health & science

New system passes the buck on public health

Analysis: Public health experts say the health and disability sector review is calling for a system that will further fragment the institutions responsible for preventative care, Marc Daalder reports

Years-long calls for an independent public health agency have been ignored in the latest proposed shake-up of the health sector.

The Health and Disability System Review, released on Tuesday morning, calls for an overhaul of the health sector, culling or merging of District Health Boards and the formation of two new health agencies: Health NZ, to oversee the rest of the system, and a Māori Health Authority. 

Public health, however, does not receive the same in-depth treatment. It certainly doesn't get the independent body that epidemiologists like the University of Otago's Michael Baker and Sir David Skegg have been calling for for years.

Instead, the Director of Public Health would be elevated to a position that directly reports to the Minister of Health, instead of the role's current post reporting to the Director-General of Health and not even placing on the ministry's 13-person executive leadership team. The director would also take on many of the obligations currently embodied by the Health Promotion Agency, which would be dissolved under the new plan.

The second public health plank of the review would create a Public Health Advisory Committee, which "should provide independent advice to the minister and be a public voice on important population health issues". Beyond this description, details are sparse.

Epidemiologists and other public health experts expressed disappointment at the news that their campaign for a public health agency had not come to fruition.

Speaking to Newsroom in April, Baker elucidated the reasons for an independent body.

"We’re such a small country, at a certain point you have to say, 'actually we have to put a whole lot of these population health functions together into organisations of critical mass'. That also makes it much more adaptable because they’ve got more surge capacity," he said.

"Even though our Ministry of Health has done, I think, very well, it still clearly has not enough staff to do this properly. Also, for policy-making agencies, it’s hard for them to take almost a wartime or civil defence mode of operating. There’s no accident all around the world, pretty much every high-income country has a dedicated public health agency. Public Health England, Scotland, Wales even, Ireland, CDC in the US, Public Health Canada. New Zealand’s really out on its own a bit."

Nick Wilson, a colleague of Baker's at the University of Otago's public health department, told Newsroom the lack of a public health authority jeopardised New Zealand's chances of dealing successfully with future pandemics.

"One benefit of [an independent body] is that in a crisis, like we've had with Covid-19, that agency will have the legal mandates and the resourcing to focus on it," he said.

Jim Mann, an expert on non-communicable disease at the University of Otago, told Newsroom a public health agency was widely supported by the New Zealand public health community.

"All of us in public health would have liked to have seen an independent public health agency. I don't know a single senior health professional who wouldn't like to see that," he said.

Wilson also excoriated the existing status of public health in New Zealand.

"For a high-income country to have measles epidemics is a really bad situation," he said.

"The Havelock North campylobacteriosis outbreak, the biggest waterborne outbreak of campylobacteriosis ever in the world, happened because we haven't sorted out basic things like clean water. One of the most shocking recent examples was the lack of good risk assessment advice around meth contamination in homes, [which led to] booting low-income people out of their homes and destroying the home for infinitesimally low levels of meth contamination."

Health Minister David Clark defended the lack of a public health agency in the proposal, saying population or public health approaches were embedded at every level of the new system.

"It's like saying public health is everybody's responsibility but it then turns out to be nobody's responsibility."

"This report wants that public health or population function across everything. It basically says let's not set up a siloed agency, let's make the Ministry of Health responsible for population health outcomes, for planning towards population health outcomes, let's require our DHBs to do that planning, let's require Health New Zealand to be operationalising that," he said.

"It, in one sense, goes a step further than [an independent body]. It says this has got to be the basis of our health system."

Mann told Newsroom that explanation doesn't hold up. Spreading responsibility for public health to every part of the system effectively fragments that duty into oblivion, he said.

"It's like saying public health is everybody's responsibility but it then turns out to be nobody's responsibility."

Moreover, when officials and institutions are tasked with acute care, like surgeries, and public health at the same time, the acute care will always take precedence, Mann said.

"If Jim Mann is charged with looking after acute services and long-term public health issues, acute services are going to take priority. The demand of acute services, when you've got people lying in corridors because there're not enough beds for them, of course that's going to take priority. Which is why you need to do some kind of ring-fencing to make sure that public health doesn't lose out," he said.

Mann was also unimpressed with the handful of public health measures that were explicitly laid out in the review's vision for a new health system. The details on the Public Health Advisory Committee were too scant to give him comfort, he said.

"I am totally not reassured by that. I don't know how many advisory committees I've been on, but I would have to say we haven't achieved an enormous amount because they've been advisory."

The promotion for the Director of Public Health was uninspiring, Mann said. It would leave that role far overburdened and unable to focus on the vast array of public health crises in New Zealand.

With Covid-19 still fresh in the public consciousness, he is also worried that non-communicable diseases would lose out in whatever limited attention public health would receive.

"We have still got the epidemics of diabetes, obesity and cardiovascular disease and cancer."

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