It is rare to get excited about institutional reform, but the government’s announcement of wholesale changes to the health system has the potential to be transformative.
The restructure comes in response to last year’s Health and Disability System review. Among other changes, it will create a centralised organisation, Health NZ, which will replace 20 district health boards and take responsibility for the day-to-day running of the health system.
History of public health
New Zealand’s national health service goes back to the vision of former Labour prime minister Michael Joseph Savage, best remembered for his landmark “cradle to grave” social welfare reforms, especially the Social Security Act 1938.
The health system was legislated a decade before the UK’s NHS. It provided for universal healthcare with publicly funded hospital treatment, free medicines, a maternity benefit and subsidised doctor’s visits. It sought to make healthcare free for all.
Fierce opposition by general practitioners at the time resulted in them being given the right to charge patients for their services. But over time, the level of user charges created a significant barrier to access to primary healthcare for poorer New Zealanders.
New Zealand now has a chance to finally develop a more constructive relationship with general practitioners and seek to resolve the problem of access, this time with a partner Māori health authority to honour obligations under the Treaty of Waitangi. This could begin to resolve health inequalities.
General practitioners have applauded the reform. If the new NHS-type crown entity and the Māori health authority can collaborate in a way that truly engages general practitioners, this could be revolutionary.
Comparison with England
My comparative research into health disparities and their many drivers compared GP services in New Zealand and England between 2004 and 2014, when both were responding to a new national pay-for-performance scheme designed to improve quality of care.
It was abundantly clear that the close partnership of general practice and the NHS in England, which reduced variations in care quality related to deprivation, was the secret weapon in reducing health inequalities in that country. There were continuous improvements in life expectancy until 2011, although progress has now stalled as a result of austerity-based policies.
By comparison, New Zealand’s pay-for-performance scheme made only small, albeit promising, progress towards reducing admissions to hospital for conditions that should have been treated in primary care, before it was abandoned in 2017.
This shows why New Zealand needs the kind of institutional reform the government has proposed.
We can look at the prevention and care of diabetes as an example. In 2018, English academics reported on a successful trial of a prevention programme which delivered interventions compliant with best practice nationally to attack the onset of diabetes.
Through close partnership with its general practitioners, England has gone on to attack major health issues such as diabetes more effectively than New Zealand.
Through a single central contract with all general practitioners, NHS England provides financial incentives to deliver best practice diabetes diagnosis, prevention and care (along with incentives linked to many other conditions).
General practitioners are rewarded with additional payments where their care of patients meets these nationally agreed quality standards and their practice data provides evidence for this.
New Zealand could build similar partnerships with general practitioners to tackle our most costly and debilitating health conditions through a centralised approach. This has the potential to bring better healthcare to every New Zealander — and this is worth getting excited about.