Tony Ryall - Speech to Annual Conference of ASMS
Hon Tony Ryall
Minister of Health
28 November 2013
Speech at the Association of Salaried Medical Specialists annual conference
Good afternoon. Thank you for the opportunity to speak with you at your annual conference this afternoon. This is my fifth time in six years.
My speech today is in four parts, and covers the major objectives of the Government’s health plan: helping families stay healthy, better performance, best use of every dollar, and a strong and trusted workforce.
Good health is hugely important to New Zealand families. A strong public health service gives families peace of mind – knowing that the care they need will be there, when they need it. And that’s the priority of our government too. Protecting and growing the public health service for New Zealand families.
And with your support, the public health service is making a lot of progress.
More patients are getting the treatment they need, sooner. Our district health boards (DHBs) are employing more doctors and nurses than ever before. And there’s a more effective focus on preventing illness.
We’ve moved resources from the back office to the frontline. There are fewer managers and administrators. We are harnessing the power of standardisation and bulk purchasing. And our hospital wards are becoming more productive and efficient.
Our country has come through the global financial crisis in much better shape than most other countries. OECD forecasts have New Zealand as the sixth fastest growing country in the developed world over the next few years.
That’s because of this government’s careful and prudent financial management. Our approach has been to protect the most vulnerable in our society, and rebuild the economy’s capacity to create jobs, higher incomes and security.
Providing better public services within constrained funding increases has been part of the economic reality. Despite the toughest of times, our government has invested on average an extra $500 million a year into the public health service. That’s without counting capital.
It is well known there are significant pressures on health budgets around the world.
The financial challenges faced by health ministers in general could not have been illustrated more clearly than the NZ news media over the past week.
Last week, nationwide television and newspapers reported calls for more money to go into elective surgery for older New Zealanders in particular as a priority. Two days later, nationwide television and newspapers reported calls for more money to go into children’s health as a priority.
As you know the big strategic challenges are demography, and finances.
There are more of us and we’re living longer. If the proportion of over 65s in today’s population is the same as is expected in 2025, then we would have to be spending $2 billion more on healthcare than we are now. The increasing prevalence of chronic disease will add to this, as will uneven population changes within districts.
Clearly, we need to progress health services upstream, closer to the patient. Our plan is a prudent strategy to develop health system capacity for the future pressures on the health system.
Our plan has four major objectives: helping families stay healthy, better performance, best use of every dollar, and a strong, trusted workforce.
Helping families stay healthy
The drive for patient-centred care globally is about moving services to care for people with chronic conditions closer to home. That involves primary care and supporting patients to play a more active role in their own healthcare.
So we’re encouraging integrated family health centres and clinical integration where primary care and hospital services and patients work together to provide the right care in the right place at the right time for patients.
It’s all about coordinated care which makes the patient’s journey through the health service as simple as possible.
This is why many of you will be engaged in alliance leadership teams, working with primary care clinicians to redesign care pathways, referral guidelines and the way services are delivered.
We’re also investing strongly in what we call our priorities for prevention. This is a real focus for our government. We know we have to treat people with current health problems, but we also have to engage in longer term approaches that offer some of our best opportunities to help families stay healthy.
We have created a turning point in the campaign against tobacco with more effective action than ever before on an unprecedented scale – annual tobacco excise increases, systematic screening and cessation support, the end of retail displays, and the inevitability of plain packaging.
National introduced the most significant public health initiative of the decade with the Warm Up NZ Heat Smart home insulation programme – $350 million for 235,000 homes. And as you know, warmer, drier homes bring health benefits particularly for those with respiratory conditions.
And this supports our world leading action to deal to New Zealand’s shamefully high rates of rheumatic fever. Despite becoming a national health priority in 2002, nothing happened other than rates of this disease increasing. Our goal is to cut prevalence by two thirds by June 2017.
We have also followed the advice of the Prime Minister’s Chief Science Advisor to focus more on maternal and new born nutrition as a key intervention in reducing unhealthy weight in the population.
We are rolling out a whole series of interventions that will give new mothers the skills to play a more active role in managing their own and their baby’s health. We’ll be announcing new investments in this area shortly.
And I will comment soon our diabetes and heart disease prevention work.
Building better public services is a key objective of this government. Because health is a fifth of government spending we have an important role to play here.
The six national health targets are an important way of getting better performance. These focus on areas that patients want improved. They are built on what families worry about. Three relate to disease prevention and health promotion, and three on access and waiting times.
The results have been immediate and remarkably successful. And they are improving quality. A lot of hard work by teams across the whole country has achieved this.
I’ve already talked about tobacco screening. Smoking is at record lows.
We are requiring better performance in immunising children – one of the most effective ways of preventing a lot of infectious diseases.
Six years ago the Māori immunisation rate was a shocking 59 per cent. The overall two year old immunisation rate has risen from 67 per cent five years ago to 93 per cent today across all socio-economic and ethnic groups.
In fact in over half our twenty DHBs, the Māori immunisation rate is now equal to or higher than the European immunisation rate.
As part of the Prime Minister’s drive for Better Public Services we are now aiming to have 95 per cent of all eight month olds fully immunised with the three primary series of vaccinations by 2014. We are currently at 91 per cent.
As I mentioned before, we are also targeting improvements in the detection and management of diabetes and heart disease and backing that up with improved access to Green Prescriptions, particularly for those with pre-diabetes.
The heart and diabetes check is really an entry point for a lot of people. In fact 880,000 people have been assessed in the past 5 years. This is a great opportunity to encourage people to make the lifestyle changes they need to live healthier lives.
The three hospital targets in particular focus on improving timeliness and the quality of care.
Quality is a major feature of the targets because getting care in a timely way means better patient outcomes.
Patients are getting elective surgery faster with procedures up 34% in five years. Delivery has increased from 118,000 in 2008 when we came in, to 158,000 patients treated last financial year. That is more patients, treated sooner.
Thank you to all of you who have been actively involved in the huge effort to improve the efficiency of elective services – from new care pathways, to lean thinking, to productive wards, productive operating theatres, smarter post-discharge planning, clinicians have led the way.
So too have they led improving cancer radiation and chemotherapy waiting times now at the world gold standard. Our government has approved ten new linear accelerators over the past five years.
And hospitals are providing emergency care sooner than ever before. This is really a whole of hospital flow target.
There’s been an amazing effort across the country as doctors, nurses and managers have worked together to try new ways to improve the service they provide patients.
Our focus on performance is matched by our determination to work with clinicians to improve the quality of health services.
In May this year, we launched the Health Quality and Safety Commission’s Open for Better Care patient safety campaign.
Open for Better Care challenges health care workers to be open to acknowledging mistakes and learning from them, open to working closely with patients and consumers, and open to change, improvement and innovation.
The campaign focuses on four key areas where evidence shows it is possible to reduce patient harm – falls, healthcare associated infections, surgery and medication errors. What we’ve learned through the success of the national health targets is you need fewer, higher profile, higher impact objectives.
Open for Better Care’s first area of priority has been to address harm from falls in care settings with a focus on older people. The natural priority has been on public hospital settings. The focus will spread to aged residential care and wider community settings as the programme develops. Key interventions highlighted through the campaign have been on risk assessment and care planning.
The Commission has also had significant early success with its programme to prevent bloodstream infections from inserting central line catheters. The programme has seen the national infection rate fall from 3.32 to 0.88 per 1000 line days. Patients are benefiting from fewer infections and reduced complications, pain and suffering. They are also spending less time in hospital.
There have also been encouraging signs from the Commission’s hand hygiene campaign, which has seen an increase in the national hand hygiene compliance rate from 62.1 per cent to 70.5 per cent over the past year.
In October, the focus of Open for Better Care shifted to include preventing surgical site infections. This is a key patient safety priority in New Zealand.
I congratulate all of you who have been so active in supporting these clinically led initiatives that contribute to safer and better performance in our health service.
Best Use of Every Dollar
The government has continued to invest strongly in the public health service – an average $500 million extra each year. Vote Health is now $14.7 billion.
To better deal with the growing financial demands of the public health service, a lot of effort is going into getting best value from every dollar. And we have had a particular focus on non-clinical and administrative costs.
The Ministry of Health by way of example has reduced from over 1600 positions in 2008/09 to under 1200 today.
The Ministerial Review Group recommended that DHBs should work collectively to harness the power of standardisation and bulk purchasing to free up savings. Savings that can be reinvested back into improving frontline services for patients.
So right across the health service on a district, sub-regional, regional and national basis, teams are working be more efficient and contribute to our financial sustainability.
Part of that is the shared service agency Health Benefits Limited. HBL is working across the health service to support and lead a number of key initiatives. HBL has a Clinical Council which provides direct input and advice on these initiatives.
For example DHBs are collectively gaining $4 million a year from lower bank fees and higher interest payments as a result of moving to one bank nationally.
And for the 2013/14 financial year the estimated savings from DHBs working together to secure insurance cover is $6.6 million. These things add up.
There are a number of high profile initiatives they are consulting on including food service and laundry services.
Currently they are working on a Finance Procurement and Supply Chain programme. This is essentially about standardising the way DHBs purchase supplies, so that we can capture the best discounts and rebates on bulk purchasing.
A strong, trusted workforce
It is this Government's firm belief that strong clinical leadership is essential to improving our public health service. There are very clear links between clinical leadership, morale, quality and efficiency.
Globally, clinical leadership is recognised as the fundamental driver of improved patient outcomes. We want to use the wealth of frontline experience nurses and doctors have accumulated to improve quality of care and rebuild confidence in the public health system.
The Clinical Governance Assessment project undertaken by Robin Gauld last year provided us with assurance we are making progress but I acknowledge there’s more to do in promoting clinical governance and leadership.
The report found all DHBs have worked to proactively promote and provide an environment for clinical leadership. The survey finds that 78 per cent of respondents believed that the DHB worked to enable strong clinical leadership throughout the organisation.
This is a very positive indication of the encouragement provided within DHBs for clinicians to contribute.
Additionally, 71 per cent of respondents felt that health professionals in their DHBs were involved with management in shared decision making, responsibility and accountability to some extent.
I think this is perhaps the best indication that most DHBs are effectively supporting and implementing clinical leadership.
We’ve invested strongly in growing our health workforce.
A few days ago the Medical Council’s workforce survey was released. Among their results, the medical workforce has grown by 1700 since 2008. Over 1100 were house officers, registrars or specialists. This is a very similar number to the DHB workforce count report we released at the time.
This leads to a major challenge we face together over the next five years.
You’ll be aware that in 2008 the National Party undertook to increase the number of funded medical school places from 365 to 565 over two terms. So far we have funded 140 of these.
At the same time New Zealand was the world’s biggest exporter and importer of doctors. It was also estimated that around a third of our medical graduates departed for Australia and elsewhere upon graduation.
As has happened in Australia, Canada and elsewhere, this movement of medical graduates…and for that matter senior doctors… has slowed right down.
As an aside, a recent report by the Royal College of Physicians and Surgeons of Canada reports 16 per cent of new specialist and subspecialist physicians there cannot find work and a further 31 per cent are pursuing further training to become more employable.
As has happened in Australia, the pipeline that medical graduates follow to become senior medical officers has slowed down. Because vacancies and turnover are down, there are fewer available places for those who have been working as house officers for the past two to four years. This means there’s fewer places for new graduates to move into.
This year we have placed all 377 New Zealander medical graduates in our public health service, thanks to the willingness of our provincial hospitals to find more places for these young people.
Next year we expect around 410 graduates, and the next year 442.
We have been expecting this wave of new medical graduates. And we are planning for that now.
However, this will mean goodwill on all sides as our public hospitals – and our specialist doctors who teach these new graduates – gear up to accommodate these extra numbers.
Thank you for the invitation to speak with you today.
Earlier this morning I read your new President’s first conference speech in that role. Dr Stander conveyed a real commitment and compassion for patients and their families. And after all, the purpose of what we’re all doing is to improve the health of families and communities.
It has been an exciting 5 years, dealing with a lot of challenges, moving our public health service onto a better path.
There always have been, and always will be, some aspects of our complex health service that you might have a differing view on. This is health and everyone has an opinion!
As a whole though, our public health service is making a lot of progress for families and patients.
Over the coming months, the Government will be setting out its agenda in health for the next three years, if we have the privilege of being re-elected.
That agenda will continue protecting and growing our public health service, and putting families’ priorities at the heart of everything we do.