Source: New Zealand Government
Tēnā tātou katoa,
Ngā mihi te rangi, ngā mihi te whenua, ngā mihi ki a koutou, kia ora mai koutou.
Thank you for the opportunity to be here and the invitation to speak at this 50th anniversary conference. I acknowledge all those who have gone before us and paved the way over 50 years and longer.
I want to thank you Sam for your leadership and advocacy for general practice and rural hospital medicine, and for your decades of dedicated service as a GP and GP trainer.
It’s not clear to me that the college has had quite the access to a Minister before as it does now. Within 12 hours of getting my Ministerial warrant, I was meeting face to face with the College as a key stakeholder – that’s the value of long-term relationships.
I also want to thank the Royal New Zealand College of General Practitioners team, for all the hard work that’s made this major conference possible.
This conference is a highlight in the calendar, and you have an excellent turn out with hundreds of dedicated doctors, nurses, allied health professionals, practice managers and others.
You have an impressive line-up of speakers, who will cover a diverse range of topics over the next few days.
The theme for this conference is kia whakatōmuri te haere whakamua – which can be translated as walking backwards into the future with eyes fixed on the past.
This theme is entirely appropriate this week, given the announcement I made on Monday about the steps I’ve had to take to address the performance of our publicly funded health sector.
It reflects the balance I am having to strike between taking swift action now to remedy the issues caused by successive governments over many years, and remaining focused on driving long-term, structural change to ultimately achieve better health outcomes for New Zealanders.
As of Monday, from a fiscal perspective, you now know what I know about the precarious position the health reforms have placed us in. Health New Zealand is overspending at a rate of $130 million per month.
I look at the four per cent uplift to primary care capitation that I will speak more about later – this is 11 days of Health New Zealand’s overspending.
I know you will have many questions and expect to hear from me directly around general practice, however, first and foremost I would like to talk about the future of the health system more broadly and how I plan to get there.
The Government’s goal is for all New Zealanders to have timely access to quality healthcare, to improve life expectancy and quality of life.
We will achieve this with a strong, long-term vision and clear targets to drive that forward.
Primary care is a key to the health system and has an important role in helping us achieve the Government’s health targets and ultimately improving the health of New Zealanders.
Recently, I published the Government Policy Statement on Health, where I have clearly and concisely set the direction of travel for the health system.
The GPS is the document that will lead the actions of health entities. It’s the primary mechanism for the coalition Government to translate our expectations into action. Outside of legislation, this is the most important strategic document.
The GPS sets out my five priorities for the publicly-funded health system:
- Access
- Timeliness
- Quality
- Workforce
- Infrastructure
The GPS recognises the complexities of a growing and ageing population and prioritises reducing the burden of long-term diseases such as cancer, diabetes, respiratory disease, cardiovascular disease and poor mental health.
The GPS also outlines my expectation that the health system will prioritise investments that support greater prevention, including modifiable risk factors – alcohol consumption, poor nutrition, physical inactivity, adverse social and environmental factors and smoking.
Each of these areas will be strongly supported by the Minister of Mental Health and my Associate Minister for Health Matt Doocey, as his delegation includes mental and rural health, neurodiversity, youth and rainbow health and eating disorders, and Associate Health Minister Casey Costello, who is responsible for maternal and women’s health, emergency road and air services, aged care, the Therapeutic Products Act and smokefree legislation.
I will pause there to address an issue I know is important to us all.
This Government has a different approach to reducing New Zealand’s smoking rates. The decision to repeal the smokefree legislation was taken not by one person, but by Cabinet, with collective responsibility, as has been the convention across multiple governments.
Minister Costello is currently leading work to improve the regulatory regime around all nicotine and tobacco products with a view to having a system that is aimed at reducing harm, that is coherent across products, and enforceable.
The coalition Government is committed to helping smokers quit to reduce harm from smoking and achieving Smokefree 2025.
It’s important to have aspirations like this that drive performance. We may often disagree on how to get there, but it’s important that we outline where we want to go.
The vision and expectations set through the GPS must be backed with strong and decisive action.
The Government’s five health targets came into effect on 1 July. These targets are tightly focused on faster cancer treatment, improved immunisation rates, shorter stays in ED, and shorter wait times for specialist assessments and elective treatment.
Some of these targets were hard for the previous Government, and they will be hard for me too. I’m committed to targets, but targets alone won’t drive change – they need to be backed up with careful planning, new thinking and new models of care around the targets.
Having said that, I do believe that targets save lives, that they focus resources, attention and accountability, and set a direction and an ambition.
In the GPS, I address unfair differences in health needs and outcomes across New Zealand’s population. We want to ensure groups with the highest need get the appropriate services at the right time.
To that end, we know that Māori are one of the highest need groups in New Zealand, disproportionately represented in many of the worst health metrics.
We aim to address these challenges through initiatives such as the $50 million Māori Health provider immunisation programme that we announced last year, recognising the unique mana and opportunities Māori health providers have to reach into and support under-served communities.
I also have high ambitions for Iwi Māori Partnership Boards to deliver local services in their areas. To do this I had to unlock the Pae Ora legislation and replace the Māori Health Authority with enabling legislation that gives Māori strategic commissioning and more choice.
IMPBs will have greater influence over health decisions in their rohe, with true devolution of decision making, as close to the home and as close to the hapū as possible.
What is also true, however, is that as much as two thirds of Māori actually receive their healthcare from mainstream providers and so it is important that mainstream providers are also supported to enable better Māori health outcomes.
This brings me to the role I see all of primary health playing in driving the changes we want to see, to provide better healthcare for New Zealanders.
Overall, we expect to see the health system prioritising care closer to people’s homes, particularly for the families and communities with the highest health needs, and poorest health outcomes.
It is often within general practice that these people are identified.
The Government wants to see new and expanded models of healthcare in primary and community-based settings, designed in partnership with local communities and Iwi-Māori Partnership Boards, and other providers such as community pharmacies, laboratory, radiology, Plunket and other NGOs.
There are already examples of local primary and community health care working well in New Zealand and meeting the needs of their communities. We want to see these strengthened.
Let me give you an example of a new model of care, led by general practice, that will help us achieve our targets and that I strongly support.
Last month, I announced a $30 million initiative to level up access to community radiology services, referred directly by GPs – like yourselves.
This funding will remove co-payments on X-ray, CT scans and diagnostic ultrasound – removing barriers for people who might otherwise miss out because of a steep fee – and enable primary health providers to refer patients directly to private facilities where clinically appropriate.
Enabling primary health providers to refer patients directly, without waiting for a specialist, will help New Zealanders get an earlier diagnosis and enable specialists to determine the right treatment, sooner.
With this policy, I back GPs as the specialists that you are, to make the right referral decisions to community radiology, and reduce first specialist assessment follow up appointments.
I am also very interested, for example, in primary care’s interest and readiness to do community cancer infusions, with additional funding. The Purchase Unit code, or the amount of funding allocated for a chemotherapy infusion, is hundreds of dollars. A Keytruda infusion is a giving set, an armchair and from cycle three onwards, infusion of a few hours with associated medical supervision.
As you will probably be very aware, the Government recently confirmed a $604 million investment in Pharmac, which will deliver up to 54 new medicines, including around 26 new cancer treatments.
The challenge now, then, is to make sure the health system is ready to deliver these treatments to patients as they become available from October and November.
I recall during FMTP training being at a practice that did chelation with an EDTA infusion, and, regardless of your views on chelation, at the end of the day it was still just an armchair and a giving set in a controlled general practice environment all of which would also lend itself to chemo infusions.
Already, aged residential care have shown interest in providing chemo infusions, as have others.
I challenge you to think about how you and your practice might be interested in contributing to faster cancer treatments for New Zealanders, and being a remunerated part of the rollout of cancer treatments.
I am also acutely aware that primary care is chronically understaffed, and you feel the effects of this every day.
I know there are a number of practices with closed books and I am also aware of the fragile nature of afterhours care especially, to which end I am awaiting a report on the current review.
Achieving the Government’s goals and driving health targets with the support of primary care can only happen if we have the workforce to deliver it. This remains one of the biggest hurdles in health. It is the health workforce.
Reflecting my urgency in this area, the Government’s current quarterly plan includes an action relating specifically to the health workforce.
Health New Zealand will soon publish an updated health workforce plan to address staffing needs across the whole system, which must include increasing training, improving recruitment, better recognising people with overseas qualifications and reviewing regulatory settings.
We need to train a medical workforce that’s highly skilled and reflects the people it serves. I am encouraged by the largest number of GPEP registrars ever who are currently out in practices, and I believe good numbers again next year, but still there are shortages.
We have already invested in growing the medical workforce by supporting domestic training, including:
- committing $22 million through Budget 2024 to increase medical school places by 25 doctors each year. This adds to the placements the previous government announced last year – though this is a long-term plan.
- progressing work on a proposed new medical school in Waikato, which is proposed to have a graduate entry model and a rural, train in place, stay in place methodology. A cost benefit analysis that is now underway, but this is another long-term initiative.
Increasing and retaining our workforce not only involves training more new doctors. It also requires supportive work environments with strong relationships and opportunities to grow.
We are looking at actions we can take across the board to better support the workforce and retain our critical staff. That’s why I’ve established a new 4-person Ministerial Health Workforce and System Efficiencies Committee, led by Dr Andrew Connolly.
This is important because I want workforce advice directly to me and not filtered through layers of officials. I want regular insights from people working on the frontline to provide long-term, strategic direction to address workforce issues. Already I have heard a strong primary care voice from Dr Bryan Betty who I appointed to that committee.
There are other models of primary care that are workforce related and talk to extensions of general practice. The role of telehealth is one of these. The advice I have is that there is clearly a role for telehealth but currently the perfect role remains a work in progress.
Artificial intelligence is making interesting inroads in areas such as note taking, appointment triage and inbox management.
The previous government’s comprehensive primary care teams are due for review to determine what has been effective and might be carried forward.
In discussing primary care workforce I am also interested in dialogue around two recent areas that have been discussed with me:
- The potential role of physician assistants. Most of the 40 or more PAs are currently in general practice and I am being asked to provide a regulatory framework for them. I am interested in continuing to receive advice in this area.
- A question of repeat prescribing has been put to me to further reduce GP workload with the suggestion that this actually may consume 10-20 per cent of resources. The suggestion is as follows:
The ability to prescribe for three months with a further 3 repeats, that is, a years’ worth of prescriptions where:
- There is a single prescriber taking responsibility for the 12-month script.
- The patient attends a single pharmacy.
- The prescriber is satisfied the condition is stable and the medication is required for longer than the three-month duration with no plans for dose alteration.
- The patient attends the same pharmacy and if on repeat dispensing the pharmacist has any concerns, the patient is referred back to the original prescriber for clinical review.
I welcome your thoughts on this.
Earlier I spoke about addressing the immediate, urgent challenges we’re facing while progressing longer-term change.
It would be tone-deaf not to address with you the challenges I see for Health New Zealand, particularly those I shared with the public on Monday.
In response to serious concerns around oversight, overspend and a significant deterioration in financial outlook, I announced on Monday that the Board of Health New Zealand will be replaced with a Commissioner, Professor Lester Levy, for the next 12 months.
The health reforms have created significant financial challenges at Health NZ that, without urgent action, will lead to an estimated deficit of $1.4 billion by the end of 2024/25 – despite this Government’s record investment in health of $16.68 billion in this year’s Budget.
Health New Zealand first reported a deteriorating financial position to me in March 2024, despite earlier repeated assurances that it was on target to make savings in 2023/24.
In the months since, the situation has worsened. Health New Zealand is currently overspending at the rate of approximately $130 million per month.
My move to appoint a Commissioner is one of several steps the Government has been forced to take over the past eight months due to concerns about the governance of Health New Zealand and resulting performance issues, including health workforce and hospital wait times.
Previously, I have appointed a Crown Observer, a new Chair and a Board member with financial expertise. Through those measures we have been able to identify long-standing issues with the existing governance and operating model.
What we have seen at Health New Zealand is an overly centralised operating model, limited oversight of financial and non-financial performance, and fragmented administrative data systems which were unable to identify risks until it was too late. Importantly, there has been a disconnect from frontline services.
Professor Levy is now tasked with implementing a turnaround plan with a savings objective of approximately $1.4 billion to ensure financial balance, and actions to strengthen governance and management.
The performance of Health New Zealand should be important to everyone in this room because under the reforms, Health New Zealand is the operational arm for 3 key pillars: Hospitals, Community Care and Māori Health.
That means how Health New Zealand performs affects every person in this room through the Community Care and Māori Health appropriations.
The overspending I mentioned earlier is substantively in the hospital sector and what has happened in the past, is that funding for community and primary care has effectively subsidised deficits in that hospital sector.
The Minister of Finance and I have made it clear very to Health New Zealand that funding should stay in the three pillars to which it is appropriated and should not be used to subsidise other underperforming areas.
More specifically, community funding should not be used to subsidise an underperforming secondary sector.
I understand that a four per cent uplift in capitation that has been offered in discussions with Health New Zealand may not meet expectations.
However, it is the single biggest uplift compared to other large community providers, policies have been loosened for further cost recovery and calculations did not take into account what looks to be a declining rate of inflation over the next year.
You also now know that it is in this challenging fiscal context that cost pressure uplift discussions were set in, and understand that we are barely seven months into Government. But clearly, more change is needed, which I will talk about now.
I know and understand the pressures that are put on the primary care sector.
The workforce shortages, the increase in complexity and urgency of patients we get to see, increasing migration numbers and the difficulty New Zealanders have getting to see their GP in the first place.
I am sure that you feel this as acutely as I do.
It’s been 20 years since a considered look at primary and community health care has been undertaken. Around the same time, we all moved from fee for service to capitation.
We need to ensure that further investment in primary and community health care is informed by strategy and planning.
We need to ensure the way the system operates is in a way that achieves the desired outcomes, namely:
- that people have access to quality comprehensive primary and community healthcare, when, how and where they need it, and
- that they are informed and have what they need to manage and optimise their own health and wellbeing – and lead the lives they want.
I have noted some of the many challenges facing primary care such as workforce and after hours, and would note others such as nursing pay parity, but I want to briefly address some of the structural changes that need attention.
The GPNZ report earlier this year “Sustainable General Practice in Aotearoa New Zealand 2024” made three key recommendations: to stabilise the sector, enhance PHOs, and focus on equity.
I agree with these recommendations, so much so that I have instructed the Ministry of Health to work with Health New Zealand to develop an implementation roadmap for some of the recommendations in the 2022 Sapere report. Specifically, the first transition will look at reconfiguring capitation so that capitation funding better accrues and the resources are applied where the morbidity sits.
I have made it clear in previous statements and in meetings with Primary Health Organisation (PHO) chief executives, that localities will not progress in my hands and that PHOs are an important part of a health system. The GPNZ report calls for enhancement of PHOs
I have also previously described how equity will be addressed on a principled needs basis first and foremost.
Meanwhile, our publicly funded health entities are progressing significant programmes of work to address the needs of primary healthcare now and into the future.
Health New Zealand is focused on strengthening community and general practice within the current settings.
This work covers areas like funding, ensuring continuity of care and developing the primary healthcare workforce.
I have already described structural change workstreams.
Part of this work is focused on the future functions of primary and community organisations, such as PHOs. The project is being carried out in partnership with General Practice NZ and other primary and community care providers.
Health New Zealand is also leading work on a reweighting of capitation rates to better reflect patient need and provide more sustainable services.
This work is supported by a technical advisory group, with a range of sector leaders from general practice, nursing, emergency medicine, rural, Māori and Pacific Health providing advice.
I look forward to seeing the outcome of these pieces of work and you will hear more on these in the months ahead.
At the same time, the Ministry of Health is progressing a policy work programme to look at the way primary and community health care services are organised, funded and provided in the future.
In closing, the significant challenges our health system are facing and the structural change we desperately need will not be resolved overnight.
You now know what I know as we lift the lid on Health New Zealand and two years of challenging health reforms, in the middle of a COVID-19 pandemic.
What I can say is that we will take real action to deliver a health system that provides all New Zealanders with timely access to quality healthcare.
We understand the importance of preventative measures, including in mental health, and I have signalled that through the Government Policy Statement.
We recognise and are interested in the innovative models of care that are already out there. We have indicated through the GPS that we want to see these models extended.
We have set a clear direction of travel for our health system, and we have set our priorities and targets for delivery.
Primary care plays an important part in improving the health of New Zealanders and your support is needed to achieve these objectives. I invite you to continue to provide input into the changes needed to achieve better health outcomes for New Zealanders.
I wish you well with your conference and thank you again for what you do.
Kia ora mai tātou.
