Q+A Health Debate – National’s Dr Jonathan Coleman and Labour’s Dr David Clark

DHB funding has been in the political spotlight this election campaign, but on TVNZ 1’s Q+A programme this morning National’s health spokesperson Dr Jonathan Coleman defended his party’s efficiency gains in DHBs.

“Patient care comes first and every service has improved. The deficits are a fraction of less than 1%. They’re less than when Labour was in power. The big picture is $13 billion into DHBs. All services are improving,” he said.

Labour’s health spokesperson, Dr David Clark, highlighted shortfalls in the current health system.

“Half a million New Zealanders could not afford to go to their GP last year. They’re not getting the care, and that means that they’re ending up in the ED department further down the track – bad for them and costing the system more money.

Q + A
Episode 25
JONATHAN COLEMAN AND DAVID CLARK
Interviewed by CORIN DANN

CORIN Let’s bring in our guests, Dr Jonathan Coleman from National. Welcome to you this morning. And David Clark from Labour. Good morning to you. What we should note is that you are a doctor. A medical doctor?

JONATHAN That’s right. I’m a medical doctor. I worked as a GP for many years. Extensive experience in the New Zealand health service, as well as overseas.

CORIN Very good. Let’s start on the issue of whether we have a sustainable health system funded in the current way by the government.

JONATHAN We do. We’ve got $5 billion that’s gone into the health system over the last nine years. Hundreds of services, all of them better apart from a handful.

CORIN Is it sustainable to do it this way, whereby taxpayers pay their tax, we have basically a free health system as much as possible on acute things, those sort of things. Is that still sustainable?

JONATHAN Absolutely. We’re not thinking of changing the funding model. If you look at it - $2 billion into infrastructure, free under-13s visits. We’re implementing the New Zealand Health Strategy. 50,000 more operations, more appointments, 7000 more doctors and nurses - everyone is getting more access to services on an ongoing basis.

CORIN Sure. I don’t dispute that you’re putting money in and you’re doing all of those things. I’m saying is it sustainable into the future when we’ve got an ageing population, a growing population. Can we continue to do things the same way?

JONATHAN No, we’ve got to do things differently, and that’s why we’ve brought in the New Zealand Health Strategy, which is about early intervention, prevention, services in the community based around patients and their families. I’ll tell you, patients and their families, providing services to them, is paramount. Through my experience as a doctor, I know-

CORIN Great. Will you rule out the use, the greater use of private providers in the future?

JONATHAN Oh, look, basically there’s private provision now in the health system. There was under Labour, but it is going to be funded by the state. No change to that.

CORIN David Clark, you’re going to put $8 billion extra into health, so just walk me through this a little bit here. In the first year, in a first Budget, how much extra goes into health on top of what the government already put in this year?

DAVID It’s over $800 million. $554 million to meet cost pressures and demographic changes. I’d challenge the minister to do the same. It would be the first time. And then on top of that, $293 million, and that is to start back paying the shortfall that has occurred under National.

CORIN It’s roughly, though, staying at 6% of GDP?

DAVID It’s about on that trend. Corin, I couldn’t tell you exactly how many on GDP. Core Crown health expenditure has gone down from 6.5% down to 6.2% under the current government. We want to start it trending back in the other direction.

CORIN Do you think that is a sufficient amount?

JONATHAN That just illustrates that they don’t know what their figures are. They’ve got $300 million promised for $8 GP fees. He’s just said $800 million in the first year. No allowance for that $300 million. It just shows their figures don’t add up. He said $500 million for DHB pressures, $300 million for something else. Where’s the $300 million for-?

CORIN I’m going to stop you both. I’m not sure we get anywhere with a debate at the moment. I’ll be honest. It’s turned into some ridiculous post-truth debate about funding for health. No one has any idea whether you’re doing it right or you’re doing it right? It’s very frustrating for the public, I have to say.

JONATHAN It may be, but that’s why the 50,000 operations, free under-13s and the $2 billion of infrastructure-

CORIN Okay, let’s just break it down. Wait, wait, wait. I want to stop. I want to break it down here, because we don’t get anywhere with this debate.

JONATHAN Well, you raised it.

CORIN The DHBs - okay, the issue is that you’re pushing them too hard to make savings. Let’s just take the money off the table here. Are you pushing them too hard to make efficiency gains?

JONATHAN No. Patient care comes first and every service has improved. The deficits are a fraction of less than 1%. They’re less than when Labour was in power. The big picture is $13 billion into DHBs. All services are improving.

CORIN Lester Levy, he calls it a white-knuckle ride. You’ve got letters coming from DHBs all over the place. Forget the money - they are struggling to do what you want them to do.

JONATHAN Look, it’s always tough in health. It has been for 20, 30 years. No one’s ever going to say stop sending money. The key thing is more services. That’s what we’re about, and that’s what Labour can’t deliver. They can’t deliver it.

DAVID Can I pick up on something? Because he’s talked about families, patients, getting the care closer to home.

JONATHAN Absolutely. And they are.

DAVID And under National, the doctor’s fee has gone up from $29 to $42 under their watch. That’s the average fee.

JONATHAN No, it hasn’t.

DAVID And what we know is that half a million New Zealanders could not afford to go to their GP last year. They’re not getting the care, and that means that they’re ending up in the ED department further down the track – bad for them and costing the system more money.

CORIN Wait a second, please. What National is clearly doing is they are driving efficiencies and they’re trying to get more on less. What is wrong with that? We want, as taxpayers, our system to work well.

DAVID There is nothing wrong. The Treasury has said there have been no efficiency gains notable in the sector under their watch. They have also said there have been no efficiency losses. It’s actually not a bad record in terms of efficiencies-

JONATHAN You’re right. It’s a good record.

DAVID However, we do need to fund the system adequately for the demographic changes. We’ve got an ageing population with more complex needs, and that means currently that the thresholds for surgery, for cancer treatments are going up.

CORIN This is the point I’m coming to. You can put in your extra $800 million or so, but where does the taxpayer get the assurance that they’re going to get better services?

DAVID Because $10 cheaper doctor’s visits means that people can afford. Okay, take an example. There’s a woman in Wellington called Paula Kohler-Saunders. She had a headache, spread to back pain, then to pelvic pain and she got secondary infections in her liver and her kidneys from toxins that built up in her blood in five days because she couldn’t afford to go to the GP. A St John’s ambulance person said late last year 40% of the cases they deal with are people who could be looked after in the community if they could afford the care. Diabetes, bronchitis-

CORIN Let Jonathan respond here.

JONATHAN I get dozens of letters from people who are absolutely pleased with the care that they’re getting in the New Zealand health system. David has said it - we’ve done a good job and we’re on the right track. Those are his very words. So, we have a fully costed plan for $18 GP visits. 2.5 million New Zealanders are either going to get free or $18 visits. That took a year to work that out. These guys have done no policy work. Three days later, he says it’s going to be $8, but he hasn’t got the $300 million to pay for it.

DAVID That is absolute rubbish. Can I challenge those figures? I don’t want to have a debate about the spin-doctor stuff. All of that is costed. We’ve got a clear fiscal plan that has been independently reviewed by BERL. The numbers are there, and it’s just a matter of priorities. They’re refusing to fund health adequately. We are saying no to tax cuts, because that’s not our priority. We are putting to money into health and education.

CORIN Dr Coleman, there’s been a case recently, a high profile case of a woman with a cochlear implant who was on a wait list. She had a 26,000 petition, and you have funded cochlear implants-

JONATHAN Yes, $6.5 million that’s going to tackle that waiting list.

CORIN It took a big effort to get there, didn’t it?

JONATHAN Look, there’s always pressures in health-

CORIN Because of media pressure.

JONATHAN The key thing is 40 people were getting a cochlear implant. Now 100 per year will. We’re clearing that waiting list, and that 22 year old is going to have her hearing saved and I’m very pleased about that.

DAVID She actually waited three years.

CORIN Wait, wait, wait. Let’s get to the issue here. This is the issue. There are always these priorities and trade-offs made-

JONATHAN Absolutely. Whoever’s running the health system, and it happens like that internationally.

CORIN But are we saying that a woman could effectively go deaf-?

JONATHAN No, she’s not going to, because we are funding it.

CORIN She was three weeks away from going deaf, and she was denied the cochlear implant, and you stepped in and funded it in election year.

JONATHAN I did step in. I did step in.

CORIN Yes, but the point is- I need New Zealanders to see this point.

JONATHAN No, the point is we need to save her hearing.

CORIN Your health system that you run had a cut-off point that said she would lose her hearing. Now, is that acceptable?

JONATHAN She isn’t going to. No, it’s not, and that’s why we’re funding it-

DAVID And here’s the magical money tree.

CORIN Wait-

JONATHAN And this is the point. I tell you, no government has ever been able to give every New Zealander every procedure that they would like, but we’ve got to actually make sure that those that really need services get them, and that’s why that 22 year old is having her hearing saved.

DAVID I met Danielle, and she is an amazing woman. Surf lifesaver going deaf over three years.

JONATHAN We all agree on that.

DAVID The minister announced, as you said, a few weeks out from the Budget, that they were going to fund cochlear implants. He hasn’t said what they’re going to give up. He’s said the DHBs must fund this out of their baselines, and what’s happening is that that’ll mean for all other kinds of surgeries, that’ll be harder to get that care. We know, because of a study that David Gwynne-Jones did, that it is now harder to get orthopaedic surgery than it used to be, and that’s true across the board. It’s harder to access services for New Zealanders. They have to be more disabled than they used to be because the health system is underfunded.

JONATHAN That’s not true.

CORIN Here’s the thing. You can’t promise New Zealanders that you’re going to be able to fund every single person’s operation.

DAVID We cannot. We can do a hell of a lot better than we’re doing now, though, and I think that’s what New Zealanders care about.

CORIN There is always a cut-off point. All right. The issue of primary care. You’re both cutting, obviously, the primary care. There is some agreement here that getting people to the GP is the right solution.

JONATHAN Absolutely.

DAVID Yep.

CORIN Why not go further and just make it free?

JONATHAN Look, there’s nothing in life that’s free, and we are targeting resources to where they are needed. 2.5 million New Zealanders now are either getting free with the under-13 visits or very cheap GP visits. That took a year of really detailed analysis. These guys came out three days later with a piggy-back policy, no policy work- and just said hey, we’ll cut it to $8.

CORIN But if we all agree, why have any cost?

JONATHAN Well, there’s always going to be a cost. These services are not free. You and I can afford to pay for the GP. So can David. So we should. But kids under 13, low-income New Zealanders, they should have cheap or free GP visits, and that’s what we’ve delivered.

DAVID Well, make them cheaper.

JONATHAN They do not add up. You don’t have the $300 million in the budget.

DAVID Our policy makes it $10 cheaper for every New Zealander. Sure, Community Services cardholders will be $8 - same as under the very low-cost access scheme - but other people who don’t quite qualify for a Community Services card are doing it tough, and we don’t think they should be missing out on that health care. One study estimates that one in four adult New Zealanders now cannot access the primary care they need. That is personally affecting them, but the costs for that avoided care that they’re not getting flow right through to the system-

CORIN Okay, quick-fire questions before we go into the break. Do you have private health insurance?

JONATHAN Yes.

DAVID Yes.

CORIN Is that a signal that you don’t have faith in the health system?

JONATHAN I’ve had it for many years and I’ve continued it. I’ve had it well over 20 years.

DAVID I would like to not have it, to be honest.

JONATHAN Well, give it up.

DAVID Countries that have fewer in the private sector actually do better internationally in terms of health outcomes. Right now surgeons around the country tell me they have it because they’re worried about their health.

CORIN We’ll stop there. We will have more after the break. Do come back.

CORIN Welcome back to the Q+A health debate. I will go to Jonathan Coleman first. Do we need a concerted closing-the-gaps programme to deal with the clear disparities for Maori and Pasifika children in particular in this country, who are far more likely to get infectious diseases and suffer?

JONATHAN Two things – we’ve got free under-13s; also we’ve got a better public service result around reducing the number of preventable hospital admissions by 25% by 2021. So that’s things like respiratory illnesses. It’s head injuries. It’s the sort of things that could be treated in the community. And that’s why we’re delivering two and a half million New Zealanders free or very cheap GP visits.

CORIN Is it good enough that a Maori child is three times more likely to get meningitis?

JONATHAN No, it’s not good enough. And that’s why we’re fixing house.

CORIN So why don’t you stop it?

JONATHAN Well, we’ve done a lot. We’ve got the Healthy Homes initiative, so going in, making sure homes are warm and dry. 300,000 homes insulated. Free under-13s. We’ve got to do more, but we’re increasing access to primary care, and we’re also focusing very clearly on the economy, raising incomes, getting families off welfare. 60,000 fewer kids living in a benefit-dependent home, and that all makes a difference to health status.

CORIN Okay, David Clark, have you got a specific policy for improving the health outcomes for Maori and Pasifika children?

DAVID Well, we think that making those doctors’ visits cheaper will make a big difference, because once sickness gets into the family-

CORIN That’s not a specific policy, though, is it?

DAVID It is not a specific policy. The one that I would say is specific is that I want to have a study that looks at unmet need in a really granular way so that get detailed feedback on where the problems are.

CORIN What does that mean?

JONATHAN A study is not a policy.

DAVID So where Maori and Pasifika are falling behind and we don’t have that research, because the Minister won’t fund the research. He doesn’t like the results.

CORIN To be fair to Dr Coleman, it’s not that hard to find the research that shows that Maori and Pasifika kids are doing not very well.

DAVID I’ll tell you the other big thing – we know in our country that those in lower socioeconomic groups, including Maori and Pasifika, are falling behind in health outcomes. And the thing we can do about that is make a fairer tax system, and that’s actually what we have promised to do.

CORIN You’re saying the thing that we can do about it is have another study. Where is your specific policy?

DAVID I’m talking about a tax review that will actually make sure that we have a system of taxiing those who are most wealthy fairly.

JONATHAN A study and a tax. That’s it. More tax.

CORIN But why don’t you have a specific policy about this? For Maori and Pasifika kids?

DAVID Sorry, the GP visits will make a big difference when people can get affordable access to care. Now, half of New Zealanders will pay $8 or less to go to the GP under our system. Under Jonathan’s system, it’s $18. That’s a big difference for those families that are struggling.

CORIN Jonathan Coleman, one of the issues that is clearly coming through is that you’ve got the Waipareira Trust telling West Auckland families to go to the hospital rather than A&E, because A&E’s $90 for a treatment. There is a massive barrier for lower-income New Zealanders to get healthcare.

JONATHAN The first point I would like to say is David Clark has just announced a higher tax rate for New Zealanders.

CORIN No, no, no, no, no. I’m sorry, Dr Coleman. You need to answer my question.

JONATHAN I’ll go to Waipareira Trust. So, look, it’s not $90 to go to A&E. A&E is free in New Zealand. That’s the reality of it. Two and a half million New Zealanders under our policy get free or $18 GP visits.

CORIN So why are some of them charging that?

JONATHAN No, ED, a hospital ED, is free. It always will remain so under National.

CORIN Sorry. I put you wrong. After-hours medical clinics.

JONATHAN After-hours care – free under-13s. It is free for children under 13.

CORIN Yeah, because Dr Lance Armstrong, he hit out in-

JONATHAN Wrong Lance. It is drugs, but different drugs.

CORIN Sorry, Dr Lance O’Sullivan, he hit out in a Hamilton newspaper saying that he basically treated a family because he happened to be in Hamilton because they were turned away three times from an after-hours clinic because it cost $90.

JONATHAN So with our expansion of the Community Services Card, the extra 350,000 New Zealanders will get the benefits, including cheaper private GP visits if they’re seeing another doctor other than their own after hours. Look, it’s quite complex, Corin, but in the end, it’s free under-13s, including after-hours.

CORIN So what do you tell families watching this now if they get sick on the weekend, and they’ve been told by the likes of John Tamihere to go to A&E because it’s free, should they do that?

JONATHAN No, they are getting the wrong information. After-hours with their registered doctor for under-13s is free.

CORIN But what if they’re really, really sick? What are they supposed to do if they don’t have the money and they’re getting turned away?

JONATHAN Anyone who’s really, really sick should go to an ED. No, no, anyone who’s really, really sick goes to an ED, but that’s the point – ED is for people who are really, really sick.

CORIN But sometimes you can’t make those judgements.

JONATHAN No, seriously, we never turn away are anyone from ED. Doctors beyond politics.

CORIN Dr O’Sullivan is saying that three places turned this family away.

JONATHAN No, look, there’s a lot of complexity in that situation. That is around people visiting a doctor other than their registered doctor after-hours. It’s a red herring in this debate. Two and a half million New Zealanders getting free or very cheap GP visits. We are increasing access all the time. And we’re investing for patients and families.

CORIN Okay, is it a red herring? What would you do? What is your advice to that family at home?

DAVID We need to take the pressure off the ED. Lowering our doctors’ visits policy, that will be $10 cheaper under Labour than it would be under National to go to a doctor.

CORIN After-hours?

DAVID It’s going to take down the level of care needed because fewer people will get sicker and present at ED, and then we won’t have signs going up saying ‘eight-hour wait’ at Middlemore Hospital like we had last weekend. We won’t have old people waiting.

CORIN Admirable goals. Admirable goals.

DAVID And achievable.

CORIN But what is your advice to the family that goes to the after-hours clinic, they’re being charged potentially $90.

DAVID Well, they won’t be if it’s under-13s. Jonathan’s right on that point.

JONATHAN That’s right.

DAVID He does get some things right.

CORIN Then what?

DAVID If they’re over 13, that’s the issue. We’re going to take that down to $2.

JONATHAN Wow, a new policy. How much will that cost? This is a new one.

DAVID Sorry, not the after-hours. Not the after-hours, Jonathan. I’m talking about the GP clinics so that we actually make sure those services are accessible to people during regular hours so they don’t get so sick-

CORIN Let’s just clear this up in case there’ll be a press release flying around before you know it.

JONATHAN The 30 billion promise monitor is going up.

CORIN Are you talking about cutting after-hours costs?

DAVID No, no. Not at this stage. That’s part of the review that we will hold.

JONATHAN Oh, it’s a review, not a policy.

DAVID Because Tim Molloy and others in the sector have said that we desperately need to review the way these services are funded. We have pledged to do that. Jonathan won’t front up to that issue.

JONATHAN But what’s David Clark going to do? Look, he hasn’t got any policy. They have not done the policy work. They have had nine years.

DAVID Rubbish, Jonathan.

JONATHAN When we were in Opposition, we had discussion documents. We were out there developing policy.

DAVID Jonathan, we have plenty of policy around mental health and GP visits, nurses in schools. We’ve got plenty of them, Jonathan.

JONATHAN We don’t know what these guys are going to do, but we know it’s going to cost a lot.

CORIN Let’s pick up on that issue of mental health. Dr Coleman, why are we seeing a spike in the cases of mental health, depression, suicide. Give me your personal view. Why do you think we’re getting that increase?

JONATHAN It’s incredibly complex. It’s the same as is happening all around the world. Demand for hospital services in mental health has gone from 96,000 a year six years ago to 168,000. It’s the environment we’re living in, in terms of social media, changing social dynamics, the changes to family structures.

CORIN Just break that down. What does that mean? What are you saying? Are you saying that people are isolated?

JONATHAN Look, we live in a different way. If you look here in Central Auckland, there’s a lot of people living by themselves, not necessarily connected to whanau, not necessarily connected to the support systems that in years gone past, it’s really…

CORIN Just before I go to David Clark-

JONATHAN But social media, I need to talk about that.

CORIN No, no, no. But if you think that, if you think it is those isolation issues, etcetera, and connections, why aren’t you prepared to do more to make those connections? Build a society where those connections are made.
JONATHAN Listen, the government’s not the answer to all this. This is the responsibility of all of us - families, mates, sports clubs, workplaces, looking out for people. The government has to set the framework and provide the money, but the government just can’t be the total answer-

CORIN Okay, let’s go to David. Can you set the framework? Can you be the answer?

DAVID The worst youth-suicide rates in the world. Five times worse than Britain-

CORIN Sure. What would you do?

DAVID Inequalities that are driving it and domestic violence, and we’ve got to tackle this.

JONATHAN And what will you do?

DAVID We’ve already discussed this.

JONATHAN You’ll tax.

DAVID A fairer tax system-

JONATHAN Higher taxes - here we go. He’s announced it.

CORIN Dr Coleman, please wait.

DAVID A fairer tax system will make a difference.

JONATHAN He’s putting tax up.

DAVID I mean, I know people who do three cleaning jobs and do not get to spend time with their children. That is not okay. We need to live in a society where everyone can make a decent life, where everyone can have affordable access to care when they need it, including mental health care, and we’ve got a plan to roll out a service of mental health coordinators-

CORIN This is interesting, because there is a clear difference here. You’re saying that the government can in fact make a difference by providing those community aspects.

DAVID The government can make a difference by putting nurses in schools. The government can make a difference by having mental health coordinators in GP clinics and free care in GP clinics when it’s a mental health concern. There are things the government can do. Government is not the whole answer. Don’t get me wrong in that. We’ve got to tackle these things as a society, including violence and poverty. But government has a role to play in those things too, and this current government is shirking responsibility.

CORIN And you think this needs an inquiry?

DAVID We’ve got the worst teen-suicide rate in the world.

CORIN We know that, but you think there is the need for an inquiry?

DAVID I think we need a short, sharp inquiry to draw together all the previous inquiries and what’s known in the community sector. Unfortunately, the Treasury says the Ministry of Health doesn’t know what the mental health sector looks like. They wouldn’t know what a successful one looked like if it hit them in the face.

CORIN Well, they have said it was slow. I’ve seen the paper.

JONATHAN That was around a specific budget, but, look, all we’ve heard-

DAVID It was your process after nine years-

CORIN Let’s get Dr Coleman. Hang on-

DAVID After nine years, that’s what the Treasury had to say about your policy.

JONATHAN Studies and reports are not a policy. All we’ve learnt today is that Labour will put taxes up, so he's said they’re going to put up income taxes.

DAVID That’s not true, Jonathan.

JONATHAN You said it, you said it.

DAVID Stop making stuff up. No, I said we’d have a tax review to make our tax system fairer.

JONATHAN You said taxes will go up.

CORIN We always end up back at tax. Okay, I want to let Dr Coleman finish this off. So you are saying no to an inquiry? Why not?

JONATHAN Because we know all the issues. We are putting $100 million into new ways. So, there’s $224 million gone in this Budget. Mental health spend has gone up $300 million. There’s 150 more psychiatrists, 600 more mental health nurses. So we’ve got to do more.

CORIN If you know what the issue is, how has it got so bad?

JONATHAN Because I tell you, Corin, these are tough problems, and, as I said, it’s not government; it’s a whole of society approach. It’s a social investment approach that’s needed.

CORIN Jonathan Coleman, thank you very much. David Clark, thank you very much.

JONATHAN Thank you.

DAVID Thank you.

CORIN It’s been a fun debate.

END

link to both Part 1 and Part 2 of our debate.

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