Tony Ryall

15 June, 2009
Health Minister's speech notes for NZMA GP Conference

Thank you for the invitation to participate in your medico-political session this morning, and to speak to you.

I'd like to talk about our direction in Health as the new government, including some of our main goals over the next few years. None of it will be a surprise to those of you who have read Better Sooner More Convenient, as that 50-page document is the road map for our direction and policy.

But first, it has become clear in recent days that with a rapidly changing world situation on swine flu it may no longer be possible to maintain our tight containment strategy. This flu is about to become significantly more widespread in New Zealand.

In Australia, there are over 1,200 confirmed, and it they are no longer placing as much emphasis on counting as it spreads further.

Every day we slow the spread is another day where we can keep the rest of our health services available to others in need.

As we enter the traditional winter flu season with its strong pressure on Emergency departments and GP clinics, swine flu will add to that demand.

So while many of you have been getting busier with seasonal flu, it is about to get busier. And that is why many DHBs will be establishing community based assessment centres - or flu centres - to divert flu sufferers away from GP clinics and busy E Ds. And we will need your assistance in this regard.

Thank you for the contribution so many of you in primary care have made - and will continue to make - to the national effort. It is appreciated. And we will keep you informed of developments.

It is a great privilege being the Minister of Health. And it's made even better by having a Prime Minister and Finance Minister both with an equally strong commitment to the public health service. And I am fortunate to also have a strong team of Associate Ministers.

In last month's Budget, Health secured around half of all new government spending. One out of every two extra dollars over the next four years.

In the most difficult financial circumstances for generations, John Key and Bill English ensured that critical investment in the New Zealand health service.

This is a National Government committed to a strong public health service.

While we have secured an additional $750 million of new health investments for 2009/10, finance is a lot less certain for 2010/11. The next Health Budget will be very dependent on how the economy goes over the next 12 months.

Over the next three years the economy will lose around $50 billion of output, compared with what was forecast in Budget 2008.

An operating deficit of $8 billion is forecast in 2009/10 and over $9 billion in 2010/11.

If the economy improves, as we all hope, then we can maintain the $750 million annual increase. If the world economic situation continues to deteriorate, then the government will have to tighten its belt as well.

What this means is that while Health has done well this year, next year will be a lot less certain. The public health service will need to ensure a strong and ongoing focus on value for money, with resources moving from administrative overhead and low priority spending into more important frontline services.

Against this quite sombre backdrop the Government has begun delivering on its pre-election commitments around the three biggest problems in health today: workforce, workforce and workforce.

We've established a wildly popular voluntary bonding scheme to encourage graduate doctors, nurses and midwives to stay in the country. We're funding 60 more medical student places, and 50 extra GP training places. We're investing $70 million in additional training and education to staff our dedicated elective surgery super centres. And we're working to improve job satisfaction by insisting DHBs re-engage their frontline health staff in the planning and running of health services.

The Government has also begun delivering on commitments in maternity, medicines, aged care and hospice.

We've also worked with the Green Party on the Home Insulation Programme that will make a real difference to improving the health of tens of thousands of kiwis.

The Government has a number of objectives over its first term, and I would like to highlight four of my most important.

A strong commitment to Clinical Leadership and engaging health professionals underpins the government's health policy.

Clinical leadership is about putting our clinicians at the centre of leading our health system. International evidence shows empowering clinical leadership improves service, improves patient outcomes, improves job satisfaction, and of course that in turn keeps clinicians in New Zealand.

Earlier this year I asked Jeff Brown President of the Association of Salaried Medical Specialists to lead a group to provide some guidance to DHBs on the importance of clinical leadership and what they could do about it.

That paper - In Good Hands - is important. I was particularly struck by a quote from the British Health Minister Lord Darzi because it clearly enunciates much of our thinking:

"If clinicians are to be held to account for the quality outcomes of the care that they deliver then they can reasonably expect that they will have the powers to affect those outcomes. This means they must be empowered to set the direction for services"

Darzi was further quoted as saying: "....where change is led by clinicians and based on evidence of improved quality of care, staff are energised by it and patients and the public more likely support it".

Prior to the election - and in our policy documents and public statements - we made it clear that a National Government wanted a new partnership with the health professions... one of engagement and trust. And we are working to achieve this because a motivated and engage health workforce is more effective and productive.

The obvious has to be repeated: it is doctors, nurses, midwives, pharmacists, and other clinicians who provide the care patients need and want, not managers or boards or even Ministers. And we are working to enshrine that in the way the health system works.

A second major objective is our strong focus on lifting elective surgery performance. Over the past nine years, despite a doubling in the health budget, elective discharges increased an average of only 1,400 a year.

We want to lift that to an average increase of 4,000 discharges a year. This will help us keep up with ageing and population growth. And it will help you deal with the needs of your patients.

The third significant goal I have is one of the most important, but one of the least head-line grabbing of our goals. We want to move to a more regionally/sector-driven public health system, as opposed to the more centrally Ministry-driven system.

Over the last number of years the general pattern was, if there is a problem in the DHBs in the regions, the solution was to create a unit in Head Office and mini units in 21 DHBs. Elective surgery failure? Create a unit in Head Office and mini units in 21 DHBs. Want healthy eating? Create a HEHA unit in Head Office and staff in 21 DHBs.

We're determined to cut down on the bureaucratic burden from Wellington. In the past few weeks, the Government has focused the Health Targets on fewer more achievable goals, cut the number of things DHBs have to measure, and reduced the number of reports DHBs send to the Ministry of Health by over 40%.

The Ministerial Reference Group is looking at how we can do the same in primary care.

The fourth goal I want to highlight is my determination to turn Health away from its current downhill track to financial crisis.

The outgoing Government had official deficits totalling around $111M for this financial year. Post-election the DHBs' revealed total deficits of around $160M were expected, for this financial year, and increasing next year up to around $200M if action wasn't taken. The fact of the matter is that particularly in an economic situation such as that faced by New Zealand and the world today, money has to be found to cover such deficits ... money that can't go to other worthy parts of Health.

In addition to the $160M in DHB deficits we inherited, it was also quickly revealed that we had over $600 million of capital demands from DHBs with few funds to meet those demands. These capital demands include essential and important projects in our hospitals across the country, and resources need to be found to deliver a good number of them.

The Government has a strong commitment to improving public hospital services.

But I want to make it very clear -As the National Party said throughout its last term in Parliament, we are committed to the PHCS -- but we are committed to making it work. We want to achieve the quality improvements side of it ... the multi-disciplinary teams, co-location, and better integration between primary and secondary.

We want to fill-in the missing links.

Better primary-secondary integration, more assessments and minor surgery, faster access to diagnostics and other services, public health, mental health and disability support services, multi-disciplinary teams focused on comprehensive care....these are big challenges for the sector.

As a starter, DHBs have received around $6.5 million this year, and $13 million a year from 2010 to kick start devolving more secondary services to primary care. People have talked about it for years, we want to make it happen. My expectation is that this year DHBs will engage strongly with you about how this can happen in your district and region, with specific devolution and delegated funding arrangements in place for the start of the next financial year.

This is a priority for the government, and if resources allow, we will invest further in this initiative next year.

You know that all our DHBs are under significant financial pressure one way or another. They are also under significant pressure from growing acute demand as children and adults arrive at the nation's hospitals for medical care in ever increasing numbers. It is that growing acute demand which is the major challenge to the position of DHBs.

There is no better time for primary care to show individual District Health Boards how you can help Boards manage acute demand. There's going to be real pressure: shortage of workforce, shortage of capital, shortage of funding, and access targets like ED waiting times. This gives primary care an opportunity to step up.

Through extended hours, walk-in access, convenient nurse-led services, structured care for long-term conditions and for older people, self-management and education, telephone and email support, referral guidelines, decentralised specialist clinics ... community based care that is responsive to the needs of patients with acute demands.

The worsening economic situation and the uncertainty around future finances means our DHBs need partners to help them deal with the needs of these people....your patients.

The Government is open to DHBs entering into arrangements with you to better manage acute demand. We aren't into command and control or one-size-fits-all. It's up to you to demonstrate capacity, expertise and clinical leadership to help make this happen.

And if you are to enter into delegated funding arrangements with DHBs to provide more surgical assessments and minor surgery, or direct referral to certain diagnostic tests, then your PHOs need good governance, good managers and strong clinical leaders.

The failure to move healthcare from secondary (hospital and specialist focused) to primary care in any significant way, despite its constant restatement as a policy objective, is one of the greatest puzzles of health policy over the past few decades, according to British Professor Paul Corrigan.

Prof Corrigan suggests that the lack of critical mass in general practice - small scale - has been the main barrier. Issues like capital, operating costs, and personnel prove daunting for any small business looking to change its configuration.

That's why we're promoting Integrated Family Health Centres. We don't own general practice so we have no authority to consolidate at will. But research demonstrates such consolidation built around co-location of multi-disciplinary teams improves patient outcomes.

Many of you today are keen to know the government's attitude towards the number and size of the 80 PHOs.

Latest information from the Ministry of Health shows that 30% of the country's population is in four PHOs. At the other end of the scale 12% of the population is in 41 PHOs.

Some DHBs have as many as 7 PHOs, while others have only one.

It is going to get harder for small standalone PHOs to step-up to the opportunities that look likely over the next few years. Already many smaller PHOs are discussing how they can work more effectively with others to increase ability and save costs. Some may amalgamate, some may confederate.

Governance, management and clinical expertise are spread too thinly. If we are all to make the PHCS work, then you need to step-up.

The Ministerial Reference Group led by Dr Murray Horn is looking at these issues, and will be making recommendations to the Government about how we can realise the vision of the PHCS in a high-trust low-bureaucracy way.

The new government is determined to provide a better sooner more convenient health service. Because that's what your patients wants.

Patients want more convenient opening hours and locations, and more ways to get medical advice and support. Patients also want a wider range of services closer to home and with much less waiting.

Primary care offers the best way to deliver timely healthcare

closer to home for New Zealanders. It is a priority for this government.

To make this happen we need you in primary care to step up, and meet the challenges. I am very optimistic about what we can achieve over the next few years.

Thank you for the opportunity to speak with you.

ENDS

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