Integrated Care

  • Bill English


Thank you very much for the opportunity to talk to you today. I put my hand up for Minister of Health for one reason, I could see things should be better, and I could see some ways that they could be.

That expectation after twelve months is undiminished. It has been sustained by the hard work and enthusiasm of many in our health services, including members of this organisation.

This ongoing work in our public health service is much more important than politics.

Today I want to talk about integrated care because it is one way, and only one way, we can make things better. Today I want to talk about:

why we are implementing it
where we are implementing it
the approach that it represents, and;
what this may mean for you.
And I would welcome any questions afterwards. I'm sure there will be some.

Since I have been Minister of Health I have received somewhere over 6000 letters. These letters are the stories of New Zealanders in our public health service, some good, heart warming stories, many unsatisfactory. I won't tell one of them because that would simply invite debate with such a specialist audience, but two themes stand out.

1. First people recognise that our service is not always focussed on their on-going health, but is mainly focussed on their illness and the public comment regularly on this.

2. Secondly while individual professional service is almost always regarded as of a high quality, people find that moving around the different parts of the service hazardous and uncertain.

In short many of our people feel that the public health service could be more obviously organised around our own needs, and those of our communities. My letter writers feel they have to find their way around a health service that is often organised to suit itself.

Integrated care is partly about meeting the legitimate expectations of the public for a service where the bits fit together in a way that makes sense to them.

Simply examples that often come up in these letters:

where examinations aren't duplicated
where information taken by the GP is useable at the hospital
where they aren't turned away from the theatre door at the last minute
where someone seems to be responsible and accountable for their care.
Many of my letters are motivated by a wide-spread view that it is me who is responsible and accountable for their care.

Achieving these things 80 or 90 percent of the time isn't enough these days - it has to be right just about all the time to meet public expectations of any service but particularly a personalised service such as health which for so many people represents the most vulnerable time in their lives.

But just as important as these concepts of service are the way that concepts of integrated care align our services better with what we are all trying to achieve - and that is better health status in our community.

Health debate has been replete with rhetoric for years about better health goals, improving heath status, health gain, prevention, early intervention. You've probably all heard a Minister of Health give those speeches.

The reality is that the way we have organised and paid for public health services makes it very hard to achieve these goals directly. It is actually hard to find many people in the public health service with a good reason to carry out good preventative health. Many people have nevertheless had this focus, but it's been good fortune and good motivation rather than good management.

I just want to put up one slide in this speech just to show the picture that many of the people who write letters to me and come to my meetings actually see.

[SLIDE Fragmentation]

What they see is a lot of bits and of all of those bits are maintained in their places by the political barrier that fractures this whole system between Government-owned and public, private and independent on the other side.

What is so important, and fresh, about integrated care, is it does put the patients perspective first. The patient and community are at the centre of interlocking providers, instead of at the mercy of an inflexible system.

So the first step in integrating care, whatever we think that means is, wanting to put patients and community needs at the centre of the system.

So the future of integrated care is just not about hospitals and GP organisations, it's about a whole new range of organisations incorporating community interests, taking part in providing and governing our public health service.

Integrated care is and will be driven from the grassroots - not from the top down.

It starts with communities, consumers, and providers identifying unmet needs, and wanting to do a better job.

Having identified these needs, the next step is working together to achieve better service delivery.

The working together in my view is what integration is all about. The key is to build relationships of trust and confidence.

From what I have seen around New Zealand it can take months of meetings to get over the suspicion, the territorial and professional jealousies, the lack of respect for the skills and contribution of others, all of which have been rife across the publicly funded services.

In time this activity of building relationships of confidence and trust may lead to structural change, but only if structural change means better services, and a healthier community.

And that is the final test of the concepts - will health professionals and communities see benefits in it for themselves and the people they care about? Increasingly the answer is yes.

A stricter test is whether communities in the most need, see benefits in these concepts. Again the answer is increasingly yes.

Maori and Pacific Island peoples who have well established, low health status have no trouble with the concepts, nor increasingly do rural communities who see these kind of arrangements as a more responsive, locally controlled way of running a public health service in partnership with Government.

In my view integrated care is not about savings, and I don't expect to see savings out of it.

From what I have seen of changes in health care, for most services costs look after themselves if we are really honest about quality and effectiveness.

What I'm talking about here reflects the experience of many people around New Zealand. I find it extremely heartening to talk to people involved in developing ideas of integrated care, and to feel their enthusiasm. They are fired up by new possibilities. They know what the overlooked needs are, they see how they can improve services, and they are willing to get to grips with the difficulties of working with others who they traditionally have not worked with.

The process of integrating care is taking place at many different levels and different scales, and between different sorts of providers, and in some cases not those just in health. Just to give some examples: Wellchild initiatives in Rotorua, proposals for an Age-related service in Canterbury.

One discussion in which I took part about this service made it clear that GPs could see that they often admitted the frail elderly to hospital because they were not sure of the best way to make sure that older people could get the best treatment.

They know hospitalisation was not always appropriate, and they know that if they had good access to specialist care earlier, they could do a better job for their patients but they haven't had that access. No-one's offered it to them and they haven't really known how to go about getting it.

In Wanganui, a community has spent 12 months discussing various initiatives for integrated care in that area. You can be sure that this kind of community ownership of health problems is going to be crucial to whether they succeed or not. You'll be familiar with disease management is an area where there is a huge number of initiatives. Diabetes in Otago, Auckland and Manawatu; cardiovascular disease on the West Coast and in Otago; chronic obstructive respiratory disease in Auckland City, and a number of mental health initiatives throughout the country.

The keenness of Maori provider groups has been a great impetus to pushing our public agencies along.

In Wanganui, for example, a comprehensive whanau-based health service, including a capitated primary and secondary mental health is well underway.

The service being integrated here - quite an impressive list. GP and family support and advocacy services, budget-holding for pharmaceutical and laboratory services, mental health, Disability Support, health education and promotion and they have their own plans for phased management of secondary care budget holding.

In Southland Maori providers are very enthusiastic about a proposed drug and alcohol integration proposal. This will bring involvement from the justice sector and many different Maori groups, as well as the health sector. Knowing my local GPs I suspect progress towards co-operation will be very careful, although the needs are great.

An even more comprehensive version for a large population is under discussion in Wairau/Blenheim. People there are working very hard to work out how to integrate all their primary and secondary, public and private services. Within this they're working on demonstration projects to begin soon which include the integration of A&E and radiology.

A process born out of a real threat to their hospital is turning into an opportunity for a healthier community which the community is coming to support.

We can't prejudge the effectiveness of this project in Wairau or in any other one. These proposals, or more modest ones, need to be assessed. We need to see them in action. But the relationship building that has gone on has to be a step forward. The fact that people who provide public health services have decided it's worth talking to each other and understanding what each other must be an advantage. At the other end of the scale there are initiatives such as the recent signing up of Auckland Healthcare and ProCare to launch a joint Task Force. These organisations receive more than $600 million of public money between them. I defy anyone to say it's a bad thing that they talk to each other and I'm sure that slowly but surely we they can work out better ways of using that $600 million.

Even the Otago Medical School is reorienting itself to changes in rural health that reflect the reality of the region of which they are part - my own region.

They can see that the small rural towns who one way or another are grappling with major changes in their health services need support and expertise, and a medical school does well not to ignore the trend but to work out how to support it and provide the expertise.

In turn our rural health services will provide real life context for a different style of medical training

These changes are all bottom up changes - better relationships can only be built by willing parties.

The Government can't make people get together, though history shows we certainly know how to stop them getting together. This organisation has often criticised government and at times rightly so for imposing misguided change, and has criticised integrated care in the same vein.

Your argument this time is not with me, it's with the thousands of health workers considering the options, who see benefits in tearing down the barriers that I might say this organisation has sought assiduously to maintain.

In particular the fracture between public and private has loomed like the Berlin Wall, and in time, like the Berlin Wall, it will be torn down.

The drive for integrated health care has happened without clear government endorsement or a clear policy framework. I have been reluctant to politicise a process that already has been so constructive. However, now the demand for clarity is so widespread that more guidance is needed.

I want to announce today that the Transitional Health Authority will be running 18 integrated care pilots by 1 July 1998.

These pilots will test integrated care concepts in an open and accountable way, provide valuable information and lessons, and build the skills of the Transitional Health Authority and providers.

The THA is developing criteria for the pilots which will also guide others who wish ultimately to change the way they are funded.

Along with their technical attributes, I expect these pilots to show the following characteristics:

they will be examples of co-operative health care
they will demonstrate consumer, patient and community participation, and;
each participant will share the common objective of improving health status.
As I have shown we have some examples of aspects of integrated care in action, and many in the making. The THA, and the Government are right behind this developing approach to our public health service.

It is my job to ensure that government and public agencies accommodate the good ideas that arise from these processes. Concepts of integrated care challenge our traditional ideas about control and authority in our public health service and I need to ensure that those shifts aren't frustrated by government or by politics.

I expect that these 18 projects will give impetus and focus to what is already happening nationwide. In particular they will test the issues around contracting and funding and the THA will need to work closely with providers, since we are all learning the way forward. They will no doubt provide a forum also for wider political discussion about this concept of a public health service.


I've discussed the basic motivation for integrated care; where it's beginning to work in New Zealand already; and why we believe it is a fresh way forward. Now let's look at how this may affect you.

Some of you already have a good idea of what it means in your speciality. Some of you have already been involved in these projects. You have been among those generating ideas and putting them into practice.

I haven't talked today about hospitals or funding, two issues that I know are important to you because increasingly hospitals need to see themselves in the larger context of how health care is changing.

Your organisation and its members needs to understand these wider changes because they will in time have a profound effect on what hospitals do and how they work, and therefore on your work.

Hospitals, and yourselves as leaders in hospitals, will increasingly be involved in external relationships with GPs and others who have a legitimate interest in how you look after their patients for the short time they are in your care.

I hope that our public organisations won't be last on board. I hope they won't be slow to incorporate the values of partnership, co-operation and relationship building which must characterise integrated care arrangements.

Of course, regardless of the speed of progress of what we call integrated care, changes in technology will drive us in this direction anyway. In particular, powerful, low-cost information technologies will improve your capacity to make sound clinical decisions, a capacity of others to know what clinical decisions you are making and your capacity to help others with clinical decisions that they are making in their own context of health care.

In recognition of this I recently announced $3.5 million for the support of Information Technology initiatives, most of which are designed to gather up information from different related parts of the public health service and put it into a form that enables people to make more effective health decisions. I can tell you the queue for that $3.5 million was a mile long.

To share with you one very simple story of how it can help people to share information, I was discussing recently with an interested group information that they had gathered from GPs and the local CHE and discovered that at the paediatric out-patients clinic, for every twelve children who came along, there was only one new patient.

The benefits from sharing information through technology are obvious.

Integrated care is happening now.

In most areas it's growth will be incremental building up from current strengths as experiences gain, as relationships are strengthened, as confidence grows and as information is shared. You are going to be part of these changes. Your initiative is valuable now. As this sort of change picks up, and we try to understand how it will change our health service the knowledge, experience and expertise of our specialists is going to be crucial in assessing which roads are dead ends and where progress lies.

Today I have outlined how government is taking the next step in the direction of our public health service.

We endorse concepts of integrated care, we intend to provide clear guidance on how we see it contributing to improving the health of our communities.

Progress from here will be an open process - no-one has the monopoly on good ideas, in particular neither the Minister nor the policy advisers, and your contribution will certainly be welcomed.

The success of our public health service will depend on building relationships of confidence and trust within it. It's my responsibility to do that as a Minister and your responsibility as professional leaders in our public health service.

Thank you