Thank you for the invitation to open your conference today.  I hope you have a productive two days and I would like open by acknowledging that you provide a vital service which thousands of people depend on.

Opening your conference provides me, as Associate Minister of Health, with the chance to speak to you about the challenges and opportunities for the home support sector in the context of the Government's fiscal position and the work the Government is doing in the sector.

I would like to acknowledge the New Zealand Home Health Association executive, and its chair Trish Neal, and also the NZHAA CEC Julie Haggie.

How the Government will manage overall expenditure

All over the world governments are facing significant financial pressures in health and this will only increase. People are living longer and whatever our age, we all expect better services, modern technologies and new medicines.

To provide some context on the economic environment we're operating in, we are just emerging from the worst global financial crisis in 70 years. 

New Zealand used to have large Government surpluses but this week we borrowed $240 million and next week we will borrow another $240 million. We'll do the same every week after that for the next four years - just to keep public services like Health ticking over.  Due to economic constraints, new spending across Government across has decreased or been curtailed in some many areas.

This Government has taken the deliberate decision to take a long term view of our country's economic challenge, but we are not cutting back on health investment. We are putting in more funding.

Despite tough economic times, the Government is investing more of the country's resources in Health than ever before. The coming year will see the highest percentage of GDP invested in the public health service in our history. 

Last year Vote Health got half of all new government spending. In Budget 2010, an additional $2.1 billion was allocated to Vote Health for investment in health priorities over the next four years - including an extra $512 million of new spending in 2010/11. That means Vote Health has kept pace with inflation and population change and the Government will spend $13.5 billion on Health in 2010/11.

Health spending is now $1.4 billion a year more than when we came into government. The public health service will, however, need to ensure a strong and ongoing focus on value for money, with resources moving from administrative overhead and low priority spending into more important frontline services. And this applies equally to services whether they are being delivered in the hospital or the home.

An ageing population

The increasing demand for your services due to an ageing population is obviously one of the biggest issues your sector faces over the next 10 - 20 years. 

We will however have a window to prepare for the effects of population ageing on the health sector, as it is primarily people over 80 who use services intensely. 

At present 580,000 New Zealanders are aged 65 or older (13 percent of the population).  By 2030, this is projected to rise to over 1 million - an increase of over 85 percent. As you will all know older people have an increased likelihood of ill health and disability.  As the number of older people increases in absolute terms and as a proportion of the population, resources will need to shift to support the needs of this group.

When looking at the health needs of older people, there is a continued objective to improve community-based care services and the continuum of care for older people as part of a vision of high quality and sustainable services into the future. 

Better Sooner More Convenient

One of the Government's goals is to provide New Zealanders with better access to a wider range of services closer to home.  

A major driver of this is the Government's Better Sooner, More Convenient primary care initiative which is seeing Primary Health Organisations and District Health Boards work together to enhance care for their communities.

They are developing new ways of working across a broader range of services and include a focus on the frail elderly.

Improved primary care is likely to reduce some of the triggers for entry into acute hospital and/or residential care.  This is part of a prudent strategy to begin developing health system capacity for the future demographic and to reduce financial pressures on the health system.

Two issues I know you are interested in are pay rates for support workers and mandatory minimum standards for the industry. The New Zealand Home Health Association notes home support workers are a low-paid workforce and there are concerns around training and adequate compensation for travel costs.

In recent years there have been Government interventions to help improve the home support workforce. The Ministry of Health's home support prices, which have been geared towards improving support worker wages and conditions, have grown by about 30 percent in the past five years The Ministry is also investing around $4 million in 2010/11 - up from $2.2 million in 2009/10 - in workforce development initiatives.

Two of the key initiatives are:

• Training grants over three years for all disability support service workers who wish to study towards approved basic training national certificates and qualifications;
• A fund which aims to support training of disability support service workers and families and carers to better manage their own services and resources.

The NZHHA is also seeking a single mandated standard for the sector to protect clients from substandard care.

Although home support services do not fall under the legislative framework of the Health and Disability Services (Safety) Act 2001, the sector has developed a voluntary standard and compliance with the Standard is required in ACC and Ministry of Health contracts, and a number of DHB contracts.  Effectively it should mean the majority of providers are required to meet the Standard.

However, it is in everyone's interests to ensure people are getting a good level of care and support so the New Zealand Home Health Association, Standards New Zealand, ACC, and the Ministry of Health have established a joint initiative to undertake a review.  This recognises that over the past seven years there have been significant changes to models of service delivery and in the particular services being provided.

Home Support Expenditure

The care of elderly people, and specifically their level of home support, has received a lot of media coverage over the past few months. It's been reported that DHBs are cutting the level of home support for the elderly when it's important to note that across all DHBs the number of older people receiving DHB funded home support had continued to increase in recent years and overall DHBs are budgeting to spend more on home care in 2010/11 than in 2009/10.

DHB expenditure on home support services has grown from about $110 million in 2004/05 to about $230 million in 2009/10. 

This year, around 75,000 mostly older people have received home support. In 2004/05 there were approximately 58,000 older people receiving home support services.

Some DHBs are reviewing their home support services using a method that was introduced by the previous government.

The Health Minister has sought assurance from DHB chairs that people who really need domestic support get it and DHBs have been meeting with all providers and people involved to explain the review changes and what they would mean for elderly with exceptional circumstances. DHB chairs have given him that assurance.

We are committed to spending money on the people who have been assessed as having the greatest need.

New Model of funding disability support for younger people

The Ministry is also developing a new model for supporting disabled people who receive Ministry funded support.  There will be significant implications over time for providers and services.

Key characteristics of the new model - which are to be tested later this year include:

• improving access to information and personal assistance through introducing Local Area Coordination
• moving towards allocating indicative dollar values of support rather than allocating particular types of service
•  introducing Individualised Funding which gives more choice and control for people over the support they purchase through making funding available to most people and for most supports and making contracted supports and services more flexible and focused on outcomes
• broadening accountability arrangements from the present focus on providers to also cover the responsibilities of the Ministry of Health and disabled people and their families, and have a stronger focus, through quality monitoring, on whether people are living an everyday/good life.

 I am sure that you will have many robust conversations on the challenges and opportunities for the home support sector over the course of this conference.

There are a diverse range of speakers from across the industry covering many topical issues which will provide thought-provoking sessions over the next two days.

Thank you.

Posted by Jonathan in Speeches at 11:27

It is an honour to be here at the 8th Annual conference of the Australia and New Zealand Academy for Eating Disorders and the first such conference to be held here in New Zealand.  This move is timely, as much-needed progress has recently been made here to improve our eating disorders services in New Zealand.

I know you’re interested to hear about those changes, particularly on those here in Auckland. First though I think it’s important to remember what the environment for eating disorders in New Zealand has been like just to place into context the improvement made in a relatively short period.

In 2007, the Mental Health Commission undertook a stock take of mental health services, including eating disorders services. The Commission found that there were considerable problems with access to eating disorders services, evidenced by a lack of beds and long waiting lists. There were also next to no inpatient or residential care for people seriously ill with eating disorders in the Northern region.

As you all know eating disorders are complex and encompass a range of conditions that have overlapping psychiatric and medical symptoms. The impact on the individual and their family is immense.

Mortality rates for eating disorders are high and around 1.7 percent of New Zealanders suffer from the illness. Having to seek treatment overseas would only serve to compound the situation and it’s estimated more than 20 people have been sent to Sydney for treatment since 2007 due to the lack of facilities in New Zealand.

One of those people was an 18-year-old whose plight was reported in last Saturday’s Weekend Herald. Two years ago she was eating only half a grapefruit a day, had lost 10kg in two weeks and at the height of her illness she weighed only 33.7kg. She was referred to the local eating disorder service here in Auckland, but due to a three-month waitlist and the seriousness of her condition, she was sent to Sydney for treatment where she and her mother spent four and half months. Thankfully today she’s making progress and her weight has almost doubled.

But while we appreciate the support of our Australian colleagues and the quality of the services provided, the situation was less than ideal for her and other young Kiwis and their families in the same situation. People need the support of loved ones close to home when they are going through a deeply difficult time.

This is why, last month, the government was pleased to announce further progress for providing a new regional eating disorders service in the top half of the North Island.

Auckland DHB has contracted Challenge Trust to set up a residential treatment facility and day programme by the end of the year.  The new services have been funded from an extra $26 million over four years that this government announced last year to improve eating disorder services nationwide.

Starship hospital established five new dedicated beds for children under-15 years with eating disorders last year as part of this extra funding.  Challenge Trust’s new facility will eventually include up to nine residential beds available for older adolescents and adults and will provide a home-like environment for patients, where they can spend time with their families.

The Auckland Regional Eating Disorders Service, working with these services, will act as a hub for service provision for patients from the Northern and Midland regions.

While recent attention has been rightly directed toward developing in-patient and residential services here in Auckland, it is important to acknowledge that community-based services continue to provide the range of interventions that are essential to effective delivery of a continuum of care for eating disorders patients across the country.

Of the $26 million, around 80% has been allocated to improving services in the Northern and Midland regions as these were the regions with the least well developed services. The remainder of the funding is being spread across the country and is providing other regions with extra and invaluable resources.

In the Central region new funding has been allocated to provide improved access to paediatric in-patient services for children and young people.  The Central region has an existing six bed residential service and day programme in Johnsonville, near Wellington.
 
In the Southern region new funding has been allocated to provide additional community eating disorders clinicians in Nelson Marlborough, Canterbury and Otago Southland.  Canterbury DHB has an existing seven-bed eating disorders in-patient unit serving the southern region.                  
                                                           
The additional funding will result in people having greater access to care and support across the country which is a significant improvement for the sector.

The economic backdrop

To provide some more context to the situation, we are just emerging from the worst global financial crisis in 70 years.  New Zealand used to have large Government surpluses but this week we borrowed $240 million and next week we will borrow another $240 million. We'll do the same every week after that for the next four years – just to keep public services like Health ticking over.

Due to the economic constraints we continue to face, new spending across Government across has decreased or been curtailed in some many areas.

In areas that impact heavily on peoples’ lives however, the Government has provided funding increases and Health is the biggest single item of new operating spending in Budget 2010 – up $512 million to $13.5 billion in 2010/11.

Health spending is now $1.4 billion a year more than when we came into government. An additional $2.1 billion is being invested in health priorities over the next four years.

Of that District Health Boards will directly receive $1.4 billion extra over four years, and will also receive a large share of the extra funding going to targeted initiatives. Mental health funding increases by $40 million over the next four years and DHBs are expected to allocate $174 million from the new funding to mental health.

So while there will be a constant need to review where money is most effectively spent, and that will result in some reprioritisation across the sector, there is more money going into health than ever before. The problem here is that costs in health grow at a faster rate than our national income.

The hub and spoke model

So given the difficult economic situation, we have to make targeted and intelligent use of the resources we have – which is what the hub and spoke model can offer. 
This model also provides support closer to home for patients and their families.

In New Zealand, the hubs of care provision will be in Christchurch, Wellington and Auckland.  The most specialised care will be provided in these centres.

Through regular contact, strong relationships and smart use of technology, specialists will be able to support primary and secondary eating disorders services throughout New Zealand.

In Health, the aim is to facilitate clinical support by specialist clinicians in large regional centres (hubs) to clinicians in generic secondary services and, when appropriate, primary care in smaller provincial centres (spokes).

The ultimate aim must be to provide the best service and level of support for patients and their families in what is a very difficult time.

In 2007, the Mental Health Foundation found a lack of co-ordination between different mental health services for people with eating disorders – a finding echoed throughout the sector.  An integrated approach through the hub and spoke model will directly address this issue.

Integrated care

To work, the model needs effective formal and informal relationships between each hub and its associated spokes.  This includes regular structured supervision and training combined with ad hoc consultation and liaison support when it is needed.

Such an approach is most effective when an individual in the spoke service has a dedicated co-ordination role, often in conjunction with a local ‘virtual team’ (including in some cases primary care clinicians).  Team members often have a clinical interest and experience in the specialty.  Closer relationships between clinicians can build closer relationships between services and a better path for patients through the varying aspects of their care.

 Beyond hubs and spokes we know that within services across primary, secondary and tertiary care, multi-disciplinary teams are required to address the complexity of eating disorders treatment and associated co-morbid conditions.

This means that practitioners from medical, nursing, dietetics, psychology, psychiatry, psychotherapy and other disciplines all need to be skilled at working together.  I commend ANZAED’s open and multi-disciplinary approach, reflected in your conference programme.

Clinical leadership

It is also why clinical leadership is so important to this government.  In March last year, we issued a significant document called 'In Good Hands' to help district health boards introduce greater clinical leadership into the public health system.  Globally, clinical leadership is recognised as a fundamental driver of a better health service.  We had heard countless stories of clinicians feeling ignored and disengaged.

As clinicians, your involvement in the further development of eating disorders services is critical.  If the system is to focus on the patient we need to know what those providing care day in and day out have to say.

I am aware that at times managers and clinicians have not engaged collaboratively like we would hope.  It is also worth acknowledging that there are competing visions of how best to do things and that meeting the needs of different stakeholders is sometimes challenging.

What we need is robust debate, productive engagement and partnership between funders, managers and clinicians that focuses on both fiscal discipline and clinical best practice.  We also need a system that allows clinicians to be centrally involved in decisions about service configuration.

Eating disorders are complex.  We all know that there are often co-morbid disorders that are present alongside eating disorders.  We also know that the mortality rates for eating disorders are high.  Patients and families struggle through confusing and difficult times.

It would help if services were easy for them to navigate.  We have made progress to bring patient care closer to home and to provide better coverage and integration of services.  But things can always be better.  We need your ideas, and your input into how to make the path through treatment as smooth and effective as possible.

We also need the research evidence and clinical experience such as will be presented at this conference to inform our understanding of best practice as we deliver eating disorders services.  Patients deserve nothing less.   I hope you enjoy the next few days and have many thought-provoking conversations with your colleagues.

Thank you.

Posted by Jonathan in Speeches at 13:56