Today the biggest shake-up to the health sector in two decades comes into force, with Health NZ and the Māori Health Authority replacing all 20 district health boards. Health Minister Andrew Little says they are key to addressing severe inequities across the country. Meanwhile, National health spokesman Dr Shane Reti says the centralisation has gone too far and comes at the worst possible time, with the system already straining through the pandemic. Michael Neilson speaks to them both.
"We should all be horrified."
That's Health Minister Andrew Little's take on the severe inequities that plague the country's health system.
Māori die seven years younger than the average New Zealander, at about 74 years of age.
But in Tairāwhiti, with extra geographical challenges, on average Māori reach just 71 years of age - 10 years below the national average of 81.
Little says these inequities are due to a combination of factors - colonisation and the dispossession of land and culture, government neglect and ensuing intergenerational poverty, and geography and inaccessibility of health services.
In other rural parts of the country too are countless stories of delays and/or people missing out on vital cancer scans and treatments, among other issues.
From today the country's 20 district health boards cease to exist, replaced by Health NZ in charge of the health system both clinically and financially.
The Māori Health Authority, run by a board of up to eight, will jointly develop and implement a New Zealand Health Plan with Health NZ.
Within those new structures will be about 80 locality networks, and iwi-partnership boards to guide decision-making.
Little sees the major health reforms coming into place today as the means to address those inequities and ensure a high standard of care across the whole country.
"What we've had is simply not sustainable."
Little is also referencing the hundreds of millions of dollars in deficits racked up by the DHBs, and the inefficiencies with each operating in their own manner.
"A population of five million, it does not make sense broken into 20 different parts plus a ministry plus a few add-ons as well.
"I took the view we could get a lot more out of a single, unified structure that could streamline decision-making, get greater consistency and offer better career structures for the workforce."
The Simpson health review that preceded the reforms recommended shrinking the number of DHBs to eight to 12. But Little said the same argument to reduce them was the same as taking them all away.
One example he pointed to was the bowel screening rollout.
"It had to be negotiated 20 different times, and took the best part of five years. It should have taken two.
"Then we have inefficiencies in the current system, we have got 20 of everything throughout the system."
Little said rather than give reason to pause, the pandemic highlighted why the changes needed to happen immediately.
There were issues early on in quantifying the number of ICU beds, stocks of PPE, and then in testing and the vaccination rollout.
Little said the Ministry has acknowledged it did not get some things right, which is why it changed tack over the course of the pandemic.
"Covid-19 exposed the big inequities in our system and some of the organisational challenges.
"The vaccination programme had to be negotiated with 20 different DHBs on how to roll that out.
"Given this is an organisational change and it's not immediately going to affect the frontline services, there was no reason to delay.
"If we wanted to seriously address the inequities and get some greater consistency and streamline decision-making, we have to do that now."
Practically speaking, it won't change a lot immediately for those interacting with the health system.
They'll still go to their nearest hospital, still go to their same GP, although in a few years Little said there could be more "health hubs" across the country, centralising different services.
The main outcomes will be in greater consistency in quality of health care, Little said.
"It shouldn't be if you live in Southland, your expectation of our cancer treatment is different than if you're in a big centre."
Little has acknowledged the pressure the health system is currently under, but said feedback from the medical community was positive.
"They're concerned about the pressure they're under but they all say these changes are so important."
He said major outcomes were not expected for several years, but structural changes meant they should start to see vacancies being filled in hospitals within two years, along with greater consistency of care.
The Māori Health Authority was "not about two separate systems", as branded by the Opposition, Little said.
"It's actually one system, working intimately together to make sure that we're really seriously addressing those inequities."
He also disputes claims the authority and Health NZ, each with commissioning functions, will end up competing with each other.
"We do want top Māori medical professionals offering leadership in Māori communities and delivering the best on Māori health care, but they are medical professionals, and they will want variety, too.
"So they'll do some stuff commissioned by the authority, and some commissioned by Health NZ. That's the way the health system typically operates anyway.
"It's not about doing their own thing either. The Māori Health Authority is as much a part of the rest of the system. But it is very much the leader for Māori and is very much by Māori for Māori.
"We saw with the vaccination programme, and Māori have been asking this for a long, long time: give us the ability, the space to lead and resources, and give us the space to lead our people on health and we can make a big difference."
The "veto" power for the authority is no longer, removed at the committee stage, but Little said there still had to be an agreement reached with Health NZ.
If there were disagreements it would come to Little, as Health Minister, the Minister for Māori Crown Relations and Minister for Māori Development to resolve.
As such it was still within the Crown, Little said.
"I would describe it as we're getting closer to fulfilling our obligations under the Treaty. It is a step closer to tino rangatiratanga and mana motuhake when it comes to Māori health."
National's Dr Shane Reti:
That there are major problems with the health system "across multiple governments" and change is required is not disputed by National's health spokesman Dr Shane Reti.
Nor are the enormous inequities, particularly for Māori - and Reti also agrees a specialist body needs to be established to address them.
"I absolutely agree with the inequities we're trying to solve," says Reti, from Whāngarei and of Ngāti Hine, Ngāpuhi and Ngātiwai.
"As a Māori doctor it has bothered me for years. I ran one of the longest-running marae-based clinics in the Upper North Island.
"I understand the challenges and importance of a culturally competent component. I see that as bringing the Treaty to life.
"But I disagree with the pathway we are trying to get there."
Reti outlines three main concerns with today's health reforms: the scale of centralisation; the timing, in the middle of a pandemic; and what he says are a "lack of measurable outcomes".
"There will be a loss of the local voice," he says.
Along with that, he fears the new locality networks- at least 80 proposed - will create further layers of bureaucracy. He's also unhappy at the initial $1.8 billion announced in the Budget to bring in the system.
Reti said National accepted there were inefficiencies and might have opted for the Simpson review's recommendation of a reduction to eight to 12 DHBs.
Reti said he was also very concerned about the timing of the changes.
"Anytime except now. We've got people dying in a pandemic.
"I don't agree with it in its entirety. But if they were going to press forward with it, they should have paused.
"If you don't start with a stable platform your likelihood of good outcome is poor.
"We've got some of the worst health outcomes we could ever have, and the health workforce is dispirited.
"So this is not good timing to be doing the biggest reform of health the past 20 years."
However, if National came into government next year, Reti said they would not be rolling everything back.
"The sector have said to me it is exhausted and don't want any big structural changes.
"It will have been 15 months. If [the changes] are successful we'll assess the environment and look at what is working and what is not."
One thing Reti is certain about though is disestablishing the Māori Health Authority.
In its place Reti said would be a well-resourced and funded Māori Health Directorate.
"It will be policy, but not commissioning. That's one of the faults of the Māori Health Authority," Reti said.
His concern was the authority would become a separate system, competing for the same resources as Health NZ.
"You'll have two sets, potentially two contracts. There'll be competition for providers, like Māori health doctors."
While Health Minister Andrew Little sees the authority as a step towards recognising Māori sovereignty, tino rangatiratanga, over health as under the Treaty of Waitangi, Reti said he was more concerned with outcomes.
"I see [Treaty obligations] in terms of outcomes and treating people in a culturally competent context.
"I would bring the Treaty to life. Because at the end of the day, it's about the outcome in health that people want. And we get there in a culturally competent context.
"Here's the despair I have, if they get this wrong, Māori health initiatives will go back decades, because no one will be brave enough to go here again."