NZ Accident and Medical Practitioners Association
Langham Hotel, Auckland 8th March 2008
Speech notes, Hon Tony Ryall
Thank you for the invitation to speak at your conference this morning. AMPA is fulfilling an important role, and its one that I can only see increasing in the future. Thank you for the work you do.
With a team of colleagues, we’ve travelled all over the country listening, learning and being impressed with the calibre and commitment of people in the health system.
And we’ve learned a lot about what the public wants from their health service.
That’s why we released a discussion document last year called “Better, Sooner, More Convenient”. Because that’s the sort of health system New Zealanders want. For us to achieve that we need the active participation of organisations like your own.
Later I’d like to share some thoughts on how AMPA can help improve our public health system.
Before that I’d like to talk about National’s plan for a new partnership with the health professions, the real crisis affecting our health workforce, and the pressure on our country’s emergency departments.
New Partnership with the health professions
Over the past eight years, Labour’s obsession with control and structure has seen the malignant spread of bureaucracy throughout the health system.
This can’t go on. It’s sucking resources that could be used elsewhere for patient care, and it’s sucking the motivation and commitment out of the health workforce. Our health professionals tell me their commitment is taken for granted. The current health system is running on their goodwill, and that is rapidly evaporating.
National wants a new partnership with the health professions. We will give commitments and, in return, challenge doctors, nurses, and the other professions to play a greater role in achieving a better health service.
We will trust and value our health professionals. We will give more authority to clinicians than bureaucrats. We want you fully engaged in decisions about the future of health services. We will deal with the current neglect of workforce planning. We will improve medical training.
In return, we will challenge the health professions to take leadership in improving the delivery and quality of patient care across all parts of the health system; and to deal effectively with poor standards of practice within their own professions.
It is clinical professionalism that underpins the public trust in the health system and the people who work in it. Therefore, we should expect that the management structures that shape the health system should also share that trust in health professionals.
A fortnight ago the Government released a first attempt at a national reporting system on sentinel events. It was the tip of the iceberg. It was highly sanitised. Even one of the authors admitted her hospital wasn’t including some events because they were confidential! There’s no national consistency despite repeated calls since 2001 for such.
The next week focus was on quality again with Ron Paterson’s report on Wanganui Hospital.
What will worry New Zealanders who read that report most is this: the revelations of botched practice at Wanganui did not result from a professional monitoring or clinical governance system, but from the complaint of an individual patient.
New Zealanders will be asking why there was no adequate system to deal with staff concerns. In fact, it seems a brave nurse was the only person to regularly raise alarms. These were rejected by the DHB system.
Yet again the Government has failed after 8 years in office to deal with the underlying issues of plugging gaps with people of doubtful qualification, and shortages of staff putting good and competent supervisors under intolerable pressure. No one believes they can deal with it now.
That is why National’s plan for a new partnership with the health professions puts clinical governance at the centre of a quality agenda. The new partnership is a plan of action. We want participation and responsibility. And what goes with that is accountability for quality.
Sentinel events and other errors in our hospitals won’t be improved with yet another bureaucrat committee. Quality will improve through clinicians taking responsibility for improving services and dealing with poor practice by others.
If the professions don’t take responsibility for their own performance, then that risks an untrusting government forcing a new bureaucratic regime upon them. National will work with you to find the best ways to improve quality of care and minimise misadventure.
The health workforce crisis
While the Whanganui inquiry revolves around the performance of one doctor, it is in fact a symptom of a wider shortage of doctors in health services throughout New Zealand.
Wanganui is not the only regional hospital struggling to maintain doctors. The commissioner says these workforce shortages are 'endemic'.
And that is why the New Zealand health system is in real crisis. Workforce is the bottom line. And quality is the big issue flowing out of that.
Workforce shortages are affecting all parts of the health system.
Yesterday, Wellington Hospital said 10% of its beds were vacant because of staff shortages.
In many communities, patients are unable to register with a general practice. This situation is expected to worsen. Shortages in the health workforce are predicted to grow.
This gloomy picture is compounded by limited training places, the increased rate of retirements as the workforce ages, increased part-time participation, and lifestyle choices.
Our country is at the same time both the world’s largest exporter of doctors and also importer of doctors. To reverse this position means finding smart approaches to recruitment and retention.
People who work in our health system are in it because of their commitment to caring. Money talks, but it is not the only, or even the prime, motivator. If we can make working in our health system a more rewarding career for our health professionals, we will be able to retain and build a stronger workforce.
On recruitment, National’s discussion paper talks of a move to self-sufficiency in medical training. This means increasing the number of funded medical student places.
More of that training should be done in rural and provincial communities. Both the Canadian and Australian experience indicates that medical trainees with substantial training in rural and provincial communities are more likely to work in those areas.
In our health discussion paper released last September we discuss the use of bonding and student loan write-offs.
A number of countries offer scholarships and loans to students in return for a bonded commitment to practice in rural and deprived urban areas for a number of years. For instance, student-loan write-offs are used in Norway, Japan and the United States.
However, bonding schemes have been less successful in Canada and Mexico where a substantial number of students have been able to buy their way out of their service commitment. Few of these students opt to remain in rural and deprived urban areas after their required period of service has expired.
A quarter of Australia’s current intake of medical students is now in a bonding scheme.
Improving job satisfaction for health professionals will have a significant impact on New Zealand’s ability to retain and recruit health professionals.
Fully engaging health professionals in the health system will recognise and utilise the expertise and professionalism currently being lost. Dealing to command and control bureaucracy will also help.
Professional development is important to job satisfaction. Improving access to new medicines and modern equipment should assist in retaining and recruiting hospital specialists.
At a macro-economic level, lower personal taxes will make working in New Zealand more attractive to all health professionals.
As I travel around the country it is clear patients face long and uncertain waiting at emergency departments and for after-hours care. Visit North Shore Hospital. Every day, there patients are ... languishing in corridors on hospital trolleys ... mostly elderly and obviously uncomfortable, often hungry, scared of making a fuss, waiting for hours on end. It’s been described as an ugly, open wound.
Sadly, it’s happening all around the country to a greater or lesser extent. These problems aren’t the fault of the dedicated staff working under intolerable pressure. There are fundamental problems with the rest of the health service that impact on these professionals.
Emergency department demand is very sensitive to alternative provision of after-hours services by GPs and independent Accident and Medicals (A&M). In many parts of the country, after-hours services are under pressure. Demand is also sensitive to the cost of GP visits.
DHBs were required to submit detailed after-hours primary care proposals to the Government by Christmas 2006. Only one has been implemented, 6 are being phased in, but 14 still are still not ready to go.
This inaction is driving up demand on our over-stretched hospital emergency departments. Growth in triage 4 and 5 presentations at E Ds has far outstripped population growth. Some provincial hospitals report a doubling of triage 4 and 5 in the past year alone!
So what’s behind this? I’d be interested in your experiences. But from my observations I would suggest:
After-hours GP care is becoming increasingly rare and increasingly expensive. Sure, the cost of going to your GP has come down, but generally only if you go during business hours! More and more patients are reporting longer waiting times to even get a GP appointment.
Staff capacity at E Ds is too stretched. Once again workforce shortages are affecting the care patients receive. More and more patients are turning up at emergency departments, most in triage 4 and 5, some of which could be dealt with in GP care or an A&M.
Lack of contingent capacity. Every hospital bed in Greater Auckland was full last week. Research shows that at 85% occupancy there is a high risk of long waits, cancellation of operations, patient infection and error. How could Wellington’s new hospital be built with the same number of beds as the old one?
Services don’t match. The current system doesn’t suit a lot of patients after-hours. Many A&M users are lower income people who have trouble seeing a GP during work hours, and the cost can be a real struggle.
All this adds up to patients waiting longer and longer. And that’s not the patient-centred, more convenient service people want to get and you want to deliver.
So what’s the answer?
The answer to so many of these problems lays in much smarter use of non-hospital services - GP clinics and A&Ms - up and down the country.
A lot of the patients presenting at hospital emergency departments could be well cared for in a non-hospital or primary care setting. One of our key policy principles is care closer to home. It must make financial as well as health sense for patients to have these choices.
By making smarter use of existing A&Ms – both stand-alone and GP clinic based – we can expand capacity across the whole system to the benefit of patients. This is a real opportunity for public-private co-operation in my view.
But there are also new models of service that could improve convenience.
In Britain I visited what they call a nurse-led walk-in centre. Near a tube station, people were able to call in and be seen by a nurse able to offer advice and treatment within her abilities. No appointment needed. Basic. Quick. Convenient.
If a patient needed to see a GP then advice was given on that. Leading GP practices in New Zealand offer a similar “drop in” service.
You may have read about the proposal to expand these services in the US. America’s second biggest pharmacy chain has bought the “Minute Clinic” chain and plans to double the number of in-store clinics to 300. Their slogan “You’re sick. We’re quick”. Patients arriving at another chain – RediClinic – are given a pager so they can shop in the mall until the clinic can see them.
In some provincial areas, GPs, A&Ms and hospitals should be able to work together as they do at Wanganui and Blenheim’s Wairau Hospital.
These options are far from all that is required, but they will help.
National’s drive for “better, sooner, more convenient” healthcare will mean a growing role for your organisation’s members. It seems to me AMPA was formed by people who wanted responses to New Zealand needs.
Our country needs more ED doctors in our increasingly busy E Ds, and the current system is not doing that.
Whether it’s in an A&M or a hospital, FAMPAs are an important health resource and we need more of you.
We also need AMPA working more closely with ACEM to improve co-operation and understanding.
Across the world, people are looking for solutions to many of the similar problems in health. Governments have increased spending on health services, and yet the problems remain.
Labour told the country that more and more money would fix the health system. In fact, most people would struggle to say things are any better.
New Zealanders are not looking for dramatic changes that would disrupt the delivery of health services in their communities.
But they do want new leadership.
And over the next six months you’ll see more of that new leadership from John Key and the National Party team.