Speech to the Association of Private Surgical Hospitals
23 March 2012 SPEECH
Speech to the Association of Private Surgical Hospitals
Thank you for the invitation to address your conference today. It is a pleasure to be here.
I spent some time thinking about what I might say to you which might be of any interest at all. After all, it is customary to be pleasantly polite but quietly dismissive of Opposition Spokespersons at this stage in the electoral cycle. It is only in year three in the cycle that Opposition spokespersons start attracting attention, and then, only if there is a remote possibility that they might have to be listened to the following year. But it is my hope that this will not be the last of our conversations over the next three years.
First, just to lay some of the predictable bugbears to rest, can I say that the Labour Party recognises clearly the role that surgeons in private practice contribute to the ongoing health and wellbeing of New Zealanders.
That is not in question.
There will always be mixed public and private health care provision in New Zealand. I believe, as your organisation does, in a balanced healthcare system for all New Zealanders. I believe, as you do, in the public and private sectors working cooperatively and collaboratively together. The private sector currently provides a full range of elective surgery including complex Neurosurgery and Cardiothoracic Surgery and in 2010-11 completed approximately 149,000 procedures.
The public sector has needed to contract services from private providers in the past and I anticipate that need is likely to continue. That is one way in which the private sector can benefit the public sector. This is not simply the obvious orthopaedic procedures which are so celebrated, but more recently radiotherapy in Auckland where at least three linear accelerators in private hospitals in Auckland are working well and those hospitals are contracting with DHBs to provide better service for Aucklanders.
One of ways in which public benefits private is in providing advanced training and collegial professional development which can reinvigorate private practice through exposure to more complex and ultimately, interesting, procedures in the public sector. I hope none of the orthopaedic surgeons here do operations on hips and knees blindfolded, but I am sure many think they could, given the numbers which are being done routinely every day of the week. Extra capacity in this area in recent years has seen the DHBs scale up enormously, but still, there is need for demand to be met by working in concert with private hospitals.
I must say, however, that I share the concerns expressed recently in the NZ Herald by Tim Parke, Clinical Director at the Adult Emergency Department at Auckland City Hospital. He warned of a tipping point, when a burgeoning private sector might have sucked out sufficient staff, patients, public support, money and morale from public hospitals to compromise outcomes in those public hospitals. As far as I am concerned, the public system is not just the place you go when you can’t afford to “go private” as they say. It is the part of the system which is geared for all comers of all complexities and it should be resourced to remain the dominant provider of acute healthcare for all.
So yes – I believe in a balanced healthcare system for all New Zealanders. We may disagree on where the fulcrum in that balance lies. I will only find that out if I engage with you, which is what I am doing today.
Having dispelled any lurking anxiety you might have had about the Labour Party's intentions for the private health sector (or not!), let me move on to the things which I really wanted to say and which hopefully, might have some passing interest for you.
It seems to me, after even just a short time in the Health shadow portfolio, that there are two compelling imperatives facing our health system. The first is the need for a focus on prevention and early intervention, which I will expand on in a moment, and the second is the much talked about but not yet clearly planned for or mapped out phenomenon of an ageing population.
It is self-evident that a dollar spent in prevention saves many dollars further down the line in expensive interventions Not only is it self-evident, but it is also the subject of research.
I am firmly of the view that we need to be spending more effort and expenditure front-end loading the health system. If we spent more on prevention by investing in public health, health education and promotion, and early intervention, both in the life of an illness and chronologically in the life of a person, we would reap benefits in the long term.
It is difficult to move to that emphasis while we are trapped in the kind of “short termism” which has beset consecutive governments. Measuring easily and quickly measurable “outputs” does little to monitor the effectiveness of our efforts at curing and preventing illness and improving New Zealanders’ wellbeing over time.
I am of the view that the two major political parties should be able to agree, on the basis of evidence, exactly what the major health challenges to New Zealanders are. Then we should agree that these challenges remain priorities until they are no longer major threats. That would require an agreement to look at the long term, not the short term, and outcomes, rather than outputs. Insisting that DHBs deliver increasing numbers of elective surgical procedures for example is a worthy goal, but it shifts resources away from prevention and treatment of chronic illnesses which kill the greatest number of New Zealanders.
The fact that the waiting list for a hip operation at Counties Manukau DHB is two to three months, is a tribute to their ability to meet output goals dictated by the Minister of Health.
We know what the top four non-communicable diseases are: cardiovascular diseases, diabetes, respiratory illnesses and cancers. There is sufficient epidemiological research to give us a very sound evidence base for asserting those as the four biggest killers. These non-communicable diseases make up 80% of the disease burden for the total population and are largely preventable. The main risk factors are smoking, diet, physical inactivity and harmful use of alcohol. But where is the political will to attack these things head on over the long term?
We politicians get subverted by a three year electoral cycle and the need to campaign on things which attract attention. Elective surgery – hips and knees – attracts attention. And then we deliver, which both parties have in recent years. But would it be so bad if people waited a little longer in the Counties Manukau catchment? I understand they wait eight months in Tairawhiti DHB. The lesson from that is simply that our health services are distributed inequitably.
It is possible, however, to agree on the status of these top four NCDs. Then, by increasing our focus on proven preventative measures and earlier interventions, we could reduce the impact of the NCDs, pull back the associated risk factors, and increase the cost-effectiveness of services in the process.
But this requires investment in things which don’t deliver tangible results in short order – and certainly not in three years! This means NOT going to the electorate with a promise of more hips and knees, but perhaps with a promise to improve the health, wellbeing and independence of New Zealanders, and their as yet unborn children and grandchildren.
Focussing on child health is a critical part of the equation. This is where early intervention is literal – early in a human being’s life. Sir Peter Gluckman’s emphasis on ante-natal health care is right – establish the best dietary and exercise patterns here and we are truly investing in our future.
Focussing on teenagers to prevent intergenerational transfer of suboptimal behaviours is also critical.
Addressing the poverty trap and the social determinants of health is the underpinning commitment required of politicians.
The fact that this government has picked up our rheumatic fever immunisation programme and accelerated it is a good thing. It needed to be. That is valuable preventative work. The fact that this government has picked up our housing insulation programme and is continuing it is a good thing. It needed to happen. That is also valuable preventative work. We know we can reduce respiratory illnesses and the incidence of communicable diseases if people can live in warm, dry houses without overcrowding.
We need to treat people with some maturity and ask them, as well as ourselves, to look at the long term prognosis for the health of our society. I am sure that people will get it.
But we need to invest more substantially in public health, health education and promotion, and epidemiological studies which can tell us over time what works and what doesn’t. We can draw from useful overseas research, but if we are to devise successful methods for reaching into Māori and Pasifika communities and helping them to stay healthy and reduce harm, then only we in New Zealand can assess that.
If we are to manage down the increasing incidence of serious infectious diseases and inequalities in New Zealand, we must have sound evidence-based policies and appropriate funding for research and public health.
Grassroots initiatives which assist families to change behaviour and take responsibility for their own health and wellbeing, must be piloted, monitored and assessed. Then they must be adapted to generate the greatest success.
At present, the Health Promotion Forum receives $880,000 per annum. They use that money to develop capability to deliver health promotion, prioritising Māori and Pasifika. This is not front-end loading the health system!
Currently Tony Blakely of the Wellington School of Medicine is doing work on the cost effectiveness of prevention, similar to an Australian study. We need more of that work, if we are to invest tax dollars effectively.
But the second of the two great challenges is developing some systematic plan to address the needs of our ageing population. This also brings us back to prevention and early intervention, but this time in the life of an illness, not a person. Life expectancy in New Zealand is now 78 for men and 82 for women. But while people are living longer, many are entering old age with multiple long term health conditions. 75% of older adults have at least one major physical or mental long term condition, and 19 % have three or more. Dementia prevalence is increasing by at least 4% per year.
We need to invest in effective management of long term conditions, as well as prevention and early intervention. The starkest example of this is the approximately 223,000 people with diabetes. Interventions through primary care can reduce risk. Supporting people to make the responsible choices for themselves and their families is neither easy nor fast but it is the most effective way of reducing harm and using tax dollars efficiently.
There are many other pressing concerns in the Health portfolio. I haven’t even begun on mental health, tobacco, alcohol and drug addiction.
But my take home message for you today is that our two major parties ought to agree on the pressing health needs of New Zealanders, both now and impending, and load health services more at the front end with prevention, and not as much at the acute end, when the horse has well and truly bolted. This may mean fewer operations for you to perform in the private sector, but it will eventually mean New Zealanders who are healthier for longer, supported by health services which are accessed early enough to make a difference.