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Royal New Zealand College of GPs conference

Fri, 16 July 2004

Royal New Zealand College of GPs conference

Health Minister Annette King announced that the Cabinet has now approved details of the final rollout of low cost access and low cost pharmaceuticals for all New Zealanders enrolled in PHOs.

The Royal New Zealand College of General Practitioners conference is always an auspicious occasion, and I hope this year's conference will be remembered as even more noteworthy than usual.

I have a number of new announcements to make over the next few minutes, but before I do that, however, it is certainly worth commenting that for the second year in a row the College has chosen what I consider to be a most appropriate theme for the annual conference.

Last year that theme was towards unity. As far as I am concerned, the College has been a constructive and unifying force at a time of a dramatic new emphasis in New Zealand on primary health care.

I do not believe, in fact, that the Government would have been able to act as quickly and decisively as it has done in terms of implementing the Primary Health Care Strategy without the College's support and encouragement, and the enthusiasm of forward-thinking people like your past president Helen Rodenburg, current president Jim Vause and chief executive Claire Austin. Thank you all very much.

I hope I have been able to play my part too in working constructively with the college across a range of issues, including some of those being discussed at this year's conference under the broad theme of facing complexity.

I acknowledge that the greater emphasis the Government places on the importance of primary health care, the greater reliance we place on primary health care teams improving the overall health of New Zealanders, and the older our population becomes, the more complex the role of GPs is likely to become. I also hope it will become more satisfying and rewarding in a number of ways at the same time.

I am aware that your discussions yesterday featured issues like having 'authentic conversations' with patients and their communities, understanding patients, and walking with them on their journey rather than just trying to 'fix things'. It may be too much to expect all Primary Health Organisations to provide this sort of environment immediately, but my vision for them is that they will provide GPs with opportunities that maybe haven't existed as much as they would have liked.

At last year's conference I acknowledged the College's view that the Government should bring forward funding more quickly for implementing the Primary Health Care Strategy, and I promised to work with the College on the issues it had raised with me. And although I was unable to give you any details at the time, I was delighted two months later to be able to announce that the Government was bringing forward by a full year the funding of cheaper primary health care for over-65s enrolled in Interim-funded Primary Health Organisations.

As everyone here knows, that funding, an extra $47 million, became available from the first of this month, and it has resulted in considerable reductions in the fees many older New Zealanders are paying around the country. The Ministry of Health has informed me that the average co-payment now paid by older New Zealanders is $22.88.

From 1 July the Government also began injecting an extra $26 million into Care Plus, a programme aimed at people who need to visit their family doctor or nurse often because of significant chronic illnesses such as diabetes or heart disease. People with acute medical or mental health needs or a terminal illness are also eligible under the Care Plus programme.

The number of PHOs involved in Care Plus is 45 out of a total of 73. These 45 are either preparing for or implementing Care Plus, with 18 approved by DHBs to go into the implementation phase.

Some two million New Zealanders, about half our population, are now eligible for access to lower-cost primary health care. As well as the over-65s enrolled in Interim PHOs and those entitled to Care Plus, that number includes all those enrolled in Access-funded PHOs in areas of high socio-economic deprivation and all under-18s enrolled in Interim PHOs.

New Zealand has come a long way since I launched the Primary Health Care Strategy in February 2001, and announced the first modest contribution of $48 million toward implementing that strategy in the health budget for 2002-03.

Just how far we have come is illustrated on the one hand by the amount of money we are now investing in primary health care, and on the other hand by the number of people now enrolled in PHOs.

In Vote Health this year I was able to announce that the Government's commitment to implementing the Primary Health Care Strategy now amounted to an extra $759 million over the four years from 2002-03. That's quite a step up from $48 million.

In terms of the numbers belonging to PHOs, the figures are equally startling. When the first two PHOs started in South Auckland in July 2002 they had enrolments of about 40,000 people between them. There are now 73 PHOs in New Zealand, looking after the health of 3,570,000 New Zealanders.

My original estimate was that it would take eight to ten years to implement the Primary Health Care Strategy, to reduce financial barriers and address many of the country's worst health disparities.

I am not normally a conservative person, but it is clear now that my initial prediction erred on the cautious side. I think I can be excused, however. The Government can certainly not be accused of over-promising in this case, and the fact that the rollout is happening faster than anyone anticipated is something that I believe we can all celebrate.

Given what has happened in the past two years, and what lies ahead, it is important to place the Strategy's implementation in the historical context of primary health care in New Zealand.

Compared to other countries, New Zealand has been relatively unusual in having a high reliance on private funding for primary health care services.

Though patient subsidies largely funded the cost of GP visits when they were introduced in the 1940s, by the time we became the Government in 1999 the real value of subsidies had declined to the point where individual patients bore the greatest burden of costs, and about half the adult population paid the full cost of GP visits.

That simply did not make sense to me, and I know it did not make sense to many people in this room either. The most innovative modern international thinking is firmly committed to taking advantage of the opportunities offered in the primary health care setting to embed the philosophies of early intervention and prevention.

Early intervention and prevention and improving access are all crucial to improving the health of New Zealanders. High user charges in primary health care, of the sort we used to have more often than not, and health tokens or tokenism like the Community Services Card, or Kiwi Poor Card, clearly were not offering the healthy solutions New Zealanders needed, particularly in areas of socio-economic deprivation.

As everyone here knows, high user charges are associated with people not getting services when they need them, and also with high rates of avoidable hospitalisation for conditions that could be managed in a primary health care setting.

The Government believes that significantly increasing the share of public funding will encourage primary health care providers to show the lead in providing services to existing patients and those who have been missing out, in addressing health priority areas, such as cancer and diabetes, in coordinating care across a person's life, and in collecting vital health data.

We all know that the only way we will cope with the predicted burden of chronic illness, such as growing levels of depression, obesity, diabetes and cardiovascular disease, is by strengthening prevention, early management and health promotion.

Certainly there is no way it can be done, as our political opponents have suggested, by tinkering with the Community Services Card. It has been demonstrably unsuccessful in tackling the problem of low take-up by high need populations.

I am firmly convinced that the PHO model, providing a population health focus and involving a whole team of health professionals offering a variety of services and providing continuity of care for their enrolled populations, is the way to go.

PHOs are bringing public health initiatives alongside traditional general practice to strengthen health promotion and prevention.

Examples around the country include free home visits to educate parents about immunisation, free transport for children to be immunised, monthly meetings for people with diabetes and asthma, longer opening hours for medical centres, and nursing outreach services for people requiring care after discharge from hospitals, or for people who cannot attend scheduled medical appointments.

One excellent specific example is the HealthWEST CVD guidelines implementation project, designed to improve the current health of those with existing cardiovascular disease by tracking down and screening the target population. The target population includes 48,000 out of the PHO's total population of 152,000.

Another excellent example is Hutt Valley District Health Board's cardiac continuum of care programme, which covers treatment, rehabilitation and education.

And initiatives are also occurring on a whole-of-region basis in areas like Wairarapa, where the Wairarapa Community PHO started a new Sexual Health Service this month, and a Primary Mental Health service is in development. Such initiatives will make a significant difference to the health of the people of Wairarapa.

Other innovative examples in Wairarapa include plans for a Mäori GP service, while a transport initiative, designed to get people to their doctors, has been led by mayor Bob Francis, with cooperation from Wairarapa DHB, local bodies, Masterton Licensing Trust, the Wairarapa Organisation for Older Peoples, the Red Cross and the PHO itself. I understand that soon there will be two minibuses, with volunteer drivers and coordinators, making sure that lack of transport is no longer a barrier to accessing health care in the Wairarapa.

On the face of it, these all sound like straightforward initiatives, though you wouldn't be staging a conference on the theme of facing complexity if everything was always as simple as it sounds.

>From my point of view, probably the most complex and certainly most contentious issue has been resolving our approach to rolling out the strategy's implementation. Although some of our political opponents claimed our decision was race-based to target increased funding initially at improving access to low-cost care for particular groups of people with high health needs, I believe most New Zealanders have been open-minded enough to understand that we must tackle such health disparities for the sake not only of individuals, but for the sake of wider society as well.

The charge that funding has been race-based has been the most disappointing. Not only does the National Party appear to be disowning some of the valuable work it did itself in the 1990s in building Maori health providers, but it is seeming to ignore the shocking Maori health statistics that everyone in this room knows only too well.

As noted Wellington School of Medicine and Health Sciences public health researcher Tony Blakely says, need and ethnicity co-habit in the health funding system.

The most fundamental elements of any funding formula are population size, age and gender, but there is no doubt in the New Zealand context that such formulae also have to be weighted with socio-economic deprivation and ethnicity factors as well.

There are clear links internationally between poverty and poor health. They certainly exist in New Zealand too. But in New Zealand it goes further than that. We all know Maori on average die younger than European New Zealanders, but the even grimmer reality is that Maori people can expect to die earlier than European New Zealanders with similar levels of socio-economic deprivation.

A well-off Maori male will die much earlier than his European friend who earns the same amount and lives next door; while across the tracks in the poorest area of town the disparity is even greater between Maori and European neighbours.

So the Government certainly makes no apology for having unashamedly targeted the worst health needs first, but my overall aim has always been to provide lower-cost primary health care for all New Zealanders who want it.

I am absolutely delighted, therefore, to be able to tell you today that the Cabinet has now approved details of the final rollout of low cost access and low cost pharmaceuticals (a maximum cost of $3 per item for all subsidised medicines) for all New Zealanders enrolled in PHOs.

I certainly hope that what I am now going to announce more than satisfies the College, given your urging last year that the Government look at rolling out funding more quickly than it originally planned.

Instead of taking eight to ten years, the Government will now complete the rollout in just five years, allowing all New Zealanders enrolled in PHOs (and there won't be many left who are not enrolled) to benefit from lower cost access and from the integrated care PHOs provide.

The next group of people to benefit will be those aged 18 to 24 enrolled in Interim PHOs, who will become eligible for lower-cost care from July 1 next year.

Improving access to primary health care for people in this group can have a lifelong impact on health through, for example, better detection of early symptoms of mental illness, early signs of alcohol or drug abuse, or detection of sexually transmitted infections. There has been an alarming increase in sexually transmitted infections among young New Zealanders, and the increase in the number of HIV/AIDS cases in New Zealand is also of concern. Many DHBs are emphasising the sexual health of young New Zealanders as an important health priority.

The more we can get the prevention messages across to younger New Zealanders, the more likely we are to be successful in promoting better health generally.

Funding for all people aged 45 to 64 enrolled in PHOs will come into effect on July 1, 2006. It is also important to include this group as soon as we can, because they suffer more from chronic illnesses, are more frequent users of the health system, and have higher rates of avoidable hospital admissions. The final group of New Zealanders, those aged 25 to 44 enrolled in PHOs, will be funded from July 1, 2007, five years to the day after the first two PHOs began providing primary health care.

There are a number of other elements also to the final implementation plan. A high priority in the short term is to reduce prescription costs for Care Plus patients to a maximum of $3 an item from 1 April next year, or sooner if this is possible.

I am also proposing to increase Government funding for influenza injections in an effort to help keep older people out of hospital. As you know, two of the clinical performance indicators for PHOs relate to immunisation, one for childhood immunisations and one for influenza immunisations for older people, and I think it is fair to increase the rate of benefit for influenza immunisations from $11 to $18 to bring it into line with the rate for childhood immunisations.

I also hope that this initiative, by demonstrating our commitment to immunisation, will support two other important initiatives, implantation of the meningococcal vaccine strategy and continued development of the national immunisation register. It is also important that the immunisation benefits will be subject to the same annual adjustments as the rest of PHO funding, ensuring that the real value of these payments is maintained.

The cheaper health care for the last three groups of New Zealanders, plus the other benefits I have just outlined, will cost an extra $415.7 million in total --- an extra $58.3 million in 2005-06, an extra $144.9 million in 2006-07, and an extra $212.5 million in 2007-08. By then the Government will have committed to investing more than $1.7 billion in implementing the Primary Health Care Strategy.

If the amount of money the Government has already been spending on primary health care has been unprecedented in our history, then $1.7 billion is something else again. By 2007-08, in fact, we will be spending $492 million a year, and each year the funding for the Strategy will increase to ensure it maintains its real value. I have not spent much time today discussing specific issues of complexity, but it is important to acknowledge that while getting PHOs up and running and providing funding are critical in terms of implementing the strategy's vision, they do not in themselves mean that implementation is complete.

The Ministry of Health has established a PHO Future Development Taskforce and is consulting with the sector on initiatives to ensure PHOs actually achieve the aims of the Strategy. The Taskforce comprises members from the Ministry, your College, the New Zealand Medical Association, IPAC, various PHOs and DHBs and nursing. The Taskforce is working in a number of areas, including teamwork, broadening the scope of services, and developing management and governance capabilities and PHO infrastructure. I also believe it is important that PHOs share ideas and initiatives, and learn from each other's successes.

The evaluation of the implementation and intermediate outcomes of the Strategy is also well underway. Political opponents have claimed PHOs are too bureaucratic. I do not accept that, but nor do I want to run the risk of the system becoming top-heavy and not delivering the health care we want it to deliver. That is why continuing evaluation is so important. Pilot interviews with case study PHOs have been completed, and data is now being collected for other PHOs. Most PHOs have positively welcomed the opportunity to take part in evaluation exercises.

I hope you have found today's announcements both encouraging and satisfying, and thank you again for inviting me to your conference. There has been a significant shift in the way primary health services are delivered, a shift that involves working together, meeting community needs and being innovative in service delivery. This is a creative time in which PHOs and communities have the opportunity to influence future development.

I understand that significant change brings pressures as well as opportunities for GPs and other primary health providers, and we could not have created the new emphasis on primary health care without the support and encouragement of your college and you as members of the college. I look forward to that support and encouragement continuing. There are exciting and innovative times ahead over the coming months and years, and while they will sometimes be demanding, I hope you also find them rewarding and fulfilling.

I will continue to work with you and your college as we implement the Strategy's vision of improving the health of all New Zealanders, and also on a number of other joint workforce and quality projects that I hope to announce in the near future. Thank you for today's invitation. I wish you well for the rest of your conference.


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