Bringing primary health and community care in from the cold in the New Zealand health reforms? Tracing reform recommendations to budgets and structures

Early messaging from the government about the 2021 health system reforms placed considerable emphasis on the central role of primary health and community care (PHCC) to meet reform goals.¹ The PHCC sector welcomed this focus. For over a decade, the Ministry of Health (MOH) has allowed gaps to develop between strategy, policy and health system performance, especially for PHCC as noted by two major reviews, the Waitangi Tribunal Hauora Report (Wai 2575)² and the Health and Disability Services Review Report (HDSR 2020).³ Since the 2010s, there has been little government attention or acknowledgement of the importance of primary care, despite PHCC being the ‘front door’ to our publicly funded health system. Meanwhile, PHCC’s guiding strategy remains the 20-year-old Primary Health Care Strategy (PHCS 2001).⁴ In light of this, how does PHCC fare in the reforms so far?

The Pae Ora (Healthy Futures) Act is the health reform’s legislative vehicle. With population health as a principle and a strong focus on health equity, it establishes new Pae Ora health system entities, including the Māori Health Authority (MHA). The Act places considerable emphasis on localities and locality plans; however, the Act is silent on PHCC, its features and its role. Although the legislation stipulates specific sector plans and strategies, PHCC is again absent, though six other strategies are present, including five population health strategies.¹

The Budget 2022–23⁵ is an early indicator of PHCC resourcing in the reform. The overall increase in the health budget largely goes to pre-existing District Health Board (DHB) deficits, correcting historical under-investment in hospital services. Simultaneously, under-investments outside the government’s books remain invisible and inadequately addressed. The 2022–23 Budget ignores pay parity and long-term underinvestment in PHCC relative to hospital services. The underinvestment in PHCC has broad negative impacts: from affordability for patients, to distribution of care and facilities, and substantial workforce shortfalls in medical, nursing and allied health. Importantly, at the population level, the Budget underplays the equity gap between current services and the investment required for PHCC (and preventative services) to attain equitable health outcomes. Concerningly, the Budget signals to the Pae Ora entities that the key deficit problem exists in hospitals, reflecting the structural bias of the previous DHB system towards hospital services and the lack of acknowledgement of PHCC’s significance to the reform goals. Responsibility now shifts to the Pae Ora entities to remedy this structural bias in sector resourcing.

How PHCC is represented in in Pae Ora entities is concerning. Neither Health New Zealand (HNZ) nor the MOH has a directorate with a specific focus on PHCC. At HNZ,⁶ there is a National Director of Primary and Community Care, sitting in a small clinical leadership group alongside other clinical posts (medical, nursing and midwifery, allied health). Thus, the main relationship with the PHCC sector occurs indirectly via contracts, through the Commissioner in the powerful Delivery Leadership Team (DLT). Conversely, the Hospital and Specialist Lead is on the DLT with direct management responsibilities for hospital services. This structure reveals the different positioning of different sectors of the system. The PHCC sector is seen through the restricted lens of commissioning, whereas the secondary, hospital-based sector is part of the DLT. PHCC’s vulnerability in HNZ further is exacerbated by the MOH’s new structure. The MOH lacks a PHCC focus, a focus fundamental for successful stewardship, and to properly inform commissioning. Notably, PHCC’s situation contrasts with public health, with its strategic homes in MOH and HNZ.

To bolster PHCC in future, the new health system entities will require greater PHCC representation in leadership and governance. The MOH requires a PHCC focal point to own, update and drive the PHCS (2001), measure the impact of investment towards population health goals, and to lead a consistent approach to PHCC across all population-level strategies (eg Māori, Pacific, Disability, Rural, Women).

How PHCC fares in next year’s Budget will be the acid test for the Pae Ora reforms. Will government be able to break the cycle of the past, and make the necessary investments in PHCC and prevention? The shift to commissioning makes relationships vital. The MOH has not maintained relationships evenly across the health sector, as pointed out in the reviews in the lead up to the reforms. Now, with many MOH staff shifting into HNZ to commission services, the MOH must take care to build an even suite of linkages across the PHCC sector. Caution will be needed to not drive fragmentation and division, or rely solely on existing relationships. To ensure that localities take a comprehensive PHCC approach and build enduring relationships that enhance services, the approach to commissioning will be critical. It will require much greater engagement with the PHCC sector to build relationships with a broad range of service providers and the community, with equity at the fore. Essentially, the strength of relationships will be vital, both between hospital and PHCC and non-hospital providers, and among providers and the community they serve.

To date, and with the possible exception of the MHA, the reform’s legislation, budgets and structures have downplayed the potential role of the PHCC sector to drive health improvement and equity. The MHA’s role in advocating an equity-based response is promising, although it has modest budgetary at its disposal relative to the equity gap that needs to be closed.

The historical PHCC funding, strategy and policy deficits must be addressed by sustained strategy, governance and leadership to maintain and enhance PHCC infrastructure. Although coronavirus disease 2019 (COVID-19) has demonstrated locally⁷ and internationally the enduring value of primary care services, especially for vulnerable populations (eg^8–10), the new entities are in danger of repeating old mistakes. Further work on the structures, budgetary allocation, policy and strategy is needed if PHCC is to be brought in from the cold.

The authors declare no conflicts of interest. RK is member of the Editorial Advisory Board of the Journal of Primary Health Care.

This work did not receive any specific funding.