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Little's Law in the Waiting Room: ED targets are whole-system flow targets wearing ED shoes. The emergency department (ED) is where the public sees the queue. It is often not where the queue is caused.

ED targets are whole-system flow targets wearing ED shoes

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Health systems do not need to be “inefficient” in a moral sense to produce long waits. They can be operating close to capacity, which is exactly when small shocks create large queues. 2/4

An ED six-hour target can create useful urgency. It can force hospitals to improve flow. It can make senior leaders care about bottlenecks they previously left to the frontline. At that point the game becomes ugly. 3/4

Move the patient to a short-stay unit. Reclassify. Stop the clock. Make the dashboard better. The patient is still in the system. The queue has just changed costume... 4/4

This Bill (Definitions of Woman and Man) Is Not Legal Clarity. It Is Bad Governance.

A universal legal definition may promise certainty, but good governance asks what problem is being solved, by whom, with what evidence and safeguards.

A law can rely on biology. But then it has to say what biology counts, who decides, on what evidence, with what safeguards, and for what purpose. 1/4

The debate is being framed as biology versus ideology. That framing misses the public-governance problem. Does this Bill make the institutions that rely on sex-related information work better? 2/4

The practical test is not status in the abstract; it is whether the rule solves the institutional problem in front of it. What is the function, and is this definition the least harmful effective tool for that function? 3/4

A law can rely on biology. But then it has to say what biology counts, who decides, on what evidence, with what safeguards, and for what purpose. This Bill does not do that. It should not proceed. 4/4

Telehealth is an extender, not a replacement for local care

Post 12 in the Rare Insights primary care funding series. A technical appendix on digital access, local resilience, and the risk of substituting away...

TH is useful, can save time, reduce travel, help people after hours, support rural communities + provide quick advice when a physical exam isn't needed. It doesn't replace in-person contact.

A Tumour Walks Into a Sequencer: Cancer and the rise of histomolecular diagnosis

Cancer and the rise of histomolecular diagnosis

Part of a series on the classification of dx (nosology) providing context + how lumping/splitting impacts more than autism, psychiatry, genetics + gender affirming care...

Who should be allowed to generate primary care supply?

Post 11 in the Rare Insights primary care funding series. A technical appendix on provider scope, claim eligibility and clinical governance.

The problem with NZ's primary care doctor-to-patient ratio mindset is that it freezes the system around a workforce that is already short. 1/3

The problem with a pure telehealth model is that it can scale simple contacts but hollow out local in-person supply. The problem with a pure capitation model is that it may fund responsibility without paying enough for activity. 2/3

Each of these have already happened in New Zealand. Entire services ground to a halt by doctor-to-patient ratios that are unachievable. Telehealth models that increase widgets but don't solve the in-person problem. Capitation models that can't prevent most conditions. 3/3

New Zealand has watchdogs. It also has gaps. "Public integrity is not only about catching wrongdoing. It is also about making sure the State's own powers are lawful, specific, proportionate, recorded, auditable, reviewable and accountable."

The issue is not whether New Zealand has integrity institutions. It is whether the gaps between them are visible enough.

Values Are Not a Retraction Policy Prof journals can have values. They also need editorial independence, procedural fairness, + a durable scholarly record. This commentary evaluates the context of JNZCCP's recent article retraction. @RetractionWatch

Professional journals can have values. They also need editorial independence, procedural fairness, and a durable scholarly record.

Amendment frequency in New Zealand health legislation: a 20-year stable trend with no post-consolidation change

Background Amendment frequency is a proxy for legislative responsiveness and a practical indicator of governance transaction costs. Whether health system consolidation changes those patterns has not been examined empirically in New Zealand health legislation. Methods We analysed 73 legislative versions of four core New Zealand health acts across 2007-2026, yielding 20 annual observations. Mann-Kendall trend testing with Theil-Sen slope assessed the long-run trend, and Mann-Whitney U compared amendment frequency before Pae Ora (2007-2021) and after Pae Ora (2022-2026). Bootstrap confidence intervals used 1,000 resamples. Act-level inter-amendment intervals were also examined. Results No significant long-run trend was detected (Mann-Kendall τ=+0.283, p=0.10; Sen’s slope +0.22 amendments/year). Post-Pae Ora amendment frequency (mean 4.8/year) was not significantly different from pre-Pae Ora frequency (mean 3.0/year; Mann-Whitney U=22, p=0.19). Amendment activity differed by act: the HDC Act 1994 was most amended overall, the HSWA 2015 showed the shortest mean inter-amendment interval, and the MH Act 1992 showed the longest. The post-Pae Ora increase is most consistent with implementation-burst dynamics rather than a durable structural shift. Conclusions The Pae Ora 2022 consolidation neither reduced nor increased annual amendment activity within the first five post-consolidation years. Policymakers should not assume that structural consolidation lowers ongoing legislative maintenance burden without direct evidence.

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Background: Amendment frequency is a proxy for legislative responsiveness and a practical indicator of governance transaction costs. 2/4

Method : We analysed 73 legislative versions of four core New Zealand health acts across 2007-2026, yielding 20 annual observations. Legislation was accessed using the NZ-Legislation CLI tool (

CLI tool for searching and retrieving New Zealand legislation data - edithatogo/nz-legislation

) wrapping the Parliament Counsel Office's API. 3/4

C: The Pae Ora 2022 consolidation neither reduced nor increased annual amendment activity within the first five post-consolidation years. Policymakers should not assume that structural consolidation lowers ongoing legislative maintenance burden without direct evidence. 4/4

Stable structure, hollow substance: accountability erosion after health legislation consolidation in New Zealand

Background New Zealand’s Pae Ora (Healthy Futures) Act 2022 consolidated health legislation to streamline governance. Legislative consolidation is frequently justified on the grounds that it will improve accountability by reducing fragmentation, but the assumption that structural reform translates into substantive governance improvement has rarely been tested. We examined whether consolidation achieved three concrete governance goals: structural stability, preservation of accountability language, and preservation of accountability provisions. Methods Analysis of 73 legislative versions of four core NZ health acts (version history 2007-2026). Three measures were used: structural stability (Jaccard similarity on section-number sets, Mann-Kendall trend); accountability language frequency (15-term count per 1,000 words); and accountability gaps (content analysis of 14 mapped provisions with weighted Accountability Governance Index (AGI). Results Structural stability was near-perfect throughout with no post-Pae Ora change. Accountability language density declined significantly, with a marked post-Pae Ora drop. Weighted provision-gap analysis found 36% meaningful accountability erosion, exceeding the pre-specified substantial erosion threshold. Across the 14 mapped NZPHD-to-Pae Ora provisions, 50% were Present, 29% Diluted, and 21% Absent. HDC Act triangulation provisions showed substantially higher preservation, confirming that erosion was concentrated in the Pae Ora consolidation rather than a system-wide drift. Conclusions Consolidation preserved legislative architecture while weakening substantive content, producing a “stable structure, hollow substance” pattern. Structural reorganisation can mask governance erosion. Future consolidations require concurrent accountability codification. The scheduled post-Pae Ora legislative review should incorporate an explicit accountability audit using the three-dimension framework demonstrated here.

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Pae ora consolidation preserved leg architecture while weakening substantive content, producing a “stable structure, hollow substance” pattern, masking governance erosion. 2/3

The scheduled post-Pae Ora legislative review should incorporate an explicit accountability audit using the three-dimension framework demonstrated here. 3/3

As RSV season arrives again, we must count the cost of waiting for medicines

When appointments become warnings: How appointments power can become a shadow direction power.

How appointments power can become a shadow direction power

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On the evidence, the Minister was incorrect + has sanctioned MCNZ for executing their core statutory function: HPCAA 2003: s118(1)(i) to set standards of... cultural competence..." 2/4

That is to say, the Min sanctioned MCNZ for: 1) doing their stat duty, not in spite of it 2) whilst still under consult on the matters he's taken issue with 3) whilst MoH prepares related leg 4) reflecting a cab decision that this is parliament's issue not his 3/4

For those unfamiliar with MCNZs role, it raises the q whether it's a strawman: i.e. whether the is another reason for the Min's decision such as a Public Interest Disclosure about serious wrongdoing which Min Brown is trying to influence. 4/4

Only I Exist, and I’m Not Here: Solipsism, absurdism, and the consciousness illusion

Solipsism, absurdism, and the consciousness illusion

Why formulas do not solve games:

Post 04 in the Rare Insights primary care funding series. Why allocation formulas matter, but incentives and behaviour decide what happens next.

Funding formulas look technical + feel objective. They use numbers, weights, datasets, regression models + official language. But formulas do not remove politics. They often concentrate it. 1/2

A better allocation formula can distribute a fixed pool more fairly. It does not, by itself, remove the supply constraint. Capitation’s dominance in our funding system, perpetuates the marginal supply problem. 2/2

Before the Spectrum: Where Were Autistic People? The absence of an autism label in the past is not proof of the absence of Autistic people.

The absence of an autism label in the past is not proof of the absence of Autistic people.

Can We Ever Know How Many Autistic People There Were?

Autism prevalence is observed through systems that see some people clearly, some people late, and some people not at all.

The primary care queue is where funding theory meets Tuesday morning. This piece looks at Marginal supply: the tiny economic idea that decides whether….

Post 03 in the Rare Insights primary care funding series. Why the economics of the next appointment matters more than the average payment.

The primary care queue is where funding theory meets Tuesday morning. This piece looks at Marginal supply: the tiny economic idea that decides whether….

Post 03 in the Rare Insights primary care funding series. Why the economics of the next appointment matters more than the average payment.

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