Health policy Q&A: Annette King

Annette King says it is unfair to set arbitrary thresholds on primary health care. Picture / Martin Sykes

The Herald invited politicians to answer questions at a range of policy forums - so far we have covered tax and the economy, transport and education. Today we examine health.

Below are edited highlights of the 45-minute question and answer session with Health Minister Annette King.

There's been a Labour-led Government for six years, but people still say health is their number one or maybe second issue. Have you failed to convince us that we've got a better health system?

I don't think that health would be out of the top issues for New Zealanders in any time that I can remember. People worry about their health and their family's health and the health system. I'd look at something more tangible - the rolling patient satisfaction surveys that are carried out by all DHBs and see that over the time we've been in government they've continued to climb in terms of patient satisfaction from people who access the health system. It's about 87 per cent.

In the annual Commonwealth fund survey, which compares New Zealand, the US, the UK, Canada, and Australia, New Zealand comes out either first or second in all the categories they ask. We do extremely well, particularly on access to health services and timely access to health services.

Are you happy with the state of hospital waiting lists?

We actually saw waiting lists as a measure removed with the introduction of the booking system in 1998 and the implementation of a system where we book people and give them transparency and honesty about what we can do and when we can do it. As you're probably aware there are four categories to the booking system - from those who are given a date for their operation, those that are given certainty that they will get an operation in six months, "active review" which is those that will not be done now because there's insufficient capacity and those that won't get an operation.

We have seen improvement in the time that people are going through and the speed at which they are going through. In terms of operations, we have seen more people booked and fewer people on active review.

In some cases - and heart surgery would be the obvious one - there are people on active review who most doctors would feel really do need an operation right now. They're not officially on the main waiting list for surgery, but they need it.

Whether people are on the waiting list is very much the decision of the clinicians. It's not a political decision. If they decide that you can wait, you will wait. What's been happening in heart surgery is quite interesting, because the ratio between acute and elective surgery has actually changed, even in a year.

So people are arriving at an emergency department with a chest pain, they are holding them in the hospital and operating on them, ahead of people who are on a waiting list. We've done at least 200 more heart operations in this last year than we did last year.

What are you doing about pay rates and staff shortages?

I think the commitment to the half a billion nursing settlement is a major step forward in trying to retain our nursing workforce and that is paid out over the next four years.

Nurses were obviously underpaid and they had better opportunities to go and do other jobs or go offshore. In the last three years our doctors in our hospitals have had a 50 per cent pay increase. Our radiation therapists have had a big pay increase. There's a big claim in for dental therapists.

So a lot of work has had to go into recruiting and retaining our health workers. The crucial error of the 1990s was not to plan for a health workforce. Bill English, when he was minister of health, said the market would provide. The trouble is it takes 15 years to get one psychiatrist. So it's a slow old market in health.

The biggest example of that error was in radiation treatment. As you know, we've had to send people to Australia for radiation therapy because we didn't have enough radiation therapists. We trained 16 a year. We didn't even replace those that went off to have babies or go over to work in Canada for twice the money.

We now train 38 and for the first time we've filled all the positions and had two who didn't get a job immediately. But they take three years to train. So we didn't get our first graduates out of those additional trainees until last year.

The same in dental therapy. All the training schools for dental therapists were closed in the 1990s. So people are saying to me, "Why aren't you providing oral health services to children - you were a school dental nurse, shame on you". I say, well you actually can't do that if you don't train people to provide it.

Your opponents say there are too many bureaucrats in the health system ...

Well I'd like them to tell me, which bureaucrats are they going to get rid of? They haven't been able to name one yet. Is it the ward clerk, the people who do the bookings, is it the receptionist, is it the telephonist? These are all counted as bureaucrats.

Are too many health boards doing the same thing when you could be pooling resources?

If that means forced amalgamation for district health boards, I absolutely reject that, because everyone knows how parochial districts are.

Even to try to draw your three in Auckland together - which I think is inevitable over time because they've now got a lot of regional projects - there would be a certain amount of angst about that. But if you try to join Wanganui with Palmerston North in a forced amalgamation, or you force Tairawhiti into Hawkes Bay and then into Waikato, you will find communities have very strong views about their own autonomy in terms of health decision-making. The way forward - and it's happening now - is regional co-operation.

Why don't you make more use of private hospitals to reduce waiting lists?

There's nothing stopping any DHB using whatever capacity there is. So it is simplistic to say, let's use more of the private sector. We use what we can.

Have you had problems in trying to move to a fully subsidised system of doctors' visits?

GPs have worked incredibly well on this project. They first of all supported the primary health care strategy, as an overall approach with the early intervention, prevention etc. Then you get down to the details and we've resolved each one as they've come up. I would expect that to continue.

What most of them say to me, though, is don't suddenly change direction and head off somewhere else, leaving us holding this baby.

The other thing is that general practice and primary health organisations aren't only about doctors, there's a huge shift in those that are involved in the provision of health services.

Because you don't have to see a GP to be paid and you pay on an enrolled population, it means that you can use a number of health professionals.

Chronic-care management is a role absolutely tailored for nurses - managing people with diabetes, heart conditions, etc. That's the area where I think we're going to get some real gain. So I think there will be problems along the way in the implementation. It certainly would be a problem for us if we stopped where we are now with a change of government and we leave out these chunks of people with no assistance at all.

Why not pay subsidies for doctors' visits for those on low incomes, as National says, and put the rest of the money into getting a few more operations done?

Why is it okay to have universal access to operations and hospital services, but you say you should have it targeted to primary health care - the very part of the health system that could stop them ending up costing you $30,000 for a heart operation, costing you hundreds of thousands for dialysis? Why wouldn't you have universal access to primary health care?

The other thing is the absolute unfairness of setting an arbitrary threshold where you are rich and you pay. Dr Brash mentioned a figure of $30,000. So if you earn $1 over that $30,000, then you will not get a subsidy and you will be on the same footing as Dr Brash on $200,000 - except he's going to be 65 soon and he's covered. So you can see that an arbitrary cut-off in saying someone is rich, therefore, they don't get subsidised pharmaceuticals, or subsidised primary health care is an incredibly unfair system. Why not use that for hospitals?

Working for Families is all income thresholds and so is the eligibility for child rebates. Why is health so different?

Because we say it is based on a health need. People on $30,000 would find it really hard to pay the top dollar for their primary health care. It is really hard if you have to pay $60, $70, $80 for a visit and you need to go several times.

Even with the old high user health card, you had to go 12 times a year to qualify. It is a much fairer system to have universal access.

I guess they're paying about $50 now for a visit.

Only those that aren't subsidised.

Yes, but that's a big chunk of the population.

Yes, and that's why we're going to roll it out to all of them.

Is Pharmac going too far in cutting drug costs?

Pharmac is reviewing its operating practices and procedures but I'd have to say that Pharmac has ensured that we have 80 per cent of all our pharmaceuticals subsidised.

We have high-quality drugs and we are able to provide that on a pretty small economy. What we have to realise is that every day new drugs are coming on to the market.

You might have noticed recently a group of people with breast cancer said there is a new drug called Herceptin, which is still under clinical trials. The cost of that one drug is estimated to be $300 million. Now that's what we face every day and we have to make decisions around what we can afford.

* Jargon explained

PHO: A primary health organisation. A group of GPs, nurses or other health professionals, funded by the Government through subsidies.

DHB: A district health board. Runs the hospitals and other public services in an area.

IPA: An independent practitioners association. Basically a group of doctors.