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King Speech: Priorities in Health Care

Annette King Speech: Fifth International Conference on Priorities in Health Care

Welcome to Wellington, New Zealand, and to the Fifth International Conference on Priorities in Health Care.

This is the first time this important conference has been held outside Europe. New Zealand is honoured to be the host this time following Sweden in 1996, England in 1998, the Netherlands in 2000, and Norway in 2002.

I know many of you have attended some or all four previous meetings in the series, and I hope this meeting lives up to both your expectations and previous experiences.

I would imagine many Health Ministers around the world share my conviction that a health minister’s main role should be to focus on significant health priorities rather than to be involved in the day-to-day running of a health system.

In the real world, however, there are always events and demands that distract attention. That is why it is so important to use opportunities like this to look at the bigger picture.

This conference certainly provides an ideal environment in which to do just that. There are some 375 participants here from 34 countries --- policy makers, health planners and health funders, service providers, consumers, researchers, health economists and ethicists.

Between you, you represent the entirety of a health service. You represent exactly the mix of experience and expertise needed to debate the range of health care priorities we face around the world.

I will spend most of my time today discussing some of New Zealand’s priorities in health care, and the approach the Government is taking toward establishing and meeting them, but I would like first to remain in the international context for a few moments. I have now had the privilege of being Health Minister for almost five years, and I know, from various international forums I have attended, that five years is far longer in the portfolio than many ministers spend.

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I am not quite sure why that should be so. Certainly health is often a stressful portfolio, but it is also one of the most satisfying. There is surely nothing more rewarding than seeing policies starting to make a difference to the health of people in your own communities.

And if that is so as New Zealand Health Minister, it must be even more so as Health Minister in a country like China, with its vast population.

That reality was put in sharp perspective for me at the World Health Organisation’s Western Pacific Regional Office Committee Meeting in Shanghai in September, when the regional director, Dr Shigeru Omi, discussed Chinese life expectancy.

He said that since 1979 life expectancy in China had increased from 64 to 70 years, and that in the past decade the maternal mortality rate had dropped from 89 to 53 per 100,000 live births. As he said, such advances in a country as big as China made a great difference not only to regional health statistics, but also to global statistics.

The message that has been reinforced for me most strongly at international health forums, like the World Health Assembly, WPRO, the Commonwealth Fund, OECD health ministers, and other more regionally focused meetings, is just how significant global health leadership is, particularly in public health issues.

There is a popular New Zealand song based around the theme of “we don’t know how lucky we are”. I won’t sing it for you, but when I look back on the past five years at some issues nations have grappled with at international forums, there is more than a little truth in the lyrics.

In terms of leadership, the WHO has the daunting task of moulding an international will to cope with sometimes almost overwhelming global priorities and problems like HIV/AIDS, malaria and Tb, the spread of communicable diseases and the increasing prevalence of non-communicable diseases, the availability and cost of pharmaceuticals, tobacco control, poor diet and nutrition and declining physical activity.

Such problems only exist on a comparatively micro scale in New Zealand, but that does not lessen our responsibility to play as full a part as we can in international initiatives and solutions.

New Zealand is one of those countries where many health problems are non-communicable diseases associated with lifestyle, and we can do something about them. Many countries do not have the same luxury, but one thing you learn quickly from working in an international context, is that if countries do not work with each other, then health problems spread across so-called borders very quickly indeed.

HIV/AIDS provides a continuing and chilling reminder of this. Last year SARS provided a frightening global threat, and avian influenza is now providing one of potentially even more alarming significance.

If there is one compelling priority in international health care, it is for countries to trust each other, to work together, and to find solutions together. New Zealand is committed to this, and the participation here of so many countries is certainly heartening proof of an international will to use our energies and resources in the best ways possible.

In the New Zealand context, the Government committed itself very soon after taking office in December 1999 to use its finite resources in the most strategic way it could to deliver more effective, affordable and accessible health services to New Zealanders. In a sense, the Government’s first health priority was priority setting itself. When that occurred, after just a year in office, with the launch of a comprehensive New Zealand Health Strategy, developed with input from the Health Ministry, a sector reference group, an expert advisory group and public consultation, we could get on with the business of putting the strategy’s priorities into action. Having to set priorities in health is inevitable. I doubt if there is a Health Minister or Government anywhere who doesn’t face choices every day. There are always new programmes or treatments that could be funded, but there is no such thing, even in a relatively wealthy country like New Zealand, as limitless funding.

The scenario for the debate later this morning raises one such choice, but almost daily there are choices to make, some more wide-ranging than others, but all of them significant to the people most affected. In New Zealand health funding has increased by almost 50 percent under this Government, and now accounts for one dollar in every five of public spending. Funding had to increase because we weren’t even spending enough to sustain, let alone improve, our public health system. But it also had to increase to cope with a complex range of factors, including new technologies and treatments, an ageing population, and the time people now live with chronic conditions.

New developments open up possibilities for treatment or care we simply could not have envisaged even 20 years ago, but no matter how exciting the opportunities, financial constraints are always a reality. The decisions governments make must be fair, and I strongly believe that to be fair they must be based on a strategic approach and they must be based on evidence.

Evidence is essential to developing priorities, and in that respect I want to acknowledge the enormous contribution in New Zealand made by the National Health Committee and the New Zealand Guidelines Group, both of whom are sponsors of this meeting.

The National Health Committee has been working since 1992 to develop evidence-based advice to inform government decisions on those health services that are a priority for public funding. I have found its work extremely helpful in my role as Minister, and the committee also has much credibility within the wider health sector. I also welcome the work of the Guidelines Group, a network of health service providers and researchers developing the best evidence for effective treatments or health services. The Group grew out of a National Health Committee initiative and is led by health professionals and consumers in the health sector for the benefit of the sector. I was very pleased to speak at a meeting hosted by the Group this week.

The setting of key priorities in the New Zealand Health Strategy has occurred within an overall population approach to improving health outcomes. Nowhere is that more evident than in our approach to primary health care, the priority I will spend most time on today as it most closely reflects what we are trying to achieve with the New Zealand public health system.

Naturally, there can be no discussion about primary health care without talking about other priorities, such as tackling the root causes of chronic diseases. I also want to briefly describe New Zealand’s transparent system for elective services, and lastly, but certainly not least, to talk about a new initiative to reduce the incidence and impact of cancer. In all these areas, New Zealand is taking an approach based squarely on what we perceive to be the country’s most important health priorities.

Last week I attended the Commonwealth Fund meeting in Washington, and was encouraged by the Fund’s 2004 International Health Policy Survey on primary health care. It indicated New Zealand is going down the right track in its determination to make primary health care more affordable and accessible for all New Zealanders.

The survey also re-emphasised for me just what a real problem New Zealand might be starting to face now if the Government had not made a commitment to investing heavily into primary health care.

It was clear to me very early on as Health Minister that many tens of thousands of New Zealanders were not getting access to the primary health care they needed. If the Government was to be serious about principles like early intervention, a desire to prevent illness, and reducing complexity of need and the development of chronic conditions, then we had somehow to ensure more affordable access.

In 2001 the Government set up a broadly-representative sector group to look at the existing targeting regime for primary health care. It concluded that the existing regime was not working well, that many high need groups were missing out on care, and that the ultimate goal should be a universal approach with low-cost access for everyone.

The Government had no difficulty at all with that conclusion. That was the first step. Our second decision was to secure initial and then long-term funding to implement the changes, with initial funding targeted at highest-need populations. This decision fitted well within the overall strategic population health approach the Government was taking to improve health outcomes.

The Government agreed that funding would be applied first to achieve low cost access through new groupings of health professionals called Primary Health Organisations, or PHOs, that served populations with the highest need. We set a threshold of having at least 50 per cent of enrolees living in areas of high deprivation, as measured by the New Zealand Deprivation Index, or being Maori or Pacific.

These PHOs qualified for funding sufficient to provide low cost access to consultations and most prescriptions for all enrolees. The Government’s priority was to improve access quickly for those with the poorest health status and the biggest potential for health gain.

That was only the starting point, however, and since the first two PHOs set up in July 2002, we have been encouraging others to set up right around the country. The rapidity with which they have done so has surprised even me. There are now 77 PHOs, with some 90 per cent of New Zealanders enrolled in them.

As well, in keeping with the high priority we attach to making more affordable primary health care available to everyone, we have already been able to lower the cost of access in all PHOs for young people up to 18 and for people aged 65 and over. In July 2005 we will add young people aged 18-24, followed by people aged 45-64 in July 2006, and the rest of the population in July 2007. The rollout is happening up to five years faster than I originally thought possible. By July 2007 I confidently predict almost all New Zealanders will be enrolled in PHOs, and in the first six years of implementing the strategy the Government will have invested a cumulative $1.7 billion in making primary health care more accessible and affordable.

I am very proud of the way we have tackled this priority, and, as I said, the Commonwealth Fund’s survey reinforces how essential it was that New Zealand faced the emerging health inequities in this country head-on.

I also said earlier that evidence is an essential factor in determining priorities. The evidence in New Zealand concerning the health needs of people living in regions of high deprivation, and Maori and Pacific people, is stark.

These groups have the poorest health status in New Zealand. For example, Mäori and Pacific people have higher than average rates of avoidable mortality (twice as high as other New Zealanders), morbidity (such as diabetes and heart disease) and avoidable hospital admissions. Mäori and Pacific people are more likely to present later, and to be at a more advanced stage of illness when diagnosed.

Maori on average die younger than European New Zealanders, but the even grimmer reality is that Maori can expect to die earlier than European New Zealanders with similar levels of socio-economic deprivation. A well-off Maori male will die much earlier than his European friend who earns the same amount and lives next door; while across the tracks in the poorest area of town the disparity is even greater between Maori and European neighbours. I believe most New Zealanders are open-minded enough to understand that we must tackle such health disparities for the sake not only of individuals, but for the sake of wider society as well.

Primary health care has a key part to play in preventing and managing chronic disease, and this is particularly important in New Zealand where diabetes and cardiovascular disease are major causes of morbidity and premature death.

It will take some time before we can really see the impact of our policies, but we must ensure adequate data is collected so that we can accurately measure progress.

An independent evaluation strategy has been developed to enable this. It will include reporting on a wide range of measures, including an analysis of fees, the types of services available, the success of programmes designed to improve access, clinical performance, and the impact of PHOs on specific health status indicators.

The more reliable evidence we can collect, the more confidence we can have that we are on the right track to making New Zealand a healthier place in which to live.

Before I finish today by discussing cancer, I want to talk briefly about our transparent system for elective services, because I believe that provides a good example of prioritising within available resources.

Instead of running waiting lists, we focus on waiting times and booking systems. The fundamental principles of our electives strategy are clarity, timeliness and fairness. Clarity means that patients know if they will receive publicly funded services or not; timeliness means that where services can be delivered within the available capacity, patients receive them in a timely manner; and fairness means ensuring available resources are directed to those most in need.

New Zealand is one of the few countries to explicitly acknowledge the need to prioritise resources in delivering elective services. Being honest with patients and their GPs ensures that, where feasible, all options for treatment are considered. Providing clarity to GPs also allows them to discuss expectations honestly with patients.

Our expectation is that all patients taken into the booking system are either treated or clinically assessed within six months. Publication of national data on a public website on a monthly basis allows people to assess the performance of their local providers.

We do not promise what we cannot afford to deliver, and the establishment of consistent assessment criteria is giving greater consistency and fairness to decisions about access to services. Naturally, there is ongoing clinical debate around the validity and reliability of the criteria, but information suggests that on the whole patients are being treated in priority order.

A Continuous Quality Improvement approach has also been introduced in two specialties, Cardiology / Cardiac Surgery and Orthopaedics. The approach is led by clinicians and will result in a refinement of the tools they use to assign priority.

The development of evidence on access is supporting my decisions on funding services. It also allows me to make a case to Cabinet for new funding, such as our decision this year to double the number of major hip and knee operations we do each year. We will reach that target in four years. This initiative was based on the collection of good data, allowing a comparison of our intervention rates with overseas rates. It is also premised on the ageing of the population and therefore on the increasing need for such interventions.

We are now using a similar process in terms of cataract operations, looking at disparities in access, the level of unmet need, the impact on people of having to wait, and workforce issues, though it is still too early to discuss the outcome of this project.

Finally, as promised, I want to discuss the strategic approach New Zealand is taking to reducing the incidence and impact of cancer, including a new initiative I announced today that is the next step in cancer control.

Cancer is a leading cause of death in New Zealand, accounting for 29 per cent of deaths. Some 16,000 New Zealanders develop cancer each year and around 7500 people die of cancer each year. Cancer incidence is expected to increase in the next 10 years, although mortality rates are expected to decline.

In August last year I launched the Cancer Control Strategy, and a month later announced members of the Cancer Control Taskforce, consisting of experts across the cancer sector and NGOs, including the Cancer Society, who are charged with reducing the burden from cancer in this country.

We are working across so many areas, such as treatment, screening, workforce training, smokefree environments and legislation, that it has become ever more essential to focus on our overall priority, and that is why I have been pleased today to announce a new structure for cancer control so that we can continue to make progress on implementing the Cancer Control Strategy.

I intend, following a recommendation from the Taskforce, to establish an independent Cancer Control Council that will provide an annual report to Parliament. The Minister of Health will appoint members of the council, whose key tasks will be to provide leadership in cancer control, to monitor and review implementation of the Cancer Control Strategy and to foster collaboration and co-ordination in cancer management. The council will provide a sustainable focus on cancer control. It will be supported by a secretariat, of a size and skill mix that allows it to develop and deliver a work programme. The secretariat is likely to be comparable in size to the National Health Committee secretariat, to be employed by the Ministry of Health, and could include members on secondment from other agencies. A position of Principal Advisor Cancer Control will be established in the Ministry to drive implementation of the strategy, and to foster collaboration and co-operation. The Principal Advisor Cancer Control will report to the Minister of Health on cancer control issues, will attend council meetings to report on progress with implementation, and will help coordinate the work of the council, the ministry and the wider sector. Collaboration will be a key to fostering links between regional and national participants in cancer control activity. When the council is established shortly, one of its early tasks will be to set up a Cancer Control Collaborative, with the aim of identifying groups and activities around the country contributing to cancer control, and fostering collaboration between them. The Taskforce’s action plan for implementing the Cancer Control Strategy will be completed by December 20. I certainly hope this initiative I announced today will help us make great progress in achieving another of our key priorities. Thank you very much for listening to me today, and for taking part in such an important conference. Earlier today, I discussed the compelling international priority of countries working together, trusting each other and finding solutions together. In closing, I want to reiterate the importance of that priority, but I also want to reinforce another message that I believe is essential if we are to bring about lasting improvements in health in a country like New Zealand. That message is that ‘governments can’t do it alone’. The Government can fund more and better services, it can seek to make services more accessible, but in the long run improvements depend equally as much on changes in personal behaviour, particularly in terms of the impact of lifestyles on non-communicable diseases, and on our health professionals and providers working together on common goals.

I wish you all the best for the remainder of the conference, and look forward to joining you again later today for the facilitated discussion.

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