Those at the vanguard of the country's healthcare system say new Health Minister Simeon Brown has inherited a broken, 'systemically racist' and woefully under-funded machine that drives its workers overseas and results in premature deaths of New Zealanders, especially Māori. John Campbell reports.
New Zealand's health system is under-funded, systemically racist and inequitable, its workers are stressed, morale is low, and “we're not doing the right things, for the right people, at the right times, or in the right places.”
They’re some of the comments I heard from four health professionals who, between them, represent tens of thousands of healthcare workers – from nurses, to midwives, to GPs, to specialists and dentists.
After Prime Minister Chris Luxon's announcement, on January 19, that he was sacking Dr Shane Reti as Health Minister and replacing him with Simeon Brown, I visited the New Zealand Nurses Organisation (NZNO), the Association of Salaried Medical Specialists (ASMS), the Rural Health Network (Hauora Taiwhenua), and General Practice New Zealand.
The latter organisation, alone, covers an enrolled patient population of more than 4.4 million New Zealanders, including more than 80% of the enrolled Māori population. While the NZNO represents more than 60,000 nurses.
In short, the people I spoke to have an in-depth and rigorous understanding of the country’s health system, directly informed by the daily experiences of thousands of people working within it.
What they described, as president of the NZNO Kerri Nuku put it, was a “health system that has been in crisis for so long, it's gone beyond that.”
Doctors looking to new careers
I asked Sarah Dalton, executive director of the ASMS, how the specialists she represents are feeling.
“Tired, grumpy, irritated, questioning, I think, some of their career and life choices, to be honest… And increasingly, we have our members coming to us through surveys and in direct conversations saying, ‘I am thinking long and hard about something different’.”
Why?
“I think they're frustrated of, you know, howling into the void… of not being heard.”
Dr Bryan Betty, from General Practice New Zealand, told me, “there's a huge sense of uncertainty and pressure that's occurring in the health system that actually needs to be sorted.”
Sorting it is Simeon Brown’s job.
He said so himself, in an opinion piece he wrote for his local, east Auckland newspaper. “Kiwis deserve better," the new minister said, describing being tasked with delivering “improved outcomes”, “improving outcomes”, and “better health outcomes for all Kiwis".
“All” may be the crucial word.
Poor access and avoidable deaths
Surveying the access to healthcare in more remote rural communities and in rural communities with a disproportionately high Māori population, Dr Grant Davidson told me: “The health of those populations is dire compared to urban populations. People [are] dying from preventable causes such as diabetes and early stage cancers and things like that. If picked up early, they would still be alive today.”
Davidson is the Chief Executive of the Rural Health Network. I put his word, “dire”, to the other three organisations, and all agreed that was a fair assessment of aspects of the system, at least – not just at present, but for some years.
I asked Sarah Dalton if the country understands the kind of pressure she describes those working in the system as being under?
“It's been a boiling frog situation for quite a while. So I don't know, do we get habituated to it?”
And then, seemingly in reference to Simeon Brown’s previous role as transport minister, Dalton added: “The thing is, our health system isn't potholes, right? You know, it's hard enough to fix roads, I imagine. But healthcare is not potholes and roads. It's, I think, a fundamental component of a decent society, and it shows how we care for each other… the kind of society we are.”
Shorter lives for Māori
When Dr Shane Reti became Health Minister, at the end of 2023, he was provided with a Briefing to the Incoming Minister (BIM) which is customarily provided to all ministers in new governments.
It stated, with a somewhat greater diplomacy than the organisations I spoke to: “some New Zealanders experience avoidable health outcomes, particularly for Māori, Pacific peoples, disabled people, women, and those in lower-income households.”
What does this mean?
For Māori, in particular, it can mean significantly shorter lives, even when compared directly with other people in the same communities, including wealthier ones.
“Māori living in the least deprived areas still have a life-expectancy gap of more than six years when compared with non-Māori non-Pacific people living in the same areas. For Māori living in rural communities, their amenable mortality rates are 2.5 times higher than non-Māori living in rural communities”.
Echoing what we heard from Dr Grant Davidson, earlier, the ministry explains “amendable mortality” means, “premature deaths that could potentially be avoided given effective and timely care.”
This inequity is part of what led Sarah Dalton to tell me our health system is “systemically racist” and “systemically inequitable”.
A post code lottery
Grant Davidson, with an eye on rural communities, described “a post code lottery, absolutely a post-code lottery”.
Dr Bryan Betty, who is both Chair of General Practice NZ and a working GP in Cannons Creek, Porirua East, says the health system contains such profound inequity that addressing it is a matter of urgent need.
“Think of areas like Cannons Creek, South Auckland, Northland, rural populations, high Māori populations, Pacific populations… how do we address the inequities in health outcomes that have occurred? Because they are real, they are there, and they are, in many ways, a broken promise.”
So, with the Prime Minister insisting he appointed a new health minister to ensure people “can access the care they need, when they need it,” and with the new minister himself promising, “Every decision I make will focus on improving outcomes for patients and supporting our hardworking health workforce”, what does that health workforce most want?
That’s what I went out to ask them. In a sense, I went to collect a shorter, more informal version of the BIM (briefing) Shane Reti had received as incoming minister. Not from the Ministry of Health, but from those in the system. The people you see when you go to your local doctor, wherever that may be, or to hospital.
The health sector’s answers were strikingly consistent. The areas in desperate need of address, revolved around four recurring themes: workforce pressures; inequities in access and outcomes; funding – better targeted to meet specific needs; listening to those who work in healthcare and who know the system and its patients from the inside out (literally).
Newly trained nurses leaving NZ
All four organisations identified immense pressure on the health workforce, and in nursing, particularly, although not exclusively, this means losing people to Australia (and elsewhere).
Kerri Nuku, of the NZNO, described a kind of double whammy for graduate and young nurses.
“It's extraordinary to think that… young graduate nurses are looking to Australia before they're looking here. We saw through the recruitment last year, out of the new graduates, only half of them were able to secure placements within hospitals… So, we have these young nurses pay almost $30,000 plus to train to be in part of this profession. Their calling is nursing. When they come out, if they haven't got jobs to pay back their student loan, or to fulfil their aspirations of caring, then of course, they're going to look overseas. And Australia has incentivised them to come. They've created opportunities. And a lot of nurses that are working there are also New Zealand-based nurses that are encouraging them to go. So yeah, absolutely, we're losing nurses to Australia and abroad.”
In rural healthcare, particularly in more remote communities, the workforce crisis is similar, with the added challenge, Grant Davidson says, of getting graduate doctors to work on the West Coast, or in Northland, or Tairāwhiti, rather than cities.
“We need a workforce that wants to live and work rurally, and so we need a different approach to a workforce, attraction, training and retention.”
This isn’t just workforce advocacy, to take the pressure off harried and overworked rural GPs, for example. It is an equity issue, regarding the health of those populations.
A rough deal for rural Kiwis
Grant Davidson explains that fewer doctors in those areas means longer to wait to get appointments, further to drive to get to them, a greater likelihood of people who need to see a doctor not going, and more preventable deaths. The stakes really are that high.
“All the focus is on the noise around hospitals and waiting lists for critical care. We've got more than those issues sitting in rural communities.”
Better, speedier access means better outcomes.
Grant Davidson told me there are entire communities, some surprisingly large, with, “no urgent care clinics. They rely on that one general practice, which might be up to 80 kilometres away from their rural house.” (Or which might not be taking new patients due to staff shortages.)
“And then if that fails them, then they've got hours of driving to get to a mainstream hospital. In specialist care, if they need to have diagnostics done, then they've got massive drives at great expense to even be diagnosed, let alone get the treatment..”
This speaks to another problem, too.
Delayed care means crowded hospitals
People who delay going to a GP, or who can’t get to see one, are more likely to end up going to hospital instead, to receive treatment for something that could have been prevented from requiring hospital care.
Kerri Nuku repeatedly, said: “If we were to increase the workforce in primary healthcare and community, then it would mean that we aren't getting the sick patients that are fronting up to hospitals. Hospitals that are already under resourced, under funded, under pressure.”
For Dr Bryan Betty, speaking both in his role as organisation chair and local GP, the funding model he works with isn’t even close to being fit for purpose.
In fact, all four of the organisations I spoke to believe the funding model itself exacerbates inequity, rather than addressing it.
When 15 minutes is just not enough
I went to see Dr Betty at his practice, the Porirua Union and Community Health Service, in Cannons Creek.
Cannons Creek has the highest possible deprivation index measure, making it, and neighbouring Waitangirua, the poorest suburbs in the entire Wellington region.
Over and above the obvious impacts of profound economic deprivation, Bryan Betty’s practice has the extraordinary number of 700 refugees on its books – almost none of whom speak English as a first language, and many who barely speak English at all.
They often arrive with complex mental health needs, as well as conditions related to trauma, poverty, poor nourishment, and woefully inadequate healthcare in their previous lives.
The practice also has homeless patients, they have patients with no phones or any efficient way of being contacted, and yet the model of General Practice funding essentially treats this patient base in the same way it treats those of our wealthiest suburbs.
Fifteen minute appointments? Paid for by somebody for whom a fee is no problem? Not often in Cannons Creek.
“So we're funded on a 15 minute appointment basis. That's the standard across New Zealand. That doesn't work in this clinic, because if I see a refugee patient, we have to spend 30 minutes with them, because English is a second language. If they've got complex needs. That'll be medical needs… There's things like PTSD, Post Traumatic Stress, depression, mental health issues, plus social issues.”
All of that means longer appointments, fewer patients through, a translator often being required, which is another cost to the practice.
And that’s not all.
Bryan Betty explains that poor, marginalised, remote (as Grant Davidson’s constituency often is) and vulnerable populations are more likely to use their GP as a conduit to other services.
“You know, dealing with WINZ, dealing with housing, dealing with government services. Our community workers, our cross cultural worker that we pay for, has to actually help them navigate that system. They come here not just for the medical care. They come here for their mental healthcare, and they actually come here for their social services liaison and connection. So there's an absolute huge range of service that we have to provide in a community like this for our patients in order for them to, I think, get the outcomes they need.”
And they don’t have anywhere near enough money to do that. With 7000 patients, his Cannons Creek clinic can’t keep up.
“If you take on any more patients, the service delivery becomes unsafe and the quality of what you’re delivering becomes really, really compromised. So we had to make a very difficult decision 12 months ago to close our books. We've got a very long waiting list now to get access to the clinic. It's a real problem. We don't want it, but, but again, there is a workforce shortage that is having an absolute impact, not just here, right across New Zealand. Rural areas, Northland, Hawke’s Bay, parts of the South Island, you name it. A lot of urban areas are now struggling for GPs. This is a real, real issue that's built up in the system.”
Considered in simple revenue terms you can see the inequity.
Funds vs needs: a massive gap
A high needs practise such as Cannons Creek does receive more government funding than one in a wealthier area. However, because Cannons Creek caps its fees at $19.50 (and some patients pay nothing) it still operates with a glaring financial shortfall, compared to a practice in a salubrious suburb in which patients can and do pay much higher fees (it's $68 for a visit in Grey Lynn, Auckland, where 15 minutes is more likely to suffice).
Even at that maximum $19.50 charge, many of the Cannons Creek patients can’t afford to pay. The Porirua Union and Community Health Service hopes its patients will pay, but doesn’t chase them if they don’t. And so that practice earns demonstrably less money than a practice in a wealthy area, with the increased costs of more support staff to meet a greater breadth and intensity of patient need. "We're probably underfunded by $200 to $300 per patient per year," Bryan Betty estimates.
And that's with 7000 patients on its books (and a long waiting list).
Sarah Dalton says there is immense frustration at the fact that everyone who looks hard enough can see these inequities. And that the Ministry itself has repeatedly acknowledged them. But they continue.
“You know, this is not this is not woke chat or wishful thinking. This is just what we know, what the data says. But everyone seems to just shrug and keep on doing the same thing, you know, and not enough of it.”
All four of the organisations I spoke to, representing tens of thousands of health workers, in all parts of our health system, believe they are not being meaningfully listened to.
Dalton, again: “There are lots of solutions out there. Many of our members have those solutions, and they're being stymied. They're not allowed to apply them in public settings. Research opportunities and funding are being cut.”
Too few paddlers for the waka
The “bulk” of Sarah Dalton’s concern “is about workforce. You know, we really cannot fix anything if we do not have enough people. That's like, obvious, right? If you're trying to paddle a waka that's got 20 places in it, and you've only got eight paddlers, you're not going to perform well. And it doesn't matter whereabouts in the waka you put them, you still only got eight people and 12 gaps.”
“And, you know, the places where people go to work every day are falling down, you know, because we don't look after our things. We don't look after our stuff…. And we can tell, too from the recent Health New Zealand papers that they've been borrowing from their capital works funding to try and pay their current bills, you know? So we're borrowing from Peter to pay Paul. We're kind of disembowelling our own health system just to kind try and keep it chugging along. But, you know, it's not a business, it's a public service.”
“So what kind of a health service do we want? What as taxpayers are we willing to fund?”
And how much money does Simeon Brown have to fund the work that everyone I spoke to says desperately needs to be done?
I called Simeon Brown’s office, and emailed, too.
I’ve had no reply.
But he’s a new minister, and the proof will be in what he does, not what he says now.
The Ministry of Health has told me they are providing him with an updated version of the BIM Dr Shane Reti received, although they’re not yet sure whether it will be made public.
This briefing, obtained by asking people who speak for many thousands of those in the health workforce, is clear.
“Let's not pretend it's a business,” Sarah Dalton concluded.
“Let's not just be governed by all of the dollars. And you know, the dollars are large. Whether we do it well or badly, it's still really expensive… And people are at the heart of it, right? So let's invest in the people. That's patients and it's the people who are caring for the patients, and make sure there are enough of us, enough of them, to be able to do that work in a way that doesn't burn them out, you know, and doesn't make them have to retire early or decide to move to private.”
In rural health, Grant Davidson says, there simply aren’t enough doctors and nurses. “They are under siege because their workforce isn't being replenished. Many of them are nearing or at retirement age and are continuing to serve in their community because there is no one to step in and replace them. From a community aspect, they haven't got the services that they would have in an urban setting.”
And in urban settings, Bryan Betty insists, some practices simply aren’t being funded consistent with need. Inequity is ingrained in the system.
Everyone I talked to, spoke with a belief in the system, with immense admiration for the people working in it, and with a fervent desire for the new minister to listen and to get it right.
Genuine hope? Not so much of that.
But health matters. Not just to those who can afford to go the doctor – and have one they can easily go to.
Kerri Nuku, who sees her graduate nurses leaving for Australia and worries they won’t come back, said a system in crisis is not the system we need.
“It's broken… So how do we bring it back from that state? How do we get governments to realise their responsibility of ensuring accessible, timely care for everybody, and not just those that can afford it? I always remember the quote from Martin Luther King when he said that out of all the inequities, inequity in health is the most unjust. And that is what we're seeing - this unjust treatment that's being perpetuated because of funding imperatives, budget constraints, as opposed to the human side…
"I just worry about the mokopuna that's growing up. I just worry about what is the future of healthcare going to look like.”
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