By Second Edition . Published by Institute of Policy Studies and Health Services Research Centre, Victoria University of Wellington . 2009 . ISBN 9781877347313 . 233 pages plus index ..
Reviewed by Tony Blakely
University of Otago, Wellington, New Zealand
It must be frustrating revising books on health system reforms. No sooner is your revision published, than another round of health sector reforms is embarked upon. Such is the case for this second revision of Revolving Doors by Robin Gauld, published in 2009 following the first edition in 2001. After nearly a decade of semi-stability in the New Zealand health system, reform is again occurring in 2009/10. A new National Health Board is being implemented to bring together ‘back-office’ planning activities, improve information technology co-ordination, and such like – partially echoing the Health Funding Authority of the late 1990s. But this new wave of reforms is young in tooth, and there is much to document and analyse about the 1999–2008 years with the bedding in of District Health Boards (DHBs) that still remain in place, and primary health organisations (PHOs), which also still remain (but are likely to get a major shake up in the next year or so).
Gauld's second edition includes a new final chapter, Chapter 11, The Saga Continues: The district health board system and beyond. Otherwise, the book is as per the 2001 edition. Chapters 2 to 10 document the structure of New Zealand health system from 1940 to c.2000, and has been previously reviewed by Ashton in 2002.1 Ashton found these chapters to be a comprehensive overview of the mechanics and structure of the public health system, but perhaps overlooking the private system. Ashton also notes that the previous edition did not attempt to analyse, either from a theoretical perspective or from empirical evidence, the actual impact of the health system on population health. In sympathy with Gauld, I must note that it is frustratingly difficult to actually determine how any given health system impacts on the population's health in the absence of rich empirical data or cross-national comparisons. That said, given we spend an ever increasing and large fraction of GDP on health, it is a very important question to attempt to answer.
So what is included in Chapter 11 of this latest edition? Basically, a very readable summary of the 1999–2008 Labour-led government's health system agenda and implementation, including its strengths and weaknesses, followed by a thoughtful distillation of the issues to be grappled with by the incoming and current National-led government. A concise summary of the decentralisation to a DHB and PHO system is provided, with its attendant advantages such as a transparency and community participation, and its attendant disadvantages such as duplication and uncertainty about who is accountable for what. The shift during the 2000s towards a population-level, primary care-based, and inequalities reduction focus is described. It would have been ideal to see this changes and any consequent impact of population health and inequalities more tightly analysed, but as stated this is a frustratingly difficult research task.
The concluding analyses and suggested future directions offered up by Gauld at the end of the book are spookily consistent with the analyses and recommendations of the Ministerial Review Group2 that reported just after Guald's second revision was published, and off which much of the current health sector reforms (or perhaps evolution) are being driven. If triangulation and consistency between authoritative reviews is taken as mutual validation, then it would appear that Gauld is on the money. And for what it is worth, I think he is – at least to the point of capturing much of the common sentiment within the health policy beltway. For example, that there is “widespread, but largely unwritten, agreement across the health sector that 21 DHBs and 80 PHOs and all of their associated entities is too many” for a country with the population of Melbourne, that perplexing parallel institutional arrangements exist with unnecessary complexity, and that “problems exist relating to quality and safety, information technology and workforce development, which are crucial to a high performing healthcare system”. In arriving at his description, analysis and suggestions in this new chapter of 21 pages, Gauld draws on and references a reasonable range of government policies and evaluations, academic publications examining the past 10 years, Hansard records of parliamentary questions and answers, and newspaper documentation. One minor irritation to myself was the initial description of the large increases in Vote: Health funding during the 2000s, followed by repeated assertions (or at least agreements with unnamed interviewees) that much was not able to be done in the 2000s at the DHB-level due to fiscal austerity – a deeper academic analysis of this contradiction would have been useful.
The bottom line – if you do not already have the first edition, I recommend this second edition as an easy to read description, with moderate depth analysis, of the New Zealand's health system since 1840, and reforms up to 2009.