On The Māori Health Authority

Friday, 23 June 2023, 7:50 am
Opinion: Ian Powell

Rob Campbell on Māori Health Authority

Rob Campbell appears to be on an adrenaline driven burst of writing since his dismissal as Chair of Health New Zealand (Te Whatu Ora) which shows no sign of diminishing.

This is a good thing. I have a vested interest. To paraphrase George Cole in the British comedy drama Minder, he’s not a bad little non-earner for my blogs.

Like many others who come into Aotearoa New Zealand’s health system in prominent roles, Campbell is ‘hooked’ on its dynamics and complexity along with its public good purpose. His adrenaline should continue because it’s not affecting his judgment..

Being ‘hooked is a good thing because he has valuable insights from his brief term in a unique leadership position in an unusual time. He also is cognitive and thoughtful.

What makes him even more interesting is his evolving understanding of the health system the more ‘hooked’ he gets.

Campbell’s opinion piece published in the NZ Herald (11 June) is an example of his thoughtful writing: Justifying the Māori Health Authority.

Focus and reasoning

His focus is the intention of both the National and ACT parties to abolish the Māori Health Authority (Te Aka Whai Ora) should they form the next government later this year. Campbell opposes this position.

His reasoning includes:

• National’s alternative is to establish a Māori unit in the Ministry of Health but the Ministry had such a unit for many years. Where is the evidence that this worked!
• Te Ake Whai Ora is essential to achieve the objectives of the Pae Ora (Healthy Futures) Act 2022 which created it. Achieving equity for Māori healthcare outcomes is critical to one of the Act’s three purposes.
• There are problems with the new entity but they can be worked through by having a higher degree of independence from the Crown in the setting of its governance and strategy.
• This independence includes increased funding. The current funding imbalance means dependence than partnership.
• Dismantling what has been only recently “…created will only fuel that suspicion and Māori are not unused to such treatment.”

While I would have expressed it differently, his observations broadly resonate with me. My differences are ones of degree rather than kind.

Restructuring context of Māori Health Authority

I welcomed the decision to establish the Māori Health Authority which was first announced by Government in April 2021. The Authority’s formation was one of three announced major structural changes, all to take effect on 1 July 2022.

Another structural change was the establishment of a new public (population) health agency to be located in the Ministry.

Both new bodies I believed had the potential to enable important improvements to Aotearoa’s health system and consequently to the health of New Zealanders. I still hold this view.

The third structural change was the further centralisation of an already centralised health system by replacing district health boards (DHBs) with a new more vertical structure (Health New Zealand).

That is, disempowering decision-making at the level where healthcare (both community and hospital) is overwhelmingly provided, and further empowering centralised decision-making upstairs.

At the time I said this would be disastrous. Everything that has happened since has vindicated this assessment.

‘If you don’t take the temperature you can’t find a fever’

In January 2023 my political opposite Heather Roy (former ACT MP and health spokesperson) and I collaborated to publish a joint paper designed to promote discussion on how to best improve the health system, given the restructuring we now have.

We titled it Te Whatu Ora: Achieving patient-centred care and wellbeing – If you don’t take the temperature you can’t find a fever: Taking the temperature to find the fever. The paper was also published by Newsroom in three consecutive instalments commencing on 17 January.

My political opposite Heather Roy and I were positive but cautionary about Te Aka Whai Ora

The focus was on what Te Whatu Ora needed to do but we did make the following comments concerning Te Aka Whai Ora:

The establishment of both Te Aka Whai Ora and the Public Health Agency are not the subject of this document. Both are positive initiatives. But both could have functioned, as established, without abolishing DHBs. Neither are magic bullets, however.

The Māori Health Authority’s major focus is on community healthcare and wellbeing in the context of inequities. Expectations are high on what it might achieve which may create problems. It has the potential to improve accessibility to healthcare services providing that it is practically focussed.

To be really effective an advocacy role will also be important. Advocating for government policies and legislation to address the effects of social determinants of health will benefit all susceptible New Zealanders, not just Māori.

These comments are as valid now as they were in January. Nevertheless, with the passage of time, there are further observations deserving of consideration.

In this context Rob Campbell’s published opinion piece is a constructive and thoughtful contribution reinforced by his brief experience as an ‘insider’.

Didactic risk

There are three additional observations which I would make. The first is my experience is that the further away decision-making is located from where healthcare is actually provided, the more it is likely to be top-down.

Worse still, it is also (and consequentially) likely to be didactic. There are few things that frustrate health professionals and health managers close to service provision more than having top-down directions being delivered in a morally instructive tone.

It is too early to conclude that the Māori Health Authority has gone down this path but the overarching health system culture it has to work within is conducive to top-down moral instruction.

Disempowering district level decision-making

Second, as a result of the disempowerment of decision-making at the district level, where most community and hospital healthcare is provided (achieved by abolishing DHBs), New Zealand’s health system is much more vertical than before last July.

The consequences of this disempowerment are similarly so for Māori healthcare. Unfortunately there are already indications of frustration among Māori providers with the Authority. These indications are consistent with this negative conflicting leadership culture.

It is not automatically so that a more vertically and centrally structured health system will lead to district level disempowerment. But there is a strong tendency for this to happen; it is more likely to happen than not.

If Te Ake Whai Ora is to successfully resist this powerful tendency it will need to proactively work to empower both Māori providers and Iwi Māori Partnership Boards within the districts they are based.

The Authority’s role should be to provide national cohesion, not operational direction, for this empowerment.

Funding via commissioning

My third observation is where I sharply disagree with Rob Campbell’s opinion piece. This is where he promotes a greater role for the Māori Health Authority in funding (as distinct from the adequacy of funding for it to function effectively).

In this context he means ‘commissioning’. The difficulty is that commissioning is not a term used that much in health systems.

Its main use has been in the National Health Service in England where, for decades, it has gone in and out of favour depending on the ideological bent of the moment.

Heather Simpson: her review gave ‘commissioning’ traction

Commissioning was used as a title in the Ministry of Health when Chai Chuah was Director-General. But it took the final report of the Heather Simpson led Health and Disability Review (2020) for the term to get traction.

The Review recommended the establishment of the Authority. In a divisive split supplementary decision it also recommended that it have advisory rather than commissioning powers.

This further decision shaped a subsequent forceful debate over whether its role should be extended to commissioning.

In a virtual hui organised by New Zealand Doctor in mid-2020 I argued that commissioning was not a well understood term. It meant different things to different people. The preoccupation with the term was distracting and potentially restricting.

Advocating commissioning might have the unintended consequence of constraining its role. Instead I argued that advocates of commissioning should replace it with the term ‘decision-making’.

The Government eventually chose to extend the Authority’s role to commissioning. To the extent that commissioning means something, it is funding and planning healthcare services. These were functions previously undertaken by DHBs

Decision-making is broader than commissioning. In the context of the funding of Māori healthcare it is less important for the Authority to directly fund providers.

Instead it is more important for it to have sufficient decision-making power to ensure that Māori healthcare is well funded. This might appear to be a semantic distinction but it is not.

If I were to summarise my three additional observations in one sentence it is this. If Te Ake Whai Ora is to succeed it needs to adopt and internalise a relational rather than structural culture which becomes ‘business as normal’.

ENDS

Ian Powell

This post of health systems blog ‘Otaihanga Second Opinion’ discusses the Maori Health Authority in the context of a recent published opinion piece by former Health New Zealand Chair Rob Campbell.

© Scoop Media

Ian Powell

Otaihanga Second Opinion is a regular health systems blog in New Zealand.

Ian Powell is the editor of the health systems blog 'Otaihanga Second Opinion.' He is also a columnist for New Zealand Doctor, occasional columnist for the Sunday Star Times, and contributor to the Victoria University hosted Democracy Project. For over 30 years , until December 2019, he was the Executive Director of Association of Salaried Medical Specialists, the union representing senior doctors and dentists in New Zealand.

Contact Ian Powell

• Website - Otaihanga Second Opinion