Rebuilding confidence in New Zealand’s health system

As New Zealand enters another election year, I suspect the economy will dominate the political debate; however, health will remain a major secondary issue. Health has rarely been out of the media spotlight over recent years, reflecting people’s lived experiences: longer waits, difficulty enrolling in general practice, rising out-of-pocket costs and uncertainty about whether improvements will materialise. These realities place the performance of Health New Zealand – Te Whatu Ora and access to primary care at the centre of the health debate. Around them orbit other high-salience issues: cancer treatment and screening, mental health and substance abuse, waiting times, workforce shortages and health funding within fiscal constraint.

Elections inevitably generate promises. The central challenge for voters is distinguishing between broad aspirations and policies that are credible, deliverable and fiscally sustainable. There are plenty of examples where election promises have not been deliverable. A memorable recent example of an undeliverable commitment was the previous Labour Government’s KiwiBuild programme, which pledged 100,000 affordable homes over 10 years.¹ The target was abandoned in 2019 when it became evident it would not be achieved and only a small fraction of promised homes had been completed.¹ Aspirational commitments have value, as they signal intent and may give the electorate hope. Yet they also carry risk when they outpace workforce capacity, infrastructure and/or funding. This election will be judged not only by what parties propose, but by whether the public—and the profession—believe those commitments can realistically be implemented.

Performance of Health New Zealand – Te Whatu Ora and access to general practice

A defining health issue in this election is likely system performance—particularly timely access and equity of care. Health New Zealand – Te Whatu Ora was established to unify a fragmented system, improve national consistency and enable co-ordinated planning. Reform on this scale inevitably takes time. Yet the public experience is shaped less by structural design than by persistent symptoms of strain: crowded emergency departments, long waiting lists and substantial regional and ethnic inequity.

For most people, however, the health system is experienced closer to home—through their general practitioner (GP). General practice is the critical pressure point. Many patients report difficulty enrolling, long waits for routine appointments and rising co-payments. Clinicians experience the same problem from the other side: rising patient complexity, an ageing practice workforce (especially in rural areas), increasing administrative burden and difficulty recruiting and retaining colleagues. Unmet need accumulates and manifests downstream in late emergency presentations, poor chronic disease control, avoidable hospitalisations and worse equity.

System performance cannot improve without a strong primary care foundation. A high-performing Health New Zealand – Te Whatu Ora will be measured less by yet another cycle of restructuring and more by whether timely, affordable access to general practice is restored.² Solutions will require sustainable funding models, multidisciplinary team–based care, better digital integration, robust rural support and strengthened links between primary and secondary services. Without this, downstream hospital pressures will remain structurally entrenched.

Cancer: medicines, screening and public confidence

Cancer related issues will also be an important election issue. Almost every New Zealander has lost family and/or friends to cancer. It is common, feared and uniquely sensitive to timely diagnosis and access to effective treatment. Incidence will rise as the population ages. One modelling study estimated annual diagnoses could increase from around 25,700 per year (2015–2019 baseline) to more than 45,000 per year by 2040–2044: an increase of 76%.³ This projected burden will test a system already under strain.

New Zealand’s cancer services remain distributed across multiple smaller units, with variable access to subspecialist expertise. Fragmentation contributes to inconsistent quality, weakens multidisciplinary decision-making and limits the scale needed to sustain research programmes and clinical trials. Patients requiring complex care may be forced to navigate multiple institutions, amplifying geographic, socio-economic and ethnic inequities.

International experience suggests that Comprehensive Cancer Centres (CCCs)—integrating surgical, medical and radiation oncology with pathology, imaging, supportive care, psycho-oncology, palliative services, data infrastructure and research—are associated with improved outcomes, fewer complications, greater access to clinical trials and stronger training and retention of specialists.^4,5 CCCs can address current weaknesses by concentrating expertise and volume: embedding consistent multidisciplinary case management, creating high-quality training environments, expanding access to trials and novel therapies, supporting hub-and-spoke models that connect regional providers to tertiary centres and enabling outcome-driven improvement through audit and registry systems. In this sense, CCCs are both a clinical strategy and a workforce strategy. Without them, New Zealand risks continued loss of highly trained clinicians to overseas centres offering stronger integrated clinical-academic careers. Establishing CCCs would require explicit policy decisions: formal designation, sustained investment, partnership with Māori in governance and integrated national and regional network design.

Against this broader context, public debate has focussed heavily on cancer medicines. Clinicians recognise the complexity of Pharmac decision-making, which must balance evidence of benefit, safety, equity and opportunity cost. Public frustration has arisen less from this complexity than from its political over-simplification. Pre-election signalling of expanded access to cancer drugs created strong expectations, yet delivery has fallen short of what many believed was promised.⁶ This gap between rhetoric and reality increasingly shapes clinical consultations, as clinicians must explain why treatments discussed publicly, available overseas or funded in comparable systems remain inaccessible locally or obtainable only through self-funding.

Bowel cancer screening is a related—and urgent—issue. International comparisons (particularly with Australia) and the rising incidence of early-onset colorectal cancer have strengthened calls to lower the age of eligibility. Commitments have been made, but implementation has been partial and progress has not matched earlier signalling.⁷ This delay represents a missed preventive opportunity in a disease where stage at diagnosis remains the strongest prognostic factor. For Māori and Pacific peoples—who already experience delays to diagnosis and poorer outcomes—deferred screening expansion risks widening inequity.⁸ Any move to expand eligibility must, however, be matched by investment in colonoscopy capacity and workforce; otherwise, once again, promise will exceed deliverability.

Election-year discussion should, however, move beyond single interventions towards system-level redesign. If New Zealand is serious about improving cancer survival and equity, it must address not only what treatments are funded, but how cancer care is organised and delivered.

Mental health and substance abuse: demand beyond capacity

Mental health and substance abuse remain areas where community need exceeds available capacity. Long waits for psychological therapies, limited access to culturally appropriate services and pressure on crisis care persist despite previous waves of investment. Workforce shortages across psychology, psychiatry, mental health nursing and addiction services remain central constraints.

The burden is not evenly distributed. Māori and Pacific peoples experience higher levels of need linked to structural determinants, colonisation, racism and socio-economic disadvantage. For young people, distress increasingly intersects with educational performance, employment insecurity, substance harm and family vulnerability.

Meaningful improvement requires long-term service design rather than episodic funding boosts. Priorities include early intervention, integration with primary care and schools, expansion of addiction treatment, digital support for remote communities and sustained workforce development.

Waiting lists, targets and real-world delivery

Waiting times—for outpatient appointments, diagnostics or elective surgery—remain acutely visible to the public, with media accounts of delayed care common. While targets can improve transparency and sharpen accountability, without corresponding capacity they risk becoming symbolic metrics or creating perverse incentives. Real reductions in waiting times require real increases in capacity: additional theatre sessions supported by an expanded peri-operative workforce; greater diagnostic imaging, endoscopy and pathology capability; planned post-operative rehabilitation and community care pathways; and administrative and digital systems that enable efficient triage, booking and scheduling.

Ultimately, assessment of Health New Zealand – Te Whatu Ora’s performance will rest less on whether targets exist on paper than on whether people experience shorter waits in practice.

Workforce: the fundamental limiting factor

Behind nearly every health system challenge lies the same determinant: workforce.⁹ New Zealand does not currently have enough doctors, nurses, midwives and allied health professionals to meet rising demand, particularly outside major centres. International competition and migration trends continue to complicate recruitment. Retention is equally urgent, with burnout, moral distress and fatigue increasingly reported.

Workforce constraint cannot be solved by slogans or short-term incentives. It demands sustained investment in local training pipelines, immigration settings that reflect both ethical recruitment and domestic need and working environments that are safe, supportive and professionally sustainable. This includes improved rostering, access to leave, clear career pathways that retain senior clinicians in clinical care, teaching, leadership and research. Without solving workforce constraint, even well-designed reforms will struggle to translate from policy into practice.

Fiscal reality: government debt, health budgets and the limits of the tax base

Any credible election-year discussion of health must confront economic reality. New Zealand faces rising government debt and increasing debt-servicing costs, which directly compete with other public expenditure. At the same time, health demand continues to grow—driven by population ageing, chronic disease burden, technological innovation and legitimate workforce claims for fair remuneration in a globally competitive labour market.

Health funding is inseparable from the size and stability of the tax base. When economic growth is limited and tax revenue constrained, governments face unavoidable trade-offs. In this environment, limited real growth in health spending relative to demand means many initiatives can proceed only through reprioritisation rather than genuine expansion.

The implications are straightforward. Earlier bowel cancer screening, expanded access to cancer medicines, establishment of CCCs, strengthened mental health services and improved access to primary care all require additional capacity and resource—sometimes after a long lead time. There are only three fundamental pathways: increase revenue, reallocate from other sectors, or achieve genuine productivity gains within health. Ignoring this while making confident promises fuels scepticism and undermines trust. Transparent acknowledgement of fiscal limits and trade-offs is therefore essential—while still leaving room for ambition and hope.

The challenge of broken or delayed promises

We all recognise that making health promises is easier than delivering on them. When delivery falls short of expectations, public confidence erodes and clinicians are left to manage the consequences—explaining to patients and families why anticipated changes have not occurred.

A significant contributor to this dynamic has been ministerial churn. New Zealand has had six ministers of health in the past 6 years: David Clark (26 October 2017–2 July 2020), Chris Hipkins (2 July 2020–6 November 2020, interim), Andrew Little (6 November 2020–1 February 2023), Ayesha Verrall (1 February 2023–27 November 2023), Shane Reti (27 November 2023–24 January 2025) and Simeon Brown (24 January 2025–present).¹⁰ The portfolio has increasingly resembled a political “hot potato”. Each new appointment brings an inevitable learning curve, while turnover undermines continuity, weakens relationships with the sector and fragments strategic direction.

Accountability does not imply rigidity—circumstances change and some plans will not proceed. But accountability requires honesty, early communication and evidence-based explanation when commitments cannot be met. Deliverable, costed, evidence-informed promises are ultimately more ethical than symbolic announcements that may never be realised.

What should matter most in the election debate?

I think several questions deserve prominence:

• Is Health New Zealand – Te Whatu Ora improving timely access and equity of care, particularly through strengthened primary care?
• How will access to general practice be restored and sustained across urban, provincial and rural settings?
• What is the credible pathway to earlier bowel cancer screening and improved colonoscopy capacity?
• How will access to effective cancer medicines be made fair and sustainable?
• Will New Zealand commit to catching up to the rest of the world by establishing CCCs and networked cancer systems?
• What is the long-term workforce strategy across health professions?
• How will prevention, Māori health equity and public health capacity be embedded into policy?
• How will reforms be funded within real fiscal constraints?

These are not partisan questions. They are questions on issues that may have a daily impact on patients and those who care for them.

Conclusion: performance first, promises second

The defining health issue in this election will be system performance—especially access to GPs and primary care. If people cannot obtain timely primary care, if waiting lists continue to grow and if cancer care remains fragmented, public confidence in the health system will continue to decline regardless of structural reforms.

This election offers an opportunity to reset expectations around delivery rather than rhetoric. Effective health policy must be realistic about workforce and fiscal constraints, equitable in its impact and explicit about implementation. Some goals may be aspirational, but that distinction should be transparent. Promises alone will not deliver earlier diagnosis, improved survival or restored trust.

Success in the years ahead will be judged by whether New Zealanders experience easier access to general practice, earlier cancer detection, equitable treatment irrespective of geography or ethnicity and genuine improvement in outcomes. Clinicians and communities alike will look for seriousness, transparency and courage in the health debate.

The challenge to political leaders is clear: make health not only a centrepiece of the election conversation, but the centrepiece of delivery thereafter.