King - Royal New Zealand College of GPs conference
14 July 2005 Speech Notes
Hon Annette King - Royal New Zealand College of GPs conference
I am sure many of you were in Wellington on March 10 at the Primary Focus 2 conference to hear the World Health Organisation’s primary health expert say New Zealand’s approach to primary health care, particularly chronic disease management, was vital as far as the WHO is concerned.
Dr Rafael Bengoa was paying a huge compliment to New Zealand, and incidentally to many of you at this conference today who have helped implement the Primary Health Care Strategy.
Dr Bengoa said at the end of his keynote address: “Your work is vital for developing countries and the WHO. Thank you for taking the right direction. I will be tracking New Zealand to see if you crack it.”
I can assure you that with the eyes of the WHO so firmly on us, there’s no way the Government will be backtracking on its commitment to continue implementing the Strategy and to make affordable and accessible primary health care available to all New Zealanders.
I will more to say about Dr Bengoa shortly, but firstly thank you to the College and president Jim Vause for inviting me to open this conference, and, more importantly, thank you again for all that the College and individuals here have done to help the Government implement the Strategy far faster than we thought possible.
Your role has been a tremendous support, and continues to be as the College remains actively involved in a number of primary health advisory groups – the PHO Development Taskforce, the PHO Performance Advisory group, the Care Plus advisory group, the After Hours Working Party, and the Rural Primary Health Care Forum.
The theme of this year’s conference, New Horizons, is certainly appropriate. The further we go down the path of implementation, the more new horizons appear. The College has a real opportunity to continue influencing the future development of primary health care in this country.
Congratulations to the organising committee, particularly programme convenor Dee Richards and conference convenor Karen Thomas, for all your hard work in making this conference happen.
I am impressed by the speakers you have attracted. We will all be interested in hearing Kieran Sweeney’s contribution because of his background in advocating for general practice in changing times. Both he and Marjan Klajovik share an interest in balancing evidence-based care and patient-centred medicine.
I also see that Ray Moynihan, a Visiting Editor with the British Medical Journal, is also speaking. New Zealand has been provided with free access to BMJ’s best practice website for one year. I have had positive feedback on this, and the Ministry of Health is currently working to establish national access to their website.
March 10 was not my only meeting with Dr Bengoa this year. He was so impressed by what he heard from so many of you in Wellington that he asked me to speak to WHO staff and delegates from other countries when I attended this year’s World Health Assembly in Geneva.
At the end of my presentation, and following a rigorous series of questions from a good-sized audience, Dr Bengoa provided another quotable quote when he said that New Zealand is in the “first division” of primary health care globally.
All I can say to that is: “Let’s make sure we keep it there”.
The Government has now committed to invest $2.2 billion in new money over seven years in primary health care, and the excellent news is that we are already starting to see results.
As everyone in this room knows, the whole point of placing such a huge emphasis on primary health care is to improve peoples' health and to engage our communities in prevention and health promotion strategies.
I am often asked if we can show a link between prevention in a primary health care setting and reducing rates (in terms of frequency and duration) of secondary and tertiary admissions. I believe we are now getting to the stage where we will be able to do just that.
Much of the data we are now receiving is relatively recent, but it is certainly encouraging. One good example is the Get Checked programme, which is showing excellent progress in controlling diabetes.
National data indicates that the number of people accessing free annual diabetes checks through the Get Checked programme has more than doubled between 2001 and 2004. In most DHBs there is now no difference in retinal screening rates between Mäori and other New Zealanders, and around two thirds of people enrolled in Get Checked are receiving retinal screening at least every two years. Where Primary Health Organisations work in partnership with their DHB and adopt innovative approaches, particularly with Mäori, rates of retinal screening are now truly world class.
After one year of the Get Checked programme almost all enrollees were having their cholesterol tested at least annually. By the second year of the programme very few (around 1 per cent) of those who had their cholesterol tested had very high total cholesterol, and all ethnic disparities were eliminated.
These are both truly significant outcomes given the impact they are having in terms of saving vision and reducing an important risk factor for cardiovascular disease, and they sum up what the Government’s primary health care policy is seeking to achieve. I am sure some of you will have read research undertaken by Ann Volpel and John O’Brien on Strategies for Assessing Health Plan Performance on Chronic Diseases. This was published in March shortly before John joined the Ministry’s primary health care team on an Axford Fellowship.
Of interest to me was the following quote: "...when controlling for other factors (including health status), enrollees who had two or more ambulatory care visits were approximately one-third less likely to have an in-patient admission than those who had fewer than two ambulatory care visits." This surely indicates the significance of the primary care role.
I had the privilege last month of presenting the College’s first Cornerstone Accreditation certificate to Te Puea Medical Centre. I will say a little more on that later, but I was also further encouraged that we are on the right path in primary health care when talking to Associate Professor Bruce Arroll after the ceremony.
Professor Arroll, head of the general practice department at Auckland University, is still practicing as a GP himself, and he told me that while it was relatively easy to know as a GP whether you are doing some good for an individual patient, it is now possible to know that a whole practice is achieving good things for patients generally.
That view is backed up by John Wellingham, primary care adviser for the Waitemata DHB, who says that the Chronic Care Management programme, jointly developed by primary care and secondary care at Counties Manukau DHB, is providing solid evidence of improving health statistics among the monitored group of patients with diabetes. Even smoking is trending down across all ethnic groups, including Maori and Pacific.
The CMC programme was initially modelled around diabetes, but now also involves cardiovascular disease, chronic lung disease and congestive heart failure. Dr Wellingham says CMC has been described as “putting the human face to our chronic disease”.
That, I believe, is increasingly what will be happening right round New Zealand as the new horizons open for primary health care.
There are actually positive things happening in many parts of the country, and the GP role is often instrumental in the new environment, especially in terms of innovative approaches to meet specific community needs.
You only have to think of initiatives like South Link Health's Diabetes Watch programme and the Let’s Beat Diabetes Plan, which I had an enjoyable time launching in May of this year, to realize what I mean.
There was another great example this year when Counties Manukau won the Health Innovations Supreme Award for its insulation and housing project. The story behind this success demonstrates a number of key features of the new approach to health care --- considering how to do things differently, collaboration and intersectoral action, and getting to the determinants of poor health.
Last year Lakes PHO initiated a similar project within their PHO, insulating 80 houses in Mangakino.
I have only mentioned a few examples of the new environment in action, but I hope this conference is a chance for you to share what is energising you about moving into the future.
At the recent IPAC conference in Christchurch, Dr Peter Ellyard, from Melbourne, used the term ‘destination conversations’ when he encouraged GPs to move into active conversations as they reconfigure their roles in the future. I am sure these sorts of conversations will help us all incorporate the best aspects of traditional general practice and population health in a uniquely New Zealand primary care approach. And what I think is emerging with this New Zealand approach is community participation.
I believe that community involvement in primary health is proving to us that communities have had good ideas for some time about their needs. Communities provide the key to influencing change in the health behaviour of our young, our future parents, our workers and our elderly, and drive the changes required to improve health.
PHOs are now enabling communities to harness the resources they need. PHOs have become the engine room driving the ocean liner, if I can use that analogy, and the chart for the voyage is the vision that all of you here today are working on.
Another feature of the primary health sector is increasing teamwork. I expect many of you have seen the PHO awareness advertisement featuring GP Harley Aish speaking about the team approach from ProCare Network Manukau PHO. The diabetes programme there involves doctors, nurses and visiting dieticians working together to promote healthy eating and healthy action. Dr Aish speaks about the PHO environment “planning to keep people well and make them healthy, rather than reacting when people are sick”.
This is the message we must continue to send to our communities, because they have a key role to play. I hope it is now well recognized that using a team approach involving a range of health practitioners does not detract from any one professional group. Instead, it leads to greater understanding of the special expertise of all individuals involved.
When Richard Bohmer, from the Harvard Business School in Boston, spoke at the Primary Focus 2 conference, he encouraged general practices to examine how the nature of consultations is changing within their practice.
He identified consultations that are of a ‘discovery’ type, ones that focus on more complex cases and diagnoses. He also identified a ‘delivery’ type of consultation --– one typically associated with ongoing management and monitoring of chronic conditions. These two types can be delivered in quite different ways.
And for me this is where the team approach is invaluable, by allowing different professionals to forfill the roles they are best suited to.
I would like to illustrate the freeing up of a GP’s time for more complex cases by quoting Dr Gary Sinclair, a GP from Mangere Family Doctors. He says: "The biggest change since we have been in the PHO environment is that it has freed us up as a team - we have been able to reapportion our work within the practice. Our ratio of practice nurses to doctors has increased and we have started the huge paradigm shift both for us and particularly for our patients. As a doctor I might see less people per day now, but our practice as a whole is working in a more integrated way to deliver a greater range of services to our patients."
I hope that comments like that encourage all GPs to look forward to the new horizons ahead with a real sense of anticipation, and that it also encourages all GPs to use other health professionals, including nurses, to their full potential within their primary health teams. The more that potential is unveiled, the more opportunity there will be for GPs to specialise in areas like diabetes or mental health, for example, if that is where their interests lie.
I want to return briefly to the Cornerstone Accreditation I mentioned before. What excites me about the project is that it provides a framework for practice teams to identify where changes can be made to improve outcomes for patients, as well as staff and patient satisfaction. What is significant about such accreditation is that it provides a way to celebrate the quality of general practice. It is a way of demonstrating just how important the contribution of GPs is.
I would like to congratulate the college on this initiative.
It would not be appropriate for me to talk at your conference without at least briefly discussing workforce issues. None of what we are trying to achieve in health can be achieved without developing a health workforce that can meet specific health needs, particularly in primary care. Sound progress is being made by the Health Workforce Advisory Committee’s medical reference group and through valuable advice received at the doctors’ Round Table.
Last year I mentioned the high level of applications for GP training. There were about 100 applications then for the General Practice Education Programme, and though numbers are still being finalised for this year, they look to be slightly higher. That is good news. We are doing well in international terms, and this year the College received 111 applications for registrar training for 55 places.
In terms of training, the numbers sitting Primex, either through the General Practice Education Programme, seminar only or the practice eligible path, have increased from 118 in 2000 to 134 in 2005, while the numbers completing Advanced Vocational Education this year continue to be more than double those in 2001.
We are also continuing to provide funding through the rural funding component of the Primary Health Care Strategy and I recently agreed to fund four extra PGY2 rural rotation places this year. All the positions had been filled and we were starting to get a waiting list. We needed to do something about it.
I know some GPs have issues around the rolling out of lower cost access to health care, but I am pleased that more than 90 per cent of practices have fees that both the DHBs and Ministry find acceptable. I hope that continued negotiations will raise this to 100 per cent in the near future.
Before I finish I want to thank GPs for the support for the influenza vaccination programme this year, given delays in the vaccine arriving and the concurrent Meningococcal B vaccination programme.
Preliminary data on the influenza programme is very encouraging. Some of you may have heard an announcement that after seven years, New Zealand will now have more than one supplier for the flu vaccine in the future. It is no good growing older if you don't grow wiser.
As you explore new horizons at this conference, I want to assure you how much I value general practice as providing the core of primary care in New Zealand. I am proud that our GPs in New Zealand are world class in the services they provide.
Thank you very much for inviting me once again to open your conference, and thank you to the College for helping to make my job far more enjoyable to do.