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Vision
The Alliance vision for health is a free-to-user, comprehensive and integrated health service which is funded and controlled publicly.
Strategy
This vision will be achieved by:
- Simplifying the structure
- Instituting democratic control
- A series of co-ordinated initiatives will be put in place, including a co-ordinated strategy in public health to re-emphasise the philosophy of ’spend today to save later’, and improved early access to services, believing that these are where long term gains lie.
This approach has been branded ’Kiwicare’.
Key Issues
The Alliance believes that to work, the policy should be taken as a whole, however, the three areas of most concern are:
- Access to early treatment; having the least possible delay at the lowest possible level
- Free access to primary health
- Improved access to mental health services
- Additionally the Alliance identifies that the waiting times for hospital appointments and treatment are currently out of control.
Specific issues in the current system which Alliance proposes to address are:
- Demoralisation of clinicians
- Acceleration of privatisation
- Serious underfunding of public hospitals.
Structure
The elaborate management structure within health would be changed. A simplified approach is proposed through which the emphasis would be on service delivery rather than spending.
Ministry of Health
Their role would be the setting of guidelines and goals.
There would be two ministers in one Ministry with separate departments:
- Health
- Medical services.
Population health/public health would be driven from within the Ministry.
The Ministry would have the opportunity to move closer to other ministries for a co-ordinated strategic approach, which would include Education, Social Welfare, and Maori Affairs.
Regional Health Authorities (RHAs)
RHAs would be disbanded with some planning functions from RHAs absorbed into the Ministry of Health.
Crown Health Enterprises (CHEs)
CHEs would be changed to fully elected Area Health Councils, which would have budget responsibility, determine policy, undertake planning, but have no operational role.
$10 million extra support will be made available for Area Health Councils.
Organisations known as Area Health Services would be created, to be responsible for service delivery/operational management.
Accountability within this new structure would lie with the elected members of the Area Health Councils, however, the membership criteria have not yet been fully addressed.
The term ’Council’ is used to underline the democratic nature of the election process, and because people are familiar with the concept of councils and elections.
Primary Care
The Alliance wishes to see a lot of emphasis on the primary care sector. There are plans to create Community Health Centres, through which integrated primary care services would be delivered.
The following are the key aspects of this strategy:
- Support budget-holding so long as ethics around savings are solved
- Support a range of funding mechanisms and evaluate these
- Over the long term see a range of funding options available and in use
- Primary care initiatives would have ongoing support
- Integrated community health services and existing models of ’by Maori, for Maori’ care would be absorbed within the role of Area Health Councils.
- Rural hospitals would be the base of integrated community health services
- Publicly funded access to alternative and natural therapy would be made available through the Area Health Services.
Community
Greater community input would be achieved, partly through the election of representatives to the Area Health Councils, but also through the creation of Community Health Councils, whose responsibility is to lobby for and monitor locally based services.
People
Consumers
There should be greater accountability to the consumer.
A key issue is the patient’s right to have treatment.
Professions
The professions are now more fragmented and divided with sector groups more clearly divided than ever before.
Professions are divided into those who have gained (growth in private practice) and those who have lost (services in public hospitals).
Primary care professions are over extended and face a series of difficult issues for which they no longer have a unified response.
Managers
The Alliance is extremely critical of current health managers, especially those in RHAs.
There would be a reduction in the number of managers by disbanding the four RHAs.
More managers would be recruited with a health background.
The rapid turnover of personnel since the introduction of the reforms is seen as a significant problem as it has removed the corporate memory.
Planners
The role of planning will remain in the Ministry of Health.
The Ministry of Health will take over some of the current RHA functions.
Funding
Funding for health care will be provided largely through taxation, although some savings are identified from structural changes.
The Alliance has developed a budget based on a three year cycle. This has been critiqued by Treasury and includes a 20% margin in primary health and pharmacy to allow for growth.
There will be an additional $942 million per year over current expenditure on health. In building this budget the Alliance expressed concern over difficulties getting what they regard as public information out of the RHAs.
Specific initiatives include:
- Increased funding to hospitals to reduce waiting lists; $80 million in 1996/1997 rising to $280 million in 1998/1999
- Improvements in mental health services; $50 million in 1996/1997, $100 million in 1997/1998 and $150 million in 1998/1999
- Free doctor visits: $370 million in each budget year
- Removal of prescription charges; $160 million in each budget year
- Health services for rural communities
- Health initiatives for children, women, Maori and public health.
Change
Structural change would be slow; the Alliance recognises the dangers of a re-organisation which rips the system apart overnight. Frustration and demotivation will be reduced by an increase in funding.
The current contract system is seen as a direct disincentive to patient care. Hospitals with spare capacity would be encouraged to work through their waiting lists and not to stick to the concept of contracted volumes.
Specific Issues
The Alliance does not support private funding/private insurance in public sector health.
Maori Health
A direct relationship between Maori and the Crown would not be accepted. The Alliance would support the managed care models currently being run by Maori as ’by Maori, for Maori’ services.
Managed Care
Managed care based on the model imported from the USA is not supported. Concern is expressed over the profit motivation and that savings may be removed from the system rather than ploughed back into services.
Management
There are apparent tensions between the CHEs and the four RHAs.
Managers in RHAs are extremely distant, most do not have a public service background, and do not understand public accountability.
The measures being used by RHAs are crude and focussed on financial measures.
The ’market model’ is wrong. The Alliance does not believe that ’health’ is about buying and selling a commodity.
Contracts
More transparency is needed.
Some primary health care professions see advantages in contracting, however, there are high costs in the current contracting process (eg lawyers’ fees).
Summary
The Alliance policy - Kiwicare - aims to ensure universal access to comprehensive, integrated health care when it is needed, run by elected representatives from the community, fully funded from taxes and free at the point of use.
This plan will be delivered through a multi tiered structure; the Ministry of Health, with two divisions, to set policy, determine funding and monitor performance, elected Area Health Councils to implement policy and make community level plans, Area Health Services responsible for operations and implementation, Community Health Councils to input local health needs to the processes of planning and provision, and potentially Community Health Centres to provide integrated primary care services.
In this model the RHAs will disappear. CHEs will be absorbed into the Area Health Councils. The resources freed up will be directed to ’better health care’. The cost of this policy is projected to be an additional $942 million per year over current expenditure.
The Alliance believes that to work the policy should be taken as a whole, however, the areas of most concern are:
- Access to early treatment; having the least possible delay at the lowest possible level
- Free access to integrated primary health services; budget-holding will be evaluated further but managed care is not supported
- Improved access to mental health services - increased funding is identified to implement a specific strategy
- Waiting times for hospital appointments - more funding allocated
- Health initiatives for children, women and Maori
- Demoralisation of clinicians
- Acceleration of privatisation
- Serious underfunding of public hospitals
