ADDRESS TO THE MEDICAL FORUM, OTAGO MEDICAL SCHOOLHealth
Thank you for inviting me to address this forum. I always enjoy visiting Dunedin.
I have a great affection for this city dating from my past time here, and a great interest in its future. I also welcome the chance to discuss the future role of teaching hospitals in the health system - especially while speaking in this hospital, which has been so important for the medical school and for the community.
The first things I plan to talk about today are the extensive and rapid changes in health care. Then I want to talk about some fundamental principles in health care provision. These shifting patterns in health care are quite a challenge. It always helps to go back to the basics to work out the best way forward.
Finally, I'd like to look at how all this applies to what is happening now at the Medical School and in the Hospital. I think there are ways in which we could be working together better.
The most dramatic changes in health care have been technological. There is very little I can tell you, the experts, about this area.
Information technology has transformed, and will continue to transform, not just the way we work but the very nature of our work. The Ministry of Health wants to make sure that we are using information technology the best way possible. Its "Health Information Strategy for the Year 2000" looks forward to information being shared across the board at every level. This should achieve greater co-ordination among health providers, with much better resultant health outcomes.
Medical technology is equally exciting. Much of the fascinating history of medicine is the history of its technology. We can only be grateful for such technology. Again, there is very little I can tell you about the advances in this area. But it is worthwhile to reflect on just how many benefits have been brought about by clinical developments. Hip and cataract operations, to use some simple examples, are now done just so much faster and cheaper and with so much less trauma to the patient. Developments in recent information and medical technology continue to make huge impacts on the ways we gather data, and apply knowledge.
Another change in health care is higher consumer expectations. Perhaps in the past people made exceptions for a public service. That's no longer the case. Now patients expect quality, reliability and access. We all have a strong sense of our rights, and of getting what we have paid for through tax and medical insurance.
Here again, technology is raising both people's expectations, and their knowledge. They can find out much more about what medicine can do, and about their own conditions.
The average age of the population is increasing. Many in Government are worried about funding future superannuation. The demands of future healthcare are even more worrying. Wisdom may come with age; health rarely does. We need to make a lot more changes to care for many more old people. Increased demands on resources are inevitable.
The cost-conscious payer for health care is another driver for change. Government has to share out limited resources as best it can. That has always been true, whether the government has always done a good job or not. However the difficulties of this task have grown. Advances in medicine and heightened consumer expectations mean that limitless amounts of money could endlessly feed medical services.
Another change in this area is the growth of private medical insurers. They also pay for services, and want to see value for their money. They increase the market pressures on the Government to be even more efficient. We compete to provide care, and to employ carers. We try to use funding carefully, but must pay market wages.
Finally I want to mention are a couple of contradictory trends.
One is increasing specialization. The other is the more informal delivery of health care. Doctors are only one group among those giving primary care, and secondary care is more frequently available outside the hospital context. Again, both development of tertiary care, and greater access to primary and secondary care, are helped by technology.
It's interesting to speculate on the trend towards greater informal access to health care. A recent BMJ editorial discussed the scenario of "the informed consumer". This is consumers using "information technology to access information and control their own health care." They will consult "professionals far less often(. professional care will be viewed as the support to a system that emphasises self care." Self-help is already part of our health culture, and I think this is a trend that will become stronger.
What does all this confluence of changes, this jostling of issues mean? What does it mean for the role of hospitals? What does it mean for training in hospitals? How does it affect health care funding? How can we find a sensible, just, affordable way forward?
I think the best guide through this confusion of glorious possibilities, and terrifying threats, is to go back to some basic principles.
We need to look at what is most important in health care. The funding decisions that Government must make can then follow these priorities.
As Health Minister, I follow three fundamental principles:
Number one: to put the public and population health needs first. This may be as much about prevention of ill health as cure for it. It is also about providing efficient, sufficient health care throughout the country. If the body has no major illness, all its individual parts will generally be healthier. If the body has a major problem in one area, none of its individual parts will function well. Training in medicine, and funding for that training, must follow this priority.
Number two: to ensure good delivery of health care. A well organized, efficient health care system is no use if it is not totally attuned to the individuals it serves. In fact, dynamic flexibility is essential to a well organized system.
It means too that decisions are best made where the work is being done. I am eager for more devolution of decision making away from Wellington. However, the Government still has to look at the funding needs of the country as a whole.
This second principle means that training must be responsive to the needs of the individual, as an individual, not merely as a dot on someone's research graphs. The individual's needs are paramount. This requires understanding and respect for that person's context. Good health care fosters good relationships.
The third principle is simply a corollary of the other two. The Government's priority is to pay for what is needed to meet the most needs the most effectively.
Having looked at changes, and discussed principles, let's talk about how they apply to the role of teaching hospitals. How should we allocate resources in response to changing needs in health and its training?
The best possible answers to these questions are not easy to find. These are complex issues. They are complex because of the confluence and jostling of changes I have described. This complexity is increased because medical schools and their hospitals are (or have been) conservative institutions.
The difficulty of getting to good answers is increased yet again by the fact the Government has an extra problem when looking at the work of training hospitals. We own them, but when we come to find out what needs funding, we are presented with what could be called a "black box".
We are told that there is magic inside this box, and that we need that magic. All it needs to work is some money, which we are to provide. We are not told how this money will be converted into magic, or why we should even want this particular kind of sorcery.
We no longer believe in magic, and we are not interested in black boxes.
They are dangerous for all concerned. One danger for the teaching hospitals is that the Government's funding decisions necessarily become arbitrary ones. If we do not understand what the money is for, we could disrupt important processes by inappropriate funding.
Another problem is the suspicion that the black box generates. The Government spends a lot of time fitting resources to demands. In the past, some things never had enough resources, while others did. Teaching and researching tertiary health care always seems to have had enough. With just a fraction of that funding, Maori mental health, for example, could do a great deal of good work.
We prefer to put resources where the benefits are obvious.
The Government needs to know that what happens in teaching hospitals is what it wants to pay for. It seems also obvious then, that the Government and teaching hospitals will get on far better when magic processes are replaced by comprehensible ones.
We cannot start talking together properly until transparency, and comprehension, exist. Once we start talking properly, then we can start working together on shared goals.
So - let's get onto working out some of these shared objectives. I have outlined what I think are priorities in the health system.
I would suggest that the medical schools also have three major principles.
The first is good teaching, the second good research, and, as their ethical corollary, the third is the good care of individual patients.
In practice, this has sometimes meant that the medical schools and the Government have not always agreed upon priorities. The medical schools' priorities are only a subset, albeit an important and expensive subset, of the overall demands made upon Government funding.
But, with open communication and a mutually strong desire to work well together, there is no reason why we cannot do so.
I would further suggest that good medical teaching, most often good medical research, and most certainly good patient care must follow new patterns in health care. Otherwise the teaching of medicine does not match its practice.
Teaching and research in the training hospitals need to support the public health system.
Some criticize the training hospitals because they seem to use the health system mainly to support teaching and research. It is no good doing detailed lengthy research on hospital patients if that research doubles the waiting time for treatment. It seems to me the best way for the training hospitals to work in with the Government is to show their relevance to resolving issues in the wider public health service.
Teaching hospitals have been a strong force for clinical progress. For this, many patients must be thankful. But because clinical care is so complex, and requires such resources, growth in this area can hold back the rapid development of less complex, equally important, services.
It is not easy to balance the value of these competing areas. But I can say the Government has a strong interest in increasing access to primary and secondary services, and in reducing costs. We need to have financially viable hospitals. Therefore we do need to have transparent decisions being made about that.
Given the pace of technological change, there could be an endless increase in the quality of tertiary care. It is hard to see how effective that would be. The real pressures, the ones that affect most patients, are those on the quantity and quality of primary and secondary care.
It comes back to the Government having the most concern for the overall health system, and making sure the individuals throughout it get the best possible care.
Of course, primary, secondary and tertiary care are interrelated. Good tertiary care and research should contribute to the whole system. It is a matter of working out the right balance, strengthening weaknesses, and of getting healthy, health-achieving relationships working.
My final point on training hospitals is this - the most obvious area in which there is a clash between traditional medical training, and what is happening now in most medical practice, is in the use of hospitals. Spending a lot of time and money training in advanced tertiary care is simply not appropriate.
The overall effect of complex health care changes has had one clear result. The role of the hospital is shrinking. In Dunedin, this is exacerbated by a static population.
In general, the time people spend in hospitals is shrinking. The proportion of time health professionals spend in hospitals is shrinking. And, as mentioned earlier, services that were hospital-based are now carried out in a variety of community sites.
All this can be seen in the fewer hospital beds we now need. Bed numbers have been decreasing in New Zealand since a high of 16,295 in 1994. Last year there were just over 15,000 hospital beds in this country.
The proportion of the total health vote which goes to hospitals is also decreasing, from 54 percent in 1993/94 to just over 50 percent in the 1996/97 year. But that is not to say that CHE revenue is falling. In fact it has increased by quite substantial amounts over the same period - a cumulative increase of 12 percent in the case of all CHEs and 13.5 percent in the case of tertiary CHEs.
We just can't justify spending extra money on hospitals, when it could be used more efficiently, and is needed more urgently, elsewhere.
We're going to start thinking of professional medical training in a way where the hospital is only part of that training. Even those professionals based in hospitals are now carrying out their work in a number of different contexts.
I am sure many people in the audience would agree that in fact these changes in training, reflecting changes in health care, are happening.
Otago Medical School's revised curriculum shows that. The curriculum's shift in emphasis does do a lot of what I have been talking about today.
Students are learning much more about assessing people within their own context, in their homes, in community support agencies, as part of relationships and as part of larger patterns in society.
They are working on communication skills much earlier in their training.
They are looking at the doctor's multiple roles, including being part of a wider team involved in improving community health. In the clinical training curriculum, which I know is still to be finalized, it is very likely that there will be significant increases in community-based teaching.
Designing and implementing this curriculum has been hard work, and shows the medical school's commitment to good medical teaching. I think it's very exciting. What I also think is that none of us realize fully just how quickly the shifts in health care are happening.
Unless the human condition changes beyond all recognition, we will need hospitals. And as long as we need hospitals, we need to learn how to use them.
But the hospitals of the future will work differently from those of today. I think it likely hospitals will continue to develop much as computers have.
Huge unwieldy structures are evolving into smaller but far more powerful ones. I see the future hospitals as an efficient source of highly specialized care. Most health care will take place in more accessible and responsive sites. Those sites are where most of our new doctors will do most of their working, and training.
And, as with computers, it will be the pace of this evolution of health care that will surprise us the most.