Speech from Labour health spokesperson Grant Robertson

Rendezvous Hotel, Auckland

I would like to thank you for coming along today.

I want to take the opportunity in addressing the topic today to give you an idea of my approach to the health portfolio as Labour's health spokesperson and obviously the Labour Party's and an idea of some of the priorities that we have as we move towards the general election this year.

I am obviously highly conscious I'm in a room of people who work every day in the health sector and contribute to what I believe is still a very good quality health system in New Zealand, and it's with a sense of wariness that someone who's a politician with a limited amount of background in the health sector comes to talk to you.


There is an important distinction in the topic for this speech - and that is in my mind a distinction between health and health care. 

The two are of course intertwined, but I believe that understanding the difference between them is important to understanding  the vision of health that I am bringing to you today and it is important for a number of reasons, because I think it defines some differences in approach between the current government and where I would like to see things go. 

And that difference in approach is really about a short term versus a long term view, and I think it is a significant difference in terms of how we develop a healthy population and a sustainable health system.

In some ways you can go to a definition that is simple: there is a definition that is used by the United Nations that health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity.

Now that statement used by the United Nations for what health is is in fact very old.  It is from the establishment of the WHO in 1946.  So I know that what I say today is not new as such.  But I do believe that a new approach is required in order to make real that notion of what is health.

But to start at the beginning as it were.  It is easy to think about an issue like health and to be drawn instantly into a discussion of the system or aspects of it.  PHOs, DHBs, VLCA, DAPs and the phenomenally large list of acronyms that define the lives of those who work in the sector.  In other words it's easy to enter a discussion like this one about the process and funding of delivering health care.

But for me the starting point should always be what are we trying to achieve in terms of health?   Now I could take a long time to talk about that today, but for me as a politician what I want when I think about health, is that I want New Zealanders to live healthy lives that enable them to achieve to the fullest of their potential in all aspects of their lives, and to participate fully in our society.  It is about maximising our well-being as individuals and our collective well-being to create a prosperous, socially inclusive society.

Good health and wellbeing for me is about giving people control of their own lives.  For me, poverty is the opposite of freedom - the freedom to exercise choice and opportunity can only come when people have the ability to exercise that choice.

We need to ensure that when we think about health, we think about it in its widest context.

So for me, I look at this in three ways that I want to discuss today.

The first is that I believe that we need to shift thinking away from seeing health policy in isolation.  To give an example, we need to shift from thinking of good health as something that begins in a hospital or doctor's surgery, and move to thinking of good health as something that begins in our homes, in our communities, in our schools, and wherever we gather together to live our lives.

The second thing that I believe we need to do is to ensure that we move to a longer-term focus that gives a reality to my mother's favourite phrase that "prevention is better than cure" and focus on early intervention.

And the third area is that we need to address the inequities and social inequalities that contribute to poor health outcomes. 

By focussing on those three things as measures of the way we define health, I believe that we can make good progress in terms of the overall outcomes in New Zealand in allowing people to achieve their potential. 

I want to give some examples of these three things.

Recently I visited an excellent health centre in Henderson called WestFono.  It caters to a mainly Pasifika population in an integrated centre with GPs, Pharmacy, all sorts of public health programmes.  One of the most important programmes WestFono does is one involving diabetes.

One of the nurses told me of a patient in the diabetes programme who had not shown up for a couple of appointments.  The centre called her, and discovered her phone had been cut off.   A nurse went and visited her.  She discovered that the woman's husband had lost his job, had no redundancy package, and had taken off to Australia to find work.  The woman, who is partially sighted because of her diabetes, had no car, her children were grown up and living elsewhere, and she had no way of getting to the clinic.

Now, of course, the Centre has sorted this out by putting in place a programme of visits and enabling the woman to get to the centre for other aspects of the programme, but the point of this story is that this woman's health status was directly linked to the loss of her husband's job.  

Access to adequate income, jobs, employment, are health policies.  That is the approach I believe we need to take if we are to improve the overall health status of New Zealand, to understand that the wider context of good health comes from people having jobs and adequate incomes.

Another example:  after GST was increased last year the Regional Public Health Unit in Wellington produced a study that showed that for a family living on the minimum wage they would need to spend 51% of their weekly income to put a healthy meal on the table.  If the family was surviving on a benefit, then it would be 71% of their income to put a healthy meal on the table every night.  That is unachievable for many of those families with other outgoings.

Access to adequate income is a health policy.  It is part of what has driven Labour to have as our policy the taking off of GST from fresh fruit and vegetables, increasing the minimum wage to $15 per hour, and making the first $5,000 of everyone's income, including beneficiaries, tax free.   It is also what lies at the heart of the changes to the tax system that we're proposing, including introducing a Capital Gains Tax and putting up the top tax rate to 39c for those earning more than $150,000. These are health policies - they are about setting up the basis for a fair tax system and for people to be able to make those choices that I mentioned before.

It is of course not just in tax or incomes that make a difference to our health status.  In the last Budget the government allocated $12 million to a programme of throat swabbing of children to help reduce rheumatic fever, a third world disease that has no place in New Zealand.  This is a good programme; it's based on some excellent work in Northland and Hawkes Bay that looks to stop the throat infections that lead to rheumatic fever.

But sadly, all the throat swabbing in the world will not eradicate rheumatic fever if the children who have those throat infections are sent back to the same over-crowded, damp, cold housing from which they got the infections in the first place.  Warm, dry housing is a health policy.  The home insulation programme that commenced under the last government and has carried on under this one is a good start, but I would venture to suggest that many of our most vulnerable citizens live in rented accommodation where the take-up of insulation by landlords has been poor.

So housing policy is a health policy.

I could go on into other areas, but essentially what I am talking about are the social inequalities that can define health status. 

Dealing with social inequalities, I believe, means dealing with the classic Kiwi notion of giving everyone a fair go.  This is the socialist streak that the Prime Minister allegedly talked to some US officials about.  I believe that New Zealanders actually do want to see everyone get a fair go and in a health policy that is important.

Now lest anyone be concerned that what I am advocating is the arrival of some kind of radical socialism, fear not.  I am actually saying exactly what the New Zealand Medical Association said in their statement on health equity that was released earlier this year.  If you have not seen it, it's well worth taking a look.  You are hearing from Paul Ockelford from NZMA tomorrow I understand, and I am sure he will talk about the health equity statement. 

The New Zealand Medical Association statement on health equity is in turn based on the work of Sir Michael Marmot from the United Kingdom who I am sure some of you would have heard from when he came to New Zealand earlier this year.  What he has done is put at the forefront of British political discourse the desperate need to address inequity and inequality if we are to improve overall health status.  We need to do the same thing in New Zealand.

And unless anyone thinks we don't have inequalities in New Zealand - and I'm sure none of you do - according to the 2010 Ministry of Social Development Social Report, males in the most affluent areas in New Zealand can expect to live 8.8 years longer than males in the most deprived areas (82.1 versus 73.3 years). For females, the difference is smaller, but still substantial, at 5.9 years (84.6 versus 78.7 years).

In New Zealand we also have to acknowledge the importance of ethnicity in health outcomes.  The New Zealand Medical Association have noted that Māori have poorer health outcomes and therefore have greater health needs than non-Māori as measured in heart diseases, cancer and mortality. This persists even when other factors such as socio-economic status and smoking have been accounted for. Pacific groups and other immigrant populations are also found to have a low health status. 

In turn this relates to the view, expressed most notably in the book The Spirit Level, that the societies who do the best are those who have the highest levels of equality. What their studies show is that the more equal a society is the happier, healthier, more educated, less stressed and less likely to be a victim of crime its citizens are likely to be.

There has been some debate about aspects of the conclusions by the authors of The Spirit Level, but for me what they are saying is plain common sense - if we harness everyone's potential we will do better as a society.  Not just those at the lower end of the socio-economic spectrum, but all of us.

Inequalities will continue in the kind of society that we have.  What we must do is address how big those inequalities are, how much they grow, and how much they affect our overall health and wellbeing.  My thesis is that they do affect our overall health and wellbeing.  They affect our security, both economic and social, and we need to address those inequalities.

And this makes another important point, that taking an approach to health, setting it in its widest context and looking at the quality of health outcomes that delivers, will also ensure over the long term a more economically sustainable health system.  There is not a politician going around who does not at some point say, "There is no bottomless pit" for health.  So I will say it: "There is no bottomless pit" for health expenditure.  Our expenditure on health is over $14 billion now.  As you all know our population is ageing, the growth in technology opens up all kinds of opportunities - but also all kinds of costs.

I believe that as a country we have to have an honest conversation about the scope of health care in New Zealand and how we best address sustainability in health - and as I've said, I think that's by taking a more preventative, long-term approach.  But we do need to talk about this honestly.

I have to say I do tire a little of hearing the Minister of Health tell the country that he is spending a record amount of money on the health budget.  Well, yesterday I went to the supermarket, and I spent a record amount of money on my groceries, and you know what, there were fewer items in my shopping basket than there were the week before.  The same applies in the health sector - the last two Budgets have been hundreds of millions of dollars short of keeping up with the increased costs facing the sector, and the reality is that services are being cut.

Now it's not to say that this is easy because, as I have said, there is no bottomless pit for health expenditure.  But I do believe it is time for an honest conversation with New Zealanders about what they can expect from the health system and how we can enable people to have more control over their own health.

I've recently been travelling around a number of provincial towns and sort of feel like a latter-day Selwyn Toogood:  "What do you say, Whanganui, Rangiora, Temuka, etc."  But the reason I've been visiting those provincial towns is because in a lot of them their access to health services is changing.  I'll be in Temuka on Thursday night speaking at a public meeting about the loss of their after-hours GP service.

I've been in Rangiora recently speaking to them about the loss of their after-hours GP service.

What people in those communities are feeling is a loss of confidence, and what health system can deliver to them.  And a feeling, particularly in provincial New Zealand, that while they pay the same amount of tax as the rest of us, they perhaps are not receiving all of the services that they might.

The answer here, I believe, is not necessarily to say we must give everything that is wanted in those communities, but that we do have an honest conversation and we don't resort to ad hoc approaches to how to deal with these problems.  And unfortunately I believe that's what is happening in a number of those areas.

The wider approach to health is part of addressing the issue of an honest conversation.  A focus on addressing the social determinants of health and access to healthcare will not only improve health outcomes, but will also prove cost-effective and good for economic growth over time.  This is because we will reduce the need for expensive interventions and treatments.  Investments now in proven early interventions should reduce the need for expenditure not only in the health system but also in other areas of government spending including social development and corrections.  Anyone who doesn't think that we have a problem in terms of our correctional system, only needs to reflect on the fact that it will soon be the largest part of the government's budget.   We need to do better to stop people going to prison, and health and wellbeing are an important part of that.

Recently when I was visiting one of the local schools in my Wellington Central electorate, a very experienced Year One (new entrants) teacher looked at her class.  She pointed at one girl and said, she will probably get a PhD, she pointed at another and said, "he will probably go to prison",  and so on and so on. 

This teacher was pointing out from her experience what we know from evidence that the early years of life are critical to determining the future outcomes of our children. 

If we know the problems, we can do something about them.

In opposition Annette King has led a process for Labour where we have listened to the experts in child development, and in a radical departure for a political party in New Zealand, we have decided to base our social policy on evidence!

Michael Marmot and others have told us that the best interventions are in the early years and they are in prevention.

We will put children at the centre of our social policy to make sure they all have the best start in life.   Annette King has announced some of the policies that go with this such as a Minister for Children, legislated targets to eliminate child poverty, automatic enrolment with a well-child provider and there is substantially more to come, including specifically in the healthcare area.

All of this adds up to a different approach to health.  We must address issues of inequality, and to do that we need to address issues that have traditionally fallen outside the scope of what is seen as healthcare.  We have to focus on early intervention as the way to make the biggest difference.  And we need to make sure that we create the conditions where people are able to make choices and not just be the passive recipients of health care but able to have more control over their own lives.

So using that idea of health as a base, affordable and accessible healthcare is vital to achieving greater equality and success for all New Zealanders. 

When we look at the New Zealand health system I believe we can say that there are a number of things to be grateful for.  When I lived in New York City working at the United Nations, I walked out the door of my apartment one morning to see a woman collapse on the crossing in front of me.  A number of us come to her aid, and an ambulance was called.   When the ambulance arrived, the first thing the driver did was reach into the woman's handbag to see if she had an insurance card.  I was shocked.  It was not that she would not be transported, but if she did not have a card she would not be going to the hospital I could see a few blocks down the road, she would be driven across Manhattan at rush hour to another hospital that accepted uninsured patients.

I will never support a healthcare system that creates that kind of inequality and I will never support the ethos of commercialisation of health care that underlies that.  I still believe the public health system is the best insurance policy that we can all have.  We do have a mixed model of health care in New Zealand.  I understand that and I accept that that is the situation which we find ourselves in.  But the heart of that model to me is the public health system.

So that is something that we can be grateful for.

Another thing that we can be grateful for about the New Zealand health system, is that if you get sick in New Zealand, you will, generally, get very very good treatment.  What I believe we need to do is be as good at keeping people healthy as we are at treating them when they get sick. 

To do this we need to ensure that sufficient priority is given to public health and accessible primary care.  For a future Labour government we will make be making sure that we keep our eye on keeping populations healthy.  I am sorry to say that I believe the government has taken its eye off the ball in this area by shifting its focus to scratching the itch of elective surgery and waiting lists.

Don't get me wrong -secondary health services are vitally important.  We must have high quality hospital level care that gives the public confidence.  But we must not just focus on the ambulance at the bottom of the cliff.

Recently, in Parliament, I raised with the Minister of Health the report of the Children's Social Health Monitor that shows that 5,000 extra children in the last three years have been admitted to hospital for avoidable conditions such as skin infections and respiratory illness.  Avoidable admissions are seen by many in the medical profession as a good proxy for whether people are getting the access to primary healthcare that they need.  Reducing avoidable admissions was a target of the last government for this reason. Sadly the current government removed that target, and it seems to me that attention has drifted away from meeting it, to the cost of the most vulnerable in our community.

A major public health issue that I believe we need to focus on is obesity.  The Adult Nutrition Survey released last week shows that rates of obesity are climbing.  A recent article in Lancet had New Zealand with the 9th worst rate of obesity in the world.   It is the root cause of a number of chronic conditions and is emerging as the number one public health issue for our future.   An increase in the number bariatric surgeries might be good for those who get it, but it is not a strategy for dealing with obesity.  That requires investment in public health programmes and in government action.  

This week in New York the focus of the United Nations will be on dealing with non-communicable diseases.  The World Economic Forum has estimated that the five leading NCDs, cardiovascular disease, chronic respiratory disease, cancer, diabetes and mental ill-health could total US $47 trillion in costs over the next twenty years. 36 million people globally are dying from NCDs each year.

When the World Economic Forum starts talking about the cost of these diseases we know that the message is getting through at an international level that it is only long term investment in public health that will make the differences we need.  And anyone who wants a warning sign about the importance of dealing with public health issues only needs to think about the measles outbreak and the issues around meningitis in the Far North.

In New Zealand to address these issues we have to re-assert the priority of basic public health measures.  We need an overarching strategy to address diabetes and the chronic conditions that follow from it.  We also know that a third of cancers are preventable, and we must educate and inform New Zealanders about that and adopt programmes that can make a difference there. 

We must also improve the progress that we make in implementing the primary healthcare strategy.

There is no doubt that primary healthcare is more affordable than it was a decade ago and Labour is proud of having brought that into being.  However, it is clear that the primary healthcare strategy is not being implemented in the way that it was initially envisaged.

We do need more work to ensure better coordination and cooperation within the sector.

We also have to address the issue of costs, particularly the issue of costs around access to after-hours care in my view.  Recently when I was in Rotorua a GP told me of a case where he was rung by a mother just after his surgery had closed for the day.  The first question the woman asked the doctor was how much it was to go to the After Hours Clinic.  On hearing of the fee, some $80, she said she could not afford that. Further questioning revealed the woman had a child with a high fever, headache and developing redness.  He told her to come and see him right away.  It was the beginning of meningitis and the girl received treatment, but it was highly likely the cost of after-hours care would have seen medical treatment delayed for that girl had it not been for the actions of the GP.

Labour will be making specific announcements about primary care in the near future, but I can tell you today that it will be a top priority for us.  As a country, we still only invest 1.3% of the health budget in primary care.  That is not good enough in my view. 

The way that primary care is delivered needs to be a major focus for any government.  We want to continue the development of genuine collaborative arrangements for the delivery of services, particularly looking at the role of the nursing workforce and community pharmacists, outreach teams and other innovative measures.  

On the subject of early intervention there is one other area of primary healthcare that I believe needs significant further attention - that of oral and dental health. The 2009 New Zealand Oral Health Survey shows that 44% of New Zealanders are not receiving any form of dental care.  Under the last Labour government significant progress was made in improving the oral health care of children, particularly for those up to Year 8 through the mobile School Dental Service.  But there are still major issues to be resolved in terms of accessible treatment.

The case for increased attention to oral health is strengthened by the increase in diabetes and obesity, both of which are linked to an increase in dental health problems.  Also the "baby boomer" generation is the first generation entering their older years with their own teeth, which will require interventions for a longer period.

As with other areas of health policy, prevention needs to be a major focus in oral health policy.   This is also a long term investment.  Addressing these issues is costly, but continuing to neglect oral health will have a much higher cost.

We must make sure that we have the workforce to deliver the health and healthcare I have discussed today.  That means a strategic approach not just to the medical workforce but also to the nursing and allied health professionals who make our health system tick over.   We need to train community health workers, we need more nurse practitioners and we also need to think again about how we ensure there are sufficient General Practitioners. 

Earlier this year I spoke to a group of medical students nearing the end of their degree.  For those who were interested in general practice the idea that they needed to become small business people was a significant turn-off.   The ageing general practice workforce is a warning sign that we need to think about different models of employment for GPs that give them the ability to work in an area that they are passionate about without turning themselves into something that they don't want to be.

A focus on addressing inequities and inequalities, early intervention, public health and affordable and accessible primary healthcare is I believe the only responsible way to approach health as a portfolio.  Anything else means sacrificing the long term well-being of New Zealanders for short term political measures.   The answers to getting to a better state include more resources.  They also include making the best of existing resources.  I have seen some terrific innovations in health and healthcare as I've travelled around New Zealand, but time and again when I see these, I am told that they are confined to the individual DHBs who've developed them.  We must be better at sharing good practice and new and innovative methods of delivering health services.

System change will be part of this.  To deliver on the kind of approach that I've talked about today, we do need a more collaborative approach both within the health system and across other parts of government.

I don't believe that there is any appetite in the health system for major structural change, to throw all of the cards up in the air one more time.  But we do need to look at the way the system operates to make sure that we harness innovation, that it is patient centred, and where possible we link together primary and secondary services to provide the kind of care that people will look for.

I finish on the notion that I do believe leadership is vital for all of these things.  There is some work being done by the Counties Manukau DHB where they talk about the three things that are needed to make change.  And those are:  will, ideas and execution.

The political will needs to come from politicians and from clinical leaders.  The ideas need to come from the sector and be understood by the politicians.  And the execution of those ideas comes down to all of this.  You in the room today, other people in the health sector and politicians such as myself.

We have much to be grateful for in the New Zealand health system.  But  what we can do is be better at making sure that all New Zealanders can achieve their potential and live healthy lives.  We can only do that by a cross-sectoral approach and one that focuses on early intervention and reducing inequalities.

Thank you.