My View: From ‘health system knows best’ to ‘patient knows first’

VIEW - Karl Cole, GP and Fellow of HiNZ

For too long, our health system has been built on paternalism: the idea that the system knows best, while patients wait passively for instructions. 

That model might have worked in a health service world made of episodic illnesses, but it is hopelessly outdated in a world of ageing population, with increased chronic disease, multimorbidity, where we have medicalisation of social issues and the rising demand we face today. 

Here are my ideas of the building blocks to enable this transformation.

Continuity by default

When people do need to use the health system, care must default to continuity, which is not just a series of episodic encounters. Every consult should build on the last, with full access to the patient’s evolving story. 

This is where value is created: relationships, context, and trust leads to speed and efficiency.  Episodic care without continuity is not just inefficient, it is unsafe.

The evidence: continuity + open notes

The international research is clear: continuity of care lowers mortality, reduces hospitalisations, improves adherence, and boosts satisfaction. In one BMJ review, patients with continuous primary care had up to 25 percent lower mortality than those without. 

Meanwhile, open notes - now mandated in the US - improves trust, medication adherence, and patient engagement, while reducing diagnostic errors. In short: patients do better when they are trusted, informed, and connected.

Build a national “pull” data grid

Every health record available even if it doesn’t live in one secure place, always up-to-date, in a portal for all providers to view, and granular data that can be pulled into any clinical system as needed. Accept a hybrid federation model is inevitable, so plan for both.

This needs to be in a standard layout but in a flexible UI. Each provider must be able to view and filter - in patient and clinical context - tasks, recalls, cohort management and decision support, without duplication.

Patients can access and contribute anytime. This is not just a list of events but includes patient goals and wearable data and context.

Patient empowerment with digital tools

The future is not AI as a backbone, but AI and all digital tools enabling patients to steer their own health. The tools only come after we understand the problem to solved but are likely to include

• Validated symptom checkers, chatbot triage, home monitoring, personalised plans, and journaling platforms all shift agency back to the patient.
• Automated coaching tools help people adjust in real-time, with clinicians as guides rather than gatekeepers.

Imagine patients self-managing blood pressure medication at home, adjusting within safe guardrails set by their provider. Algorithms support daily decisions, flag outliers, and escalate when needed — confidence for the patient, oversight for the clinician.  Safety nets built in: results unreviewed within 48 hours go straight to patients.

“AI as co-pilot” for clinicians and patients

AI should not be a gimmick but an embedded support in everyday care. In clinical hands, its strength is pattern recognition and sequence matching: surfacing missed signals across notes, labs, and imaging, and embedding open evidence directly into the work flow as just in time knowledge. Instead of more clicking, it quietly augments judgement.

For patients, AI extends empowerment with safety rails. BP self-management is just the start: diabetes care, asthma plans, even post-op recovery can be scaffolded by AI prompts and monitoring, all while clinicians stay informed. 

This is partnership, not paternalism.

Hyper-local community hubs

Build bigger local health teams that include different types of professionals, with leadership coming from the community itself. Make social care, mental health, and family support a standard part of care, not an afterthought. 

Make it easy for health providers to share messages and hand over care smoothly, centred on the patient, not blocked by the walls between different organisations And instead of using blunt rules or age cut-offs to decide who gets help, trust local providers to manage budgets and make decisions based on real needs.

Each hub tracks and manages population health, shifting from reactive firefighting to proactive prevention. No need to re-invent the wheel here, as there is infrastructure in place.

Outcome-focused funding - not activity-focused

Fund outcomes, not transactions. Reward providers who keep people healthy and out of hospital.

Continuous feedback and live dashboards

A national, public-facing “Health System Fitbit” shows live data on equity, access, and outcomes. Patients and communities help steer improvements, not just politicians and executives.

Why I Care

I have seen too many people slip through the cracks in South Auckland, and I have seen families in rural areas with no safety net. 

In our stretched, budget restricted, value-based system, we cannot afford duplication, yet multiple departments reinvent their way for remote monitoring instead of treating it like a basic service, as normal as say ordering blood tests or imaging. 

These are not abstract system failures, they are lived inequities I encounter every week.

It is also why I chose to be a specialist vocational General Practitioner in my own health field of medicine. I was inspired by patients and doctors who saw health in its full, holistic sense - patient-centred and whole-person care. That vision is possible in hospital environments, but never easy. 

In general practice, it is the everyday work, and it remains the most powerful platform for continuity, equity, and trust.

The bottom line

We cannot wait for more pilots or endless white papers. We need a leap:

• Self-care first, system care second.
• Data available, shared, and used for patients, not funder policing.
• Patient empowerment as the organising principle.
• Outcome-driven, not activity-addicted.

If we do not act boldly, we will drown in our own demand. If we do, we can become the first country where digital and human care truly work as one, and not just on conference slides.

Three times the demand is coming. We need one bold epic plan. Zero excuses.

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