Hīkoi for Health: A People’s Inquiry

— protesting the current state of the New Zealand health system

by Dr Glenn Colquhoun and Dr Art Nahill

The NZHS (New Zealand Health System) has been damaged by years of poor political management. A succession of governments over the last 25 years have been responsible for this. They have failed to display vision and leadership. None have made adequate plans to maintain or grow the necessary workforce and infrastructure required for the NZHS to function well. They have turned it into a political football. They have lost sight of its mauri and its connection to us. Our political process is at the heart of this dysfunction. It is at odds with good stable management of a health system. The people of New Zealand deserve better.

The NZHS should be uplifted from politicians. It is a national taonga that is too important to be abandoned to sectarian self-interest. The political process has shown no care for it. And no understanding of its mana. It should be redesigned and run by patients and clinicians with real world experience of the health system. It should make use of sound social science and medical expertise. It should make use of proven management principles. Māori should be permanently represented at a governance level. It should be led with heart and head. Governments should not be able to alter policies set by a new governance board once it is re-established unless > 75% of MPs vote for such change.

What are our key criticisms of the New Zealand health service?

The poor state of the current NZHS is due to a number of factors:

• The neglect of the primary care health system: GPs are retiring faster than they are being replaced. An overwhelming number of the population are unable to access timely appointments with their primary care health service. This in turn overloads the secondary care health system.

• Poor health workforce maintenance and development: Many doctors trained in New Zealand leave the country and practice medicine overseas. The NZHS relies on importing doctors to meet its needs. The creation of a private health care system draws doctors away from the public health system. This creates a two-tiered health service where those who are able to can purchase private health care. Those who cannot afford it are forced to rely on an increasingly threadbare public service. Situations occur in which there are too few staff in primary and secondary health care settings but due to chronic underfunding of health care graduating health professionals are unable to get jobs.

• Changing demographic patterns in New Zealand: The baby boomer generation are now 60 years of age or over. This swells the health care needs of the population and places extra demands on both primary and secondary health care systems at a time when they are particularly understaffed. Successive governments have been warned about this coming crisis for 25 years and have still failed to deal with it.

• A failure to come to grips with key public health crises: These include obesity and diabetes epidemics, poor health outcomes arising from the abuse of alcohol, and the exposure of children to adverse childhood events (ACEs). These issues drive significant rates of avoidable health problems for many New Zealanders. Having brave and well thought out plans to deal with them would greatly reduce the load on the NZHS.

• Increasing economic inequality: Wealth distribution in New Zealand is a driver of poor health. 50% of New Zealanders own 98% of the wealth in our county. The other 50% share the remaining 2%. Developing ways to ameliorate this disparity would lead to better health outcomes.

How could things be better?

We do not want to simply criticise the NZHS. We are mainly interested in finding solutions to its problems. We believe that it is time to be innovative and courageous in dealing with the current health crisis. An important goal of the protest is to stimulate debate and encourage others to offer solutions to the problems experienced by the NZHS. With that in mind we propose the following:

• The NZHS should be redesigned. The country should be divided into local primary health hubs. These would be matched to population distribution and serve 10,000 to15,000 patients each. Most small towns in New Zealand could be serviced from a single hub. Cities would be serviced by urban and suburban hubs. These hubs would provide access to all people entering the health system. Each hub would be staffed by a team of healthcare workers including GPs, community health workers, nurses, midwives, physiotherapists, pharmacists, psychologists and social workers. They would work as a team so that a patient’s total health needs would be easily assessed and addressed in the same place. The hubs could also house laboratory and radiology services. Staff at the hub could also help patients access appropriate services that would assist with any income, employment, education and housing needs. Patients with complex health needs would be case-managed. The hub team would also have time available to construct a profile of their community so that they might deal with any public health problems within that area, as well as identify any vulnerable families with potentially high healthcare needs. Staff skilled in building connections with these families could make ongoing links to the individuals within them. This profile could be supported by monthly meetings with representatives from local schools, police, Oranga Tamariki and WINZ. The hubs would be representative of their local community and in touch with it. If patients move out of their hub area, their care would be actively transferred to a new hub in the region they shift to, and the transferring hub would follow up until they had made contact with that new service. Secondary healthcare services would also be located throughout the country, and also represent its population spread, with special allowance for rural areas. These should offer ED services, in-patient care and specialty clinics, and help to support a number of primary-care hubs. A single computer-based system for medical notes would also be available to clinicians in primary and secondary care throughout the country. The Ministry of Health should develop a national set of evidence-based protocols for the management of common medical presentations. This would help best practice across the country. Projection of population growth over the next 10 to 20 years should guide the construction and staffing of the hubs and secondary-care facilities.

• Given the current crisis in primary care a redesigned NZHS should develop and train a new workforce of community health workers (CHWs). This workforce would be drawn from people who are already committed to local communities. They would be trained to manage common presenting problems in primary care and work under the supervision of a GP. They would be trained on the job using an apprenticeship model and rotate at times through their local hospitals to help gain experience in the health care conditions they would see and manage. The could treat simple acute presentations as well as manage chronic conditions. They would be guided by clear nationwide protocols for each presentation and work under standing orders which would give them the ability to prescribe a range of common drug treatments. They would be responsible for a number of patients and build long term relationships with them. GPs and CHWs would then be under the guidance of an experienced specialist team in the local hospital to facilitate easy review and management of escalating illness and to avoid the inappropriate use of EDs. These units would essentially form a wedge of care from hospitals to hubs to homes in any given city or district throughout New Zealand. It takes up to 14 years to train a new GP workforce. A workforce of CHWs could be up and running within the next 5 years.

• Greater rates of graduates entering and staying in the primary care workforce could be achieved through bonding and debt forgiveness schemes for medical students, as well as higher rates of pay for GP trainees and registered GPs, particularly for those choosing to serve in remote and rural areas. We must significantly improve the remuneration of GPs relative to other medical specialties in order to entice and retain quality people into this critical workforce. The number of training spots available in New Zealand should be adjusted based on projected workforce needs, allowing for proactive management of shortages. By aligning training positions with anticipated demand, the system can ensure long-term sustainability and prevent an oversupply of trainees in specialties where they are not needed.

• It is crucial that a redesigned NZHS develops robust plans to deal with the primary public health problems of our age. These are needed to increase the overall well-being of our population — as well to decrease the burden of ill health presenting in the health care system. These problems include the obesity and diabetes epidemics, poor health outcomes resulting from the abuse of alcohol, the burden of adverse childhood events, and the growing economic inequalities in our society.

• It is important that a new NZHS has a conversation with the general public about the escalating cost of health care in New Zealand. A problematic cycle has been created by the development of more and more expensive medical technology that within a generation come to be expected as fully funded treatments by the general population. This makes health care more and more expensive and eventually unaffordable. This conversation might ask the following questions: What core medical services should be fully funded in New Zealand? Would it be better to spend the bulk of our health dollar on young people and children to ensure good child health that then flows on into adulthood? What is the role of private health care in New Zealand? Should ACC be expanded into a general health insurance company to fund more elective procedures in New Zealand — such as joint replacements and CABGs? Should another compulsory health insurance scheme take it’s place?

• Current political process work against good medicine. It is time for new thinking and imagination. Health care reform must be addressed urgently and must stop being fodder for political squabbling. With those thoughts in mind we need to marshal the best minds from across the stakeholder spectrum to design, implement, and evaluate a healthcare system that can deliver cost-effective and equitable care of the highest quality. We must move ahead with healthcare reforms based on data, consensus, and long-term vision. We also believe it is important that people of all walks on life throughout New Zealand be given the opportunity to have their say about how they would like the NZHS to look. This could be achieved by establishing a submission process the general public could access as well as via a number of nationwide hui to gather those thoughts. A core goal of our protest is to stimulate an alternative vision of health care in New Zealand to the one that is currently brain dead.