Cullen: Speech to Diabetes NZ Conference
7 May 2005
Saturday 7 May 2005
Cullen: Speech to Diabetes NZ Conference
War Memorial Centre, Napier
Thank you for inviting me here today.
I would like first to acknowledge the vital work that Diabetes NZ has been involved in for the last 43 years. This organisation has been a tireless supporter of people with diabetes in their day to day management and control, and a tireless supporter of health professionals and researchers addressing the treatment, prevention and cure of the disease.
Over the last 43 years, Diabetes NZ has worked to increase the general public’s awareness of diabetes, with a view to reducing the incidence of undiagnosed diabetes.
While much has been achieved in 43 years, and Diabetes NZ has many reasons to be proud, diabetes remains one of the greatest challenges to the health of our population.
There are an estimated 118,000 people with diagnosed diabetes in New Zealand and potentially a similar number with undiagnosed diabetes. Maori and Pacific people are vastly over represented among those with diabetes.
It is commonly said that in New Zealand we are in the middle of an epidemic of type 2 diabetes. The evidence for that is hard to refute:
Type 2 diabetes is the most common type of diabetes and its frequency is dramatically rising.
What is more it is occurring at younger and younger ages. Now some children are being diagnosed with type 2 diabetes, and almost all of these are Māori or Pacific children.
Nevertheless, we need to be careful about our terminology. The word ‘epidemic’ is commonly used to describe a temporary, but widespread, outbreak of a particular disease. It conjures up in the public mind the image of an infectious virus or bacterium on the loose within the community, hunted down by medical professionals wielding vaccines and other magic bullets. Placing diabetes in the same category as SARS or meningitis, however, carries the risk that the community hands over responsibility for fighting the disease to others.
This is something to be strenuously avoided, as the theme for this conference – ‘Diabetes in our Communities’ – reminds us. We are not dealing with a microscopic invader to be repelled with hi-tech medical heroism, but a chronic condition that is either an inherited trait, needing to be managed over a lifetime, or a preventable condition arising from placing excessive pressure on the metabolism through poor diet, lack of exercise, smoking, and several other risk factors.
Fighting diabetes is largely a low-tech exercise, although medical research and technology are invaluable supports, and offer hope of more effective interventions. The major battlefield remains in our communities, in the lifestyle choices that individuals make and that communities encourage and facilitate.
The cost of Type-2 diabetes and cardiovascular disease to society, and to individuals and families, is enormous. In New Zealand, chronic conditions are responsible for the majority of all deaths. They afflict increasingly younger groups of people and have impacts, yet to be measured, far beyond the health sector. The material costs are also huge. In NZ, the US, and the UK chronic diseases account for 70% and more of all health expenditure.
Chronic diseases disproportionately affect some groups over others. Poor outcomes in both diabetes and cardiovascular disease (CVD) are significant issues for Maori, Pacific people and those on low incomes. Ironically as society becomes generally more prosperous, as we have greater access to high calorie food and live more sedentary lives, the adverse impacts of this fall more heavily on those with lower incomes.
Addressing these outcome inequalities is a major government priority.
This morning I would like to go through the rationale for the government’s diabetes strategy, and why we think it has the best chance of long-term success. As you will appreciate, I am not the Minister of Health, and although I am a doctor, I am the wrong kind for speaking with any authority on health matters.
I am, however, Minister of Revenue and in that capacity I would like to discuss the option that has been mooted recently of using the tax system to encourage people to abandon lifestyle choices that put them at risk of diabetes and other conditions.
Many chronic conditions (including diabetes, cardiovascular disease some cancers, respiratory conditions, and depression) are closely tied to the type of society we have and the way we live our lives within it. The wider determinants of health, social, cultural and economic, are the matrix from which many chronic conditions arise.
Because these major chronic diseases have common or related risk factors, it makes sense to tackle them as if they were one at the prevention stage, in addition to the interventions further down the track when the diseases have become a problem and may have their own particular characteristics.
To have a positive impact on chronic disease outcomes we must act to prevent them in the community where they arise, using all the tools at our disposal and at all levels. This includes:
Government agencies collaborating across sectors and promoting health in their policies and services;
District Health Boards planning for and funding both health promotion and clinical interventions to prevent and manage chronic conditions;
Primary Health Organisations working with practitioners to improve outcomes locally, and
Local health care providers working every day with enrolled populations and those at risk, or with disease who have not yet been reached.
This is never a simple task, since chronic diseases have a multitude of contributing factors, some of which are amenable to change, while others are very hard to influence. When it comes to influencing behaviour there is no way around the need for a multi-pronged approach aimed at education and at prompting individuals and families to voluntarily opt for healthier lifestyles. Since we do not live in a totalitarian state, collaboration and not coercion is the name of the game.
So, for example, the Ministry of Health’s “Healthy Eating, Healthy Action” strategy, stresses collaboration among central agencies to improve health outcomes. This strategy was launched by Hon Annette King in March 2003 and its implementation plan in June 2004. The plan promotes collaboration among agencies (coordinated by the Ministry of Health) and aims to reduce risk factors for type 2 diabetes, such as obesity, inactivity and poor nutrition,
This collaboration includes cross sector relationships that DHBs and PHOs have with other government agencies, local and regional councils and non-government agencies such as Diabetes New Zealand.
This brings me to the role of the NZ Primary Health Care strategy in tackling chronic conditions as early as possible.
Eighty percent of New Zealander people visit the GP or primary care nurse at some stage so that is clearly the place to start. We can reach out from there to people at risk, or with the disease, based on the information we already have. We need to work not just with individuals but also with their families and whanau and with entire communities to identify risk and do everything we can to prevent it turning into disease.
Health Care Strategy aims to reconfigure the primary care
sector, to shift it from a system based on episodic visits
to the GP, and to build capability to combat chronic
long-term conditions like diabetes. The first step in this
process has been to establish Primary Health Organisations
which will focus on:
better access to primary care (cheaper visits to GPs);
taking a population health focus (i.e.: focussing on the needs of whole populations rather than just the presenting problem),
shifting from an episodic to an ongoing health care approach that treats peoples illness and wellness as a continuum;
shifting from an individual practitioner to a team approach that includes nurses, dietitians, podiatrists etc. who each have some of the range of skills needed to manage chronic illnesses;
breaking down the barriers between primary, secondary and tertiary services; and
making better links with, and becoming part of, local communities;
These are not shifts that we can make overnight. Early intervention means identifying people and their families at risk of developing chronic conditions. This means getting better information about the health status and risk profiles of our practice populations better. We need to know who is in greatest need and target services to them, rather than wait till they turn up at the surgery door! If that is not hard enough, we need to take account of the fact that many who are at risk are not necessarily happy to be ‘targeted’ with services.
Overcoming these barriers is a major part of the exercise. That is why the government has created the “Get Checked” and “Care Plus” programmes to supplement primary care services by enabling free checks and continuity of care for people with diabetes.
Team-based approaches are integral to the Primary Healthcare Strategy. Effective prevention and management of diabetes and other chronic conditions calls for a wider range of expertise in addition to the efforts of GPs and nurses. Primary Health Organisations are key elements in moving away from episodic care to a situation where multidisciplinary teams to provide continuity of care and support self-management among patients.
The mandate of PHOs is to provide affordable primary health care services in the community. In addition to being more affordable, the nature of those services is changing to meet the needs of chronic conditions. International experience and research demonstrate the need for these changes. Our PHOs will play a leading role in the move toward new modes of providing care.
Another important emphasis of the government has been the role of chronic disease in DHB planning and funding. As you know, District Health Boards are responsible for primary health care services in their districts. PHOs give effect to this on the local level, working with the range of providers and agencies delivering primary health care services. I want to emphasise here that DHBs and PHOs, are working on essentially the same project. That project is to fight chronic disease in our community and Diabetes New Zealand’s activities are a vital contribution to this.
If we look at the NZ Health Strategy through the lens of chronic conditions, at least 8 of the 13 priority areas are chronic conditions or their risk factors. It makes clear sense to treat these as a cluster of related components, a grouping that will in many cases use the same resources, benefit from the same institutional arrangements, have similar workforce implications, and demand the same changes in the way we think about and deliver healthcare.
When we put these considerations together with the huge impact and cost of chronic diseases, DHB priorities become very clear. The priority is chronic disease, its prevention and management in community settings. There are many benefits to this approach:
If we can succeed in preventing and managing cardio-vascular disease and diabetes among groups at highest risk and most in need, we will start to reduce health inequalities. In doing so we will improve the health of all New Zealanders.
If we can influence the root causes of cardio-vascular disease and diabetes through strong community action, we will affect more than just people’s health. We will build social capital, durable relationships, and improve the overall health of all our community.
We will start to see DHBs fulfilling their potential as organizations in improving health and disability outcomes among their whole populations. There are some wonderful examples of this engagement with other partners in achieving this goal, such as explicit agreements with local and regional councils, other government agencies, and Maori and Pacific organisations. It is to this level of collaboration that we should all aspire.
If we can begin to see health in this way, as a fully collaborative effort, then we can start to talk meaningfully about access to homes that are warm and dry, income levels, access to fresh fruit and vegetables and opportunities to exercise, access to health services which can help us give up or reduce smoking or lose weight. We must be active in working with our schools to promote healthy fulfilling lives. We need strategies like Health’s Healthy Eating, Healthy Action strategy, that are not focused on one or two disease risk factors but which address the whole picture.
Is there a place within this strategy for a so-called ‘fat tax’, a mechanism whose effect would be to raise the price of unhealthy foods relative to healthy ones? This is an established practice with tobacco products, where the tax system is used to increase the price to consumers and hence to place an artificially high price barrier with the hope that this will reduce consumption.
The idea is superficially attractive, but it would need to pass two important tests before it merits serious consideration. It must first be possible to design a fat tax that effective targets major types of risky dietary choices. And secondly it must be a tax that does not have unpalatable side effects, in particular for those on low incomes who would comprise a good portion of the target population.
Fat tax proposals tend to fall foul of both tests. Tobacco is an easy target for behaviour modifying taxation because it is delivered in a small number of easily recognised forms and because it is harmful regardless of how small the dose. By contrast, fat comes in a variety of forms, some of them more harmful than others, and some of them in fact important in a balanced diet. It is present in a wide range of foodstuffs, which are consumed in differing quantities by different individuals. An effective tax-based system of encouraging the right level of consumption would need to focus on the significance of different food-stuffs as vehicles for dietary fat and set the tax rate according to an accurate assessment of what the price level would need to be before consumers opt for other lower fat alternatives.
In short, it would be an exercise in enormous complexity, if not futility. What is more, to be effective in changing spending patterns it would probably have to be set at a level that would hurt those on low incomes.
That is probably why the most commonly proposed form of a fat tax is one which targets symbolic foods such as those sold by fast food chains. This is in fact a very dangerous strategy, since it may merely prompt consumers to opt for un-taxed, but not particularly healthy, foods and fool them into thinking they are therefore eating more healthily.
The only benefit of a symbolic tax on certain fatty foods would be to raise awareness of dietary fat. In other words, it would be at best another kind of education programme, and a poorly designed and targeted one at that.
So in summary a fat tax proposal, while it is superficially attractive, is in fact too simplistic a mechanism to be part of a well-rounded strategy. As such I believe it is a distraction from the real work of fighting diabetes and other chronic diseases.
In the end we return to the task of marshalling the extraordinary human resources spread throughout the community, amongst community workers, health professionals, and groups such as Diabetes NZ. If we can achieve better links with each other, more effectively focused on common goals, there is no limit to what we can accomplish.