30 May 2002
Hon Annette King
Speech Notes

Primary Focus --- the future of primary health care

Welcome everyone to this special and significant event.

Given the emphasis this Government places on the importance of primary health care, it makes me feel very happy as Health Minister to be opening a primary health care conference attended by so many experienced, skilled and influential people in the sector.

I know you have come here for a variety of reasons.

Some of you have come to learn more about the future of primary health care in New Zealand – and you will certainly be able to do that.

Some of you will be here to tell us about your ideas and experiences – and you will certainly get a chance to do that too.

But I think all of you have come here because you care about the health of New Zealanders, and because you share the conviction that the most effective way of improving the overall health of New Zealanders is to provide access to affordable primary health care.

This forum will provide stimulating opportunities to meet others who also care passionately about the subject, even if sometimes they have different views and perspectives. I am sure you have all come ready, however, to respect and listen to each other’s views.

My hope is that everyone leaves here better understanding how implementation of the Primary Health Care Strategy will create a system that really does make THE difference to the health of New Zealanders.

And as an added extra I also want to talk to you this morning about initiatives this Government is introducing to strengthen and reinforce primary health care in rural New Zealand.

Before I explain those initiatives, however, I think it is important to acknowledge that New Zealand has been fortunate for many years in having such a high standard of primary health care professionals.

Our general practitioners are held in high regard for their professionalism and the quality of care they provide. As well we have a strong community nursing workforce, including Plunket, practice, district and public health nurses, and many dedicated people work hard to provide services for Mäori, Pacific and rural communities.

That might all seem self-apparent, and hardly worth emphasizing, but the fact is that for all sorts of reasons our health system has not always supported primary health care or those who work in it.

Successive governments have only paid lip service to the importance of primary health care, and to the need to prevent disease as well as cure it. Somehow, when it comes to the crunch, hospitals and waiting lists always get the attention and the resources.

As a result we have ended up in a situation where our system is topsy turvy. Compared to people living in similar countries, New Zealanders pay more out of their own pockets to see the doctor, and we have traditionally under-funded primary health care.

I do not want to be unduly negative about the previous Government, but it is significant that the Opposition health spokesman still regards hospital funding, rather than primary health care, as the core issue.

That said, despite the huge upheavals in health in the 1990s, the decade did see some positive developments in primary health care in terms of a growth in Mäori and Pacific providers, the emergence of IPAs, and the development of community groups in rural areas.

What was lacking, however, was the setting of clear strategic goals and strong structures for the future, and, of course, the lack of guaranteed and long-term funding.

That is, I strongly believe, no longer the case. The past two-and-a-half years have been characterised by developing and setting strategic goals that are accepted by communities and professionals, and providing the funding to begin implementing those goals.
The New Zealand Public Health and Disability Act set the legislative framework, and established District Health Boards with elected local representation and responsibility for the health of their communities.

Strategies like the New Zealand Health Strategy, the Disability Strategy and, of course, the Primary Health Care Strategy have set clear directions for progress in the new health era.

You are all aware of some of the statistics that demonstrate how we have neglected primary health care in the past. About 30 percent of hospital admissions for those aged under 75 are avoidable, for example, and about two-thirds of these can be avoided through early access to effective primary health care.

We have unacceptably high levels of preventable sickness and death especially among Mäori and Pacific people and those from the more deprived parts of the country.

When the Primary Health Care Strategy is fully implemented, we should be able to prevent more than 60,000 hospital admissions each year.

Those figures are not just pie in the sky, though pie is not a word we mention lightly in terms of preventative health care, unless they come with a heart tick, of course

There are so many areas of prevention that we must do better in urgently. We have a growing epidemic of diabetes as well as high levels of meningococcal disease and rheumatic fever – conditions that should be out of place in an advanced country like ours. And our aging population will place increasing demands on health services.

Quite simply, the need has never been greater for strong primary health care to be put at the centre of our health system.

A key change in the way we deliver primary health care will be an increased emphasis on population-based care. Primary Health Organisations, of whom you will hear much more during this conference, will take responsibility for a defined population, and that means all those people who enrol.

Services will be directed not just at those who seek care when they are ill, but will be there to look after the health needs of the whole population group. So primary care providers will need to know not just who is sick, but who might become sick because they are not getting access to preventative health care and health education.

We need to coordinate our primary health care professional resources far better. For example, we have 11 or more different types of primary health care nurses. We need linkages between all sorts of community care, hospital services and other key areas like social welfare, disability support, housing and local government.

We also need continuity in care – especially for the increasing number of people with complex long term health needs.

But I am sure I am talking to people who already know all this, and are impatient for governments to provide the help they need.

This Government has made it clear that it is getting on with the job. I have already announced the first three years of funding for implementing the Primary Health Care Strategy, and together we can now get on with doing the job that we know needs doing.

In the new financial year we will increase spending on primary health care by $50 million, with $165 million in new money the following year and $195 million in new money the next year. In future years I hope we will be able to increase funding levels still further to achieve the aim of timely and equitable access for all regardless of ability to pay.

The key mechanism to achieve this better primary health care will be, as I said, the PHOs that will develop in various ways around the country. Some will arise from existing small communities and providers, some from current Independent Practice Associations, Mäori groupings, Pacific providers or other groups.

Last November I released a non-prescriptive minimum set of requirements for PHOs, and deliberately argued that they should be kept simple and achievable. DHBs are now going through the process of deciding who will be involved and where groups will be set up.

I know many of you are already involved in these discussions, and I’m impressed with the level of interest.

The Government is firmly committed to the new approach. We need to shift the way primary health care is funded so that the public purse – rather than individual patients – carries most of the cost. We cannot afford to keep on putting more funding into old ways of doing things.

When I announced the additional primary health care funding, I said that it was aimed firstly at areas of low income and high health needs. That does not mean, however, that PHOs need to be serving high need populations to get started.

PHOs can be formed when providers and their DHBs are ready, but those serving populations with a high concentration of people in high health need groups will be the first to be funded at higher levels. This will allow them to charge only low patient fees for all their patients with no need for community services cards. I expect that up to 300,000 people may be covered by these arrangements in the next year.

Some providers and PHOs will take more time than others to get ready. There is no need to panic or get worried. The new money will not run out. It will be managed so that PHOs serving high need populations will be funded when they are ready to start.

Some PHOs will no doubt provide free health care. In most cases, modest co-payments will remain, even in the long term. The Ministry of Health is talking with GP groups about options for reducing costs to patients.

People must be able to get primary health care services without facing barriers such as cost. The Government plans to remove the need for Community Services Cards over the next eight to ten years and instead move to a system where everyone is able to get low-cost access to care regardless of their income.

Good primary health care is community based and involves people. That is why PHOs will need to show how their community is involved in the organisation’s governing processes.

It is also crucial that providers and individual practitioners have a say in PHOs. Good clinical involvement is essential for strong primary health care provision.

Over time, it will be very important that PHOs broaden the range of services that they either offer themselves or that are closely linked in. Already DHBs have initiatives with many primary care groups to provide a varied range of services – and I would expect to see more such arrangements in future.

It will take time to achieve the ambitious vision that we have for primary health care – but we have to get started now.

From the middle of 2003 the increased funding will allow us to reduce fees for all school age children – not just the under sixes. After that we will move progressively to include different groups – with the elderly being the first priority.

And now I want to spend some time addressing rural health issues.

Many rural communities are showing great interest in the changes in primary health care arrangements because these communities reflect the values we are talking about --- a population focus, community involvement and co-operation between providers.

However, I am acutely aware that many of these same communities struggle from day to day to retain adequate health services and to attract new practitioners.

It was to address these serious issues that the Ministry of Health set up a Rural Expert Advisory Group late last year. The group has produced an excellent report that has been circulated for comment and the full report will be released in the near future.

I am pleased to be able to announce today that I am accepting the group’s recommendation that a primary health care premium be paid to help rural areas to retain a skilled health workforce.

The rural primary health care premium will be in two parts: the first to enable extra payments to support primary health care workers to stay in rural areas, the second to enable those practising in such areas to maintain reasonable on-call rosters.

The amount of the premium will depend on how isolated an area is.
In Matamata, for example, a practice population of 1200 people would be paid a premium of $8900 while at the other end of the scale a similar practice population in Reefton would get $22,500. Rural areas will be graded on the basis of an already-existing rural ranking score.

Our intention is to make this money available through Primary Health Organisations. However, I am well aware that some rural communities need it now. I am currently looking at how best to make the money work straight away.

The reasonable roster allowance will be allocated on a case-by-case basis, targeted at practitioners who are on call every second or third night, or even every night.

Establishing reasonable on-call rosters is important for several reasons. We need to maintain access for rural people to urgent primary health care out of normal business hours, as well as aiding practitioner recruitment and retention.

While rural New Zealand has a lot to offer a doctor and his or her family as a place to work and live, it is important that they have adequate time to enjoy it.

And how much are we going to spend exactly? Well, I am delighted to announce that over the next three years GPs, nurses and other health workers serving rural communities will receive extra funding of more than $32 million, made up of $6.5 million in the new financial year, and $12.9 million in each of the two subsequent years.

These new payments will be in addition to the existing rural bonus of $4 million, and $1 million in each of the next two years for the rural locum scheme. It is also in addition to funding for primary health care to be delivered through PHOs, many of which are likely to be established first in low income, high health need rural areas.

This package is important not only in itself, but also to reassure rural communities, to recognise doctors, nurses and other health workers who serve them, and to underline our commitment to make effective primary health care the way forward for all New Zealanders.

By now I expect some of you have lots of questions and want more detail – and you will get a chance to ask your questions of the Ministry of Health team in sessions this afternoon and tomorrow morning.

Change is challenging – and I know that we have had more than enough change in our health system in recent years.

But remember these primary health care developments are building on what we already have. Almost a third of general practices are already paid for their registered patients rather than fee for service. Many existing primary care provider groups include community representatives on their boards and have begun to take a much more population based approach to delivering services.

The changes in the Strategy move us all further along the path that you have already started to walk along.

Let me also correct a few myths and fears. The Government does not intend to take over the provision of primary health care services. We have always had a mix of public, private and voluntary providers of primary health care – and this mix will continue.

PHOs will not have to be large organisations with extensive staff and impressive corporate offices. There’s much to be said for smaller local PHOs that really get to know the people they serve. I would like groups to work together to reduce overheads and to share expertise.

There is no agenda – hidden or otherwise – to replace GPs with nurses. We need all of you – and more - to deliver what the Strategy promises, but there are significant new tasks that nurses will be heavily involved with – and a need to look at better ways to develop the primary health care nurse. For this reason I will soon be announcing a scheme for innovative primary care nursing pilots.

The Strategy will move primary health care to centre stage, and this conference will provide considerable impetus for doing so.

I strongly believe this conference stands at a watershed in the history of the New Zealand health service. Never since the first Labour Government in 1939 have we made the sort of commitment to primary health that this Government is making. Now New Zealanders depend on us to make it work.

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