Sunday, September 21, 2008

18-22nd August, 2008. Auckland and Wellington, New Zealand
New Zealand holds a great deal of interest to anyone interested in health policy and living in the UK. In both countries the executive has almost unchallenged power to introduce laws, with no need to build supportive coalitions at other tiers of government or with civil society organisations. This has many attractions for politicians – after all, why explain your decisions if you don’t have to. However, the absence of detailed scrutiny also makes it easy to enact unworkable laws, and then to revise them with ever increasing rapidity.
New Zealand acted as a health policy laboratory in the 1980s and 1990s, introducing market reforms that went well beyond those then being contemplated in the UK. The word “hospital” was no longer acceptable, being replaced by Crown Health Enterprises. They were intended to work like businesses but to continue to be socially responsible. Inevitably, those running them failed to resolve the contradictions. Many chief executives left. Costs increased rapidly, as did waiting lists. By 1996 the Treasury concluded that ““The health reforms have yet to yield the original expectations. By a range of measures … the pace of performance seems, if anything, to have been weakened since the reforms.” However, lessons were learnt. Those bits of the system that had worked were retained, especially Pharmac, the pharmaceutical purchasing scheme that ensures that New Zealanders get low cost drugs. However the purchaser-provider split was abolished and a new system was put in place in which health care was delivered by 21 district health boards. The most important lesson was the destructive effects of what can seem like endless attempts at reform. Reform fatigue set it and even though there is widespread agreement that the current system is not perfect, there is little appetite for structural change.
I was in New Zealand for a series of meetings, concluding with a conference entitled
“Building tomorrow’s health services”, held in a spectacular community and conference centre built in the form of an upturned Maori boat.
My trip included several meetings at the Minstry of Health in Wellington and a masterclass in Auckland. New Zealand’s health system faces many familiar challenges, including an aging population and the rise of complex non-communicable diseases, as well as some that are less familiar, such as a long-term redistribution of population, away from the South Island and into the greater Auckland area. It also experiences a high level of emigration of health professionals although, as we learnt, the emigration rate is not significantly different to other graduates. There is, however, a remarkably clear vision of what needs to be done, embracing prevention (and especially action to reduce the persisting inequalities between Maori and European populations) to integrated delivery systems.
In 1948 Aneurin Bevan, when asked to speculate about the forthcoming introduction of the National Health Service replied “do I need a crystal ball when I can read the book”. He was referring to the successful introduction of a health service in New Zealand a decade earlier. Could it be that English politicians will once again learn a lesson from New Zealand and place major structural chage on hold for a while to allow people to just get on with the job of delivering better care. Somehow I doubt it, but we can but hope.

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