Action for Health and Independence ConferenceHealth
Opening address to
Action for Health and Independence Conference
Michael Fowler Centre, Wellington
7 pm, 15 October 1998
This is a special gathering of people. You have come from all parts of New Zealand and all parts of the health sector.
Many of you I have met and had the privilege of working with.
The job of a Minister of Health can be difficult but my own commitment to better health for more New Zealanders is constantly nourished by the commitment and energy I see in so many of the people who serve our public health.
You have been invited here essentially to tell your stories and learn from the stories of others.
The Hikoi of Hope ended here in Wellington recently. For many people in need you have been their hope, and it is our obligation to apply our huge personal resource to bettering our service and bettering the health particularly of those most in need.
If we need reminding why we bother to seek better solutions, why we argue about policy, why we learn how to work with others - it's because we here at this conference can make a huge difference to the lives of so many people and their wider community - people in pain, who have lost family, work, independence and their sense of belonging to a community where life rushes on regardless, because they have lost their health.
We can make a huge difference to a community by understanding its needs, and using health funding to meet those needs and prevent them arising.
We have a wider obligation as well.
The resources we use are not ours, they represent the expression of the collective will of New Zealanders to improve the health of our country. We are obliged to reciprocate the good intentions of the community by using their resources to the absolute best of our ability. Anything less lets them down.
In health the road behind us is paved with good intentions and brave words. The key word of this conference is action. The problems are well rehearsed - in health we have come up with some solutions. This conference is about the problem solvers showing what they have done - it's about the learning process that will assist each of us, including me, to become part of the solution.
Today I want to outline principles of the Government's social service delivery. The health sector does not exist in isolation from any other sector. The action we take always affects the other dimensions of people's lives and therefore the other support they need.
The common thread in how we approach social services is empowering people to manage their own lives. How we do it is through positive support, partnership and participation.
Positive support is about getting alongside people and communities to work with them on the needs they have.
We acknowledge the capacity of a community or a family and seek to build on that capacity, rather than create dependency.
Supporting their ability to achieve independence is more important that proving my capacity to care. Work capacity testing has been controversial concept in health and welfare circles. I find people with disabilities and mental illness much more interested in the concept than some of their advocates.
Partnership is about forming a relationship with communities and families where through mutual responsibility we meet their needs.
Partnership is about a relationship of equality - everyone rightly benefits from the association because they contribute to it. Maori health providers contribute the social and cultural capital that makes services appropriate - government contribute the funds and the backup. As you will know real partnership is about more than just sitting down talking to people. For government it means doing something hard - handing over power and thereby empowering.
And finally participation.
Everyone has a role they can play. A social service works better if it reinforces the networks and relationships in a community. That means an effective health service isn't just about the few who are qualified, it's about a whole family, or a whole community. Everyone has strengths that are needed. People are less willing to rely on the strengths of government, once they realise what they can offer by their own participation.
We are currently looking at the responses to the proposed Code of Social Responsibility. It's clear people don't want a coercive code or legislation. This exercise has been like a big public meeting more than a survey, and the responses are all the more vigorous for it.
Putting aside the extreme views expressed, the bulk of the responses indicate people want government alongside them, supporting individuals and building up the social capacity of families and communities, rather than government replacing those capacities.
These principles add up to a different balance of the relationship of government and the communities it serves, a balance where more power lies with the people we regard as needy.
In health, in education and in welfare these principles are widely understood, widely supported, they are changing the face of social services and changing the way policy makers think about social problems.
There is another social benefit.
New Zealand will be better served by vigorous organisations which strengthen the networks and relationships within our communities. The tendency to fragmented families, higher mobility and isolation can be countered. This government has actively sought to build up organisations which foster a sense of collective action and collective purpose in our communities.
I am proud of your achievements in this respect in health particularly in those communities which are generally regarded as lacking the capacity to carry their weight. In truth they can, and I point to rural communities, to the union health movement - now so vigorous - to Maori health providers, and the growth in confidence of the mental health consumer movement as the destigmatisation project takes hold. These are moves along the path away from dependency and paternalism.
If it's a measure, you may be interested to know that a bit more than a third of this audience represents groups who did not exist five years ago.
I am disappointed in the Labour Party health policy because it fails to recognise that any of this has happened. If you have poured your efforts into building social capital and a better health service you are part of the "unmitigated disaster for the public health service", to quote Labour. Indeed they attacked every change that lead to the opportunities you have taken. Labour is mining the best thinking it did on health in the early 1980s. If that's where the answers lie to the hopes of the Hikoi, then they are not listening very hard. Real change is harder than nice words.
The developments in social policy are well and good but they don't of themselves recognise the wider determinants of people's health and welfare, nor the complex interactions many people have with all our social services. That requires co-ordination between the different service sectors. We want to aim to organise social support to around the needs of a family and a community, rather than expecting them to find their way around the myriad of services.
That's why the Strengthening Families policy is so important.
Strengthening families is about bringing social services together at a local level to get better co-ordination, to work across the boundaries particularly with respect to high needs families. It is not a social programme of itself, it is a vehicle for intersectoral co-operation. It has been started in every local body area in New Zealand with the early versions starting now to gain momentum. The concept has strong support among the people in the field even if their agencies can still be a bit territorial.
Initially Strengthening Families involved Health, Education and Welfare. It is the umbrella behind Family Start, an intensive support service run on behalf of all three agencies for at risk families. Now we are adding housing to the mix and, in some places, the justice services are participating.
This will grow and grow because it makes sense.
We see so much potential in the Strengthening Families concept that the respective Ministers now meet regularly in a formal group to maintain the direction and argue about the funding.
I can see Strengthening Families becoming a vehicle for much large scale co-ordination and local decision making for public social services in regions of high need - a kind of community action zone where the wider determinants of health and welfare are targets for direct co-ordinated action by government. This, I believe, is one credible response to the hopes of the Hikoi.
The conceptual parallel with ideas of integrated care within health mean we as a sector can contribute greatly to reinventing government social action.
I want to give you one small example of how we can fan the flame of hope.
I attended a function in a Mangere hall recently to hand out certificates to the people who helped in our meningitis campaign in Auckland this winter. A+ public health services worked with community groups and the employment service to train and organise people to go door to door explaining to families what the disease was and how they could tell their children had it.
Among this group of students, housewives and unemployed people there was a palpable sense of pride and achievement because they had made a difference. They spoke the languages of that community. That was their contribution and it was probably more effective than our traditional public health programme. A+, not known for its strong community orientation, found a method of educating parents which built on the capacities of a community too many regard as hopeless.
So that's a framework for social services - positive support, partnerships and participation.
Now I want to turn to health to tell you why your work here in the next few days is so important.
Health goals are part of the health scene and have been for some time.
There are a number of ways to express our goals. Each year the Ministry of Health publishes a detailed description of our progress against 89 measured outcomes. It gives us a detailed insight into health status and its change.
At a political level we talk much more simply about three priority areas, mental health, Maori health and child health. In each case we have given priority to strategic planning and to creating forums for representation and discussion, for instance the Maori Health Commission, the Mental Health Commission and the Child Health Advisory Committee.
It's too easy to talk about goals and then for practical purposes ignore them. I have not let that happen and do not intend to do so in the future.
These goals are serious. I expect to see them increasingly make a difference to where the money goes, and how we contract for services.
If low health status can be improved with more equitable distribution of funding and services, we will do it.
If it can be improved by changing providers then we will do that.
If it can be improved by better co-operation and integration of services then we will seek out those who are willing to provide such a service.
This is part of a continued shift to a population focus for our funding and contracting. The HFA has restructured and one of the benefits I expect to see from that change is a greater capacity to reorient contracting and funding around populations and disease states, rather than how providers choose to organise themselves. Funding will increasingly become aligned with defined needs. Many providers can see the trend, and the innovation I see and you will hear about should give us some optimism that we can develop systemic rather than marginal solutions to complex problems such as the increasing prevalence of diabetes.
It's simply not enough to address such a problem by overlaying the existing funding and services with a new programme and a glossy booklet.
Tacking public health ideas on to the margins of treatment services has worked sometimes but not nearly often enough. A real focus on population health will mean public health concepts of prevention and measures of public health will become part and parcel of everyone's thinking.
There are 20 million GP visits per year in this country, each an opportunity to communicate one on one about better self care. Many GPs take that opportunity but others don't. The way we pay for primary health care needs to change so that we pay for credible, effective population health measures as well as day-to-day diagnosis and prevention.
I don't believe we will bring about these changes through dreaming up new structures.
I have consciously chosen a path of incremental change, of listening and learning by doing. We have for instance set up the integrated care demonstration projects so that they can be transparently evaluated, so you can assess professionally whether a different way of organising services makes the real difference we think it can.
There is an international tool kit for better care and better service. It's our job together to take the best of it and adapt a Kiwi version of better care and better service. I ask you to keep an open mind in that process. I hear extravagant comments about the ethics of various ways of managing health's limited resources. Let's look, listen and learn and judge the results for people with health needs first, and then against our own interests second.
I want to hear your stories, share your understanding, and acknowledge your experiences, so that others can follow your lead.
In particular, we need to learn from each other. We need to learn what makes people take responsibility for action, and then commit to taking it. I want to learn what reasons you need to take the action that makes sense for the patient and the community and how government can remove the barriers and encourage you to take it.
Tomorrow we are going to hear about successful initiatives, and I hope you will identify the keys to these.
You will hear from a wide range of organisations, on a wide range of services. Most of these are new, and they exist because a few people had the vision, leadership and energy to make them happen. I hope you will be inspired by them as I have been.
You will hear from an IPA (Pegasus), a hospital-based service (such as the Otago Diabetes project, or New Traditions in Hamilton), or a community-based service (such as the Whanganui Disability Resource Centre, 198 Youth Health in Christchurch or the numerous Maori and Pacific Island initiatives we will hear about).
Our work on Saturday is to apply the lessons of success to priority health and independence issues. You will select the issues you wish to examine in each of your work groups. However I would ask you to consider one or more key outcomes for Maori, for children, for mental illness and a disability issue in each of your streams. These are the highest priority areas for action across our sector.
To extend and spur our discussions, we will be hearing from speakers from the UK, USA and New Zealand on their experiences in making a positive change for health.
Perhaps our speaker from Seattle will be able to dispel some of the prejudices we hold here about the US health system. I have never met anyone in health from whom I haven't learned something. Everyone knows something we don't.
Most of the money in the New Zealand health service is invested in salaries. That is, on people serving people.
You are our most valuable and most effective tool for change. And the culture you are establishing through your examples will last much longer than any one individual in any one position.
Positive support for the people we serve comes from partnership. It comes from working with our sibling social services, and with communities as equal participants. You are leaders in health, people that New Zealanders rely on and trust, people New Zealanders want to be proud of. We can't ask others to adopt principles of partnership or learning if we do not model those behaviours ourselves.
I like the line I've heard more than a few times lately - "We can't be leaders and victims at the same time".
This is a conference of leadership.
Finally can I remind you why we are all here. Three and a half million New Zealanders rely on our public health system. Most have no choice of private care - they are entirely in our care.
You and I have the daily job of dealing with consequences of ill health - people in pain, people under pressure, people who lose their jobs, their livelihoods, their independence because of bad luck and ill health. We talk with and work with people who share with us their vulnerability and their dependence, but they also share with us their human dignity.
You and I have the privilege of the opportunity to make a difference to their lives when such a huge difference can be made, and the chance to protect a community from the suffering. That is an opportunity that brings with it a profound ethical obligation of higher motives but also greater efforts.
I now declare this conference on Action for Health and Independence open.