The roll out of the Primary Health Care Strategy was not about rebranding. It was not a new logo or a different look for the same level of functioning. It required a significant paradigm shift and as such, it was quite different from previous reform in New Zealand. The unpredictability of the possible consequences of implementing the Strategy created uncertainty and has resulted in concealed resistance.
In New Zealand the government is the foremost provider of funding for health service delivery (New Zealand Parliament, 2009; Quinn, 2009). This serves to increase the susceptibility to relentless restructuring. The three year electoral cycle also compels politicians to produce change within those three years (Gauld, 2008). With fewer obstacles in the pursuit of major policy alteration in New Zealand, it has become easy to bring about significant legislative and
previously are often slightly modified and reintroduced (Parker & Glasby, 2008). Accordingly, Parker and Glasby (2008) state history repeats itself and the process of reform is commonly circular. This repetitive cycle of change was recognised by the following manager:
I mean there are things come around. You know if you went through all the health reforms you have had diversity and you have had national bodies, your big structures and diversity. So you come into a recession that we have now and times are tough on a wide scale ....So probably if we sat back it’s like a railway track that comes around again. (I.9, p.6)
Health structures might have a new look or a different name, but if the root of the problem is not addressed, nothing really changes. Politicians use history to justify policies rather than learn from history when creating them (Timmins, 2008). Still, policy change is dependent upon the political viability of any new structures and the degree to which politicians are influenced by public opinion (Gauld, 2008). Governments have an agenda to stay in power (Carroll et al., 2011). Like all previous policy change, the Labour-led coalition did not enforce desired behaviour within the existing health structures and systems. Political interference and constant change became a hindrance to service delivery as the following participants identified:
There seems to be so much politics that gets in the way of health delivery really. (FG.3, p.15)
Again politics get in the way of good ideas and health care. (I.7, p.8)
You are getting the consecutive governments, Labour party and National party, although they come with their baggage for them it is trying to grasp you know what the hospitals are doing and then unbundle hospital care to put these things into primary care and are we doing the right thing. (I.9, p.1)
Reform-minded governments have imposed constant restructuring since the 1970s (Blank, 1994; Gauld, 2001). Just as the health sector was recovering from one bout of disruptive restructuring another would arrive (Gauld, 2009a). The frequency and impact of the changes was noted by one of the nurse participants employed in the health sector for a number of years:
Things are constantly changing you know they might only move a little bit but they are moving....You have got to be quite flexible to take up new things and run with them. (FG.3, p.5)
I found limited literature specifically on health reform weariness, although this notion might be identified under other search terms. Nor is it addressed in the diffusion of innovation theory. The constant restructuring of the health sector over the last thirty years probably contributed to limited tolerance of the Primary Health Care Strategy as an instrument for change. Intolerance of the multiple changes to health policy in New Zealand was written in the 2002/03 District Annual Plan:
Other primary care providers have expressed skepticism about the implementation, given the multiple changes in health policy over the last decade (TDH District Annual Plan, 2002/03, p.49).
One of the managers identified the need for continuity in the focus on primary health care:
So you know you need the continuity of that sort of policy to keep the momentum going. (I.9, p.1)
The impact of political directives can divert implementation activity away from the innovation toward second guessing what they were required to do rather than concentrating on local priorities (Greenhalgh et al., 2005). Parker and Glasby (2008) contend constant change makes systems highly change- resistant; the workforce becomes increasingly cynical and short-term in their focus. The innovation performance of organisations is then far below their potential. Lindsay, Perkins, and Karanjikar (2009) argue innovation fatigue stifles innovativeness. One of the nurses talked about the constant turnover of contracts although she did not seem too perturbed by the constant change:
Just different contracts like you know. I suppose that is the nature of our environment is that contracts come and contracts go. (FG.3, p.5)
Parker and Glasby (2008) suggest instead that investment on reorganisation would be better spent on supporting the workforce to move from being policy victims to policy entrepreneurs to deliver sustainable transformation.
7.7 Concluding statement
The Primary Health Care Strategy strongly challenged traditional structures and processes and resulted in layers of resistance. The antecedents addressed in this chapter demonstrate a significant lack of receptivity in Tairawhiti toward the system wide paradigm shift the Strategy required. A reluctance to embrace change and a desire to maintain the comfortable conditions that already existed manifested itself across all levels of the health sector. Resistance was based on age old traditions and attitudes, related to funding, hegemonic interests and the required move away from biomedicine toward population health, and a collaborative multidisciplinary approach.
The DHB was not ready to adopt the broader intent of the Primary Health Care Strategy, nor were the individuals in the workforce ready. GPs demonstrated resistance to the proposed changes and managed to firmly retain power and control. The majority of nurses were unaware of the changes taking place around them, seemingly content with the status quo and yet not content as revealed in the data. Accordingly, nursing continued to focus on attempting to meet patient needs through traditional models of care. Reform weariness was also evident and negated the appetite for change. The high complexity and critical dependence on simultaneous adoption by multiple users of the Strategy meant only the acceptable parts of the Strategy were implemented to any degree of success. As a result, enthusiasm for primary health care development lay dormant.