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Speech to 'On the Pulse' - Turia Speech

Hon Tariana Turia
12 October 2001 Speech Notes

5pm, Friday 12 October 2001
Speech to 'On the Pulse', the 4th Annual General Practice – Continuing Medical Education Conference, Taupo


Mihi

I hope you have had an informative and enjoyable first day.

I want to acknowledge the importance of this conference. It is vital for you to come together, learn what each other is doing within the communities you live and work.

The trials, the tribulations, and the triumphs that you have all experienced, in the past year since you last met together, can and I am sure, do, provide valuable information that may well have remained unspoken and the lessons lost.

It is good to be here with you today. It was a close call I must say, with Parliament sitting in Urgency until midnight last night and not originally due to conclude until 6pm today. The government's efficiency in the House has allowed me to be here with you today. Luckily we concluded our business at 1pm.

It has meant that I have not been able to spend as much time with you as I would have liked, listening to the presentations today. It is great to see a range of people sharing their ideas and experience, including those who have just spoken in this session, John Adams, new chair of the New Zealand Medical Association, and CEO Cameron McIver and those such as rural doctors sharing their stories.

I note this is the fourth annual General Practice – Continuing Medical Education Conference to be held by the New Zealand Medical Association and the Rural Doctors Association. So it seems it is a fairly new annual event and I am sure that some, if not many of you, will have attended all of the conferences to date.

That you continue to return each year demonstrates clearly, how useful you find a forum of this nature.

It is great to see the College of General Practice involved, and also nurses attending and that they are also part of the formal programme for the Conference. It is great to see this collegial support aimed at improving health.

I am excited to be here today. I know that there is often much talk of hospitals and Independent Practitioner Associations (IPA's). They have large staffs and large resources at their disposal. Getting your views across in an environment that seems to be dominated by these larger groups I am sure can seem quite daunting.

I would like to assure you, that your views are of great importance to this government. But let me explain why that is.

The local GP, has long been an important part of any community. The innovation of local GP's, especially rural GP's is admirable. I have heard many a story of the lengths that rural doctors who serve our rural communities go to, to provide the necessary care to members of their communities that need them.

There are many examples of doctors arriving on every kind of vehicle, with four wheels, more or less, and I am sure that you dream up many more innovative and creative solutions to get the job done.

Such as the incident, up in Northland, where the doctor was willing to risk the wrath of the police and the judiciary to reach his patients, not once, but twice. I believe this is an example and one that has caused us all to seriously consider the importance of the role rural doctors play in their communities.

The relationships you build, and the long-term nature of those relationships is just so valuable. You see not only babies grow up, those babies themselves go on to have their own families themselves. One cannot replace that kind of relationship, we must protect and build on from those relationships.

We are now in a new health environment. We have for the first time in many years a coherent New Zealand Health Strategy and strategies following from that, such as He Korowai Oranga, the Maori Health Strategy that will be finalised in the coming months and the Primary Care Strategy.

It is the Primary Care Strategy, in which you will play a vital role that I would like to spend some time discussing with you today.

While I know that change is often daunting. When I became a Minister, I was a bit daunted by the extent of the job a job, that I did not fully understand the role and responsibilities of. I did, however, understand the expectations and I was excited by the opportunity I was offered.

It was exciting to think of the progress that can be made. I had been given the opportunity to participate, in a very real way, in whanau, hapu and iwi development. It was a challenge, and I relish a challenge, if it is one that will work toward strengthening our whanau.

Making the expectations of whanau, hapu and iwi and the responsibilities of being an associate Minister of the Labour Alliance Government gel together, is a daily challenge. So I think that in some ways I can understand your concerns about the changes that are occurring within the health system and where you fit into that picture.

We are looking to build a team approach not a mandatory approach in which you are a critical part of that progress.

I am sure most of you are already familiar with the Primary Care Strategy's (the Strategy) ethos and proposals but as an introduction, I will briefly reiterate them.

The Strategy and its implementation and its implications for whanau, hapu and iwi development are, critical.

The Strategy’s vision is that: “People will be part of local primary health care services that improve their health, keep them well, are easy to get to and co-ordinate their ongoing care. Primary health care services will focus on better health for a population, and actively work to reduce health inequalities between different groups.”

The Strategy has six key directions as part of its vision:

1. Working with local communities and enrolled populations
2. Identifying and removing health inequalities
3. Offering access to comprehensive services to improve, maintain and restore people’s health
4. Co-ordinating care across service areas
5. Developing the primary health care workforce
6. Continuously improving quality using good information

With time the strategy should lead to:

 prevention of disease,
 reduction in the numbers of avoidable hospital admissions,
 better identification of unmet health needs such as undiagnosed diabetes which is also of particular relevance to Mäori,
 greater overall efficiency from more workforce flexibility, and
 better management of associated costs, such as pharmaceutical's

As you are aware achieving these goals will require a change in the way primary health care is planned, delivered, and funded. For doctors such as yourselves, these changes will represent a shift from:

 provider-focused organisations to community-focused organisations
 fee-for-service to population-based funding
 doctor dominated care delivery to a team approach
 episodic care to comprehensive and continuing care.

The changes will also:

 encourage work towards improving the health of enrolled patients,
 encourage an integrated view of patient care focusing on improved access to primary health care and links to secondary, tertiary and specialty care, and
 encourage health promotion and providing outreach services to people from communities at risk of poor health outcomes

Elements of all these approaches are already in place and in this sense the Strategy looks to build on existing gains. The Strategy can also be viewed as formalising elements of the common sense and professionalism that general practitioners and other primary care providers have always shown.

Nonetheless, the Strategy does signal far-reaching changes and a new vision that maps out a clear path for the future of the sector.

Implementation

In particular I want to talk about the far-reaching funding and organisational changes signalled in the Strategy.

The most important of these changes will be:

 the establishment of primary health organisations (PHOs),
 enrolling populations,
 funding primary health care at a sustainable level through a population formula,
 outreach services,
 health promotion services,
 performance monitoring,
 training for nurses and other health care workers, and
 more certainty around service provision for rural communities.

Development of primary health organisations PHOs

PHOs will be provider organisations responsible for planning, delivering and coordinating health services for a defined population. Under guidance from the Ministry of Health, district health boards (DHBs) will be responsible for developing PHOs.

PHOs will need to meet certain criteria with respect to breadth and content of services offered, community governance, provider involvement, non-profit status, planning, and organisational capacity. They will evolve over time and will have to reach a certain minimum threshold before gaining formal status as a PHO.

Iwi and Maori providers, IPAs, nurse-run organisations, Pacific Island providers and members of the Health Care Aotearoa network are all candidates, although each will need to make changes to become a PHO. The Ministry of Health also expects new organisations will be formed as PHOs.

Sustainable funding of primary health care services

The Strategy also encourages a shift of funding from fee-for-service payment to funding based on the needs of an enrolled population. Payment through a needs-based population funding formula is preferable because it promotes long-term care for a defined population, allows more flexible use of nursing staff, and facilitates innovative strategies to serve the most needy.

People will be encouraged to enrol with a single primary health care provider – usually a general practice or a health clinic – and in turn will become a member of the provider’s PHO.

At present, approximately one third of primary health care payments (general medical subsidy and practice nurse subsidy) are made to organisations on a per capita or bulk-funding basis through a variety of formulas. Implementation of a needs-based funding formula will require PHOs to have robust information systems to support the collation of clean patient registers from participating primary health care providers.

Funding of PHOs will reflect the needs of their populations. It will take account of the age, gender, socio-economic status and ethnicity of the people enrolled.

At the practice level, the new policy will require primary health care providers to implement a new enrolment strategy (including informed consent protocol) and assemble their patient registers according to agreed formats. PHOs will be charged with managing patient registers that meet data specifications and standards.

I know that many of you are concerned about these administrative requirements. I assure you each PHO will receive financial support to provide for these new requirements and we are mindful of the need to keep compliance costs to a minimum.

Health promotion and disease prevention

The Strategy also provides the direction for proactive services to promote people’s ability to self-care, prevent disease, promote health and improve early detection of disease.

On an individual level this means health status tracking through recall services for national or locally agreed programmes such as cervical screening, proactive health education such as health education for lifestyle risk factors, education about treatment interventions and their side effects, and communicable disease services such as immunisations.

On a group or community basis, this means promoting healthy behaviours and lifestyles through local media campaigns, distribution of education materials, presentations to community groups, and advocacy to public and private institutions.

Primary health care providers are familiar with offering anticipatory guidance at an individual level. However, health promotion/disease prevention on a community-wide basis is not as common.

Outreach to high need groups

The Strategy also highlights some of the gaps in morbidity and mortality between more deprived and less deprived groups. Evidence has shown that continuous and comprehensive primary health care will reduce the number of hospital admission and extend life expectancy, particularly for the most needy groups. This is crucially important to Mäori and the stability of hapu and iwi, and most especially, the longevity of our kaumatua. Achieving these outcomes will help us repair our foundations and contribute to our strength and renaissance.

In the most disadvantaged communities there is a need to address wider access barriers including financial, geographic, cultural, and psychosocial barriers. Improving access to primary health care for needy populations will be done by PHOs by:

 reaching out such as employing community health workers, conducting culturally-appropriate media campaigns, providing health services in more accessible locations including marae, schools, homes, and churches

 Changing the practice environment such as using translation services, employing Mäori / Pacific workers and spending time with patients.

The Ministry of Health in collaboration with the primary care sector will need to define the new outreach services. In some instances, this may entail a re-organisation of existing resources. However, it is expected new services will be required, especially from Mäori and Pacific Island providers.

Enhanced roles for nurses and other health professionals

The various initiatives in the Strategy will also require health professionals to change the way they deliver care and manage their practices.

Primary health care nurses for example, have been shown to work alongside communities to set priorities for health promotion strategies, plan and implement activities that help communities to achieve improved health.

There is international evidence that appropriately trained nurses provide first-contact primary clinical care as safely, effectively, and with as much satisfaction to patients as a general practitioner. The development of nurse practitioners (nurses with the highest level of clinical expertise) will provide a key interface role in the primary care sector and also between primary and secondary sectors.

At the same time, GPs are being called upon to treat more complicated cases in the primary health care setting and co-ordinate care of these complex cases with specialty providers and community support agencies.

In some cases, this will require additional training for existing staff, the introduction of new types of staff, and re-organisation of health service delivery. There will be additional costs to the system in the short term, however, in the medium to long term, these developments should lead to a more efficient system where health services are improved and health workers fulfil their professional potential.

Improvements to the rural infrastructure

The Strategy also acknowledges health care delivery in remote rural communities is handicapped by difficulties in recruiting and retaining care providers. Strategies such as the allocation of the rural bonus according to the rural ranking scale have helped reduce the problem in some areas, but the systems remain fragile.

The successful implementation of the Strategy in rural areas is therefore contingent on successful strategies to recruit and retain rural practitioners, and enhance teamwork.

Funding

I am aware that although the Strategy has been well received, there is also widespread concern about funding for its implementation. The Ministry of Health is currently undertaking extensive work around this issue and I hope we will be able to allay these fears on completion of this work. However, it is clear that there will need to be substantive changes in funding arrangements in the long-term as primary care assumes a more prominent role in the health sector as a whole.

While most countries make use of some form of patient part charge, New Zealand is unusual among OECD countries in having a relatively low level of public funding of primary care. As a proportion of total health expenditure, New Zealand spends less on primary care than comparable countries such as Australia and Canada.

There is evidence that current part charges are a significant barrier to accessing services for some groups.

Low income earners and Maori and Pacific people in particular are likely to defer seeking help in primary care and have lower rates of primary care utilisation despite high health needs.

The Community Services Card

A closely related issue is the review of the Community Services Card. If there were universal funding of primary care services, then a targeting mechanism such as the CSC would not be necessary.

At present, subsidies for general practice cover approximately 39% of the cost and 55% of the New Zealand population.

The CSC Review Committee will most likely recommend a new way of targeting subsidies. Three meetings are planned with a report before Christmas.

Thank you again for the opportunity to speak with you and for all the work you do, that at times you may think goes unnoticed.

I hope you will further consider the issues surrounding the Primary Health Care Strategy in your discussions and thinking during the next couple of days and when you return to your practices.

The role of relationships within this Strategy can not be over emphasised. You know the importance of relationships. We want to build on these.

I hope you will consider carefully how you can work with whanau, hapu and iwi to further the principles of the Strategy.

Aotearoa / New Zealand has very real public health problems and I wish you well in your endeavours as you continue to contribute to the improvements the Strategy looks to achieve.

But also have some fun while you are here. Enjoy the surroundings and facilities in this lovely setting. I am sure handicaps of birth and circumstance will not be the only sort of handicap on you mind in the next couple of days.

Thank you for the opportunity to talk at your conference and good luck for the remainder of your conference.

No reira, tena koutou, tena koutou, tena koutou katoa.

I also have a message that my colleague Hon Lianne Dalziel has asked that I pass on to you all.


A Message from the Minister for Accident Insurance, Hon Lianne Dalziel to the Conference regarding medical misadventure:

The Minister for Accident Insurance has stated her intention to review the Medical Misadventure provisions of the Injury Prevention, Rehabilitation & Compensation Act. She has made no secret of the fact that her intentions in this regard were in part sparked by the sense of injustice surrounding the case of Patient A, whose personal determination resulted in the Gisborne Inquiry. Patient A is now off to the Privy Council to seek to overturn the Court of Appeal decision, and to pursue the claim for exemplary damages.

The Minister believes she would not be involved in a court case, if the ACC scheme had been able to deliver fair and reasonable compensation.

The Minister is herself a lawyer, but she is vehemently opposed to the restoration of the right to sue, as is the government as a whole. The ACC scheme was founded on the no-fault principle, and this government is committed to those founding principles.

Herein lies the irony. To gain cover under the medical error test of the medical misadventure provisions, the claimant must prove fault. And ACC, a no-fault scheme, has to set up a process of determining fault – a process, which by its nature, tests the competence of the health professional. It is the Minister's view, and I agree, that the bodies that are specifically set up to address competency issues should be the ones involved in this work – namely, the professional registration bodies and the Health & Disability Commissioner.

The other limb of medical misadventure is medical mishap, where the adverse consequence has to be both 'rare' and 'severe'. Of course it is reasonable to exclude obvious consequences of treatment like piercing the skin when putting in stitches – technically an injury. However, why are not adverse consequences covered? It seems to have been a purely financial decision taken in the 1992 Act, to cut the cost of the scheme.

So, if we restored all adverse consequences, then who would pay?

At the moment the medical misadventure account is funded from the earners' account and from general taxation.

The Minister would like to explore all these aspects:

 From the name – why should it be called medical misadventure implying that it only covers medical practitioners?

 To the coverage – why not simply cover adverse consequences and refer the professional competency issues to the appropriate body?

 To the cost – how would we fund the medical misadventure account? Could a low, flat, standard levy meet the concerns about defensive medicine practised in other countries as a result of exorbitant, private malpractice insurance?

The Minister has asked me to make it clear that these are simply questions she is posing – the scoping paper has not yet been completed, and no decisions have yet been made, even at a preliminary or in principle level. Your input is not only important, it is critical to the process of policy development in this area.


ENDS

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