Friday 23 April 2021

Labour’s Health Reforms: Boldly Going Where It Might Not Be Wise To Venture.

Breaking Bold: Andrew Little's reform of the health sector smacks of the sort of desperation that seizes politicians who know very well what the solution to the problem facing them is, but, having been told they cannot choose that solution, have opted to distract us with something so huge that our first instinct is to say: “Crikey! They’d hardly choose to do something this big if the odds of it succeeding weren’t exceptionally high.” But, are they?

THERE IS NOTHING WRONG with being bold, the real trick is to be bold about the right things. Is “Health New Zealand” (HNZ) the right thing? Labour supporters are saying it is with a suspicious degree of vehemence. (The sort of vehemence usually reserved for the defence of a dear friend who has done something that we all know, deep down, is really, really stupid.)

Meanwhile, the National Party has promised to repeal the legislation setting up HNZ the moment it’s re-elected. For good measure, they’re labelling the proposed Maori Health Authority (MHA) “separatist”.

So, there you have it. This “bold” reformation of New Zealand’s health system will proceed without the slightest hint of bi-partisan consensus. Excellent.

What do I think of Labour’s proposed reform? From what I’ve been able to glean over the course of the past few hours, the whole exercise smacks of the sort of desperation that seizes politicians who know very well what the solution to the problem facing them is, but, having been told they cannot choose that solution, have opted to distract us with something so huge that our first instinct is to say: “Crikey! They’d hardly choose to do something this big if the odds of it succeeding weren’t exceptionally high.”

It’s a good trick – but is it the right trick?

Regretfully, I’m forced to say “No.”

What has been at the root of our health system’s problems for the past 30 years? Inadequate funding and a management regime intended to replicate the incentives and disciplines of the free market. As New Zealand’s population has aged, the demands upon its public health system have steadily increased. Unfortunately, this rising level of demand has coincided with the imposition of neoliberal economics. Accordingly, from the mid-1980s onwards, the necessary fiscal adjustments have been deemed impermissible by politicians and bureaucrats alike. Rather than raising taxes to fund New Zealand’s hard-pressed health system, successive governments have commanded those charged with running it do more and more with (in real terms) less and less.

Had Andrew Little and his colleagues announced this morning that, thanks to a major fiscal re-jig (to be announced later in the day by Finance Minister, Grant Robertson) there was to be a significant and permanent increase in Vote Health, then we would have been able to say that this government had indeed grasped the nettle of reform. If they’d also announced a return to the ratio of administrators to health professionals that prevailed in the early 1980s, then we could be certain that what we were witnessing was a wholesale repudiation of the neoliberal model in health delivery. That would have been “transformational” – with bells on.

Sadly, that is not what Little and his colleagues announced. Rather than more money, more professionals and fewer administrative overseers, this government has opted to construct a massive single bureaucracy out of its current collection of 20 smaller bureaucracies. There is no hint that this new HNZ bureaucracy will be run on anything other than neoliberal lines. The same determination to prevent “professional capture” of the health service will lead to exactly the same sort of bureaucratic interference that eliminated the outstanding professional leadership of the Canterbury District Health Board only a few months ago.

For good measure, the new health system has been shorn of all the pitiful vestiges of democratic accountability still clinging to the DHB model. How the new, improved, neoliberal bureaucrats of HNZ will be held to account is anybody’s guess.

“But what about the new Maori Health Authority?”, I hear you ask. “Surely this innovation is an unequivocally progressive advance?” We must certainly hope so, but even here the Labour Government’s proposals fill me with nagging doubts.

In this morning’s media release, the Minister announced that: “A new Māori Health Authority will have the power to commission health services, monitor the state of Māori health and develop policy.”

On its face, this sounds excellent. Indisputably, Maori and Pacifica New Zealanders fare much worse at the hands of their health system than Pakeha New Zealanders. A MHA run by Maori, for Maori, is surely more likely to produce better results than the present system, which insists on treating all patients “the same” – regardless of the very different (i.e. inferior) health outcomes its one-size-fits-all approach produces.

If, however, we unpick the Minister’s statement, it becomes apparent immediately that the MHA will not, itself, be the provider of Maori health services. These will be “commissioned” by the Authority: presumably from private Maori contractors. Exactly who these contractors will be is not spelled out. Urban Maori Authorities will almost certainly be involved, as will health providers established by Iwi. We may even see the rise of Maori health entrepreneurs: individuals keen to profit from the needs identified by the MHA’s “monitors”.

If Little had announced that HNZ would be commissioning private sector providers to supply the health needs of New Zealanders, then the Left would have condemned him roundly. Labour would stand accused of privatising the public health system. People would demand to know how the citizen’s right to publicly provided health care can possibly be reconciled with the pursuit of private profit. That no such outcry has greeted the Government’s decision to hand over the health care of New Zealand’s poorest and most vulnerable citizens to private entities – some of them quite likely profit-seeking businesses – is telling.

Is Labour of the view that Maori are incapable of exploiting Maori? Is it saying that the operating principles of capitalism cease to function when the capitalists’ skins are brown? That indigenous people, simply by virtue of being indigenous, possess moral qualities that render them incapable of wrongdoing and that, as a consequence, they must be permitted to operate freely, without the strict bureaucratic oversight deemed essential for businesses conducted by the descendants of settlers and immigrants? Surely not.

Labour might also like to answer how it could possibly be in the MHA’s interest to report anything other than a strong improvement in Maori health outcomes. Were it ever to report that in spite of its best efforts the general health of Maori New Zealanders, as compared to Pakeha, continues to decline, then one of the key rationales for its establishment would be seriously compromised. Is it reasonable to ask the MHA to be a judge in its own cause?

Readers may find these propositions jarring, but that will not stop them being advanced by Labour’s political opponents. Indeed, it is happening already. What’s more, if any of them turn out to be true, then Labour’s health reforms will stand revealed as the wrong sort of boldness. Jacinda’s government will have tricked itself.


This essay was originally posted on The Daily Blog of Thursday, 22 April 2021.

24 comments:

Kat said...

Another devil in the detail situation, who the appointees are to run this new ship HMS HeathNz is the critical factor. I would say this is even a bigger challenge for Labour and Andrew Little than the reform itself.

National can whinge and sulk all it likes, difficult to champion neoliberalism and offer any consensus involving anti neoliberalism. Then again the National party itself is having great difficulty knowing what it stands for these days.

Jasper said...

I feel a 'Republic' coming on.

Shane McDowall said...

Free universal dental care for all adults should have been part of the new system.

And St.Johns should be totally publically funded.

As for a seperate Maori health care authority I saying a big "NO!". I suspect that the main beneficiaries will be - as usual - middle class Maori.

Most of the poor health of Maori and Pasifika are a result of poor lifestyle choices. The tsunami of Polynesian obesity is already with us and is just going to get worse.

greywarbler said...

For reading that will either make you sleepless at bedtime or smother you with facts and send you to sleep. The Nuffield Trust in the UK has an extensive study of their health system and its presented in a way that anyone can understand it.
Here is the 2008-2017 report, and there is an earlier one that can be accessed from it.
https://www.nuffieldtrust.org.uk/chapter/2008-2017-an-uncertain-path-ahead

Something in The Guardian from 2017 on the NHS and Labour by Polly Toynbee.
https://www.theguardian.com/commentisfree/2017/feb/28/labour-nhs-jeremy-corbyn-hospital-theresa-may
There is response when something drastic happens she says.
Tony Blair in 2000 had an attack of flu with one case publicised bringing a change in their austerity budget on the health system.
Margaret Thatcher in 1987 had dying babies forcing 100 million pound input but punished it somehow through 'the internal market'.
Theresa May - already two patients have died on Worcester Royal hospital trolleys, one after a 35-hour wait.

Status in 2017 - With its lowest ever funding rises, its hardest years are still to come, despite soaring numbers of the old, hospital admissions up by 31%, and 22% more A&E patients since 2010. Staff shortages follow cuts in nurse training and worsening GP and specialist recruitment...Hospital beds have been cut, cancer operations have been cancelled against surgeons protests. Ambulances frequently stack up outside hospitals.

Look at King’s College hospital, in south London: its chair, Bob Kerslake, calls official finances “kidology”. Ordered to make a surplus this year, King’s can’t avoid a £2m loss – yet the punishment is a cut in funds, sending its deficit to £30m, and an instruction to make a £26m surplus next year: this is mirage accounting, mirrored everywhere.


Starting from scratch in NZ if that is what is planned, may just be opening another can of worms when we all hoped for more spaghetti. We have got spaghetti now, so cross our fingers and toes that we find the right recipe, and things tick along okay while we look for it.

John Hurley said...

To quote Einstein: ‘If you can’t explain it to a six-year-old, you probably don’t understand it yourself.’
.........
i was listening to this
https://www.rnz.co.nz/news/national/441069/local-government-review-to-focus-on-evolution-over-next-30-years

So they are going to improve local democracy while incorporating TOW "partnership" = Maori + Migrants.

The article is useless unless it analyzes the interested parties and I doubt it is anything like a local community attempting to continue their way of life.

National has embraced woke because it is a carve up of power and National just wants a regular flood of migrants and no obstacles. The other side want international students and a completely new society and fame and glory "on the world stage". Maori get high paying jobs (and regular jobs).

Anonymous said...

Public Health system defined:
1) The system that will remove a growth from a woman's jaw but NOT do the reconstruction surgery so that she can the speak and EAT! Amazing.

2) The system that will give me - a 68 year old woman - one more breast exam and then tell me to come up with the equivalent of $500 every two years if I want to go on being checked for breast cancer. If I do not find that money and come down with the bug a) by the time it makes itself known the disease will be likely less survivable and b) cost the public healh system far more than to treat than it might have done if found early.

Rosie

CXH said...

Jasper, it looks more like totalitarianism than a republic. That Maori have the right to overrule decisions being made for the rest of NZ is not a good look.

It seems Vision 2040 is aiming for a partnership straight out of Animal Farm. All partners are equal, but some are more equal than others.

Jays said...

The separate Maori health body is by definition separatist and resoundingly racist.
The only people to benefit from this coming fiasco will be public servants.
Health NZ will make Kiwibuild look like an unqualified success as building 10,000 houses per year is trivial when compared to the reformation of the health system on this scale.
I doubt any government in the last 50 years could have achieved this and the current Government is the most incompetent since Muldoon, although once the fluff this policy they make actually surpass him.

Jack Scrivano said...

I heard a Maori spokesman saying the other day that Maori want healthcare at a time and place that suits them. And non-Maori don't?

John Hurley said...

I've watched "Maori" kids grow up and overtake me. When you boil it down it is class and subculture.
It is hard to believe that someone with the IQ to go to medical school is disadvantaged (don't stop them jumping up and down though - Emma Espiner).

Tom Hunter said...

[If] there was to be a significant and permanent increase in Vote Health, then we would have been able to say that this government had indeed grasped the nettle of reform.

I was a little surprised about that missing factor as well, especially considering the money they're throwing at other things:
- $100m on the Royal Commission of Inquiry into Abuse in Care.
- $30m on Ihumatao.
- $50m on Pike River.
- $105m on the media.
- $100m on the new train set for Hamilton-Auckland.

That's almost one new hospital there if Labour had chosen to merely re-direct the funding to Health, and all without raising taxes.

But it really won't affect taxes anyway, at least not in the short-term, because this is all created credit; Modern Monetary Theory that has been pushed by numerous Left-wing activists around the world and appears to have won by default. Social Credit reborn it would seem.

Unlike the MMT folk however, I don't think all that created debt can be just ignored, wiped away or reduced in relative scale by any foreseeable economic growth rate. It will be paid back with increased taxes, not by us but by our children and grand-children.

Assuming they stick around in NZ of course.

Tom Hunter said...

What has been at the root of our health system’s problems for the past 30 years? Inadequate funding and a management regime intended to replicate the incentives and disciplines of the free market. As New Zealand’s population has aged, the demands upon its public health system have steadily increased.

Hmmmm. Well for about half that period, one still dominated by NeoLiberal Economics,
between 2000 and 2018:
- NZ population grew from 3.857 million to 4.955 million
- Proportion of the population aged 65+ grew from 12% to 15.2% of the population
- Health care funding per person grew from $US 1054 to $US 4037 (ppp adjust)

Which means annual growth rates of:
- NZ population, 1.4%
- Population aged 65+, 1.3%
- Health spending per person, 7.7%

Obviously there's a multiplier effect in that the costs of serving even a slightly higher number of people 65+ won't be the straight-line growth rate of that population, since our health care demands increase faster the older we get.

Still, I find it hard to accept that the multiplier is so large as to have a 1.3% annual growth rate of 65+ population translating into a 7.7% per year growth rate in health care spending per person across the whole NZ population.

Inflation in the wages and salaries of medical staff, drugs, machines, surgical treatments? I guess there would be something in there.

Whatever the reason, there's nothing to indicate that the new Labour proposal - or its deficient predecessor - would be better able to combat whatever those drivers are.

So basically your remedy of just spending more money will likely be what happens going forward, except of course that it will never be enough. If an already annual growth rate of 7.7% is not enough then exactly how much over what time frame would work for you? Ten percent per person per year? Twenty?

Final note: increased taxes will ultimately depend on an economy that has increased in size. Don't kid yourself that we have enough rich pricks to pay for this, and that's before we get into their methods of escaping such taxes. No, as usual, it'll fall on the middle income earner and their income increases are very much dependent on the economy growing, and we haven't grown by 7.7% per year in this time frame. Or ever really.

Don Franks said...

Most of the poor health of Maori and Pasifika are a result of poverty

PaulVD said...

"If Little had announced that HNZ would be commissioning private sector providers to supply the health needs of New Zealanders, then the Left would have condemned him roundly. Labour would stand accused of privatising the public health system. People would demand to know how the citizen’s right to publicly provided health care can possibly be reconciled with the pursuit of private profit."

I understand how awful it would be to have a health-care system contaminated by the pursuit of private profit rather than public benevolence. So I will immediately cease drawing on the services provided by profit-making private entities:

* My primary care has been provided by a doctor who owns his practice and employs several other doctors and supporting staff. He apparently lives off the profits that he makes from this business, much like any builder or plumber.

* I have been in the habit of getting both prescribed and over-the-counter medicines from privately-owned and profit-making pharmacies.

* My optometrist, dentist, and periodontist all run their services as profitable businesses, structured like my doctor's practice.

* Over the last couple of decades, my wife and I have each had minor surgical procedures, performed in a private hospital by private surgeons, with the expense being paid for by an international insurance company. In my wife's case, the doctor had also put her down on the public surgical waiting list. Some months after the private surgery had been completed, she got a letter from the public sector that she had been taken off the waiting list and referred back to her doctor.

My grandchildren have been born in public hospitals, so I understand that some parts of NZ's health system are in fact operated by the public sector. But I have personally had very little contact with that part of the health system. I hope that it works well and efficiently, because I pay for it even though I have not used it much. But my experience has been that health services provided by organisations that are in pursuit of private profit work perfectly well.

Some of the health services that I draw on are publicly subsidised, although most are not, and justice requires that there be public subsidies for services to people with less disposable income than me. And if the system is producing poor outcomes for certain citizens, that must be addressed (although I seriously doubt that a central Government bureaucracy will address it effectively). But a "right to publicly provided health care"? What is the basis for this right? Why not a right to publicly provided food, so that we are spared the necessity to acquire food from profit-seeking supermarkets?

sumsuch said...

Amusing response. So, out of the blue. And you suggest it's a diversion. Zertainly it could be left alone. But it's just a bureaucratic matter.

The only things that matter are fairness and climate change.

greywarbler said...

I doubt any government in the last 50 years could have achieved this and the current Government is the most incompetent since Muldoon, although once the fluff this policy they make actually surpass him. Anybody who can make a sweeping assertion like this, doesn't deserve to receive a look at their other opinions Jays.

Don Franks - 'Most of the poor health of Maori and Pasifika are a result of poverty'. Perhaps you could keep dropping that single sentence into the rhetoric every month or so; cutting through the clots like a hot knife through butter.

That would give Jack Scrivano a pause to go fact-finding and sorting of research findings for the answer to his naively wry comment. I heard a Maori spokesman saying the other day that Maori want healthcare at a time and place that suits them. And non-Maori don't?

David George said...

Don:"Most of the poor health of Maori and Pasifika are a result of poverty"

Poor people generally are less healthy, have shorter lives.

My late mother's doctor, a European immigrant, couldn't understand why is Kaikohe patients were so unwilling to make basic changes to protect their own health, their own life. Lose weight, more exercise, better diet, that sort of thing. They just carried on as before but would come back for medications that were only really helping the symptoms if that. He was disillusioned, why should he even bother?

The willingness to bargain with, and to sacrifice for, the future is what separates the successful from the unsuccessful.

Guerilla Surgeon said...

"But my experience has been that health services provided by organisations that are in pursuit of private profit work perfectly well."


"I had a small wound on my toe which wasn’t healing for almost a month. Worried about it I went in to urgent care to have a doctor check it out. That was in August, 2017. This was my first experience at a medical facility of any sort in the US.

I had joined a new job in the month of July and opted for health insurance from my employer. But until the end of August I was also covered by my husband’s insurance through his employer, which was a pricey one costing almost 750$ for us together.

At the urgent care, I waited for an hour and then a doctor came in. He had a simple look at it and told me that it looks perfectly normal and would heal in a few days. The only thing he gave me was a single band-aid. I used the insurance through my husband’s employer and walked out.

After a month I get a mail from the insurance provider stating that they would not be able to cover the cost of my visit as I was also covered by another insurance. So then I wanted to process it through my new insurance. But it was in vain too because at the urgent care I used my old insurance to cover the cost.

In the end I was stuck in the middle of both the insurance providers but was still uncovered for my visit. I ended up paying 400$ for a single band-aid. That was one pricey band-aid!!"

Maybe it does, maybe it doesn't, but the American medical system has thousands if not millions of stories like this attached to it. Have a look at a question website such as Yahoo answers or Quora. Post a question about people's experiences with the private US medical insurance system and its costs. Then wait to be inundated.

greywarbler said...

David George - One illness that many people have is the ability to make facile negative judgments about matters they find wrong, and don't understand. I do it myself, and I see it in your comment. Only by trying to understand the mindset, the thoughts that reinforce the behaviour can an effective approach change the pattern of behaviour.

Tom Hunter said...

Post a question about people's experiences with the private US medical insurance system and its costs. Then wait to be inundated.

There are many such stories and they arise from the ridiculous lengths that hospitals and clinics in the US go to in boosting their charges sent back to the insurers. People who fall outside the insurance get caught up in the nonsense. Used an IV line? $X. Added a particular type of needle to it? $X+X. There are literally qualifications you can get for the process.

Having said that the inundations never seem to overcome the regular sample surveys of the 130 million or more Americans who have health insurance paid for by their employers. Which is not surprising given how many of those insurance plans cover everything, so people think it's all "free", which is yet another flaw that constantly boosts the costs of their system.

Never mind. The US public:private spend is now past 50:50, having grown from 5:95 in the mid-1960's, and it will continue to grow. In NZ it's something like 80:20 so we're not as different as people often think. That 20% figure I find somewhat surprising, but then one of my best mates has always had private medical insurance here, despite being a Labour Party and Public Health (and anything else "Public") supporter to the max so perhaps it's more widespread than I'd thought.

sumsuch said...

Can you talk about how immediate things are killing us? By diverting us from addressing what really matters.

Inspired by seeing Chomsky on MSM for the first time in many a year -- all 10 or so minutes.

David George said...

Thank you Grey, that Doctor, though he said he didn't understand, I think he did and I think I do too. Even though the stakes are so high people avoid the confrontation with reality, maybe they've done it all their lives. It's human frailty, habits are hard to break, maybe I'll be lucky, have my cake and eat it too. We can lie to ourselves, maybe I can cheat reality but reality is way bigger than we are.
The final judgement is not ours, God, reality if you like, has the last word. Wasn't that made clear right from the get go in the Garden of Eden story: You are now human, you have the knowledge of good and evil and your own mortality. Make your choices but remember, henceforth it's on you. How could it be otherwise.

That thing about sacrificing for the future isn't something I just made up, it's a fact, observable and eternal. It's the essence of the Christian story.

greywarbler said...

David George - that Europen immigrant who was a doctor may have been one who had been through WW2. He may have been Jewish, one of the small percentage who was not 'selected'. Once one reads the stories from that time, and how hard it was, it is understandable how they would consider that others need to summon mental strength, determination and courage in living. I notice in books that post-war authors seem to bring a sensitivity to human behaviour.

We have a battle before us against climate problems, lazy thinking, a desire for enjoyment without obligation, a shuffling off of responsibility and becoming informed about human behaviour. There is a need for practical planning and involvement in our settlements and country and those who won't take steps to co-operate in good practices to benefit the group can get involved in education, say night classes, in what being a citizen involves. I have an acquaintance who is vehemently against vaccinations, all for individuality, listens to Jordan Peterson and follows his suggestion to be strong yourself, get your own life in order, without seeing that has limits. Though it is a weakness for people to just use temporary measures like prescription pills etc which don't cure or change, and getting oneself strong is important, joining with society to be strong together is essential.

As you put it, '...you have the knowledge of good and evil and your own mortality. Make your choices but remember, henceforth it's on you. How could it be otherwise.' Those who won't try to be part of the whole, may have to face their own fate prematurely, perhaps alone.

Anonymous said...

The real difference between National and Labour ended the day Muldoon became National leader. Muldoon was an old fashioned Nationalist. A bright Irish working class boy.An authentic New Zealand ER, more impressed with JA Lee than Coates and would have been no more impressed with Key.National today is even further to the left than National. Collins is very much more in the China camp out of a determination to maintain working class employment of the unemployable and respect and fear for the recalcitrant farmers and their yesteryear New Zealand.
The Labour health plan is of course a terrible regression and an attempt to impose a standardized NHS National health system to most of all stymie any independent developments in the South Island
Maybe someone should establish a South Island Party based on supporting the West deporting John Minto, any Bradford and of course reopening Christchurch- and Queenstown 24/7 and prosecuting anyone opposing Americans, Germans topless bars etc.