Dr Bev O'Keefe's Opening Address as IPAC's New Chair

Summary:
The following speech was made on the final day of the 2006 IPAC Conference, held in Auckland bewteen October 6-8.

Two remarkable people have driven this conference, Harry Pert and Victor Klap.  I must begin by thanking Harry, Victor and the team who have put together this outstanding conference, and the keynote speakers who have given us so much to think about. We have learned about good practice and bad practice, the changing role of patients in the management of their health care, the international and local policy environments, and the drivers for improving performance.

The theme of our conference has been "enhancing performance – breaking down the barriers" and we have been treated to an excellent performance over the past few days, with a stimulating cast, and a carefully constructed set.

Thank you all for taking the time out from your busy schedules to share this conference with us, whether you have come from Australia and the UK., the Ministry and the DHBs, or our own organizations.

The 2 simple questions I would like to briefly address today are these:

Where have we been?
What next for general practice?

Sir Donald Irvine mentioned early in the conference that he sensed an air of uncertainty in the New Zealand general practice scene. Perhaps that has something to do with change.

It has been said that before we can know where we are headed in the future, - we need first to look at where we have been, and where we are now. Conway Powell has already shared some insights into where we are now, and it is clear we want to be in a different space in the future.

In the context of the history of primary care in New Zealand over recent years, the words that spring to the front of my mind are "change", "reform", and "bureaucracy", and the pace of change has been swift.

My sense is that as doctors and nurses we would prefer to be left alone to care for patients - which is what we were trained to do, and what we are best at , but the torrent of change has been almost overwhelming. Yet the cornerstone of general practice and primary care, - the fundamental relationships between doctors, nurses and their patients has not changed over decades, and that is what defines our core.

Last week as I visited a 60 yr old dying woman twice daily in her own home, and then at her deathbed on Saturday, where she was surrounded by her grieving family, I was reminded why I chose this career. I had been involved in her care over the past 15 years, I care for her children and I had delivered her 4 granddaughters. I was privileged to be part of this family at this sad but very special time.This scene could have been enacted any time over my practising life, and would have not looked markedly different.
But, human relationships aside, almost everything else has changed...

So what HAS changed and how have we been affected by that change?

In deference to our speakers from Fonterra earlier this morning, I have chosen to begin this discussion from my own roots.

I am a fifth generation Kiwi, raised and educated in the dairy heartland of South Taranaki on a farm which is still owned and farmed by my brothers some 82 years since my own father was born there. So the changes that have been the focus of this morning’s Fonterra presentation are not totally unfamiliar to me, but they bring to mind some parallels within my own profession, one with which I have a much briefer acquaintance of some 30 –odd years.

Fortunately with farming too, some things have not really changed – as this slide of farmer and cow depict.

One of my childhood treats was the occasional trip to one of the many nearby cheese factories in the old Bedford truck which was laden with cans of milk - the social encounter of the day for my father and the neighbouring dairy farmers. Those days have long gone..

When I had occasion to visit the impressive Fonterra factory South of Hawera several years ago I was overwhelmed by the technological  revolution that had taken place in those few decades – the sheer size and clinical cleanliness of everything, the white boots, coats and caps, the security, the automation. This could have been a hospital, but was in fact a global dairy giant in my own backyard.

So what happened to general practice in that district over the same period?

For the first 40 years of my life my long standing and highly respected local solo GP worked and lived here, in the small village where I was born. The front room was the surgery, the family living quarters behind.

Now there is no doctor there, just as there is no cheese factory there. The trip to the nearest town which took a day in my great grandparents’ time is now a brief 30 minutes away, and that is where the medical centre can now be found.

For medical care today, there is a smart modern centre, with all the trappings and technology that we associate with modern general practice. Back in the country the village community is struggling to survive as the farms have become larger and the population smaller. Transport and technology have altered the way that people go about their lives.

These social changes have been but ONE of the environmental changes that have influenced general practice as we now know it. Our keynote speaker Sir Donald Irvine in his 2004 Gordon Arthur Ransome Oration summed up his observations very eloquently –

To quote him…

"Today we are in a different world. In my practising lifetime medicine has altered out of all recognition. Advances in science and technology have given us the ability to do wonderful things but also to do more harm. Information technology is itself transforming practice. At the same time there have been dramatic changes in the social context and the practising environment especially in developed countries".

And within general practice itself, we have seen marked social changes.

Practice nurses, highly skilled professionals in their own right, have become an integral part of every general practice team.
Our medical workforce has become urbanized, globalised, and feminised. Of a class of 60, I was one of 12 female graduates in the inaugural class of the Auckland School of Medicine – we were derided by the media for keeping good men out of a noble career. Last year over 70% of graduates were women.

Young graduates of generation s X and Y may have different aspirations as work/life balance becomes a significant factor in their career planning. Student loans, attractive salaries overseas, and a commitment to organized leisure have created new expectations.

General practice itself has over the past 15 years undergone what has become known as the quiet revolution, as practices have organized themselves into effective networks, many of whom spawned IPAC. And more recently have become the foundation upon which functional PHOS are now built.  Organised general practice was born, and underpins the way we now work. Names like Pegasus, Southlink, WIPA, and ProCare, (and a special mention for my own Rotorua General practice Group), are part of general practice language in NZ.

We have developed a new way of working with constant audits on clinical quality, peer review, continuous medical education, and personal and practice accreditation now a part of everyday life. Clinical governance is a tool of trade.

Our organizations manage numerous programmes across our enrolled populations, and our patients are often more demanding and better informed than we have known in the past. The community based clinical programmes that have arisen out of organized general practice are numerous – be it chronic care management, managing acute demand, immunization, retinal screening, mental health, or many others. However we have a long way to go to realize the potential of organized general practice, so that the learnings and benefits gained from these ventures are shared nationally for the benefit of all.  The need to share the learnings has been a recurrent theme at this conference. The challenges of data collection and analysis were mentioned yesterday.

Over this same time however, the political environment has become increasingly hostile and general practice has felt weighed down with the burden of bureaucracy.

As I have already stated, Doctors and nurses want to care for PATIENTS – that is what we are trained to do, and that is what we are best at.  General practice has become tired of reform and change as over the past decade or so we have lived with the moves from hospital boards to area health boards, to regional health authorities with funder provider splits, and then to  a single health funding agency because 4 were considered too many.


Now our path is being shaped by the Primary Health Care Strategy which we have all supported in principle, but the implementation has been cumbersome and distracting for general practice. Suddenly it is now acceptable to have 21 regional DHBs, often with different sets of rules, and a conspicuous lack of differentiation between funder and provider with our hospitals now being called the “provider arms” of the DHBs.

Whatever happened to the “primary provider arm”?  Or are our DHBs in fact really one armed hospital boards, rather than health boards in many areas.

We have just seen thousands or people around the country “returned to their GP” because they will not meet waiting list criteria.  Another $200 million has been poured into the system to solve the problem, but will it?

Would it not have been better and cheaper if the DHBs had enlisted the help of OGP to come up with some innovative solutions together, to give our patients some certainty around their care?

Why is it that the DHBs find it acceptable to have their secondary provider compete with general practice in the provision of primary care services for example free general practice consults in ED depts., but if there is an RMO strike, or a radiographers strike, general practice can suddenly manage those services perfectly well?


In our capitated environment there is no financial risk to a DHB to send patients back to general practice, as there will be no additional FFS claims for the extra general practice visits that may result from disruption of hospital services. General practice often feels used as a DHB dumping ground, and this must change.


So in spite of some of the great changes that organized general practice has made, embracing clinical governance and information technology, being innovative, taking care of  enrolled populations and trying to prevent poor health , as Conway has illustrated, there is a strong sense of being undervalued.

So - what does general practice need to do to move forward?

Eleven and a half thousand dairy farmers have organized themselves in a highly impressive manner to become what is now Fonterra, positioned at the helm of a global market. We have learned a great deal today as to how that has come about, and the lessons we may take from that.

New Zealand has only three and a half thousand general practitioners and a similar number of practice nurses. We too are part of a global market, and we produce a highly sought after product in a world where there is an international shortage of doctors and nurses.

I believe there are three key ingredients to a healthy future for New Zealanders through Organised general practice and I will touch very briefly on each of them:

We must control change
We must have a vision
We must be united.

Change:

Political, social and technological changes will continue to surround us and we need to reflect on how we deal with that.
Patients will continue to become better informed and more demanding of their general practice teams, and the burden of complex chronic disease will increase,  so what can we change to ensure we can deal with these pressures and turn them into opportunities for general practice.

Put simply,

We need to know where we want to be, and we need to move as one to get there.

As doctors and nurses, relationships are our core business, and we need to focus on building relationships with our DHBs and the Ministry of Health, locally and nationally, to come up with effective solutions for our communities. The issues that Conway describes could change dramatically if the Ministry and DHBs engaged with general practice.

The “Next 5 years” document outlining the future of primary care in the eyes of the ministry struggles to mention general practice, let alone organized general practice, and we have limited (though improving) clinical representation in the work-streams that are flowing from it.

The PHOs were going to become broad based multi-provider organizations to deliver the strategy. Certainly in my area, general practice is the only provider group yet to be funded through the PHO after 3 years.

Where are the pharmacists, the physios, the dentists, the midwives?  Again we have over 80 PHOs throughout NZ providing 80 sets of care in 80 different ways to a population the size of Melbourne.
It makes me angry to hear the Minister stand up here and say there is no further funding for after hours services or maternity services, yet there has been unquestioned funding for 102 new bureaucracies.

Fonterra has shown us very clearly that in order to make change work for us rather than against us, we need to be in control of our own destiny. If Fonterra knock on the door of our politicians, do they get a smack on the hand and told to go away and behave themselves – or else. I don’t think so.

Vision:

In the words of Margaret Mead –

Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.

What general practice needs is a common shared vision, and a commitment by everyone to be working together to achieve that.

The IPAC vision has always been to support a primary led health system through organized general practice and I believe strongly in that vision as the logical way forward. And yes, we do need to build a consumer focus.

Barbara Starfield from John Hopkins school of Public Health late last year wrote her paper “The Primary Solution” in which she espouses the thesis that the reason the American Health system is so bad for people’s health is that it is specialist dominated,

AS she says
"There is lots of evidence that a good relationship with a freely chosen primary care doctor, preferably over several years, is associated with better care, more appropriate care, better health, and much lower health costs…"

New Zealand has a good health system – but we all need to be working together to make it a lot better.

Looking at the waiting list problem again – we know that there will always have to be rationing of health care – would it not be much better to have this decision making much closer to the patient, in conjunction with the general practice team who know the patient, the family and the social situation??


As those who are closest to our patients and know them best, we need to be involved with them in the decision making processes where it really matters. We need to be involved in the formation of policy, not the reaction to it.  IPAC has been called obstructive by politicians and their agents – it doesn’t have to be that way – general practice needs to be involved in shaping the policy that will ensure the best outcomes for our patients. Strong local networks of organized general practice working with their communities will continue to be the cornerstone of primary care and of the PHCS.  Without organized general practice, the strategy will fail.

We need to be working with our DHBs, and they need to be working with us, to ensure we are all referring appropriately, and that we are collectively working towards the best solutions for our patients, not just the best solution for funding our hospitals or their deficits.
I believe that within   a political culture of  support  - patients and their general practice team could make very sound decisions around appropriate resource allocation, and I am looking forward to next week travelling to the UK with other GP leaders to study the trends there.,
Our DHBs could easily revise the professional committees who are involved in allocative decision making for secondary services. These committees should have some specialist representation, but should more importantly have a strong general practice and primary care input, so that services are designed around genuine community need.

The vision for general practice has to involve strong networks of teams working closely with other providers and communities across the country to provide consistent high quality care. Again I am looking forward to learning a great deal more about the British quality and outcomes framework on the forthcoming tour, but such initiatives can only achieve their potential within a supportive and enabling political environment, and this is a vital ingredient for future progress.

Unity:

The vision for general practice can only be achieved if it is shared and actively supported by us all, but most importantly it CAN be achieved in general practice just as it has been achieved in dairy farming. We want to attract the best doctors and the best nurses into our field as their chosen vocation, and we want to reward them well for the work they do. Most importantly, we want our children and grandchildren to enjoy the best health and the best care in the developed world.

It is up to us.  Do 3500 GPs and 3500 practice nurses really need 3, 4, or 5 or 6 national organizations? Not only does it spread our leaders thinly, it dilutes our effectiveness as advocates for general practice. Our national bodies all do good, important, work, but is this the best way?

We have started down that path already.

The GPLF, an informal liaison between the leaders of our 4 national GP organizations , works at present because the national leaders and CEOs all work well together , but this has not always been the case, and may not necessarily be so in the future.  General practice needs strong leadership and advocacy; there is much to be done. It is my belief that we need to be taking further steps towards unity just as Fonterra have done, to seriously improve the performance, and break down the barriers for the future of general practice in New Zealand.

We must all be ambassadors for our vocation, and as was said by Roger Neighbour, president of the RCGP:
 
"I ask myself whether the future of our profession is safe in the hands of the next generation. And I think, only if it’s been safe in the hands of my own"

And so I reiterate my key messages – to keep general practice safe for the future – we must
Take control of the changes,
Have a clear vision,
And become united.

The future of general practice is then in OUR hands and is it up to us to take charge of it.
I look forward to working and meeting with many of you in the next while as I play my part in working towards these goals. I hope YOU are willing to play yours.

And so I leave you with these thoughts of Benjamin Franklin:
"We must all hang together, or assuredly we shall all hang separately."

Finally may I wish you all a safe journey back to your homes and workplaces, and hope you have found this conference a stimulus towards improving your performance and breaking down barriers wherever you are.

Publish Date :  13/10/2006
Author :  Dr Bev O'Keefe