Steven Joyce: Government prescription won't cure health system

The old top-down approach to managing health needs to change. Photo / Sylvie Whinray

OPINION:

There's been no shortage of headlines this week documenting the struggles of our health system in coping with the Omicron outbreak. There has also been no surprise in those headlines.

The outbreak itself has not yet put massive pressure on hospital admissions. The hospitalisation rate of this variant of Covid-19 is low, although not negligible. The numbers are boosted by asymptomatic people who happen to test positive for Omicron while in hospital for other reasons.

Nevertheless, those people have to be managed separately from non-Covid patients.

The current pressures on hospitals are primarily caused by shortages of staff, not helped by isolation requirements, and exacerbated by an unforgivable failure to prepare, which goes right back to the start of the pandemic, two whole years ago.

Blame for the failure to prepare must lie with the Ministry of Health and the Health Minister. There was no decision to urgently hire or train more staff, and no rapid move to create temporary facilities. "Plans" to upgrade hospitals to cope with Covid patients were announced just three months ago. A pronouncement six weeks ago that the Ministry was "about to start" recruiting offshore for ICU nurses was rightly ridiculed.

These failures are emblematic of the Government's ponderous approach to almost every aspect of the health response. Provision of PPE, vaccines, RAT tests and new medications have all been very slow, and served with a diet of dissembling and obfuscation.

The ministry and the Government have been way too reliant on the generosity of New Zealanders in accepting restrictions on their freedoms to "avoid putting pressure on the health system", where too often it has really been about avoiding pressure on themselves.

Criticisms of the health response have also been used to justify the large-scale shuffling of the deckchairs that is the Government's upcoming health reforms. "There you go — system's broken. We need to change it."

However surely the most ardent proponents of those reforms are starting to have queasy feelings about giving even more control of this country's health system to the same bunch of Wellington-based bureaucrats who have made such a dog's breakfast of the Covid response.

Don't hold your breath waiting for an improvement in health services from the middle of this year when the reforms take effect. Many highly experienced observers believe they will achieve next to nothing.

That's because the reforms involve the same people giving themselves new jobs in huge new entities, probably at higher pay, with nothing else changing. The usual suspects will continue to dream up new ways of telling medical staff, hospitals and private practices what to do in the time-honoured top-down way.

There is nothing you can point to that will improve patient care, nor even a funding formula. Just lots of shallow statements about "fixing the health system". Oh, and a half-billion-dollar-and-counting price tag.

It was ever thus. Incessant rounds of reforms at the top of the system end up leaving the same people in charge and no plan to improve patient care.

It's enough to make a frontline health worker weep with frustration.

So what would real health reform look like? What would really make a difference to the healthcare of New Zealanders?

The experts agree that we must end this obsession with the supply-side structure of the system, and focus on what is right for the patients. That means allowing the funding to follow the patient — wherever they best get their care. Sometimes that will be in hospital and sometimes at a GP clinic.

But at the moment, the funding is controlled by a central bureaucracy which is always playing catch-up and forcing people into prescriptive and often antiquated methods of care guarded by vested interests.

I'm all in favour of a greater range of health providers including Māori health providers, who often do a better job of reaching their communities. But it doesn't make sense that a health provider with the country's largest number of Māori and Pacific people enrolled gets paid less per patient than one which is Māori-owned. Funding according to the ownership of the supplier means patients miss out.

Similarly we shouldn't be prioritising provision through government-owned suppliers as we did in the early stages of vaccine rollout, when GP's in private practice and pharmacists were left on the sidelines. How was that good for patients?

The other big reform needs to be about urgently growing our health workforce. We have long been too dependent on overseas-trained GPs and nurses to prop up our workforce here, and we are just coming off two years where that tap has been turned off. There are critical shortages everywhere and they are likely to get worse as New Zealand-trained staff head off on delayed OEs.

Our model for nurse training urgently needs to be overhauled to speed up and expand throughput. Universities and polytechs face massive restrictions in trying to grow their nursing provision to "protect" other providers. This is another supply-side restriction damaging health care.

We have long had a highly restrictive model for doctor training in New Zealand. We have a duopoly of two medical schools who fiercely defend their patch and lobby aggressively to prevent another one opening. That's a ludicrous situation in a country of 5 million people. A third medical school, focusing on hard-to-staff areas such as general practice, is needed urgently.

Restrictive trade practices within the professions need to be relaxed. One example raised at the recent New Zealand Economic Forum was New Zealand's requirement that colonoscopies must be performed by the consulting specialist. In many other countries they can be performed by specialist nurses. That would lower the cost of colonoscopies and allow more to be done, which would improve patient care.

All these fixes will take time to work, so in the meantime we need a sustained drive to attract more immigrant staff to work in our health system. That means being considerably warmer and more welcoming to migrants than we have been in the past two years.

Constantly putting up barriers to individual doctors and nurses practising here must stop — it is damaging our reputation.

Changes are needed in health to make the sector more robust so it can deliver more to New Zealanders. Reform that provides more patient-centred care and a larger workforce will make a difference. Reform with a big price tag that just rearranges the bureaucracy won't. Unfortunately, the Government is serving up the latter.

- Steven Joyce is a former National MP and Minister of Finance.