Good afternoon. Thank you Professor Joyce. Thanks for inviting me here to the University of Otago, Christchurch campus, to talk to you about my favourite subject – our public health system - and to answer your questions.

Thanks too for being so flexible with a change of date for this event. It's good to be here.

Introduction

I've had an interesting morning at Canterbury District Health Board seeing first hand how the DHB is rising to and meeting the challenges facing the New Zealand public health service.  

I went on a patient's journey at Christchurch hospital.
Like most DHBs, Canterbury is making a big effort to put the patient first. 

And they've been doing that while bearing the brunt of one of the potentially more serious threats to the public's health in decades

Swine flu has seen a remarkable health response by our health professionals around the country.  The speed and professionalism with which our health workforce responded to this enormous and ongoing threat is impressive.  It could have overwhelmed our hospital system this winter and you here in Canterbury have been at the forefront.  

It is too early to say we are out of the woods yet but the signs are comforting although a second wave is possible.  The indications are that the rate of GP presentations and hospital admissions of patients with flu like illnesses is slowing.  Let's cross our fingers – and keep washing out hands

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.

Historically our health services have been built around the hospital's needs and not specifically around the needs of the people they actually serve. By improving a patient's journey DHBs can provide better quality service for more people.

My journey this morning involved quite a bit of walking and a lot of talking and for a moment I thought I was back on the campaign trail.

I'd much rather be out walking the corridors and meeting as many patients and staff as I can than be stuck in board room watching a power point presentation.  But those have their place too.  

I really appreciate opportunities such as this morning provided – particularly today because it gave me the chance to talk to staff about the quite major workforce announcements I made yesterday which I'd like to talk about in just a moment.

When appointed Minister of Health last November, a short nine months ago, I was faced with a number of major challenges confronting our public health system.

We had inherited a health system that was on track to financial crisis with capital requests from hospitals of over $600 million and only a small amount of money available to fund them.

We had the 21 District Health Boards reporting their spending would go $160 million into the red by June this year.  They are now $159 million in deficit, but they’re making progress on filling this gap of unfunded services.

It didn't help matters that the outgoing Government had stripped $150 million of extra health spending out of the Health portfolio just before the last election.  This unpublicised cut has really put the pressure on an already tight financial position.

We also have serious pressures on a number of health services particularly in hospitals – long waiting times in Emergency departments, unacceptable waiting times for cancer treatment, growing waiting lists for elective surgery and a burgeoning bureaucracy.

Too much of our valuable health dollars are going into administration and waste.

The Ministry of Health advises it  had at last count 157 committees, not to mention the vast monitoring infrastructure of 13 health priorities and 61 objectives, with an additional subset of 13 health objectives; a set of 10 health targets measured through 18 indicators; 25 other indicators of DHB performance; not to mention 4 hospital benchmark indicators assessed through 15 measures; and an outcomes framework with 9 outcomes, measured against 39 headline indicators.

All that effort – yet a major report on cardiac surgery last year revealed that New Zealand delivers between 25% and 45% fewer surgery services than other comparable countries.  The number of cardiac surgical discharges actually dropped from 2,539 in 2002/2003 to 2.313 in 2007/2008.

This Government is determined to build and sustain a strong public health service but we have considerable and serious challenges in Health.

And the most fundamental challenge facing Health today is workforce, workforce, workforce.

Workforce Challenge

We have an aging population, growing demand and competition from overseas for our nurses and doctors.  All that is placing enormous demands on our health sector.

Here are a few things to know about our health workforce.

It is getting older.   The average age of nurses is 45 and of doctors is 44.

It is also increasingly international.

New Zealand relies on overseas trained doctors and nurses more than any other country in the OECD and they are very mobile.

More than 40% of our medical specialists were born overseas.  More than half of doctors working in New Zealand come from overseas.  Many of our nurses were also internationally recruited.

Auckland University evidence suggests that the medical students most inclined to stay in the country and become GPs are New Zealand born.  Yet more than 40% of the medical students studying in Auckland were born overseas and a fair proportion leave quickly after graduating.

We are grateful and pleased to have international health professionals come here to work. But there is a global health workforce shortage and given that New Zealand lags behind the OECD in terms of our incomes we are not in a strong position to compete on the basis of higher salaries.

So we are largely dependent on foreign doctors and nurses and we face significant shortages in particular specialties as well as regions.  I think this audience will be familiar with which ones we're short of – there's quite a long list -   

The government has targeted some of those specialities in the new Voluntary Bonding Scheme. It aims to encourage young health graduates to establish careers in hard to staff specialities and communities in New Zealand.  It offers payments against graduates' student loans or cash incentives for those that do not have a loan for three to five years.

It has proven very popular.

We expected up to 100 doctors and 250 midwives and nurses to apply for the scheme but we have in fact confirmed  around 115 doctors, 95 midwives and 680 nurses into the scheme.

We didn't want to turn anyone down.

The government is funding the extra applicants to the scheme with an extra $7.6 million over five years. If all extra applicants complete the scheme this will bring the total cost to $17.5 million a year.

This is one way to keep New Zealand's own front line clinical doctors, nurses and midwives, who we train specifically to care for kiwis, to work in the country that trained them.

But we also need to keep our health workforce happy – and engaged – and feeling valued.  Recent research says they are not happy, engaged and feeling valued.   

Over the last several years, there have been numerous reviews, reports, committees and studies on the health workforce.  Some have been useful to a greater or lesser degree and have contributed to where we are today.

But what is clear is that our workforce problems are worsening and after years of reports and indecision, decisions have to be made.
We've inherited disjointed and uncoordinated resources in the health sector attempting to deal with serious and longstanding workforce issues.

A raft of health workforce reports over the years have been critical of this duplication and called for a coordinated national response to workforce issues but little progress was made.

Funding needs to be better coordinated both across programmes and providers.

There are few across-sector and across-educational continuum views, either operationally or financially.

For example, the undergraduate programmes for aspiring health workers are largely funded by the Tertiary Education Commission, which appears to have little accountability to the health sector in any way.  The subsequent education and training is variously funded, including by the learner, their employers, the Clinical Training Agency, and DHBs.

The Medical Training board was simply advisory. It had no control over the resourcing and funding.

The funding for post entry training is held in different places including around $120 million at the Clinical Training Agency in the Ministry of Health. 

Around $70 million is held in the Ministry budgets to train up to 800 health professionals connected with the government's commitment to build 20 extra dedicated elective surgery theatres. Other resources are held at District Health Boards New Zealand.

Some of you may have read the recently released reports within the last 24 hours describing the situation for our health workforce and the need for  a major change in the way we plan and organise the training of our health workforce.

Well, we're doing that.

Clinical Training Agency Board announcement and reports

Yesterday the Government announced a new national health workforce training board to unify workforce planning in New Zealand. The Government wants better integration of health education and training with less duplication and clearer focus.

We have established a Clinical Training Agency Board which will be led by Professor Des Gorman, the Head of the School of Medicine at the University of Auckland. The Medical Training Board is being disestablished.

The CTA Board's purpose is to work with me to drive the rationalisation of the funding and planning of health workforce training, ultimately consolidating it within the Clinical Training Agency. It will operate from within the Ministry of Health until decisions on its longer term placement are made.

Modern health care is about teamwork, and that is why we are taking a pan-workforce approach rather than separate training boards for medicine, nursing or allied health.

The CTA Board will be backed by the financial resources of the CTA budget, and the extra $70 million for the elective surgical workforce.  Their decisions and recommendations will have grunt.

Shortly, colleges, councils and DHBs will be invited to nominate members of the CTAB to work with Professor Gorman, the Director General and myself.

Yesterday I released four reports which again, are in overall agreement that the health workforce status quo is untenable.   The reports agree we needed one single agency to ensure coordination of workforce training, planning and funding as nurses and doctors and other health professionals move along their career continuum in the public health system.

The four reports I released yesterday are:

• Treating People Well – the report of the Director-General of Health's Commission on the Resident Medical Officer ( Report of the RMO Commission),


• Foundations of Excellence: Building Infrastructure for Medical Education and Training – Report of the Medical Training Board ( MTB Report),


• A Nursing Education and Training Board for New Zealand – the report from the committee on Strategic Oversight for Nursing Education (Nursing Report) and


• A Review of How Training of the New Zealand Workforce is Planned and Funded: a proposal for a reconfiguration of the clinical Training Agency – report of the Ministerial Task Group on Postgraduate Education and Training (CTA Review Report).

It is interesting what the most recent reports have to say. Two are reports about our doctors - the senior doctors commission report released a week or so ago, and now the junior doctors commission report.

The senior doctors said they felt undervalued and without influence on their working environment and how the health system works locally, regionally and nationally.   The SMO Commission report called for resources to support the participation of senior clinicians as leaders.

New Zealand's junior doctor workforce is also characterised by long standing dissatisfaction, industrial conflict and many poor training experiences according to the RMO Commission Report.

The Commission report paints a grim picture of a junior doctor's experience in our public health system and calls for immediate change. 

Junior doctors are our future, yet this report says they have felt undervalued and unsupported for years.  RMOs should be apprentices learning on the job but did you know some of them spend 80% of their time on the wards doing work you don't need a medical degree for. 

The report writers conclude District Health Boards and senior doctors need to take much greater responsibility for mentoring and pastoral care.

I know the senior doctors want to do that – but they need the resources and the time.

It is the intention that the new Clinical Training Agency Board will enable that to happen. It will oversee and drive the rationalisation of planning and purchasing of most of health workforce training, at the national level.

They will also take responsibility for improving pastoral care – as it were – of junior doctors.

After years of reports and indecision, decisions have been made.  Unified leadership and direction will make a significant difference.

But this is not the full answer to our workforce crisis; it is part of the solution but I am confident that New Zealand will be better placed to deal with its health workforce crisis as a result.

Workforce training, recruitment and development needs to be driven by the future needs of the sector, in particular the need for changing roles and practices to deliver improved models of care and service delivery. 

Models of care and workforce roles
The ageing of the population alone over the next decade will require at least 50% more health workers if the status quo in standards of care and access to care remains.  And about the same time, the bulge of baby boomers in our workforce will also be starting to retire.

There needs to be much greater flexibility in the health workforce.  We need much greater workforce innovation – new roles, new scopes of practice.

Internationally and in New Zealand new models of care are emerging which call for greater flexibility in the nature and deployability of the health workforce with respect to roles and scopes of practices to meet those ends and to adapt to ongoing shortages in various specialties.

For instance, the shortage of GPs in rural areas is to some extent being alleviated by Nurse Practitioners working as part of a primary care team.

Or an emergency department specialist doctor's role can be helped by different specialist nurses.  

Our health professionals already work in multi disciplinary teams and the future of our health workforce will be increasingly one of greater flexibility, new roles and scopes of practice. 

But many overseas innovations in this area have not  been adopted here.  We must plan our training accordingly.

It is therefore obvious that for the above reasons, but also for good professional reasons, that we continuously push out the skills, work scopes and training boundaries of our health professionals.

I consider it a tremendously exciting time for Health. as we work together to prepare for the future demands of an ageing population.

I am particularly excited about tapping the huge experience and leadership skills of our nurses and doctors in helping address the challenges facing us in Health. 

Unified, collective leadership of clinicians and managers can help to heal the tensions and dissatisfactions revealed in the workforce reports I released yesterday.  Clinical leaders and managers together can develop the desirable behaviours and attitudes, better communication, conflict resolution and clinical and corporate governance that under pins an engaged and productive workplace.

To sum up what we have talked about today.

The way forward with our workforce crisis is in simplified and unified national planning, and more flexibility in work roles and practices. This is needed to ensure that we have the health and disability workforce we need to provide quality services throughout the New Zealand.

Action is required across six areas: 

• The simplification and unification of the existing workforce planning and funding efforts across the whole sector;


• Greater flexibility in the creation of new roles as well as the definition of existing roles and scope of practice, and making it easier for existing health workers acquire additional skills to take on wider roles,


• Greater flexibility  in work practices and a faster and wider spread of the best work practices,


• Improving the configuration of service delivery across the local, regional and national levels so that scarce professional skills are better utilised;


• Better use of technology to improve clinician collaboration and to better utilise and economise on those specialist skills in shortest supply;


• Improving working conditions and job satisfaction, including by more effective clinical engagement, less paperwork, and improved hospital conditions.

Which leads me to the government’s drive to give doctors and nurses more say in the health service: clinical leadership.

Clinical Leadership
Globally, clinical leadership and engagement is recognised as a fundamental driver for better health outcomes.
In contrast this government inherited a health system where the influence of clinicians on patient outcomes here in New Zealand was less than it had ever been before.
This failure to engage the very people with the right expertise - doctors and nurses who know the patients' needs best – was seriously eroding their ability to provide patients with the care they needed.
Stronger and more direct clinician involvement means more service and better quality.
We trust and value our health professionals – enough to engage them in the very important decisions about the future of health services.
And that is why the new National Government commissioned a significant report called 'In Good Hands' to guide District Health Boards in introducing greater clinical leadership into the public health system.  The President of ASMAS, Dr Brown, lead this work.

The 'In Good Hands' report provides strong guidance to DHBs on how they can institute a more engaging and less top down approach for their doctors, nurses and other health professionals.

This Government is serious about re-engaging doctors and nurses in the running of front line health services, not just talking about it, and we have instructed DHBs to act on this report.

As a practical example, we have established the National Cardiac Surgery Clinical Network - a team of the country's leading heart surgeons who will lead much needed reform of New Zealand's cardiac surgical services.

We need better planning to improve the rate and availability of cardiac operations across the country and the best people to do that are the experts in this area – the heart surgeons themselves and their teams.

Greater cooperation and coordination between our senior clinicians across the country will improve frontline surgical services for all New Zealanders.  We plan to work with clinicians to instigate and encourage more national clinical networks, as a way to improve clinical viability and patient service.

This is not to say that we want doctors and nurses to stop doing what they were educated to do and become managers.  But we do want to use the wealth of frontline experience nurses and doctors have accumulated to improve quality of care and rebuild confidence in the public health system.

Conclusion

As importantly in this time of unique economic crisis, the worst since the 1930s – is the need for us to live within our means while we try to improve the public health system for patients and health workers alike.

You will be well aware of the global financial challenges facing the New Zealand economy.  Sadly unemployment is rising and will rise further.

This recession 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 has had to 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.

During the boom times the Government increased overall spending by around $3 billion a year. It gave Health about $750 million of that each year – that’s around 25% of all new spending each year.

Because of the 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 – and has continued to get the same $750 million increase.

In other words, Health got $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 finances.  Next year money in health will be even tighter.

In conclusion, I want you all here to know that this government is determined to do two big things.

Firstly we are committed to building a strong and sustainable public health service and to supporting and protecting it through this unprecedented economic recession.

But, better than that, as I have shown today that will not stop the government’s plan to take huge steps forward in the way we reorganise the training and engagement of our biggest and most valuable asset in Health, workforce, workforce, workforce.