‘Complex, fragmented’ health system is fuelling inequities

‘Complex, fragmented’ health system is fuelling inequities

A complex, fragmented health system is compounding inequalities in New Zealanders’ access to care and health outcomes, University of Auckland experts argue in a new, sweeping critique. Māori, Pacific and low-income New Zealanders in particular are losing out and the way the health system is organised is partly to blame, they say.

A major overhaul could help realise our health system’s founding vision of equal, universal care for all New Zealanders. This would involve a far greater focus on prevention and tackling the underlying drivers of health inequities, such as housing, institutional racism, and food and alcohol industries; and further empowering Māori groups to lead and govern indigenous health services.

It would also mean syncing DHB district health boards (DHBs) and primary health organisations (PHOs) geographically, integrating their activities and potentially cutting their numbers to end fragmentation, duplication and the ‘postcode lottery’ effect.

The article, by University of Auckland professor of general practice Felicity Goodyear-Smith and health economist Toni Ashton, has just been published in the prestigious medical journal The Lancet.

It outlines the unique history of Aotearoa New Zealand’s efforts to provide universal health care, and delivers a report card on its current strengths and weaknesses.

“We have a very good health system in many ways, we provide very good care, but not everybody receives the same quality of care,” says Professor Goodyear-Smith, who is Goodfellow Postgrad Professor in the University’s Faculty of Medical and Health Sciences. “That needs to change, urgently.”

Among the weaknesses the experts identify:
• Complexity and fragmentation: New Zealand has 20 DHBs serving populations that range from just over 33,000 to almost 600,000; 32 PHOs, 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,” the authors write.
• A divide between first-line community-based health care and hospitals: while secondary health care (hospitals) are fully publicly funded, primary health care (e.g. GPs) is only partly public funded. This divide has led to a lack of integration of services. And despite subsidies for children and people on low incomes, it can still cost $30-$50+ to see your family doctor, and many people put off visiting the doctor or just show up in the emergency room because of this cost, Professor Goodyear-Smith adds.
• A divide between treatment for injuries versus other conditions: Professor Goodyear-Smith: “ACC has done an amazingly good job of providing care for people who have suffered an injury, and preventing expensive malpractice suits and the defensive medical practices they encourage. But it’s created a dual system: if something can be deemed to be the result of an accident, you get Rolls Royce care; whereas if your condition is deemed to be the result of wear and tear, you may have to wait years for treatment, and that’s inequitable. And sometimes it’s impossible to know if something was due to an injury or was coming on over a long time.”
• A failure to tackle underlying drivers of health inequities: Over the past decade, the authors write, “population health approaches to health policy and social determinants of equity have, in general, been weak and ineffective… New Zealand’s legislative and health system responses to modern drivers of health outcomes – food and alcohol industries, poor quality housing, and institutional racism – have been in many instances wholly inadequate, with resulting persistent inequities.”
• Funding has not kept pace with rising costs: the ageing population, rapid immigration, and the rising cost of health care have helped mire DHBs in the red.
• Historical pressures and incentives to neglect infrastructure: Short-term pressures for service delivery have led to deferred maintenance of hospital buildings and other physical and IT infrastructure. Also: “infrastructure decisions tend to be negotiated with each DHB in isolation and thus lack a whole-of-system perspective”.
• Health workforce issues: Ageing, stressed, tired GPs; strikes by junior doctors, high feelings of burnout in the senior medical workforce all reflect and exacerbate the strains in the system. “Training models for health professionals could be transformed to meet the future challenges of community-based generalist care and the new normal of multi-morbidity,” the authors write. “A workforce is needed that is responsive to patient needs, rather than persisting with a system designed around out-of-date configurations for health professionals.”
A key argument is that a “focus on individual-level secondary services and performance targets has been prioritised over tackling issues such as suicide, obesity, and poverty-related diseases through community-based health promotion, preventive activities, and primary care”.

The authors call for better co-ordination across patient record systems, across DHBs and PHOs, different groups of health care professionals (e.g. GPs, midwifes, specialists), and health NGOs. Technology could help too: for example, each patient could get a single virtual electronic health record accessible by all health care providers.

The article also highlights strengths: DHB innovations born of fiscal constraints; new models of indigenous-led health care; PHO-led innovations, such as taking health care into churches and marae. Goodyear-Smith: “Pharmac has done an amazing job of getting us far more pharmaceuticals and medical devices for our budget, and that means making hard choices. Pharmac is successful because it is independent and not subject to political interference.”

She also applauds Auckland District Health Board’s recent move to tackle institutional racism, but says a co-ordinated, holistic approach would be even more effective.

“We need to make our health system more integrated and less complicated. And we need to strengthen general practice and community-based services that help keep people well – it’s recognised internationally that the stronger and more equitable you can develop your primary health system, the more equitable and cost-effective the whole system will be.”

The Lancet: New Zealand health system: universalism struggles with persisting inequities

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