The case for change in the health system - building a stronger Health and Disability System that delivers for all New Zealanders
Morena ki a tatau,
Tena tatau i nga kaupapa hauora,
E tuitui nei i a tatau i tēnei ata,
Ka nui te mihi ki a koutou katoa.
When we were re-elected with a clear mandate for change, our Government made three promises:
- To keep New Zealanders safe from COVID-19
- To accelerate our economic recovery
- To lay the foundations for a better future
Health is critical to all three of these.
We all recognise the world-leading response to COVID-19, which has made New Zealand the envy of many. The success we have had to date has been built on the dedication and professionalism of the health service.
Our publicly-funded health system is one of New Zealand’s greatest assets. It not only drives people’s health and wellbeing, but it is also our largest employer, and therefore a source of human capital and a major contributor to local economies.
The health system touches all of our lives. Every two seconds one of us sees a GP or nurse, and each year there are around 1.2 million hospitalisations, carried out in over 150 public and private hospitals, by some of the 220,000 people working in the sector.
But we know that our system is under serious stress and does not deliver equally for all.
It was in that context that this Government set up the Health and Disability System Review nearly three years ago. The aim of that review was to develop options to reform the system to address two major challenges: equity and sustainability.
We have been working since the election to take the Review’s analysis and develop a proposal for the future to improve how we deliver healthcare so more New Zealanders get the health services they need.
Next month we will announce the new shape and structure for the future health and disability system. This will be the blueprint for how the system will work in the future.
What I want to do today is reiterate the rationale and objectives of the reforms, what underpins our thinking, and the principles that will guide our choices. I hope this will give you some clarity on what we want to achieve.
Our guiding vision is for a health system delivering pae ora / healthy futures for all New Zealanders, where people live longer in good health and have an improved quality of life.
If we are to realise this vision, the reforms need to focus on how we achieve five outcomes, above others. These are:
Equity for all New Zealanders – so everyone can achieve the same outcomes, and have the same access to services and support, regardless of who they are or where they live.
Partnership – through embedding the voice of Māori and other consumers of care into how the system plans and makes decisions, ensuring that Te Tiriti o Waitangi principles are meaningfully upheld.
Excellence – ensuring consistent, high-quality care is available when people need it, and harnessing leadership, innovation and new technologies to the benefit of the whole population.
Sustainability – focusing the health system on prevention and not just treating people when they are unwell – ‘wellness not illness’ – and ensuring that we use resources to achieve the best value for money.
Person and whānau-centred care – by aiming to empower people to manage their own health and wellbeing and put them in control of the support they receive.
I am sure that people listening today will recognise elements of this vision. These are some of the essential principles on which all good health systems should be based.
By seriously addressing the shortcomings in our public health system today, we have a real opportunity to truly achieve this vision.
The current system
It is worth reminding ourselves of the scale of our publicly funded health and disability system.
The current system covers many organisations and a significant proportion of New Zealand’s workforce. 77,000 people work in the 20 district health boards.
And another 145,000 work in health organisations across the country, including in our 30 primary health organisations. There are nearly 17,000 practising doctors in New Zealand and nearly 60,000 nurses.
Representatives of many of those people are here in the room today and watching on the livestream. Thank you for everything you do for New Zealand.
The case for change
Compared to other countries, our health system performs well on a range of measures. On average, New Zealand is around or above those countries we like to compare ourselves with for key indicators such as life expectancy and avoidable deaths
But we know that ours is a system under increasing stress and its design has not enabled it to deliver equitably for all New Zealanders.
First and foremost, we must make changes to tackle the persistent inequity in health outcomes.
Life expectancy at birth for Māori and Pacific peoples is more than five years below the New Zealand average. Around half of Māori and Pacific deaths are potentially avoidable, compared to under a quarter of those for other New Zealanders.
We can change these results if we re-think how Māori and Pacific communities get access to healthcare and think about how healthcare services are delivered. This is in part about how we support kaupapa Māori services. But it is also about how the rest of the health system engages with these communities.
Let me turn to our disabled community. They also face inequitable outcomes. Only 50% of disabled people rate their health as good, compared to 89 percent of the rest of the population.
We have heard the disabled community’s views on the Review recommendations about how disability support services are governed in the future; and we know that work is still needed to improve access to health services and outcomes for disabled people. The Minister for Disability Issues Carmel Sepuloni and I have requested separate advice looking at the governance of disability support services and where it sits in wider government structures. We need to bear in mind that members of this community are not only high users of health services, but users of other services that enable them to live safely in the community.
We will continue to actively engage with the disability community on any future governance models.
Improving outcomes for those traditionally underserved by our health system – for Māori, Pacific, disabled and rural communities, among others – is central to the reforms we undertake.
It is not good enough for our health system to be good for many if the outcomes for others are lesser because of social and community factors that, with a bit more effort, can be readily addressed.
Cohesion / variation across the system
Part of the reason for inequity is the way that the health system is structured and operates.
The Health and Disability System Review report said that the system has become complex and unnecessarily fragmented. Organisations have unclear or overlapping roles, responsibilities and boundaries. There is significant duplication of activity, and variation that creates a post-code lottery when it comes to accessing services.
- In some DHBs, people are twice as likely to die from potentially preventable causes than in others, and three times more likely to be re-admitted to hospital for urgent needs.
- Some New Zealanders are twice as likely to get knee replacement surgery than others.
- In over half of our DHBs, more than 10% of people did not receive cancer treatment within 62 days from diagnosis. In the lowest performing DHBs, nearly a third of people were still waiting for cancer treatment after 62 days.
Where you live in New Zealand should not dictate your access to good quality health services.
This postcode health lottery is well documented – and it is the consequence of a system that is too disjointed and not sufficiently focused on the population as a whole.
In the future, the health and disability system should be centred more around what people need and want from their health services.
The public do not have a consistent say in the operation of the system or often have little choice about how they access services. Iwi and Māori communities are frequently consulted, but often in an advisory rather than decision-making capacity.
Service improvements and the uptake of new technologies has been sluggish, with little shift of services from hospital to community environments, despite this being government policy for more than 20 years.
Funding arrangements provide little local discretion for innovation and are unpredictable, making long-term planning difficult.
Split and fragmented responsibilities for everything from IT to human resources make it difficult to work across the system, share data and analytics, and identify and spread best practice.
The future system will need to have the right settings in place to make it easier to innovate, to be able to rapidly adopt new technology that can enhance people’s experience of health services, and to help people to better manage their health at home and in their communities.
As noted in the Review, the system will also need to take a stronger population health approach in the future. This means understanding what the population needs from services and the best ways to deliver on these needs. It also means working together to address the wider determinants of health.
All this adds up to the need for a system that is more consistent and cohesive across the country.
Urgency to act
The system is under stress now.
We know this from the indicators I have described, and the financial position of district health boards.
And this situation is only going to worsen without reform. By 2030, it is expected that 20 percent of New Zealanders will be aged 65+, compared with 16 percent in 2020. With an ageing population and growing burden of chronic disease we know that the demand for health services is going to grow substantially over the next decade.
What’s more, from talking with many people within the sector and around the country I am overwhelmed by widespread agreement on the need for change and an expectation that we move quickly.
The reformed health system
So how do we tackle these longstanding issues and take the opportunity of reform to build a better, fairer health system?
I want to say a little about how I see the system changing, and the most important shifts that will be needed in the future.
In my mind, there are five key shifts that must happen.
Firstly, the health system will reinforce Te Tiriti principles and obligations. We have to accept that the way our system presently delivers for Māori is inadequate. This simply must change.
We must ensure partnership and effective iwi and Māori leadership at all levels. Māori involvement in determining direction, priorities, service design and delivery to address Māori health needs will be the norm, not the exception. And to ensure that support is appropriate and accessible, the system will provide more kaupapa Māori services and options as part of integrated service arrangements.
At the core of our reform is a by Māori, for Māori approach - our role as the Crown is to be the enablers of change, and the not the barriers to it.
Addressing inequities is not about creating an advantage. There is no advantage in being sicker and dying younger. It’s about removing disadvantage and ensuring everyone has access to the same level of high-quality care and the same opportunity to experience good health outcomes.
As already announced, the health system of the future will include a Māori Health Authority to centre the Tiriti o Waitangi partnership. It will also be key to shaping how Māori exercise rangatiratanga over their own healthcare.
But this is not just about creating a new entity. Reinforcing partnership is the responsibility of all people in the system and will need to see active change in all organisations to further embed a Māori voice.
Alongside that, we are focused on ensuring Pacific people and disabled people have a voice and influence in shaping the care they receive, and exercise agency over their own wellbeing.
Secondly, all people will be able to access a comprehensive range of support in their local communities to help them stay well.
This means ensuring a better range of integrated primary and community services in all areas, with increased access and protected funding. Services will be designed around the needs and priorities of communities and will work together to improve the health of their local population.
People and whānau will have more options to manage their own health and wellbeing through access to information, advice, community support and targeted services. Government services will work together better around communities to link up support for those who need it most.
There are already many examples of innovation in primary and community services. The Health Care Home model, for example, is encouraging a multi-disciplinary team based approach to meeting people’s needs, and supporting more convenient access through both digital and face to face channels to a wider range of services in local clinics. Evidence shows this helps people to stay independent, reduces hospital admissions, and supports staff to develop new skills.
This is the sort of change we need, but at present it is confined to certain areas. The opportunity is to redesign the system to encourage integration and innovation in all places.
Thirdly, everyone will have access to high quality emergency or specialist care when they need it.
Services will be planned across the whole New Zealand population to ensure the best distribution of care and equitable access for people in different regions. Hospital and specialist services will work cohesively to share best practice, operating as part of a single system and not just in the interests of their organisation.
Increasingly, we have seen initiatives in recent years that are attempting to break down barriers between areas of the country. There are now a number of clinical networks which bring together professionals around different pathways to share innovation and inform planning. There are more examples of DHBs providing specialist services for people in other areas where their local DHB is not able to meet demand.
But these developments are often in spite of the system, not because of it. We need to see cohesive and collective planning as the norm for many services.
Fourthly, digital services will provide more people the care they need in their homes and local communities. Digital technology must finally, after years of promise, become a key feature of the system for patients and professionals.
Digital technology is already a part of our everyday lives, and is increasingly becoming part of health services too.
We have already seen through the COVID response how many services were able to shift quickly to using digital platforms, without a reduction in quality of care. With the pandemic as the catalyst, we achieved greater transformation of digital services in a matter of weeks than we did in many years.
This shows what can be done – the challenge is now to build on this and take the opportunity to shift models for good.
If we get this right, the ways in which people access services will be more simple and more equitable, with greater innovation and choice for digital options bringing some services closer to homes than ever before.
People will have access to virtual diagnostic services, primary care and increasingly to more specialist services wherever they live – meaning that many unnecessary trips to hospitals and clinics can be avoided.
Throughout the system, proven technologies that improve care will be adopted faster and rolled out at scale.
And, finally, health and care workers will be valued and well-trained for the future health system.
I acknowledge our health workforce is feeling increasingly stressed, managing growing demand on services with limited resources. A key element of these reforms is helping to ensure we have enough trained people who are resourced to provide better services for our communities.
Long-term planning and funding will ensure the system has enough workers with the right skills to improve equity and meet the challenges of an ageing population. Across the system, professional groups will focus on the health and wellbeing of the population as a whole, and the shared values and motivations that underpin the system. Organisations will not compete for, but will work together on where and how skills are deployed for the benefit of the whole system.
You will notice, I’m sure, a few things that are common across these five shifts.
One of these common drivers is the desire to make the system work more cohesively and collectively, framed by a spirit of collaboration that sees one system delivering for all of New Zealand.
Another is the aim to promote wellbeing and quality of life, to reduce avoidable contacts with the health system, and to rebalance away from a reliance on hospital services, towards greater investment and access in primary and community services.
And finally, what they have common, is that in each case there are examples of these shifts already happening around New Zealand. Local leadership is already pushing at these changes. But often their efforts do not get recognised and cannot easily be scaled and implemented more widely. The opportunity we have now is to build from the best of the current system.
None of the shifts I’ve discussed are easy to achieve. This Government certainly does not underestimate the size or the complexity of the task.
Many of the challenges we face are not just specific to New Zealand but are being faced by health systems around the world.
Of course, we must maintain services for our communities as we transition to the future – and this includes delivering the COVID-19 vaccination programme in full as our top priority. The work of the health system every day is essential, and must be protected from disruption.
But we should not let this become a barrier to change – and we owe it to the dedicated health and care workers in our system and the wider public to make the transformation needed.
But I am convinced that the scope of our ambition is right, and that we have a real opportunity for meaningful change.
What I want to emphasise is the need for partnership.
In the coming weeks Cabinet will make decisions about the high level structural elements of the system.
But we all know government alone cannot achieve the change we need. To build a better health system will require input from and partnership with organisations, groups, professions, patients and whānau.
The hard work lies ahead in designing how the future system will work, the relationships and accountabilities, and the care models which people will experience.
The immediate need after Cabinet’s decisions will be engagement about how we get the details right.
Those in this room and watching on the livestream will be critical to the success of Health and Disability Reform.
I look forward to working with you to deliver change, and truly create the “one system” culture in our health services; one excellent system to meet the diverse needs of our small nation.
Kia ora tatau katoa.