A recent column was concerned that the next health system redisorganisation was about centralising control, without adequate accountability, rather than about how to provide better health care. There has gotta be a better way.
The New Zealand Health and Disability System Review (Simpson report) proposes fewer District Health Boards in order to increase Central Government’s control. I would go for five, but for entirely different reasons. Much medical treatment is both becoming more specialised and evolving rapidly. That suggests that hospital care needs to be built around advanced medical centres (say medical schools) attached to a base hospital. There is sufficient room in New Zealand for only five such centres – say in Dunedin, Christchurch, Wellington, Hamilton and Auckland.
The five centres might be thought of as ‘tertiary’ medical centres and would offer levels of care that the hospitals away from the base are unable to. You would not want to have your brain surgery in a hospital which is servicing 50,000 people.
Even a single specialist in a smaller hospital has difficulties. Take a sole-practising pediatric oncologist. There will be other oncologists in the hospital who give some support, but the consultant needs to be interacting with other pediatric oncologists to share experiences and to keep up with new developments. Moreover there is no simple provision to give the specialist cover if he or she wants to go on holiday. (In one instance a hospital snaffled a couple of specialists, but they were married and wanted to go on holiday together.) So there needs to be a pediatric oncology (or whatever) network across a number of hospitals with a tertiary hospital to coordinate and provide the cover.
Such collegial networks exist (although they do not systematically provide cover). The significance of this proposal is to build a secondary health system which strengthens such co-operative arrangements.
Even so, there has to be considerable independence for each local hospital. It is worth recalling that while the health redisorganisation of the early 1990s was focussed on competition and privatisation, there was also a concern that some areas were suffering from a lack of attention from the central hospital. A positive reason for separating Middlemore Hospital from the Waitemata (Auckland) hospital system was that South Aucklanders’ health were being neglected. (There was also the mad idea that the two would compete for government funding.)
Once more, we have run into the problems of centralisation neglecting the periphery, albeit this time at the supra-regional, rather than national, level. To restrain the worst effects we need local accountability.
Recall that the Simpson report proposed an accountability via the Minister of Health and parliament. (It has been commented that the extra central layer of Health New Zealand between the Ministry of Health and the District Health Boards will reduce parliamentary accountability.)
Instead introduce local accountability by extending the notion of hospital visitors to community committees which would not be concerned with the management of the hospital (which is the responsibility of the centrally appointed boards) but with the quality of the care. There is no need for these ‘visitor’ committees to match the boards; rather, there could be one for each locality.
Oh, I know that centralists will hate this arrangement, but when did they ever think accountability and local democracy relevant?
There are at least two issues this proposal does not yet address – but neither did the Simpson report. The first was how the just-established Cancer Control Agency should fit in. It has to be a national institution working with the professional networks described earlier – probably already is (keep away from generic management and there is a lot of cooperation in the public health system). There may be a place for similar agencies on other key issues; the disability support community is unhappy with the Simpson proposals.
The other issue is about what the Simpson report calls ‘first tier’; most of us think of it as the general practitioners, residential care and everything in between. It is no good saying they should be better integrated as if this will resolve the problem. We have been saying this for almost a century.
In addition to the proud independence of GPs (and, yes, you value that independence because you do not want the Minister of Health interfering with a consultation), the ‘tier’ is very heterogeneous. As well as offering a multitude of very different services, there are regional differences – a rural GP may work part-time in the local hospital. The integration needs to proceed organically, based on local experiments rather than imposed from the top. The design problem has not been given enough priority in the past. Hopefully the local visitor committees will demand the DHBs focus more on this.
Implementing the Simpson report may seem some distance off. The Covid crisis continues to be a focus, there is an election soon, after which we shall have a new Minister of Health. (Whatever the election outcome the current minister, Chris Hipkins, cannot indefinitely carry the portfolio burden, given his other responsibilities.) However, it is possible that the centralists have lit a fire out in the regions and some people will vote to preserve their local hospital. Too often they overlook that the real problem is not to have the edifice of a hospital, but to have high quality health care when they need it.