NZ Rural GP Network Annual Conference

  • Bill English

Parkroyal Hotel, Wellington

(Note: The following is a transcript of the speech)

Good morning and thank you for the opportunity to speak to you this morning. I'm sure it's a positive experience for all of you to be able to get together and talk about a lot of things that you think about while you're almost all the time working on your own.

This morning I want to talk about some of the progress that is being made in dealing with rural GP issues. I want to talk about some of the thorny issues I can see that we need to deal with at the moment and then thirdly about some future initiatives which I think are going to be helpful.

There are a whole host of initiatives underway that one way or another assist with the process of supporting our rural GPs. They are in fact all inter-related. The significance of IPAs, changes in education, community support, professional development and moving to one central funding agency. All these things have some impact although not all of them directly.

I want to look first of all about at the actual doctor numbers. It's been a long-standing issue as to the difficulty of recruitment of GPs and I just want to give you a picture of where doctor numbers are moving so that we can get an idea of the context. If we look at total medical practitioners, in 1980 we had 156 per hundred thousand population. In 1996 we had 211 per hundred thousand population - an increase of somewhere around 30 percent. For GPs, in 1980 we had 50 per hundred thousand. In 1996 we had 81 per hundred thousand. To put it another way round - in 1984 we had 2,000 GPs. In 1996 that's gone up by nearly 1,000 General Practitioners to 2,935. The total New Zealand population hasn't increased by anything like that ratio.

I now want to talk briefly about the rural practice bonus. There has been, I think, a widespread perception that the rural practice bonus and support for rural practitioners is substantially less than it used to be. We're actually spending considerably more on this. In 1986 it amounted to just over $1 million. In 1996 it amounts to $3.2 million so the rural practice bonus has virtually trebled in the last 10 years.

I am aware there are discussions taking place right now about how to make this payment fair for GPs who are in the situation for which the bonus was always intended, that is with the small population base and in remote areas. The trial going ahead in the southern region using the rural ranking scale I hope will sort this issue out.

The substantial increase in the number of GPs has lead to restrictions in Section 51 notices and you'll all be aware of that. That is done for one reason and that is to get better health results throughout the country. You'll all be aware with the theory behind it that if you have more doctors you generate most cost. More doctors almost always accumulate in the places where Government is less keen to spend more money and that is higher income metropolitan areas, and various research work that has been done confirms this.

In the long run this has to advantage our rural doctors as long as all the surplus doesn't go overseas which I suspect is partly what's happening now. If we have Section 51 restrictions in almost all of our metropolitan areas now, one wonders where all the GPs, where all the doctors are going. There is some anecdotal evidence that is becoming easier to get locums in more isolated areas but it is only anecdotal.

New applications for Section 51s are being considered on a case by cases basis and where there are a number of applications the funding authority is tending to the view that it should be an advantage to have had prior rural experience.

I now want to look at some of the thornier issues that we have to deal with right now. One in particular is of growing concern to me and that is the operation of the Medical Practitioners Act. I had some trouble persuading my constituents and my fellow Caucus members that the Medical Practitioners Act is about providing for the medical profession a strong degree of autonomy giving them the capacity for professional self regulation. The Medical Council has been constituted in a way which allows for the election of medical practitioners to the Council alongside Government appointees, but its legislation does create autonomy.

Therefore the rules that apply for registration for vocational registration are rules that are made by doctors for doctors. They're not Government decisions. I have to say it could well become a source of great frustration for a Minister of Health.

The moves that are being made by the Medical Council seem to me to be going to create quite a lot of problems in our rural and provincial areas. It is going to be harder for overseas doctors to get registration and they have been a major source of supply for our rural practices.

Some of the rules that are now coming in for specialists in our provincial hospitals could create major problems unless some changes are made. For instance I was told yesterday the College of Anaesthetists is now designating ICU as an anaesthetic speciality. Very few of our provincial hospitals would ever be able to sustain a specialised ICU anaesthetist. Are we to close down the ICUs in our provincial hospitals? Of course we aren't. We can't do that but Government policy looks like it may be heading for some kind of collision with the rules that the medical profession is setting for itself.

I certainly intend to have further discussions with the Council about how the Medical Practitioners Act works, but if we are to continue along the road that it appears we're on, then there may be a case for revising that Act if it is the legislation that is a problem rather than the views of the Council and the Colleges who make the rules.

The second problem to which we have not yet found a sustainable solution is the problem of locums. As expectations about lifestyles change particularly among our younger GPs and younger doctors, there is a greater demand for locums in our rural areas as the need for continual medical education grows because of the requirements of vocational registration that also adds to the demand for locums.

One attempt has been made and you'll be able to tell me how successful or not it has been and that is the efforts of the Centre for Rural Health in Christchurch to run a rural locum scheme. I understand it is very popular but then you would expect it would be. Whether it is able to generate sufficient locums is another issue. But the concept of a GP paying a fixed fee that covers advertising, travel, accommodation and transport costs for the locum makes an awful lot of sense and I'm pleased to see that Southlink Health is getting involved as it should since many of its members work in rural areas and an IPA has as one of its functions the support of the professionals who are members of it.

I'd now like to talk a bit about the changes that are ahead of us and how this group can be involved in moving forward. There are a number of changes in the general primary care involvement which are going to impact on rural practice. The first is that it is almost inevitable that we will be moving to capitation type funding or at least mixed payment systems rather than fee-for-service alone. Many GPs are now involved in practice that is funded by capitation type systems. The move to capitation doesn't necessarily mean that every GP would be funded by that means. It does mean that Government would be looking for an organisation which it would fund on a capitation basis whether that's an IPA or some other sort of organisation. We virtually did this through the old Regional Health Authorities. Effectively we had capitated funding of primary care for four regions in New Zealand. In the future that capitation funding will be broken down to populations or physical locations that are much significantly smaller than the large regions that we've been dealing with.

Once an organisation receives that capitation funding then their own internal payments systems would be fairly much up to them. That's a move which a number of GPs are seeking which makes sense to Government in terms of managing its budget right across the board rather than just managing the elective surgery budget and paying the bills for everything else. That's not a sustainable situation in a political sense and the public tire of it rather quickly because they actually want some certainty about things like elective surgery, but it's also important in aligning our dollars with the needs that are out there.

Another change that is occurring is the way in which the IPAs are able to negotiate directly with the funder. That gives them a more powerful voice in the process but it does mean they have to focus their energies on particular issues. I have the privilege of getting around the country and hearing all the different ideas that people have. Almost all of them involve quite complicated change to what is already a fairly complex system of funding and risk management. So groups of GPs and the funder will need to concentrate on what it regards as the most important objectives in the shorter term so that we can get out to achieve those. We do run the risk of having so many good ideas and our energy so fragmented that we don't actually achieve anything.

I think in the future that the trust between the funder and the GPs will grow. Traditionally we have had relationship of some suspicion and occasionally animosity, but face-to-face negotiation over a range of issues where objectives are shared does help a degree of trust and confidence in the relationship. I think GPs have come a long way in understanding the benefits that arise from working more closely with each other in this rural network that it's formal organisation and its growing standing in status in our health system is an example of that. People who work independently are often quite independent minded, but have realised that alongside that they can benefit from the contribution of others from shared understanding of problems and from having common voice to articulate those problems to Government.

There are some very good examples of how the scene is changing. One example you are probably familiar with is Unihealth - the Otago University's enterprise which is designed to provide support and advice for those in primary care who feel they will benefit from it. It's a major change in orientation for the University and I congratulate them for taking the step, which has not been easy for them to take. It does also mean though that people in rural areas can get used to the idea that the University actually wants to help them.

I was brought up with the idea, as many I think in my part of the country have been, that services get sacrificed to support the University. I think that probably has been the case for about 50 years, so Unihealth signals something of a turnaround in that attitude. I was fortunate enough to be at a meeting where they first outlined their services to a group of the people from Trusts in the South Island and I think they were slightly surprised to find that they weren't welcome with open arms.

Nevertheless the relationship has continued and I'm sure trust and confidence will grow. But it is about time that the huge resources of our education system of Otago University and other institutions are applied to what is a substantial part of our health service - and that is the health service in our small towns and rural areas. If they were unable to support that then we would have to have a hard look at what benefits we do get from them, but they're getting ahead of Government and that's excellent.

Another major initiative coming up which I think signals the growing status of the issues that you deal with is the conference that's going to be held in Invercargill in May about rural and provincial health. It will feature a range of speakers from New Zealand and overseas. It will have a working focus to it so that people get the opportunity to discuss the real issues they're dealing with rather than just sit and listen. I expect that that conference will have direct feedback both into the curriculum and Medical School itself, into the contracting and negotiating process with the funding authority and into a general understanding and high profile for rural health issues.

I want to talk about one of the more recent developments in rural health and that is the Community Trusts.

This is a development which I have supported quite openly and Government has to some extent funded. Not because we think it's the answer to everything, but because it looks like a viable way of breaking up the stalemate that was occurring in many of our rural towns. It's a movement that builds on the strengths of rural communities, that is their ability to put strong support and community commitment behind local services and their dedication to doing something better if they get the opportunity to do it.

Community Trusts have a long way to go in my view to understand the full extent of the responsibilities they take on. Actually running a small health service is a substantial responsibility and carries an awful lot of risks. Funnily enough when Government's doing it everyone thinks it's simple and it's only difficult because politicians make it so. If people get to do it themselves they actually find that it is quite a complex exercise.

But Trusts do bring much more of a community health focus to the public health services in their town. I think they have been a force for integration of services; they have assisted the process of moving towards a more multi-disciplinary approach to rural health. I expect though that in the future they will have to learn to work with each other to get some of the economies of scale that you need in order to provide good managerial systems, proper professional support to health professionals and deal in a sustainable way with the financial issues that any health organisation gets to deal with.

Finally I want to refer to changes in the Health Funding Authority.

For those who have been close to the contracting process, the last 15 months have been a time of confusion. We've had three different agencies with different names often changes in personnel, and some confusion about where the decision making actually lies and what the policy actually is.

There was a very clear mandate from the 1996 election, for whichever Coalition was going be, to move from four Regional Health Authorities to a national agency of some sort. We had had to devise a transition which allowed us to continue with the business of wisely spending $5.2 million at the same time as bring four organisations that had become fairly autonomous together into one national structure.

That's been a challenge because we want to get the benefits of consistency and clarity of national policy, but at the same time keep what the RHAs had built up as a very good understanding of the local relationships and local needs in their regions. So there are some costs to moving to the Health Funding Authority but there are certainly benefits. One is simply the virtue of consistency. Every New Zealander wherever they live should get roughly the same deal. It also means that good ideas can be spread more easily around the country.

When we're looking at solutions for rural GPs the Funding Authority does have the obligation of looking at solutions for all rural practice in New Zealand because the issues are pretty much all the same. Your network represents a lot of our rural GPs but by no means all. I was in the King Country earlier this week where the issue of primary care and maternity services is one of great importance. A system there that needs more depth to it to ensure that we are providing good primary care services to a large and sparse population. So solutions that the Funding Authority picks up from this group from other parts of the country it will be looking to apply across the country.

Last time I spoke to you I emphasised the importance of this collective bringing together its views and presenting those to the Funding Authority. I worked with the purchasing agencies to ensure that they are dealing directly with the issues you've raised and in my view there's been some success in dealing with issues which have not been resolved for some time. One example would be the exercise with ACC and the Prime service, which is a significant step ahead although there's still a long way to go to get our acute emergency services to the kind of shape that New Zealanders deserve.

So that represents I think progress from a time when rural GPs were quite isolated from the system itself and found it difficult to get in to get an ear let alone to get some concrete decisions made. More progress can be made but there's two points I'd make about that.

The first is this: it is going to be hard to recruit people to general practice if it's always represented in such a negative way.

The overwhelming picture for a Minister of Health, for medical students, the members of the public, for the media is that general practice is some kind of purgatory that only the odd strange person would want to wish upon themselves. This is a problem we have with mental health services as well. In that respect we are our own worst enemies. It's certainly not part of my job to get around the place saying how terrible it is to be a general practitioner and I would hope that this network will be able to express a lot of the positive aspects of general practice which are the aspects of course that keep you motivated and committed to a reasonably difficult branch of medicine. If we want to recruit GPs we need to make it look as attractive as possible not as unattractive as possible.

The second point I'd make is that the lessons of the recent past are that when we focus on a few high priority issues we can make progress. We find we can't go as fast as we would want to and we find that having dealt with those issues it doesn't solve all our problems.

But we have made progress when we've moved past the stage of working with unaffordable, unprioritised wish lists and that is a lesson for the future.

I think it's really important for this conference and for this group of people to be able to sort out just which issues it thinks are the most important, just what are the affordable solutions that you can suggest and if you do that you will certainly get a good hearing from Government and that is no less than you deserve for the very hard work that you do for many New Zealanders.

Thank you very much.