Speech to New Zealand General Practice Conference and Medical Exhibition

Health

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.

Acknowledgements

Thank you and good morning and I acknowledge you Alistair, as chair of the association, and acknowledge the comments that you’ve just made. 

Some of your figures I might question. I don’t think we’re 12,000 nurses short. It’s not the figure I’ve been made aware of.

But I think it’s important to note that we have a health system across the board that is under pressure, and I acknowledge the role that the New Zealand Medical Association has played for many years as an umbrella organisation and as an important advocate in the health system and in the health sector for a variety of professions it represents.

Thank you to the Medical Association again for inviting me to join your conference this year. As I think we all know, the past two years have been exceptionally challenging for everyone.

When I spoke at this conference last year, we were already more than 15 months into the COVID-19 pandemic, but we were yet to see the widespread outbreaks and community transmission that we saw with the Delta and Omicron variants. COVID continues with a reasonable degree of prevalence even today.

The pace and pressure on the health system since then has been sustained, and I recognise the immense effort that continues to be made by the whole sector to keep people safe.

The system has responded and continues to respond well. That is a tribute to the professionalism and dedication of GPs and other health professionals around the country.

The value of General Practice

As I said last year, for most people, general practice is the front door to the health system.

Every year, there are more than 20 million consultations with general practice.

Of these 20 million visits, nearly 14 million are to GPs, and 4.3 million are visits with practice nurses. These figures doesn’t include visit paid for by ACC and visits for immunisations and maternity care, and casual and after-hours visits.

The past two years have put more strain on a system and profession already under pressure. I’m talking about GP shortages, nurse and nurse-practitioner shortages, burnout, an outdated funding model, and rapidly changing and evolving clinical guidelines.

On top of that, you’ve had the additional workload of caring for COVID-19 patients who have got COVID-19 and for those whose planned care has been disrupted by the pandemic.

The communities you serve have unique needs and need strong primary and community healthcare.

In fact, strengthening primary and community healthcare is one of the greatest opportunities we have to improve the health and wellbeing of our people, particularly Māori, Pacific and rural communities under the reforms which will start to take effect on the 1st of July.

Empowering communities to develop their own solutions to deliver seamless and comprehensive care is central to the health system reforms.

Health reforms and the locality model

Which brings me to those health reforms I announced in April last year.

While the interim agencies are already up and running, Health New Zealand and the Māori Health Authority will be formally established on 1 July 2022 – just three weeks away today.

The health reforms are focussing on structural changes to the way our health system as a whole works and where decisions are made, to set us up for continuous improvements in care into the future.

We expect there to be real changes in the way the health system supports communities, including: 

  • The shift to a locality approach to primary and community health care – meaning care centred around communities with care providers working in closer partnership to wrap support around whānau.
  • A shift towards a genuine voice for communities in shaping health services that meet their needs.
  • Health and social services that are joined-up, instead of fragmented and difficult to access.

I expect that primary and community healthcare will start to change over the next two years, where that is necessary.

Integrated primary and community health care with localities

The shift to a locality approach one of the most fundamental changes we are making.

Localities and locality planning bring together local health providers into networks so communities get more seamless, connected care closer to home.

Primary care teams will be encouraged, and supported, to do things differently.

Clinicians will continue to play a critical role in the care of patients, but will be joined by other healthcare professionals in primary healthcare teams, giving patients access to a wide range of health services without having to be referred to another place or organisation.

Comprehensive primary care teams will be commissioned according to the needs of the community, with a focus on high-needs and rural areas.

For example, in some areas patients will get immediate access to a physiotherapist who works in a primary healthcare team.

The point is there is an opportunity now to re-thing the way primary care can be provided so we make the best use of the clinical and non-clinical skills and talents we that have in our health system.

New funding and accountability arrangements

But is we change the way we manage primary care, then that will almost certainly mean changes to the way we fund it.

The Government is a major funder of primary care - $1.3 billion a year through the Primary Health Organisation Service Agreement, of which about $1 billion goes to GP practices.

Private fees account for about $600 million of the total annual revenue of GP practices.

I know there is dissatisfaction with the PHOSA and I agree that it is no longer working.

Eventually, it and District Health Board contracts will be replaced with a new set of agreements, which will include standardised terms for all primary and community health providers, supplemented with additional funding for specific services.

The future of rural general practice

So, what changes can you expect to see?

Take rural primary care as an example: The interim New Zealand Health Plan will have a series of actions to address rural general practice sustainability.

This includes actions to support rural health needs such as:

  • The provision of after-hours telehealth services.
  • Workforce initiatives including support for rural GP registrar programmes, nurse prescribing roles, and advanced paramedic roles.
  • A review and implementation of changes to the Primary Response in Medical Emergencies (PRIME) model, which places a significant burden on rural general practice.

Budget 2022 included $102 million over three years to establish integrated and comprehensive primary care teams within locality networks. Rural general practice will be supported with targeted funding through this initiative.

Funding of general practice

As I’ve said before, the existing capitation funding formula is no longer fit-for-purpose, and does not support those most in need, particularly Māori, Pacific people, and those living in high deprivation areas.

A technical review of the current capitation funding formula is under way, and I expect this to provide the basis for further advice on possible changes.

Interim Health New Zealand and the Interim Māori Health Authority will work with the primary care sector to consider the options that follow.

Budget 22 did not explicitly deal with pay relativities within primary care and DHB employees. Central government agencies insist on a framework to deal with this, and I have this week received an assurance that this work is now being accelerated and I should have something on my desk in the next month or so.

Equity and WAI2575

Turning to equity and in particular the WAI2575 interim report from the Waitangi Tribunal, one third of people over the age of 15 are not getting the primary healthcare they need.

Increasingly, people are finding it hard to get a local general practice to enrol in, or difficulty getting a timely appointment once enrolled.

Some cannot afford the consultation fees, and others have difficulty getting time off work to get to an appointment. For some people, poor prior experiences or accumulated debts result in unwillingness to use services. 

Inequitable access and health outcomes for Māori, and overall negative experiences with primary care services were identified in the WAI 2575 report. 

Health New Zealand will work towards addressing the issues identified by this report, alongside implementing broader measures to address barriers to access and improve outcomes, including changes to the GP capitation formula to address need, growing the range of services offered by Māori and Pacific providers, establishing provider networks and comprehensive primary care teams that deliver more accessible and seamless care. 

Māori leadership will be engaged in the redesign of funding and accountability arrangements for primary and community health care.

Addressing workforce challenges

We can’t do any of this though, without a sustainable health workforce.

Retention and recruitment into primary and community health services is critical.

There isn’t a magic bullet solution here. We are committed to a multi-faceted approach, with elements of the solution to workforce challenges including:

  • Increasing the supply of GPs to replace those retiring, and to match expected increases in demand with the ageing population.
  • Expanding the primary care team to include clinical pharmacists, allied health workers, kaiāwhina, and others, so that a comprehensive multidisciplinary team becomes the norm.
  • On-the-job training programmes and pathways to increase the scope of nonregulated and regulated roles – including pathways for nurse prescriber and nurse practitioner roles.
  • Ensuring that salaries and terms and conditions of employment for those in the primary and community health care sector are competitive with other sectors.

Planning to improve general practice and community care workforce capacity includes the following actions: 

  • Addressing GP registrar programme issues .
  • Credentialling general practices as training hubs, and funding them.
  • Addressing the community-based placement issues for PGY1 and PGY2 trainees, to ensure they are well supported with mentoring and with practice costs.
  • Introducing prescribing pharmacist ‘supervision placements’ or ‘development pathways’, with a focus on high-need areas.
  • Supporting unregulated Māori and Pacific kaiāwhina roles with skills staircasing framework (in partnership with the Māori Health Authority).
  • Health New Zealand hospitals in locality prototypes will test innovative ways of integrating clinical capacity with the establishment of primary health care teams.
  • Reorienting community services to work as part of the comprehensive teams in prototype localities.

This will take time, but our health workforce is absolutely vital, and we are committed to finding solutions to the current challenges.

Addressing unscheduled care

There are 2.5 million urgent-care clinic consultations and up to six million more to general practice each year, compared with around one million hospital Emergency Department visits. 

As our population grows, ages, and diversifies, it is essential that primary and community health care providers are resourced to support the growing demand for unscheduled care, and that people can access this care as close to home as possible.

There are several ways that the management of unscheduled care will be strengthened in the future health system, including:

  • Telehealth. We will work with Whakarongorau Aotearoa to develop new telehealth offers for New Zealanders, so that people can increasingly access health information, advice, and support from trained professionals in their own homes
  • General practice and after-hours appointments. We want to improve access to primary care appointments, including during weekends and evenings, and will offer a broader range of services to people, including services that have traditionally been provided in hospital settings.
  • Partnership with ACC and road ambulance / paramedic services. The PRIME service provides a framework for ensuring that people requiring emergency care get the right care, at the right time, in the right place from the right person. We will work with ACC and ambulance services to deliver the PRIME service and develop care pathways that ensure people are supported to receive care as close to home as possible.

Closing

The Government recognises and values the work that GPs and the primary and community healthcare sector do – you are pillars of our health system.

I am under no illusion that there are, and will be, many challenges ahead.

The Government is committed to change, to finding solutions and building a truly national health system that is co-ordinated, equitable, and sustainable.

Of course we can’t do that without you, and that is the reason why in this year’s Budget we committed more than $11 billion over the next four years to cover the funding gaps that we’ve seen, particularly in the hospital services, but in primary care services as well.

It’s why we are actively engaging with the relevant unions to increase remuneration and conditions for health workers. That work is ongoing.

The next months and years are a pivotal point for our health system, and I’m excited about the future ahead and the opportunities that the reforms hold.

Thank you again for your time this morning and the opportunity to speak to you today.

Nō reira, tēnā koutou, tēnā koutou, tēnā tātou katoa