Emergency Department conference

Good afternoon.

Thank you for inviting me to speak at your conference - "EDs: their place in the community and the ED six hour target." 

It's good to be here.

This is your third annual conference, and the third time I have come to speak at it - once in opposition, and now twice as Minister of Health. Your work has always been important to the government, and always will be.

When I met you last year I talked about the world financial crisis and how that is limiting our financial options in the public health service.

Since I last met with you, the international financial situation has continued to deteriorate. And that of course has an impact on us here in New Zealand. Our proximity to Australia and China masks much of the impact of the financial crisis particularly in Europe.

The United Kingdom is facing the largest peacetime deficit in their history. Public servants including doctors and nurses earning more than $40,000 are facing a two year wage freeze, and performance-related pay for civil servants will be cut by 2/3rds. 

Just last week the Governor of the Bank of England urged unions to accept public sector reforms and job cuts by warning that anything short of tackling the UK's Budget deficit would "fail the next generation."

In Italy the Government passed an austerity package of around $50 billion of saving which includes a freeze on public sector wages.

In Ireland the Government has cut public service salaries - including doctors, nurses, and teachers - by up to 15%.

Greece's socialist government has frozen public sector wages and pensions for the next three years.

In Hungary they plan to cut the cost of public servants pay by 15% and freeze government spending.

The Portugese government has put a hiring freeze on its civil service, along with a 5% wage cut for top earners in the public sector.

Germany has the strongest economy in Europe.  But the Germans plan  to reduce the number of their federal public servants by 15,000 - or 5% - and cut their salaries by 2.5%.

Canada has frozen wages in the public service for the next two to three years.

The next year will also be difficult in the health sector as the increase in funding in next years Budget will not be as substantial as throughout the 2000s or even our first budget. It will still be an increase but not as big an increase.

Our focus must remain on getting better and more health care from the resources we already have. And that's why treating ED patients sooner makes sense at both a patient and financial level.

When the National Government took office we established six streamlined health targets - one of which was shorter stays in Emergency Departments.

Our target is for 95% of emergency department patients to be admitted, discharged or transferred from the ED within six hours.

You, the Emergency Department community, had been voicing concerns about worsening overcrowding of your departments for some years.

You were frustrated that many of the contributors to overcrowding were outside the Emergency Department's influence.

ED presentations have grown by an estimated 20% in the past five years. This is well in excess of population growth.

The Ministry of Health in 2008 surveyed patient-level length of stay information from one large and two medium-sized Emergency Departments over a two-week period in the usually less pressured month of February.

While the majority of patients were seen within several hours, a significant minority waited much longer. At one of these three hospitals up to 20% percent of patients spent longer than eight hours in the ED. But if you look at only those patients later admitted to hospital, between 10 and 37 percent of patients spent longer than eight hours in the ED.

As Professor Michael Ardagh has written: International evidence is clear that overcrowding and long patient stays in ED are linked to poorer patients outcomes, longer in-patient stays in hospital, and less service.

And since we are in these difficult financial times, we must all note that delays in the long run are likely to be more expensive than doing things sooner. Eg: delayed treatment of fractures and other injuries can lead to infections, more pain and DVTs.

Timely care makes sense. It's better quality care.

When we met in 2008 you asked for an appropriate ‘whole of system' focus to be put on the issue of acute patient flow through our hospitals, and we obliged with the shorter stays target.

As you all will know, achieving the targets is a priority for this Government and we are closely watching the progress being made.

And we are publishing the results.

That is one way of engaging the public in how well their DHBs are doing.  Public scrutiny and some friendly rivalry is also good for results.

You are to be commended for what you have achieved so far.

Across the country, EDs are seeing and treating more patients faster. 

But more importantly - I am hearing from some of you that the frustrations of overcrowding are much less now.

This is despite increasing demand for your services, and another busy winter.

A significant feature of this target, compared to examples of Emergency Department length of stay targets in other parts of the world, is that it is ‘bottom up', not ‘top down'.

It is driven by concerns for good quality clinical care.

It is driven by you. You designed the target.

Increased acute demand

The changes in ED acute demand you are experiencing vary across DHBs.

Some of you are experiencing falling demand, many of you are getting growth above the level of population growth.

Some of that increased acute demand is translating into more inpatient admissions.

Nationally inpatient acute demand is only a little over population growth but like the increase in numbers of people presenting at EDs, this varies from region to region.

Growth in one doesn't necessarily parallel growth in the other. 

But both are impacting on our hospitals.

If we are to maintain the improvements we have seen in acute care in our public hospitals - we need to examine the drivers of the increases in both kinds of acute demand.

Some of those drivers include an increased supply of services driving demand, the greater burden of illness and injury - changed public behaviour or expectations, and our ageing population.

It's important that DHBs look at those drivers to identify ways in which the growth could be stemmed through prevention or dealt with elsewhere.  

For example, the recent Aged Residential Care Review reports considerable numbers of rest home residents present at emergency departments.

During 2008 over nine thousand rest home residents arrived at EDs - that's 26%, or over a quarter, of all DHB subsidised aged residential care residents.

Many of them presented multiple times.  The number of presentations to EDs during 2008 was nearly 15,000.

And New Zealand aged care residents appear to use more acute hospital care when compared to international best practice.

The ARC Review found that acute hospital days for aged residential care clients are 27% higher than international benchmarks.

And that aged residential care residents visits at EDs in New Zealand hospitals are roughly twice the level of an international benchmark. 

There is an opportunity to consider reallocating the costs incurred at hospital level towards preventing rest home residents presenting in the first place by improving clinical and professional resources in the community.

Caring for the frail elderly is important for New Zealanders. And that is why I would welcome your involvement with the Government, the Ministry, geriatricians and DHBs as we focus more on the drivers of acute demand particularly for our most vulnerable older folks.

Progress already made

It's encouraging to hear of steps many DHBs have been taking to improve performance. 

Although the target may seem easier to reach in smaller hospitals, the achievements of bigger hospitals such as Middlemore over the past year show that it can be done. 

Counties Manukau DHB achieved the 95 percent target in the last two quarters of the 2009/10 year.  This is a great result. 

Other big DHBs such as Waikato, Waitemata, Capital & Coast and Auckland also made strong progress against the target during 2009/10.

Canterbury continues to be above 90% - Waikato has increased by 15.5 percent, Waitemata 13.2 percent, Capital & Coast 12.8 percent and Auckland 10.2 percent. 

Although most of these DHBs still have a lot more work to do to achieve the 95 percent target, this is encouraging progress.

The work and effort which has gone into achieving those results is appreciated.

It was particularly pleasing to hear that Nelson Marlborough, which has already achieved the 95% target, is continuing to pursue impressive quality improvement measures.

They are not alone. The target is the stimulus, but quality is the goal.

Keeping the momentum for the ED Health Target

The Government wishes to see these positive steps continue. 

Last year, you discussed the "Five Big Issues" that had been identified as needing to be addressed to lift ED performance.  They were:

• Managing Acute Medical Admissions
• Engaging Inpatient Specialists
• Managing Overnight Patients
• Efficient Bed Management Processes; and
• Discharge Planning.

Professor Ardagh, and his ‘shorter stays team' from the Ministry of Health, will discuss the top 10 issues barriers to achieving the target, based on their visits to all DHBs over the first year.

I understand the conference will finish with a session entitled ‘Where to from here?

That session will be seeking your input into where efforts should be focused to continue the momentum of improvement in acute care in New Zealand. 

I urge you all to contribute to that session.

Close

We are relying on you to help ensure that the Shorter Stays in ED target is done right - so that quality is not sacrificed to achieve it. 

We also need you to involve and inspire the whole hospital in this work.

It is important for you to know that your work is highly appreciated. 

Time and again, we hear stories about your professionalism, courage and kindness, even when some of those you help do not recognise the good work you do. 

You maintain these values in the midst of critical situations that call for calm and judgment, while many urgent things happen at once.

Thank you for doing this day in, and day out.