The Royal Australasian College of Physicians Annual Scientific Meeting

  • Bill English

Aotea Centre, Auckland

I take great pleasure in being invited here this morning to open this annual Scientific meeting for the Australasian College of Physicians. I understand that you only meet once every seven years in New Zealand and that you meet in the various Australian states and territories the rest of the time, so I would especially like to welcome you back to New Zealand. I particularly welcome this opportunity to speak to you, not only as the first Coalition Government Minister elected under MMP but also as the first National Party Minister of Health to address you since my party re-entered office in 1990.

A lot has happened in that time. I would like to comment on the role doctors have in managing our hospitals in a health system that has become increasingly accountable to the public in the past seven years.

I feel this conference is the ideal forum for exchanging ideas from either side of the Tasman and I'm keen to share with you a New Zealand political perspective on health management and as the conference progresses I'll be just as keen to hear back on what's happening on the Australian scene and to learn about the synergies you'll be developing here.

Doctors as senior professionals in hospitals have a very definite role in the management of hospital resources and as I will talk about a bit later in the management of patients across and outside hospital services. I have heard stories of doctors being told: "you don't understand this stuff about money. You keep telling us you're about people not profits, so you look after the people and we'll look after the profits."

That is simply not satisfactory and it doesn't make sense. What does make sense is to bring the people with clinical capability together with those who relish the other domains of management and have real dialogue about the best ways to use the available resources.

The tradeoff for doctors getting their hands on the control levers of hospital power is taking increasing financial responsibility and accountability.

Those doctors who have their hands on the levers are now the ones responsible for working within their budgets. And the result is management understanding clinicians are capable and actually well positioned to deal with issues of costs and clinicians saying: "If we don't consider the financial implications of our work some twerp in a suit will do it for us".

We need doctors working in this way. The price of doctors not taking financial costs into account, in the public sector is either increased taxes or less money for other things - be it computers in schools or cardiac services in public hospitals - dare I mention the word. And in the private sector the price is more likely to get translated directly into increased insurance premiums. Premiums that many would argue are high enough already with the average New Zealand household last year spending more than double what it in 1990 on medical insurance. A showdown seems likely as insurers start signalling they will no longer passively accept cost increases and that they intend to contain and even reduce them.

There is also the risk that private insurance is getting so expensive that lots of people will either drop out or be deterred from going into it, and we could end up with the same situation as in Australia where the big problem is that private funding is drying up.

Back in the public domain as clinicians and managers move closer together in the running of hospitals, they will face the need to change and develop how hospitals serve patients. I hope they take on board some lessons from the late eighties and the early nineties - that incremental changes are less risky and disruptive than major structural ones, that even if you do change systems, many of the same people will still be the ones working in them and that any change should start by looking at the patient and working backwards to the professionals and wider providers.

If we turn the management issue around and take a look at it from patients' view point, then one of the simplest and easiest things we can do to improve it for them is to ensure someone is looking after them across services and across institutions. Doctors are well-placed to manage this integration of care. Many are already setting out to achieve it. We need to strengthen this integration and the communication that enables it to happen. Because as we aim to be more customised and flexible in our service delivery we need better, faster and more frequent communication between the parts of the service that an individual patient requires in their personal service.

The public expects GPs, district nurses, outpatient, lab technician, hospital clinicians and any other health professional to talk and share information when there is an issue about a patient's care that crosses professional bounds.

The public expect it but as recent publicity about one of our CHEs shows sometimes doctors, even in relatively small towns, don't do it. They don't pick up the phone and talk. Or if necessary bother to make a second phone call if the line is engaged on the first attempt. It's not a tall order and it's a good place to start. I know most doctors and indeed other health professional are already making the links.

But unfortunately I hear about the gaps not the glue in the health system. Let me quote form a letter I received recently

Our baby was recently born in one of your hospitals. The maternity care was good, but I am angry about the hospital care.

I was sent by staff to get a key to a cupboard so I could get pads I needed. I waited in my nightgown in front of a counter, in a ward corridor for 7 minutes while the person with the key talked on the phone. I was in full view. When they hung up they said they were busy recruiting staff and she didn't have time to deal with me straight away. My baby needed a blood test. They took blood from the cord, then came and told me later it wasn't enough so they would have to do a blood test. I never realised how distressing this would be for the baby, or for me. The next day they came and told me the blood test had been lost, so we did it all again.

As I left the hospital the specialist told me to come back in two weeks for another blood test. I turned up at outpatients at the appointed time and they asked what I was doing there. They said they had never heard of it and suggested I go home and come back when I had an appointment. I stood my ground having organised childcare and transport. Then they said I could use the phone to contact the specialist[ in the hospital. I couldn't find him. After about an hour they agreed to do the blood test, which was again quite distressing

After another two or three weeks I wondered what the results of the blood test were. I phoned the GP who didn't know. After much effort I found a friend of a friend who worked in the lab who told me the result of the first test. I asked about the second test and was informed that a second test was unusual and the result wouldn't matter.

I have heard you talk about a high quality health system. I am sure that if my baby was really sick, she would have been well looked after. But she wasn't really sick and I am angry at the way your hospital treated me. I don't believe a word you say. You are just another dishonest politician who expects the public to believe what you say and you haven't got a clue.''

Humane compassionate responses to distress can't be purchased with all the structures and funding resources in the world. Doctors at a basic level have to manage cases with sensitivity and intelligence that goes beyond what mere procedure and structures prescribe. If there are gaps it is for the health professional to watch out for them and keep the patient out of harm's way, not for the patient to watch out for them in an alien environment where they certainly feel vulnerable.

No one is going to fix or define your role in the management of hospitals for you or to prescribe the right way to be a physician.

Nor will debate on your role be resolved in theory but what will definitely determine it will be the ongoing realities of technological change, public expectation and your contribution to the development of better services in and outside our traditional hospitals for patients.

I want to build on the very motivations that have brought you here today. If we are all to learn as much as we can from each other, then we will all have to work on developing an environment with the values that encourage accountability, both in how we use resources and in how seamless the care can be for people who have to use them.

I appreciate that doctors need sufficient confidence and security to try out new ideas and to know they will be responded to and not ignored. My own wife is one of your professional colleagues. I have some understanding of the stresses you live with on the job and that haven't left you when you get home.

The Government shares with doctors' in wanting a health system that is responsive, solutions driven rather than complaints driven, and geared to rewarding people who work in it in a meaningful way.

To overcome public scepticism we need to dispel the strong suspicion the public has that change is being driven by cost-cutting, or profit-making, by interests that are not identical with the interests of the patient or in the interests of the best health care.

The facts and figures on health expenditure go some way to showing this suspicion is unfounded. Rather than a cost-cutting exercise in health, the government has been spending more with the total climbing to in excess of five and a half billion last year and the news is its rising though it will be up to the Treasurer on Budget night to say by how much.

If you get the appropriate clinical and financial accountabilities working then doctors and other staff will be able to present to the public and their patients a personal confidence in the quality of health care they are providing. That confidence will do more to dispel public scepticism than anything a politician can say or do.

In conclusion then, how the organisations you work in develop, is in your own hands, that is in the hands of people I consider best qualified and motivated to strive for more effective and better targeted health care. It's my job to encourage you, as thinkers, as innovators, as risk-takers, to challenge you as artists as well as scientists to take the motto for this conference -``Integrating the Art of Science and Medicine.''

I look forward to working together with you to free you up from the constraints that hinder you providing seamless care for your patients, and I welcome the future of health management that integrates doctors into the processes of financial responsibility and decision-making.

Thank you.