The Health System and its Future

  • Bill English

Key Word: Strengthen Key Phrase: The fastest rescue has had the best preparation.

Good afternoon. Many thanks for the invitation to speak to you.

I welcomed the opportunity to speak to you today because you are specialists, and leaders. Your work is essential for the functioning of our public health system. We all need your technical skills. We also need you to be involved in designing and implementing a better ambulance and rescue service. This is the groundwork we all need to be working on together.

It is good to be able to explain how I see the changes going on and your involvement. And, as importantly, to hear from you. I'll welcome your questions after this.

The given topic for today is the future of the health system. I know you actually want to finish sometime this afternoon, so I don't intend to cover this particular topic in its entirety.

However, I do want to talk about some ways in which changes in our health system will affect you.

The themes and changes in your particular area do illuminate the themes and changes going on throughout the health sector.

The main topic I want to discuss with you today is the work on developing " 24 Hour Clinically Integrated Acute Management System for NZ" - or the Acute Management Project. I am sure you are all aware of some of this work, and hope that many of you have been involved in it.

I want to talk about the project's aims, and the issues and length of time involved in its implementation.

Finally, I want to touch upon the particular challenges of rural emergency care. In many ways, meeting the needs of rural people has been the catalyst for the work on reviewing emergency services.


The Acute Management Project
The best place to start talking about the future role of air rescue and ambulance work is with the Proposed Acute Management System. This is a project which has been led by the Ministry of Health, but with much consultation from many other agencies and providers.

The Ministry of Health have been very keen to have as much sector input as possible into this project, right from the beginning.

The project's aim is encapsulated in the phrase "the right care at the right time and in the right place."

To have such a backboneof safe care throughout the country is an essential requirement of our publicly funded system.

One of the key aims of this project is to address the issues that surround co-ordination of air ambulance services.

An initial consultation document was put out earlier this year. The New Zealand Ambulance Board, the New Zealand Society of Air Rescue Trusts and the Aviation Industry Association are among the many agencies who have been involved in the consultation process. You can still get a copy of this document by contacting the Ministry, and it ?s also on their web site.

The Ministry is now collating all the input received, and should have a final concept paper out by the end of next month.

The responses to date have all been in broad and positive agreement, which means we do have a strong base to work from.

It has been agreed that key elements of a 24 hour clinically integrated acute management system are:

an appropriate emergency transport system;
patients transferred directly to a hospital that can provide definitive care, or appropriate local management
integration of all services involved in the management of acute health needs;
regional networks of all agencies involved (i.e. pre-hospital care, emergency transport including air ambulance services, hospitals);
safe practices guided by agreed guidelines, protocols and standards;
streamlined processes.
Once the theory has been sorted out, we need to move to the implementation of this system.

This implementation will begin with the development of a detailed work plan for implementing key changes. That's expected about November of this year. The work plan will include an outline of the responsibilities of the various agencies involved.

The actual implementation of the new plan should start in December this year. It is important to note that this plan will take time to put into place. We need to go one step at a time with full understanding and co-operation.

It will take a good two years to create the kind of service we think we need.

We will need to form regional networks between agencies, and this does require leadership and a willingness to work together.

In fact, it is true to say that behavioural and contractual changes are more important in making the system work than purchasing new technologies.

Work on gaining agreement over key specific changes is currently underway. Thus far three key changes to pre-hospital services have been identified:

an emergency number 111 provider that is independent from providers of land and air ambulance services;
simplification and streamlining of contracts for pre-hospital services;
the recognising and enhancing of the status and value of pre-hospital services - that means work on training, support and developing professional linkages.
All the organisations involved will again be able to comment on these changes in the next few months.

We also want to identify key changes to hospital services and any overall key changes that will also significantly improve the current system. The idea is to focus on a limited range of achievable key changes. We can only build from there.

Time Criteria and other Guidelines
An important part of the work on the Acute Management Report is work on guidelines.

The Ministry is calling together a group of doctors nominated by the combined medical colleges to update time criteria guidelines for first response services.. This working group should have an initial draft document up by September, and then it will be circulated for comment about October and November this year.

Again, comment from all the organisations involved in emergency medicine is needed.

Developing guidelines and standards is ongoing throughout emergency medicine. For example, guidelines are being updated by the Australasian College of Emergency Medicine to reflect the move towards the use of triage. That is a trend I am sure you are all well aware of.

Rural Emergency Services
Let me finally say something about the specific needs of rural emergency services. New Zealand faces particular difficulties in providing emergency services to all its citizens. We have a sparse population in a challenging landscape. The challenges are not quite so extreme as, say, Australia, but they are interesting enough.

New Zealand's particular challenges of low population and high geography have been intensified by changes in hospital services that have occurred world-wide. Many things we used to need a hospital for we now do in a doctor's surgery. Many things a small hospital used to attempt is now done where the equipment is more modern and the staff are more specialised. Every small rural hospital simply cannot provide the quality of service now demanded by patients.

However we must ensure all New Zealanders have access to acute and emergency care. This is why we are developing the Hospitals Plan. This is why we must have a comprehensive network of services to cover even the remotest areas. We must ensure the right care at the right time and in the right place.

I expect we are going to be relying even more upon air ambulances and helicopter rescues in the future. This is why we have to use these services judiciously, so that they are present and affordable when most needed.

We cannot rely on helicopters alone to provide good rural emergency care. Traditionally we have relied a great deal of volunteers. However, this is not a simple option, due to high turnover rates and the expense of retraining.

One innovative idea that I think will prove to be of benefit nation-wide is the PRIME system. It's a way of ensuring high quality access to medical emergency treatment. It was developed by the Southern office of the HFA, is mostly funded by the ACC, while training is provided by the Order of St John and has been endorsed by the Rural GP Network. Efficient transport is an essential part of the plan. The PRIME scheme is only operating in the Southern Division of the HFA at present, but will gradually be implemented throughout the country.

The most exciting thing about this particular scheme is, of course, that it should save a lot of lives and prevent a lot of long-term injury. But what I also find particularly indicative and hopeful is that it has been the product of a lot of agencies working together. It was a far from easy process, and there are no doubt issues still to be worked through. But the fact is that better emergency services are being provided through people working together, in new ways.

I think that much of what is happening in emergency services is indicative of changes in the health system as a whole. I think it signifies an increasing maturity and an increasing emphasis on quality.

One sign of maturity is collaboration. That comes from the realisation that if we want to achieve a common goal, if we want a higher quality emergency service, then we do need to work together to achieve it. We are all interdependent parts of one whole service.

This maturity can be seen in the PRIME scheme.

It can also be seen in action in the ways the Ministry, the HFA and ACC are working together to better co-ordinate pre-hospital services.

One example is the work the HFA and ACC are doing on streamlining ambulance service contracts. This is why these contracts have only been renewed for one year. It will allow the agencies to complete the streamlining exercise. That work can then be included in the following year's contracts, with a better co-ordination of the service.

In fact I see the contracting processes in general as another sign of increasing maturity and collaboration. Now many agencies do use contracts as fair and straightforward tools to help them reach a common purpose.

If you want to have a good air rescue or air ambulance service, you do the groundwork. The fastest rescue has had the best preparation.

But that groundwork, that preparation, is not just about technology and flying skills.

It is about teamwork - even with people that have never had the privilege of flying in your machines. Only then do you know when to take patients, how to take them, and where.

It is about planning and working together. Only then can we have an integrated, comprehensive, high quality emergency system everywhere in this country.

I look forward to your contributions.