What about a “worthy” document? Worthy means having adequate or significant merit, character or worth. In the context of a document, it can mean deserving of praise.
However, in the context of the healthcare system, particularly one in which corporate consultants have been influential in its design, another word comes into play: satire. That is, the use of irony, sarcasm, or ridicule to expose the document as less than ideal, or worse.
Charters in health systems are not new. They can also be global. The World Federation of Public Health Associations, for example, has a global health charter that was developed with the World Health Organization.
This global charter provides an overview of public health direction and guidance for ‘services’ (protection, prevention and promotion) and ‘functions’ (governance, advocacy, capacity and information).
Public Health Associations Global Health Charter
However, this charter concerns the state of health of populations rather than the quality, exhaustiveness and accessibility of the diagnosis and treatment of patients.
The “New Zealand Health Charter: Wow!
So will the New Zealand Health Charter – established under the Pae Ora (Healthy Futures) Act 2022 which now governs Aotearoa New Zealand’s healthcare system – be praiseworthy or deserving? satire?
This is one of the key features of the legislation introduced by Health Minister Andrew Little. At least one health union (the Association of Salaried Medical Specialists) has high hopes in its power to change the game for a better health care system.
The health charter one of the features of Andrew Little’s Pae Ora Act
Section 56 of the Act states that the purpose of the Charter is to support the achievement of the “Health Sector Principles” described in Section 7. With particular emphasis on equity and (but not exclusively) on Maori, these principles include access to services; commitment to developing and delivering services and programs; choice of quality services; and protect and promote the health and well-being of people. All highly commendable, albeit abstract.
Section 57 goes on to state that the Charter is a statement of the values, principles and behaviors that Health New Zealand (Te Whatu Ora) and the Māori Health Authority (Te Aka Whai Ora), together with other health entities , are expected to adopt. demonstrate. Those working in the health system are also expected to demonstrate this, both collectively and individually.
Section 57 of the Act states that Health New Zealand and the Māori Health Authority are responsible for facilitating the development of the Charter. They have obligations of engagement with other health entities, organizations and workers involved in the provision of publicly funded services, organizations that they consider representative of the interests of workers who work in the health system ( presumably health unions) and professional Maori health organizations.
The Charter becomes official when, after this process, it is endorsed by the Minister of Health. Section 58 of the law requires that it be reviewed at least every five years by Te Whatu Ora and Te Aka Whai Ora.
The former territory of Helen Clark
This will not be Aotearoa’s first health charter. Back then – on December 14, 1989, to be precise – a health minister named Helen Clark officially announced a national health charter. It was the days of the regional health boards, which were relatively new organizations.
These councils marked a significant change in the provision of health care capable of covering both hospital and community care. Indeed, they were the forerunners of district health boards, which came into being in 2001.
However, the regional health boards were quickly replaced by a competitive health system driven by a business model under the elected national government less than 12 months later.
But this 1989 charter gives an indication of what a charter might look like, even if worded very differently to represent the health care system 33 years later. It begins with an objective as a charter should.
This objective was to “…maintain a nationwide public health system with the overall aim of protecting and improving the health of New Zealanders”. This meant that the provision of essential health care had to be “universally acceptable” (rather odd wording today, but one that made sense at the time).
Next, the Clark Charter went to principles, including respect for individual dignity, equity of access, community participation, disease prevention and health promotion, and efficient use of resources. All commendable and a step up from the system that preceded regional health boards.
Finally, there was a series of health care goals, including a strong focus on population health. They included:
- reduce smoking;
- improving nutrition;
- reduce alcohol consumption;
- reduce preventable death and disability from motor vehicle accidents;
- reduce the prevalence of high blood pressure;
- reduce hearing loss in children under five;
- reduce preventable disease and death from heart disease and stroke;
- reduce both the incidence of invasive cervical cancer and the mortality rate from cervical cancer; and
- reduce the incidence of skin cancer and the mortality rate.
All of this is commendable, with a notable emphasis on prevention and protection (population health) rather than treatment (personal health). Unfortunately, after 1990, the regional health boards focused on preparing for their abolition, which took place on July 1, 1993.
There was no opportunity to assess the effectiveness of the charter. Although it is impossible to know, it is reasonable to assume that the extent to which it could have been operationalized is arguably the extent to which the health system could have been in a much better space than it was. ‘is actually.
Contrast 2022 with 1989
What does this mean for the health charter of the Pae Ora law? The years 1989 and 2022 couldn’t be more different times.
On the one hand, surgery has become much less invasive, allowing shorter hospital stays for planned surgery; treatments have improved considerably with new drugs; emergency medical specialists have become the cornerstone of emergency services; and general medicine gained specialist status through professional registration.
On the other hand, the social determinants of health, such as low income, poverty and substandard housing, have worsened, thus increasing the demand and cost of health care. Successive governments have neglected the welfare of health workers to the point of creating severe shortages that have left them teetering in a state of crisis and carnage.
The culture and design of the health system are also fundamentally different. In 1989, it was recognized that a level of statutory decision-making should reside locally, where the vast majority of health care delivery took place. Commercial consultants had minimal involvement in the design of the regional health boards (as was also the case with the DHBs).
We now have a health system with a vertical structure and considerably increased centralization. Decision-making is more top-down and, with the removal of DHBs, even further from the point of delivery. Also, unlike in the 1980s and early 2000s, business consultants were instrumental in shaping the design and decision-making culture of the new system.
Integrate with Workforce and Onboarding
For a health charter to have meaning for 2022 and beyond, it must incorporate recognition of the central role of health professionals in the quality and accessibility of the health system.
This workforce is the main source of innovation and continuous improvement. He must be empowered. But this is hampered by worsening severe shortages.
To be meaningful, a health charter today must also incorporate the importance of improving the integration of the patient journey between community and hospital care. The more this is done, the better the health of the population and the less pressure on the health system. It also means improving the cost-effectiveness of the health system.
However, in what we have seen so far of the design of the new health system and its leadership culture, these are the elements least likely to appear or be highlighted in the next charter.
Therefore, the most likely description of it will be satirical. If I’m wrong, I’ll eat my keyboard (that is, metaphorically).
[This is an amended version of my column published in NZ Doctor on 12 October 2022]
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