Speech – New Zealand Government
I am very glad to have the opportunity to join you today for this important conversation about the future of the New Zealand health system.Jo Goodhew
30 April, 2013
Speech: Waitemata DHB CEO Lecture Series
E aku Rangatira, tēnā koutou katoa. Ka nui te honore ki te mihi ki a koutou.
Thank you, Dr Bramley, members of the Waitemata DHB Executive Leadership Team and Awhina Health Campus partners for your warm welcome. I am very glad to have the opportunity to join you today for this important conversation about the future of the New Zealand health system.
It’s a conversation that matters to all of us. All New Zealanders value the security of knowing we will get the care we need, when we need it – now and in the future. Actually, I will go further than that, New Zealanders want to know that they receive quality care.
Today I want to talk about:
• the successes of our world class health system and some of the particular areas where Waitemata DHB has led the way;
• the significant challenges ahead of us to put patients first while managing increased pressures on our health services;
• the importance of continuing to make on-going improvements in the quality and safety of health care now and into the future; and
• the better clinical integration which puts patients at the centre of health services is vital in helping our system adapt to the future challenges.
The New Zealand health system is something we can all be proud of.
Life expectancy is at a level similar to other OECD countries which spend more on health than us. Since 1980, life expectancy in New Zealand has increased at a faster rate than in Australia, the UK, US and Canada. Our life expectancy for both men and women rivals these four countries, which all spend more per head of population on health than we do.
We owe our longer lives primarily to reductions in cardiovascular disease and cancer mortality. Better prevention, better detection and better treatment over the last few decades have helped improve survival rates for both of these conditions. We have some great success stories to celebrate in other areas too. The National Health Targets have made a real difference to prevention and care.
Over the past five years, New Zealand has gone from having one of the lowest immunisation rates in the developed world to one of the highest. In 2007 only 67 per cent of two year olds were fully immunised, by June 2012 this had risen to 93 per cent. This is a significant public health achievement.
Fewer people are now smoking. We’ve reached a turning point in the campaign against smoking and the government has set itself the aspiration of making New Zealand smoke-free by 2025.
More New Zealanders are getting the elective surgery they need and they are getting it sooner. In 2011/12 we significantly exceeded our health target in providing over 78,000 elective operations. We have also invested in new elective surgery theatres to deliver these extra operations.
As you will be aware, in July, Waitemata DHB will be opening a new elective surgery centre here at North Shore hospital. It will be one of the most advanced in New Zealand and will help reduce patient waiting times for elective surgery in your DHB.
You have had great success at Waitemata on another health target – reducing the length of stay in the emergency department. Today 97 per cent of your patients are admitted, discharged or transferred from the emergency department within six hours compared to just 61 per cent in June 2009. Waitemata is now in the top two DHBs in the country for achieving the shorter stays in the emergency department.
The impact of the global financial crisis has demanded that we are very careful about every dollar the government spends. It is therefore also very important, not to mention impressive, that all of the gains on the health targets have been achieved while also improving DHB finances. DHB deficits are down to the lowest levels they have been since 2006/07.
That same financial crisis has battered other health systems. Many OECD countries have had to cut their health budgets. In Ireland they have cut medical professional salaries, closed hospital beds and increased how much older people pay for their care.
By contrast New Zealand is one of a handful of OECD countries that have increased health spending in real terms. The rate of growth in health spending has slowed, but we have been able to protect front line services and the numbers of clinical staff. In fact, in 2012, the number of practising nurses increased by 1.7 per cent and the number of practising doctors increased by 2.9 per cent.
As we focus on getting the government’s books back into the black by 2014/15, we must continue our drive to make the best use of every health dollar. As the second largest area of government spending, health has a vital role to play in balancing the budget. If we want to continue to provide New Zealanders with a world class health system, we will need to find new and improved ways of keeping people healthy.
Our health system, like others around the world, faces big challenges in the future. The biggest challenge comes from our very success in increasing life expectancy. More people are living beyond the age of 85 and many will need the support of the health and disability system.
More of us are living with chronic diseases. Four non-communicable diseases that are largely preventable – cardiovascular diseases (CVDs), diabetes, cancer, and chronic respiratory disease – make up around 80 per cent of the disease burden for the total population.
With more older people in our population, the pressures on services will rise. If we had the same share of over 65s in the population now as we will have in 2025, spending today would be $2 billion higher.
The population in your district has a high life expectancy and is one of the fastest growing in New Zealand. Managing this growth in demand, particularly from those over 65, means you will need to continue to be innovative, while ensuring that patients are always put first.
In the UK, recent events at Mid-Staffordshire hospital serve as a stark reminder of what can happen when health systems lose sight of this. The Francis report into the events at Mid-Staffordshire documented many examples of failings where the most basic elements of care were neglected; from patients being left unwashed for as long as a month to essential pain relief being delayed or even not provided at all. These failings arose from a culture that had a tolerance of poor standards and did not put patients’ care first.
The central message of the report is that improving quality and safety requires the right culture of care. Patient care needs to be top of the agenda, the first concern of professionals and the shared responsibility of all. While we face a different set of circumstances in New Zealand, the report’s key findings should give us pause for thought about what we can do better to create the right culture of care; a culture that puts patients first.
To address the challenges of the future and improve outcomes for patients we need to focus on driving on-going improvements in quality and safety and increasing the clinical integration of services. Focusing on quality and safety is a key way of making the best of our investment in health. Mistakes and poor quality care are not just expensive for our system; they can have a lifelong impact on our patients.
The 2011 Commonwealth Fund Survey of Sicker Adults in Eleven Countries found that, in New Zealand:
• 22 per cent of sicker adults had experienced a medical, medication or laboratory test error in the past two years; and
• 51 per cent had experienced gaps in their hospital or surgical discharge over the same period.
If we do the right thing first time we can minimise harm to patients and be more cost effective. Improvements in quality can result in more accurate diagnoses, fewer treatment errors, lower complication rates and faster recovery. If anything, the Commonwealth Fund figures tend to underestimate the gains to be made for patients and families from improvements in quality and safety.
This government has demonstrated the importance we attach to quality and safety by setting up the Health Quality and Safety Commission. We established the Commission to create a sharper focus on quality and safety by building a culture of quality improvement in our health system that will reduce harm to patients and improve efficiency. The Commission’s role is to provide leadership across the health sector on quality and safety issues. It drives on-going quality and safety improvements through its work programmes.
One of the Commission’s initiatives will involve all DHBs measuring the quality of their services and making this information available to the public, as well as explaining the actions they intend to take to improve quality. Part of this work involves developing indicators to capture patient experience. These will be important markers for our health system. The evidence from other countries shows that measuring patient experience improves the quality of health services.
Waitemata DHB is already taking a number of steps to develop the right culture of patient care. In 2012 you appointed a Clinical Leader for Quality, adopted new values and overhauled your complaints process. You have reduced the average complaints resolution from 34 days in 2010 to around 16 days today.
One of your new values is to “work with compassion”. I commend you for adopting this important value. A culture of compassion is central to ensuring that we see things from the patient’s perspective. We should never underestimate how vulnerable individuals and their families can feel when they or their loved ones are in hospital.
The Commission’s early successes demonstrate that when we make the right changes, there is huge potential to save and improve lives. For example, their programme to prevent bloodstream infections from inserting central line catheters has achieved a reduction in the national infection rate from 3.32 to 0.88 per 1000 line days.
This programme has been rolled out to 50 areas nationwide and involves using standardised checklists to ensure all medical professionals follow the same, best-practice process for inserting a central vein catheter, maintaining the catheter, and looking for any symptoms that could lead to an infection. Patients are benefiting from fewer infections, reduced complications and pain and suffering. They are also spending less time in hospital, which has resulted in an estimated $1.4 million being saved over 12 months.
The Commission is also focusing on reducing surgical site infections, which are the most common form of healthcare-associated infection, occurring in 2-5 per cent of all patients undergoing invasive surgical procedures.
Consistent and reliable use of evidence-based interventions has been shown to drastically reduce the incidence of surgical site infection. Eight DHBs throughout New Zealand, including Waitemata DHB are currently piloting a new patient safety programme to reduce surgical site infections from hip and knee surgeries. This will be rolled out nation-wide in July this year.
Next month I will be launching the Commission’s national patient safety campaign. This aims to reduce patient harm by increasing health professionals’ use of interventions known to improve patient safety.
Preventing falls and reducing harm from falls is the first focus of the campaign. Injuries associated with falls have a severe impact on patients, their families and the sector. During 2010/11 and 2011/12, two hundred people fell and broke their hips while in our hospitals.
A serious fall-related injury can extend a person’s length of stay in hospital by over a month, with an estimated cost for each extended stay varying between $27,000 and $47,000. Conservative estimates suggest this represents a total additional cost of between $3 million and $5 million per year for the health system. For some patients, falls have even more serious consequences. Over the same period, there were around 22 additional deaths due to falls in our hospitals.
Making small changes to what we do can have a real impact on people’s lives. Today is the last day of the month-long April Falls promotion and I have been very impressed by the range of activities underway in DHBs to highlight and prevent the danger of falls.
For example, when staff at Whangarei Hospital looked into the pattern of falls in one ward they found that most were happening in the morning, around the time patients needed to go to the bathroom. They rearranged staff schedules so health care assistants started earlier and the number of falls dropped significantly.
And earlier today I had an opportunity to see some of the falls prevention initiatives underway right here in Waitemata DHB.
The Commission is developing a set of quality and safety markers that will track progress in reducing health-care acquired infections, surgical harm, medication errors, and in-patient falls. The initial focus of the markers will be on harm caused in hospital settings. The first of a regular series of progress reports on these markers will be distributed to DHBs and made public in mid-2013.
The quality and safety markers will build on the success of the six national Health Targets. I am confident that having publicly available information about progress in improving safety will only help to further lift public confidence in the public health service. It will also demonstrate to clinicians how these activities improve services.
In addition to improving quality and safety, clinical integration is another important way that we can keep people healthy and make best use of every health dollar.
Clinically integrated healthcare is a top priority for the Government. It brings organisations and healthcare professionals together to provide more patient-focused services. This is particularly important for patients with long term conditions and complex co-morbidities, such as older people.
Putting the patient at the centre of health services should provide a better experience for patients by enabling them to move smoothly from primary to secondary services and back to the care of their primary health provider. It can also be more cost effective, cutting out duplication and reducing fragmentation.
Better integration across the primary and secondary divide is one way our system can adapt to increasing demand for services in the future. It’s an area where you are already making progress in Waitemata.
Waitemata DHB is on track to provide over 6,000 referrals to treatment and diagnostics this year through your primary options for acute care programme. This will enable primary care to manage more patients in community settings as an alternative to a hospital admission.
The new Integrated Family Health Centre in New Lynn that will provide one stop, convenient access to GP, dentist, pharmacist and other services is part of this integrated model of care.
With your regional colleagues, and the Greater Auckland Integrated Healthcare Network, you are establishing clinical pathways to manage patients with gout, deep vein thrombosis and community acquired pneumonia.
You are working to increase gerontology, dietician and clinical pharmacy specialist support to aged residential care facilities, to better identify and manage chronic conditions and cognitive decline in the community. A team of gerontology and wound care nurse specialists are providing outreach services to support health professionals in primary care and aged residential care.
We want to see these kinds of initiatives spread more widely through our health system.
To support greater clinical integration we are making changes to strengthen primary care and incentivise performance. The government, DHBs and PHOs are negotiating a revised PHO agreement for implementation. This agreement will strengthen PHO minimum requirements, set out what PHOs will be expected to achieve, and provide greater clarity about their functions.
A new performance framework for PHOs will be developed during 2013 and will sit alongside the PHO agreement, helping to ensure that we appropriately reward improved performance and facilitate stronger relationships between PHOs and DHBs and the clinicians that work in hospitals and in communities.
We are also implementing a new Community Pharmacy Services Agreement that enables community pharmacy to work in a more integrated way, with general practice and other primary care providers. Community pharmacists will be able to provide support for patients with long term conditions and other high need population groups. The agreement will be fully implemented by July 2015.
The Government has put a big focus on agencies working together to improve public services for New Zealanders. The Prime Minister has set ten challenging targets for public sector agencies which will require new ways of thinking about solving difficult problems. In health, we have targets to meet for increasing immunisation and reducing rheumatic fever.
The first part of Result 3 under the Supporting Vulnerable Children result area is “Increase infant immunisation rates so that 95 per cent of eight-month-olds are fully immunised by December 2014 and this is maintained through to 30 June 2017.” The second part of Result 3 is “Reduce the incidence of rheumatic fever by two thirds to 1.4 cases per 100,000 people by June 2017.”
Maori and Pasifika children are at much higher risk of rheumatic fever. It is unacceptable to this Government that our children should continue to be affected by a disease that has almost vanished in most other developed countries.
We are therefore investing in a school-based throat swabbing programme and we have asked the health sector to work with housing agencies to help families find healthier homes.
We have introduced new ways of working together, such as the Social Sector Trials, which put local communities in the driving seat to help their young people. Social services and health providers in trial localities are taking an integrated approach and working together to respond to community needs.
Waitemata DHB is involved in this initiative and is part of a trial in Ranui to reduce offending, truancy, alcohol and drug use and to increase the numbers of young people participating in education, training and employment. This will start on 1 July 2013.
The Prime Minister’s Youth Mental Health initiative is another example of working together across government to make youth mental health services more accessible and clinically integrated. As a result of this initiative, over 8,000 more secondary school students will be able to see a registered nurse or access other health services at school when they need to.
In conclusion, we can, and we do, deliver a well performing public health system but there are significant challenges ahead for us all as people live longer with multiple health conditions. If we want to continue to provide New Zealanders with a world class health system, we need to find new and improved ways of keeping people healthy and making the best use of every health dollar.
Thank you for all you do for health in New Zealand. Your work in the frontline of health care delivery is crucial in ensuring that the health system performs well and can rise to meet future challenges.
Nō reira, tēnā koutou, tēnā koutou, tēnā koutou katoa.