Fri Apr 19

Why the government’s haste in changing the health system could come back to haunt it

Written by Tim Tenbensel, Associate Professor, Health Policy, University of Auckland, Waipapa Taumata Rau

Since coming into power, the coalition government has adopted a simple but shrewd see-how-fast-we-can-move political strategy.

However, in the health sector this need for speed entails policy risks that could come back to bite the government before the next election.

The biggest such risk comes from the disestablishment ^[1] of the Māori Health Authority-Te Aka Whai Ora. This required an amendment to the Pae Ora Act ^[2], pushed through under urgency ^[3], to remove all references to the Māori Health Authority and its relationships with other entities from the law.

Unlike other law changes (such as the repeal of New Zealand’s smokefree law ^[4]), the dismantling of the Māori Health Authority had been clearly signalled during the election campaign and in the coalition agreements.

Few people doubted the government would follow through. But it has exposed itself to unnecessary risks and the speed of change could become a liability.

More health sector confusion

There was no practical need for the amendment to be passed under urgency, without the scrutiny of the select committee process.

This approach may provide an electoral sugar hit for the coalition parties, but it could also sow the seeds for practical and political difficulties in health policy later in the parliamentary term and beyond.

While the parts of the act referring to the Māori Health Authority have been excised, the act retains its primary focus on reducing health inequities. The planning, reporting and accountability requirements still reflect this policy direction.

To date, health minister Shane Reti has avoided using the words “equity” or “inequities”, instead preferring a generic focus on improving health outcomes, including for Māori. But the planning and decision making mandated under the legislation still require government health agencies to address health inequities.

The amendment has also delayed the establishment of “localities” – 60 to 80 local networks of government and community health organisations that co-design and deliver community-based services. Under Pae Ora, all regions were to have localities established by July this year and plans produced by July 2025. This timeline has now been pushed out by five years.

The government may well decide to make further amendments to Pae Ora, but in the meantime, the gap between its rhetoric and the policy priorities embedded in the legislation creates an existential bind for the Ministry of Health and Health New Zealand Te Whatu Ora.

Many structural changes introduced by the former Labour government in 2022 remain. Despite having misgivings about the re-centralisation of the health system, the government has not reversed the merging of 20 District Health Boards into Health New Zealand.

Minister Reti has also indicated that iwi Māori partnership boards ^[6] will have a significant role in the health system. But with the removal of the Māori Health Authority and hitting the pause button on localities, it is not yet clear what this role will be.

People waiting in hospital emergency department

Health targets, such as reducing the time people have to wait in emergency departments, were first introduced more than a decade ago. Shutterstock/Medical-R ^[7]

Health targets rebooted

Other changes resemble initiatives introduced during the last National-led government in 2009, including specific health targets.

The health targets involve specified performance levels, such as ensuring that 95% of patients visiting emergency departments are seen within six hours.

When these targets were last tried during the 2010s, some reported improvements such as fewer deaths in emergency departments were real ^[8]. Others were achieved by gaming the system ^[9].

Examples included falsifying data (stopping the clock) of when patients left the emergency department and placing untreated patients in short-stay units which were not subject to the target. We don’t yet know how the government plans to avoid such unintended consequences.

The government’s funding boost for security guards in emergency departments was temporary. Shutterstock/ChameleonsEye ^[10]

In another policy change, the government allocated NZ$5.7 million of temporary funding late last year for hospitals to contract more security guards in emergency departments ^[11]. This was to address the growing problem of violence and aggression towards doctors, nurses and other emergency department staff.

But this is another example of a PR-driven approach. This earmarked funding has now ceased. Health New Zealand bears either the cost of continuing to fund security guards or the reputational risk of their reduced presence.

Other policy items include the expansion of the maximum age of eligibility for breast cancer screening from 69 to 74 and the commitment to develop a plan toward establishing a third medical school at the University of Waikato.

Both these policies will have reasonable support within the organisations responsible for them. But the extension of breast cancer screening will face challenges of workforce capacity and the rollout will be gradual.

Progress to date on the third medical school is the signing of a memorandum of understanding between the government and the university. If it goes ahead, it won’t have any impact before the mid-2030s.

The government may have already dented minister Reti’s chances of building positive relationships with health sector leaders and interest groups. The Māori Health Authority had widespread support from health sector groups ^[13]. Alongside everyone else who had a view or an interest, these groups had no opportunity to have input on its disestablishment.

Along with the health sector groups’ vocal opposition to the u-turn on the smokefree legislation and the looming prospect of budgetary austerity, the coalition government has arguably already created a rocky relationship with the sector.

While governments often draw criticism from the health sector, few have done so quite this rapidly.