The government implemented a full health system review in 2018, with Heather Simpson as chair of the review panel. The panel’s interim report was released in August 2019 and detailed the findings, including the problems it identified and what needs to change. The final report was completed in March 2020 but its release was deferred due to the energy required for the Covid-19 pandemic response.
The final 274-page report with recommendations for wide-ranging health service reform has been released today. Cabinet has approved the general direction of the report but is yet to decide whether to implement the specific recommendations. Any changes will be implemented by the next government after the election.
Central to the report’s recommendations is an acknowledgement that the current health service is of high quality by world standards, but is overly complex to navigate as a service user and has perpetuated, rather than ameliorated, inequitable outcomes since the last reform in 2000. Specifically, the needs of Māori, Pacific, disabled people and rural communities, along with some other population groups, must be addressed as these groups currently experience significant health disparities.
Key recommendations
Hauora Māori
- Establish an independent Māori Health Authority to lead hauora Māori, advise the Minister on all aspects of Māori heath policy, promote, incorporate and embed mātauranga Māori (Māori knowledges) into all aspects of the system. Support all organisations and services to deliver culturally safe, competent and effective services to Māori. Combat institutional racism.
- The system and legislation to be underpinned by Te Tiriti o Waitangi, and reflecting the Te Tiriti partnership governance on DHB boards and national health entities should be 50:50 Māori-Crown representation.
- Invest in Kaupapa Māori health services and providers
Governance and funding
- Two new crown entities should be established: a) Māori Health Authority; b) Health NZ.
- Health NZ would lead the delivery of health and disability services across the country and provide direct leadership and strategic direction to DHBs.
- The number of DHBs should be reduced from 20 to 8-12 over the next 5 years.
Tier 1: Community-based Services
- DHBs should be fully accountable for planning and organising community-based health services on a locality basis for their population.
- Maternity services and Well Child/Tamariki Ora should be planned and organised at the DHB level. This would include contracting for community midwives.
- Community-based health services should be connected in networks.
- The new national entity, Health NZ, would ensure consistency in contracting protocols.
- DHBs should ensure Mātauranga Māori is embedded in all services by all providers, and that Kaupapa Māori services are developed.
- There should be a wider range of services (from maternity, general practice and nursing services, through mental health and behavioural, medicines optimisation, home based support and outreach) in locality networks with the ability to have shared patient information (with permission)
Tier 2: Hospital/specialist services
- Hospital and specialist services should operate as a cohesive Tier 2 network and also work in an integrated and collaborative way with Tier 1 (community)
- Rural services should be specifically planned for, recognising the unique challenges of geography and distance.
Population Health
Population Health becomes a driver of all planning within the health system. This includes an explicit focus on health equity.
There are also sections on Digital & Data, Workforce and Facilities & Equipment.
Interpretation
As midwives are aware, the College has been working and advocating for both employed and self-employed midwives’ pay and conditions – the former by working closely with MERAS and supporting the Midwifery Accord and CCDM work, and the latter by working closely with the Ministry of Health on a co-designed contract model.
Central to the College’s advocacy has been the knowledge and evidence that midwifery care is the crucial bridge to safe outcomes for women as they become mothers and for whānau as a new baby is welcomed. Appropriately resourced midwives provide several levels of safety: medical – midwives are skilled health professionals; environmental – protecting the woman’s birthing space; emotional – women’s whole experience is considered important; and cultural – midwifery practice is grounded in cultural safety. These layers of safety are realised by care that is grounded the relationship between the midwife, the woman and her whanau.
Our current continuity of care model is strongly evidence based as the optimal framework for maternity care. It has the capacity to promote health equity by a deep understanding the woman’s context and flexibility to provide a highly accessible, preventive primary care service at the most important time of life to influence long-term health outcomes. However, the current contract model is too rigid to incentivise the necessary additional care that some women and population groups require to achieve equitable outcomes. The College has proposed clear solutions to this issue through the co-designed community midwifery funding model and ongoing advocacy for the provision of IT solutions that enable enhanced connectivity between midwives, their colleagues in the community, including Well Child services and primary care, and secondary/tertiary services.
The College therefore commends the Review Panel for its exposure of the inherent flaws of a disjointed health system and the need for an equity focus by centring Te Tiriti o Waitangi in all innovations and by funding contracts that directly meet the needs of the communities that we serve.
The College notes that all tier 1/community-based services are recommended to be contracted and commissioned at the DHB level. However, there is provision for options for contracting primary care services to be developed at a national level, so that DHBs have a consistent approach to commissioning community services. The College will therefore expect to work closely with the new national entities – Health NZ and the Māori Health Authority – to continue its work on contract models for midwives.
In conclusion, the Health and Disability System Review is a high-level report that sets the direction for the future of this country’s health service, but individual recommendations have yet to be accepted. No significant changes will be made before the election, and the structural reforms will be implemented over a number of years. The College of Midwives will seek feedback from members at each stage of the process and will continue to advocate for its members and maternity services at all levels.