Health Minister's Speech to RNZCGP Political Plenery

Good morning Panel, good morning everyone. Thank you for inviting me to open your Political Plenary today. 

May I begin by acknowledging the College's new president, Dr Harry Pert from Rotorua - and your new deputy president, Dr Tony Townsend from Whangamata.

This morning - with assistance from the panel - I understand you will be discussing the barriers to implementation of better primary care.

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 economic crisis, 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 workers 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 that it has replaced the large government surpluses of recent years with equally large deficits.

The truth is the Government will borrow $30 billion dollars to protect vital social services such as health, confident that the New Zealand economy will eventually come right and we will have protected our communities during that time.

Because of the economic crisis, the Government is now in deficit.  New spending has shrunk to $1.5 billion, and we've had to borrow that. 

Despite this, such is the priority this government places on protecting and supporting our public health service, Health received half of that in the Budget -  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 will be around $1.1 billion.  Maintaining a $750 million dollar share for health will be unlikely unless there is a significant turn-around in our country's finances.  Next year money in health will be even tighter.

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. And this applies equally to hospital and community services.

We are however investing heavily in dealing with the major issue of workforce, workforce, workforce.

Our voluntary bonding scheme, increasing the number of GP training places, and lifting the medical student intake are important steps.

The new pan-health workforce authority the Clinical Training Agency Board led by Professor Des Gorman will cut through the myriad of reports and duplicated effort to help lead real change and improvement in our workforce.

Barriers to Implementation

In looking at the barriers to implementation of better primary care, I'd like to draw on a soon to be released report by English academic Judith Smith from the Nuffield Trust. Smith has completed 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.

Progress was further impeded by the lack of an overall implementation plan.  The failure to even succinctly set out the actual functions of a Primary Health Organisation is also cited by Smith as a key inhibitor of progress.  It is hard to imagine how organisations can be expected to operate effectively when their precise function has never been clearly set out.

Members of the public continue to struggle to understand the role and importance of the PHO system even though the vast majority are now enrolled with one.  This is quite understandable if the PHOs themselves do not have a clear idea.

Additionally, Smith identifies a series of fraught relationship - both within the PHO sector and across sectors - which resulted in fragmentation and slow progress.  PHOs still relate first and foremost to their general practice or community provider.  Consequently, clinical involvement varies considerably around the country. 

Smith also considers the funding system to be rigid with inadequate incentives to encourage the behaviours originally envisaged in the Strategy.  These factors combined to create a situation where there was more talk than action on many key aspects of primary care.

Smith also observes elsewhere there needs 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 the past, the relationship between Government and doctors has been fractious. But your insight and perspective are crucial to understanding the key issues moving forward.  We are committed to improving this critical relationship.

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 specify what the Government was looking for in terms of primary health care provision in return for significant new investment of public funds, nor to engage professionals in such a process of service specification and design."

In other words, implementation was frustrated by a lack of clarity and a lack of engagement and respect.

Next Steps In Primary Care

Addressing this is part of the motivation behind the Government's recent announcement calling for Expressions of Interest (EOI) from primary health care organisations capable of delivering larger scale change and a wider range of health care to their communities.

This could include initiatives such as more walk-in access, extended hours for primary care, reducing the number of people showing up at hospital emergency departments and shifting some hospital services to the community.  It should promote new ways of working in co-located multi-disciplinary teams. Health professionals are in the best position to tell us how to make this work for patients. 

Our goal is to provide New Zealanders with better access to a wider range of health services closer to home.

We are inviting primary care organisations to develop proposals which will be assessed by an expert panel later in the year.  The final decision on which initiatives to support will be made by the Director General of Health and implementation should begin in 2010-11.

The EOI is a very open and permissive request to help us take the next steps in primary care.

I made this announcement at the start of the month and the reaction has been very favourable.  There is a sense that this move is what many in the sector had expected to happen years ago.  It is an important next step in the Primary Health Care Strategy.

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.

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 you 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 your PHOs need good governance, good managers and strong clinical leaders.

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.

Let's be clear. None of this will happen without strong clinical leadership. This is the time to step up.

Conclusion

Primary health care is fundamental to the health of New Zealanders. Every dollar that goes into an effective primary health care should be money well spent.  

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. 

A strong productive primary health care system contributes to better management of long term conditions, improved continuity of care, reduced pressure on our hospitals, greater accessibility, and earlier intervention.  

I wish you productive and interesting discussions at this plenary.