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Mid-Winter Dialogue - Annette King Speech

26 June 2002 Hon Annette King Speech Notes

Mid-Winter Dialogue, Christchurch School of Medicine

I hope I am not the only one here who can remember the old Telethon song, Thank you very much.

I promise you I am not going to sing it!

But I will say it.

Thank you very much for inviting me the first time two years ago to speak to your Mid-Winter Dialogue as Minister of Health.

And thank you very much for inviting me back last year for my second visit as Minister of Health.

And, of course, thank you very much for inviting me here this year for my third visit.

And, finally, thank you very much in advance for an invitation in 2003.

Seriously, it has been a privilege to attend this forum, and if I were to have the privilege of remaining Minister of Health in the second term of this Government, then I would dearly love to continue being part of this dialogue.

This forum is not the easiest environment for a Minister of Health to enter, but it is one that encourages plain speaking, and it is also one in which I feel comfortable that we share a common interest in making our public health system as good as we can possibly make it.

It is fairly well recognised that the role of Minister of Health is among the more challenging of Cabinet portfolios, and it is rare, in fact, for any health minister to want to do a second term.

But I believe that there is unfinished business. And the most important of that unfinished business is what I want to talk about today, implementation of the New Zealand Primary Health Care Strategy, and the role of health professionals in that implementation.

I was not so naïve when I became Minister that I believed that restoring a genuine public health system in New Zealand would be easy. Quite the contrary, in fact, but even I was taken aback by some problems, particularly those caused by the lack of health workforce planning in the 1990s.

Even now I remain angered, for example, that we cannot implement the Mental Health Blueprint any faster than we are doing because of shortages in the mental health workforce.

And I was even angrier that we had to send cancer patients to Australia because according to the market theories of the 1990s the market would train the right number of radiation therapists.

In 1999 there were 16 radiation therapists in first-year training. This year we have 38. Quite simply, the market doesn’t provide in health. We have to plan strategically. That is what I am proud that this Government has been doing.

It is impossible not to be cynical sometimes in politics, but even as a seasoned politician I was flabbergasted at the cynical and self-serving hypocrisy of the National Party in trying to exploit the shortage of radiation therapists for political reasons.

They campaigned for patients to be sent to Australia as if this was some sort of virtue on their part. The reality, of course, was that the need to send patients to Australia was to the utter shame of the National Government of the 1990s. I am sure the vast majority of families affected were well aware of this.

Excuse me for that diversion from primary health care, although that is another area in which health workforce issues have a vital role.

I probably need to reiterate why this Government believes that primary health care offers the best opportunity to make significant progress in improving the health of New Zealanders.

When we became the Government, we inherited a situation in which, despite positive developments like the formation of Independent Practitioner Associations, the development of Maori and Pacific health providers, and the development of rural community groups, there remained wide inequities in providing and funding primary health care services across New Zealand.

The reality, as it almost always is, is that the populations in most need are those least likely to get the services they require.

Funding is currently distributed quite unevenly across the country and across population groups. Some of this variation may reflect need and therefore be appropriate, but sadly some reflects variable barriers to access, and practitioner rather than patient factors.

Funding for GP access is often lower in deprived areas where there are fewer GPs per head of population.

Unexplained variation is evident in spending on pharmaceuticals and diagnostic testing. For example, a comparison of per capita spending on pharmaceuticals across several primary care networks shows considerable variation that is not clearly related to need. The spending is $56 per capita for a Counties Manukau network, $96 for Tairawhiti, $120 for Northland, but $144 per capita for networks in Taranaki and Tauranga.

Neither logic nor health needs can explain such differences satisfactorily.

Looking at national aggregates, the most deprived 10 to 20 percent of the population appears to receive relatively lower rates of funding for pharmaceuticals and laboratory tests compared to the next most deprived 20 percent. The level of need of these groups suggests their share of funding should be higher.

Moreover, the imbalance in funding becomes even more apparent when it is considered that some providers serving disadvantaged groups are already delivering population based services and managing to keep patient fees low. This factor is not always recognised in the level of public funding going to these providers.

There are many statistics to suggest the Government is absolutely right in making its commitment to implementing the Primary Health Care Strategy, with a total of $400 million committed in this year’s Budget over a three-year funding path.

One such statistic concerns the number of Maori aged 15 to 65 who die from causes that could have been prevented if they had received suitable health care. The death rate for Maori in that age category is 2.4 times the overall rate. The figure for Maori men aged 15 to 65 is even worse, with the death rate five times the overall rate.

Improving early access to health care in innovative ways is crucial in making a real difference to the health of people. One consequence of not doing so is the number of avoidable hospital admissions, with all the social and fiscal costs that entails.

It is estimated that up to a third of hospital admissions for people under 75 are avoidable, and that two thirds of those admissions could be avoided with earlier access to effective primary health care.

The number of admissions per 1000 each year for Maori people could drop from about 115 to 85, and for European and other ethnic groups from around 85 per 1000 to 70.

That is a goal certainly worth striving for, but those figures also illustrate the extent of the risk to health under which some groups in our society are living, or have been living.

For all sorts of reasons, our health system has not always supported primary health care or those who work in it. Too often governments have paid lip service to the importance of primary care and to the need to pay more attention to preventing as well as curing disease.
We can all understand how it happens. Somehow, when it comes to the crunch, the demands of hospitals and waiting lists get the attention and the resources.
That simply cannot go on, and I am committed to ensuring it does not go on. Our health system is not oriented the way it should be. Primary care services are fragmented, not organised for continuity of care and not well linked into the planning or delivery of the overall health system.
Until now, there has been a lack of strategic planning and focus.
The past two-and-a-half years have been a time of setting clear goals and strong structures for the future.
The New Zealand Health Strategy and the Disability Strategy set clear overall directions and the New Zealand Public Health and Disability Act set up District Health Boards with local representation and gave them responsibility for all the health of their people.
The need for strong primary health care has never been greater. I believe that primary health care must be put at the centre of our health system if we are going to meet the challenges of the future.
And if primary health care is at the centre of our health system, then it should go without saying that the best interests of patients must be put at the centre of primary health care planning and thinking.
I know that most health professionals agree with me already on this, and this philosophy is at the very kernel of the concept of primary health organisations (PHOs) in which ranges of health professionals will be working together for the better health of New Zealanders.
One key change in implementing the Primary Health Care Strategy will be an increased emphasis on population-based health care. PHOs will take responsibility for a defined population, for all those people who enrol, and not just who seek care when they are ill.
Primary care providers will need to get to know who in their enrolled population is not getting the care they need for their health, and where education and preventive care can make a difference.
History has bequeathed us a large variety of primary health care professionals, and that is both an asset and a disadvantage. It is an asset in the sense we have expertise in many areas; a disadvantage in that the expertise is not always coordinated as well as it should be.
For example, we need to find better ways for our 11 or more different types of primary health care nurses to work better together, and I have just announced an $8m funding package to develop models of primary health care nursing. I know many nurses around the country are proposing to come up with models they believe will work.
We need to develop strong linkages between all sorts of community care, hospital services and other key areas like social welfare, disability support, housing and local government.
We also need to strengthen continuity of primary health care, especially for the increasing number of people with complex long-term health needs, and our aging population will place increasing demands on health services.
And we need urgently to do far better in so many areas of prevention. We have a growing epidemic of diabetes as well as high levels of meningococcal disease and rheumatic fever – conditions that should be out of place in an advanced country like ours.
The Government believes a population-based approach to primary health care offers our best chance of addressing all these needs.
The key mechanism will be, as I said, the PHOs that will develop in various ways around the country. Some will arise from existing small communities and providers, some from current Independent Practice Associations, Mäori groupings, Pacific providers or other groups.

Last November I released a non-prescriptive minimum set of requirements for PHOs, and deliberately argued that they should be kept simple and achievable. DHBs are now going through the process of deciding who will be involved and where groups will be set up.

I hope I will be making announcements about the first PHOs next week. In the past few days I have sensed a real excitement in certain parts of the country from doctors, nurses, midwives and other professionals as they contemplate the new approach. It is time to start turning that anticipation into action.

It is fair to say that while progressive health professionals are showing such anticipation and excitement, there are others who are voicing some negativity and putting up a rearguard action.

The history of primary health care in New Zealand is littered with arguments, fragmentation and some self-interest. But this Government is firmly committed to shifting the way primary health care is funded so that the public purse – rather than individual patients – carries most of the cost. We cannot afford to keep on putting more funding into old ways of doing things.

When I announced the additional primary health care funding, I said that it was aimed firstly at areas of low income and high health needs. That does not mean, however, that PHOs need to be serving high need populations to get started.

PHOs can be formed when providers and their DHBs are ready, but those serving populations with a high concentration of people in high health need groups will be the first to be funded at higher levels. This will allow them to charge only low patient fees for all their patients with no need for community services cards. I expect that up to 300,000 people may be covered by these arrangements in the next year.

Some providers and PHOs will take more time than others to get ready. There is no need to panic or get worried. The new money will not run out. It will be managed so that PHOs serving high need populations will be funded when they are ready to start.

Some PHOs will provide free health care. In most cases, modest co-payments will remain, even in the long term. The Ministry of Health is talking with GP groups about options for reducing costs to patients.

People must be able to get primary health care services without facing barriers such as cost. The Government plans to remove the need for Community Services Cards over the next eight to ten years and instead move to a system where everyone is able to get low-cost access to care regardless of their income.

Good primary health care is community based and involves people. That is why PHOs will need to show how their community is involved in the organisation’s governing processes. It is also crucial that providers and individual practitioners have a say in PHOs. Good clinical involvement is essential for strong primary health care.

As I said at the recent Primary Health Care Forum, change is challenging – and I know that we have had more than enough change in our health system in recent years.

But remember these primary health care developments are building on what we already have. Almost a third of general practices are already paid for their registered patients rather than fee for service. Many existing primary care provider groups include community representatives on their boards and have begun to take a much more population based approach to delivering services.

The changes in the Strategy move us all further along the path that you have already started to walk along.

Let me also correct a few myths and fears. The Government does not intend to take over the provision of primary health care services. We have always had a mix of public, private and voluntary providers of primary health care – and this mix will continue.

PHOs will not have to be large organisations with extensive staff and impressive corporate offices. There’s much to be said for smaller local PHOs that really get to know the people they serve. I would like groups to work together to reduce overheads and to share expertise.

And there is certainly no agenda – hidden or otherwise – to replace GPs with nurses. The reality is, as GPs know, that we need all the health professionals we can get.

I firmly believe that never since the first Labour Government has a New Zealand government made the sort of commitment to primary health that this Government is making, and I strongly hope that each of you here can become involved in helping us turn the Strategy’s aims into reality.
It may now seem a little perverse to finish this address by changing the subject, but I cannot come to Christchurch without making an announcement that I know has been awaited eagerly in Canterbury.
The Government has now approved the business case for the redevelopment for Christchurch Women's Hospital.

The redevelopment will provide a significant boost for women's health services in Canterbury. The relocation of Christchurch Women's Hospital to a new building on the Christchurch Hospital campus will cost about $79 million.

Building will begin later this year and is expected to be completed in 2005. The new development will have six clinical storeys with theatres and related facilities on one floor, and women's health services in the rest of the building.

This represents a real quality upgrade for women using hospital services in the area, and that's good news for patients, their families and staff. I am sure the Canterbury District Health Board will have more to say about this development later today.

New Zealand women and their families have a right to expect the best possible care from our health professionals and our health system. This new facility will allow for the provision of services in an environment that meets the most modern Australasian standards.

This decision to relocate Christchurch Women's to the Christchurch Hospital campus makes good sense, and even better sense when it is considered that Christchurch Hospital is already the South Island's largest tertiary, teaching and research hospital.

As I said, it may seem slightly perverse to be making a hospital announcement at the end of a speech about primary health care, but I do not see it that way.

The Government is committed to its belief that primary health care offers the best way forward for improving the health of New Zealanders, but it would be foolish to ignore the fact that we need top-quality hospitals as well.

The big change under this Government is one of emphasis. We want to keep people well and out of hospital as long as we possibly can, but when they need to go to hospital, we want them to feel assured of the level of care they will receive there as well.

Thank you very much again for inviting me today. And I repeat that I would love to be here again next year to talk about progress on the unfinished business. Thank you.

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