Gregor Coster: The national health board in New Zealand
The National Health Board in NewZealand: Delivering Better, Sooner, More Convenient Healthcare Professor Gregor Coster University of Auckland 22 September 2010
Overview• Purpose of this paper is to discuss the rationale for setting up the National Health Board (NHB, Board)• legislative framework in brief• board accountabilities; how the role of Ministers has changed• how the Board was set up in practice; how it is intended to operate; the role, if any, of the public in the Board’s workings• how the Board’s impact will be assessed• overlapping roles, including with the body responsible for new technology assessment• comparison between NZ National Health Board and UK NHS Commissioning Board• lessons that can be gained from the New Zealand experience.
Arrangements until 2009• Health Funding Authority till 2000• health reforms shifted from a single purchaser to 21 District Health Boards (DHBs) 2000/01• DHBs responsible for planning and funding of all services in district except some services e.g. disability• provide hospital services• democratically elected boards, with some appointed members• intended to ensure local needs are met• evaluations found that intended devolution did not occur – central control continued – local autonomy difficult to achieve – prioritisation of services limited by level of control by central government over services (Coster, 2010)
Arrangements until 2009‘The reforms involved a shift away from a ‘quasi’-market modelto a more collaborative set of arrangements for purchasing andproviding health and disability support services with a strongercommunity voice in relation to decision making about healthand disability support services’(Mays et al., 2007).
Growth in health expenditure 1950-2010Assuming that relative health spend will remain atabout 20% of total Government expenditure, then themaximum tolerable increase in the health budget willbe about 40% between now and 2020.
NZ Population Projections by Age Cohort (Assuming medium population growth) Source: NZIER (2005) 400,000 2001 2011 2021 350,000 300,000 250,000 200,000 150,000 100,000 50,000 0 0-4 5-9 90+ 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89
Age Distribution of Population Statistics New Zealand, March 2006
Ministerial Review Group Report 2009 ‘… we must find a way to deliver these public services within amore sustainable and, therefore, slower path for healthexpenditure growth… Bureaucracy, waste, and inefficienciesmust be reduced and resources moved to the front-line asspending growth slows. We must focus on quality which willdeliver better patient outcomes and on ensuring better accessto health services through smarter planning and resourceutilisation, at regional and national levels.’ (Ministerial ReviewGroup, 2009) p.3.
MRG recommendations (1)• Stronger clinical leadership in decision-making• accelerating improvements in quality and safety• higher system performance and secure future sustainability• improved national and regional service planning and decision-making• minimising administrative costs and reducing bureaucracy and waste.
MRG recommendations (2)• The MRG considered that the complexity of the current roles of the Ministry made it difficult to focus on its core responsibility of policy development. They believed that a much clearer focus on the Ministry’s core policy and regulatory functions was required, along with reduced bureaucracy and a smaller Ministry of Health.• Foremost among the recommendations was a proposal that a new National Health Board be created by revamping the Crown Health Funding Agency to manage national capacity and service planning, to plan and fund national services, and to fund and monitor DHBs i.e. to establish a separate Crown Entity.
Cabinet decisions• Rejected the notion of a separate Crown Entity – established a NHB within MoH with a GM – Chair of NHB reports directly to Minister – Take over funding and planning of certain national services (paediatric oncology, clinical genetics, major burns) – Infrastructure planning for IT, Capital, Health Workforce• Establish Shared Service Organisation• Strengthen regional cooperation in service planning and delivery• Devolve funding of $2.5b to DHBs, where appropriate
Accountability arrangements in the New Zealand health system in 2010 Minister of Health Director General Ministerial Committees Crown Entities of Health National Health Board Pharmac Health Workforce Regional District Health New Zealand Health Quality and consortia Boards Safety Commission National Health Information Technology Board Shared Service Organisation National Health Committee
Reconfiguration of the Ministry• National Health Board Business Unit (750 staff) – National Director – reports regularly to NHB• Health Workforce New Zealand Business Unit (50-60 staff) – Director – reports regularly to HWNZ• Ministry residuum => policy and regulatory functions, plus service delivery responsibilities (e.g. disability) (600 staff)• split ministry• public accountability for MACs through State Sector accountability framework => MoH SOI, information supporting the Estimates, and Annual Output Plan.
Role of the Minister• Retains significant powers• minimal devolution• NHB may be directed => remains accountable to Minister• may direct DHBs, regional consortia of DHBs, and numerous Ministerial Committees and Crown entities in order to achieve the government’s objectives for health• requires DHBs to prepare plans that address local, regional and national needs for health services as directed• has power to intervene and resolve disputes between DHBs• contrasts with UK where the government proposes to establish an independent and accountable NHS Commissioning Board limiting the powers of Ministers over day-to-day NHS decisions
Empowering legislationThe Bill, which is expected to be passed:• amends the objectives and functions of DHBs to ensure that DHBs work together for the most effective and efficient delivery of health services to meet national, regional, and local needs.• amends planning requirements for DHBs in order to provide for a planning and accountability framework that takes account of national, regional, and local requirements• amends regulation-making powers in the current Act relating to arbitration and mediation to enable these powers to have wider application, particularly where there are disputes between DHBs about how national, regional, and local requirements are best provided for• provides that the Minister may give a direction to all DHBs to comply with stated requirements for the purpose of supporting government policy on improving the effectiveness and efficiency of the health and disability system.
NHB“Anybody holding the NHB National Director’s role would bewise to come up with a process of developing recommendationsto the Minister that will incorporate and involve not only theMinistry’s view but that of the NHB as well.”– Chai Chuah, new National Director of the NHBBU
Planning arrangements in the New Zealand health system in 2010 Minister of HealthDirector General National Healthof Health Board Annual, five year and ten year health plans Service District Health ConfigurationsRegionalconsortia Boards National Health Plan and Models of Care Regional Health Plan IT Capital Workforce District Health Plan
NHB Annual Plan 2010/11- eight prioritiesThe programme includes the following priority areas:• developing an approach to long-term service planning that is more effective and unified• identifying, planning, funding and monitoring the delivery of national health services• supporting the ongoing development and implementation of regional service plans by DHBs• DHB funding and planning, and improving DHB performance• ensuring workforce, information technology and capital requirements support future service plans• encouraging clinical leadership and engagement• reducing waste and bureaucracy and improving the productivity of the health and disability system• devolving relevant non-departmental expenditure to the regional and district level.
Comparison of New Zealand and UK Plans for NHBs NHB NHSCBMinisterial Advisory Committee Statutory commissioning boardResponsible for national funding, monitoring and Lead on the achievement of health outcomes,planning of health services allocate and account for NHS resourcesDeciding which services should be planned, funded Ensuring the development of GP commissioningand provided at national, regional and local levels consortiaPlanning and funding of designated national Commissioning responsibility for national andservices regional specialised servicesManagement of certain national services Promoting and extending public and patient involvement and choiceOversight of regional service planning and funding, Ensure commissioning decisions are fair andincluding arbitration of disputes promote competitionStrategic planning and funding of future capacity Determining health data standards for collection(IT, facilities, workforce) and transfer of information[Improve quality and safety – Health Quality and Lead on quality improvementSafety Commission] Promote equality and tackle inequalities in access to healthcare
Do we need a NHS Agency?“The evidence is mounting that reforms of this sort rarely ifever produce the expected benefits. Devolution can be pursuedwithout setting up a new agency. It is a matter of the centredetermining what it will and will not seek to control and direct.A less disruptive approach would be simply to pass legislationrestricting the scope of business that the Secretary of Statecould be legitimately be expected to be responsible for toParliament.”Nicholas Mays. ‘Should the NHS be freed from political control?’ J Health ServRes Policy Vol 9 No 1 January 2004.
Do we need a NHS Agency?“It is time for the health sector to catch up with moderngovernance practices and establish an independent agency tomanage the NHS. The greatest advantage would be that itwould free government ministers and Parliament to provideleadership in health policy rather than just NHS policy or,worse still, policy on how best to look after Rose Addis.”Nick Black. ‘Should the NHS be freed from political control?’ J Health Serv ResPolicy Vol 9 No 1 January 2004.
Key themes of the new arrangements• ‘Devolution’ to a new agency• Few new Crown entities• New accountabilities• Future change is possible
Effectiveness of the new arrangements in NZ• Indications are that NHB is already showing stronger engagement with clinicians in decision-making, and more focussed planning of national and regional services than previously• better regional collaboration between DHBs is being achieved• amalgamation is possible in order to achieve greater regionalisation• relative invisibility of the NHB will need to be addressed, along with providing both the public and health sector with a clearer explanation of the interrelationships between various committees and components of the revamped health sector.
Potential for overlapping roles• Policy-setting – NHB vs ‘Ministry’• health workforce – HWNZ vs ‘Ministry’• priority-setting (medical devices, new technologies, disinvestment decisions) – National Health Committee vs Pharmac vs NHB• health quality and safety – HQSC vs NHB vs DHBs
How will the NHB’s impact be assessed?• ‘Better, sooner, more convenient’ – achieving the aspirational goals• greater economic efficiency• reduction in growth of health expenditure (capital and operational)• improving health and performance indicators• achievement against NHB annual plan• greater clinical involvement in decision-making• less bureaucracy• reduction in health committees• co-ordinated regional planning• But not decided yet
Lessons from the New Zealand experience• Avoid dual accountabilities for the NHS Commissioning Board• ensure clear pathways and responsibility for provision of Ministerial advice in policy and administrative matters from the Department and the NHS Commissioning Board• legislate clearly the powers and functions of the NHS Commissioning Board, and the ability of the Minister to hold the board to account• clarify the accountabilities for the Care and Quality Commission, Monitor and other statutory bodies in relationship to the NHS Commissioning Board• commissioning by GP Consortia may run the risk of inhibiting the development of partnership relationships with other non-government providers if there are no controls on commissioning behaviour• New Zealand can learn from the model of promoting and extending public and patient involvement and choice.