Speech Notes – NZMA GPCME Conference, 11 June 2010

Good morning.  Thank you Dr Peter Foley for your welcome.

Today I'd like to talk about some of the pressing challenges facing the New Zealand public health service, and in particular the vital role you as health practitioners will play in our country's future.

I'm going to cover:

• Our recent Budget and the international context,
• dealing with the health workforce crisis we inherited,
• providing better, sooner, more convenient service in primary care;
• and a new partnership with the health professions to improve quality and leadership in health.

It is a great privilege being the Minister of Health. That's made even better by having a Prime Minister and Finance Minister both with an equally strong commitment to the public health service. And I am fortunate to also have a strong team of Associate Ministers.

Financial Restraint

That's significant in this time of financial restraint, the worst since the 1930s - where it is more important than ever that we live within our means while we protect and improve the public health service for patients and health professionals alike.

Despite the recent encouraging news that we are coming out of the recession, its impact has had such a profound effect on our economy. The large government surpluses of recent years are replaced by larger deficits lasting another four years.

But this is not unique to New Zealand.

Internationally, public services including public health services in particular are feeling the pinch.  Dramatic decisions are being reported.

In Ireland, the Government has cut public service salaries - including doctors, nurses and teachers - by up to 15%.

Canada has frozen wages in the public service for the next two to three years.

Spain has just announced a 5% pay cut in public sector pay.

Italy has established a 3 year wage freeze for all public servants and will not replace one in five staff who leave.

In England - before he lost the election - the former Prime Minister Gordon Brown said up to £3 billion would be saved in the NHS by freezing pay for doctors, dentists, hospital consultants and senior managers across most of the public sector.  The new Coalition Government in Britain has

signalled that the NHS may need to find more than £20 billion in efficiency savings to simply keep pace with rising demand and aging.

New Zealand is part of the same world, and the same international economy. 

We face the same economic pressures and uncertainty.  They are real and with us.

But this Government has taken the deliberate decision to take a long term view of our country's economic challenge.  We are not cutting back on health investment. We are putting in more money - even if we have to borrow it - because we know eventually we will be able to pay it back.

The truth is the Government is borrowing $240 million a week to protect vital social services such as health, confident that the New Zealand economy is coming right and we will have protected our communities during that time.

Last year Vote Health got half of all new government spending. This Budget we got $512 million of new spending. That means Vote Health has kept pace with inflation and population change.

Despite tough economic times, the new Government is investing more of the country's resources in Health than ever before. This next year will see the highest percentage of GDP invested in the public health service in our history.

However, the public health service will need to ensure a strong and ongoing focus on value for money, with resources moving from administrative overhead and low priority spending into more important frontline services. And this applies equally to hospital and community services.

This year's Budget included:

• An extra $410 million to DHBs this year meaning they keep pace with inflation and population change
• An extra $144 million over four years for primary care
• The launch of a bowel cancer screening pilot
• Significant new investments in elective surgery and neglected disability support services
• And another big increase in the Pharmac budget so we can give kiwis better access to more innovative new medicines.

And your patients are seeing the benefits of our focus on priority services in our hospitals.

In the past year, hospital staff performed a record 13,000 extra elective operations than the year before.  This means the Government reached it's three year goal of four thousand extra operations per year - in just one year.

More patients are also getting surgical  first specialist assessments, up over 17,000 in 2009 over 2008.

Cancer radiation treatment waiting times are well down from the time only a few years ago when patients were regularly sent to Australia. And breast reconstruction surgery has been restored in the Lower North Island.

Workforce Crisis

But we can't do any of this without a strong health workforce.

Our clinical workforce is the greatest asset that the health service has, but it is clear to all of us that New Zealand needs more health practitioners - doctors, nurses and allied health professionals - particularly in some regions and some specialties.

In medicine we are increasing the number of medical school places by 200 over the next five years.  The first stage of this increase began this year with 60 additional medical students and this Budget  funds another 20 on top of that. 

Since we took office, we have established a voluntary bonding scheme to encourage our young midwives, nurses and doctors to work in hard-to-staff specialties and regions by offering payments against student loans or cash incentives. 

The scheme has proven very popular.  It works on the principle that if we can keep them in the country for 5 years, biology will do the rest!. We have 900 health graduates - doctors, nurses and midwives-registered from last year in this bonding scheme, and this year another 500 have applied to join.

We are aiming to increase the number of GP registrar training places too as a short term measure to address New Zealand's GP workforce shortage. 

More of this training needs to be in rural and provincial regions to encourage more GP trainees to choose to stay in these communities.

The next round of tax cuts will also help us retain clinical staff and attract kiwis back home. An SMO earning $165,000 gross a year will see their take home salary rise by almost $7,000  a year (before GST)  (or $4,400 after GST) as a result of the tax cuts.

A raft of health workforce reports, endless committees and commissions, competing bureaucracies across the sector has led to paralysis by analysis over the years. Sector leaders have been critical of how workforce issues are dealt with, and have called for a more coordinated national response.

You've heard this morning from Professor Des Gorman who is leading Health Workforce NZ, a clinically led group that is bringing all this disjointed effort together with real focus and action.

You may know that Health Workforce New Zealand, the Royal New Zealand College of General Practitioners and the Medical Council of New Zealand are working together to improve the way general practitioners are trained. A revised vocational training programme for GPs will be up and running from January 2012. This review aims to promote general practice as a career choice among medical students and junior doctors and is likely to see more cross over of training and working between hospitals. I appreciate the support NZMA is showing for this.

HWNZ is also working with relevant organisations to support innovation in nursing roles.  There are a number of projects in development but an example of one is the diabetes nurse specialist prescribing innovation project - the first of prescribing innovation demonstration sites.    

Better Sooner More Convenient Primary Care

And while much of our focus in the first year was on our hospitals, our attention this year has increasingly turned to Primary Care. An important part of Better, Sooner, More Convenient is about realising the potential of the Primary Health Care Strategy 2002. 

Last September English academic Judith Smith from the Nuffield Trust released a well-considered "Critical analysis of the implementation of the Primary Health Care Strategy". Her conclusions will not be news to many in this room.

Smith noted that the Primary Health Care Strategy had reduced the cost of access to services but had not been able to lever significant change in models of care at practice and provider level.  In other words, the integrated, multi-disciplinary services had not eventuated to the extent intended.

Importantly, Smith stressed there needed to be greater recognition that the success of the Primary Health Care Strategy is dependent on the engagement of general medical practice. You can't have primary care teams without GPs.

In a crucial passage of Judith Smith's report she argues:

"What appears to have been missing from the Strategy implementation was detailed work with ‘mainstream providers' to explore how they wanted to develop (or were already developing) new approaches to service delivery and health promotion...  there does not seem to have been a concerted attempt to ...engage professionals in such a process of service specification and design."

In other words, implementation was frustrated by a lack of engagement and respect. The professions' insight and perspective are crucial to understanding how to make things happen. 

This was part of the motivation behind the Government's request for Expressions of Interest (EOI) from primary health care networks capable of delivering larger scale change and a wider range of health care to their communities. We wanted you to set the agenda to make the primary health care strategy happen.

It is worth me restating the objectives of the government's BSMC policy.

The primary-care led EOI process and the Integrated Family Health Centre concept in particular are patient centred. They are also part of a prudent strategy to begin developing health system capacity for the future demographic and financial pressures on the health system.

As you heard earlier this morning, if demand for health services is to double over the next 10 years, then we are not in a position to double Auckland Hospital or double the number of nurses. That is why we need to move services to a lower cost platform that can deliver care closer to home ... and that is primary care.

The evidence base for this comprehensive multi-disciplinary approach suggests that these will greatly help patients to get the right care in the right place - which they often can not because the necessary primary teams and infrastructure do not broadly exist today.

This is about beginning to prepare the public health service for the future.

And that is why we turned to you.  For your ideas.  For your leadership.

Our goal is to provide New Zealanders with better access to a wider range of health services closer to home. It's a goal so many of you share.

As you know, nine primary health care groupings have been working to establish strengthened approaches to primary care, and significant work has been put into getting secondary and primary health professionals to work together.

These initiatives will commence as they are ready over the next several months, and they will take different forms. The nine primary health care groupings cover 60 per cent of New Zealand's population, and we expect to see them working with their DHBs to deliver better services closer to home than in the past.

But advances will be made carefully, inclusively and with strong clinical engagement. We encourage primary care networks and DHBs outside the scope of the initial nine to develop their ideas for better patient care.

Clinical Leadership:

Clinical leadership is a key priority for this Government. It is manifesting itself in many ways throughout the health service as we grow our partnership with the health professions.

Yesterday we announced the interim Board that is taking the next steps towards the new independent Health Quality and Safety Commission, which is another example of this Government's commitment to clinical leadership. It's led by Professor Alan Merry of Auckland  who played a key role in the World Health Organisation's Safe Surgery Saves Lives Initiative -  a surgical safety check list that is being rolled out internationally.

Board members include your Chair Dr Peter Foley, and Pegasus' Shelly Frost. The new Commission -- when passed by Parliament -- will help organisations and practitioners across the whole health sector improve patient safety and service quality: public and private, community and hospital.

You can't influence clinical behaviour unless the people you're trying to influence have trust and respect in you. And that's why we've listened to your strong support for a clinically-led independent Commission .

This increased dialogue and engagement with clinicians will not stop, for I see it as an essential part of our strategy to make things better in this portfolio.

So Ladies and Gentleman, this is a time for clinical leadership, and for change.

We've only had the time to mention a few aspects of developments over the first year and a half. A lot of progress has been made, but there is a lot more to be done. 

I'd like to thank you all for the work you are doing to ensure New Zealanders have access to quality health care services.

Thank you. 

END.