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WHO Kobe Conference, Dunedin - Annette King

Hon Annette King Speech Notes

WHO Kobe Conference, Dunedin

Thank you for the invitation to speak today. I appreciate this opportunity to talk of New Zealand's experience in providing health care and interacting with the private sector, and to hear of the experience of other countries in managing their health resources. There is much we can learn from one another.

This topic is particularly pertinent to New Zealand. As the importance of private providers in the health sector has grown, it is important that we are concerned with total efficiency and the resource allocation of both sectors.

The situation actually goes further than that in New Zealand, because we have a unique situation in this country.

As well as public providers and private providers, and a crossover at times in the way they operate and are funded, we also have a not-for-profit, non-government sector whose extensive work can range from hospital treatments to delivering meals on wheels.

So there is little point in any government in New Zealand focusing on the public sector alone. The delivery of services is being shared more frequently now than ever. Funding and patients are moving from one sector to the other. A key goal of the Labour-Alliance Government is an improved health status for New Zealanders. That means we need to consider the health service as a whole, public, private and the NGO sector.

In illustrating that theme today, I will be talking about subjects such as healthy cities, collaboration between providers, involvement of communities in health decision-making, and strengthening of the health workforce.

Some issues will also be common to other countries. Others may be unique to New Zealand because of the way our population is made up, and our health services dispersed around the country.

The Government's commitment to ensuring all government-provided health-related services meet a high standard certainly includes an emphasis on the infrastructure of cities.

As is the case in many other democracies, New Zealand has a double tier of elected government, central and local. Local government is empowered by central government to improve, promote and protect public health within in their districts, and has a duty to do so.

Health issues that involve local government include areas such as noise control, water, and environmental issues generally, and all those areas can involve a partnership with private providers too.

I have been interested in the past year in efforts, particularly in small communities, to make our drinking water cleaner and safer. Clean and safe drinking water is absolutely crucial to good public health.

Just before Christmas the Government announced that enhanced management measures to improve the safety of drinking-water supplies would be introduced over the next five years. All drinking-water suppliers in the public and private sector will be required, under an amendment to legislation, to monitor the quality of drinking-water and to take all practical steps to remedy problems when they are detected.

It is all very well having a good idea and intentions, and passing legislative amendments to put them into effect, but sometimes the practice is not as easy as the theory. Small communities are perhaps less likely to have clean and safe drinking-water supplies; but they are also less likely perhaps to be able to afford them.

That is why we will have a five-year introductory period. In that time central and local government officials and private suppliers can work together on issues such as affordability, because we must ensure public health standards are met right across the country.

Another water issue in which I have taken a personal interest, as a former dental therapist and tutor, is fluoridation.

Quite simply, fluoridation works. It also remains, and I received plenty of reminders of this last year, a highly controversial issue.

I wrote early last year to all local councils, urging them to adjust fluoride levels in water supplies to meet the Ministry of Health's recommended levels. Now, of course, I cannot force any council to fluoridate its water, no matter how compelling the public health good is, but from the reaction to my letter in some parts of the country, you might have thought I was set on some evil purpose.

I am undeterred, however, and will keep up the campaign. I will not succeed without the help of our private sector dentists all round the country, particularly in areas where drinking water supplies are not fluoridated. We have to work together to ensure children in these areas do not suffer unnecessary and excessive tooth decay.

I mentioned a few minutes ago an amendment to legislation concerning drinking-water supplies. I believe it is absolutely vital New Zealand has modern public health legislation that provides an efficient and effective framework for managing the risks to public health.

For that reason a review of our public health-related legislation is essential. Legislative responsibilities for environmental health and some communicable disease control functions are shared, sometimes with ill-defined boundaries, between local government and the health sector. Overlaps between central and local government also give rise to risks of conflicting objectives, and can perhaps lead to ineffective and inefficient management.

Maori and low-income communities are disproportionately affected by many communicable diseases and by adverse environmental health conditions. Improved management of risks to public health will benefit these groups who are most in need of health gains.

A new Public Health Act will clarify responsibility as to who manages public health and ensure closer monitoring of local government performance in managing public health matters at a district level.

My position from the outset is that I believe clear responsibility for managing risks to public health should lie with central government, primarily the Ministry of Health.

Protecting the health of New Zealanders is ultimately the responsibility of central government, and central government has the mandate and operational resources to manage risks to public health

Take, for example, the private provision of sanitary services. Regular assessments will allow central government to check that such provision is safe. If assessments suggest the provision is inadequate, the local authority dealing with the private provider will be told to provide the service at its own cost. In that way communities can feel assured that services will be operated at a high level of safety indeed.

The overall aim of the legislative changes is to ensure lines of responsibility for environmental health and communicable disease control are clear and managed to a high standard.

I also believe that an important aspect of developing healthy cities involves understanding the needs of the community. If the public has input into services and plans, then they will be better plans and services as a result of that input. If a sector is consulted on a strategy that affects it, then that strategy will ultimately be far more acceptable.

I had personal experience of that last year when the Ministry of Health released a draft New Zealand Health Strategy document for public consultation. This is the first time for a decade that New Zealand has planned a truly strategic approach to developing an outstanding public health system.

I was greatly heartened, though not surprised, by the results of public consultation. I was not surprised because I knew New Zealanders wanted a health system they could trust, but even so it was still most encouraging that more than 60 public meetings were held, and more than 500 written submissions were received.

Much of the feedback was positive, and what it demonstrated more than anything else was that the health sector and New Zealanders generally wanted to have a say on how services could be improved.

They wanted a coherent approach, one that focused on key health problems where significant health improvements could be made through proven effective interventions.

It is noteworthy that such exercises in consultation are not limited to the public sector. Private providers are also consulting with the community.

General Practitioners, for example, are increasingly developing links with their local communities through meetings, regular written communication with patients, and surveys of community views.

This level of existing consultation by both the public and private sector is an excellent omen for a new strategy the Government has developed for primary health care. The Government wants primary care providers to work together in organisations that are funded to give care to a defined population according to their needs. The more knowledge primary care organisations have about their community the more easily they will adapt to this change

An example of the private sector recognising the need for community consultation and involvement is provided by Southern Cross. Southern Cross is well-known in New Zealand for its hospital services, but it has now established a charitable trust for providing primary health care services, and it will be working closely with community advisory groups and through community forums.

And another example of an non-government organisation recognising the importance of consultation is provided by the Hokianga Health Enterprise Trust. This charitable trust, formed in April 1992 in the far north of the North Island, consults annually with 9500 predominantly Maori consumers of their health services. The comprehensive consultation includes meetings or hui in each of the 10 communities in the region. The consultation is a two way process.
„h the meetings guide the trust on new services for which it should advocate, and
„h the trust reports back to the community on progress it has made during the past year

I strongly endorse such examples of consultation. If changes to a health care system are to have a positive effect, the community must be included in the decision making process.

This philosophy was fundamental to the establishment of the new district health boards that began operating last month, replacing the former Hospital and Health service boards that were set up as companies by the previous Government.

The new boards are directly accountable to their local community through local elections held every three years, and through their annual and strategic plans.

Close to half of New Zealand¡¦s health and disability support services, measured in dollar value, are delivered by non-government providers. In the case of some types of providers, such as rest homes, there are no publicly-owned alternatives.

The new boards and the public are therefore heavily dependent on non-government providers for the delivery of some public services. There will also be cases when the new boards wish to become involved in the delivery of privately-funded services, perhaps, for example, to help make a public service viable in a smaller centre. Because of this, the Government has allowed the boards a degree of flexibility to work with private providers in achieving the Government's health objectives.

In the future, access to services and health outcomes for public patients will be improved by a co-operative approach between public and private providers.

One example might be for a board to contract with a private hospital to take patients at peak times, or to reduce backlogs for elective surgery, if funds are available.

I want to encourage partnerships and innovative solutions that benefit public patients. The small town of Thames provides a fine example.

The private sector runs an MRI scanner in the public hospital in Thames, and public hospital patients get the benefit of the service. The small country hospital could not have afforded such a scanner, and without it some public patients would be travelling some two hours for appropriate treatment.
The health workforce is another area where private and public sectors naturally intersect.

One thing New Zealand has learned is that relying on the marketplace to determine the strength and size of the health workforce simply does not work.

This Government is not going to risk the mistakes of the past. The health workforce is depleted across the board. Much of this is related to international shortages, of course, but New Zealand has simply not undertaken the sort of health workforce planning it should have undertaken. That makes us vulnerable.

We will be remedying this by establishing a Health Workforce Advisory Committee as soon as possible. The committee will involve experts from the private sector as well as the public sector, from both health and education. It is in all our interests to build our workforce strength.

I believe two recent developments in the public sector will be beneficial in terms of the workforce issues we currently face. The establishment of DHBs will allow health professionals to have input into decision-making processes, and an increase in the range of services the public sector offers means working in the public sector is going to be more diverse and interesting.

Salary is, of course, only one reason health professionals work in the public sector. They do so for a whole variety of reasons, including study and conference leave provisions, research opportunities, and also, I believe, the chance to be involved in decision-making about how best to manage health services.

One outcome of the health reforms in New Zealand in the 1990s was a growing sense of alienation and disempowerment among health professionals. Many felt cut out of the decision-making working in hospitals set up as companies.

Health professionals saw little or no opportunity to inject clinical expertise into board decisions on the best way to manage the dollars to achieve the greatest health gain.

As Minister, I believe the Government, health sector managers, and public and private health professionals, and communities themselves, must all work together.

The whole sector faces the problem of getting the best and most effective services for New Zealanders out of a finite health budget. We need to work together to find acceptable and practical solutions.

With the move to new district health boards and open decision-making processes, health sector workers can once again make a valued contribution to decisions.

Both public and private health sector workers can become appointed or elected members of the boards. A number of doctors, nurses and other health workers have already become board members. Their understanding of how best to achieve health improvements will provide vital input into board advisory committees.

The public sector has also recently increased the range of services it offers. This increased diversity and volume of work adds an incentive to health professionals to work in the public health sector.

I believe that working as a health professional in the public and private sectors in the new millennium will be diverse and rewarding. That is particularly so in New Zealand as the collaborative approach becomes more and more established.

I look forward to building a quality health system in partnership with health professionals and local communities. Thank you for offering me the chance to speak today and to contribute New Zealand¡¦s experience to the discussion.

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