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NZMA General Practitioners Conference Speech

NZMA General Practitioners Conference

Rotorua Energy Events Centre, Queens Drive

Hon Peter Dunne
Associate Minister of Health

Thank for the invitation to speak with you this morning.

I want to acknowledge the New Zealand Medical Association and Conference Matters for organising this conference year after year and for the critical role primary care plays in improving population health outcomes and lifting performance across the health sector.

The GP CME conference is a great educational, information and knowledge sharing platform for our clinical workforce, which brings together a diverse range of health practitioners in one place at one time.

The industry exhibition component of this conference offers you the opportunity to learn about the latest innovative solutions in pharmaceuticals, Information Technology and supply equipment to improve patient management across general practices.

I see you had a session with Professor Boyd Swinburn on the role of primary care in childhood obesity prevention.

Tackling obesity, in particular childhood obesity is a key focus for the Government, and I acknowledge Professor Swinburn’s work with the Ministry of Health Technical Advisory Group on Childhood Obesity.

As you know, the causes of obesity are complex and a cross sector approach is necessary to address this serious health problem.

Obesity is also a major risk factor for diabetes and other long term conditions and a major contributory factor for morbidity.

New Zealand is not unique in its battle with obesity. We already have several initiatives underway. Budget 2014 allocated $40m over four years for Healthy Families NZ.

The programme challenges communities to think differently about how to address the underlying causes of poor health at a local level. Over $60 million is invested each year on a range of programmes to promote healthy lifestyles through initiatives such as fruit in schools, Green Prescriptions and Kiwisport.

The Government is also looking to adopt a voluntary new Health Star Rating labelling system on food packaging to help New Zealanders make healthy food choices. However there is more that we need to do and the Government is currently looking at options to address the increasing incidence of childhood obesity.

This includes looking at existing Government actions as well as the international evidence for possible interventions. As part of this, advice is being sought on a possible obesity target.

If we went down this track the target would have to be meaningful and evidence based. Also, in December 2014, Ministry of Health officials were asked to develop a five year strategy for diabetes.

The strategy will cover the continuum of care from risk assessment to self-management. The strategy will soon be released for consultation and I encourage you to provide feedback.

Oral Health – Fluoridation

Community water fluoridation is safe, effective and affordable.

It is recognised as the most effective public health measure for the prevention of dental decay, and reaches all segments of the population.

It is particularly beneficial to those most in need of improved oral health. This is the position taken by a number of national and international health authorities.

In 2014 the Office of the Prime Minister’s Chief Science Advisor and the Royal Society of New Zealand jointly published the report Health effects of water fluoridation: A review of the scientific evidence.

This report found that community water fluoridation within the range of concentrations currently recommended by the Ministry of Health and used in New Zealand poses no health risks, and the report provides compelling evidence of dental health benefits for New Zealanders.

On average, New Zealand children and adolescents living in fluoridated areas have 40 percent less tooth decay than their peers living in non-fluoridated areas.

There is scope to increase fluoridation coverage in New Zealand, which currently covers 54 percent of the total population. The Ministry of Health continues to work with stakeholders to expand fluoridation coverage in New Zealand.

This is one, significant, part of a comprehensive approach to improving oral health outcomes.

Shifting services closer to home

Achieving integration across all parts of the health system is a priority for 2015, particularly shifting services from secondary to primary and community care.

Integrating primary care with other parts of the health system is vital for better management of long-term conditions such as cardiovascular disease (CVD), diabetes, mental health, an aging population and patients in general.

The Government’s expectation is that health services will be more accessible to people and people can receive services in their communities, closer to where they live. We need to continue to change the way healthcare is delivered for more people to get the care they need away from hospitals.

Shifting services will be varied based on local need, context and scalability, and will range from co-locating out-patient clinics into the community, through to substantial redesign of service structures, resourcing and facilities. Primary care is well placed to lead some of the changes and deliver services designed to achieve integration.

I am aware work is already underway in some areas and the $6 million investment through Budget 2015 to create new community based multi-disciplinary early intervention teams, for diagnosis and management of orthopaedic conditions, will make a real difference to patients and their whanau.

Budget 2015 update

Health is receiving the largest share of new funding in Budget 2015.

As mentioned earlier, the Government wants to see more services being accessed in primary care settings, which is in part why around $35 million extra will be invested in primary care in 2015/16. This is the largest increase for the primary healthcare sector in the last six budgets.

This comes on top of the $90 million over three years announced in Budget 2014 for free doctors’ visits and prescriptions for children aged under 13. This will take effect from 1 July 2015 and benefit over 400,000 children.

New Zealand Medicines Strategy

Medicines play a significant role in helping New Zealanders get well, stay well and live well.

There are significant challenges ahead of us.

We need to procure, use and manage medicines wisely, including new innovations, in order to meet the needs of our ageing population, tackle the growth in multi-morbid long-term conditions and achieve fiscal sustainability.

Medicines New Zealand sets out the outcomes we want to achieve.

Since its introduction in 2007 it has been the backdrop against which medicines policy has been developed, and its accompanying Action Plan is currently being refreshed. We want New Zealanders, regardless of their ability to pay, to have access to safe, high-quality, effective medicines, and we want those medicines to be used in the best possible way.

Implementing Medicines New Zealand is the plan that outlines the actions required over the next five years to achieve these outcomes.

The Plan moves away from building systems and capability, and ensures activities are:
• integrated and patient centred
• support health professionals to work at the top of their vocational scope, and
• lead to meaningful improvements in health outcomes that are aligned with the priorities of the wider health system.

In order to achieve this, the Plan focuses on seven impact areas but with enough flexibility to allow for activities to evolve over time.

The Ministry of Health has developed the impact areas and actions with a range of stakeholders, including the NZMA.

Actions may be broad or specific, and are divided into two types:
• work that is already underway, or activities that we know are already common and regarded as good practice across the health sector
• new and aspirational actions that may evolve over the next five years, which are often based on developing innovative practice that already exists in pockets.

Activity under each impact area will be coordinated and actioned by a combination of stakeholders in a range of settings that extends beyond government agencies and includes health professionals, service providers, responsible authorities, and patient groups.

The Plan is currently being considered by Cabinet and if approved I intend to launch it later this month. Implementing Medicines New Zealand will support innovation and help the sector move towards better, integrated, consumer-centred care.

Psychoactive Substances

The Government enacted the Psychoactive Substances Act 2013 to regulate psychoactive substances because illicit street drugs and untested psychoactive products were already widely available and long-term effective prohibition of all psychoactive products was proving impractical.

Internationally, no other jurisdiction has found a more effective approach to dealing with new psychoactive substances.

Some countries have introduced product bans, however all that has achieved has been to drive the market underground and out of sight of the Police and health authorities, to the detriment of those adversely affected by their use.

The Government’s view is that it is preferable to regulate such substances and to permit access to low-risk products rather than drive potentially more harmful products underground. The Act specifies that if a substance is psychoactive, it must be approved before it may be sold and that it pose no more than a low risk of harm to the user.

The criteria for product approvals are very stringent, similar to the pre-market approval regime for medicines. Currently there are no approved psychoactive products and it is likely to be some time before any are approved, due mainly to the prohibition on animal testing for psychoactive substances.

While all psychoactive substances are currently illegal, it is important that users feel comfortable to report any adverse reactions they may experience. Reporting provides valuable information on the health effects of these new and un-researched substances in the absence of clinical trials, as well as signalling there are new potentially dangerous psychoactive substances on the market.

Adverse reaction report details (such as names) are not passed to the Police, who mainly have an interest in identifying the suppliers of such substances, and so I encourage you as GPs to report any adverse reactions you may come across.

While I am speaking about drugs, let me make two additional comments. The National Drug Policy is currently being reviewed and I am expecting to release the revised policy shortly.

It will largely build on what is already in place, and will demonstrate a coherent, and integrated approach to the health issues associated with illicit drug use. The issue of medicinal cannabis has also been in the news of recent days.

Let me reiterate that my recent decision to authorise the use of a particular product in a particular case has no greater implications than that. There has been no change in policy, nor opening of the floodgates, and those who assume a new precedent has been established are mistaken.

This case proceeded according to the long standing procedures which enable clinicians to seek approval for the prescription of certain otherwise restricted products in specific circumstances. There has been no change to that procedure, and any future cases that arise will be treated strictly on their individual merits, with no assumptions of an automatic favourable outcome.

I have received anecdotal reports of clinicians refusing to apply for permission to prescribe Sativex, due to the stigma associated with it being a cannabinoid-based product. I hope these reports are mistaken.

It is my expectation that clinicians will act in the best interests of their patients, regardless of any associated stigma that may exist.

As I said to the United Nations Commission on Narcotic Drugs meeting in Vienna earlier this year, I believe it is essential that we address the issue of medicinal cannabis on its merits, and as a global community. I have asked my officials to look into the evidence and efficacy for cannabis as a medicinal or therapeutic relief.

But I have to say that based on the evidence provided to me, I have grave reservations about the efficacy of cannabis for the vast majority of indications that it is being put forward for. My concerns do not stem from a personal antipathy towards the drug – despite the sneers of my many critics on this issue, I am quite agnostic.

Rather, they stem from the very real likelihood that many sufferers – and in many cases they are children, are being given false hope that cannabis use will significantly ameliorate their symptoms, their pain and their reduced quality of life.

We have to do better, and shut out all emotion or personal prejudice and concentrate purely on the reputable, proven facts, of which there as yet few, when reaching long-term decisions.

Primary Care Workforce

Growing our primary care health workforce is crucial as demand for primary care increases due to increasing chronic diseases, ageing population and the need to shift more services closer to home.

Health Workforce New Zealand (HWNZ) has been actively working with stakeholders to increase the number of doctors entering Vocational General Practice training and the number of the health workforce training to be nurses.

HWNZ and the Royal New Zealand College of General Practitioners have been able to increase the number of training places for GP registrars.

In 2007, 69 new trainees entered the general practice training programme and more than doubled in 2014/15.

General Practitioner training remains a key focus alongside multidisciplinary teams including nursing and allied health.

HWNZ is funding and working with the RNZ College of GPs on vocational training to promote general practice and primary and community care as an attractive career option for new medical graduates.

Information available from the Nursing Council of New Zealand (as at 31 March 2015) shows that there are about 6,860 nurses employed by Māori providers, Pacific providers, PHOs and primary health care (community services (non-DHB).

This sector makes up thirteen percent of nursing workforce. The total number of nurses registered with the Council is 52,729 nurses.

If you include DHB community nurses are there will be a total of 11,325. The fastest growing area of practice for Nurse Practitioners is in primary care.

Nurse practitioners are one group of health practitioners who have been prescribing for 14 years. There are currently 138 nurse practitioners prescribing and practising in a range of settings, working closely with doctors and other health practitioners to provide quality care.

In May 2015 the Nursing Council advised that there were 36 diabetes nurse prescribers authorised to as prescribers. These nurses work in collaborative teams within primary and secondary care.

Closing remarks

Before I leave, I want to give you a quick update on other work happening across the Ministry of Health.

The Ministry of Health is currently undertaking three major reviews. The first one is the refresh of the New Zealand Health Strategy which was published in 2000.

The refresh will set a new vision and a road map for the next three to five years for the health sector and I know some of you will have had input into this process. The other two reviews are also taking place concurrently.

These are the review of health system funding and a review of capability and capacity. The funding review is looking at the arrangements needed to support a high quality health sector that integrates across the social sector and is sustainable in the long term.

While the capability and capacity will ensure we have an adaptable and responsive health and disability sector to support the updated New Zealand Health Strategy. The Minister of Health will share the findings and his position with you in early July 2015.

Thank you again for the opportunity to speak with you this morning and for your commitment to primary care, I hope you have an enjoyable and informative session.


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