The stunning election outcome led to the largely unexpected outcome confirmed on 1 November of both New Zealand’s first single party (Labour) majority government since mixed member representation was introduced in 1996 and a cooperation agreement, including two ministers outside cabinet, with a smaller party (Greens) which did better than expected. It is the first time in our proportional representation history that we have had such an outcome.
Opportunities under cooperation agreement
On 30 October I wrote about possible implications of Labour governing alone or with some form of cooperation agreement with the Greens. I argued that in relative terms, whereas Labour veered towards incrementalism, the Greens veered towards transformation. In the context of our health system these approaches could be blended provided that the Greens regained a more independent voice and was prepared to exercise it.
On 1 November right-wing political commentator Matthew Hooten writing in the NZ Herald (paywalled) praised Prime Minister Jacinda Ardern for this outcome describing it as a completed victory and a loss for the Greens.
I have a different view although much depends on the Greens themselves. The critical issue is whether the Greens can establish themselves as an independent voice capable where necessary of generating public noise on issues where either they disagree with Labour or believe Labour’s position is inadequate. The cooperation agreement allows for this.
No more is this important as the health system because of its impact on, and importance to, all New Zealanders. An effective accessible health system for all is at the core of social justice. In the outgoing government the Greens health voice was inaudible partly because of the coalition governing arrangement and partly because of too few MPs. Now they are not constrained by that arrangement and they have more MPs (and no shortage of talent).
The Greens need at least one MP to be allocated the prime spokesperson responsibility for health who should be sufficiently resourced. Julie Ann Genter has been a competent health spokesperson and outgoing associate health minister but health was always secondary to transport. Health is too important to be a secondary role.
First challenge for the Greens: end disruptive disruption
There is nothing more certain to distract and disrupt the ability of the health system to meet the health and wellbeing needs of New Zealanders than major restructuring. The Helen Clark government recognised this when it introduced the district health board system in 2000 – it extended the role of existing structures.
The Heather Simpson review of the health and disability system unwisely recommends massive and disruptive restructuring by increasing centralisation through the installation of both a much smaller number of ‘mega DHBs’ and an additional powerful new national health bureaucracy. A new authoritarian centralist leadership culture is the most likely outcome and guaranteed to lead to more systemic dysfunction.
Simpson allows for up to five years of upheaval without evidence that the health system will be any better as a result! And at a time when the country has a highly contagious pandemic swirling around the globe! Could there be a better scripted Baldrick clever idea in the Black Adder comedy? This is a rhetorical question by the way.
The first challenge facing the Greens should be to advocate the dropping of this restructuring and in order to focus on improving our health system processes.
Focus on improving processes and approaches
The Greens next need to focus on strengthening our health system by improving its processes and approaches. Most important is to publicly advocate reducing (with the objective of eliminating) social determinants of health. External to the health system, they include housing access and quality, educational opportunities, environmental factors, occupation, income level, food insecurity, racial discrimination and gender inequity. Unfortunately the Simpson review fails to give them the central focus they deserve.
The health system needs to operate nationally and at a DHB level to reduce social determinants of health because they drive so much health demand. This links into addressing our high level of unmet patient need (conservatively estimated at 9% of the population) which is significantly driven by these social determinants of health.
Health systems are not just about patient diagnosis and treatment. Population (public) health, which includes assessing healthcare needs, is also critical but has been under-valued. The Simpson review does get this right. The Greens should advocate that population health services should be significantly upgraded including investing in its workforce.
Managerialism dominates the leadership culture of the health system. It pervades the Health Ministry-DHBs relationship and within DHBs themselves in which management or bureaucracy is the driver and controller rather than supportive enabler. But much of the expertise on how to improve health services, including access, rests with the health professional workforce rather than management.
The Greens should advocate the empowering of this workforce through distributed leadership at all levels including the clinical frontline. They are the ones, more than others, who have the capability to improve the quality and financial performance of the health system (what makes good clinical sense also makes good financial sense). This means also addressing the severe workforce shortages (around 24% in the case of DHB employed specialists) with the inevitable consequences of burnout, fatigue and job dissatisfaction.
The Greens should call for ending the tunnel-visioned scandal where hospital rebuilds are not based on expert clinical and epidemiological advice and instead built for short-term capacity needs. In order to turn around the rundown state of public hospitals, we need a paradigm shift where job rich major capital works for environmentally sustainable longer-term rebuilds form a central part of the Government’s Covid-19 infrastructure fund.
Continuing patient co-patient payments for general practitioner consultations should end. They are a barrier to both access and the further development of health pathways between community and hospital care. This is a bread-and-butter issue for the Greens to promote.
The Labour-Greens cooperation agreement provides the Greens with the opportunity to forcefully advocate first dropping the disruptive bureaucratic restructuring and then get on the front foot for moving towards transforming our heath system’s processes and approaches. The non-rhetorical question is whether they can seize the moment.
Originally published here.