New Zealand has far too many DHBs
The following commentary was written by Professor of Health Policy Gregor Coster, Dean of Faculty of Health and former Professor of General Practice.
11 October 2017
New Zealand should reduce the number of district health boards (DHBs) and Primary Health Organisations (PHOs), align subsidies for high needs to patients rather than to practices, and if the government intends to increase subsidies we should know more about service dimensions and quality of care.
A recent paper by Amy Downs, the Ian Axford (New Zealand) Fellow in Public Policy, confirms the view that we have too many DHBs. They lead to duplication of services and costs.
For a small country, we should have no more than six DHBs serving larger populations. DHBs are in regional groups now and those could form the basis for amalgamation.
For a country of 4.8 million people, we have 31 PHOs providing GP and primary care services for populations. Many of these are working with up to four DHBs and some DHBs are working with up to five PHOs.
This is time consuming and wastes resources. It is time to reduce the number of PHOs and map these to new DHB boundaries.
At the same time, Downs recommends that "Treasury and the Ministry of Health should undertake a rigorous and data-driven review of primary care funding". It may be that out of that review there is a case for a single national purchaser of primary care services.
DHBs have every reason at present to focus on their hospitals, almost certainly to the detriment of primary care services. We can do better with primary care in such areas as prevention, reducing some hospitalisations, improving access to care, reducing inequities, and better use of the primary care workforce.
I agree that "separating DHBs' dual functions as a provider and funder needs an extensive and objective review".
At present, subsidies are paid to practices based on how many patients they have enrolled and whether they have high numbers of disadvantaged people.
The effect is that some disadvantaged people do not receive higher subsidies to help get access to general practice and some wealthy people receive subsidies they do not need. This is unfair and we need to rectify it.
Subsidies should "travel" with the patient and not with the practice. Such funding should align with patients depending on their Community Services Card, ethnicity and deprivation.
Both of the major political parties are proposing to lower the cost of GP visits by increasing subsidies. Before subsidies are increased, we should ensure the health system gains greater information about the nature and quality of services being provided.
We should know how many of these services prevent avoidable hospitalisations, how services are utilised and what conditions are being treated, and we should have quality metrics and demographic information.
None of this information is available to the Ministry of Health now and we need to know more to better plan services to meet patient needs.
We need more research and evaluation on the effectiveness and outcomes from primary care. We are very dependent on our primary care practices and need to know how best to support them to keep people well and out of hospital.
Amy Downs also recommends that "philanthropy should consider providing new funding or redirecting existing funding to finance an organisation that specialises in evidence-based health policy analysis. This could be an academic entity or a non-governmental organisation.
This entity should be separate from government, but would provide robust analysis that could be used by government agencies".
Victoria University of Wellington has established a Health Policy Think Tank to do just that.
This opinion piece was originally published in Stuff, 11 October 2017.