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GUEST BLOG: Ian Powell – A prime minister and health minister unresponsive to a best effort

I have expressed my concerns in these posts and in other media about the government’s decision, without a mandate or engagement with the health sector, to abolish District Health Boards (DHBs) in the health system. Aotearoa Public Health in New Zealand (thus abandoning the long-standing democratic principle of subsidiarity between central and local government).

I also expressed my concern over the government’s growing drift towards a laissez-faire response to the pandemic since last October.

On February 2, I mixed the two concerns in an email to Prime Minister Jacinda Ardern, saying it was dangerous to dissolve DHBs in the midst of a pandemic. These concerns then escalated dramatically with the onslaught of the highly transmissible Omicron variant.

In addition to plunging our health system, both community and hospital, into crisis, it has led to a massive increase in mortality; from around 50 before this year (over 21 months) to nearly 600 more deaths so far this year.

Email to PM

Below is the text of my email:

Dear Prime Minister

I am writing to you regarding the decision to abolish DHBs by July 1, as provided for in the Pae Ora (Healthy Futures) Bill currently before Parliament. You probably know that I was Director General of the Association of Salaried Specialist Physicians from April 1989 to December 2019.

It has given me the opportunity to observe and analyze several restructurings in Aotearoa, including the one that I consider to be the best and most effective, the Public Health and Disability Act 2000 which established the system district health boards.

During this job, I also had the opportunity to look at healthcare systems internationally, including the UK, Germany and other parts of Europe, Australia and the United States. It also allowed me to meet and dialogue with the OECD, the WHO and the World Medical Association.

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You may know that I am currently an independent health systems commentator and blogger. What I did post includes issues relevant to what I discuss below.

For the avoidance of doubt, I am not opposed to the entire Pae Ora Bill. I strongly support the proposals to establish both the Maori Health Authority and the new Crown Public Health Agency. Either way, these have been discussed and advocated in various forms for some time. They didn’t come from left field. The latter was not included in Heather Simpson’s review of the health and disability system, but the need for a public health agency has been discussed and debated for many years. In both cases, the argument is not new and their time has come.

The same cannot be said for DHB suppression. It was not part of Labour’s 2020 election manifesto (quite the contrary) and was not recommended by Simpson’s review. Its announcement last April came as a complete surprise, and the public had no opportunity to engage or seek a mandate (the restrictive parliamentary process for the bill falls far short of that threshold).

It is important to recognize the role and purpose of DHBs. I say this as someone who has been more critical than most of some of their actions over two decades. The creation of DHB meant for the first time the creation of statutory bodies responsible for the health and welfare of geographically defined populations and integration between the community (including general medicine and residential care for the elderly) and hospital care. [area health boards gradually established in the mid to late 1980s also had this objective but had insufficient time to develop it before being abolished by the National government in 1993]

This full responsibility across the health spectrum has been a strength of our public health system since 2001. This includes the obligation to “regularly investigate, assess and monitor the health status of its resident population”. Structurally, this has given New Zealand significant advantages over many other modern health systems where, for different reasons, community and hospital care are much less integrated as they are more structurally separate.

The greatest difficulty has been uneven and inconsistent national leadership (structurally and politically) to ensure the necessary level of national cohesion. Much good has been achieved but much more potential unrealized. The responsibility for this lies much more with the central government than with the DHBs.

In my assessment, DHBs have come under unfair criticism for managing the vaccine rollout. But I have looked closely at the international data which confirms that they have been very successful. Our full vaccination rate is one of the highest in the world. It was even higher than the European Union which had the enormous advantage of being able to both negotiate as a powerful collective bloc with the monopolistic pharmaceutical companies and to have vaccine-producing countries among its members.

The particularity of having statutory local structures responsible for geographically defined populations has proven to be a major factor in this success. Although they had no control over the supply, DHBs were able to offset our big disadvantage as a small economy far from vaccine-producing countries.

Unfortunately, earlier in the rollout, some DHBs were criticized. But the fact is that the comparative achievements of DHBs have been ranked according to the size of the workforce and population density. The larger the DHB workforce and the denser their population, the sooner they reach vaccination milestones. These were the DHBs with a smaller workforce and lower population density due to rural communities which were comparatively slower.

As you well know, the omicron effect will put the entire country’s healthcare system under unprecedented dangerous pressure, especially our public hospitals. The impact will no longer be confined to one region. Transmission will be too high and too fast to prevent the increase in hospitalizations. This will likely increase death rates.

Hospitals are also likely to be mired in a “long covid” where the effects of the virus continue for weeks or months beyond the initial illness. This will leave our public hospitals unable to do anything but do their best for Covid-19 patients (unfortunately with trade-offs). This situation is compounded by an already overworked and tired workforce. It’s much more likely than not that omicron won’t be the last Covid-19 variant this year. Some of its successors will be less virulent and others more virulent.

As you can see from my comments above, I think abolishing DHBs is wrong and will be counterproductive. The loss of statutory bodies that are familiar with their defined populations compared to a national body (with or without regional branches) will reduce the efficiency of the health system. It is compounded by the fact that there are few ideas other than “prototypes” of what will replace the community care functions of the DHBs.

But, on top of that, doing this during a pandemic is dangerous. It’s dangerous for patients, for those who work in the health care system (especially those involved in treatment), and it’s electorally dangerous.

I urge you to reconsider this decision. I’m sure it could be conveyed with integrity in a way that wouldn’t feel like pushback. In fact, the structure of the DHBs is well placed to better contribute to the effectiveness of the Maori Health Authority and the Crown Public Health Agency.

I appreciate that you are far too busy to discuss this directly with me further, but if any of your advisers or someone else on your behalf would like to do so, I would be happy to do so…

Good for you

Ian Powell

Not even a compilation of sound bites from the Minister of Health

I received a prompt and courteous acknowledgment from the Prime Minister’s Office that this email had been forwarded to Health Minister Andrew Little who would respond to me directly.

Needless to say, nearly three months later, there has been no response from the minister; not even a brief compilation of sound clips. Well, I tried. I have no sense of outrage because I had no sense of expectation. Back to the blog.

Ian Powell was executive director of the Association of Salaried Medical Specialists, the professional union representing senior doctors and dentists in New Zealand, for over 30 years until December 2019. He is now a health systems commentator , labor market and political living in the small river estuary community of Otaihanga (the place by the tide). First published at Second opinion of Otaihanga