THE ANNUAL CONFERENCE OF THE EDITORS' COMMITTEE OF THE COMMONWEALTH PRESS UNION

  • Bill English
Health

I appreciate this opportunity to speak today as we share a common interest in what you print.

For a politician your pages directly influence how people see us, as one of our coalition partner's number is finding out the hard way.

From my stand point as Minister of Health you have a powerful affect on public perceptions of health services.

I want to acknowledge that I understand you are driven by more than circulation figures.

The core values of good journalism - the freedom of the press, the belief in the public right to know the truth and fearless exposition of fact and opinion are central to the success of a democracy. It must be a demanding task balancing these values with commercial reality.

And while it could be a surprise to some, I believe most politicians chose what can be an equally demanding life for more than taxi chits and subsidised accommodation. I put my hand up for the incredible opportunity that it is for anyone to be Minister of Health, not because it is easy, but because the effort and frustration is worthwhile. There are so many ways we can do better for people and communities with real human needs.

The press have a pivotal role in the public system because you can tell us real stories about real people. When we are sick we have few choices and rarely to make what choices put to us.

A Paternalistic health system needs occasionally to see itself in a mirror. For my part, tales of woe are often difficult to deal with, but each incident tells us something we might not have otherwise known.

Overall the coverage given to health is good. In recent months, health news coverage seems to have shifted from problems with the treatment people receive, to considered coverage of wider issues, like integrated care, hospital viability, the superbug and the measles epidemic.

There have also been some stories in the metropolitan dailies about how the Coalition Government handles health issues. I want to tell you today the job gets done regardless. The final test for the public is how the job gets done, not the quality of the philosophical discussion in the morning tea room.

A Minister of Health has to concentrate on what's important, not what's urgent. Every issue is a potential swamp of conflicting issues and mind numbing detail. It's like steering a super tanker, and what matters is the strategic direction of New Zealand's largest, most complex service industry.

Public health funding exceeds the export earnings of the dairy industry. We employ over 40,000 professional, skilled, articulate people in our CHEs. And CHEs use up only half of public health funding. At best, a good number of similarly talented people are likely to be employed in the rest of the health sector.

Health is New Zealand's biggest business and in your local area, the CHE is almost always the largest organisation in staff and turnover and certainly the most complex. All the other health and disability services outside the CHE are just as large in staff numbers and turnover though less easily identified.

What I enjoy about health, is the challenge all this represents as well as the challenge of changing the political environment, the challenge of motivating so many people and of bringing a sense of shared mission to a sector traditionally weighed down by its own internal and external politics.

To meet these challenges, I like you, need to know what's on your readers' minds - because your readers are the same people who have babies, need obstetric care, have accidents, need urgent surgery and grow old with creaking joints that are painful and need replacing.

I believe these people, as readers, taxpayers and health consumers are increasingly interested in whether services work for them.

They have high expectations for what services should be. They expect services to deliver value for money, to be high quality, delivered fast and tailored to their individual needs.

So many of your stories in recent years have been about the system failing to meet these expectations.

No service provider is immune from the increasingly loud call for greater customisation. And the consumer isn't grateful, nor are they ever satisfied. To do a good job for them is simply to raise expectations about the next round of improvements.

In health, as I'd expect in newspapers publishing, we need the capacity for continuous self reflection. This is something for which public institution are not well known. As one of my colleagues says, you have to keep on eye on the sacred cows or social changes will ensure they become cull cows. This is perhaps an apt metaphor for our CHEs.

In the past, the public sector was in many ways insulated from public intolerance to any slackness in the system because people felt a sense of ownership and loyalty to the service. Today, people are less tolerant.

Furthermore they want more certainty about the quality and availability of a service and their entitlement to it. They have a stronger sense of their rights and getting value for what they pay for.

The benchmark for the public health system isn't just what happens at the private medical clinic down the road. It's the service people get when they book their car in for an oil and grease, the service they get when they take out a mortgage, get a haircut, or read a newspaper.

A one cut fits all, short-back-and-no-sides style is no longer good enough in the hair care, healthcare or newspaper business. People, and I include myself, don't want to wait for haircuts, healthcare, or for the paper to be delivered.

But health isn't all about services alone. It's also about values. People want to know the health system is driven from values they can relate to personally.

As well as expecting health services to be underpinned by excellence, timeliness, personal attention and flexibility they want them to be driven from values like equitable access, giving children a healthy start and providing a fair go for everyone.

They want to be reassured that decisions are made for the right reasons, in their own interests and in the interests of their community.

The times when the service fails, when our communal values are disrupted, that can be news. However, the system in fact fails every day, in ways that don't make the news, but in ways that do matter to New Zealanders who deserve better.

I would like to tell you a story which is not remarkable in itself but illustrates what your readers, and the people I represent, want from a publicly funded health system.

On the weekend, I met a mother of five who was watching over her little team playing when her daughter fell and hit her head.

The woman gathered up her children trying to keep the injured child pacified and the rest quiet while she headed to the after hours emergency clinic in Newtown.

She waited there some time whilst the child was probed and poked and tested before the duty GP decided an Xray was needed. This wasn't available at the capital city's urgent doctor premises. The GP explained the mother would have to gather up her five children from the far reaches of the waiting room, and pop down the road to the hospital.

So the mother and her five children made their way to the hospital A and E department.

The ordeal dragged on with another three hours of waiting interspersed with more examinations from various people of increasing ascendancy in the hospital hierarchy. By the time of the Xray, the child was so distraught from the endless stream of people in white coats turning her eyelids inside out, that the mother had to physically hold the child down on the table.

They arrived home at six o'clock having set out at one o'clock. Now what is so remarkable is that this is as I said an unremarkable story. It's an every day occurrence.

My job is about a public health system where people want to do a better job than this. In fact it's more about these issues than about the higher profile stories like new cardiac surgery in Christchurch.

This mother and these children deserve a service that reflects their dignity as New Zealand citizens, at a time when they are vulnerable and anxious.

Let's look at the system from the mother's point of view.

This mother expected the GP at the medical clinic to pick up the phone, ring the hospital A and E, and talk to the clinicians there.

She expected, that in this age when her children can use the internet at school, a doctor could key into a safe, reliable information system, make a quick check on her child's medical history including the examination that had just occurred less than a mile down the road, and safely prescribe any further treatment without putting the mother and child through yet another round of the same questions.

If this couldn't be done, then she expected at least that the GP could have given her a photocopy of the results of his examination.

So why is it like this? The answer seems to lie in intangible things like culture, patch protection, general professional practices, and politics.

This mother of five has had time to read and tune into the news. She tells me she is a little disillusioned. She sees her elected Minister more interested in debating the employment status of some surgeons in Christchurch than he is in getting the after hours GP service and the hospital A and E to talk to each other. I advised her one was public and one was private. She told me she didn't care.

I think she is right. Political debate about the health system has trouble with the real public concerns. We have not been talking enough about the things that matter to the public.

And I don't mean just the articulate public who can or want to tell their story. The public health system has as its first duty the care and health of the most vulnerable in our society, the aged, the very young, people with mental illness, multiple disability, and communities with low health status, Maori and Pacific Island people. In theory the public system looks after these people the best, in practise its failed all these groups except the elderly.

So it's not just the middle classes wanting a better service for themselves, that drive changes in the public health system, its the increasing assertiveness of people whose needs we cannot ignore. To meet their needs as they deserve and we are obliged will mean kicking away the political crutches of the status quo - maintaining hospitals and surgery at all costs, relying on good intentions rather than results, funding power bases rather than effective services.

We are now in the early stages of a quiet revolution that is changing these things for the better. The principles driving it are simple. To provide the services the public expect, within our limited dollars, health and disability providers, be they public or private, employees or sub-contractors will increasingly work together to provide the best service for an individual and their family.

This is what the concept of integrated care is about. It is about providers working together for the benefit of the patients and even better still, trying to stop them becoming patients.

In your town people - doctors, nurses, pharmacists, rest home operators - are thinking about it - about how to look after the many thousands of people who bump around the current system, often but not always bumping into the service they need.

Change is coming from inside the health sector. The more news concentrates on the politicians the more it will miss the point in health because the engine room of change and improvements is not stoked in my office. It is out there in the heads and hearts of the people who work on a daily basis in health and who are coming up with new ways to look at old challenges.

Importantly, it's driven by the traditional values of health, care and consideration, respect for the dignity of each person and the values of their family and community.

Almost all the GPs that people in this room attend are now members of an organisation called IPAs. Around 80 percent of New Zealanders see a doctor who belongs to an IPA organisation.

These organisations are run mostly by doctors with very substantial public revenue, in some cases over $100 million. The GPs involved are starting to learn how much more they can do for their patients, by collective action.

Traditionally each GP worked on their own, just seeing the patients who come in the door, and doing a good job of it. Operating as a collective they have realised they can do a lot more for the people they care about with the same public money.

They get together and talk about the pills they prescribe, and the drugs they order. They have found they can provide better care at less cost if they share information about whether a cheaper drug works just as well, or some lab tests don't actually help with a diagnosis.

Without fail they have saved money, but what is more interesting is what they do with it. Traditionally government has sat in Wellington deciding how to spend a bit more money on some new national programme. We have traditionally made commitments for a million here, a million there, but it's hard for government to come up with the small, cheap, local initiatives which actually make a difference to people's health.

So instead of the Minister sitting in Wellington serving up cash to the latest fashionable health scheme, the local GPs decide on the most important need among their patients.

Some use the savings to get their patients simple treatments which are hard to get in a public hospital. Others have been using their savings for several years now to provide free visits to low income families.

These IPAs have also realised they need to get alongside others in the health service particularly to improve the care of people with chronic illnesses. Our hospitals see so many regular patients with asthma complications, or diabetes complications which can in fact be dealt with in the community at an early stage.

These health providers have moved past the talk and around the country now there are many examples of cooperation and understanding where there was none before. An obstetrics specialist told me the other day that after 30 years he had visited a GP practise as part of a cooperative maternity scheme. He said he had found out so much now he's decided not to retire.

It's not just groups of GPs who are quietly changing the way they work. Some of you will be familiar with community trusts. People in smaller communities have found that if they gather up all the public services into one place they can organise them more effectively and get more services and more control over the public money. I come from the South where there are six of these organisations, and there are now many others across the country, where none existed five years ago.

Governments only let people do what makes sense when all other options have gone. In most cases it's been the threat of hospital closure that's brought people together, required a common vision for their community, and overcome traditional antagonisms.

Trusts aren't just rural. In Auckland there are two large and fast growing trusts, Waipareira and Mangere, and all the main centres have union clinics which operate in a similar way.

The pattern of innovation at the margins of the system continues for Maori. The most interesting changes in our health system are happening among Maori. Maori communities have got together and are building up sophisticated modern health systems for anyone who wants to join up.

Before long the best Maori organisations will be well ahead of mainstream services in their ability to actually influence the health status of their community. Maori providers are building systems for the next millennium, without the baggage of history. They don't have to start with a system set up in the 1940's - they start with nothing except the will to better for the lot of their people.

They face huge needs, with little money. They are showing us how to really focus on needs, and they have the social processes which mean the community can successfully participate.

These organisations almost certainly do a better job than the traditional public providers. The reasons why are common sense.

The people who run these organisations, are better motivated, they have a clearer understanding of the needs in their community and in particular they are better able to form relationships with other parts of the health system that deal with you and your needs. In our traditional system each part functioned as if it were sufficient unto itself. The new health organisations will only improve health if they realise they need the rest.

These newer organisations have the capacity to turn the usual rhetoric about preventative health into reality. We all believe it's a good idea, but we need people with resources who have a good reason, and have the incentive to seek out and implement effective preventative health measures.

Their further development will almost certainly include taking on a wider range of health services and then government revenue outside of health and disability services. Because they are closer to the people they have the capacity to organise resources more appropriately around the highly complex social needs we are familiar with.

Running a big health budget is a tricky business, and those aren't very committed are weeded out early. Not everyone could or should build the infrastructure of a health organisation. But we do want to move decisions on health resources closer to the people who see the needs, while improving accountability for public resources.

It will not be long before we will have enrolment, where each of you will be enrolled with some organisation that takes a greater degree of responsibility for your health. So where do our CHEs fit into this future?

A recent complaint I had came from a person who had a colon operation in one of our big hospitals. Unfortunately the surgeon and the dietitian weren't on speaking terms, so the GP gave the patient the wrong advice about what to eat.

The patient went on the wrong diet and by the time the staff got to talk enough damage was done to require another two weeks back in hospital.

We have some way to go to really develop a culture of personal responsibility for the quality of service right across the public hospital. Ninety percent is good but not good enough these days.

I visited a hospital recently where they told me that from the time you visit the GP till the time you finally get your hip replacement, you will fill out 35 forms and see over 60 different health professionals.

The hospital has now cut that down to three forms and I think about 20 people, simply by going through the exercise of talking to each other about what they did for the patient.

The CHEs are now starting to see themselves as part of a chain of healthcare. They are starting to get alongside GPs, disability providers, non government organisations and alongside each other to keep people out of hospital, and to decide the best way to look after them if they have to go to hospital.

So the quiet revolution is not about more public or more private, but about public and private. Government and local groups getting together to do a better job. It's also about trying to answer a question whose answer keeps changing - who is in the best position to get the best care and support for the public resource. In that sense our approach to public health has to be open minded and pragmatic, because the answers will depend as much on say progress on information technology as it does on political will.

We have an environment where we will make significant progress to better health care and better disability support over the next five years. The Coalition Agreement has given us in health, a much more positive atmosphere in health and I want to explain why I think that is.

People will accept changes, in fact they will want change if firstly they can be convinced that change will mean better services, that it will be a change for the better, and secondly that the change doesn't offend their values. The Coalition Agreement talks about health in a way which reflects the values people hold about their health system - the emphasis on better health, the move to non-profit hospitals, the recognition of children as a vulnerable group who need special concern, the emphasis on cooperation and collaboration.

These words are just words but they have made a difference, because people in the system and outside it have more confidence that decisions are based on values they recognise.

Can they have confidence in the health system and improvements? I don't think they will believe politicians simply because we have a bit of a track record marked by the election process which encourages over promising and under delivering.

That is why it is so important to win the hearts and minds of the people who deliver health services. They will be the ones who can convince their patients and their communities that a change is a change for the better.

It is my expectation that a consensus will develop at the coalface, out there where these people are working with their patients. It will be Government's job to have sufficient courage to accommodate their solutions.

I believe the New Zealand public, your readers want and are interested in seeing their tax money providing better publicly funded services rather than hearing more bitter philosophical debate.

I welcome your column inches devoted to health. There are changes happening and more on the horizon. These deserve and need detailed journalistic scrutiny and further public debate.

Thank you.