Revolving doors: New Zealand's health reforms
By Robin Gauld
Institute of Policy Studies, Victoria University of Wellington
Toni Ashton
Senior Lecturer in Health Economics
University of Auckland
Revolving Doors was published as part of the Institute of Policy Studies work on the evaluation of social policy and social service delivery. A book on the health sector is certainly timely, given that the public health system in New Zealand has undergone what the author, Robin Gauld, calls “incessant policy changes” over the past two decades. These changes have included several waves of structural change at the system level, as well as ongoing incremental developments at the service-delivery level. This book provides a detailed account of these changes.
The book begins with an introduction, which includes a summary of the key themes that emerge from the book’s exploration of New Zealand’s experience of health sector restructuring. Some of these “themes” are simply observations, such as “since the formation of the area health board system, the health sector has been under constant structural change”. Others provide useful insights into the development and implementation of health policy, if not public sector policy more widely. Examples include, “the process of adaption takes at a minimum two years, possibly more”, and “many politically desirable changes could take place within existing structures”.
Following the introduction, Gauld provides an historical overview of the early formation and development of the public health system from 1840 through to the 1970s. These developments are not only of historical interest: they also explain the sources of many of the perceived problems that the recent reforms have been attempting to address.
The remaining chapters cover the main reform periods in chronological order. Chapter 3 covers the 50-year period from 1938 to the end of the 1980s. It describes the problems that began to emerge in the health sector during this time and the various unsuccessful attempts made to reform the system. Chapters 4 and 5 cover the period the fourth Labour government was in power (1984–1990). Chapter 4 gives an overview of the general economic and political reforms that were introduced, including the philosophy and theories that underpinned these reforms. Chapter 5 then focuses on the public health sector. It describes the two major reviews that were undertaken during this period (the Health Benefits Review and the Hospital and Related Services Taskforce), and provides an assessment of the strengths and weaknesses of the health sector in the 1980s.
Chapter 6 covers the years leading up to and including the announcement, development and implementation of the “health reforms” introduced by the National government in 1993. The focus of this chapter is on the reform process, including a discussion of the estimated costs of reform and the evolution of the design of the new system. Chapter 7 then describes the new system in operation. It discusses the institutional arrangements of the Crown Health Enterprises and Regional Health Authorities, and explains some of the difficulties and tensions these organisations faced in practice.
In Chapter 8 the changes introduced by the first coalition government (1996–1999) are described. This period included the formation of a single national purchaser (the Health Funding Authority) as well as various changes at the service-delivery level (for example, the change from Crown Health Enterprises to Hospital and Health Services, the introduction of prioritisation processes and booking systems for elective surgical procedures, and the move towards integrated care). Chapter 9 brings us up to the present day with a description of the latest round of restructuring into District Health Boards.
All of these changes are documented in great detail. To this end, Gauld has made excellent use of the numerous (published and unpublished) government reports that have underpinned policy development over the years. Indeed, the reference list alone will be of great value to any student of health care organisation.
It is important to emphasise that this book is about the structure and organisation of the New Zealand health system rather than about health policy more generally. In spite of the depth of detail, the description of the system is unfortunately confined almost entirely to changes in the public sector. Innovations in the private sector – such as the development of Independent Practitioner Associations – are included only to the extent that they have some relevance for public policy. Other aspects of the private sector, most notably the role of private health insurance, are not discussed at all. This is a pity, given that improved integration of the public and private sectors was one of the stated objectives of health reform in the 1990s.
The main conclusion that Gauld draws from the series of reforms since 1993 is that there is little evidence to suggest that any one structure has performed significantly better than the others. Despite the changes, it has been “business as usual” in many respects in terms of service delivery. These conclusions are based primarily on observation rather than any serious theoretical or empirical analysis. Although Chapter 4 mentions some of the theories that influenced the reforms of the early 1990s, there is no attempt to explore the application of these theories in the New Zealand context in any depth, or to use the theories as a basis for further critical analysis. Nor is there any attempt to undertake any detailed empirical analysis of the impacts of the reforms.
Overall, the book is clearly presented and easy to read, in spite of the depth of detail, and fills an important gap in the literature by providing a detailed historical record of the series of recent changes that have been introduced into the public health system. It will be of interest to all serious students of the New Zealand health sector and is also an excellent reference book for anyone wishing to check up on particular details of health policy changes and their supporting documents over the last few years.
