Photo: 123rf
An official gauge of how the country's health reforms are going has found huge gaps of people, planning and resources that could undermine its success.
"There is not a sufficient understanding of the resources required for the implementation of the reforms," said a new progress report out on Friday from the Ministry of Health.
"There is general risk of there not being sufficient funding for specific reform initiatives."
Basic fundamental gulfs and grey areas persist 16 months into the country's largest-ever reform process, which was preceded by two years of transition planning.
However, two-thirds of system leaders believe the reforms are on track - and Director-General of Health Dr Diana Sarfati agrees.
"We need to keep going," Sarfati said on Thursday.
This came after her ministry released more than 300 pages of reform assessment documents to RNZ under the Official Information Act.
The progress gaps were risks that were being addressed, she said. The progress report was helpful for fixing them, though it was difficult in the country's fiscally tight environment, she added.
"Most of the [reform] initiatives were experiencing, or expected to experience resource constraints," especially of skilled people to implement them, the progress report stated.
Despite the time passed, the huge sums put in, and a restructuring that has claimed 900 jobs so far, the report identified fundamental omissions:
- "There is no integrated change management approach."
- "A key observation across the system is that planning is not sufficiently integrated."
- "There is no common, clear articulation of health reform intent and specifically how the government intends ... the health system to deliver."
- A lack of leaders skilled in large-scale change "poses a very significant challenge to the delivery of reform overall."
The fixes listed - a capability plan, a change management plan, a communications plan - are basics the public might have expected to be in place when Te Whatu Ora was set up.
At the coalface, the report judged it "is not yet possible to identify" how patients and their families were being impacted by the reforms.
"There are some indications that some services are improving there through a national system that is enabling patients to be referred and treated outside their region."
The question of who might fill what skills gap has not stopped Te Whatu Ora from restructuring areas covering 5000 employees, with 3300 facing some impact and 921 roles disestablished so far. The restructure is affecting core work, such as commissioning and how it gets non-hospital care delivered.
"Reviewing contracting arrangements to support new models of care and service by the end of 2023 is looking unlikely, due to the disestablishment of existing staff and the restructure of the... commissioning function, and due to the high volume of existing contracts (approximately 8000)," the report said.
"The scale of the task has meant that implementing the national commissioning operating model within Te Whatu Ora has taken longer than planned and there is still work required."
The report ranges across 50-plus pages, with not a scorecard or rating in sight, in contrast to the review of the Māori Health Authority Te Aka Whai Ora in August.
The new report has several references to initiatives "underway" or "progressing" but without any figures to shed more light. For instance, moves to improve planned care are "progressing" - but there is no mention that only three out of the 101 moves recommended had been completed by last month, while more than 70 are in the early stages or not actioned at all.
"As expected, at this early stage of reform, it is not yet clear that there are sufficient activities in place to achieve the objectives and system shifts," the progress report states.
Uncertainties abound around funding and integration.
The transition work never came up with a new way of funding health. That work was put off. Now the progress report identifies a "significant risk" that agencies' plans to secure multi-year in funding from the government will not line up.
"The focus is on addressing significant uncertainties identified in achieving a multi-year appropriation" by coming up with a 'roadmap' to give ministers and Treasury "confidence" for a big shift in 2024.
It has been stressed that not only must Te Whatu Ora, Te Aka Whai Ora and the ministry collaborate, but they must also work with other agencies like Pharmac and ACC.
Yet the progress report states: "The interdependencies, risks and opportunities with a tighter integration of entities into reform are not yet defined. Therefore, the level of integration required between the various entities is unknown and could result in unintended consequences."
The report found among health leaders:
- 70 percent believed the reforms' scope and success criteria were sufficiently clear
- half believed the reforms were adequately funded
- 70 percent foresaw risk with resources or with being ready to implement changes.
Dr Sarfati stressed it was a five- to 10-year process. Health reform on this scale was probably unique and people only had to look at the challenges Europe's health systems face to see there was no easy option, she said.
'Self-inflicted' wounds
A former director of the Association of Salaried Medical Specialists says the new health system's problems are more to do with its inherent structure than its current management.
Dr Ian Powell says the documents focus too much on the performance of Te Whatu Ora, Te Aka Whai Ora and the Ministry of Health, and not enough on the way the new system has actually been designed.
He said the report noted "implementation of new operating models and new models of care" were yet to come, 15 months after the new entities took control.
"One of the things that tells you is that this work was supposed to have been done by the transition unit that was established for responsibility for implementation, and this core work was not actually done."
"What happened here is to a large extent self-inflicted" - Ian Powell
He said relying on "business consultants" to do the work was a "recipe for disaster", but there was no going back to having 20 DHBs.
"The last thing the health system needs is further restructuring. It's got to find a way of actually making the structures work better.
"And I think that what it needs is first of all, to focus on the actual real issues that are affecting the health system at the moment: severe workforce shortages that we have that are affecting everything in both community care and general practices and in hospitals across the spectrum of health professionals.
"We have increasing acute admissions to hospitals - these are admissions that cannot be deferred, they are increasing at a rate greater than population growth, that's why we have overcrowded hospitals; and… the restructuring has led to a very corrosive command and control culture. The more you centralise in a very vertical way, the more that culture is going to emerge and that's what we have.
"So what it requires is primarily an immediate investment in the workforce backed up by action plans to implement that.
"And secondly, changing the culture of the organisation, devolving more empowerment - but not statutory, not restructuring - to the regions and the districts, because overwhelmingly health care is provided locally by our GPs, NGOs and in our local hospitals. There needs to be a greater level of decision-making at that level without actually restructuring."
Powell said the incoming "heir apparent" health minister, Dr Shane Reti, was "inheriting quite a crisis".
Ian Powell. Photo: Supplied
"There needs to be very strong signals from him that this culture of Te Whatu Ora has to change and that may well require changing the board.
"I'm not criticising the board, they're doing the best they can. But for a change of culture, you probably need new faces around that board to then provide some more greater direction to the senior management leadership of Te Whatu Ora."
Powell said the health system was also in crisis when Labour took the reins in 2017, but it failed to address it.
"The UK a good example of a terrible situation - but there are different drivers there. That's a level of austerity in the health system and incompetence, it's pretty unprecedented.
"But what happened here is to a large extent self-inflicted. When the Labour government came back and came in in 2017, at the end of that year, they already knew the system was in crisis and there was severe workforce shortages. They delayed and delayed and delayed and focused on restructuring, which distracted.
"And among other things, the absurd decisions that were made was to actually restructure the way health services are delivered and provided in the midst of Omicron. Now I struggle to find a decision that's more irresponsible and more incompetent than that."