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Dunne Speaks: Back To The Future Health Reforms?

At first glance, there is a strong back to the future flavour to the government’s just announced health sector reforms. National in the 1990s abolished elected area health boards and replaced them with a single national Health Funding Authority, supported by four Regional Health Authorities, reporting to the Minister of Health through the Ministry of Health. Labour in turn in the early 2000s abolished that structure and returned to elected district health boards. Now, Labour plans to overturn its own model in favour of a new national health authority, Health New Zealand, with four regional divisions, reporting to the Minister of Health through the Ministry of Health.

The irony of this will not be lost on long-term observers of the New Zealand health system. It goes deeper than just the structural changes. When Labour upended the previous model in the early 2000s, amongst the primary officials driving change were Heather Simpson, the then Prime Minister’s chief of staff, and Stephen McKernan, Director-General of Health from the mid-2000s. The latest health changes which unwind the system they set up emerge from a task force led by Heather Simpson, with Stephen McKernan leading the implementation unit responding to the taskforce’s recommendations.

However, this is not to say that the new reforms are merely a carbon copy of the system in place over 20 years ago. While the structures look broadly identical, there are some significant changes to take note of. 
Whereas National’s 1990s changes were about driving better efficiency through controlling costs, the current changes seem more about removing duplication and inefficiency and driving policy more directly from the centre than has been the case in recent years.

There is also the added dimension of the independent Maori Health Authority. Conceptually a good idea, its challenge will be, like Whanau Ora has faced in social services provision, to maintain the freedom to promote “by Maori, for Maori” solutions without heavy-handed bureaucratic intervention concerned that it might be going “too far”.

The re-establishment of a new separate Public Health Agency has been long signalled. However, some aspects of it raise concern and are probably worthy of further consideration before final decisions are made. For example, while it is perfectly understandable that in the wake of the pandemic a group be established to oversee current and future pandemic preparedness plans, it is questionable whether that should be within the narrower focus of the Public Health Agency or more broadly based. One of the criticisms of the current pandemic approach, especially as we begin to move to a post-pandemic phase, is that continued sole focus on a public health approach is too narrow and inflexible. It may therefore be more prudent to establish a dedicated multidisciplinary separate pandemic response team outside the Public Health Agency, but able to work across the full health sector and the machinery of government as a whole.

Similarly, the plan to absorb the Health Promotion Agency within the new Public Health Agency is problematic. When the Health Promotion Agency was established to replace previous stand-alone agencies like the Alcohol Advisory Council and Smokefree NZ, there was criticism that this could impact upon the credibility of the public health messages being promoted. Public health messages coming from an overtly government agency always look far more authoritarian than when promoted by stand-alone bodies. The complete absorption of the Health Promotion Agency that was just starting to find its own feet after several years, into the Public Health Agency might lead to a very Orwellian, counter-productive approach to future public health promotion.

The government may well point to the response to the “official government announcements” we have been subject to on Covid19 over the last year in defence of this move. However, that would overlook the fact those messages have become more easily discounted as time has gone by. More worryingly, they have become less about purveying information and more about pushing propaganda. While that may have been fine for the Covid19 response, it is unlikely to work over the longer term on more broad public health themes like healthy living, diet and exercise. The last thing people will take kindly to or treat seriously is government dictums about what they should eat and when they should exercise!

There is plenty of time over the next two to three years to iron out some of these wrinkles as the new system is put in place, and the government should seek to work closely with affected communities accordingly.

However, there is one over-arching aspect to this reform which it is difficult to escape. This is fundamentally a statement of Labour philosophy about the role of government in the delivery of health and social services. At its heart, Labour believes that the primary responsibility here lies with central government, and that community initiative, let alone personal responsibility and self-management, come a distant second. The health reforms are a clear statement of that belief.

It is no coincidence that the heavy centralisation inherent within them mirrors similar recent moves in the education sector to centralise more control in central agencies like the Ministry of Education, at the expense of school boards of trustees. Likewise, performance failures in aspects of local government as well as new emerging responsibilities in water management, and forthcoming changes to resource management legislation make it virtually inevitable that major local government reforms, including perhaps a streamlining and further reduction of local authorities, lies ahead.

While the health reforms are being promoted as a necessary response to a system that is failing they are also a strong reminder that this is probably the most fiercely ideologically flavoured Labour government since the 1970s. That alone will make for an interesting public response.

MY SECOND WEEKLY COLUMN IS ON NEWSROOM.CO.NZ

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