New Zealand’s health system reforms: an uncertain road paved with good intentions?

The Aotearoa New Zealand (NZ) health reforms came into effect on 1 July 2022 through the Te Pae Ora (Healthy Futures) Act.¹ A new national health system has been established with two new entities: Te Whatu Ora – Health New Zealand and Te Aka Whai Ora – Māori Health Authority. The reforms will, according to the government, lead to ‘a more equitable, accessible, cohesive and people-centred system that will improve the health and wellbeing of all New Zealanders.’² But will these good intentions come to fruition? ‘Big bang’ health reforms come and go, and only sometimes do they result in an improvement in the existing system; at other times they lead to little more than structural redisorganisation.^3,4 A related question is ‘what’s in the reforms for general practice and primary health care?’ – given that there is no new primary health care strategy, with the existing strategy now over 20 years old.⁵

In this issue of the Journal of Primary Health Care our two guest editorials explore what the health reforms may mean for primary health care. Don Matheson and colleagues ask whether primary health and community care (PHCC) will in fact be brought in from the cold, as the last decade has seen little government attention to, or acknowledgement of the importance of, PHCC to NZ’s publicly funded health system.⁶ Their analysis raises two concerns. First, PHCC historically has been underfunded relative to hospital services, and the 2022–2023 health budget does nothing to readdress this longstanding problem. Second, there is an absence of a specific PHCC directorate within either Te Whatu Ora or the Ministry of Health. They conclude that the reform’s legislation, budgets and structures have largely played down the considerable potential of the PHCC sector to drive health improvement and equity. In contrast, Tim Tenbensel focuses on the most important aspect of the reforms for PHCC, the development of ‘localities’, defined as a place-based approach to planning and delivering health and wellbeing services.⁷ This approach fits with current international trends to promote integrated health and social care and to use health services to address the social determinants of health. Nonetheless, the devil is in the detail. Tenbensel highlights the challenges that need to addressed if localities are to be more than a set of good intentions: funding flows and structures that work; building successful partnership and collaboration in localities; health sector managers and primary care providers will need to think and act differently.

The health reforms are also highly relevant to the findings of two original scientific papers in this issue on rural health. Blattner and colleagues surveyed rural hospital leaders on their perspectives of the place and contribution of rural hospitals in the NZ health system.⁸ In short, rural hospitals do not fit neatly into the new Tier 1 (home and community services) nor Tier 2 (hospital, specialist and diagnostic services) categories of NZ health service provision.⁹ Walker and colleagues, in their scoping review of the rural allied health workforce,¹⁰ note the paucity of evidence to inform policy makers on how to improve health outcomes for rural populations. NZ’s health system is also the focus of Akhtar and colleagues’ survey of recently immigrated Pakistani women.¹¹ They found that a lack of information led this group of skilled immigrants to face many difficulties navigating the health system.

This issue also offers insights for NZ from different health systems. Taye and colleagues’ paper highlights the major barriers – patient retention and diagnostics access – that Australian general practitioners (GPs) face in delivering a primary care-based model of care for patients with viral hepatitis.¹² NZ, in contrast, has been successful in delivering primary care management of hepatitis C. Holt and colleagues have explored the beliefs held by the Niuean community in Niue towards ear and hearing health.¹³ They conclude that Niue’s hospital system is responsive and accessible to the community’s needs, contrasting with Pacific people’s access to hearing health services in NZ. Research methods also feature in this issue. An Australian study¹⁴ offers suggestions as to how better questionnaire wording can improve GP survey response rates. Wallis and colleagues show the benefits of using a process evaluation to help understand the general practice implementation of an intervention to reduce high risk prescribing.¹⁵

Two clinical areas are prominent in this issue: diabetes and palliative care. Barthow and colleagues focus on pre-diabetes.¹⁶ They found that evaluating pre-diabetes related health risks by relying on HbA1c alone does not identify those most in need of interventions to prevent or delay the onset of type 2 diabetes and/or cardiovascular disease. Habers and colleagues, in contrast, conducted an audit of patients with diabetes in a large Northland rural general practice, to identify addressable barriers preventing patients from attending diabetes eye screening.¹⁷ The barriers included lack of direction to be screened from GPs and nurses, and difficulties with the practice’s appointment system. Palliative care is an important part of PHCC, as the majority of those receiving it are under the care of their GP either at home or in residential care. Landers and colleagues highlight that ongoing palliative care education is required to both upskill and maintain GPs’ skills in in end-of-life care. Relevant to the delivery of such continuing professional development is Bidwell and colleagues’ demonstration that this can be successfully delivered online.¹⁸ In a viewpoint article, Shomel Gauznabi reflects on the role spirituality may play when providing end-of-life care.¹⁹

The place of the ‘lightning process’ – a psychological intervention – for chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is controversial and is debated in the letters section. Vallings²⁰ highlights that the UK’s National Institute for Health and Care Excellence (NICE) reviewed its evidence base, considered it could potentially cause harm, and recommended that it should not be offered to people with CFS/ME. In contrast, Arroll and Oliver,²¹ proponents of the therapy, consider the evidence shows the contrary, and that NICE’s processes were flawed. This issue is rounded off by a Cochrane Corner on low-sodium salt substitutes and cardiovascular health²² and Charms and Harms considers kratom, an evergreen tree whose leaves have psychoactive and opioid-like properties.²³

Felicity Goodyear-Smith and Tim Stokes are Editors in Chief of the Journal of Primary Health Care.