Posted: 10 June 2009
Health Minister's speech notes for PHO Alliance meeting in Wellington, Friday 5 June 2009.
Thank you for the invitation to speak to you this morning. Last time I spoke with you, it was as Opposition Spokesman on Health just prior to the release of our health policy document Better, Sooner, More Convenient.
Today I'd like to talk about the work we are doing as the new government in Health, particularly in primary health care. None of it will be a surprise to those of you who have read Better Sooner More Convenient, as that 50-page document is the road map for our direction and policy.
Firstly I'd like to report on last week's Budget and how Health fared, then talk about some of the new Government's major objectives, and how you in primary care can help us achieve those objectives and a better health service.
It is a great privilege being the Minister of Health. And it'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.
In last week's Budget, Health secured around half of all new government spending. One out of every two extra dollars over the next four years.
In the most difficult financial circumstances for generations, John Key and Bill English ensured that critical investment in the New Zealand health service.
This is a National Government committed to a strong public health service.
While we have secured an additional $750 million of new health investments for 2009/10, finance is a lot less certain for 2010/11. The next Health Budget will be very dependent on how the economy goes over the next 12 months.
Over the next three years the economy will lose around $50 billion of output, compared with what was forecast in Budget 2008.
An operating deficit of $8 billion is forecast in 2009/10 and over $9 billion in 2010/11.
If the economy improves, as we all hope, then we can maintain the $750 million annual increase. If the world economic situation continues to deteriorate, then the government will have to tighten its belt as well.
What this means is that while Health has done well this year, next year will be a lot less certain. 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.
Against this quite sombre backdrop the Government has begun delivering on its pre-election commitments around the three biggest problems in health today: workforce, workforce and workforce.
We've established a voluntary bonding scheme to encourage graduate doctors, nurses and midwives to stay in the country. We're funding more medical student places, and GP training places. We're investing $70 million in additional training and education to staff our dedicated elective surgery super centres. And we're working to improve job satisfaction by insisting DHBs re-engage their frontline health staff in the planning and running of health services.
The Government has also begun delivering on commitments in maternity, medicines, aged care and hospice.
We've also worked with the Green Party on the Home Insulation Programme: a campaign to fit homes built before 2000 with insulation and clean heating devices such as heat pumps and approved wood burners. About 180,000 households will be eligible for grants of up to $1,800 regardless of income. Community Service Card holders will be eligible for grants of up to $3,000.
Vote Health is contributing $100 million to the $323 million programme that will make a real difference to improving the health of tens of thousands of kiwis.
The Government has many objectives for the next three years but four are particularly noteworthy for this audience.
- We want a sea change in Health that re-asserts the importance of clinical leadership and clinical networks. This underpins our approach, and I'll comment further on this soon.
- We've a strong focus on lifting elective surgery performance. Over the past nine years, despite a doubling in the health budget, elective discharges increased an average of only 1,400 a year. We want to lift that to an average increase of 4,000 discharges a year: from 118,000 in 2007/8 to a minimum 130,000 by June 2011. This will help us keep up with ageing and population growth. Commence 20 dedicated elective theatres and train up to 800 additional staff.
- We want to move to a regionally/sector-driven public health system, as opposed to a command and control Wellington-driven system. The previous Government thought Wellington could make everything happen and therefore needed more of the resources.
- We are working to turn Health away from its current downhill track to financial crisis. Deficits of $160 million growing to $200 million if action isn't taken. Over $600 million of capital demands with few funds to meet those demands.
A strong commitment to Clinical Leadership and engaging health professionals underpins the government's health policy.
Earlier this year I asked Jeff Brown President of the Association of Salaried Medical Specialists to lead a group to provide some guidance to DHBs on the importance of clinical leadership and what they could do about it.
That paper - In Good Hands - is important. I was particularly struck by a quote from the British Health Minister Lord Darzi because it clearly enunciates much of our thinking:
"If clinicians are to be held to account for the quality outcomes of the care that they deliver then they can reasonably expect that they will have the powers to affect those outcomes. This means they must be empowered to set the direction for services"
Darzi was further quoted as saying: "....where change is led by clinicians and based on evidence of improved quality of care, staff are energised by it and patients and the public more likely support it".
Prior to the election - and in our policy documents and public statements - we made it clear that a National Government wanted a new partnership with the health professions... one of engagement and trust. And we are working to achieve this because a motivated and engage health workforce is more effective and productive.
The obvious has to be repeated: it is doctors, nurses, midwives, pharmacists, and other clinicians who provide the care patients need and want, not managers or boards or even Ministers.
You'll have all seen the new Government's Letter of Expectations to District Health Boards. In it we made it clear we are holding DHB chairs accountable for achieving the improvements we need in their parts of the public health system.
We make no apology for the strong focus we have on improving public hospital services this year as a priority. Patients wait too long for elective surgery, for emergency department care, and for cancer treatment. This must improve, and that is what DHBs are expected to put considerable effort into this year.
But at the same time we reminded DHBs of our commitment to the Primary Health Care Strategy, and asked them to work over the next year with you as the Government prepares to focus more on primary care in 2010/11. More on this later.
In that Letter of Expectation we made it clear there was a bi-partisan commitment to the Primary Health Care Strategy. But that does not mean a bi-partisan commitment to the status quo.
Even though the stated goal of the "Primary Health Care Strategy" (PHCS) is to revolutionise primary care services, much remains to be done. Apart from lower fees and the formation of 80 Primary Health Organisations (PHOs), there has been remarkably little progress in achieving the other, more quality-focused goals.
The former Health Minister Mr Hodgson told the previous Cabinet that the Primary Health Care Strategy was failing to deliver:
- The "quality improvements" offered by multi- disciplinary teams.
- A wider range of services provided in a primary setting.
- A strong and expanded involvement of nurses.
The PHCS envisaged a wider range of services provided in a primary care setting, such as pharmacy, oral health, community nursing, midwifery, hospital follow-ups, and Wellchild services.
However, the Minister admitted to the Labour cabinet that progress here was also weak.
Similarly, he was forced to acknowledge slow progress in getting primary and secondary services working together, and said that, in general, performance "lags behind the policy direction".
A year later his close colleague Mr Cunnliffe told the Cabinet the same thing! Little progress has been made in improving population health, prevention or coordinating care.
And it wasn't only Labour Ministers who thought the PHCS was failing.
So do the OECD. In their April 2009 report on New Zealand the OECD took a particular focus on the health system.
After reviewing the objectives and performance of the PHCS, the OECD said these things:
"The results for the first six years of the PHCS have been mixed, and mostly disappointing....
.... despite changes in consultation rates and co-payments in the desired direction, there is little available evidence that the reformed system is making a contribution commensurate with the large increase in public funding ....
.....The PHCS has likewise failed by and large to deliver on its promise of more effective outpatient care for chronic conditions by means of a major structural shift in the primary care services toward innovative, co-ordinated, multidisciplinary and efficient forms ...
..... The PHOs should be either eliminated as an unnecessary new bureaucratic layer or else their role and obligations must be more clearly defined..."
A soon to be released Treasury analysis of the PHCS prepared under the previous government says:
"The rate and extent of progress towards Strategy goals has been variable partly due to PHO management capability .... Some PHOs are predominantly "post-boxes" though which funds pass directly to practices".
As the National Party said throughout its last term in Parliament, we are committed to the PHCS - but we are committed to making it work. We want to achieve the rest of it ... the multi-disciplinary teams, co-locations, and better integration between primary and secondary.
We want to fill-in the missing links.
But we need you to have the capacity to step-up.
Better primary-secondary integration, more assessments and minor surgery, faster access to diagnostics and other services, public health, mental health and disability support services, multi-disciplinary teams focused on comprehensive care ... these are big challenges for the sector.
An important opportunity for general practice is the provision of more assessments and straightforward procedures now restricted to the secondary sector.
Clearly, only PHOs with appropriate skills, clinical leadership and capacity will be able to accept these additional responsibilities and the delegated funding that will go with them.
As a starter, DHBs have received around $6.5 million this year, and $13 million a year from 2010 to kick start devolving more secondary services to primary care. My expectation is that this year DHBs will engage strongly with you about how this can happen in your district and region, with specific devolution and delegated funding arrangements in place for the start of the next financial year.
This is a priority for the government, and if resources allow, we will invest further in this initiative next year.
You know that all our DHBs are under significant financial pressure one way or another. They are also under significant pressure from growing acute demand as children and adults arrive at the nation's hospitals for medical care in ever increasing numbers. It is that growing acute demand which is the major challenge to the position of DHBs.
There is no better time for primary care to show individual District Health Boards how you can help Boards manage acute demand. There's going to be real pressure: shortage of workforce, shortage of capital, shortage of funding, and access targets like ED waiting times. This gives primary care an opportunity to step up.
Through extended hours, walk-in access, convenient nurse-led services, structured care for long-term conditions and for older people, self-management and education, telephone and email support, referral guidelines, decentralised specialist clinics ... community based care that is responsive to the needs of patients with acute demands.
The worsening economic situation and the uncertainty around future finances means our DHBs need partners to help them deal with the needs of these people ... your patients.
The Government is open to DHBs entering into arrangements with PHOs to better manage acute demand. We aren't into command and control or one-size-fits-all. It's up to you to demonstrate capacity, expertise and clinical leadership to help make this happen.
And if you are to enter into delegated funding arrangements with DHBs to provide more surgical assessments and minor surgery, or direct referral to certain diagnostic tests, then you need good governance, good managers and strong clinical leaders.
And that raises the question: does size matter? With general practice? Or PHOs?
The failure to move healthcare from secondary (hospital and specialist focused) to primary care in any significant way, despite its constant restatement as a policy objective, is one of the greatest puzzles of health policy over the past few decades, according to British Professor Paul Corrigan.
Prof Corrigan suggests that the lack of critical mass in general practice - small scale - has been the main barrier. Issues like capital, operating costs, and personnel prove daunting for any small business looking to change its configuration.
That's why we're promoting Integrated Family Health Centres. We don't own general practice so we have no authority to consolidate at will. But research demonstrates such consolidation built around co-location of multi-disciplinary teams improves patient outcomes.
Many of you today are keen to know the government's attitude towards the number and size of the 80 PHOs.
Latest information from the Ministry of Health shows that 30% of the country's population is in four PHOs. At the other end of the scale 12% of the population is in 41 PHOs.
Some DHBs have as many as 7 PHOs, while others have only one.
It is going to get harder for small standalone PHOs to step-up to the opportunities that look likely over the next few years. Already many smaller PHOs are discussing how they can work more effectively with others to increase ability and save costs. Some may amalgamate, some may confederate.
Governance, management and clinical expertise are spread too thinly. If we are all to make the PHCS work, then you need to step-up.
As we said in our September 2007 policy document: "As primary healthcare develops in line with our proposals, we would expect PHOs and their associated providers to respond and organise themselves to best offer improved care and services to their enrolled populations. For example a PHO would need to demonstrate a high level of capacity and expertise to receive delegated funding".
We further said: "PHOs should be a partnership between community and clinicians. Strong clinician engagement is fundamental to achieving quality service".
The Ministerial Reference Group led by Dr Murray Horn is looking at these issues, and will be making recommendations to the Government about how we can realise the vision of the PHCS in a high-trust low-bureaucracy way.
Take the opportunity to work with you DHB on scaling up successes, jointly solving problems with growing acute demand, and importantly, involve the key people ... clinical leaders at primary and secondary levels.
The new government is determined to provide a better sooner more convenient health service. Because that's what your patients wants.
Patients want more convenient opening hours and locations, and more ways to get medical advice and support. Patients also want a wider range of services closer to home and with much less waiting.
Primary care offers the best way to deliver timely healthcare closer to home for New Zealanders. It is a priority for this government.
To make this happen we need you in primary care to step up, and meet the challenges. I am very optimistic about what we can achieve over the next few years.
Thank you for the opportunity to speak with you. |
