Health New Zealand wants to reduce the number of chief medical officers, from 18 to 14 nationwide, while also promising not to cut front-line medical roles.

The senior doctors' union says this will lead to a reduction in critical clinical leadership roles overseeing safe patient care in hospitals around the country.

The proposal is to cut the four roles by integrating the small health regions of South Canterbury, Wairarapa, the West Coast, and Whanganui into neighbouring larger ones, and merging the Lakes and Bay of Plenty regions' leadership.

The Association of Salaried Medical Specialists (ASMS) union says some chief medical officers' jobs would grow in size, with others' jobs would disappear.

In the proposal HNZ said the move would ensure more clinical input into all service decisions, and smooth out unwanted "variability" in clinical leadership round the country. The agency is due to begin consulting staff on Wednesday about the plan.

The move is part of a reset and restructure triggered by a shock descent into a huge deficit that is forcing HNZ to try to recover from $150m of losses per month by Budget 2026.

HNZ pledged on Tuesday not to cut front-line medical roles amid the reset.

HNZ released 450 pages of documents about its financial plight on Tuesday.

RNZ asked Te Whatu Ora chief executive Margie Apa and Commissioner Lester Levy if they could give confirm there would be no cuts of senior medical people in the near to medium term.

"Yes, absolutely yes, definitively yes," Levy said.

Senior medical roles were a focus, Apa said.

The papers released on Tuesday confirmed that a rapid deterioration in finances was triggered by employing a lot more nurses to address a dire nursing shortage. Critics say this is evidence that underfunding is the key problem.

The new proposal marks the beginning of changes to clinical leadership structures, envisaging national, regional and local "clinical chiefs".

"It is time to make sure we have the right clinical leadership structure and roles at a regional and local level," a document said.

Health Minister Shane Reti told Levy in July that HNZ had deep problems, including "an absence of clinical voice".

The new proposal said it would boost clinical and operational links.

"We are proposing that the Clinical Chief roles would work in partnership with operational leadership to implement models of care, develop service delivery improvements, ensure safety and quality of services and provide advice and direction including professional considerations for the clinical workforce group they represent."

It is unclear how the proposal would be affordable, with HNZ under pressure to avert a $1.76 billion deficit.

Reti noted in his July letter to Levy - released on Tuesday - that a revised national health plan was coming, but "even once these plans are in place, I am concerned about Health NZ's ability to successfully implement them, given that the looming financial issues were not recognised by the board prior to them becoming a material issue earlier this year".

Health watchdogs warned late last year of a "general risk of there not being sufficient funding for specific reform initiatives", well before the deficit issue came to light.

ASMS surveys of members have noted how "entrenched" shortages of senior doctors were a feature of the health system, which risked them burning out, putting more pressure on to junior doctors to step up, as well as on clinical leadership, which the proposal would subject to further upheaval.

In the new proposal document, the words "shortage", "pressure" and "workforce planning" occur just a single time each.

The proposal suggested a greater stress on regional leadership would help a "regional focus on workforce planning in the areas where we have shortages".

Some of its stated goals were vague, such as to "ensure what we design will enable clinical leadership to be patient centred and focused on patient and whānau outcomes".

The proposal comes as HNZ moves away from the centralised management seen under HNZ since mid-2022, towards more regional management.

Levy said on Tuesday he and his three deputy commissioners were "forward focused" and doing in-depth analysis, while having a "very good" working relationship with the executive leadership.

-RNZ.