Rob Campbell on Māori Health Authority
Rob
Campbell appears to be on an adrenaline driven burst of
writing since his dismissal as Chair of Health New Zealand
(Te Whatu Ora) which shows no sign of
diminishing.
This is a good thing. I have a vested
interest. To paraphrase George Cole in the British comedy
drama Minder, he’s not a bad little non-earner for
my blogs.
Like many others who come into Aotearoa New
Zealand’s health system in prominent roles, Campbell is
‘hooked’ on its dynamics and complexity along with its
public good purpose. His adrenaline should continue because
it’s not affecting his judgment..
Being ‘hooked is
a good thing because he has valuable insights from his brief
term in a unique leadership position in an unusual time. He
also is cognitive and thoughtful.
What makes him even
more interesting is his evolving understanding of the health
system the more ‘hooked’ he gets.
Campbell’s
opinion piece published in the NZ Herald (11 June) is
an example of his thoughtful writing: Justifying
the Māori Health Authority.
Focus
and reasoning
His focus is the intention of both the
National and ACT parties to abolish the Māori Health
Authority (Te Aka Whai Ora) should they form the next
government later this year. Campbell opposes this
position.
His reasoning
includes:
- National’s alternative is to
establish a Māori unit in the Ministry of Health but the
Ministry had such a unit for many years. Where is the
evidence that this worked! - Te Ake Whai Ora is
essential to achieve the objectives of the Pae Ora (Healthy
Futures) Act 2022 which created it. Achieving equity for
Māori healthcare outcomes is critical to one of the Act’s
three purposes. - There are problems with the new
entity but they can be worked through by having a higher
degree of independence from the Crown in the setting of its
governance and strategy. - This independence includes
increased funding. The current funding imbalance means
dependence than partnership. - Dismantling what has
been only recently “…created will only fuel that
suspicion and Māori are not unused to such
treatment.”
While I would have expressed it
differently, his observations broadly resonate with me. My
differences are ones of degree rather than
kind.
Restructuring context of Māori
Health Authority
I welcomed the decision to establish
the Māori Health Authority which was first announced by
Government in April 2021. The Authority’s formation was
one of three announced major structural changes, all to take
effect on 1 July 2022.
Another structural change was
the establishment of a new public (population) health agency
to be located in the Ministry.
Both new bodies I
believed had the potential to enable important improvements
to Aotearoa’s health system and consequently to the health
of New Zealanders. I still hold this view.
The third
structural change was the further centralisation of an
already centralised health system by replacing district
health boards (DHBs) with a new more vertical structure
(Health New Zealand).
That is, disempowering
decision-making at the level where healthcare (both
community and hospital) is overwhelmingly provided, and
further empowering centralised decision-making
upstairs.
At the time I said this would be disastrous.
Everything that has happened since has vindicated this
assessment.
‘If you don’t take the
temperature you can’t find a fever’
In January
2023 my political opposite Heather Roy (former ACT MP and
health spokesperson) and I collaborated to publish a joint
paper designed to promote discussion on how to best improve
the health system, given the restructuring we now
have.
We titled it Te Whatu Ora: Achieving
patient-centred care and wellbeing – If you don’t take
the temperature you can’t find a fever: Taking
the temperature to find the fever. The paper was also
published by Newsroom in three consecutive
instalments commencing on 17 January.
My political
opposite Heather Roy and I were positive but cautionary
about Te Aka Whai Ora
The focus was on what Te
Whatu Ora needed to do but we did make the following
comments concerning Te Aka Whai Ora:
The
establishment of both Te Aka Whai Ora and the Public Health
Agency are not the subject of this document. Both are
positive initiatives. But both could have functioned, as
established, without abolishing DHBs. Neither are magic
bullets, however.
The Māori Health
Authority’s major focus is on community healthcare and
wellbeing in the context of inequities. Expectations are
high on what it might achieve which may create problems. It
has the potential to improve accessibility to healthcare
services providing that it is practically
focussed.
To be really effective an advocacy
role will also be important. Advocating for government
policies and legislation to address the effects of social
determinants of health will benefit all susceptible New
Zealanders, not just Māori.
These comments are as
valid now as they were in January. Nevertheless, with the
passage of time, there are further observations deserving of
consideration.
In this context Rob Campbell’s
published opinion piece is a constructive and thoughtful
contribution reinforced by his brief experience as an
‘insider’.
Didactic
risk
There are three additional observations which I
would make. The first is my experience is that the further
away decision-making is located from where healthcare is
actually provided, the more it is likely to be
top-down.
Worse still, it is also (and
consequentially) likely to be didactic. There are few things
that frustrate health professionals and health managers
close to service provision more than having top-down
directions being delivered in a morally instructive
tone.
It is too early to conclude that the Māori
Health Authority has gone down this path but the overarching
health system culture it has to work within is conducive to
top-down moral
instruction.
Disempowering district
level decision-making
Second, as a result of the
disempowerment of decision-making at the district level,
where most community and hospital healthcare is provided
(achieved by abolishing DHBs), New Zealand’s health system
is much more vertical than before last July.
The
consequences of this disempowerment are similarly so for
Māori healthcare. Unfortunately there are already
indications of frustration among Māori providers with the
Authority. These indications are consistent with this
negative conflicting leadership culture.
It is not
automatically so that a more vertically and centrally
structured health system will lead to district level
disempowerment. But there is a strong tendency for this to
happen; it is more likely to happen than not.
If Te
Ake Whai Ora is to successfully resist this powerful
tendency it will need to proactively work to empower both
Māori providers and Iwi Māori Partnership Boards within
the districts they are based.
The Authority’s role
should be to provide national cohesion, not operational
direction, for this
empowerment.
Funding via
commissioning
My third observation is where I sharply
disagree with Rob Campbell’s opinion piece. This is where
he promotes a greater role for the Māori Health Authority
in funding (as distinct from the adequacy of funding for it
to function effectively).
In this context he means
‘commissioning’. The difficulty is that commissioning is
not a term used that much in health systems.
Its main
use has been in the National Health Service in England
where, for decades, it has gone in and out of favour
depending on the ideological bent of the
moment.
Heather Simpson: her review gave
‘commissioning’ traction
Commissioning was
used as a title in the Ministry of Health when Chai Chuah
was Director-General. But it took the final report of the
Heather Simpson led Health and Disability Review (2020) for
the term to get traction.
The Review recommended the
establishment of the Authority. In a divisive split
supplementary decision it also recommended that it have
advisory rather than commissioning powers.
This
further decision shaped a subsequent forceful debate over
whether its role should be extended to
commissioning.
In a virtual hui organised by New
Zealand Doctor in mid-2020 I argued that commissioning
was not a well understood term. It meant different things to
different people. The preoccupation with the term was
distracting and potentially restricting.
Advocating
commissioning might have the unintended consequence of
constraining its role. Instead I argued that advocates of
commissioning should replace it with the term
‘decision-making’.
The Government eventually chose
to extend the Authority’s role to commissioning. To the
extent that commissioning means something, it is funding and
planning healthcare services. These were functions
previously undertaken by DHBs
Decision-making is
broader than commissioning. In the context of the funding of
Māori healthcare it is less important for the Authority to
directly fund providers.
Instead it is more important
for it to have sufficient decision-making power to ensure
that Māori healthcare is well funded. This might appear to
be a semantic distinction but it is not.
If I were to
summarise my three additional observations in one sentence
it is this. If Te Ake Whai Ora is to succeed it needs to
adopt and internalise a relational rather than structural
culture which becomes ‘business as
normal’.
ENDS
Ian
Powell
This post of health systems blog ‘Otaihanga
Second Opinion’ discusses the Maori Health Authority in
the context of a recent published opinion piece by former
Health New Zealand Chair Rob
Campbell.
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