Broadly speaking, there are two ways to make sustainable, transformational changes in universal public health systems – structural change or changing the culture.
Structural change lends itself to blue-sky thinking by whiteboard warriors. Unless it arises out of cultural change, it's likely to be simplistic and fail.
Cultural change, including at a leadership level, takes longer but it's more likely to be sustainable.
To be effective, it needs to recognise that the experience and expertise in health systems rests first with its workforce of health professionals. To best use this impressive intellectual human capital, leadership needs to be spread throughout this workforce.
Universal health systems are complex, dynamic, interdependent and workforce-dependent. This means cultural change has to be the main driver.
Health professionals, especially medical specialists, are experts in complexity. It makes sense to use this attribute to continually improve the systems’ complex processes.
The more widely distributed this culture is, the more likely it is that outcomes will make both good clinical and financial sense.
This is the recipe for sustainable transformational change. But cultural change has a problem. It requires paragraphs to explain it, while structural change can be explained in sound-bytes.
Nevertheless, until minister of health Andrew Little announced his surprise decision in April to abolish district health boards by July 1, 2022, the expression ‘cultural change trumps structural change’ was a mantra in our health system.
However, these approaches don't have to be opposite alternatives. Structural change can be justified when it reinforces cultural change. But structural change alone won’t lead to sustainable improvement in systems.
The loss
Elected late in 1999, the Labour-Alliance government wanted to remove the competitive market culture from the public health system.
It put cultural before structural change, but used the latter to enable the former.
A critical feature of the change in culture was to shift from commercial competition as the driver of the health system to cooperation.
It introduced new legislation – the Health and Disability Services Act 2001 – which, in effect, removed the application of the Commerce and Companies Acts.
Another cultural change was integrating care between communities and their hospitals. To enable this, the state-owned companies running public hospitals were replaced with new crown entities called district health boards (DHBs) whose responsibilities went beyond hospitals to community health for geographically defined populations.
Labour’s approach in the early and mid-2000s under health minister Annette King couldn’t be more opposite to Labour’s approach under health minister Andrew Little in the early 2020s.
For Little, the structural abolition of DHBs will be a huge driver for his new system.
There are high risks in simplistic structural change designed by business consultants, including unintended consequences.
One immediate casualty will be the loss of decision-making by those who know their populations well; decision-making will be further away from populations and workforces than it is now.
When community and hospital care are more structurally separated than they are now, it will be more difficult to achieve integration between community and hospital healthcare.
Compounding the situation is the factor that the decision to abolish DHBs was only made late in the process.
Abolishing DHBs was never proposed by the Heather Simpson review of the health and disability system or even discussed in its two reports in 2019 and 2020. It was never part of Labour’s election policy last year.
Despite the ability of health system leadership to leak like a sieve, there was never any hint of it prior to Little’s April announcement.
The disadvantage
The cabinet-approved decision was very much last minute and knowledge of it was confined to a limited number of people.
The prime minister’s transition unit set up to implement the Simpson review is effectively run by business consultants, primarily EY. Its head isn’t even an employee of the prime minister’s department; instead EY is contracted to provide its senior partner Stephen McKernan. The experience and expertise to advise government is primarily in the health system, not in this tight transition unit.
By the end of June next year, a multitude of challenges will have to be addressed resulting from abolishing DHBs. They include reconfiguring new hospital structures, resolving what the structures for unknown new community networks will be, general practice local representation and engagement, and determining funding formulas and mechanisms for both public hospitals and general practices.
All this has to happen while the health system is in the middle of a pandemic, vaccinating people in the face of more deadly variants.
Abolishing DHBs is justified by appealing sound-bytes. One is that that we have 20 different health systems, which is inefficient; consequently we need a national system.
Nonsense. We have a national system delivered locally to better address local health needs, but through decision-making that is already significantly centralised.
Abolishing DHBs doesn’t make our health system a national system. Instead it centralises an existing national system at the expense of the effectiveness of local input.
Another sound-byte is that abolishing DHBs would be consistent with the National Health Service in the United Kingdom. But England is abandoning this structure. It's moving to something closer to DHBs – and Wales and Scotland have already done this.
The argument for DHBs requires paragraphs rather than sound-bytes. Consequently, it's at a great disadvantage.
However, as the implications of such unplanned massive restructuring unfold, perhaps words like hare and tortoise might come to mind.
