New Zealand Nurses Organisation Conference

  • Bill English

Quality Hotel, Wellington

Note: The following is a transcript of what was said

Thank you for the invitation to be here today.

This is the first opportunity I have had to address the New Zealand Nurses Organisation.

I have come because I believe you are the key to the Nation's health. Not just because there are so many of you, but because you have a track record of being the most open minded and the health professional group most ready to change.

Today I want to talk about the Coalition Agreement and the Government's commitment to a public health system. I want to talk about some principles that show us the way forward and I want to talk about the opportunities that we will be able to take if we are able to work together.

No politician can afford to ignore the nursing profession.

In recent weeks we've seen so many pictures of two famous people around the world - Princess Diana and Mother Theresa. If you think of the pictures of them that actually stick in people's minds, that sum up for people the regard and respect we have for those individuals, it is the pictures of them in some kind of personal relationship with people they care about and want to look after and that's what nursing is about.

What the public value about nursing isn't so much your qualifications and your skills, but that they identify with nurses and with the personal relationship and care that they get in a hospital or in the community. That is why you're so popular with the public and that is why politicians can't ignore you even if they wanted to.

I want to run quickly over the Coalition Agreement because it sets some of the framework for the ongoing progress of the public health system.

There are three crucial parts to the Agreement.

The first is its statements and values. There's no doubt at all that the new Coalition Government felt the need to restate Government's commitment to a public health system and commitment to using that health system not to make money but to improve the health status for New Zealanders. That's against the background of several years of political discussion about whether that was the case or not.

The second part of the Agreement outlines a number of specific policy proposals which we are currently putting into place - the move to one RHA, making CHEs officially non-profits as opposed to unofficially, free visits for under sixes, a policy review which was carried out by the Steering Group.

The third important part of it is the commitment to funding for the public health sector. Often the numbers we've used in the public discussion are so large that they don't make much of an impact. But in the Budget round we were able to procure most of the money that was promised in the Coalition Agreement and over the next three years we will spend an additional $1.5 billion in the public health system.

It is in this context that I as a Minister have to work with the funding pressures that we're all very familiar with. Even with that much extra money - $1.5 billion over the next three years - there is already considerable pressure on the budget. Most of that money is already fully committed.

So what is it that we are spending most on? Well we have some areas which are growing quite quickly. Disability support services which make up 20% of our budget are under an awful lot of pressure. The expenditure has increased quite considerably in recent years and will continue to do so because there's so much unmet need in our community when it comes to disabilities.

The growth of pharmaceutical and primary care expenditure has been very considerable. Increases in acute admissions to hospitals has been very considerable. In addition to that we have made a number of ongoing commitments to funding the Mason Report, providing free visits to under sixes, Maori provider development funds and so on.

So the funding is all committed and that is why there is some pressure on the CHEs. I have to say that's not necessarily by choice. The way the traditional funding system works doesn't give purchasers or governments much choice and we have to change that. We are too much the victim of what is technically called demand driven expenditure and often the CHEs end up carrying the residual burden. I looked up some figures for my own region recently - the Southern region - where there's quite a bit of discussion at the moment about hospitals. In the last three years primary care expenditure in that region has grown by $100 million and hospital expenditure hasn't grown at all. If you asked me what we got for that $100 million I couldn't really tell you because it is just a matter of the Government paying the bills as they turn up. That sort of dynamic has to change.

I want to talk directly with you about the issue of the wage round because otherwise you'll ask me at question time. We have made it clear that the Government has an expectation, which is the same expectation the public has, that additional money committed to our hospitals ought to result in additional services.

In the last three years revenue to hospitals has gone up by 13% and costs have gone up by 15% and that accounts for the substantial deficits we now have. We have made it clear to hospitals we are not willing to use our deficit funding as a way of funding further wage increases.

To put the nursing position in context, the primary beneficiaries of wage increases over recent years have actually been the best paid people in our system and that is the specialists. They have had the biggest increases and we've employed more of them.

So the context of the extra money the Government has for health services is that we certainly have to watch every penny. The question is not so much whether the constraints will go away - I can assure you they won't and you can't vote them away either - it's a matter of how constructively we can work within those constraints. We now know what the funding is for the next three years and I'm happy to work with anyone who wants to work constructively about dealing with the inevitable pressures that we know will come.

I now want to talk briefly about the kind of principles by which I can see the public health system evolving over the next few years. These are four ideas that come from observation and discussion with a lot of people over the first few months that I've been Minister of Health.

The first principle is that we will be looking to organise services around patients and communities and not the other way around. Too often in the past we have, for generally political reasons, organised our funding and our services in a way that suits us and expected patients and communities to find their way around them and some communities have never been able to. Mental health has suffered, Maori health has suffered, child health has suffered because they are the people who have found it hard to find their way around that traditional system. We want to organise our services around them.

The second principle is that we need to strive for better relationships. There's no doubt at all that we can significantly improve health care in New Zealand for New Zealanders if the different people who are looking after a patient in a community actually communicate with each other. You will be familiar with many examples where personal relationships and relationships between different organisations, between public and private, between hospitals and GPs, between rest homes and GPs don't work well and care suffers for it.

The third principle is that we'll be looking for local solutions for local problems. What works in Tuatapere doesn't work in South Auckland. We know that but for years we pretended it does work. We're not going to be sitting in Wellington devising models of health care and forcing them on the whole country. What we will be doing is looking for innovation, backing it wherever it arises and looking to change our rules, our funding and some of the bad habits of our public agencies in order to accommodate good ideas that people have built up - ideas that are built around the local history, local relationships and local needs. Again, this is crucially important for the groups which have been marginalised in our health system in the past. Some of the best work that is currently being done in New Zealand in health is being done among the well organised Maori providers - usually without much money, but also without the baggage of history, and they come up with quite logical answers to solving quite difficult problems.

The fourth principle is that we want to get the decisions about resources closest to the needs. I think nurses, from what they tell me, often feel very frustrated that decisions about resources don't seem to bear much relationship to their work, don't seem to bear much relationship to the needs that they are dealing with every day.

I can tell you I get to make decisions about resources that I can only get wrong. If we are managing a $5 billion or $6 billion budget, putting a problem that's about $10,000 or $20,000 in front of me is a total waste of time. Whatever the political pressures are, whoever is on the other end of that decision is at some peril if I'm the one who is making it!

We must make the decisions about resources closer to where the needs are which means trusting people who know what they're doing.

So there's four principles. Local solutions to local problems; striving for better relationships; organising services around patients and communities; and getting decisions about resources as close as possible to the need.

So where do nurses fit into this particular way of looking at the public health system? Because you are the largest and by far the most diverse workforce in our health sector, you are a key to the further progress of the public health system. You have a record of being more open-minded about change than our other professional groups, but I also sense a strong degree of frustration from nurses who have been traditionally employed within structures generally dominated by your medical colleagues. There is restrictions of roles and people feel hemmed in, people feel over-managed, people feel that simple things that could be done don't happen and major problems that should be addressed don't get addressed.

Things can change and I'd like to quote an example of a group that is part of the NZNO and that's midwives. There's been a lot of controversy about maternity in this country in the last eight or nine years since the Act was originally changed. This is a group who have, with a lot of motivation, got into a position where they are now funded in their own right to carry our maternity care in a way which is generally regarded as doing a high quality job for mothers of children in New Zealand.

There's been a lot of political pressures to stop that happening but it has happened and as a group they now appear to be considering a range of options for how to reorganise themselves in way that would mean they could do an even better job.

So that tells you that the system can change - it tells the nurses who feel hemmed in and restricted there are opportunities there if we have the political will to look for opportunities for change and if we work together to take them.

I want to go through a few possible examples.

Nurse prescribing is an idea that I support strongly. It has to be done in a way that is safe against the background of good education and training. In fact if we bring in nurse prescribing it will formalise arrangements that operate quite successfully now informally. It's been discussed for a number of years - endless discussion - and it's time that we did move it through to some sort of decision making.

There's no doubt that some of the strongest views about the role of nursing comes through from nurses who are working in our public hospitals.

We have been through a phase where a lot of the decision making in hospitals has been made by managers. I think that is starting to change and I believe it certainly needs to change. But there is a straight trade-off involved. To the extent that nurses are willing to take responsibility for the use of resources, that is the extent to which they will be able to expand the degree of control they have over the professional environment.

It's not for every nurse; it's not for every doctor either but there are plenty of opportunities. I hope there will be more opportunities for yourself and your professional colleagues to step up and incorporate in your professional practice the management functions that must go on.

We need those management functions. The question is who can do the best job or who can bring the best integration of management and clinical and professional functions. It does entail taking responsibilities. It does mean having a budget and being accountable for the use of it. In the end, if you don't do it yourselves someone who knows less about your job will be doing it for you.

My challenge to you is to put the pressure on the organisation so that you do move into those roles rather than leave them with someone else. I hear all the time stories about bad decisions, inappropriate behaviour, negative relationships.

In the end the solutions to those problems don't lie in my office - they lie in our hospitals, which are large complex institutions. While I can, as the representative of the taxpayer who owns these organisations, put pressure on and give guidance, in the end the people who work in those organisations are responsible for their functioning.

I might say as an owner looking back over how our public hospitals have operated they can do a lot more to take responsibility for the people they employ. Too often our hospitals have regarded professional development/employee morale as something that is carried out by other organisations like the NZNO or the various medical colleges. It is crucially important that they develop a strong ethic of looking after, of developing, and of encouraging their own workforce.

Another group with whom I've had discussions recently are practice nurses. The practice nurse scheme was put in place at some stage in the past and the way it's developed doesn't reflect the way that health care is changing. This is a group who certainly feel that their role is restricted. The way they are often treated even within the new structures of IPAs doesn't seem to be taking their role far enough.

I am very keen to work with that part of your organisation to see what Government can do with the $30 million it spends on practice nurses to try and lever some change into the way they operate.

The fourth area where the system is sadly lacking is that we don't pay for promotion and educational activities in any coherent way. It's increasingly clear, as we move into more co-ordinated care and as we get a better focus on how we're spending our primary dollars, that it's no longer sufficient to be sitting in a medical surgery waiting for patients to come in the door.

The fee-for-service service system has some advantages but it has some very substantial limitations.

One of its limitations is that it doesn't promote the kind of activities we know can make a big difference to people's health. We have in bits and pieces some of these activities growing up but it hasn't always been easy. Independent nurse practitioners have really struggled to find a niche even though they have a lot of experience and a lot of knowledge. We have in various organisations people like asthma educators and diabetes educators but they've always been sort of grafted on, never quite legitimate, and certainly not regarded as a core part of a primary health team.

It's time that we did take on that challenge, it's time that those activities were recognised for the very substantial value that they can give to patients. All the time now I come across people who are starting to think more holistically about their community and the way they're treating a patient and treating people in the community. They realise that it's these activities that will make the biggest difference, even if it is, for instance, a pharmacist who has decided that they want to actually train people on how to use the ventilator for their asthma problem. It takes time, they're not paid for it, and you wonder why it doesn't happen in all the interactions that an asthmatic has with the health system. But one of the reasons is simply the Government has never actually paid for that activity in a coherent way.

I can imagine in the not too distant future exactly the situation that Nigel Kee talked about and that is that nurses will be carrying out some of the roles currently carried out by doctors.

There are a number of reasons why that may happen. Junior doctors are simply pricing themselves beyond the capacity of our system to pay for them. Particularly in our smaller hospitals you are going to see a change in the mix of health professionals carrying out health care.

I think in the area of primary care, where nurses represent a very substantial workforce both in their capacity in community services run by CHEs and working with GPs, working as public health nurses and so in, you're going to see some shifting of the professional boundaries. This won't necessarily be because of any particular political view about it, but simply because when people sit down and look at how the skills are deployed in order to enhance the health status of a population you will come up with answers that are different from the traditional way of doing things.

So there will be some shifting around of roles, there will also be new roles. If we are going to take seriously the priorities we've laid out for health care - mental health, Maori health and child health - if we're going to take seriously getting good value for what we spend on primary health care, if we're going to take seriously that resources should be directed to the areas of highest health need, we all know what they are but we never seem to get around to actually putting real dollars into those areas, then there will certainly be new roles and nurses will play a very substantial part in developing and carrying out those new roles.

There's no such thing as health care on the cheap. People deserve to be paid for their qualifications, for their skills and for their experience. I have to say nursing hasn't always done itself a lot of favours with developing a sensible career path for experienced nurses and nor have our public organisations. I think there is a lot of potential to work together for achieving better career paths, achieving better remuneration, achieving a system that does reward performance, skill and experience.

There's a lot of potential there and if we work together we can make some progress.

The future roles of nurses are going to be different. They are going to change and there's going to be new ones.

To achieve all of that we are going to need to change the rules and change the system. In primary care it's obvious - fee-for-service payment keeps nurses out of the loop. Fee-for-service payment restricts their roles and keeps them in the position where they're always helping out. That has to change. Not because of political reasons, not because we want to provide more opportunities for nurses, but because we need to do a better job in primary care for our population.

We have the choice of whether we can use the next couple of years constructively or whether we will honour the time honoured strategy of waiting for the next government.

I have to tell you that the changes going on in health care are not actually plots dreamed up in Ministers' offices. They are international trends. They are driven by the same needs that any government has and that is the need to get a high quality service delivered cost effectively.

I suggest you watch the actions of the Labour Government in the UK to see whether the changing of government completely changes the rules on health.

If you want to wait fine - I don't. I want to work with people who want to do a better job for the many New Zealanders for whom we can create better health care.

If it means changing the rules and changing the system then my door is open. If it means innovation and good ideas then my door is certainly open.

The public deserve us to do the best that we can. I don't think there is anyone in this room who believes we cannot do better. I want you to go away from this with a sense that I'm here to support the changes that you want to make. I'm here to share the common objective we all have of improving the health status of New Zealanders.

So I look forward to the pressure. I look forward to good ideas coming forward that are going to ask Government to change the rules, to do things that it's always found difficult to do.

I hope through the course of this two-day conference you will be able to get a sense, not just of the industrial issues that you are certainly going to be dealing with, but a sense of the opportunities that are available and a sense that if we work together we can make something of them.

Thank you.