Health Minister Simeon Brown's desire to make greater use of private hospital capacity to bring down elective surgical waiting lists makes sense. So too does his plan to increase the period for which private hospitals can be contracted to the public sector from three years to ten years. That will provide more certainty to both sectors about future capacity requirements and should allow for better long-term planning. Not to mention better service to the public.

However, it will inevitably raise the spectre of intensifying concern over what is already called the "postcode lottery" approach to the provision of healthcare. This refers to the perceived uneven distribution of healthcare resources and services, leading to significant variations in the quality and availability of care depending on where a person lives. The concern is that health outcomes and access to healthcare may depend more on someone's postcode or geographic area, rather than their individual needs.

The general assumption underpinning this is that the further away someone lives from a main centre, the more difficult it can be to gain access to quality healthcare. The focus of attention is far more likely to be on the needs of large populations than smaller or more isolated communities whose healthcare will consequently suffer.

Brown's critics say that his moves to incentivise greater use of private hospital surgical capacity over the next decade will simply mean more and better private hospitals in larger communities - where the patients and the money are - leaving smaller communities out in the cold once again. But these concerns may not fit with what is happening at present.

Earlier this week Health New Zealand released results to show how well various districts are tracking in achieving the government’s key health targets. In general, the government is aiming for 95% attainment of each of the five goals by each health district by 2030. The current average score is 70.7%, so there is still a long way to go.

However, what is more interesting is that the figures show smaller health districts generally doing better than the larger ones. For example, the Lakes (Rotorua and Taupo), Tairawhiti and South Canterbury districts have already surpassed the 2030 target of 90% of their patients receiving cancer management service within 31 days of the decision to treat. Bigger districts like Waikato, Canterbury and Southern (Otago/Southland) are well down that list.

West Coast, Tairawhiti, South Canterbury and Lakes are doing best in terms of shorter stays for patients in emergency departments, with West Coast having already met the 2030 target. By contrast, Auckland, Waikato and Capital and Coast languish near the bottom.

Lakes, South Canterbury, and West Coast are at or near the top when it comes to patients waiting less than four months for first specialist assessment, with Lakes already having met the 2030 target. But when it comes to childhood immunisations and shorter waiting times for elective treatments, the bigger districts are generally performing better than their smaller counterparts.

The overall picture that emerges is that while overall the country has a long way to go to achieve the 2030 targets, the gap between smaller districts and their large urban counterparts is far less than might previously have been imagined. Indeed, the smaller health districts are outperforming their larger urban colleagues in many of the critical areas. While the figures are a snapshot in time covering the first quarter of this year only, and therefore need to be treated with caution, they do suggest the capability and capacity gaps across the country are far less than what might be generally have been expected.

All of which is relevant to Brown’s plans to make greater use of private hospital capacity. Access to cancer treatment services, and elective surgery procedures remain specific bottlenecks across the country, especially in the major centres. Greater utilisation of private hospital capacity in these areas could free up more acute public sector resources in other areas, which could be used to meet patients’ needs in both the large cities and nearby smaller population areas. That would be a positive step forward.

However, a bigger problem still looms unresolved. Brown’s acknowledgement that private hospitals need a greater sense of long-term certainty before they can be expected to invest in service development the way he hopes is laudable. But the same applies across the whole health sector – not just the private hospitals.

Six months on from Brown taking on the health portfolio and promising more certainty and purpose, there is still no clear sense of the government’s intended overall direction. Health professionals, general practitioners, and specialist services remain no wiser than they were at the start of the year about the professional and regulatory structures they will be expected to work within, or what long-term public funding arrangements will be put in place. And there has been no firm indication of when decisions on any of these areas can be expected. It is therefore little wonder that staffing shortages remain in the public system as many staff seek more certain futures elsewhere.

Patients, whom Brown says are his top priority, are as frustrated as ever. While they acknowledge and appreciate the efforts of health professionals amidst this uncertainty, they find it increasingly difficult having to wait weeks to get an appointment with their GP, for example. They are looking despairingly to the government, which promised at election time to sort out Labour’s health reforms, to honour that commitment.

Brown’s primary challenge remains convincing voters before the next election that the government is doing so.