Speech to Association of Salaried Medical Specialists – Virtual Conference on Equity of Health Outcomes for New Zealand
Tēnā tātou katoa
Kei ngā pou o te whare hauora ki Aotearoa, kei te mihi.
Tēnā koutou i tā koutou pōwhiri mai i ahau.
E mihi ana ki ngā taura tangata e hono ana i a tātou katoa, ko te kaupapa o te rā tērā.
Tēnā koutou, tēnā koutou, tēnā tātou katoa.
Greetings to everyone,
I acknowledge the pillars of the ‘house of health’ in New Zealand.
Thank you for inviting me here today.
I acknowledge the ties that bind us together, one of which is the reason we’re here today.
Thanks and acknowledgements to everyone.
Thank you for the opportunity to speak with you this morning.
I acknowledge the work of the association, not just as an effective representative of its members, but as an essential voice in our health system.
As senior clinicians, the association’s members are both clinical leaders – determining the best pathway for patients and keeping in touch with new techniques, technologies and approaches – and also system leaders – often occupying lead roles in health organisations and influencing policy and investment decisions at the centre.
I have appreciated my exchanges with, and the public commentary of, your executive director, Sarah Dalton, and I look forward to continuing to strengthening that relationship.
I also acknowledge your president, Dr Julian Vyas, and the wider ASMS national executive.
Thanks also to our other virtual co-hosts – The Canterbury Charity Hospital Trust, and the valuable work you do to support people when they need it most.
I want to take the opportunity today to look at the current public health system landscape, as well as to set out what I expect the reforms I announced in April to achieve, and to update you on where we are with the reforms.
I will also give a mid-project review of the changes we’re making in the field of mental health care.
There is no question our public health system is under major stress.
SYSTEM UNDER PRESSURE
Our hospitals are under unprecedented pressure.
We are seeing spikes in presentations at hospitals and GP clinics, and as clinicians are pointing out, we are only at the beginning of the winter season.
In many emergency departments, higher proportions of patients are not being sorted out within the target six-hours of arrival.
We know with reasonable certainty some of the factors that lie behind what’s happening:
- More people are unable to get access to primary care because patient rolls are closed, there are no after-hours services, or those services are unaffordable.
- More elderly people are presenting with more complex problems and are needing to be admitted.
- We’ve got more patients who are already in hospital being unable to be discharged. Whatever the reason for that is – and there can be many – it means one less bed is available for an emergency patient to be referred to.
These pressures have been building, to a greater or lesser extent, within most DHBs for some time.
The Ministry of Health has a team working with the management and clinical leadership of DHBs to help in dealing with these challenges.
This group meets with each DHB weekly to review patient flow and develop approaches to assisting with good-quality patient admission and discharge.
Of course, this isn’t anything other than an immediate response to an issue that requires more substantial and longer-term solutions.
The health and disability system reforms are intended to address some of these longer-term issues, and I will come to these shortly.
As well as these deep-seated issues putting pressure on our system now, we also have the challenge of putting into effect the biggest vaccination programme this country has ever seen, using the largest and possibly most diverse vaccinator workforce ever.
This will ramp up considerably over the next month.
On top of that, we’re keeping the annual influenza immunisation programme going, as well as implementing major health reforms.
The reality is that the challenges in the public health system we are dealing with today are the product of years of under-investment in health.
Short-term and narrow performance improvements were pursued at the expense of much-needed system-wide change.
Look at the numbers: Over nine years, from Budget 2009 to Budget 2017, National increased operational spending on health by $3.7 billion.
In just four years, the Labour Government has boosted operational spending by an extra $5.8 billion. This year we will spend a record $22.8 billion on health.
Our record on capital expenditure also stands up well: in the eight years between Budget 2010 and Budget 2017, National put $1 billion into infrastructure.
In just half that time – between Budget 2018 and Budget 2021 – we’ve committed $3.9 billion, with another $1.4 billion set aside for the new Dunedin Hospital, described as the most complicated “vertical” construction project this country has ever seen.
That’s a total spend of $5.3 billion – in just four years, and there are still more significant hospital builds in the queue, which we will consider later this year.
The consequences of those previous years of underspending are being felt today. Whether it’s new buildings, new IT systems or addressing workforce issues, it takes time to catch up when you’re starting from a long way behind.
Outside of health capital and operational spending, the Government has increased Pharmac’s budget by 25 per cent to a record $1.1 billion. That includes an extra $200,000 million over four years announced in Budget 2021, which will help an estimated 370,000 people get access to more medicines.
Just this year, we’ve committed $385 million for a nationwide health IT system upgrade.
And on workforce issues, we’ve increased the number of people working in the public health systems, and will continue to address the longstanding remuneration issues and workforce development issues as expeditiously as we can.
Let me turn for a moment to mental health.
We identified even before we formed a government in 2017 that New Zealand’s mental health and addiction services were under extraordinary pressure.
We set up the review of these services in 2018.
Following the report at the end of that year, we made the single biggest investment in mental health ever - $1.9 billion over four to five years.
Contrary to the assertion in the ASMS report last week that not much of that funding has been spent, two years into the programme, we’re making good progress:
- Of the $1.1 billion allocated to Health, $748 million has been spent or committed.
- 520 fulltime-equivalent roles have been added to primary healthcare, covering an enrolled patient population of 1.4 million people and dealing with those with mild-to-moderate mental health issues, which the review said was the gap that had to be filled as a matter of priority. In May this year, more than 20,000 sessions were delivered under this programme.
- Four out of five rebuilds or upgrades of acute facilities have been approved, and detailed design and planning is under way, with construction due to commence next year.
- New services have been funded for kaupapa Māori providers, Pacific providers and specialist youth providers. Contracts are currently being let for services in the rainbow community.
I say this not to suggest we can rest on our laurels, but to account for progress so far. There is plenty more to be done to expand frontline primary-care services, and there is more to do to address the problems at the acute end.
There is also more we need to do to expand mental healthcare community-based services, which will make a vital contribution towards taking the pressure off acute services.
Workforce issues across the health sector are serious, and, arguably, especially in our mental health services.
Addressing the continuing challenges in mental health is not just about more buildings and more beds, wherever they may be. Building the skilled workforce is just as – if not more – important.
Many of the challenges we are addressing today are not only the product of inadequate funding and a failure to seriously address workforce issues over many years; the structure of the system itself has become a problem.
That is why we have committed to system change.
The plan includes replacing all 20 district health boards with a single national agency, putting more effort into primary healthcare to stop as many people as possible from getting so sick they need to go to hospital, and finally addressing the frankly appalling inequity that sees Māori die, on average, seven years sooner than non-Māori.
This is a significant undertaking. It was a Labour Government that in 1938 established our public health system, and this Government is committed to putting in place a health system fit for the 21st century.
The changes will see a shift towards greater coherence across the system as a whole.
It will allow us to put greater emphasis on primary and community care, which will not only help address major equity gaps in health service provision, but will help with the pressure on hospital services.
The new system will also help us address some of the workforce problems we face.
Recent surveys by the Royal New Zealand College of General Practitioners suggest high levels of burnout and plans by more than half the workforce to retire in the next 10 years.
And as your own association has noted recently, senior doctors, nurses and many other specialised health workers are dealing with serious staffing shortages.
Nineteen medical specialties are forecast to have fewer full-time-equivalent positions in 2029 than in 2019 – with radiation oncology predicted to drop a startling 38 per cent.
COVID-19 has not been identified as a major factor in burnout, indicating the problem is with the system itself.
Unifying public health services under a single agency means we will have the scale and reach to actually anticipate, plan for and train the workforce we are going to need for the benefit of the whole system.
Work on putting the reforms in place is well under way.
The Ministry of Health and DHBs are mapping the changes we need so we can get the new entities running from the first of July next year.
We are considering forms of operational and clinical leadership.
Consultation has started on the new public health service, amalgamating the existing public health units.
This month we start consultation on the New Zealand Health Charter, a key part of the reforms that will enshrine our aims and overarching principles for the health system.
Soon we will unveil the system that will let us monitor and measure the way the health system is performing, giving us real information in real time so we can to adjust services so they are doing what we want them to do.
More than 300 people have put themselves forward for the interim boards of Health NZ and the Māori Health Authority. I expect to announce the interim boards in due course.
By September or October, I expect to introduce into Parliament the legislation needed to put the new public health system in place. I expect it to be passed in April next year.
And this time next year – at the start of July – our new system will be in place.
In closing, I want to lay down a challenge. Ahead of us is a once-in-a-lifetime opportunity to create a truly excellent health system.
A system that takes health services to the people who need them, no matter who they are or where they live.
A system with people at its heart.
My challenge to you is to consider what it is that you can do, as individuals and as a profession, to support a vision of a truly equitable health system.
Reading through the agenda for the next two days of your conference gives me immense hope and optimism.
I know that some of the conversations and realities that we have to consider are uncomfortable. That some of the solutions are challenging and complex.
But if we are to achieve pae ora – a healthy future – we are going to have to tackle inequity once and for all.
I am confident that the health system we will build with you will give us the best possible chance of doing it.
Thank you again for the opportunity to speak to you today.
Nō reira, tēnā koutou, tēnā koutou, tēnā tātou katoa