The Government's Health Agenda
Thank you for inviting me to speak as part of the Dean's Winter Lecture Series.
This series provides a great opportunity for AUT staff and students to build connections with the wider worlds of health, community services, government and business and to consider and discuss the challenging issues we face today.
I'm here today to talk to you about the Government's health agenda.
Our health workforce is world class, but it is clear to me that many of those who participate in it are concerned about the current state of our health system.
Like health professionals, the public - and therefore patients - see a system where increasing amounts of money have been invested in recent years, taking up an ever larger proportion of the national income, without commensurate growth or improvement in services. People have become frustrated by unnecessary bureaucracy, long waits for patient assessment and specialised treatment, and an evident deterioration in some services.
The Government is determined to turn this situation around. The Government wants our public health service to deliver better, sooner, more convenient care for all New Zealanders. We want reduced waiting times, better individual experiences for patients and their families, improved quality and performance, and a more trusted and motivated health workforce.
We are working to achieve these goals in the context of the worst global economic crisis since the 1930s. It is more important than ever that we live within our means while we try to protect and improve the public health service for patients and health workers alike.
Despite the recent encouraging news that we might be coming out of the recession, its impact has had such a profound effect on our economy that it will replace the large government surpluses of recent years with equally large deficits. New spending has shrunk to $1.5 billion - and we've had to borrow in order to provide for that.
The Government places a high priority on protecting and supporting our public health service. For this reason, Health received half of new spending in the Budget - the same amount it has received in recent years.
In other words: Health got a $750 million increase, while the other 30 or so ministries and departments shared the other $750 million.
Next year the new spending allocation for the entire government could be even less than this year - perhaps around $1.1 billion.
Maintaining a $750 million dollar share for health will be highly unlikely unless there is a significant turn-around in our country's finances. There will be a significant time lag between the economy returning to growth and fuller employment and the Government's deficit being reduced by increased tax revenues. In other words, next year's budget will be even tighter.
Our goal is to move resources out of the back office and bureaucracy into frontline services.
The government has stopped funding for 200 vacant positions in the Ministry of Health, freeing up nearly $20 million to support better frontline services in DHBs.
This is part of the success of the government's cap on public servant numbers: 200 vacant positions gone, and nearly $20 million put into frontline services.
The Government is committed to a strong and enduring public health service but the health service in turn will need - more than ever - to ensure a strong and ongoing focus on value for money, with resources moving from administration and low priority spending into more important frontline services.
Improve service and reduce waiting times
New Zealanders should have timely, high-quality access to healthcare services when they need it. For many, confidence in the health system over recent years has been damaged by excessive waiting and delays.
One of our main priority areas is to improve public hospital services and reduce waiting times for patients.
The Government has introduced a slimmed down set of Health Targets aimed to focus progress on the Government's goal of achieving ‘better, sooner, more convenient' services. The streamlined goals reflect the Government's desire to simplify the current complex and multi-tiered monitoring and reporting system.
Of the six Health Targets, three specifically focus attention on the urgent issue of excessive patient waiting times in public hospitals and seek to make improvements to achieve genuine reductions in waiting times for patients.
The first target is improved access to elective surgery - since DHBs were created in 2000/01 to 2007/08, despite a doubling in the health budget, elective discharges increased an average of only 1,400 a year.
The new Government aimed to deliver an average extra 4,000 discharges a year over the first three years. Our goal was to reach around 130, 000 discharges per year by the end of the 2010/2011 financial year. We were very pleased to announce just over a fortnight ago that we have seen an increase of 11,805 patients receiving elective procedures in the 2008/09 year. The largest increase came in the six months from January to June, and for the first time the number of discharges in the second half of the year has exceeded the number in the first half.
Additionally, the average caseweight, which measures the complexity of procedures, has remained unchanged from the previous year.
This result means thousands more patients have received elective surgery than in previous years, and in part shows what can be achieved with a consistent and clear focus.
The second target is shorter waiting times for emergency department treatment - improved service in emergency departments in relation to the new emergency department length of stay target.
This new health target will mean 95% of patients will be admitted, discharged or transferred within six hours. Emergency department performance is seen as a marker of overall hospital performance - if the ED is working efficiently for patients, it means, for example that the x-ray department is working well, and wards admitting patients are being managed appropriately both with resources like beds, and staffing.
Treating patients sooner in ED also improved outcomes and recovery.
The final target I want to highlight is reduced waiting times for critical cancer treatment - less waiting between patients' diagnosis and treatment, particularly radiation treatment.
Every patient needing radiation treatment should have this within six weeks by the end of July 2010 and within four weeks by December 2010.
The Government's strong focus on improving public hospital services reflects the public's priorities. This was the mandate and message given in the last election. Patients have waited 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 forthcoming year.
We will shortly be publishing a national report card showing how well each DHB is doing meeting these targets. You will be able to see the progress your DHB is making, both against the priority targets and compared with other DHBs.
For the first time, the public will be engaged in monitoring the performance of the local health service. For those that are not achieving, their performance issues will be clearer as will our expectation that they can do better.
At the same time as we are looking to improve public hospital services, we are looking to advance primary health care. Primary health care is fundamental to the health of New Zealanders, and it offers the best way to deliver timely healthcare closer to home.
Primary care also has a part to play in helping reduce acute demand pressure on hospitals by better managing chronic conditions and proactively supporting high need populations.
International research demonstrates that those health systems with strong and vibrant primary health care services have much better health outcomes for a lower cost than those that focus on specialist or tertiary care.
I would like to underline this Government's commitment to the Primary Health Care Strategy ... but a strategy that works.
There is much to be done if we are to achieve the goal of the PHCS to revolutionise primary care services. Apart from lower fees and the formation of Primary Health Organisations (PHOs), there has been little progress in achieving the other, more quality-focused goals.
After reviewing the objectives and performance of the PHCS, in April this year 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 ...
We want to achieve the quality improvements side of the Primary Health Care Strategy - the multi-disciplinary teams, co-location, and better integration between primary and secondary. We want to fill-in the missing links.
A package of new models of care is proposed to accelerate change in primary care. This includes the establishment of multiple Integrated Family Health Centres which will provide a full range of services in the community, stronger focus on prevention and health promotion, nurses acting as case managers for patients with chronic conditions, providing a wider range of care and support for patients, and shifting some hospital services closer to home.
Last month, the Ministry of Health called for Expressions of Interest to get proposals from eligible primary health care providers to implement the Better, Sooner, More Convenient policy for primary care. The deadline was earlier this week we've received 74 Expressions of Interest. This indicates a sector recognising a need for change and ready to lead the change.
We will never be able to take the next steps in the Primary Health Care Strategy without strong clinical leadership from primary care. That is why we have asked primary care organisations for their proposals to help us deliver on the promise of the strategy.
It is the Government's intention that improvements will begin to be implemented as soon as practical, with initiatives reaching up to 30 per cent of all New Zealanders from this first tranche of proposals.
We see this as an important opportunity to realise the full potential of the Primary Health Care Strategy. The outcome will be a more personalised primary care system that provides improved services for New Zealanders, closer to home.
Clinical leadership and engagement
Globally, clinical leadership - the active engagement of doctors and nurses in how health services are provided -- is recognised as the fundamental driver for better health outcomes. Yet here in New Zealand over the past decade, the influence of clinicians on patient outcomes has been less than ever before.
This failure to engage the very people with the right expertise - doctors and nurses who know the patients' needs best - is seriously eroding our ability to provide patients with the care they need.
Recent research by McKinsey and Company based on 126 hospitals across the UK found a clear link between strong clinical leadership and hospital performance.
The researchers found that best practice operational approaches in hospitals had a positive impact on productivity, infection rates, readmission rates, and patient satisfaction. And finance.
But the real key to this success was the level of involvement of clinicians in running their hospital services. Stronger and more direct clinician involvement means more service and better quality.
And that is why the National-led government considers clinical leadership and the re-engagement of doctors and nurses in the running of healthcare as so important.
New Zealand's public health system needs better productivity, an adequate and well-settled workforce and improved quality.
People who work in our public health service are in it because of their commitment to caring. Money talks, but it is not the only, or even the prime, motivator.
Greater clinical participation in the running of our public health services is fundamental to improved staff satisfaction and quality improvement.
In fact, many clinicians tell me that improving productivity is a key route to professional satisfaction.
We must make it easier for people to do the work for which they are skilled and employed.
And that is the major challenge for our public health service over the next few years.
As I travel around the country listening and talking to doctors, nurses, midwives and other health professionals I often ask: what really frustrates you about working in health care today? Is it the money? Or is it the inability to use the skills you trained for and the experience you've gained?
The answers always make me optimistic for the future of the New Zealand public health service.
Our hospitals and GP clinics are staffed with dedicated people who want to do the best for their patients and New Zealand. They want to be valued, respected and involved. They want to make a difference.
Strengthening the Workforce
Our clinical workforce is the greatest asset that the health system 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.
The Government is committed to building the capacity and capability of New Zealand's health workforce.
In medicine we are increasing the number of medical school places by 200 over the next five years. The first stage of this increase will begin with 60 additional medical students in the 2010 academic year.
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 if the graduate doesn't have a student loan. The scheme has proved very popular.
We are aiming to increase the number of GP registrar training places to 154 a year 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 increase the likelihood that more GP trainees will choose to stay in these communities.
We are investing $70 million in additional training and education to staff our dedicated elective surgical theatres. And we are working to improve job satisfaction by insisting DHBs re-engage their frontline health staff in the planning and running of health services.
You know that this Government inherited a disjointed and uncoordinated system for addressing the country's serious and longstanding workforce issues.
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.
In August, the new government announced the establishment of the Clinical Training Agency Board to be led by Professor Des Gorman, the Head of the School of Medicine at the University of Auckland.
The CTA Board is charged with unifying workforce planning in New Zealand, and ensuring coordination of workforce training, planning and funding for our nurses and doctors and other health professionals. We want the CTA Board to give this whole area a shake-up and help us actually get changes made. We want them to crack a few eggs - so to speak.
We are announcing today, that the government has appointed to the CTA Board, joining Professor Gorman:
- Professor Max Abbott, is a Clinical Psychologist, Pro Vice-Chancellor (North Shore Campus) and Dean of the Faculty of Environmental Sciences at the Auckland University of Technology; and Deputy Chair of Waitemata District Health Board.
- Professor Gregor Coster, is a General Practitioner, Dean of Graduate Studies at the University of Auckland, and Chair of Counties Manukau DHB.
- Ms Helen Pocknall, is a nurse, Director of Nursing at Wairarapa DHB; and Chair of the Central Region Directors of Nursing and Chief Medical Officers group.
- Ms Karen Roach, is a nurse and midwife; Chief Executive Officer (CEO) of Northland DHB; Chair of Northern Region CEO Group; and Chair of the 21 DHB Employment Relations Strategy group.
- Professor Don Roberton, Paediatrician; Pro Vice-Chancellor, Division of Health Sciences; and Dean of the Faculty of Medicine at the University of Otago. He was a member of the Medical Training Board, the Health Workforce Taskforce.
- Dr Andrew Wong is a specialist in Public Health Medicine; CEO of Ascot Mercy (private) Hospital. He is Managing Director of HealthCare Holdings Limited
These people are not appointed as sector or professional representatives. They are there because of their abilities to support Professor Gorman and the government in driving change.
You know the workforce crisis we inherited. It won't be fixed overnight, but we are taking action rather than taking stock.
Strengthening collaboration and coordination across the health system
The final goal that I would like to mention today is the need to ensure that planning and improvement across the health system is clear, effective and coordinated.
As I have mentioned, there are significant challenges facing the public health system - challenges made more acute by the current global financial crisis, and the need for health to plan within a more constrained future funding growth path.
These challenges require a coordinated response throughout the health sector.
As services become more complex and interdependent, planning at district level alone will no longer be sufficient to ensure the viability and affordability of health services over the long term.
While we work relatively well at regional and national levels now, there is more that can be done to improve the clinical and financial viability of services.
DHBs parochial interests can get in the way of sensible regional approaches. We cannot afford that luxury any more.
The Government is seeking better coordinated and integrated planning and decision making across all levels of the health services, to deliver better services at district, regional and national levels.
This will be done working in partnership with health professionals to harness clinical expertise to improve service planning and quality.
Ministerial Review Group
Getting the mix right between the district, regional and national levels has been one of the main themes of the recent Ministerial Review Group (MRG) report.
'Meeting the Challenge' is a comprehensive report, with 170 recommendations on how to reduce expenditure on bureaucracy, improve frontline health services, and improve value in the public health service.
The MRG included some of New Zealand's best health sector professionals. Many of their recommendations have been well discussed in the sector.
There is a clear consensus across the health sector - and the public - that change is needed. You know that we need to stop taking 21 different approaches to everything - that we need to centralise some decision making and regionalise others.
New Zealand cannot afford 21 different approaches to the future of health care in New Zealand. We can't afford to have DHBs duplicating back offices and not supporting each others services.
The MRG plan is about providing clearer central direction and coordination for the future.
Huge gains can be made in improving cooperation and harnessing the power of bulk purchasing. What existed when money grew on trees in the past 10 years won't work when the country is borrowing $250 million a week. Change is needed.
The MRG Report is available on the Beehive website, and I recommend it to those of you really interested in the challenges facing our public health service. The public's feedback on the report is also available publicly on the Beehive website.
Ladies and gentlemen - today I have given you a picture of the challenges facing our public health service and the ways in which the Government is working with the sector to address these challenges.
The challenges are significant, but we are not alone in working to find solutions.
Governments in the United States, Great Britain and Australia, are also considering how to deliver better value health services to populations for whom quality health services are a top expectation.
It is a time of major challenge, but also a time of opportunity and innovation.
Given the dedication and commitment of the New Zealand health workforce, including academics and researchers in the health sciences field, I have absolutely no doubt the future of our public service is very positive.
Thank you for the opportunity to speak with you today.