Speech to Association of Bone and Joint Surgeons conference
Thanks Haemish. It’s a pleasure to be here today to be part of the Association’s 68th Annual Meeting. I’d like to acknowledge Association President Dr Marlene De Maio.
I’d also like to acknowledge the important contribution the Association makes in advancing the knowledge and practice of orthopaedics.
High levels of clinical engagement are crucial. Clinicians are the key influencers of patient management - from making the diagnosis to determining the pathway of care.
Creating an environment where high quality models of care can thrive requires strong leaders who can bring together teams with different drivers and approaches.
New Zealand’s orthopaedic clinicians and their professional organisations are active leaders in the sector. Their input has informed policy and the introduction of new practices including - clinical assessment and prioritisation tools, and enhanced recovery after surgery pathways.
NZ health overview
I’d like to start with an overview on our health sector. The feedback I get from the sector is that while there are challenges, we’re heading in the right direction.
Delivering better health services is a top priority for the Government. We’ve made health our number one funding priority.
Despite economic challenges, we’ve increased health funding each year - while many developed countries around the world have frozen or reduced health funding.
Claims by government critics that health funding has been cut are incorrect. Under this Government health expenditure share of GDP has averaged 6.5 per cent – that’s up from the previous Government’s level of under 6 per cent.
In this year’s budget health received $15.9 billion - the largest share of new funding.
The New Zealand health system faces a number of challenges, many of these are global issues, for example - tight financial times, an ageing population, tackling NCDs, changing public health expectations, and advances in technology.
Life expectancy in New Zealand has increased at a faster rate than Australia, the UK, the US and Canada, and now rivals or exceeds these four countries - which all spend more on health per head of population than we do.
A male child born in New Zealand today can expect to live to the age of 79.5 and a female child can expect to live to the age of 83.
We have seen a reduction in mortality rates for cancer and cardiovascular disease due to better prevention, detection and treatment of these conditions.
Like many other countries, our very success in increasing life expectancy also creates our biggest challenge. While people are living longer, they’re also living longer in less than full health, and need more support.
More of us are also living with chronic diseases. Cardiovascular diseases, diabetes, cancer and chronic respiratory disease make up around 80 per cent of the disease burden for our total population.
We need to find new ways of delivering health services in a more cost effective way, while continuing to improve health outcomes and the quality of services.
NZ’s health structure
New Zealand’s health and disability system is mainly funded from general taxation.
Around $12 billion of public funding is allocated to 20 semi-autonomous DHBs each year. DHBs plan, manage and purchase health services for their local population - this includes funding for primary care, hospital services, public health services, aged care services, and services provided by NGOs including Māori and Pacific providers.
Most of the remaining public funding is provided to the Ministry of Health to fund key national services such as elective services, disability support, public health services, screening programmes, mental health services, primary maternity services, Māori health services, and postgraduate clinical education and training.
ACC has particular relevance to bone and joint trauma surgery as it’s the agency which provides comprehensive no-fault personal injury cover for all New Zealand residents and visitors.
It’s the largest purchaser of health services - purchasing around $3 billion in treatment, support, compensation and prevention. ACC contributes to a wide range of medical and related costs associated with accidents, including doctor’s visits, treatment from other health professionals, surgery, x-rays and prescription costs.
In terms of my priorities as Minister for Health, I will be progressing the updated New Zealand Health Strategy.
I want to see more integrated services delivered in the community so people can get the care they need away from hospitals.
Health systems around the world are increasingly recognising that integration and care closer to home are important ways to keep people healthy, while at the same time improving the quality of care and making the best use of every health dollar.
I want to ensure speedier access to elective surgery, and we are working to quantify unmet demand to better understand the outcomes of GP referrals to specialists.
Our health targets continue to be a key focus. They are not just about numbers – they are about delivering better and quicker access to important health services.
I want to see continued progress on non-communicable diseases, particularly childhood obesity. New Zealand is now one of the first OECD countries to have a target and a comprehensive plan.
I also expect to see a greater focus on prevention and earlier intervention through initiatives delivered in the community.
I am also keen on widening access to medicines and progressing the bowel cancer screening programme.
Clear strategic direction for the health sector is also crucial.
The Health Strategy update is a good opportunity to develop a more integrated cohesive health system, better able to meet the demands of the future.
The Strategy covers five strategic themes – people-powered, closer to home, value and high performance, one team, and a smart system.
These themes signal a focus on prevention and wellbeing, more integrated services, support for innovation, better collaboration, new ways of working to reach our most vulnerable, giving every child a healthy start, and ensuring information and services are more accessible.
Updating the Strategy offers an excellent opportunity to speed up the adoption of new technologies, adopt pathways for better integration and cohesion across the sector, and focus attention on populations with the highest need.
I will be launching the revised Strategy very shortly.
Delivering more elective surgery
As New Zealanders live longer lives, access to elective surgery is becoming more important than ever.
Improving access to electives is a multi-dimensional goal. It includes reducing waiting times, increasing the number of FSAs and elective discharges.
Doing better every year is important – like many comparable countries we face a growing and ageing population which is living longer - there is always more to be done, and the answer to increased demand is to do more.
New Zealand has a first rate system for dealing with acute and emergency surgery.
During the early/mid 2000s, the rate of elective surgery had not kept up with population growth. A health target was introduced in 2008 to ensure there was a consistent increase in the number of elective surgeries across the country each year.
DHBs have made excellent progress on this, and that’s a tribute to the hard work of our surgeons and health teams.
The number of surgical and medical FSAs has increased from around 432,000 in 2008/09 to over 542,000 in 2014/15. Around 10 per cent of New Zealanders had one or more FSAs in the last financial year for either medical or surgical needs.
The number of patients receiving elective surgery has increased from around 118,000 in 2007/08 to 167,000 in 2014/15. That’s around 50,000 more surgeries over the last seven years - a 42 per cent increase.
During this period, there’s been a 33 per cent increase in orthopaedic surgical discharges.
Alongside the increases in elective surgery, New Zealand has also made good progress in reducing surgery waiting times.
The Government introduced a performance measurement in 2011 that no patient would wait over four months for assessment or treatment.
Back in 2005, over 31,000 patients were waiting over six months for a specialist assessment or surgery. Now there’s around 2,000 patients waiting over four months.
When the waiting time reduction programme was introduced, there was a lot of feedback that it was too ambitious a goal. It’s good to reflect on how far we’ve come.
Although the sector aspires to treat patients who would benefit from surgery, there will always be more patients than our health system can support.
Public health resources need to be directed to those with the greatest priority.
Prioritisation in New Zealand is based on the principles of clarity, timeliness, fairness and quality. Patients want to know whether they will receive treatment, and when they will receive it.
New Zealand is relatively unique in this approach to clinician prioritisation.
While prioritisation helps to ensure the right patients are treated at the right time, there will always be patients who do not receive treatment.
The Government launched the National Patient Flow project to measure the outcomes of GP referrals to hospital specialists for the first time.
New Zealand is one of only a few countries collecting information of this kind at a national level.
It will allow us to have a complete and consistent view on the number of referrals made for elective services and what the outcomes are. Over time it will also produce measures to gather information about other referral points within the health system.
It’s expected to enhance information about demand for hospital services, how hospitals respond to that demand, and why patients may experience delays.
Initial data shows that between July and September 2015 there were around 145,000 GP referrals for a FSA. Of these referrals, 90 per cent were accepted for a FSA. Four per cent were declined as they didn’t meet the threshold.
It’s expected that as the data builds the number of patients declined and sent back to their GP for care as they didn’t meet the threshold will rise to around 10-15 per cent.
The National Patient Flow will assist funders to identify equity of access across DHBs. This understanding will further enhance new models of care that are delivered closer to home.
Lastly, I’d like to touch on some of the areas specific to bone and joint surgery.
The New Zealand Orthopaedic Association are to be commended for establishing the New Zealand Joint Registry in 1997 which is supported by funding from a range of organisations, including the Ministry of Health.
The data contained in the Registry is a valuable research resource, with a detailed analytical report produced each year.
NZ Hip Fracture Registry
The New Zealand Hip Fracture Registry helps to inform and improve the optimal care for acute hip fracture patients.
It’s largely a quality improvement initiative, with inherent longer term productivity gains possible through reduced adverse events and better flow through the system.
Nearly 4,000 New Zealanders break their hip every year, incurring hospital costs of $105 million a year.
The Registry is one part of a more comprehensive approach to reducing harm from falls and fractures in older people. The Ministry of Health has also set an expectation that all DHBs implement a fracture liaison service.
DHBs have worked collaboratively to introduce the patient-centred Enhanced Recovery After Surgery (ERAS) pathway for people who need a hip or knee joint replacement or who have a fractured neck of femur.
ERAS is an evidenced based approach that focuses on educating patients about how they can take control of their own recovery, identifying and managing any potential discharge problems beforehand, and minimising the operative impact.
ERAS is based on the Institute for Healthcare Improvement Quality Improvement Collaborative methodology. It’s a proven model for facilitating implementation of evidence based improvements and has been successfully used in a range of clinical settings in Australia, USA, UK and Europe.
Orthopaedic ERAS has contributed to a nationwide reduction in the average length of hospital stay for people receiving a hip or knee replacement. Re-admissions for patients with a broken hip or fractured neck of femur have also reduced.
This is a great example of cooperation between DHBs and staff.
Local Mobility Action Teams
The Government has invested $6 million to create new community based multi-disciplinary early intervention teams for diagnosis and management of musculoskeletal conditions.
Early intervention can deliver improvements in diagnosis, self-management, education, exercise, and pain management.
These new Local Mobility Action Teams will work with a range of community health services including GPs, dietitians and physiotherapists. There will also be links with hospital services such as rheumatology, orthopaedic and pain services.
This is also about delivering to local communities to meet their specific needs, so we expect to see a variety of solutions across the country.
The first of these teams, which I met at a workshop recently in Wellington, will be up and running around the country in the next few months.
I hope you enjoy the rest of your conference.
I want to reassure you that our Government will continue to place a top priority on delivery high quality health services.