Similarly I am not going to spend time listing the many things than are wrong about our public health service and its outcomes. That has been done often enough in research papers and media commentary and experienced more than enough by whanau throughout the country. Enough to make it clear in my view that we have sufficient crises in different aspects of public health care to declare a ‘health crisis’ worthy of a crisis response. This is so despite the many excellent things that are done every day within the public health service by many skilled and dedicated people.
If anyone does not think that we have a health service crisis then again I don’t really have anything useful to share with you.
I start with a summary of what I do want to share:
- There are important aspects of the Pae Ora reform package which are not adequate to the task; and
- There are significant ways in which the implementation to date of the reform package is deficient; but
- This is not, and should not be accepted as being, incapable of repair.
I will cover each in more detail but first I also summarise the view of effective social service change which I apply in these thoughts. This view derives from my experience across a fairly wide range of social, government and commercial activities over quite a long time. It is not a revolutionary view, you might even label it Fabian.
This view is that to effect substantive social change you need to have:
- A clear and shared view of what the purpose of the change is;
- Leadership and strategies which are consistent with the change purpose;
- A realistic appraisal of the environment in which change is to be effected;
- A sound understanding of the issues for and ways to involve people affected by the change;
- Effective ways to communicate about the various elements of the change in all directions..
You will hear as I work through my thoughts that I do not think the Pae Ora reform process has that base and it must now be reconstructed.
We must not let that happen.
I start with what I think the architects of the reform package got wrong.
1. Removing structures like the DHBs and shared service agencies without clearly establishing or signalling replacement structures at national, regional and local levels. These levels were left too poorly defined and this created confusion and led to excessive centralisation or at least the perception of that. To repair and establish appropriate standards, accountabilities and systems a high degree of centralisation was required but that did not mean that systems of local and regional involvement and influence were not also required ;
2. Adding poorly defined new structures such as “localities” and “Iwi Maori Partnership Boards” intensified this. While conceptually these could deliver that critical local and regional involvement and influence over time, leaving a gap while they are established showed an unrealistic appreciation of the environment for change;
3. Inadequate involvement of unions and professional organisations in the structuring and implementation process restricted both support and clarity of roles. This ignored both the historic influence of these organisations and their potential (willingly available) to guide decisions in tune with the reforms and enable implementation. This showed an unrealistic “managerial” lack of appreciation of the necessity for active positive engagement.
4. Carrying through all old roles and management added confusion and cost and limited real commitment to the new structure. The same people in the same or essentially similar roles leading change showed an inadequate appreciation of the scale and depth of change required. It also restricted the capability to quickly drive real culture change;
5. Failure to define and structure quite different functions such as property development, operation, and maintenance into a separate organisation hampered focus in those roles and in the wider structure. This was compounded by not undertaking a thorough prior revision and reprioritisation of capital projects to match to the new structure and direction ;
6. Allowing IT project strategy and promises to be too aspirational and too complex - beyond the limited capability of inadequate existing systems and their renewal and repair which had to be the initial focus.
7. Failure to define a new model for funding and support of primary services in conjunction with those services ahead of establishment. This was a critical error as it obscured a clear view of the purpose of change beyond aspirational slogans and limited ability to engage primary services in the process.
8. Critically, failure to resolve major issues such as pay equity and pay parity and holiday pay and primary care funding as part of the initial package.
9. Imposing structures on Maori which stepped past existing sector structures such as Whanau Ora and kaupapa Maori providers and which were not driven by iwi and hapu, taking only limited account of Maori health views and world view while not providing anything like the funding and power to enable mana motuhake and tino rangatiratanga.
10. Not sufficiently delineating accountability for Manatu Hauora and eg Health Safety and Quality Commission and other health sector agencies. These all had to be restructured and aligned together.
Simply there was far too much undefined. Too much not rooted in stakeholder support or even comprehension. Too much which was old form public service delivery in style and content. Too much which limited efficiency and clarity throughout the system.
It may have looked ok on a whiteboard but in practice it looked like the half-baked cake it was. If there was any kind of consumer guarantee in the contracts for advice from the consultants involved, you would be calling on it.
I won’t focus tonight on “co-governance” but I do want to say that the Pae Ora reform is very far from either this concept or from Tiriti-based governance and management. Te Whatu Ora and Te Aka Whai Ora do work together in common interest. But Te Aka Whai Ora is a creation of the Crown, not Maori. It should have had much more independence, money and power than it has. Its excellent leadership will make the best it can of what it has but no-one should think this is enough, good or good enough.
It was possible for Te Whatu Ora once established to implement change even allowing for some of these things but not helpful to have it grapple with the lot simultaneously . Those of us who took on board roles did so with genuine commitment to the kaupapa but with reservations about the structures from the beginning. For myself, as my understanding of the health system grew, it became evident that our challenges were huge given the gap between aspiration and reality and this became quite intense as we battled our way to a highly compromised Te Pae Tata/interim Health Plan, tried to generate activism and accountability against a reluctant management structure, and negotiating ongoing top down controls based on past principles and practices from Ministry and other officials.
In practice the structural issues with the reform package were not helped much by failures in the implementation process:
Te Whatu Ora:
1. Remained excessively focused on serving“Wellington” in its broadest public service hierarchy sense and not on the real needs of clinical and care providers or even more crucially the wider population;
2. Did not involve unions and professional organisations in the implementation process even to the extent that was possible after commencement but treated them as something to be managed;
3. Treated the funded primary sector effectively as they had been treated before and did not engage effectively with them, listen to or involve them sufficiently in the process but again treated them as something to be managed;
4. Allowed roles and managers which were getting in the way of change to remain in place rather than quickly and effectively changing or removing them;
5. Was too slow to abandon behaviours which were not directly or effectively serving the cause of change;
6. Did not fight energetically or effectively enough against against legacy projects which were no longer appropriate priorities;
7. Did not engage or communicate positively and directly enough with internal and external stakeholders about the change process, or encourage their effective involvement and influence;
In short Te Whatu Ora became not a representative and advocate “for” those working in or using the public health service but Government’s representative “to” them.
My perception from board level is that there was the line of thought and the intent to be much more effective in this but we were held back by:
1. Too many managers at all levels who are indecisive or inadequate or even opposed in terms of being active change leaders; and
2. Lack of political will from above to embrace the necessary radicalism or urgency of change.
3. Too many objectives/priorities (call them what you will) such that many parts of the system and people within and engaging with the system were left confused and disengaged.
It felt as if having created and passed the legislation those in political control lacked the will to see it succeed.
These are not offered as excuses. The board under my leadership should have been more demanding, resolute and courageous. Timidity was not an option, especially given the structural inadequacies which were embedded in the process.
So what should be done from here? Te Whatu Ora can and will deliver some changes within its current managerial/administrative mindset. But in its current form it cannot deliver the level of radical change which is required. Inadequacies and things which are just plain wrong will persist and in many cases get worse unless there are substantive changes. I do not say this to give any succour to political parties which want to turn back the clock or to deny equity or to those who welcome further demise in public health services for commercial reasons. I say it because we all have common cause in having a much more equitable, excellent, efficient and effective public health service than we currently have.
We need to have some practical changes which require Government and Te Whatu Ora together:
1. Recognise that “localities” are not a short term answer to health service issues. We should encourage inter-agency and community group involvement in wider determinants of health but this cannot be the key focus of primary health services in the immediate future. Te Whatu Ora must work with the existing agencies and models in crisis response;
2. Recognise existing national, regional and local clinical networks as core to clinical service delivery which management serves and co-ordinates but does not seek to control;
3. Create separate physical and digital infrastructure operating units within Te Whatu Ora with their own budgets and accountabilities, contracted to serve the clinical, care and digital operating requirements of the delivery units;
4. Directly involve the funded agencies in urgent review of contracts and funding to consistently apply equity and accountability systems, effectively decommissioning the current commissioning system;
5. Directly involve the unions and professional organisations in all planning and governance processes at all levels;
6. Establish a planned transfer of substantive funding to Te Aka Whai Ora sufficient to support effective Maori health services;
7. Immediately conclude the various pay equity, pay parity and holiday pay issues. There are funding issues but delay is simply harmfully delaying the inevitable.
8. Implement promptly the internal restructure to remove the duplication and multiplication of roles from the old structure and transfer resources to where they are most needed. While consultation has started this has been far too slow in development and has had far too little staff involvement to date. It should not be an exercise on its own but an integral part of this group of major initiatives I am outlining;
9. Urgently identify and fund the best training, retraining and recruitment steps in the key roles with additional budget as required. Current work is too stolid, unimaginative and lacking in crisis urgency. This includes reform of restrictive practices imposed by occupational groups and active promotion of community based service delivery and up-skilling of these people. It is wrong that funding cuts from Covid experience have ended a very valuable workforce initiative;
10. Prioritise known public health initiatives which will impact demand for “ill health” services. Be bold about alcohol, sugar etc in the same way that smoking has been attacked. Also back this up with genuine public health campaigns which actively deliver services where most needed, not advertisements.
11. Engage more positively and effectively with the private sector insurance, hospital and other services to define roles and include them in the system objectives and principles. They are an embedded part of our system and must be part of the crisis solution. Be prepared to replace where there is not a satisfactory “working together” option. The fact is that so much of what is public about our public system has been degraded that any realistic process must include these services. But neither should there be an assumption that all private services continue.
12. Establish clear, limited and agreed targets and accountabilities in each part of the structure.
Implementing this radical change program will require throwing off some of the public service procedures and rules. Radicalising the process as well as the aims.
None of this is a panacea and yes it will cost a lot more money up front. But we have found a willingness to act decisively and expensively when one-off external events strike causing community harm and this crisis is really no different other than its greater scale and lasting potential for community harm. This could all be done with political will to really follow through on the Pae Ora principles and with the governance and management independence, energy and courage to carry it through. A lot of money up front is a fraction of what will be spent later in its absence.
We can learn from the experiences to date. For example while the localities will not form clearly, quickly and effectively enough, the activity around them has confirmed how involved local people and their community organisations want to be in the future public health system, what they already bring and with the right process can bring to it. They have highlighted the many aspects of effective health services and the social determinants of healthy whanau and communities which require multi-agency response beyond what Te Whatu Ora alone can bring. There is opportunity to involve all central and local government agencies together with the voluntary sector in common cause, with Pae Ora as a catalyst. This is exciting but does require adjustment. So we should pivot to that.
Similarly the limited experience so far has highlighted how integrated private and public provision of health services are. We need new ways to think about that on all sides. There are opportunities but they will not develop inside the old commissioning and contracting structures. Pae Ora can again be the catalyst. Another pivot.
I think that Te Aka Whai Ora has had some similar experiences and insights. I will not intrude on those but we must also be able to pivot around those experiences to develop better answers.
In other words, neither the inherent inadequacies of reform structures or the failures of implementation need to hold us back if we treat them as learning opportunities. To effect that approach means stepping outside of the old public service controls and processes. Being brave enough to do that. Being brave enough to take risks. Dare I say it, to embrace different ideas and share them openly.
I think that one of the issues to date is a widespread perception that this political will and this governance and management commitment and capability is not there. That the process or significant elements of it will not be carried through. So people prevaricate, leave the system, or work on in disillusion. This has harmed us badly and will continue to harm if there is not more clarity in a collective leadership of change. If there is a will to do this then we can use the Pae Ora Charter as a guiding principle to which all participants are genuinely committed. This has not been possible to progress effectively in the environment and the change structure we have had to date.
I have described many of the inhibiting factors. Change is caught between the old order and ways of doing things which produced the crisis and the unrealistic output from the consultancy-driven restructure. With insightful and determined Ministers and a genuinely skilled and committed board and management working with rather than against or in an uneasy relationship with other stakeholders this can be done.
Some may recoil at the prospect of further change. But that often is how progress is made. Looking forward and being prepared to meet the challenge not step back. Such a major crisis response is major social change and must be implemented within a framework such as that I identified at the outset:
-clear view and intent;
-capable and consistent leadership;
-realism about the environment;
-involvement of people;
Hopefully those involved now can see and act on that.
Pae Ora Health Reforms
St Andrew’s On The Terrace
Wellington 3 April 2023
Former Chair Te Whatu Ora