PROFESSOR JENNY CARRYER calls for courageous disruption to ensure the new Health Strategy leads to changes in the health system with a positive impact on population health.
Last year an energetic and commendable level of consultation was put into reviewing and refreshing the country's now aged Health Strategy document.
There was also consultation on funding structures in the health system and into capacity and capability issues. A new draft Health Strategy document has been produced and a roadmap of actions designed. Principally the strategy aims to enable New Zealanders to “live well, stay well and get well”. Key among the many goals is a move towards increased person-centredness as a guiding focus for the way forward.
We should ask ourselves why very similar and equally admirable goals adopted in 2001 (at the launch of the Primary Health Strategy) have not been successful. The document seems short of actual population health goals and there is almost no evidence of planned actions to address the major preventable causes of poor health and premature death.
Overall, there is an excessive focus on the “treatment of illness system” as a supposed means of keeping people well. The red flag signifying this concern is exemplified at the very start of the document when the number of GP visits per person is listed as evidence of success. I suggest we need to move to a state where we measure success quite differently.
The document contains eight principles for the New Zealand health system and they are certainly the appropriate goals to guide the strategy's implementation. However, caution is indicated. Historically, funding models have a privileged downstream and reactive focus to illness care. Even if that was not the intent of the original funding models, the control and distribution of funding has tended to sustain a reactive model of care.
The result is that it has been difficult to move beyond the 'tyranny of the acute' and to achieve reduction in overall long-term demand. In order to redesign funding models that support new ways of operating, many in nursing would argue that there needs to be a significant change in how the Ministry of Health and district health boards consult on and consider policy advice. It is vital that vested business interests do not continue to hold sway in consultation processes and that there is greater meaningful consultation with those, such as nurses, whose primary focus is on embedding community wellness rather than treating illness in a downstream manner. It is also entirely pointless to speak of person-centred care unless the public genuinely has a great deal more engagement in the planning and design of services.
The strategy is remarkably silent on workforce, beyond noting that “it is important that we have a workforce whose size and skills match New Zealand’s needs”. There are also comments about the need to ensure that every health professional is able to be utilised to the greatest extent of their potential.
Workforce and workforce flexibility will undoubtedly be critical to the success of the Strategy refresh and to health service sustainability. It will be vital to pay more than lip service to this particular goal. Every health professional should be able to use their expensively gained skill set, knowledge base and training to the fullest advantage. But perhaps this will require some courageous decisions and a move to considering the workforce as a whole, rather than in discrete silos.
The findings of the recent physician assistant trial would suggest strongly that GPs in particular are being resourced to do a great deal of work that the evaluation clearly showed could be done by others. The even greater actual and potential contribution of nurse practitioners remains largely untapped.
We should be considering how much general practitioners could alleviate the shortages of specialist positions in areas such as dermatology and many others. In a similar vein, I have long argued that there is a problem with GP employment of practice nurses, if such employment constrains nurses’ autonomous design and deployment of nursing services in the most patient-centred manner. Teamwork in general practice is of vital importance and it is generally agreed that a team functions best when all individual members have clear autonomy over the development and direction of their practice.
Yet again, this requires courage, focus and disruption. Words are easily said but the Ministry of Health should critically examine, as one example, the extensive delay that has prohibited nurse practitioners from carrying out the very processes for which they are legally authorised. There are also examples of the creation of recent barriers through failure to consider and consult outside the traditional power structures. Unless we learn from such processes, we will continue to see slow or no progress towards the necessary changes which will underpin the strategy's vision.
The Health Strategy document is of vital importance for ensuring sustainable health services in a demanding future. Here’s hoping that this time we have courage to be sufficiently disruptive in order to make the vision real and the goals achievable.