The Government’s reset of debt levels allows increased investments to be funded by more borrowing. However, all loans eventually need to be paid back. You can mortgage yourself to build a new home, but whilst doing so, you may have to fix critical issues in your current abode since the new construction will not yet be ready to move into. This is the balancing act we need to get right:

We know that the clinical staffing ratios per bed are significantly higher in Aotearoa New Zealand hospitals than OECD averages⁸ and that out of our total DHB workforce of 76,230, roughly 17% are in management and administrative positions. This ratio rose further from the additional 2,768 workers required to support the COVID-19 response with 35% in administrative or management positions⁹.

Our border and immigration policy makes it hard to attract healthcare professionals (despite medical professionals being on the new immigration Green List) and our salaries and working conditions make it even harder to retain them. Critical workforce issues are rife across many professional groups and we are facing significant industrial actions by health workers.

Aotearoa New Zealand’s ability to deliver a viable – and sustainable – health system lives and dies by the availability and productivity of our health workforce. Therefore, investments which foster productivity, changes in service model and allow people to work at the peak of their professional capacity are vital. Unless we ‘bend the cost curve’ we cannot turn around the system’s performance.

The other side of the equation is bending our demand curve. For New Zealand children, avoidable hospital admissions account for approximately 30% of all paediatric admissions nationally, and for 20-25% of admissions for adults 65 and older¹⁰. Clearly improving access to simple, lower cost and early interventions trumps the use of reactive and more expensive hospital care.

Here’s what we know about these investments from the Budget announcements:

• $76 million over four years to develop the health workforce, including $37 million to cover 1,500 more training places for primary care workers.
• $39 million invested over four years to provide the Māori workforce with additional access to training and development. Both of these workforce investments will help in an environment where it is difficult to import additional health workers.
• Pharmac gets its biggest ever increase to baselines, investing an extra $191 million over the next two years. This will hopefully help with access to new medicines.
• Joined up information technology (IT) systems will be part of the digitally enabled health system. This investment will allow access to specialist care regardless of where an individual lives. Health New Zealand is expected to develop centres of excellence for specialist care.
• Perhaps most significantly, $580 million in funding over four years to support hauora Māori health services, and support for Whānau Ora Commissioning Agencies.

For these investments, clarity of thought and purpose will be paramount to ensure that money does actually shift the needle and deliver a successful outcome and lasting change.

The theory of change or intervention framework from our State of the State report outlines the need during reforms to be very clear about who does what and how – this is akin to the role of an architect framing up the construction of a new building.

Without clarity of thought and making smart choices for the challenges ahead, reforms are likely to disappoint. Political ideology versus health sector experience will be one of the tensions the Government needs to navigate. How do you balance the rhetoric around a post-code lottery and abolition of 20 DHBs with hundreds of locality-based networks?

Irrespective of how these tensions play out, three fundamental things must be in place to keep us honest about progress with the health reform – and our ability to benefit from additional investments being made into healthcare today – namely:

• Tracking how initiatives are progressing with execution is crucial. It’s easy to announce budgets, but much more difficult to ensure that money is actually being spent and gaining traction. Are our programmes of work delivering what was promised, are they running to time and is there accountability for execution?
• When initiatives actually get delivered, we need to provide ourselves with assurance that they are yielding the intended outcomes and results. Are benefits materialising, are we shifting the needle and are we improving our health services?
• At a macro-level, we need to ensure that the health reform agenda is creating a better health system for all. Are we shifting the needle with regard to equity, access, our cost curve and our demand curve? Is our overall health system becoming a better place?

Only time will tell. But judging by today’s announcements, the focus is still on plugging holes and the story for how we will build back a better future health system is still waiting to unfold.