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Hodgson: Continuing Medical Education Conference

26 May 2006

Address to General Practice Continuing Medical Education Conference

Rotorua 26 May 2006

It is a great pleasure to be here. Your conference presents me with an excellent opportunity to make some comments on the Primary Health Care Strategy and to offer some views as to where the strategy may develop over the next year or two. I also wish to offer some comment on medical workforce issues, and on the roll- out negotiations.

There can be no doubt that the Primary Health Care Strategy is a very significant development in the history of the New Zealand health system, and certainly the most comprehensive change in primary health for many decades.

It’s a strategy, which in one respect burst out of the starting blocks faster than expected. The formation of Primary Health Organisations (PHOs), and the speed of enrolment was such that the roll-out of the reduced fees aspect of the strategy was advanced several years from the original plan. The target for completion is just 13 months away, and the necessary funding for that is fully budgeted.

In another respect the changes are still mostly in front of us. The greater use of multidisciplinary teams, the uptake of programmes such as care plus, the better use of information technology, closer links with the NGO sector, the primary- secondary interface, services to improve access, health promotion activities and so on, are still patchy, in part because the strategy is still young, and in part because we all, including the Government, have more work to do.

This is a good time and a good occasion for me to acknowledge those who have been working on this strategy over the years. Many people have. The Ministry and my predecessor Annette King are clearly on the list, as is the Cabinet who year after year have approved taxpayer investment into the sector, due to increase by another $100m per annum in five weeks all going well.

But the list is a lot longer that that. Many people in the primary health sector began developing models of care which were, in effect, precursors to the Primary Health Care Strategy, before that strategy was developed. The Newtown Union Clinic was an early example, but there are many others. The Whanganui Regional PHO is a case in point. For them the strategy was a straightforward idea because they were already doing it. Similarly today’s care plus programme began its life as an idea within IPAC.

But much of the maturation of the strategy is still in front of us. First there is more policy work to be done in the coming financial year, on laboratories, pharmaceuticals, how we might proceed with a low capped fee option for PHOs who are asking for it, whether we should progress more packages of care such as care plus, how to better link maternity care, how to improve information systems, first to reduce compliance costs, and second to enhance a GP’s effectiveness, or the team’s effectiveness.

There is more implementation to be done, in the sector. Wider deployment of multidisciplinary teams, greater deployment of services to improve access, greater uptake of care plus, attention to health promotion and so on. These are changes that are all familiar territory, where each month sees some further progress, but where a good deal more progress can be anticipated.

It is worth pausing at this point to see how we are going in comparison to other countries.

The recent Commonwealth Fund Report compares Canada, Australia, the United States, the United Kingdom, Germany and New Zealand.

This analysis is interesting because it’s a patient’s eye view of the respective health systems. Patients get to rank health care along various dimensions of quality including patient safety, effectiveness, patient centeredness, timeliness, efficiency, and equity.

In New Zealand’s case, the results are both reassuring and salutary. There are many things we can take pride in, and there are some things we need to work on.

It’s reassuring because the report ranks New Zealand second only to Germany on overall rankings – ahead of Canada, the UK, Australia, and the US.

In ten of the 38 criteria, New Zealand ranked first. And yet the overall per capita cost of our health system is lowest of the six countries.

Our strengths lie in our patient centeredness. On a whole raft of measures (7 of 15) New Zealand GPs and nurses come up trumps. That’s a pretty solid vote of confidence in you and the rest of our primary health care services.

We also do comparatively well in 'timeliness' – in getting appointments to see GPs (where we come first) and in getting care on nights and weekends (we come second), and in waiting times in emergency departments (where we also come second).

We do less well in ‘waiting time to see a specialist’ (third) and ‘waiting time for elective surgery’ where we are fourth. You will be aware of current Ministry activity in this area.

We do quite well in 'efficiency' – we are less likely than most to use an emergency department for conditions that could be treated by a regular doctor had he or she been available.

Where we do least well is in 'effectiveness'. This is the category that includes: preventive care; access to health care services; the care of the chronically ill; regular review of medications; the checking of medications on hospitalisation; and hospital care and co-ordination.

In both chronic care and hospital care and co-ordination we came sixth out of 6.

We did better in preventive care particularly in relation to women’s health – mammograms and cervical smears, but we didn’t do so well in the area of checking and monitoring diabetic and hypertensive patients. And too many New Zealanders didn’t fill their prescriptions, skipped recommended medical tests, treatments and follow up, or simply didn’t visit the doctor or clinic when they needed to. Cost was a significant factor, particularly for New Zealanders with incomes below the average.

If anyone needed evidence to support the case for more accessible and comprehensive primary health care, then this data on effectiveness from the Commonwealth Fund survey provides it.

I want to turn now to workforce issues. Some may have noticed that I have listed the health workforce as one of my priorities for the 06/07 year which is nearly upon us.

This is an area in which there has recently been a blizzard of studies and reports. HWAC has been active, the Royal College has released a series of studies, NZIER has released a report which is alarming until you study their assumptions, the DHB’s have been very active in their strategy development, the Ministry of Health has workforce plans aplenty, across the Tasman the ACC has been involved, and the Australian Productivity Commission has produced a doorstop.

Last summer I read these reports and have read the more recent ones since. My interest as Health Minister extends well beyond the medical workforce, there are tens of thousands of people working in unregulated home based support services for example, but today I will concentrate on the medical workforce.

There are two other reports that I particularly wish to concentrate on, both to do with the medical workforce, and both of which I am releasing today. One is the report of the Medical Reference Group of HWAC, and HWAC’s view of that report. The other is the Doctors in Training Roundtable reports.

These two reports have many areas of broad agreement. From them we can draw some useful statements. Here’s a list to give you a sense of the territory:

- There is probably a case to increase the number of New Zealand trained doctors
- The quality of medical training is good but graduate doctors are not as work-ready as they should be
- The apprenticeship system is important, and largely successful, but hospital systems of care have changed and the apprenticeship system needs to also change accordingly
- The length of training for a primary or secondary specialist is longer than it needs to be

- Graduate training in primary care must be improved
- On the issue of time based training versus competency based training we should shift somewhat towards the latter
- In government the linkages between the Ministry of Health and the Tertiary Education Commission must be strengthened, a lot
- There is difficulty in reaching consensus in the sector on much of the detail in these areas, but the general direction is largely agreed, and
- The season of study and advice is closing and it is now time to begin implementing some changes.

This last point, the need to move from advice to implementation, means that the work of the roundtable and the reference group is done and they have disestablished themselves. I owe them my thanks.

I shall migrate HWAC from an advisory to an action committee over the next few months with some continuity of membership and with some new appointments. We will need to change the terms of reference and the name as well. A working title is the Action Committee on Health Workforce. Its first job will be to develop the detail on how to streamline current medical education and clinical training arrangements to produce medical practitioners who are fit for purpose and for practice in the minimum time period, and to appraise the apprenticeship training model. You will see that I am seeking to build on the work of the two reports I have just released today, and to quicken the pace. I am contemplating a reporting period of 6 months from establishment.

This will work only if there is supportive leadership from the sector. We need to move from problem definition to progressive implementation of solutions. The authors of today’s two reports need the wider support of the sector and so do I. If you want a potted summary of recent history in medical training then you might want to reach for Ross Boswell’s latest NZMA article. It is a good, short read.

In addition to the work of this new action committee on health workforce the Ministry’s capacity needs to be both strengthened and better co-ordinated across the Directorates. Improving the health and education linkages at official's level has begun, but only begun. The Clinical Training Agency has some work in front of it including two areas I have not yet mentioned – a clinical training pilot for overseas trained doctors, and developing the role of medical officers.

The findings and suggestions from the Royal College of GPs surveys must be taken up and addressed. In addition DHBs are acting collectively and strategically across a range of workforce areas including the medical workforce. Finally, the New Zealand Medical Council has a number of ideas they intend to progress.

So medical training remains a busy and confusing space. But today’s two reports have offered both direction and impetus which I intend to deploy and which I hope will be supported by the sector. The status quo will not do.

Finally, I’d like to make some remarks about negotiations for this year’s roll-out. I have been in Geneva this past week but I doubt that all the claim and counterclaim around some of the detail will have been resolved in my absence so I thought I should comment.

Firstly, I would like to express my disappointment that not all issues are resolved yet. A lot of time has passed since I met with GP leaders in early March to discuss and table what the Government wanted for its $100m investment. I recall the meeting as a positive, honest and straightforward exchange.

This year’s red letter directly and clearly misrepresents the Government’s position in a number of ways, and has done so late in the piece meaning that some practitioners will be genuinely confused as to what is going on. That is risky, because the deadline is fast approaching.

Secondly, I would like to do the opposite and thank the parties for progress to date. Quite a lot of the detail is agreed. My thanks to Peter Foley in particular for his work.

Thirdly, I thought I would tell you, what the Government wants and what we don’t want, and I think its best that I limit my remarks to what appears to be the nub of the matter; the fees review process.

What the Government wants is certainty that the pass through of fees reductions, already agreed, is not amortised in the future by unreasonable fee increases.
The negotiations have been about establishing a mechanism to achieve that. One of the considerations was how to do that without creating transaction costs for small businesses, so that nearly all practices, in nearly all PHOs would be able to make annual adjustments without any process at all, except notification.

But recalcitrants exist, and I’d be happy to give you examples. The behaviour of some general practices is unreasonable. In my view these practices threaten the future of the Primary Health Care Strategy and I am intent on seeing it future- proofed. I do not want some future Health Minister winding the strategy back on the basis that some GPs have behaved badly and there isn’t a contractual mechanism to stop them. That’s nuts.

Hence a fees review process that can act if it has to. I understand that the proposal is for such a process to be independent of both contracting parties, PHOs and DHBs. Such a process is needed because the occasion will arise where an apparently unreasonable increase has an examination, a good basis. So that’s where I sit.
What the Government doesn’t seek and doesn’t need is fee capping and fee setting, and I don’t much enjoy that position being misrepresented by others. I understand the sector’s position on that well. I understand the seventy years of history surrounding it and I neither want nor need to challenge it.

One last thing, this is a two-way street. If the Government is determined to avoid unreasonable fee increases then we must continue to assure the sector that the capitation funding will not lose value. Not doing so would be unreasonable on our part which is why it too, is part of the negotiations - a part, which I understand, is already agreed.

Thank you for your attention.


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