Health Reforms: Whose voices are being heard?

25 July 2022

By Steph Julian Ngāti Porou ki Harataunga

The pitch for the new health reforms is that they will be less postcode lottery and more community focused. On paper, this sounds ideal, but as the panel of Dr Kyle Eggleton, Associate Professor Tristram Ingham, Dr Fiona Bolden and Dr Monica Liva discussed, without genuine community partnership we could fall back into inequitable old habits. 

A few weeks ago we underwent perhaps the biggest change to the health sector in New Zealand’s history with the disestablishment of DHBs in favour of the national partnership of Health NZ and the Māori Health Authority: Te Aka Whai Ora. 

According to Tristram Ingham, there are three critical points within this shift. First, it’s imperative that the pace of change is right, it needs to be timely and well informed. Next we need genuine partnership with communities, especially those expressing worse outcomes from the current systems and third, there is risk in any transformation. 

Although he says he has been very vocal in supporting the change, Tristram is quick to point out a number of concerns, including inequities for Māori, Pasifika, and disabled people. The health reforms do create an opportunity to build efficiencies, to have consistency and to remove the aforementioned postcode lottery. “This is the first time we’ve seen a standalone Māori health agency at a central government level with the power to make real change.” 

“The governance health system wasn’t working for Māori. The community has long advocated for change.” 

“We’ve been living thorugh unprecedented change in health. The workforce is facing some of the greatest challenges we’ve ever seen and we’re treating an exhausted and disenfranchised population. We have large levels of deferred care and an exacerbation of inequities in many areas. But the sytem has performed remarkably well compared to other countries. This success is due to the hard work of many.”

“We’ve learned much, changed much but much must yet change.” 

Change, Tristram warns, must be made in genuine partnership with communities. We need to ask who is leading these changes and who is actually involved? He is concerned that we have an absence of consumer voice and a ‘fledgling’ panel of senior decision-makers. 

“I’m hopeful for the future. We have the right pieces in place. We have the opportunity to make a genuine difference to our population. But we need to be mindful that the voices need to be at the table. We can’t work in partnership if only one partner is at the table.” 

Coromandel-based rural GP Fiona Bolden advises a shared common purpose as a pathway to success. “Localities are not going to succeed unless we’re all involved. We need a common purpose. We’re here for the health and wellbeing of people. We care about outcomes for our communities.” 

Using a cake-baking analogy, Fiona painted a picture of how localities need different ingredients to create the necessary flavours, or outcomes, for each cake. But we need a recipe and we need key ingredients such as workforce, funding and community in order to bake. The biggest challenge seems to be in securing the appropriate oven, or the system necessary to support the baking process. “Our ovens are currently very unfavourable.” 

Chair of the College’s Pasifika Chapter Monica Liva is excited to ride on the wave of community connection Pacific Peoples are experiencing as a result of campaigning for COVID-19 vaccinations. Monica is hopeful about an increase in Pasifika health workers, especially GPs. 

When it comes to community, Monica echoes Tristram’s calls for genuine partnership. “E fofo e le alamea le alamea,” a phrase that endorses looking for solutions affecting communities by looking within that same community for answers. 

Kyle Eggleton began his discussion with an acknowledgement of the optimisim expressed by the preceeding speakers, an optimisim, it would transpire, he does not entirely share. 

Kyle questions the misnomer of a ‘postcode lottery’ when a truly community-focused locality model will develop programmes appropriate for each area, which is, in essence, creating a postcode of programmes for each geographic space. And although he questions this model’s intention, he also questions its likelihood. With a centralisation of decision making, will localisation really happen? Kyle isn’t afraid to express his scepticism. 

“My concern is that genuine community voice may be lost as who the community actually is has not been well defined.” 

“How meaningful can locality plans be? The role of communities is to be consulted with, not to meaningfully develop the plan. The veneer of consultation hides a centralised agenda. Language and rhetoric are used to drive their own agenda. This is not a true consultation.”

“We need to be mindful of who is not in the room when decisions are made. We must involve communities in our decision making otherwise the solutions are not for everyone.” 

But how do we build the genuine community partnerships that are imperative to the success of the reforms? According to Tristram Ingham, it’s resources, or lack thereof, that blocks open engagement. “The answers lie in the community but the resources don’t. A system in which the community is actively engaged, on an ongoing basis, in a way that it’s their own conversations, not our conversations. These conversations need to be resourced in such a way that we will invest and grow capability, communities are empowered, informed, resourced and able to effectively partner in that space.” 

And if we fail in creating that partnership? “The usual suspects will rise to the surface. It’s easier to engage with those who are already in the system. The quiet voices, that we most need to hear, fall out of that process.”