Part 6: Is the Ministry of Health's leadership and guidance enabling regional services planning?

6.1
Good leadership and guidance are important if regional services planning is to be effective and efficient. In this Part, we look at the Ministry's leadership and guidance of the regional services planning process.

6.2
Regions expressed dissatisfaction with aspects of the NHB's leadership, most specifically about it not setting a longer-term, strategic view. In our view, the Ministry's regional services planning guidance has not yet significantly increased the integration of health service planning at different levels of the health sector, although relationships have improved. The guidance is not in line enough with other DHB and regional planning activities, and is too detailed and prescriptive.

Ministry guidance and the intended effects of regional services planning

6.3
The Ministry is the main authority providing guidance and leadership when it comes to regional services planning.

6.4
The senior people we spoke to in the health system identified several problems with how the Ministry leads regional services planning through the guidance provided, including:

• not enough attention being given to defining the national, regional, and local components of the health system; and
• a lack of a strong strategic focus on the whole health system.

6.5
These wider problems were identified in the Performance Improvement Framework review of the Ministry of Health in 2012.⁸ The Ministry has worked to address these concerns, in terms of its organisational development and the way in which it engages with the health sector more widely. There have been improvements in setting up opportunities for better engagement, such as the Health Sector Forum of senior leaders and face-to-face meetings about strategic priorities with DHB chief executives and chairpersons. However, senior managers still voicing concerns in early 2013 would suggest that there remains some way to go.

6.6
The problem we heard most about was that the Ministry was over-prescriptive when it was unnecessary, and did not give enough detail when detail was needed. This is a difficult balance for the Ministry to get right, but it is an important aspect to address because the Ministry is the health sector leader. The Ministry told us that the level of prescription was needed to improve consistency where regional collaboration had been less advanced in the past. Our evaluation of the plans and our fieldwork indicate that the approach has ensured compliance with a standard. However, the regions that had advanced beyond that standard were probably the most frustrated by the level of prescription.

6.7
Our evidence shows that many people think that the Ministry's regional services planning guidance is not forward-focused, strategic, or clear enough about future national health services and needs. Some of the people we spoke to expected a long-term health sector plan from the Ministry. Such a plan was referred to in the Health Sector Framework 2010 document, and the Ministry had said it was working on preparing such a plan until June 2011. About then, it seems a decision was made that the plan was no longer useful, but we could not find evidence of where that decision was taken or who was consulted. This lack of clarity could have contributed to the comments we received about how effective the NHB's leadership has been.

6.8
The Ministry's regional services planning guidance requires regional services plans to address the need for:

• local, regional, and national services;
• co-ordinating those services effectively and efficiently; and
• the best possible arrangement of health services for delivering services effectively and efficiently.

6.9
The Ministry has stated that the intended outcomes of regional services planning are improved quality of care, reduced service vulnerability, and lower costs.

6.10
The Ministry's regional services planning guidance is not in keeping with these intended outcomes of regional services planning. We do understand that the guidance is driven by the planning regulations. However, we also understand that a regulatory approach was taken to enable changes to be made, if necessary, without having to change primary legislation.

6.11
The Ministry publishes a DHB planning pack every year. The pack contains guidance for regional services plans and district annual plans. The guidance is followed soon after by a letter from the Minister setting out his expectations for the next 12 months. Regional services plans and district annual plans are submitted within a few weeks of each other. In practice, DHBs have a short time to prepare and complete their regional services plan and their annual plan, including getting the contributions of the regional networks. The Minister approves the plans at the same time, as long as they are satisfactory.

6.12
We understand that the regional services plan should be significantly more strategic and long term, whereas DHB plans reflect the operational requirements falling within that year. However, the regional services plans are also required to have an implementation plan, mostly to hold regions accountable for progress. The regional services plans only reflect part of the DHBs' regional activities. Despite this, many of the regional services plans exceed 150 pages when all the prescribed content and discretionary content is included.

6.13
Other problems with the guidance are that it:

• says little about the intended effects of regional services planning other than cost effects; and
• does not pay enough heed to the scale and speed of change needed to move to regional services that are clinically and financially sustainable.

6.14
In our view, the Ministry cannot show that regional services planning guidance has reduced the administrative costs of planning, although we acknowledge that DHBs no longer need to submit district strategic plans. We cannot see that the Ministry has significantly increased the integration of health service planning at different levels of the health sector. However, we acknowledge that the requirement to carry out regional services planning has increased communication within and between DHBs, with some improvement in relationships reported.

6.15
The detail that the Ministry's regional services planning guidance and time frames require means that DHBs might focus on complying with each of the extensive requirements rather than working with other DHBs to plan how a region will deliver services. The Ministry recognises this risk, and has increased the amount, and nature, of engagement it has with regions during the planning cycle.

8: State Services Commission, the Treasury, and the Department of the Prime Minister and Cabinet (2012), Formal Review of Manatū Hauroa the Ministry of Health (the Ministry), available at www.ssc.govt.nz.