitive.”

Raft of changes needed

Goodyear-Smith said creating the type of system that would be responsive to future challenges and demographics, as well as flexible, reflective of local needs, and equitable (especially in terms of Māori, Pasifika and rural health access and outcomes) would mean tackling the challenges from many angles.

Her research, recently published in The Lancet medical journal, looked at a range of changes that needed to be made in order to live up to the vision of New Zealand’s universal health system.

The report says if future demands are to be manageable, the emphasis must be on preventing ill health and promoting wellbeing – something the Government has also recently raised in regards to cancer care. But almost two decades on, New Zealand has not progressed the vision set out in the Primary Healthcare Strategy of 2001.

Goodyear-Smith said public health and awareness campaigns, as well as tackling the underlying drivers of health inequities, and empowering Māori, were key components of addressing the current issues.

Technology and data analytics would also play a significant role in the country’s health system in the future.

Health Minister David Clark said the Government had started work on addressing fundamental health issues, but long-term and wider systemic issues needed to be dealt with. Photo: Lynn Grieveson

Gathering data allowed better measurement of outcomes and deployment of solutions. For this to work, the funding, skills within the workforce, and inter-operability needed to be improved, she said.

Technology could also be used for “self-management”, where devices could measure someone’s blood pressure, and send the data to their GP, removing the need for a visit.

But Goodyear-Smith warned this use of this type of technology would have to be universally available in order to not exacerbate inequitable access for those who could not afford the latest gadgets.

Systems changes would also need to strike the right balance between centralisation and local responsiveness.

Government welcomes report

Health Minister David Clark launched the review in May, in the hope of future-proofing the health system.

On Tuesday, Clark said he welcomed the report's calls for a more collaborative and cooperative approach, and its emphasis on patient outcomes and fairness.

In a letter to Simpson, Clark said core focus areas of the report aligned with the Government's priorities - and recent initiatives - including a focus on the social determinants of health, the need for enhanced prevention services and a greater role for primary and community care, and a strong public health system with stronger leadership, accountability and integration.

While Kiwis were generally well-served by public health services, there were long-term and ongoing system-level challenges, which needed to be addressed, he said.

Opposition health spokesperson Michael Woodhouse said National supported some of the proposals in the report, including the pitch to develop strategies to modernise and strengthen the health workforce.

National was also in favour of preventative healthcare, as long as it didn’t come at the cost of the care New Zealanders needed now.

“But the report’s comments on system structure are muddled and if there’s going to be reform, we need to know how that will look. It says that the current structure is too confusing, but that restructuring would be ‘disruptive’," Woodhouse said.

“Either structural reform is on this Government’s agenda or it isn’t. The public and health sector deserve greater clarity on its plans,” he said.

A final report, with recommendations, is due in March next year.

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