Dunne Speaks: Do We Still Need 20 DHBs?

The politician and commentator Austin Mitchell once described the New Zealand education system as "a complex balance of groups, so nicely deadlocked as to make change impossible." Undoubtedly accurate as it was a description of educational administration at the time, it is also a description that could be applied, just as accurately, to our current health system.

The complex balance between a central Ministry of Health, allegedly policy focused, with service delivery mechanisms relying on twenty autonomous District Health Boards which the Minister has no power to direct to do anything is ready-made to ensure nothing much ever really changes. When the layer of the plethora of professional interest groups, all pushing their particular concerns in splendid isolation from the wider health sector, is added, it becomes a marvel that anything positive ever happens in health.

Yet it does, which is an unqualified tribute to the skills, professionalism and dedication of medical and nursing staffs up and down the country who do their absolute best for their patients, despite the system they are obliged to work within. It is little surprise, therefore, that while the public is often critical of the health system at a general level, they are unfailingly positive when it comes to relating their own individual experiences of it. To that extent, it could be argued that the health sector succeeds in what Mitchell also described as the basic function of any government agency - "to keep its field of operations quiet" - and just let things carry on. This has also been taken to the extreme in recent years of measuring the success or otherwise of the government of the day's health policy by the extent to which the Minister has been able to keep health stories out of the news.

This somnambulant approach might satisfy the short-term political objectives of the government of the day, and make the Minister look good in the eyes of the public and colleagues, but it does not really go anywhere. Because the public demand for health services is insatiable, and the cost of meeting new services, medications and capabilities always greater than our national ability to pay, the health system will always be under pressure and health professionals dissatisfied.

So, the only way to make fundamental change to break this complex balance of inertia is to look at structures. Do we really still need 20 autonomous DHBs, all mini-national health systems, in a country the size of medium sized city state, and in an age where technological innovation is rapidly simplifying the need for complex structures? The duplication, bureaucracy, and parochialism the current system encourages not only smacks of a bygone age, but is stifling the development of a modern, integrated national public health system. The perennial debate over DHB finances and the level of their deficits, and the difficulty of decision-making around the priority to be accorded the redevelopment of major hospitals are proof of that. They are by no means the only examples.

No-one wants to return to the disruption of the late 1980s and the 1990s, when we lurched from archaic, narrowly focused Hospital Boards, to Area Health Boards, to a centralised Health Funding Authority, and then back to District Health Boards. But, equally, there are very few who would say that the current system is working well. The new Minister is reportedly struggling to come to grips with how to make the system work to meet his objectives, and is frustrated by the functioning of the Ministry of Health. Whatever, he now has a golden opportunity to take a fresh look at the public health sector and the adequacy of its creaking structures, to make it fit for the purpose for the future. Mitchell described the principal qualification of the Minister of Education to be "a complete inability to get anything through Cabinet", thereby ensuring nothing ever changed, which the spin doctors could present as continuity. How the government approaches health policy may determine whether this soubriquet should also be applied in the future to the Minister of Health.

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