Health reforms: Problems get worse as $11b shake-up yet to help struggling sector

Multiple problems in the health sector are worsening while the Government’s flagship reforms grind into gear, sector leaders say.

The $11 billion overhaul of the district health boards is a long-term project, but a succession of leaders told the Herald they were worried that key measures were deteriorating and not enough urgency was being shown to address them.

And with Te Whatu Ora now searching for a new chair after Rob Campbell was sacked, they say his replacement needs to get to grips with myriad problems quickly.

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Campbell was leading the reform of the district health boards (DHBs), an ambitious project which aims to simplify the complicated, unwieldy sector and provide consistent levels of care across New Zealand.

“On the ground there hasn’t been a lot of change at this point,” said Dr Bryan Betty, chair of General Practice NZ.

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“We’ve got a number of quite urgent problems in terms of workforce, funding, patients unable to access general practices. There’s a degree of uncertainty about all that that still needs urgent attention.”

The comments come in the same week the Herald revealed hospital patients are being held in overflow rooms while they wait for treatment and ambulances are being diverted as under-pressure emergency departments in Auckland - one apparently at 195 per cent capacity - struggle to cope.

And on Thursday, Te Whatu Ora - Health New Zealand officials apologised for publishing incorrect ED waiting times online which didn’t accurately reflect how long patients are waiting to be seen.

Eight months after the reforms kicked in, the Herald checked in on what has been done so far and asked health representatives and workers whether they have noticed a difference.

Dr Bryan Betty, chair of General Practice NZ. Photo / Supplied

What exactly do the reforms do again?

The 20 District Health Boards are being scrapped and replaced by a single, centralised organisation called Te Whatu Ora/Health New Zealand. It is in charge of all health services, from hospital and specialist services to primary and community care.

This is to allow hospital and specialist services to be planned and delivered consistently around New Zealand - and ideally bring an end to the “postcode lottery” of healthcare, in which some patients wait longer than others or get different treatment depending on where they live.

A new entity, the Māori Health Authority/Te Aka Whai Ora, has also been established as part of a bid to address longstanding racial inequities in healthcare. It will work alongside Te Whatu Ora and commission dedicated services for Māori.

While the DHBs have been removed, the health system has been split into four regions: Northern (Northland, Waitematā, Auckland and Counties Manukau), Te Manawa Taki (Waikato, Lakes, Bay of Plenty, Tairāwhiti, Taranaki) Central (MidCentral, Whanganui, Capital & Coast/Hutt Valley, Hawke’s Bay, Wairarapa) and Te Waipounamu (Canterbury/West Coast, Nelson Marlborough, Southern, South Canterbury).

Services are being delivered by “localities”, which will take over the roles of DHBs and primary health organisations. In all, there will be between 60 and 80 localities. They will be tasked with deciding what their own area’s specific needs are, and will require all parts of the health sector and community groups (like housing providers) to work more closely together.

All of the 12 public health units which cover areas like alcohol controls and drinking water have been combined into a single entity, within the Ministry of Health. The ministry still exists but it has a narrower role, focused on strategy, policy and regulation.

There are no changes to ACC, the Mental Health and Wellbeing Commission, Pharmac, the Blood Service, or the Health Research Council.

What has been done so far?

The initial period of reform has mostly been focused on continuity of care rather than dramatic transformation.

Te Whatu Ora and the Māori Health Authority are up and running and some key roles have been filled.

Twelve pilot localities have been established in Ōtara/Papatoetoe, Hauraki, Taupō/Turangi, Wairoa, Eastern Bay of Plenty, Tairawhiti, Te Hiku o Te Ika, Whanganui, Horowhenua, Porirua, West Coast and Hokonui. The rest are expected to be in place by the middle of next year.

Some of those localities have started to submit their draft plans, which will determine their area’s health services.

Three taskforces have been set up to address urgent issues - planned care, immunisation rates and workforce.

On the recommendation of the workforce task force, initiatives have been introduced to recruit and retain doctors and nurses, including a campaign to promote nursing as a career and measures to make it easier for foreign doctors to work here.

The Public Health Agency has been established and an advisory group has been set up to report back to ministers.

Has it made a difference yet?

It was never expected that the health sector would change overnight.

But eight months in, there are rumblings of concern among health sector representatives about the pace of change and lack of certainty about the new system.

Much of Te Whatu Ora’s work depends on the development of an NZ Health Plan. An interim two-year plan is in place for now, which formalises the actions Te Whatu Ora and Te Aka Whai Ora are accountable for.

Many of the key metrics in the health system continue to worsen, including immunisation rates, waiting times, and stays in emergency departments.

Nearly every part of the sector is dealing with long-standing shortages and there are concerns that if conditions do not improve, New Zealand will keep losing staff to other countries.

New Zealand Nurses Organisation president Anne Daniels said the new Te Whatu Ora chair would quickly need to address pay equity in her sector. Nurses in the community were quitting or moving because they did not have pay parity with their hospital counterparts following a pay agreement last year.

“In a context where we have major nurse shortages and huge increases in work demand because our population is getting sicker and older … it’s a bit of a mess, really. Nurses are still going over to Australia.”

Recruitment drives had led to about 32 more nurses, she said, but that was dwarfed by an estimated 4000 vacancies across the country.

Royal Australasian College of Surgeons (RACS) chair Andrew MacCormick said his organisation was generally supportive of the reforms, which had the potential to remove duplication of roles. Goals of improving equity and timeliness of access to care were laudable, he said.

“But so far we are not seeing a huge difference on the ground. Anecdotally we are hearing that there is about a 30 per cent reduction in planned care surgery across a number of different surgical specialties.”

He was particularly dismayed by a decision by Government and Te Whatu Ora not to take up an offer by medical schools to train more graduates.

“They would need that to be in Budget ‘23 so they can increase med school intake in 2024. So if nothing happens you are looking at 2025 at earliest.”

Emergency departments are an indicator of the broader health of the system - if something is going wrong, it often shows up there first.

Ambulance at Auckland City Hospital in Grafton. Photo / Jason Oxenham

While the number of people presenting at EDs over the last year has remained steady, patients are waiting for longer because of blockages in other parts of the system. Auckland City Hospital confirmed earlier this week that it had diverted ambulances because its ED was over capacity.

“If there is any bursting at the seams, it happens at our emergency departments,” said Dr Kate Allan, Aotearoa New Zealand chair of the Australasian College for Emergency Medicine.

“That is through backlogs from the hospital, and also backlogs from [the] community into the hospital. It is an overwhelmed system.”

Allan acknowledged that the Health NZ reforms were long-term and her sector would not see change for some time.

“It’s disappointing but not surprising that on the front line, we are not seeing any significant change yet. But it is very complex and there are no simple solutions. We are preparing for a difficult winter.”

What does Te Whatu Ora say?

Chief executive Fepulea’i Margie Apa said the reforms were broadly on track at the eight-month mark in a two-year transition.

In response to the concerns raised by the nurses union and advocacy groups, she said Te Whatu Ora had committed $14.4m in its first month to increase workforce trainees in nursing, primary care and rural areas.

Apa listed a number of initiatives which had been implemented so far, including:

• An international campaign that had led to the recruitment of 34 more nurses, and new initiatives which make it easier for nurses to return to work, which had “strong interest”.
• Expanded places for nurse training and encouraged the largest intake for the voluntary bonding scheme in a decade,
• A pilot scheme to make it easier for 20 foreign doctors to get registered in NZ, and increasing funding for GP trainees to the same level as their hospital counterparts.

Apa acknowledged that addressing backlogs in planned care was “a multi-year programme of work”.

Te Whatu Ora had adopted 16 out of 101 recommendations from the task force, and planning and implementation had begun for another 47 recommendations.

Among the new initiatives in this area was the pooling of resources and outsourcing of care, so patients received their care in other hospitals or private providers or medical teams were moved between sites.

“An example of this is in South Canterbury where maxillofacial surgeries were for the first time carried out in Timaru in early February.

“The surgeries were carried out by a Christchurch-based surgeon, supported by the Timaru Hospital team.

“It required co-operation between anaesthesia, theatre, ICU, and central sterile services, recovery, day patients, preadmission, inpatient booking office and other teams from the wider region, as well as equipment from Christchurch theatres.”