Cullen: Christchurch School of Medicine
Hon Dr Michael Cullen
Deputy Prime Minister, Attorney-General, Minister of Finance, Minister for Tertiary Education, Leader of the House
21 July 2006 Speech Notes
Embargoed until: Friday 21 July 2006 at 12.30pm
Address to Christchurch School of Medicine & Health Sciences Mid-Winter Dialogue Series
Rolleston Lecture Theatre, 2 Riccarton Ave, Christchurch
Acting Dean, Professor Peter Joyce, faculty, students and friends of the Christchurch School of Medicine and Health Sciences.
I would like to thank you for the opportunity to take part in this mid-winder dialogue series.
Like most people with a PhD in the humanities, I occasionally have the interesting experience of being mistaken for a medical doctor. Luckily this does not usually involve someone seeking my advice on their bad back or being approached by cabin crew on an aeroplane to provide emergency treatment to someone who is having an angina attack.
Were that to happen I might ponder for the briefest of moments whether my academic training in history and mathematics might indeed be of some use in alleviating the suffering of the individual in question. Then I would politely explain that I am the wrong kind of doctor and that my advice would almost certainly do more harm than good.
In the last eight months this has changed somewhat. I now have a patient to treat; albeit only one. My patient is the tertiary education system, and I have to say the case is a rather challenging and subtle one.
It is challenging and subtle because there are no acute symptoms, so there is no imperative to rush the patient to A&E for heroic life-saving surgery; but there are nevertheless some clear indications of malaise that need to be correctly diagnosed and sensitively treated.
I have to point out that the patient is general healthy and productive, and in some regards very robust and energetic. In terms of physique the patient is well muscled, but is somewhat oddly proportioned and not very flexible. It is overweight in some parts, and curiously skinny in others.
Gross motor skills are generally very good, but fine motor skills have curious lapses, and result in uncoordinated movements that alarm family and friends.
Despite this the patient is fairly even tempered, but sometimes succumbs to bouts of anxiety and mild hypochondria. Family and colleagues describe a talented and insightful person, who alternates between being very constructive and focused and being oddly insensitive to their needs. In sports terms, the patient is, on a good day, the most brilliant individual on the field, but not always a good team player.
All this makes for a difficult diagnosis. Is the problem physiological or psychological? Can it be traced to some sort of nutritional deficiency? Is it a problem with one bodily system or several?
The treatment options are similarly difficult to sift through. Is it simply a matter of a change in diet and lifestyle? Or inserting needles into a few meridian points? Or a bit of surgery? Or a course of cognitive behavioural therapy?
This analogy will shortly start to run out of steam. However, as the consulting physician in this instance I think it is important that we take a principled approach. This means a number of things:
First, I do not want in any way to compromise what is by and large a healthy individual. The tertiary education system is absolutely central to New Zealand’s prosperity and to our prospects for ongoing economic growth and broader social development. There is a risk that, in trying to improve its output, we might inadvertently undermine it, and I want to avoid that at all costs.
Second, my aim is for the patient to thrive, not just to survive. The tertiary education system has enormous potential, and even at the margin improvements in its health are definitely worth pursuing. Allied to this is the importance of supporting the autonomy of the patient and not undermining it.
Thirdly, I am very aware of the inter-connectedness of different parts of the system. What is good for one part of the system may be bad for another. There are contra-indications and side effects that have to be taken into account, and it is important that we achieve balanced growth across the sector, rather than allowing one part to thrive at the expense of others.
Fourthly, it is essential that we recognise the family, lifestyle and social context in which this patient operates. The tertiary system is firmly embedded in the eco-system of the New Zealand economy (in particular the labour market and the research sector) and it is an integral part of many regional and local communities. There are many variables impacting upon its health, and we need to recognise that our efforts to improve the system may be aided or thwarted by what happens elsewhere.
Fifthly and finally, we need to accept that the treatment process is somewhat unsure and exploratory. With a system as complex and connected as this, we will inevitably learn by doing, and we should exercise a degree of caution in intervening too soon or too aggressively.
With these principles in mind, I have settled on a mix of therapies, all of them fairly mild; but my expectation is that their combined effect will be quite profound. I announced these in general outline earlier this year, and my officials have been undertaking a programme of consultation with the tertiary sector, so that I will be in a position shortly to make some more detailed announcements.
There are three main areas of focus. I want first of all to strengthen the quality systems across the tertiary sector. This involves getting better coordination between the internal quality assurance systems, such as peer review and moderation, which have long been a part of academic teaching and research, and the external systems administered by NZQA and peak bodies such as the NZ Vice-Chancellors’ Committee.
In some parts of the tertiary sector (although not, I believe, in medical and dental training) quality has been something of a taboo subject. It has been a bit like the famous adage about obscenity, that no one wants to define what it is, although we all claim we know it when we see it.
I believe we need a more disciplined approach to quality in the tertiary system. With few exceptions, I think we all agree that quality involves a better connection to the outside world, the careful use of international benchmarks, understanding and meeting the expectations of employers and students, and celebrating excellence in teaching and research. These are not concepts that should appear threatening to any institution.
The second focus involves improving the network of tertiary provision. More than a decade of laissez-faire in tertiary education has led to growth, but also to duplication and overlap, and the creation of gaps in provision that run counter to what students need to equip themselves for the modern workforce.
To return briefly to our therapeutic analogy, that means some occupational therapy to ensure better coordination between our various limbs, restoring old neural pathways and creating new ones if necessary.
There have been concerns that better coordination might be code for forced mergers. This is not the case. I do not discount the possibility that institutional changes can aid better coordination; but the change I am talking about happen at the level of individual faculty members seeing opportunities to provide more flexible learning options by pooling resources and strengthening pathways. In other words, what comes first is the desire to create more value.
The third area of focus is funding, and I want to speak at some length about this in relation to medical and dental training.
As I have said on many occasions, the EFTS system is failing us in some important ways, and needs some modification. It is, if you like, a hand to mouth system of tertiary sector nutrition in which funding is essentially based on enrolment volumes in each year. That has encouraged a kind of starvation response, in which institutions feel the need to maximise the current year’s enrolments, since there is no guarantee of a longer term revenue stream.
Whatever gains that may have generated in making institutions more ‘responsive’ have been countered by the fact that it tends to discourage long term planning. The impact of that is more obvious amongst smaller institutions, such as institutes of technology and polytechnics.
I have signalled that I want to move to a system of investing in plans. As part of the process of implementing charters and profiles, tertiary institutions have made good progress in the last five years in their ability to put together credible medium term plans. It is a relatively short step to turn a profile into the basis for a multi-year resourcing agreement.
Investing in a plan will require a more flexible set of resourcing tools that can accommodate, for example, capability building and investment in new technology such as online teaching and research tools. The changes in funding are a matter of changing the mix rather than abandoning all notion of funding individual student places. Since student numbers are a major driver of costs, it will still make sense to base a portion of tertiary funding on those numbers, although ideally we can focus more on the number who complete a course in a given year, rather than simply the number who sign up.
That is the context for the review of Student Component funding arrangements for medicine and dentistry, which I announced in February this year.
The review will examine the Student Component funding levels for pre-employment education and training. It will also recommend adjustments to the funding levels, if appropriate, to support high quality medicine and dentistry pre-employment education and training.
While it is acknowledged that student fees are an integral component of the overall revenue providers receive, it is not proposed to review the level of student fees.
The Tertiary Education Commission is leading the review and has just completed the consultation phase, which has seen many useful submissions from universities and other key stakeholders.
A number of key issues have been raised and need to be addressed. These include the need for curriculum development to meet changes in community needs driven, for example, by rural health issues, demographic changes and the trend towards community-based health delivery which is both preferred by most patients and enabled by new technologies.
Other issues include the need to upgrade facilities and equipment to maintain quality education, and the need to recruit and retain high quality teaching staff.
I cannot at this stage give any specific comments on how each of these issues will be addressed under the review. Nevertheless, what I will say is that the Medical and Dental degree programmes are very important in the context of the New Zealand tertiary education sector.
We need top quality graduates who are committed to pursuing medical and dental academic careers to significantly lift New Zealanders’ health and well-being. We need high quality and sustainable medical and dental teaching programmes.
And we need to recruit high quality international medical and dental academic staff. The government is determined to ensure that an academic career in either medicine or dentistry is a valued professional choice in New Zealand.
The review of the student component for medical and dental training is only one initiative currently under way. Indeed, it is fair to say that those parts of the tertiary system have some of the best linkages that exist between tertiary provision and industry. While there are issues to be resolved around the structure and form of post-graduate training and medical internship, the system facilitates the transition from study into the workforce in a way that other industries should envy.
Thus, for example, the training and funding, recruitment and retention and demographic changes to New Zealand’s health workforce are currently under the spotlight, in work being led by the Ministry of Health.
In April this year the Health Workforce Advisory Committee published a report that outlines future health workforce needs. Some aspects of the analysis are fairly straightforward, but there are complex shifts under way around how the global health labour market impacts upon New Zealand, and the precise mix of skills that our changing population needs to run an effective health service. It will be a significant task to align service delivery with those changing population needs and to coordinate the various strategies being pursued by central government and DHBs.
The Committee has also undertaken work that highlights the need for changes in the way in which doctors receive their clinical education and training. It recommends a coordinated approach between the health and education sectors. As a result, the Tertiary Education Commission is participating in a project to review alignment between the health and disability, and education sectors.
Another report, by the Doctors in Training Workforce Roundtable, highlights many of the same concerns as the Health Workforce Advisory Committee, namely that:
- We have a high level of overseas trained doctors, at around 35 per cent;
- There is a relatively low level of funding for health education here, compared with the UK;
- The current funding split between the TEC and the Clinical Training Agency is problematic, and
- There remains a considerable salary gap between university teaching staff and DHB-employed professionals.
Just last month, the Ministry of Health and the Royal College of GPs announced a joint review of GP training in New Zealand. This will look at the number of GPs needed in New Zealand to meet our future population demands.
While there may be some who take a jaundiced view of all of this activity, I think it is very heartening to see the amount of effort that is going into the ‘demand side’ of the market for health care skills in New Zealand. If those who plan health services and employ doctors, dentists, nurses and other health professionals can provide detailed projections of the type and volume of skills needed into the future, then institutions such as this one can invest with confidence in programmes that will deliver those skills.
Not only that, but they can invest in broader capabilities that involve tertiary institutions in developing new knowledge and expanding our international reputation for excellence. The Centres of Research Excellence are a good example of this, and one that the government is keen to promote and expand.
As you will know, the government created the Centres of Research Excellence Fund in 2001 to encourage world-class research in New Zealand. There are currently seven CoREs, hosted by Auckland, Massey, Victoria and Lincoln universities in partnership with other university research groups, Crown Research Institutes (CRIs), wānanga and private research groups.
The government is extremely heartened to see that overall, the centres are achieving what they set out to do. Each of the seven centres is now conducting groundbreaking research and they have the potential to become real players on the international stage.
In many instances, the research CoREs are doing also helps and supports the development of New Zealand industries, which, in return, has a positive effect on the economy.
The success of the CoREs so far has prompted us to have another funding round. This is open to existing CoREs and those interested in establishing new research centres.
As a result, a contestable selection round for funding after 2008 will be held later this year, and I am urging organisations to consider applying.
What these developments indicate is a definite shift towards more sophisticated funding mechanisms, based on a range of outcomes. It is important that tertiary providers understand that this shift is not simply a more sophisticated game of fiscal cat and mouse where the government changes the funding rules in order to prompt particular behavioural changes.
The purpose of the funding changes is to move to a more mature relationship between the government and the tertiary sector. That is a relationship in which we have an ongoing dialogue around the medium to long term skill needs of the economy, of the labour market, and of the community, and around how individual tertiary providers see themselves meeting those needs.
That includes how they design and undertake teaching programmes, and how they direct their own research. It includes how they invest in their own capacity, both in terms of staff and equipment. And it also includes how tertiary providers respond to the government’s own statements about important national goals and priorities.
What I am working towards is a tertiary sector in which institutions feel confident to play a leadership role in society, and play this role with a strong sense of accountability for the public funding that is invested in them. This is not something that will happen overnight, but I believe it is definitely within our grasp.