Annual Emergency Medicine Conference
Hon Tony Ryall
Minister of Health
24 October 2013 Speech Notes
Annual Emergency Medicine Conference
Thank you for the welcome and thank you to Dr John Vargo for that interesting and thought provoking keynote address which has helped set the scene for this conference: Resilient People - Resilient Teams.
This is the sixth time I have been invited to this conference. It is a privilege to be back and to hear your thoughts about how to make emergency department (ED) management better and more sustainable.
This morning I am going to touch on the wider context in which the public health service is operating, the six hour shorter stays in ED target and the huge amount of work going into improving the quality of health services.
Like virtually all other health systems around the globe, we are facing three major challenges – the first financial, the second demographic, and the third patient expectations.
When we came to office at the height of the global financial crisis, the government inherited a decade of deficits. The 10 years before had seen massive increases in government tax revenues matched by equally significant increases in public spending. In fact, the health budget doubled in nine years!
Yet fewer people got operations, patients waited longer, key health services struggled for staff, and the bureaucracy ballooned. It was a time of wasteful spending, endless bureaucracy and a lack of clinical engagement.
Because health is a fifth of all government spending, we’ve had to focus on getting better value from our existing investment and the slower growth in additional health funding. Unlike some health systems NZ has enjoyed regular but more constrained funding increases.
Our government has invested an average $500 million a year in additional funding into health. The increase in health funding for 2014/15 will be very similar to this year's increase, so district health boards (DHBs) will need to continue focusing on getting more from every dollar. There is still a lot of scope to move resources from the back office to the frontline.
Our second challenge is demographic. Beside the ageing population, the other major dynamic is population movement and growth. A third of DHBs have growing populations, a third have stable populations and a third have long term declining populations.
Which means in some parts of the country DHBs work hard to provide more and more service to more and more people, yet others have to manage sustaining safe and viable services for a long term declining number of people.
Thirdly, the public have high expectations of our public health service. New technology, new medicines, faster access, smarter prevention, safer care – the public expects this. And why shouldn't they? When taxpayers are investing $14.5 billion in our health system, they are entitled to have their priorities reflected in the services provided.
And it is the public and patients who inform the government's objectives in health care.
Our objectives are built around better, sooner, more convenient care with all the elements that suggests of quality, timeliness and patients at the centre of care. And this makes sense.
We are living longer, more sedentary lives. This means more of us have chronic disease like diabetes, asthma, dementia and cancer. The sooner doctors and nurses can detect, treat or prevent these conditions, the better they can reduce the significant burden these conditions put on patients and the health system.
Our strategy to do this is clinical integration – providing joined-up care across primary and secondary services. With resources and interventions flowing to where they are most effective. So patients get their care sooner and closer to home.
A huge amount of work is happening around the country as community and hospital clinicians work together to redesign how and where care is provided. Clearly if more care can be provided upstream...in the community rather than hospitals...then that contributes to better health for the patient and the overall financial health of the system.
Reinforcing this strategy is our work of building primary care capacity through integrated family health centres, clinical networks and the three preventive national health targets.
The government is making huge progress with its priorities in prevention. We have created a turning point in the battle against tobacco, the world first campaign against rheumatic fever is rolling out, child immunisation is at levels undreamed of six years ago, and we have insulated hundreds of thousands of homes.
Emergency department target
A lot has changed in six years. Six years ago, there was a great deal of concern around the country about overcrowding in emergency departments. The newspapers were full of stories about people languishing in ED corridors for hours on end. Everyone, patients and staff alike, were all too often finding emergency departments a stressful place to be.
Emergency departments are still a place of urgency and at times, stress. But across the country they are vastly improved thanks to the hard work of all of you and your colleagues.
In fact the whole media approach to EDs has changed...and so has the threshold for news value. The success of the Shorter Stays target has really moved the goal posts. Earlier this year a newspaper ran a major story on a patient who waited seven hours in the local ED! Six years ago that would have been a shorter stay at that hospital.
As you all know, much of this improvement has been brought about by the Shorter Stays in ED target, which was introduced by this Government in July 2009 - and has focused attention on improving acute services. The target is for 95 per cent of patients to be admitted, discharged or transferred within six hours.
It’s probably fair to say that the target was initially a bit of a struggle. Several of the larger DHBs were struggling to deal with even 70 per cent of their patients in that time.
The latest health target results show nationally over 93 per cent of patients are being admitted, discharged or transferred within six hours.
In 2009/10 only six DHBs were meeting the target, and now twelve DHBs are.
The target was introduced on
the advice of clinicians who raised concerns that:
• long stays in EDs are linked to overcrowding which can lead to compromised standards of privacy and dignity for patients, for instance, through the use of corridor trolleys to house patients
• medical and nursing literature has linked both long stays and overcrowding in EDs to negative clinical outcomes for patients such as increased mortality and longer inpatient lengths of stay
• EDs are designed to provide acute health care; the timeliness of treatment delivery (and any time spent waiting) is by definition important for patients.
The target does not only reflect how well the hospitals acute care system is working, it is also barometer of how well the entire hospital is functioning.
There is a lot of work still to be done before the improvements made across the system are sustainable and locked in. And I know that pressures to achieve and maintain targets can be a real struggle especially with winter pressures.
But I would like to note that many countries have difficulties with their ED length of stay targets and New Zealand is doing remarkably well.
Many of you have achieved these excellent results despite increasing demand on Emergency Departments. Figures show that the numbers of presentations to Emergency Departments have grown from 908,000 in 2009/10 to 975,000 last financial year.
The findings from the recently published ‘ED use at public hospitals’ report from the New Zealand Health Survey which reflected patient views on their waits in ED were also encouraging. While this is a different measure to the health target, the survey found that two out of three people reported waiting less than one hour to be treated in the emergency department.
The survey findings also found that eight out of ten adults rated the quality of care they received from the ED as good or very good.
Open for better care
Every clinician, every health service, should want to provide patients with a quality service. One built on high standards and respect for patients.
That is why this Government established the independent Health Quality and Safety Commission.
This clinically led organisation – in the words of its chair Professor Alan Merry – is responsible for assisting providers across the whole health and disability sector, public and private, to improve service safety and quality and therefore outcomes for all who use these services in New Zealand.
Patients need health professionals to use their expertise to maintain and improve quality and safety, and assure safe practice within their autonomous practice but also their wider workplace.
This matters because clinical professionalism underpins the trust the public has in the health service and the people who work in it.
We also need a culture that welcomes all members of the clinical team to play their part – without fear of repercussion.
The Health and Disability Commissioner Anthony Hill is increasingly saying in his speeches and reports that patient safety is being affected by members of the health care team who know that something is not right but do not speak up.
He has advised me that in many complaint cases someone in the health care team knew something could have prevented harm but did not share that.
It is timely for people to reflect on Commissioner Hill’s concerns and recognise that speaking up is a professional responsibility and should be recognised as such by those who are being spoken to.
I do urge you to learn about the Commission’s “Open for Better Care” campaign which seeks to engage clinicians in improving care for individuals, for populations and for the community.
DHBs throughout New Zealand are signing up to “Open for Better Care” as part of their commitment to continually improving the quality of care in our public health service.
I say often that Minister of Health is the best job in government – I get to work with quality people who have dedication, and a commitment to improve the lives of others.
The improvements over the past four years have been challenging and demanding for all of you and I’d like to thank you again for the work you do.