What National and Labour get wrong about health

While the Government and the National Party are focusing on big-ticket cancer treatments, a report from an Auckland medical professor has slammed the inequities that dominate the New Zealand medical system.

Professor Felicity Goodyear-Smith, in a comprehensive paper, in the prestigious British medical journal, “The Lancet”, says a complex, fragmented health system is compounding inequalities in New Zealanders’ access to care and health outcomes.

And she says New Zealand’s complexity and fragmentation of its health system plus a dispersed and ethnically diverse population means inevitable trade-offs between equity of geographical access, cost of service provision, quality of services, and the seismic resilience of services (i.e., the risk associated with centralised services).

A combination of the system’s complexity and these trade-offs has contributed to the inequities in access to services and health outcomes that are prevalent in New Zealand.

Goodyear-Smith’s diagnosis sits at odds with the headline-making cancer treatments proposed by both the Government and Opposition over the past fortnight.

First, it was National with a proposal for a National Cancer Agency independent of the Ministry of Health, which would focus on “greater accountability and consistency of access across New Zealand.”

And yesterday the Government, in turn, announced the replacement of half of all the country’s radiation machines.

Neither Health Minister, David Clark, nor his Opposition counterpart were willing to discuss the report with POLITIK yesterday.

A spokesperson for Clark said he was focussed on the radiation machine announcement.

But Goodyear-Smith says cancer treatment requires much more basic expenditure.

“Despite universal funding, access to care remains problematic,” she says.

“For example, at the end of 2017, only four of the 20 DHBs succeeded in meeting the national target of providing at least 85% of patients with suspected cases of cancer with treatment within 62 days.

“Although access to secondary services is not measured systematically, a small pilot study in 2017 found that 9% of the population reported unmet need for secondary health care that had been identified by a health professional.

” In the case of primary care, 28% of the population—and 38% of Māori—reported not being able to access primary care when required within the past 12 months.

“This was largely because of the inability to pay for GP consultations (14% of those surveyed) or being unable to get an appointment within 24 hours.”

One Wellington GP said patients could wait for months to be seen at Wellington Hospital, whereas if they have medical insurance, they would be seen within six weeks.

Goodyear-Smith says that over the past decade, New Zealand’s health system appears to have a diminished focus on and commitment to equity in health outcomes.

“Persisting and marked inequities still exist in access and outcomes for Māori, Pacific Island, and low-income populations,” she says.

In part, this is because of a loss of momentum over the past decade in the provision of innovative, accessible and effective primary health care.

She points to the central fallacy evident in both the big cancer announcements.

“Continued increases in hospital spending, with the number of hospital doctors increasing at a greater speed than are GPs, is contrary to the declared policy of investing in primary care to keep people healthy and reduce demand for hospital care.”

She is also critical of the way the emphasis over the past decade has gone off legislative and health system responses to what she says are modern drivers of health outcomes—”the food and alcohol industries, poor quality housing, and institutional racism”—have been in many instances wholly inadequate, with resulting persistent inequities in health outcomes.

She also points to the paradox that is the ACC.

“Although ACC is one of the great strengths of New Zealand’s institutional arrangements, it has also introduced inequities, because different funding and benefit entitlements apply depending on the cause of a health problem,” she says.

“Copayments for consultations with GPs or allied health professionals (such as physiotherapists) differ depending on whether the problem was caused by an accident or an illness.

“ACC patients requiring hospital treatment might receive treatment earlier than other patients, especially in situations for which ACC is paying income compensation while the patient is off work and could be eligible for a more comprehensive range of services, including home support.

“Whether or not a problem will be classified as accident-related (resulting in considerable patient distress) is often unclear.”

Perhaps not surprisingly, she identifies the fragmentation and funding of the health system as one of the prime causes of many of its inadequacies.

“Funding has not increased in line with cost increases, and the majority of DHBs are struggling to meet their objectives,” she says.

“For the past few years DHBs have been exploring ways to cut back expenditure, but after several years of exercising spending restraint, so-called low hanging fruit options have been largely exhausted.

“Concerns have arisen that staff are stressed and service cutbacks seem likely.”

The Ministry of Health used to publish monthly financial outcomes for DHBs but appears to have stopped doing so.

On Friday, National’s health spokesperson, Michael Woodhouse, said DHB deficits are expected to blow out this financial year to $500 million.

In May, the Association of Salaried Medical Specialists and the Combined Trade Unions calculated that the District Health Boards’ combined budget needed to rise from $13. 2 billion to $14.3 billion, requiring an increase of $1.0 billion or 7.9 percent, to maintain the current level of DHB services and cover population and cost increases.

Overall the two bodies calculated that the health budget needed to rise by $3.2 billion to maintain current levels of service.

DHB funding was increased in the Budget by $700 million ($300 million less than the ASMS/CTU figure), and the overall health budget rose by $1.6 billion ($1.6 billion less than suggested.)

Goodyear-Smith and her fellow author Toni Ashton say : New Zealand has 20 DHBs serving populations that range from just over 33,000 to almost 600,000; 32 Primary Health Organisations, or networks of GPs and other primary health care providers (which don’t necessarily line up geographically with the DHBs); and 2200 NGOs working in the health sector, of which less than half receive government funding.

“For a small country, the system is complex and fragmented, and this contributes to inequity and inefficiency,” they say.

Ironically much of what Goodyear-Smith has set out in her paper should be covered in an interim report due this month from the Health and Disability Review headed by the former Chief of Staff to Prime Minister Helen Clark, Heather Simpson.

In the meantime, it seems both political parties are more interested in big-ticket headline-making announcements than dealing with the fundamental problems of the New Zealand health system.

.