Report reveals new health system struggled with 'confusion and delays'

By Phil Pennington for RNZ

The country's nationwide public health system set up last year to address weaknesses brutally exposed by Covid-19 is struggling, according to a review, with such confusion that in one case 10 different groups were doing risk assessments around the same issue.

"Confusion and delays", "dropped baton passes" and "loss of trust" are revealed in the first progress report into the new $60m system.

The two fledgling agencies argued over who was in charge during the recent measles outbreak.

The new National Public Health Service wanted the new Public Health Agency to own the reporting, but the PHA put it back on the NPHS, the report said.

In another case, "there was an example of one meningococcal case creating four phone calls from the national office to the local Medical Officer of Health, asking if they required help ... this situation caused additional work."

During the pandemic, the country scrambled an emergency response with contact tracing and managed isolation - but later pledged to do better, through new systems delivered by the 2022 health reforms.

Last year the government put up $60m to transform the dozen district services into two national agencies, the PHA and NPHS, to cover everything from smoke-free campaigns to dealing with toxic water outbreaks such as occurred recently in Queenstown.

Public Health is front-and-centre on epidemics and pandemics - but Covid-19 took the country's systems to the wire.

Budget 2022 had high hopes for the two agencies - alongside the Māori Health Authority Te Aka Whai Ora - doing better and leading population and public health policy, strategy, regulation, intelligence, surveillance and monitoring.

The progress report done in June finds something else: Three agencies very unclear on who does what - on roles, responsibilities and priorities - just making do through change-fatigued staff making huge efforts in an "ad hoc" approach that is "taxing good will".

"Coordination issues are rife," it said.

Staff at Te Aka Whai Ora felt the worst about it all: "Very little is clear or working in an optimal way," they said in interviews.

Consultants Sapere found in interviews with 43 staff there were real-world impacts from the dysfunction:

  • An alert to ministers about a rabies case was not made.
  • Slow release of "a time-critical announcement of an infectious disease".
  • Difficulties getting support during emergencies.

"Notifications of cases of diseases currently go to multiple people, so in some instances multiple responses are initiated or in other instances everyone thought it was someone else's responsibility," the report released to RNZ last week under the Official Information Act said.

"Duplication of work or things falling through gaps were expressed as concerns."

The fragmentation and duplication exposed by Covid of siloed services with IT systems that could not even talk to each other are very far from having been overcome, the report shows time and again.

"The overriding sense from interviewees is that the reforms have made ISK [intelligence, surveillance and knowledge systems] more fragmented and getting shared clarity and firm boundaries without further delay is critical."

PHA and NPHS "teams are small" but "can end up tripping over each other".

NPHS commissioned some key work without telling its sister agency.

They both had "direct line to the Minister [which] also causes confusion".

"Outbreak management was described by some as still being in a Covid way of working, with the NPHS still doing policy yet it not really being its role," the report went on.

"Interviewees identified to us that such a way of working should not be the basis for how things operate in the future - a reset is needed to make it clear how the big picture works, what is appropriate reach-in from Ministers and internal clarity on what to escalate and when."

This echoes a separate progress report on the entire health reforms, also released to RNZ last week, showing near-new agencies that held out high hopes but lack the planning, leaders and funds to carry through, despite health bosses' belief they will get there.

Change piled on top of reform has so far proved too much to cope with.

"Many staff remain in interim roles and others have the disestablishment of their positions and limited information about what future roles and operating models will be," the Public Health progress report said.

Lack of resources saw local front-line workers getting tapped to do national or subject-matter-expert work.

It had also tripped up the push for better Māori public health outcomes, as this was running up against "superficial" engagement where Te Ake Whai Ora, as the agency with the fewest resources of the three, was called for "input late on in a process".

"Unsurprisingly, there is often a loss of trust in transitions, particularly one of this size, with a perceived gap between words and actions and leading to a degree of scepticism."

Te Whatu Ora responds

In a joint statement, the Ministry of Health, Te Whatu Ora Health New Zealand and Te Aka Whai Ora acknowledged they were making adjustments due to the review.

"As expected, there were early challenges with how roles and responsibilities worked across the three organisations, and a review was jointly commissioned to identify where we could do better," the statement said.

"We continue to make adjustments to how we work together in response to the review."

The agencies said that seven improvement programmes have been established in response to the report in the areas of policy making, surveillance, outbreak management, regulation, priorities/strategies, collaborative leadership and collaborative clinical governance and risk management.

The agencies are also strongly collaborating on a new Healthy Food Environments Steering Group, work to address alcohol-related harm, and progress towards Smokefree 2025, they said.

"While the report found there were areas where more clarity around roles and responsibilities was needed, overall most staff interviewed for it had a positive view of the working relationship between the three entities and the progress made under the reforms," the statement said.

"It also found staff across the entities believed public health was being treated as a higher priority than previously."

The clear-cut, hard-hitting report is in contrast to the fudged and vague progress report on the whole system put out by the Health Ministry.

Other papers suggest a lot of fixes for the myriad problems, such as reducing the size and layers in the surveillance and intelligence team; setting up a way for medical views, such as infection disease clinical guidelines, to be taken into account; and making it much clearer who is in charge - either the PHA or NPHS - during disease outbreaks, and resourcing that, so specialists did not have to keep on calling for help through informal, professional networks.