Annual Review Debate — Health

Thank you, Madam Chair. It’s a real pleasure to take the first call in the annual review debate on health. This year the Health Committee reviewed a large number of entities. We reviewed the Ministry of Health, Pharmac, the Mental Health and Wellbeing Commission, the Cancer Control Agency, the New Zealand Blood Service, and nine DHBs in depth. We also heard from the Minister of Health. So last sitting block, we reviewed the aspects of the health response that related to COVID-19, and in today’s debate we’re going to be considering all of the remainder of the health sector’s work. Given the number of entities that we reviewed, I’ll just focus on a number of the highlights from some of them.

So with the Ministry of Health we discussed the health reforms and the work that the ministry was doing to make sure we had a smooth transition. What the ministry said was that it was working closely with the transition unit and also the interim Health New Zealand and the Māori Health Authority, which it was hosting. We heard that the time frame for implementing the transition was sufficient, because there was really good national governance and oversight in place, and they were working well with DHBs and with other stakeholders. But also they were saying that services wouldn’t be compromised, because the agencies providing the services would be the same.

We also discussed mental health and particularly the mental health crisis call-outs and co-response services with the police, and we discussed whether these should be funded by existing DHB budgets or whether the Government’s $1.9 billion mental health investment should be used to fund these. And what the ministry said was that He Ara Oranga had highlighted the need for a wider range of services in primary care in the community. So what they wanted to do was make sure that those primary care services were available so people didn’t reach the point where they needed crisis services. So this was an important aspect of the Access and Choice programme. They also highlighted the role of the helplines that were available to people in that point as well.

So with Pharmac, we discussed the interim observations from the independent review of Pharmac and asked what progress that Pharmac was making towards addressing some of those issues raised. So what Pharmac told us was that they were seeking more consumer engagement at an earlier stage in its processes, that they’d established a Māori advisory rōpū, and had increased Māori and Pacific representation in its consumer advisory group and other statutory committees—so, basically, a real focus on engagement. In terms of the criticisms that it was reluctant to share information with shareholders and the public, what Pharmac pointed out was that a lot of commercial agreements with suppliers had confidentiality agreements, but it was able to develop processes that allowed it to provide data to the review panel without breaching any of those agreements with suppliers.

For the Mental Health and Wellbeing Commission: we discussed their first year of operation, and the commission said it was very much about establishment. They said that COVID had delayed some of their work—so, for example, the board was appointed about six months later than expected, but it was up and functioning well at the time of the review. We also discussed the commission’s independent monitoring role. While the commission said it had taken some time to develop its wellbeing outcomes and service monitoring frameworks, it felt that those would be crucial to that monitoring. It also said that in addition to their watchdog role, they would also like to act as a guide dog in highlighting areas where things were performing well.

So Te Aho o Te Kahu, the Cancer Control Agency: with our review there, we discussed the effects of COVID on delivery of cancer services, particularly through the nationwide lockdowns in March 2020 and August 2021. They talked about, basically, how treatment services had been largely maintained through those lockdowns, although some of the diagnostic services had been delayed—and that was much less impact in the August 2021 nationwide lockdown. I think the conclusion that they’d reached was that the health system appeared to be learning how to safely deliver cancer services in the context of COVID-19.

We also reviewed the New Zealand Blood Service and discussed the transfer to Organ Donation New Zealand. We also reviewed nine DHBs in depth.

I’d just like to finish by thanking all of those that worked in the health sector in the entities we reviewed for all the work they’ve done keeping us safe from COVID-19, but also delivering all of those other services that we need as a country. So thank you to all of those people out there working at the coalface on our behalf.

Thank you, Madam Chair. It’s a pleasure to speak to the annual review of the health enterprises and to address the DHBs, the Ministry of Health, and the number of agencies that, as have been described, came in front of us. I have a number of questions which I’ll ask in the first tranche.

First of all, we were interested in the financial position of DHBs. And so the first question is: what is likely to be the collective deficit of all DHBs at the end of the financial year, with and without the Holidays Act—we were very concerned with the Holidays Act—and will any ongoing deficit simply be absorbed at the end of the financial year by the Crown? So a question there around collective DHB deficits.

We had a lot of interesting discussion around health workforce, and this second question talks to pay equity and the concern that this seems to have stalled. It’s a question to the Minister around what is the progress on pay equity, and certainly around the point of discussion around purported back-pay agreements.

The third question, which extends health workforce, is the grave concern I have around the aged residential care workforce, which is breaking in front of our eyes. Should a pay equity agreement proceed, it’s been explained to me that the delta between what aged and residential care nurses get and what DHB nurses get could start at about $22,000 and go up to $30,000. Should this be the case, there are several questions: does the Minister acknowledge that this is an urgent risk for us right now? And if pay equity for DHBs does proceed along those lines, what does he think will happen to aged residential care nurses if there’s that big a difference between the aged residential care sector and DHBs? And then, thirdly, what is his plan to address pay parity between the DHB sector and aged residential care, community nursing and primary care nursing?

My fourth substantive question will be: will Pharmac provide and administer cancer medicines to children who are newly diagnosed with cancer in the public hospital system for free? There is an ongoing question we have.

Then, last question I have in this tranche, and we did scrutinise the cancer agency Te Aho o Te Kahu, and so the question becomes: what is his response to the recent damning report comparing the access to chemotherapeutics between Australia and New Zealand and the 18 preparations that are funded in Australia but not in New Zealand. What is his response to that? Has he had any response to Pharmac, and how do we address it? Those are my questions in the first tranche.

Thank you, Madam Chair. I thank the member Dr Shane Reti for his questions, which canvassed a number of issues, so I will respond to them as, indeed, he has asked them and in that order.

First of all, in terms of the financial position of DHBs, the member asked what the collective position is forecast to be by the end of the financial year. I think the member is right: one of the challenges for the DHBs for a significant period of time has been living within their means and sticking to their budgets. In fairness to them, they’ve been struggling with growing populations and a comparatively suppressed level of funding. It is true to say, however, that at least in this financial year, by comparison, their financial performance has been better than in the last financial year and, indeed, in the year before that. But at this stage the forecast for the consolidated deficit across all DHBs will be somewhere between $350 million and $500 million. Now, it could indeed be a little more than that, and I don’t disaggregate the accrued liability for holiday pay. That amount alone is quite significant, and it may well be that when the work is completed on auditing what the shortfall is, which goes back many, many years, that liability alone could in in the order of $1 billion. But that work isn’t completed yet.

On the second question the member asked, about health workforce and pay equity, what I can say to the member is agreements have been reached with the Public Service Association (PSA) and the Nurses Organisation for DHB nurses. That was due to go out for a vote to nurses. The Nurses Organisation withheld the agreement to go out to ratification, and they are now deciding whether that goes to their members for a decision about whether the members contest it in the Employment Relations Authority on the grounds that the terms of settlement reached are in breach of the pay equity legislation, or whether they actually proceed to a ratification vote.

In terms of other pay equity settlements, the pay equity settlement done for the admin and clerical workforce, which also concluded at the end of last year, is due to go to a vote to the PSA members at some point. I’m not quite sure what the timetable for that is now. They have indicated that as a consequence of the position the nurses have taken on their pay equity agreement, they may take a pause for a while.

We are currently in negotiations with representatives with DHB midwives—that’s the Midwifery Employee Representation and Advisory Services—for a pay equity agreement for midwives, but that is under negotiation, and there are foreshadowed pay equity negotiations for the allied health workforce. Their collective bargaining is in process at the moment. An issue there is the process for the pay equity claim they’ve got, but the pay equity part is yet to be negotiated.

The member raised a question about back-pay agreements. I am confident and satisfied from the documentation that I have seen going back to 2018 with the New Zealand Nurses Organisation that there is no agreement on back-pay for nurses. There was an expressed intention in 2018 by both parties, and the language was that the parties intended that the pay equity negotiations would be complete by the end of 2019, and that that would have been the basis of an implementation date. Of course it was a good intention, but the job was way harder than people thought, so that intention was not realised. I’m satisfied, as I say, from the documentation I’ve seen that there is no final agreement—no agreement at all—on back-pay, but nevertheless the Nurses Organisation has taken a position.

The third question in the set of questions the member asked is in relation to the aged residential care workforce. The member characterised it as the workforce or the sector, I think, breaking in front of our eyes. I know there were some pretty dramatic language used by one of their representatives on the radio yesterday that the sector was collapsing. I reject that. It is a sector under pressure, like all parts of the health sector, because of staff absenteeism because of COVID and a range of other issues. It is a sector under pressure, but it is a sector where people every day are turning up to work and providing the care that is needed.

The member is correct that once the pay equity agreements are finalised and concluded and implemented, there will be a gap, a reasonably significant gap, in pay rates between those in the DHB sector—or the public hospital sector, as we will call it—and the funded sector: aged residential care, primary care, and others. There are negotiations at the moment with the employers in the primary and community care sector and they will start to address those issues, but the reality is that there is difficulty in our collective agreement negotiations framework in the health sector—particularly for the funded sector—where the employer and the employee parties meet, but the funder isn’t there. We actually need to find a model where we can bring all relevant parties together to talk together about some of these big issues, and I’m doing some work at the moment with the ministry and others to work out a model that we can have to do that.

I have to say, talking to employer representatives in the sector, that they are very keen to find a model that means they can have a better discussion so that we can more effectively address these issues. In terms of any plan for pay parity, I think what I would say to the member is that I am acutely aware that we do need to see progress in terms of closing that gap, but we have to find a way to do that that is going to be effective for all parties.

In terms of the fourth question the member raised, which was about Pharmac and whether Pharmac will continue cancer treatments for children in hospital, my expectation is that they will. They’ve done a review about the funding of cancer medicines for children as a consequence of a ruling by another body, but I can tell you that this Government remains totally committed to the existing regime of cancer treatments for children and that they are free in our public hospitals.

Finally, the member asked about the Te Aho o Te Kahu report that came out last week on cancer treatments. I don’t share the member’s dramatic view of that report. I don’t think it was damning; I think it gave us clarity about what the gap is, at least, between New Zealand and Australia. It was a piece of work of the sort that we expect the Cancer Control Agency to be doing—that’s why we set it up in the first place—so we can get good information on cancer treatments, cancer diagnosis, cancer screening, and the performance of cancer services across the country. So this report gives us good information about what the gap is between the New Zealand treatments and Australian treatments, and what we might reasonably expect. I think that report would be very useful to inform both the Government and Pharmac in its future decisions about what we can and should be doing. I see it in that light, and I’m very keen to pick up the report and work with the other Government agencies to make sure that we see that through.

Thank you, Madam Chair. Thank you, Minister, for those answers. A quick question: what was the comparator for pay equity with nurses? Which profession, which career, was the comparator? As I recall with the TerraNova case, I believe Corrections was the comparator, but I’d just be interested to know what the comparator is for that pay equity.

A further sequence of a few questions: how does he explain a “D” investor confidence rating from the Treasury in the Ministry of Health, which he leads—the worst rating the ministry has ever had? My third question then would be: how many fulltime-equivalents are predicted with the health reforms? So on day one, we know that it’s a straight transfer from those in DHBs to Health New Zealand. I understand that. What is the future prediction of fulltime-equivalents under the proposed health reforms?

My fourth question becomes: how does he explain—other than COVID, which can be a convenient excuse for a whole range of things, and some I understand are legitimate; some I wonder that they’re just a convenient excuse—delays in implementation of the safer nursing accord, the CCDM model—the Care Capacity Demand Management model? I’d be interested to know some answers to that.

And then, finally, in this tranche: what is his plan to reduce waiting lists, which have ballooned both due to legitimate COVID reasons but actually, leading up to February 2020 when we started to go into lockdown, the waiting lists were substantially increasing anyway? So I’m looking for a plan for that. Thank you.

I thank, again, the member for his questions. I’ll see if I can rattle through these. The comparators were nurses in the pay equity agreement. I’ll say to the member that there were a number of comparators. I don’t recall the precise detail but it included, for example, detectives in the police force. It included management accountants. It included a range of different occupations and professions, some for senior nurses, others for registered nurses who are not senior nurses, and some for mental health nurses. So there was a range of comparators, and in the nature of the exercise, having worked out relevant comparators and the skills and responsibilities, then you sort of quantify the difference. There’s then a negotiation about how to make sense of that data and come up with the rates that were eventually agreed upon.

To the member’s next question about the “D” investor confidence rating: as I understand it, the reason for that is that the Ministry of Health has a demonstrated track record of, shall I say, being very cautious and deliberate in the implementation of its capital decisions. So I have to say, in fairness to the ministry, not assisted by a number of requirements placed on them by Treasury, particularly for significant investments that’s, you know, maybe reasonable from a public finance point of view—but the reality is, and to the extent that people criticise the length of time it takes to get investment or capital investment decisions implemented in the health sector, there doesn’t seem to be an inordinate amount of time taken and there’s a number of hurdles to get through.

I’m confident that Health NZ, once legislated for and in place, will—in fact, I know they are committed to exploring exactly why it is that there is this lengthy process and these lengthy delays, and we’re, in a sense, facing the consequences of that because projects that were priced two or three years ago now are facing material cost escalations just because of current circumstances. That is the price of delay. And we’re going to have to look carefully at the implications of that.

To the member’s next question about the number of fulltime-equivalents and the health reforms, what I would say to the member is that I expect there will be a shift of nature of roles. So we know, across the 20 DHBs, there’s a significant chunk of what I would call corporate services roles necessary in any large organisation, but the reality is when you consolidate an organisation, you can strip out some of those roles. But my expectation is that what that will mean is that what is saved from those roles can then go into front-line health services. That’s what we’re trying to achieve here, is to ensure that the dollar that we are spending on health is used to the best effect. And the more that we can see spent on front-line health services, then the better for New Zealanders looking at and in some cases waiting for their healthcare and the better for the health system.

To the member’s next question about delay in the implementation of Care Capacity Demand Management (CCDM), I mean, it’s an interesting question because the reality is the commitments to CCDM were first made in 2007 and 2008 following a review in 2005 and 2006. It was the Government in office in 2009 that made the initial commitments, set up the original pilots for CCDM, and three DHBs, including Taranaki District Health Board. It was a surprise to me—after the final deadline set for full implementation of 30 June last year that wasn’t met—in the review that I commissioned for it, to see in that review that Taranaki District Health Board, who started in 2009, were classed as one of the laggards in terms of completing implementation. I would say that there simply was not enough political drive given to CCDM between 2009 and 2017. This Government recommitted in 2018 to see the programme through. We did that. We still didn’t meet the deadline. We’ve done a review. We’ve got some good recommendations and commitment from nurse leaders and the nursing workforce to now see that fully and properly implemented.

And then the final question the member asked in that tranche is the plan for waiting lists—very timely. There’s been a bit of work—quite a bit of work, actually—gone into that, and I’m due to make some announcements tomorrow on the approach we will take to deal with those waiting lists. I can say to the member that if we did nothing else, if we just relied on kind of past practice, the projection is it would take us between three and five years to clear the current backlog. That’s not acceptable and tomorrow I’ll be announcing an approach we will take to deal with it.

Kia ora koutou. My first question is: we note that the recommendations of the Human Rights Commission report on the access to care for disabled people to health and support services—we noticed those recommendations are very, very similar to the ones in the report from January 2021, so we’re just wanting to hear from the Minister of Health about how you plan to address those recommendations.

And our second question is: given the discrimination faced by people with diverse genders, sexualities, and sex characteristics in the health sector, and the lack of a rainbow strategy proposed in the Pae Ora legislation, how does the Minister propose to provide pathways to gender-affirming healthcare, to dealing with the issues of gender-normalising surgery faced by intersex infants, and a range of other healthcare issues that, although they might be addressed in some of the locality plans—how does that connect up with needing to access services which are only available in certain places? Kia ora.

Thank you, Madam Chair. I thank the member Elizabeth Kerekere for her questions. I’m just looking round to see whether my colleague the Hon Ayesha Verrall is here—she’s not. On the second of the member’s questions in relation to any possible rainbow strategy or pathways to healthcare for gender diverse people, I can say that has been a priority piece of work for this Government, and in particular for Dr Verrall. We have stepped up, particularly in relation to gender-affirming surgery—we’re now seeing a commitment to that that we hadn’t seen for a long time. So a record number of procedures performed last year, we’ve been having a little bit of difficulty getting traction this year, but the numbers of cases being considered, and candidates for those procedures entering the appropriate therapeutic pathways, those numbers are increasing, which I hope will be encouraging to the member.

On the member’s first question about the Human Rights Commission report on the access by disabled people to support and care during the COVID pandemic, I want to acknowledge that report and the findings of that report that reflected that there has been difficulty for disabled people, and their whānau, supporters, and carers, to make sure that they’re getting good information, and in some cases good care. I can say to the member that even before the report had concluded, and the recommendations were evident, changes were already being made. I think, in fairness to those who have been running the COVID response, a lot was done very quickly, and I think that might justify some haste. And, you know, far from ideal practices in the early stages, but I think—as I understand from the member—the justified concern about the latter stages, particularly last year, when we then had another nationwide lockdown in August and then with Delta, that put a lot of pressure particularly on the northern part of the motu. And then the Omicron outbreak that, I think, caused a lot of concern and anxiety. By that stage, we ought to have had effective communications or channels in place that we didn’t harness. I’m confident now that those issues have been addressed, that we now have good engagement with representatives of the disabled community, and they are making sure that when it comes to putting together strategies and practices that we’re doing better by that community than we have in the past.

Thank you very much, Madam Chair. A good choice, I believe. Can I start by acknowledging Dr Liz Craig, with her recent announcement—I see via email—of her promotion to Parliamentary Private Secretary to the Minister of Health, I believe it is. Sadly, it sounds like she’ll be leaving the Health Committee and chair. I’d just like to acknowledge the great work that she’s done over the course of what must have been several years as chair. So, congratulations.

We are reviewing years 2020 and 2021, and I think what we learnt from bringing the DHBs in front of the Health Committee was further insight to ballooning waiting times in our mental health services, despite what’s been announced as a considerable investment. So if we take a couple of examples: Taranaki District Health Board, for their Child and Adolescent Mental Health Services (CAMHS), wait times have gone from 22 days in 2016-17 to 52 days. That’s an increase of 30 days now that young people in Taranaki are waiting, under this Government. Another one was Waitematā District Health Board, where their wait time for CAMHS in 2016-17 was 17 days; now it’s at 31 days. And I think, for those who will read the summary report, it’s fair to say that level of direct increase in waiting times was across most of the DHBs.

So I’d like to hear from the Minister of Health why he thinks that his increased investment into mental health has not worked, why we are seeing skyrocketing waiting times, and what plans does he have in place that we come back to in the next annual review—which won’t be of DHBs, of course, because we’re abolishing them, but of the new entity—to make sure young people, especially in the time of COVID-19, are receiving timely access to mental health care.

In relation to mental health services, can I just say that this is a Government that has not spent its time in Government completely and utterly ignoring the mental health challenges that are evident in this country—by comparison to the previous Government, which spent nine years ignoring an emerging health crisis. And so I’m very proud to be part of a Government that has invested, starting in 2019, $1.9 billion to address the single biggest gap identified by an independent review in our mental health services, which was the primary healthcare end of mental health services and for people with mild to moderate mental health issues. I’m very pleased to report to the House that we now have 337 GP practices, covering roughly 45 percent of the enrolled patient population; roughly 900 fulltime-equivalent roles, new roles in the front line of mental health, providing support to those with mild to moderate mental health issues—and there are people who are getting that support, getting that help, every day, right across the country. And, of course, we are part-way through the programme. We are about 2½ years through a four- to five-year programme. We’ve had a few delays as a consequence of COVID-19, so we have a wee ways to go yet and that work is progressing.

We have some challenges now in the acute and specialist end of mental health services. What the figures show, generally speaking, is that across the country, wait times have not significantly changed, on average, across the country, but there are isolated areas where there have been major challenges. In Taranaki, we know there have been major staffing issues with their mental health services, that that DHB is in the process of getting on top of.

Across all these services, new investment has gone into facilities, because that’s another area that was left completely neglected and run down. It turns out a lot of our acute mental health facilities are no longer suitable therapeutic environments for people needing to recover from serious mental health issues.

I want to add, too, the next big challenge I think we have, because I know members opposite sometimes think that we’ve just got to add more beds to acute mental health services. The challenge that leaders of the acute mental health facilities tell me isn’t that we need more beds at that end of their mental health services; there are people in our mental health units who, were it for better community-supported facilities, would not be in those acute facilities. The need is not at the acute end, in terms of bed space; it’s actually in community facilities with decent support—the sort of work that is happening with Hawke’s Bay District Health Board and their facility that they’re in the process of setting up, which is a peer-supported facility for those with lived experience supporting those being discharged and helping them get their lives back together in the community. And that’s, I think, where the next big challenge lies.

But one thing I can assure this House is that we don’t ignore serious problems. We see the serious problems, and we work with clinicians, with professionals, with others to address those problems. We don’t fix them overnight, because we want long-term and enduring solutions, but we do fix problems and we take time to do it properly.

Thank you very much, Madam Chair, and I would like to thank the Minister for his time tonight, taking us through his approach and especially he did mention in-patient care. It was interesting thinking about the drivers of getting people in in-patient facilities out into the community. But I would ask, why is the focus not on just getting shovels in the ground to build these new facilities? Because when you look at the annual reviews, each DHB pitched up with the same story of a new facility announced two or three years ago.

If you look at Capital and Coast DHB last year and occupancy in their in-patient facility, Hutt Valley DHB was from 82 percent to 99 percent occupancy. Capital and Coast was 92 percent to 110 percent occupancy. What we’ve got to remember is clinical patient safety guidelines is 85 percent occupancy for patient safety. So here we have all our in-patients blowing out, but a common theme is there’s just no shovels in the ground for these new facilities.

This is with the backdrop, of course, of the Minister himself expressing frustration at in-patient facility builds. So he initiated an independent review—that was obviously conducted by his colleague Grant Robertson’s Implementation Unit—that found good progress was being made and things were on track. So it would be helpful, I think, for the House if we can just find out why none of these projects have shovels in the ground three years later.

Madam Chair, I think the thing that I can most help the House with is to get facts straight because the member who has just resumed his seat, Matt Doocey, seems incapable of doing that. So it was very important, when we put together a complex and complicated programme to fix up a long-neglected problem like the emerging mental health crisis that we have had in this country, that you do periodically review it part-way through. So we had the benefit of the Implementation Unit that is run out of the Department of Prime Minister and Cabinet—not run out of the Minister of Finance’s office—who conducted that review. The focus of that review was on the Minister of Health end of the $1.9 billion—the Minister of Health end of that $1.9 billion is about $1.1 billion—and looked at the access and choice part of that, which was the integrated primary mental health care end. It was that part of the programme that the Implementation Unit said was on track and making progress as expected.

By contrast to the member’s reading of that report, the Implementation Unit did not say that the capital build programme was on track; they said the opposite. They said it was not on track and they identified a number of difficulties, including lack of project management skills and capability within DHBs, and that that work simply had not been given the attention that it should have done. Since then, there have been changes in the Health Infrastructure Unit, which is within the ministry, and those changes are ongoing because that’s now part of the interim Health New Zealand set up. But I’m confident now that there is impetus and momentum to get those projects under way. The single biggest one of those projects was the Waikato District Health Board Henry Rongomau Bennett Centre facility that is in poor shape. There have been a lot of critical reports about that facility. The design of that is now well progressed and is going through the decision-making processes. I’m confident that that is making good progress. I’m confident that the other facilities that are part of the scheduled programme will make good progress in the latter part of this year.

I thank the Minister for the response to that, and I would point out the two reports from the Ombudsman received in the last week about facilities in MidCentral DHB, specifically Palmerston North, and of course in the Bay of Plenty DHB, in Tauranga and Whakatāne, where he was very critical that money had not been spent. Seclusion rates—and we saw that in several reports last year—have skyrocketed after declining up to 2016 and 2017, and now have peaked, and I point that towards the Minister.

I would like to finish with the Minister’s comments about the co-response mental health service, which Dr Liz Craig raised, and whether the Minister now accepts that his Government’s decision to cancel that in 2017 when coming into office—that has now had five years where that service could have been making a difference. As outlined in the annual review of the Ministry of Health, why are DHBs expecting to fund that out of baseline funding? Because what that’s driving is we only have one, which is Wellington. And when we find, and it’s evidenced in the annual review report that we’re looking at today for the Ministry of Health, that police are not turning up to 50 percent of mental health acute call-outs last year—50 percent of the most vulnerable New Zealanders calling for help and they did not get an emergency response in mental health crisis call outs.

I’m not quite sure what the question there is—the member made a number of observations—except to say that there have been a number of approaches taken to provide better mental health support at the front line of our first responders, both the police and ambulance workers as well. So Capital and Coast DHB has been running their pilot of putting mental health workers with police and with ambulance staff to see what difference that makes. We’re still waiting to see a final evaluation of that. I think a programme that I’ve also seen is where mental health nurses were located in watch-houses of police stations, particularly bigger ones, and where assessments were able to be carried out of those coming into the police station, and indeed, those mental health nurses were then available for police officers in the front line, actually out in the field, while dealing with somebody who was mentally unwell, and getting advice, and that appeared to make a difference too.

So I think we are all exploring different ways to make sure we provide the support and help that people who are mentally unwell need and in the different contexts in which that happens. That includes providing support within our emergency services to provide assistance for people they come across who are in mental distress and who need that help. There are some models emerging. In the end, it comes back to some of the fundamentals, the fundamental foundation that I think the He Ara Oranga report was talking about that needed to be laid: that the sooner people can get help for what are minor or mild to moderate mental health issues—the anxieties, the low-level depression, the distresses that people feel on a day-to-day basis—if they get help for those and learn some skills and some responses and build their own resilience, then that can help long term to keep the pressure off other mental health services.

There will be people whose mental unwellness is a consequence of factors that are not capable of being dealt with through talk therapies and what-have-you: that a pharmacological response might be needed, or a more acute response, and we need to make sure we have a system that is there, available to respond to them. But for those for whom other more mild responses are needed, those responses have to be in place too, and that’s why we’ve taken the steps that we have.

Thank you, Minister, for receiving our questions. I’d just like to first also join with my esteemed colleagues and congratulate our chair of the Health Committee, Liz, on your new appointment.

Just a couple of things for you, Minister Little. Will the Minister support the establishment of a Māori director-general role with the introduction of the Pae Ora (Healthy Futures) Bill? And as the Minister knows, I sit on the select committee overseeing the Pae Ora legislation—or sat. On a number of occasions, I had raised the need to reflect and acknowledge recognition of Māori political authority, tino rangatiratanga, as was recommended in the findings of Wai 2575. The officials denied my suggestions, stating that the Minister didn’t want that reflected in the legislation, the concept of tino rangatiratanga, and I’d like to understand: why was this decision made and what basis does the Minister decide tino rangatiratanga should not be incorporated into legislation, and why did the Minister knowingly ignore recommendations from the Waitangi Tribunal?

Third, the Pharmac reading is really dim and grim, to be honest, and some of the aspects that came out in the inequities report were shocking. What is it that you’re going to do to ensure that it aligns more with Te Tiriti and is able to address specifically inequities in how it addresses Māori going forward? Kia ora.

Thank you, Madam Chair, and I thank the member for her questions. In relation to the first question, whether I support a Māori director-general role, no I don’t, because I think at the moment, with the Pae Ora bill, what we’re trying to set up is a system where we have the ministry, Māori Health Authority, and Health New Zealand as the important, kind of, triumvirate, if you like, and the Māori Health Authority, although not the Treaty partner, is a very important expression of the Crown’s obligations under the Treaty and a reflection of a range of recommendations coming from the Waitangi Tribunal over time about what is needed to improve health services for Māori. So I don’t see putting in place a Māori director-general alongside any other director-general in the Ministry of Health is adding to or changing what we’re trying to do with the Pae Ora health model.

In relation to whether or not there should be a reference to tino rangatiratanga in the bill, I can tell the member that that was considered, but the advice is that because of the jurisprudence that has developed around the Treaty and indeed the references to the Treaty and Treaty principles over multiple pieces of legislation over many decades now, there is concern about what a court might do when confronted with the language of that. I think in light of the High Court’s decision on the Ngāti Whātua Ōrākei case now is we’re seeing a judiciary that says that it does not want to step into and tell Māori what te reo Māori phrases or terms mean.

The other challenge I think there was too, of course, is that in the Treaty, tino rangatiratanga stands alongside Kāwanatanga, and if we are going to put expressions of tino rangatiratanga in legislation, then we also have to then also acknowledge that is within a context of Kāwanatanga, which is the other by-product of the Treaty. So that’s why that is not in the bill.

In terms of ignoring the Waitangi Tribunal, the Waitangi Tribunal makes a lot of recommendations on a lot of things in the context of its kaupapa inquiries and its other reports and findings that it makes. Not all are taken up by the Crown. Indeed, I think what the Pae Ora bill says by way of analogy in relation to the Hauora Māori Advisory Committee that advises the Minister on the exercise of powers in relation to Māori health and the Māori Health Authority is that if the Minister chooses not to accept a recommendation from that group, then that has to be publicly stated so that that at least is transparent. I think that is a useful model.

I didn’t quite catch the last of the questions that the member raised. She might take another call and raise them again.

Thank you, there were two. So the question, Minister, was in respect to Pharmac and the report and the shortcomings and inequities specifically towards Māori. I guess a follow up to your second answer is: if the Minister is cherry-picking aspects of the tribunal recommendation in the Māori Health Authority, how are you going to maintain or ensure the authenticity or the success of that model going forward?

Thank you, Madam Chair. I thank the member, and, look, I apologise to the member; I just didn’t hear the question about Pharmac. Look, I acknowledge the point the member raises and the report that said that Pharmac’s performance on equity, and particularly in relation to Māori, has simply not been acceptable. I think even Pharmac now accepts that. We now have a final set of recommendations, from the review group, that’ll go to Cabinet very shortly and then be publicised, and I think we’ll start to see there the sorts of measures that now can and need to be taken to improve that. Part of that now, and with the benefit of the Māori Health Authority, subject to the legislation passing, is that there is now a body which Pharmac can now partner with to make sure that the way Pharmac conducts itself and goes about its business does more actively seek to meet the equity shortcomings that have been identified.

In relation to what the member describes as “cherry-picking aspects of the Waitangi Tribunal’s recommendations”: I think what we see, in relation to the model set up in the Pae Ora bill, with the establishment of the Māori Health Authority, and another critical element of that also being the iwi-Māori partnership boards—so the iwi-Māori partnership boards, that is the opportunity for iwi and the iwi voice, and, indeed, hauora Māori services’ voices to be reflected. The Māori Health Authority has an obligation to support those bodies and to draw from them, to draw from their mātauranga and their experience, to inform their work. Added to that is just—I acknowledged before that we have the Hauora Māori Advisory Committee advising the Minister—the membership of that body comes from Te Ao Māori; the Minister makes the technical appointment but the recommendations come from Te Ao Māori and, indeed, from iwi-Māori partnership boards, and hauora Māori services as well.

So I think there is a balance achieved there so that the leadership that we are all wanting and needing to see, in relation to Māori health, will be leadership by Māori, for Māori. The Crown’s role is to ensure that happens, to facilitate it, to protect it, and to make sure that it is integrated into the rest of the health system. So I think it achieves what many have advocated for. I think it achieves what the Waitangi Tribunal recommended in the Wai 2575 claims. And I detect, as I get around, a real enthusiasm right across the health sector to see this model in place and to see it work—because we all know we have to make a significant difference when it comes to access by Māori to health and to Māori health outcomes.

Thank you for that clarity. So can I just ask one last question? If I understand—and I completely support your view on iwi, on the Tiriti partnership and tangata whenua part of it—at the end of the day, is it you, as the Minister, who will decide what of those recommendations that you’ll accept? Or is there an equal balance in how those recommendations—a little bit like the tribunal—will be adopted in going forward?

Madam Chair, thank you. If I understand the member’s question, when it comes to the advice and recommendations of the Hauora Māori Advisory Committee, if I don’t accept, wholly or in part, a recommendation of the Hauora Māori Advisory Committee, then I have to transparently say that. And if I’m being called upon to implement something on the basis of their advice or recommendations, and if there is any one of their recommendations that I don’t accept, then I have to explicitly state that. But that group is there to assist me in the discharge of my powers as Minister when it comes to decisions that bear upon Māori health or the Māori Health Authority, which includes discharging powers in relation to members of the Māori health board. So there is no absolute guarantee that I, or the Minister of the day, will accept the recommendations unquestioningly; it may well be that some recommendations will be rejected. But, if they are, then that has to be publicly notified and made transparent.

Madam Speaker, the committee has considered the Appropriation (2020/21 Confirmation and Validation) Bill and reports it without amendment. I move, That the report be adopted.