Speech to Royal New Zealand College of General Practitioners conferenceHealth
Tēnā koutou katoa
Tenei te mihi ki a koutou
Kua tae mai i runga i te kaupapa o te ra
Ara ko Te Royal New Zealand College of GPs hui
Tēnā tatou katoa
Thank you for the opportunity to address you today.
I acknowledge Samantha Murton, President of the Royal New Zealand College of GPs, and also acknowledge the vital role she plays in engaging with officials from the Manatū Hauora – Ministry of Health on issues of primary care and the interests of GPs. Sam, I have always appreciated the approach you have taken when dealing with me personally over difficult issues for the profession. We may not always have reached full agreement on specific issues, but I have always come away with a better understanding of the perspective of GPs.
I am acutely aware that in addition to the demands of the role of College President, Sam has her own practice to run. And like all GP practices, that work is getting busier and more complex.
I acknowledge the enormous pressure that present circumstances are putting on GPs and their practices.
COVID-19 continues relentlessly with the predicted mid-winter surge upon us.
The flu season started early and, although forecasts said there would be a higher incidence this year compared to before the pandemic, what has happened has outstripped even those predictions. Every senior practitioner I speak with tells me this winter flu season is the worst they’ve experienced.
And as we know with the rest of the health sector, COVID-19 and flu infections don’t avoid the health care workforce. So, we have seen elevated levels of absenteeism putting further pressure on health services, including GP practices.
And that is often on top of vacancies being carried by practices.
Two other factors are major causes of pressure on GPs.
One is the fact that a disproportionate share of consultations are with elderly patients and patients with complex health needs which GPs tell me is not accounted for in the funding they receive.
The second is the ongoing pressure of having to continue to manage the patients whose first appointment and planned care referrals have been delayed because of disruptions caused by COVID-19.
I am conscious as I look at the data on wait times for planned care that each of the people affected are also patients of a GP and it is GPs who are often left to manage the ongoing needs of the patient until they see the specialist or get their treatment.
I hear from GPs about the amount of administration required for many health needs which adds more hours to the working week.
I also hear that funding increases in this year’s PHO Services Agreement were less than you wanted, and that the PSAAP protocol feels more imposed than negotiated.
At the same time I certainly have heard very clearly that the real priority for you is the review of the capitation funding formula. That is under review and I am expecting advice on it later this year.
Your profession is heard. That is real credit to the College.
So today I want to take the opportunity to respond to the concerns you have raised, as well as some of the issues that underpin them, and what the government is doing to address them.
But I also want to be clear many of these are issues that cannot be addressed by Manatū Hauora – Ministry of Health alone, or by Te Whatu Ora – Health New Zealand alone.
Nor can they, or should they, be addressed by your profession alone.
The fact that many of the challenges we face are not new, and yet still prevail, ought to be a good reason to evaluate or re-evaluate how we - government health organisations, and you and your professional bodies - are engaging to address them.
Before I go further on these issues, I want to take a moment to spell out the changes we have made, the reasons for those changes, and my expectations about them.
As you will be aware, we have changed the structure of the way public health services are managed.
We now have one organisation – Te Whatu Ora Health New Zealand - where previously we had 20.
Te Whatu Ora – Health New Zealand partners with Te Aka Whai Ora – Māori Health Authority, which has direct commissioning powers and will play a critical role across the system to ensure the health needs of Māori are better met.
Manatū Hauora – Ministry of Health will focus on policy, on regulatory functions and being the government's advisor and monitor of the health system overall.
The new national public health agency, embedded in the Ministry, is the lead on public and population health policy and strategies. Te Aka Whai Ora – Māori Health Authority will also play a role in these aspects in a collaborative relationship with the Ministry.
Pharmac continues, but with an expectation of much greater engagement with the rest of the health administration, as recommended in the recent review. The Health Quality and Safety Commission continues but with an added responsibility to support systematic consumer input into health services.
As part of the accountability framework for the new system we now have the interim Government Policy Statement on Health - interim because it was put together with limited consultation in order to be ready for commencement of the new structures. The next Government Policy Statement will be subject to more comprehensive engagement.
We will shortly finalise a New Zealand Health Plan which will spell out specific actions over the next 2-3 years.
Following this, the task of putting together the longer term strategies required by the Pae Ora (Healthy Futures) Act will begin.
But coming back to Te Whatu Ora – Health New Zealand, its role is to manage the performance of the public health system including managing the funding relationships with the funded sector, that is primary care, aged residential care, ambulance services and so on.
Their job is to get the best out of the system for patients. Health is people intensive, so the job is to do that by making sure we have the right people in the right numbers in the right places.
Just as importantly, their job is to ensure the working environment is satisfactory and that front line clinical health workers are supported to do their job well.
When it comes to primary care, that lift in performance - bearing in mind we have an estimated three hundred thousand people not enrolled with a practice and, according to a survey this week, more practices closing their rolls - will come through engagement with the sector and the locality planning process which is part of the reforms.
Locality planning, carried out properly, will enable an open conversation with health providers and the community about health services, and will result in a plan on what is needed. It will be an opportunity to explore alternative ways of organising the provision of health services.
Given the long term challenges we have, we should not expect just to continue to do more of the same. We have an obligation not only to face the problems, but to fix them.
I expect there will be changes in the way services are provided, and we have put aside money in this year’s Budget specifically to encourage integrated comprehensive primary care services.
With a single organisation running all our hospitals and managing agreements with the funded sector we have the opportunity to ensure a consistent standard for our health workforce, and consistent clinical leadership across the country.
The changes are not just about lifting system performance. The reviews conducted of our system, including the Waitangi Tribunal’s WAI 2575 Interim Report, confirmed the system does not perform well on equity.
We must improve our performance on equity.
Primary and community care have a vital role – in my view, the critical role – in improving equity by enabling access to health care for more people.
One of the ways we will do this will be through workforce initiatives to build the Māori and Pacific Health workforces. This will involve a combination of adding more clinically qualified people to services whose purpose is to reach into communities currently excluded from health care, as well as enhancing the role of the unregulated workforce.
The system changes we have made this year do not stand alone. They continue the priority this government has given to health over the last five years. This year we will spend $8 billion more on health than we did in 2017, an increase of 44 per cent. This doesn’t include spending on disability services which have been separated out as a result of the establishment of Whaikaha - Ministry of Disabled People.
Since Labour was elected, more than 3,000 doctors have joined our health system – including more than 1,700 working as RMOs and SMOs in our public hospitals.
We have also added more than 10,000 nurses to our health workforce – including more than 4,000 nurses in our public hospitals.
We have committed nearly $7 billion to the hospital building programme in the last five years compared to the roughly $1 billion spent in the previous nine years.
Buildings aren’t the only vital infrastructure for health services. We expect to spend hundreds of millions on data and digital infrastructure to support connected information systems. This will benefit not only the hospital network but primary care as well.
Our investment in upgrading mental health services has seen nearly 1,000 new roles established in primary and community care offering advice and support for those with mild to moderate mental health issues.
Our COVID-19 response has required significant additional funding. For primary care, that has been to support the vaccination campaign, and from the latter part of last year to support health and social support for people and households with COVID-19 through the Care in the Community programme.
I do particularly want to acknowledge the vital role GPs are playing in Care in the Community. Thank you.
But, as has so often been observed, it is COVID-19 that has laid bare for everyone the gaps in our health system, especially the level of understaffing.
The interim Government Policy Statement makes the government’s expectation clear that making the health workforce more sustainable is a main priority. When I addressed the boards of the two new entities when they met jointly on 1 July, I made it clear that workforce issues were the top priority and that recruiting to fill current vacancies as a matter of urgency is an expression of respect for the current health workforce.
There are a number of initiatives already under action or being considered in engagement with the sector.
For example, we are:
- Working with the College with a view to increasing GP registrar numbers to 300 per year,
- Improving conditions of work for GP registrars, and accrediting and resourcing more training practises,
- Rolling out the pilot in Waikato for NZREX doctors,
- Working with the New Zealand Medical Council and colleges to strengthen pathways for vocational registration (this is alongside reforms to the Health Practitioners Competence Assurance Act to ensure there are no unnecessary barriers to registration and practice),
- Working with regulators, tertiary providers and health providers to open more primary care placement and training options across medicine,
- Considering the place of specific equity issues around rural GP coverage as part of the rural health strategy.
Turning now to the staff that work for you.
I know that a major issue for primary care for recruitment and retention of nursing personnel is the disparity between hospital-employed nurses and those in primary care. We remain committed to working with the sector on pay parity.
The issue has always been getting parity right. It was my expectation that we would have concluded the pay equity process with hospital-employed nurses by now – an agreement-in-principle was reached in December. That would have been the basis of pay parity elsewhere in the sector.
It is now apparent that is some way off and I don’t think it’s right to hold off the pay parity process for primary care and aged residential care any longer. Ministers with a stake in this issue are expecting advice in the next few weeks on a process for this and it is my expectation we can get a process under way later this year.
This government has made it a priority to lift incomes for many in the health sector. We have other pay equity claims under active consideration or about to commence. This includes claims for hospital midwives, allied health workers, and, one of the lowest paid groups, home care and support workers.
Another issue causing major anxiety for patients and GPs is the growing delay in getting planned care done.
Te Whatu Ora – Health New Zealand has set up a clinical Taskforce led by Mr Andrew Connolly to work with all hospitals to review waiting lists and plan for a reset and recovery programme. GPs are represented on that taskforce, as they must be because patients look to you while they are waiting for their specialist appointments and planned care treatments.
As I have acknowledged many times, our system is under extraordinary pressure right now. Longstanding shortages have been exposed as a result of the COVID-19 pandemic and the worst winter the health system has experienced for a long time. I extend my appreciation to you and your colleagues around the country for the herculean effort you have all made and continue to make to carry on in these circumstances.
This is unquestionably an extraordinarily challenging time. Not only for you, but also your families.
I earlier laid out the major investments this government has made in health over the last five years. Governments continually face multiple competing demands. That is the nature of government.
The choices governments make reflect priorities and underlying values. For Labour governments supporting accessible and equitable health services is a top priority. For us, being free of avoidable health issues and getting adequate support for unavoidable or chronic health issues is a basic expectation and right of every citizen. This has been in the DNA of the Labour Party since 1938 when it introduced its ground-breaking social security legislation providing for, amongst other things, much better access for way more people to health care. Then, it was a question of equity.
The system has never been perfect. It’s not perfect now. And there is plenty more to do. But our pledge is to always do what we can to make it better.
We will do that within the genuine limitations of government. Amidst all the competing demands we will never meet every health expectation. But we can and must strive for a health system that provides the best possible with the resources available.
As not only a Minister of Health but a Labour Minister of Health I remain totally committed to achieving the best possible for every New Zealander reliant on publicly funded health services.
Which brings me to my final point. It was one I alluded to earlier.
The challenges we face in our system today have been a long time in the making. This government has significantly increased investment and changed the way our health system is organised in order to give ourselves a better chance of addressing those challenges for the long term.
The opportunity is here now. But government agencies do not hold all the solutions. You are at the front end of this crucial system. You see what is needed every day. We need you and all parts of the health sector engaged in determining the future shape and look of health.
There will be limitations. It won’t be perfect. Resolving today’s most urgent needs opens the door to tackling tomorrow’s.
But working together, understanding there are different perspectives and roles, and being stronger together – we can build a better health system for GPs, health workers, and the patients and people we ultimately all serve. That is a future of health for Aoteroa New Zealand that is ours to choose.