Hague Kevin: New Zealand Public Health and Disability Amendment Bill — First Reading 
Hague Kevin: New Zealand Public Health and Disability Amendment Bill — First Reading 
[Volume:663;Page:11026] 
KEVIN HAGUE (Green) 
: 
 The New Zealand Public Health and Disability Amendment Bill as the Minister of Health said makes the legislative changes arising from the Government’s response to the ministerial review group the Horn report. I am pleased to say that the Green Party will support the bill tonight. 
Hon Member 
: There’s a rarity. 
KEVIN HAGUE 
: It is indeed a rarity. 
The Horn report itself was a bit of a mixed bag; I do not think I could share the Minister’s glowing praise for the report. Although it contained some good analysis it also contained a significant amount of needless reworking of things that the health sector was already doing and an awful lot of ideological structural ideas looking for a home. We were certainly relieved when the Government did not proceed with many of the recommendations from that review. 
This bill sets out effectively to do two things. It overhauls the quality improvement structure that is in the principal Act upgrading the structure from an advisory committee through to a commission and it provides the machinery for closer collaboration between district health boards. We support both of those objectives. 
First of all in relation to quality the first iteration of the structure was the advisory committee that had the brief of dealing with both epidemiology and quality—an unusual marriage of subjects and one that despite the best efforts and intentions of those involved and those behind the committee did not really work. That committee received a shot in the arm from the previous Minister of Health the Hon Pete Hodgson. I pay tribute to the work of the Minister in establishing the Quality Improvement Committee on which I had the pleasure to serve for a time. I think that the Quality Improvement Committee did a great job in accelerating the quality improvement agenda in health. I pay tribute to Pat Snedden the chair of that committee to the other members of the committee to the ministry staff who supported it and to all of the district health boards and others in the sector who took on board those quality improvement projects. They picked up the ball and ran with it as it were. 
The last 5 or so years have really seen a quantum leap in quality improvement in health perhaps starting with Peter Davis’ research work. That work really highlighted the extent of errors occurring in our hospitals. The work of the Office of the Health and Disability Commissioner has also been important in pinpointing the places and the mechanisms involved where things go wrong and also in establishing a culture of open disclosure and an approach of analysis of the root causes of errors with a view to health improvement. District health boards have been very willing partners in this work and have made concerted efforts both individually and collectively to improve the accessibility acceptability effectiveness efficiency and above all safety of health services. So I think this new commission has the potential to move that on to the next stage and I think that is a good thing. 
I sound a note of caution that in providing this greater central capacity to coordinate and steer quality improvement it is really important that we do not end up disempowering those who work at the coalface on quality improvement because it is really at that level that the big gains can be made. It is critical that the commission gets that balance right. 
The bill also provides the machinery for requiring collaboration between district health boards. I guess that from the beginning of our current iteration of health sector organisation there has been debate on how many district health boards there should be. Iain Lees-Galloway has just spoken about that issue. The fact is that whether it is 21 20 10 or one the number will be right for some things and wrong for other things. In broad terms the tension is this: the more locally services are organised the more sensitive those services will be to local need and the more innovative those services are likely to be yet on the other hand the bigger the unit the greater the potential for economy of scale and for coordination of highly specialised services. Those are the tensions. The trick is to find a system where we can base our health services organisation at local levels but then have the capacity to aggregate up where appropriate. That has occurred already quite a lot in the health sector as others have mentioned. 
The basic problem is one of asymmetry of need: in general a smaller district health board—and I have some experience in this area—will have need of collaboration where a larger district health board may well not. One of the obstacles to progress on that issue has been the wording in the current New Zealand Public Health and Disability Act. The Act requires district health boards to act in the specific interests of their people and of their region. That means that we end up with collaboration occurring between district health boards only when it is to the universal benefit of all. That means that situations where most people would benefit from closer collaboration do not necessarily result in that collaboration occurring. That is a problem that we must fix and I think this bill provides the machinery and the mechanism to fix it. 
The other important aspect to it is another that Iain Lees-Galloway touched on and that is the solution that some have advocated: amalgamations either encouraged or forced. Certainly it is not a solution that I favour. I favour instead the idea of an intelligent network of smaller district health boards or perhaps district health boards around the same size that we have now that have good mechanisms for collaboration. I think that although amalgamations have some potential to fix the central problem of collaboration not occurring they also have some costs. They have the cost of the change itself and they also have the cost of the loss of innovation. I think that we would face those costs at our peril. 
We support those two central thrusts of the bill. I say in relation to collaboration that it is a shame that the same approach is not being adopted in relation to primary health organisations because exactly the same dynamics apply with primary health organisations. The Ministry of Health undertook some analysis a couple of years ago of what the right size for a primary health organisation was. It found that small primary health organisations and big primary health organisations both have strengths and weaknesses so it could not come up with an optimum size. A smart solution to that problem would be better than the Minister’s intent of requiring primary health organisations to amalgamate. 
We supported other changes in the Government’s response to the Horn report. One of those was the change to Pharmac’s role: expanding it into medical devices. It is not in this bill but as I read the Act it does not require legislative change to facilitate it. So we are confident that it is still on track. We also support the change to the role of the National Health Committee. I am reminded of Gareth Morgan’s recent book where he talks about the fundamental problem that every health system in the world faces: potentially unlimited need. His solution has two elements. He says that one of the things that we need to do is to prioritise health spending and the change to the National Health Committee facilitates that. The other is to prioritise expenditure and investment in public health and primary care. It is unfortunate that the Minister has chosen not to do that.