Health Minister's speech notes for Royal New Zealand College of General Practitioners, Wellington, 12 February 2010

Thanks Harry Pert and Tony Townsend - President and Deputy Presidents of the College.

Good morning everyone - and Welcome to our international speakers here today - Welcome to New Zealand. 

Thank you for inviting me to speak at your Quality Symposium.

The last time I spoke to you - almost exactly a year ago - the National Government was three months into our first term.

I took the opportunity then to describe to you some of the Government's priorities for our first year - these included improving performance in hospitals, enhancing clinical leadership and the Government's mission for better, sooner more convenient primary health care.

The Ministerial Review Group had just been set up to advise the Government on how those priorities could be best met.

Quite a bit has happened since then.

Events 2009

In the past year we have faced the swine flu pandemic, which placed increased pressure on primary care during the already hectic flu season. 

Thank you for your hard work during that time.

Now we're preparing for a possible second wave of swine flu to hit shortly. 

New Zealanders have also experienced the worst recession since the 1930s. 

We're coming out of that now but the impact on tax revenues has hit hard and will continue to do so.

Financial forecasters say we face deficits and large scale borrowing for many years to come. 

The Government is borrowing $250 million a week just to maintain public services including health.

In the last Budget, Health secured half of all new spending. That was $750 million - half of $1.5 billion.

The thirty or so other government departments and agencies had to share the other half. 

It is clear Vote Health will not get an increase of the size it got last year, because the total new spending is $1.1 billion, compared with this year's $1.5 billion.

It is not going to get better soon.

We are moving from ten per cent yearly increases in Vote Health during the boom times of the last decade to much lower increases for some time to come.  

More than ever we have to live within our means - year on year.

The Health sector is moving to a lower funding increase track and we'll be on that for some time.

It will take six or seven years to get back into surplus and even then our public debt will be over $ 60 billion...and we will have to pay the interest on that.

The only way we can have long-term secure health services for New Zealanders is if we can get District Health Boards on a solid financial footing.

There is no certainty for staff or patients when DHBs limp along in deficit.

This financial year we gave DHBs an extra $530 million and they will get another increase next year - though not as big as this year's.

The dilemmas DHBs in deficit face will only get more drastic the longer the tough decisions are delayed.

It would be clearly unfair if the burden of living within smaller increases fell on the hospital sector only. That is why we are working with the primary care sector to identify areas of lower priority spending that can be moved to higher priorities like subsidies for first contact visits.  We are also asking DHBs to work with the sector to review the configuration of PHOs, acknowledging existing provider networks.

This will cause noise, but change is needed; not only save money for higher priorities but also to improve capacity to do more.

Achievements 2009

Despite the grim economic times, the Government is progressing its priorities this year.

It is in times like these that New Zealand's best and most innovative people shine. 

The Ministerial Review Group - made up of some of health's best - released its report on improving quality and productivity in the public health service, which the College provided valuable feedback on.

Now we've established the National Health Board within the Ministry of Health to implement the recommended shake up of health.

We've also addressed the most serious pressures on our hospital services. Our priorities were more elective surgery, faster emergency services and better cancer treatment waiting times.

We've also focused on our three preventative health targets of immunidasation, better help for smokers, and for cardiovascular disease and diabetes.

DHBs have achieved gains in all those goals. In particular we have delivered a record number of elective operations to New Zealanders - a record annual increase of over 12,000 patients. 

District Health Boards will be making further improvements in processes, productivity and quality in hospitals.

There will also be a continued focus on improving financial management, clinical leadership and regional co-operation.

Primary Health Care a greater Priority

One of the Government's key election goals was better, sooner, more convenient health care for patients closer to home.  

Progressing the primary health care strategy will be an even greater priority this year.

A key part of the government's election policy was giving New Zealanders better access to a wider range of services in primary care.

We've listened to primary care about your frustration that no one in Wellington was taking any notice of how primary care could play an even greater role in the health service.

That's why we created the Expressions of Interest process, to invite the primary care sector to set out what you could do to accelerate the primary health care strategy.

As you know last year the Ministry of Health received over 70 Expressions of Interest from primary health care providers ready and able to deliver the large scale, step change we are looking for in primary health care delivery.  Nine are now developing more detailed business cases.

We encourage other DHBs and organisations to take up opportunities where appropriate to make that step change - and draw out the extensive knowledge and energy of the health professionals from the front lines of secondary and primary care.

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

Quite apart from the patient centred aspects of better sooner and more convenient, the primary-care led EOI process and the Integrated Family Health Centre concept in particular, is part of a prudent strategy to begin developing health system capacity for the future demographic and financial pressures on the health system.

As part of creating a new and fit for purpose primary care infrastructure, IFHCs and new integrated care teams where the health professionals work together and in general accept more responsibility than in the past, are much needed policy developments.

In the past, governments have only focussed on hospitals - this govt is taking a sensible health system view - community, primary and secondary.

The evidence base for IFHCs - in particular, the UK - suggests that in the future, people will be able to get the right care in the right place - an opportunity denied to most New Zealanders because the necessary primary teams and infrastructure do not broadly exist today.

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

Part of this is the promotion of Integrated Family Health Centres - where primary care professionals see it as appropriate.

Integrated Family Health Centres enable people to go to one location and, for example, maybe see a GP or nurse without an appointment, have a blood test or an X-ray, see a physiotherapist, have a first specialist assessment, or visit a pharmacy for their prescription, even have minor surgery - all in the same building.

We don't own General Practice so we can't direct people in line with this philosophy.  But we know that more and more GPs see it as the way forward. And there are a number of examples of such centres already around the nation.

What's missing is that closer integration between community and hospital that will improve convenience for patients and take a load off hospitals.

It also calls for community and hospital professionals to work together - to make the decisions together with the patients as to the most appropriate location for their future care. 

And it is not about charging patients for services. In February last year the Government specifically told the sector and DHBs in particular that any hospital services provided in community settings would continue at no charge to patients.

It is about working together to put the patient at the centre of thinking.

We need a new and fit for purpose primary health care service with the capacity to cope with future pressures on the health system.

As I've said one, that is better, sooner, more convenient , patient centred - and clinically led.

This calls for quite significant change - a reorientation of the health system based on professionals working together rather than the past focus on structures as the solution to health system pressures.

There is no time to waste - but this is a quality journey that will take some years.

Quality improvement

This is a good moment to acknowledge the commitment and dedication demonstrated daily by you, our health professionals - across the health sector.

You work very hard and you are committed to delivering high quality, safe services to your patients.

It is best practice and best value in Health when everyone is doing the right thing, properly and reliably, the first time.

This concept is the essence of quality improvement.

Getting the best value requires a strategic, disciplined and structured approach to embed quality at the core of our health system.

But many of you have told us we can do better at embedding a culture of continuous quality and safety improvement.  

Last year the Ministerial Review Group consulted widely with doctors and nurses and other health professionals across the sector about the state of quality improvement in our health system.

You said progress has been slow, patchy and uncoordinated.

You said New Zealand has not in the past given sufficient attention or priority to the very important task of improving quality and safety in the health system.

Adverse events statistics  

Most patients receive good care most of the time.

But let me repeat some statistics you will be familiar with -

The MRG report estimates about 44 thousand people admitted to NZ hospitals every year suffer an unintended injury caused in the  management of their condition.

Most incidents - not all - are minor and not life threatening but they cause expensive delays and patients suffer.  

The estimated dollar costs to hospitals alone for all this range between $500 to $800 million a year - a lot of money that would otherwise be spent on treating more patients.

If we could just avoid some of that - and we know a significant proportion of adverse events are highly preventable - we would significantly improve the lives of those patients and in hospitals alone they estimate we could realistically save up to $100 million per year.  

And here's the thing - hospitals treat around 950,000 people a year, but there are another 15 million or so patient contacts in the community, carried out by GPs, nurses, chiropractors and other health professionals.  

Preventing adverse events across the whole health sector could free up hundreds of millions of dollars.

That would buy a lot more front line services in hospitals and GP clinics across the country.

Quality Information

Last year, the College's Symposium emphasised the need to improve information systems as part of quality improvement. 

Clinicians need clinically relevant information which is based on sound evidence which they can use.

They need better more inclusive information systems, better access and better information flow.

The Government sees public reporting of quality information as also an important way to share information both between providers and between providers and the public.

International research has recently focused on the reporting of quality information as an important tool to drive improvement.  In NZ this has led to public reporting of serious and sentinel events, and more recently of DHB performance against health targets. 

The 376 practices that have achieved CORNERSTONE accreditation from the Royal New Zealand College of General Practitioners have already implemented a significant events management system to report and learn from significant and sentinel events.

The College is currently helping another 279 practices achieve CORNERSTONE accreditation.  And you are working with PHOs developing a process for how this information can best be shared across the country.

I appreciate the College's contribution to the development of quality in primary health care.

Quality Initiatives

Many providers in secondary and primary care are carrying out initiatives to improve safety and quality for their patients.

As you know, it doesn't always have to be complicated or expensive.

Quality is a lot to do with attitude, the way we do things.

Something as simple as washing hands before and after every procedure and every contact, to significantly reduce hospital acquired infections.

Something as simple as helping patients get hold of and understand their own medical records so they can advocate for themselves.

Something as simple as a ward nurse spending more time just sitting with a patient instead of spending the time ticking electronic boxes at the ward work station.  

I saw first hand what nurses at Tauranga Hospital are doing to improve patient care by improving the time they spend with patients.   One ward team had increased their patient-contact time from 32% to 57%. Needless to say the nurses seemed happier and so did the patients.

Patients want quality improvement too - this is all about them after all.  They come first - always. 

One quality improvement initiative gaining popularity reminds Health professionals to put themselves in their patients' shoes - to apply the so called 'Granny Test' -  Doctors and nurses ask themselves would I want my Grandmother to be left in a wheelchair in an ED corridor for 10 hours? 

Wouldn't I make just one more check that my patient here is about to be given the right medication if he or she was one of my own?

Medication error is one of the most common causes of accidental harm to patients in hospitals - and it can - and has proven on some occasions to be - fatal.

Some hospitals are now introducing standardised electronic medication dispensers. The hospital pharmacist loads the  patient's personalised medication onto the dispenser - the ward nurse delivers it to the patient. 

Ultimately the element of human error could almost be completely avoided by giving those personalised medicals a unique barcode which would have to be matched to the barcode of the patient they are destined for. 

Needless to say all these initiatives are being successfully tried across the country - but in a fragmented and uncoordinated way.

Quality Improvement Commission

Clinicians told the Ministerial Review Group last year that quality improvement momentum has stalled - that while the Quality Improvement Committee has done good work on initiatives like improving information systems, improving the patient's journey - continuous improvement in health care quality has been difficult. 

The Ministerial Review Group identified a range of barriers to greater improvement in quality and safety including:

• the short-term financial incentives on DHBs which lead them to under-invest in safety and quality


• a lack of national co-ordination of some quality and safety activity, such as data collection and the rollout of national programmes


• efficiencies that can be gained by providing a well-designed quality and safety programme centrally


• a narrow focus on hospital care, rather than a whole of system view, and


• a lack of perceived independence from the regulatory, funding and performance functions of the Ministry of Health leading to health professionals lacking confidence in, and a sense of ownership of, the current institutional arrangements for supporting quality and safety

The MRG got a very clear message from you - that an independent agency led by doctors and nurses and other health professionals was the best way to step up quality improvement across the sector.

That is exactly what the Ministerial Review Group recommended in its final report - and it is what I can tell you this morning the Government now intends to do.

Announcement

The Government will establish a Quality and Safety Improvement Commission - this will be a stand alone, clinically led national agency to build on the work started under the Quality Improvement Committee.

The new Quality and Safety Improvement Commission will have responsibility for quality and safety across the whole health sector, including primary care and private hospitals.

The Commission will set quality and safety guidelines and standards, provide education and benchmarking and publish reports on quality and safety indicators across the whole sector.

I would like to thank QIC for the substantial work its members have done to drive quality improvement across the New Zealand public health sector.

It is hoped the existing qualities initiatives under QIC will become 'business as usual' and that we will enter a faster paced, more coordinated phase of quality and safety improvement across the whole sector. 

The new Commission will be independent of the regulatory, funding and monitoring part of the Ministry - and report directly to me.

It is to have at least seven members, including the chair drawn from the breadth of health care providers.

We will be wanting the sector to work with the Ministry of Health to finalise the - to develop the role and functions of the new Commission.

This Government has repeatedly said there should be much greater clinical engagement and leadership in our health system.

You have told us what you believe is best practice for improving quality and safety for patients.

We've listened and we've taken action.

We want to make this work.

Now it's your turn.

This is a critical step towards providing doctors and nurses with the right tools for improving patient safety right across the health sector. 

No one intervention will fix it, it requires a do-able work programme, expertise and support on the ground to support and assist clinicians and it will need the buy in of DHBs and primary care.

The success of this also rests with you the clinicians stepping up and taking responsibility as leaders and coordinators.

I am keen to see a strong primary health care focus to the Commission's work and primary health care representatives on its Board. 

I encourage you to seriously consider putting your name forward for the Board if you wish to contribute to this new step in New Zealand's efforts to improve health system quality.

The Ministry of Health is looking after the nomination process - they'll be receiving nominations from today until 8 March - details are on the press release.

Thank you for the opportunity to be here with you and I wish you well with the conference.