Thank you for the invitation to speak here at the New Zealand Rural General Practice Network, Annual Conference in Christchurch.  It is a privilege to be here.

The work of the Rural GP Network extends well beyond that of General Practitioners. Your network brings together clinicians from many disciplines all with the common purpose of improving health services for rural New Zealand.

Today I would like to cover some of the actions we're taking to deal with the workforce crisis, the next steps in the primary health care strategy, and our work with your network to give you a greater say in Wellington.

But first I'd like to join with so many of you in acknowledging the the late Dr Pat Farry NZOM.  His huge contribution and advocacy of rural medicine saw him recognised as a Member of the NZ Order of Merit in the 2009 Queen's Birthday Honours.

General practice, rural medicine and medical education in New Zealand are all significantly the better for Dr Farry's committed attention.  

And as always, everything he did was about making general practice better for patients.

His life and work will be remembered through the Pat Farry Rural Health Education Trust, and I congratulate you in this initiative.

Dr Farry was a strong advocate for educating young people from rural backgrounds as medical practitioners and GPs in particular.

He took an active interest in the Rural Origin Medical Preferential Entry (ROMPE) scheme established in 2004 which created 20 dedicated places at each of Auckland and Otago Universities for medical students from rural backgrounds. Rural background students are relatively under-represented in medical schools.

Evidence shows that the likelihood of a working in a rural area is around twice as much in doctors coming from a rural background than an urban one.

Further, if those doctors have some of their medical education immersed in rural areas, then that likelihood of going on to work in a rural area is doubled again.

Recent research at Auckland University suggests that those medical graduates most likely to stay in New Zealand as GPs practicing in rural New Zealand are those born in New Zealand, and born outside of Auckland.

You can see why Pat Farry believed recruiting smart young people from rural New Zealand into medicine and educating them in rural New Zealand is key to building a strong and effective health workforce for so many of our communities.

More Med School Places for Rural Students

The National-led government recognises we need to train more doctors here in New Zealand, and more GPs in particular. We have increased funding for GP training places. And we pledged to increase medical student places by 200 over 5 years. This year we started that boost with 60 additional medical student places.

Next year, as already indicated, we will increase that by a further twenty places.

I can announce today that in recognition of Dr Pat Farry's contribution to rural medicine, next year's additional 20 med school places will henceforth be ear-marked for young people from rural New Zealand as part of an extension of the Rural Origin Medical Preference.

And this group of medical students next year will be officially known as the Pat Farry Intake.

Your Chairman Kirsty Murrell-McMillan has been a tireless advocate of extending ROMPE and I'd acknowledge her encouragement in this area.

Dr Farry also worked closely with Professor Des Gorman Chair of Health Workforce NZ in establishing the criteria for the Government's $4m fund over 4 years to further promote multi-disciplinary rural immersion education. We should expect to see the results of the current request for proposals shortly.

Voluntary Bonding Scheme

The Government's Voluntary Bonding Scheme is now open for last year's graduate doctors, nurses and midwives.

Launched as part of the 100 Days of Action following the last election, voluntary bonding is a practical initiative designed to encourage medical, nursing and midwifery graduates into the communities and specialties that need them most. 

Graduates who are part of the scheme are eligible for incentive payments that mean they can write-off their student loans within 5 years.

Many of the communities included in the Scheme have a rural focus, and specialties such as General Practice for medical graduates are also likely to particularly benefit rural communities. 

The first year of the scheme was open to graduates from the previous four years. We expected 350 applications. Instead we received almost 900.  When I went to tell the Prime Minister about the over-subscription and the fact we hadn't budgeted for so many, his response was swift.

He said we'd take every single one of them. And so we have confirmed 115 medical, 96 midwifery and 684 nursing graduates on the voluntary bonding scheme.  If these young people manage their careers well over the next few years they can receive significant student loan write-offs or cash incentives.

Workforce is one of the most critical challenges the Government has inherited. I don't need to tell you that this challenge is faced most acutely in many parts of rural and provincial New Zealand. If you think New Zealand has problems with rural general practice, then the challenges facing our rural and provincial hospitals is equally important.

Rural general practice must work closely with rural hospitals. It is no longer possible to maintain barriers to co-operation and integration. And I will touch on this later.

The Recession And Vote Health

When I spoke at last year's conference in Wellington New Zealand was well and truly in the grip of one of the worst recessions since the 1930s.

While signs of improvement are visible, New Zealand still faces six years of financial deficits. And even then we will owe a massive $64 billion in public debt.

But this is not unique to New Zealand. In Ireland, public service salaries including in the health service have been cut. On Wednesday the British Government announced thousands of top-earning public sector workers, including judges, GPs, NHS managers and senior civil servants, are to have their pay frozen in 2010/11.

The British Health Secretary said NHS managers and hospital consultants will see their pay frozen, as will the majority of GPs and dentists. Lower-paid doctors at the start of their careers, as well as a small number of salaried GPs and dentists, will get a 1% pay rise.

The New Zealand Government is currently borrowing $250 million a week to maintain public services, including health, education and welfare. 

Last year's Budget saw Health secure $750 million - half of all new spending.  This year's Budget has a limit of $1.1 billion of new spending across the entire public sector.

Health will get a good share of that smaller allocation. But the budget increase will not be as large as in previous years.

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 to save money for higher priorities but also to improve capacity to do more.

In Wellington, the Government scrapped 200 vacant positions in the Ministry of Health, and that freed up $20 million of funding for frontline services. Over the next 18 months the Ministry of Health will lose 1 in 8 of its staff members, as we move resources to higher priorities areas like reducing waiting times. And further changes are expected as we reduce back-office duplication and improve regional co-operation across DHBs.

Primary care must also recognise the reality of needing to focus limited financial resources on high priority services for patients. We can no longer afford the myriad of structures and organisations that funnel taxpayer money around the system...when patients are the priority.

Primary Health Care EOI

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. We all agreed primary health care had pretty much stalled in the last term of the previous government.

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, 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 have developed more detailed business cases that are currently being evaluated.

I am told that some of the best plans come from rural areas, where DHBs, PHOs and general practice have worked well together.

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 drivers and 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, are part of a prudent strategy to begin developing health system capacity for the future demographic and financial pressures on the health system.

Over the next ten years it is expected that demand for health services will double. We can't afford to double Auckland Hospital or double Wellington Hospital. Nor do we have the means or ability to double the number of surgeons or nurses.

So what we need to do is meet more of that demand on a lower cost platform, out in the community and closer to home.

And that is the essential driver of the Government's plan to support primary care developing a stronger infrastructure in communities, closer to patients.

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 government 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. And never more so in rural and provincial New Zealand.

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.  It does mean new opportunities for GPs and other members of the family health team to branch into new areas of work.

Similarly, our work in improving rural broadband offers tremendous opportunities to better use technology to improve services in rural New Zealand.

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.

Rural Primary Health Care

The Ministry of Health is working closely with your Network and DHBs to look at the best way to support and allocate rural primary health care funding in the future. This includes simplifying what the money is for and who gets what, for what. Resources are limited so we need to get best value from them. This funding is to help ensure sustainability of rural general practice, and that's why we have asked your Network to be at the centre of decision-making around those funds.

We also recognise that rural general practice faces particular challenges from working in more remote areas.  $5 million per annum has been allocated to general practices for providing primary health care after hours services in rural areas.  And after some prodding all DHBs have allocated that funding now.

Conference Theme

The ‘No. 8 Wired' theme for this year's conference recognises the high level of innovation that occurs in rural health care.  This innovation is evident in the expanding scope of rural nurses, particularly their support in providing after hours services, in the use of tele-networking with acute care specialists and in the use of rosters across multiple general practices to ensure a health lifestyle for the rural workforce.

The Government's Rural Innovation Fund supports a number of rural health innovations. One in particular is reviewed in the latest edition of the Journal of Primary Health Care: Point of Care testing. 

The Fund paid for a Point of Care test analyzer and staff training at Rawene Hospital, which serves the remote Hokianga region.  In Rawene, the distance to the nearest base hospital (Whangarei) is two hours by road and the distance to the nearest tertiary hospital (Auckland) is four hours by road.  The turnaround for lab tests has taken up to 26 hours on a week day and up to 72 hours on weekends.

Point of Care testing at Rawene Hospital resulted in a substantial change in treatment for the majority of patients.  The results showed that patients receiving Point of Care testing were more likely to receive a firm diagnosis and, consequently, were more likely to receive appropriate changes to the treatment they received.  The testing gave doctors the means and confidence to manage more patients locally.  More patients could be sent home after initial assessment and there was a reduction in the number of transfers.  The results found an improvement in patients' attitudes in almost half of the patients receiving Point of Care testing.

Conclusion

I recognise the commitment that each of you here today have made to improving the health of New Zealand's rural communities.  The health sector is facing significant challenges and the Government is committed to supporting you as you work on the frontline of rural primary care.