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CAN THE HEALTHCARE SYSTEM BE MENDED?

Felicity Goodyear-Smith

WE ARE A HEALTHY COUNTRY, and our average life expectancy has increased since the 1970s from 71 to 81 years, which means we can expect to live 10 years longer than we did in the 1970s. Largely this has been due to lifestyle choices — good diet, exercise and fewer people smoking, and hence a reduction in vascular diseases such as strokes and heart attacks.

However, not all New Zealanders get the same benefits. There is still a gender gap, with life expectancy for Kiwi women at over 83 years, and for men at 79½. Māori women live on average six years less than non-Māori, and the life expectancy for Māori men is 73 years, about seven years less than non-Māori. While the life expectancy gap between Māori and non-Māori has been shrinking over time, there remain many disparities in health generally. Māori face significant barriers to primary healthcare due to cost and lack of transport. They are more likely to be injured by, and die from, both accidents and intentional violence. They have twice the rate of diabetes and heart disease found in non-Māori, as well as higher rates of mental health issues and suicide, and they fare worse on many other health indicators, too. Tobacco use is a big issue among Māori, especially women, who are three times more likely to smoke than the average New Zealand adult.

Living longer is not the only thing to consider. People want to have healthy and happy lives, to be able to enjoy themselves and keep doing the things they like without pain or disability. We can expect around 20 years of life after retirement, and keeping our older population fit and healthy is good not just for their own quality of life, but also for reducing the burden of healthcare in our society.

In my lifetime I have seen us move from an egalitarian society in the 1950s to a country with increasing numbers of very wealthy people, and corresponding large numbers living below the poverty line. Those who are socially disadvantaged or from deprived backgrounds are more likely to smoke, use illicit drugs, take less exercise and have poorer nutrition. They have an increased chance of suffering from mental health issues, obesity, heart disease, diabetes, gout and dental problems. Although these conditions are more common in people from poorer backgrounds, their prevalence is increasing throughout our adult population. This rising wave of non-communicable disease leads to high levels of disability and demands on our health system. While we have made many health gains from lifestyle choices in the past, in some ways we are now going backwards. A main culprit is a change in eating habits, with the rise of fast-food and sugary-drink consumption. Not only adults, but also increasingly children, are suffering from obesity. The problem is compounded by increasing time spent screen-watching, with a corresponding reduction in physical activity.

This is alarming. The health consequences of obesity are huge. They include increased risk of heart disease and stroke, type 2 diabetes, arthritis, gall bladder disease, some cancers, and mental health issues. People who are seriously overweight may have a poor quality of life, difficulty with physical functioning and body pain. The complications of diabetes can be dire, including blindness, limb amputation due to nerve and blood vessel damage, and chronic kidney disease. When their kidneys fail, people require dialysis treatment or kidney transplants to stay alive. This can impact significantly on their quality of life, as well as being an increased cost for our health system to provide dialysis services throughout New Zealand.

We have certainly achieved many health gains through scientific advances over the past few decades. Advances in medicine continue to escalate. We can diagnose many conditions using a variety of laboratory tests. We have ever more ways of looking inside the body to see what is going wrong. X-rays will reveal our bones, and, by adding contrast material that is eaten, injected or applied as an enema, we can see details of soft organs such as breasts and the bowel. We can visualise our inner organs with ultrasound. CT scans produce three-dimensional images, and MRI uses a magnetic field and radio waves to produce detailed pictures of soft tissue, fat, muscles, bones and internal organs without the use of x-rays. There are scopes for looking inside all parts of the body: eyes, ears, nose, throat, bowel, lungs, heart, kidneys, bladder and joints. All of this technology not only enables diagnosis, but can also be used to help treat the condition. As well as a camera, instruments may be passed through a scope to conduct surgery, sometimes involving the use of robots, and hence avoiding the need for large incisions into the body. Many organs can now be replaced, including hearts, lungs, livers, pancreases and intestines, and artificial organs are also in use. Cochlear implants can provide profoundly deaf people with the sense of sound. Many people have their hips or knee joints replaced with prostheses, and artificial hearts, lungs and livers are not very far away.

There are also exciting developments in pharmaceuticals. Antibodies from non-human sources can have their protein sequences modified so that they are similar to various antibodies produced naturally in humans. These are usually monoclonal antibodies, meaning that they are made by identical immune cells that are all clones of a single cell. They can be created to target almost any specific cell type. This has opened the way to develop exclusive therapeutic agents for a range of cancers, and for autoimmune diseases such as arthritis and ulcerative colitis. Drugs are being researched to treat conditions such as hepatitis C, multiple sclerosis, and Parkinson’s and Alzheimer’s disease. Known as ‘umabs’, because they have names such as pembrolizumab and denosumab, these therapeutic monoclonal antibodies are exciting new drugs, but they come at a high cost. Some treatments may be several thousand dollars per injection, needing to be repeated every three weeks, possibly for years. While bioprocessing technology to produce these drugs has advanced dramatically, with a consequent reduction in cost, the fact that they require growing cells to produce the antibodies means that they are not cheap drugs to make.

We are fortunate in New Zealand to have our Pharmaceutical Management Agency, PHARMAC. This is an excellent initiative, introducing price competition between pharmaceutical companies to minimise the prices of drugs and get the best value for medicines purchased by public money. PHARMAC recognises that health resources will never enable the purchase of all available medicines and medical devices. Decisions on what to fund are based on balancing the health needs, benefits, costs and savings, and the suitability of an available product. PHARMAC assesses the evidence of clinical effectiveness and safety, cost-effectiveness, and competitive pricing from producers, and this has given us far more drugs for our dollar. In 2008, public pressure led to the government overriding PHARMAC and increasing funding for the breast cancer drug Herceptin from nine weeks to one year, despite evidence for the effectiveness of the increased regimen not being available. PHARMAC said that the nine-week course showed comparable benefits to longer courses and would cost $6 million compared to $25 million for one year of treatment. Clinical trials now indicate that, in general, patients taking nine weeks’ treatment do as well as those taking a year. Similarly, in 2016 the government succumbed to public lobbying to force PHARMAC to fund the monoclonal antibody drug Keytruda (pembrolizumab) to treat terminally ill melanoma patients, while results of clinical trials were still pending. This drug holds huge promise, and the decision was a welcome one for melanoma sufferers.

This is not, however, about whether these drugs should be funded by PHARMAC or not; rather, the concerning issue is the undermining of its independent decision-making. We need to avoid political interference in PHARMAC. Funding decisions should be informed by the best and most objective evidence available. People will always advocate for a drug that gives hope to them and their loved ones, but politicians should not bow to popular opinion for the sake of winning votes. PHARMAC should be left to make its own hard decisions. There is a finite budget, and whenever one health intervention is funded, another is not. There has always been rationing in healthcare — there has never been funding for everybody to be funded for everything. As the cost of diagnosis and treatment, of drugs and devices, escalates, the country needs to decide what we will fund and what we will not.

Primary healthcare, provided in the community by general practitioners (GPs), nurses and other healthcare practitioners, usually working in teams, is the most cost-effective way to deliver equitable and universal care for our population. General practices have a population as well as a personal health focus, using health-promotional and disease-prevention activities to keep people healthy, as well as providing first-line services for when they become unwell. Strengthening primary healthcare, and ensuring people can access it, will greatly improve the overall health of the population.

In New Zealand in the 1930s, a socialist government envisaged a tax-funded universal health system, free to all. But there was opposition, and we ended up with a system of free public hospitals and partly publicly funded, partly privately owned general practices, along with private hospitals for those with money or health insurance. We still have this dual system today, which can be an obstacle to healthcare and creates inequities. Eleven per cent of New Zealanders in quintile 1 (the least socially deprived group) indicate that the cost to see their GP is a barrier to healthcare access, but this increases to 20 per cent for those at greatest need (quintile 5). And, as stated above, Māori — and Pacific people — report greater difficulties in accessing primary care, with increased rates of hospitalisation and worse health outcomes compared to other groups.

We need to avoid political interference in PHARMAC. Funding decisions should be informed by the best and most objective evidence available.

The government tried to address this in 2006, but we have ended up with a highly flawed system. General practices can apply for considerable additional funding under the Very Low Cost Access (VLCA) scheme if at least half of their enrolled population are deemed ‘high need’ (Māori, Pacific, or New Zealand Deprivation Index quintile 5), and this means that all of their patients have greatly reduced fees. This is fundamentally inequitable. If more than 50 per cent of a practice’s patients are well-off, then patients attending this practice who live in poverty have to pay high fees to their GP. Conversely, well-heeled patients attending a VLCA practice reap the benefit of subsidies that they do not need. Another unintended consequence is that practices not meeting the criteria for VLCA payments struggle to compete with low-cost practices in their neighbourhood. The additional funding should follow an individual person’s need, not an arbitrary population-based formula.

Many people on low incomes cannot afford the out-of-pocket co-payment for visiting their GP, nor the part-charge for any medicines that the doctor might prescribe, but which they fail to pick up from the pharmacy. They may also choose to go to the emergency department at the hospital instead of the GP, because this service is free. This overloads the system, increasing waiting times, and is a costly option compared to community-based facilities. Emergency rooms provide acute care, but they cannot deliver the comprehensive services offered in a general practice.

There is also the Accident Compensation Corporation (ACC), which began in 1974. This is a ‘no fault’ programme which removes the right to sue for any injury and, in exchange, pays for the cost of rehabilitation and compensation for anyone who has an accident. All New Zealanders are covered, as well as visitors from overseas, regardless of the nature of their injury or the cause. The aim is to support the injured and return them to their work and other activities as fast as possible. However, this system leads to huge inequities. Two people may have the same disability, one as the result of an accident and the other sickness-related. For example, they both may have joint damage needing hip replacement, with the cause of one deemed work-related, and the other due to ‘wear and tear’. The latter is not entitled to the benefits afforded by ACC, which might include private orthopaedic surgery and a higher wage-replacement than that received on social welfare.

There is a strong argument to redress this injustice and have ACC cover disability regardless of its origin. Some say that this will be too expensive, but society gains when the rehabilitation needs of its citizens are addressed, regardless of the cause of their disability. Moreover, deciding whether a condition is injury-related or not can incur huge costs. ACC pays specialists to review cases and make these decisions. People whose ACC claims are rejected have the right to contest this through the courts. This is expensive both for claimants and for the taxpayer; moreover, there is evidence that this ACC dispute resolution process does not provide effective access to justice for many New Zealanders. Those disputing ACC’s decline of cover face barriers to accessing legal resources, medical experts to review their cases, and lawyers to represent them in court. Reviewing cases and providing reports is also a waste of medical specialist skills.

Another anomaly in our health system is dental treatment cover. Basic dental care is free for children up to age 18, although this does not include orthodontic treatments such as braces to straighten teeth. After that, people fund their own dental care, unless they need treatment following an injury, when ACC will pay. As a consequence, only half the population visit dentists for routine checks; the other half attend only when they have problems, hence they do not have the advantage of early detection and treatment for tooth and gum disease. There is some limited government assistance for dentistry — mainly emergency extractions — for people with disabilities or on a low income.

Our health system is complicated and fragmented. There has been a series of reforms since the 1980s, but the dual system remains: that is, predominantly tax-funded, with user charges for many primary care services. We now have 20 district health boards (DHBs) funded by the Ministry of Health to provide hospital services in their region. DHBs also distribute funding to 31 primary health organisations (PHOs) for general practices to provide population-based services for their enrolled populations. Unfortunately DHBs and PHOs are not geographically aligned. There may be several PHOs within a DHB region, with neighbouring practices belonging to different ones, and some large PHOs straddle several DHBs. This adds a further level of complexity to the system. A diverse range of community-based health and disability services is also provided by non-governmental organisations (NGOs), which receive government funding. These vary from setting to setting, but may include youth, mental health, drug and alcohol counselling, parenting, disability support, and kaupapa Māori services.

DHBs are both funders and providers, and may be split into two separate arms, which means services within the DHB have to compete for funding (although in some, such as Hawke’s Bay and Canterbury, these functions have been integrated). Our DHBs are currently struggling, with many running financial deficits. Their expenditure growth tends towards more hospital spending, with an increase in numbers of hospital doctors rather than GPs, despite the health policy of investing in primary care to keep people well and reduce demand for hospital care. Funding will never be sufficient to provide every possible service and intervention to all, and demand will outstrip supply. People with chronic diseases are living longer, often maintained with expensive treatments. As new technologies and medications become available, there is an increased public expectation of what healthcare can and should provide. There is a need for rationing, unpalatable although this may seem to many people, who may challenge decisions to limit what is available on financial grounds.

The situation is exacerbated by the baby boomers, who are now reaching retirement age, with many suffering from chronic conditions such as diabetes. An ageing population increases the demand for health and social services and aged care, compounded by the fact that there is a smaller number in the working generation available to look after them and generate the income and tax revenue needed to fund care. The baby-boomer effect also affects our health workforce, who are similarly ageing. At the time of writing, 44 per cent of our GPs plan to retire in the next 10 years, and medical specialists and nurses have similarly imminent retirement plans. This is being at least partly addressed, and we will soon be producing nearly 600 new doctors a year. That said, the issue is not so much needing more doctors, but what they end up doing and where they do it. The aim is for 50 per cent of all graduates to choose general practice as their career, and the two medical schools along with the Royal New Zealand College of General Practitioners (RNZCGP) are working hard to achieve this. However, another inequity in our health system is the urban/rural divide. There is often an excess of GPs in the affluent suburbs, with grave shortages in the provinces. Many rural communities struggle to attract GPs, and their practices may be served by doctors from overseas doing temporary locum placements.

To address this maldistribution of the rural workforce, the University of Auckland, University of Otago and the RNZCGP, along with other institutions, are proposing a national School of Rural Health. Immersion in rural communities during training means more will choose to return there once qualified. A School of Rural Health would provide coordinated training for medical students through to registrars, and for nurses and other health professionals, using an interprofessional education model. Educational premises, academic and administrative staff and students would all be located in our rural townships, with investment in local infrastructure and resources. This will create jobs rurally, as well as assisting in rural workforce development. It will require new government investment, and whether it will eventuate remains unknown.

Another challenge we face is the rise of the superbug. For several decades, through the use of antibiotics and vaccines, we have enjoyed relative protection from epidemics of the infectious diseases that have decimated populations throughout history. But we have been squandering our antibiotic resource through unnecessary use, both in humans and in animals (through farming and veterinary care). This has led to bacteria developing resistance to the antibiotics used against them, and sometimes to more than one drug; hence we have bred superbugs. There are few new antibiotics on the horizon, and we are beginning to face a rise in untreatable infections. Operations that are currently safe and routine, such as hip replacement, may become life-threatening again.

Anti-vaccination propaganda has contributed to lower vaccination rates, and we are starting to see epidemics of measles, mumps and whooping cough re-emerge.

Adding to this is the anti-vaccine lobby. Since immunisation was introduced in New Zealand, there has been a dramatic decline in the death rate for infections such as diphtheria, tetanus, whooping cough and polio. The latter was eliminated for New Zealand shortly after the polio vaccine arrived in 1956. Vaccines are one of the safest and most effective public health interventions ever invented. Because of this, however, parents no longer see the devastating effects of these diseases, and some come to believe that vaccines are not necessary and may even be harmful to their children. Many vaccines work on the principle of herd immunity — a high percentage of the population needs to be vaccinated to prevent the microbe from circulating. Anti-vaccination propaganda has contributed to lower vaccination rates, and we are starting to see epidemics of measles, mumps and whooping cough re-emerge. In the era of the superbugs, we need vaccines more than ever.

The New Zealand health system is certainly at a crossroads, challenged by a rise in the cost of potential healthcare, while facing an increasing demand and expectation for services, especially from our growing older population. We also face unknown challenges to our health from the impact of environmental change and extreme weather events due to human activity. Merely increasing the health budget will not solve the problem. It is time to take stock and make some changes. Some are simple to do, but others will require some radical alterations to existing structures.

We are a small country and our complex, fragmented system could be significantly simplified, reducing repetition of costs and services and removing layers of bureaucracy. ACC should fund rehabilitation for all New Zealanders incapacitated from either accident or illness. The DHB funder/provider split needs to be addressed. We could significantly reduce the number of DHBs down to six or fewer, with the same number of PHOs mapped to DHB boundaries. This would result in administrative cost-efficiency and would support collaborative approaches in the sector. DHBs inevitably direct their attention to hospitals. More resources need to be focused at primary health to improve access to care, address inequalities, reduce hospitalisations and concentrate on prevention. We need to abolish the VLCA scheme and subsidise patients, not practices, so that the funding goes to those who need it, based on factors such as ethnicity, age, gender, income, health status and possession of a community health card.

We need to collect data and synthesise it to inform policy. We need information on how much the various services are used and by whom, and measures of how effective primary care is in reducing secondary service use. Many PHOs have introduced innovative pilots and programmes. These need to be monitored and evaluated to see how well they perform, for example in improving access and reducing disparities, and whether they can be scaled up.

New Zealand was an early adopter of health information technology. We were world-leading in the 1980s, with GP uptake of electronic health records, nationwide health registers and our unique National Health Index enabling linkage of data. However, our IT landscape is complex and diverse, and lacks universal systems that can easily communicate with each other. We need to reduce the fragmentation and duplication by adopting a single virtual electronic health record to enable integration across hospital, primary and community care settings, extending into patient portals to enable people to engage in their own healthcare. This would also facilitate health data being incorporated into our New Zealand Stats Integrated Data Infrastructure, a powerful tool that can provide answers to complex research, policy and evaluation questions to improve people’s lives.

We also need to support people in managing their own healthcare. Part of health prevention is assisting people to address risky behaviours, maintain healthy diets and ensure that they exercise. Technology opens many doors in this regard. We have growing use of secure patient portals provided by general practices through which patients can access their clinical notes, book appointments, request repeat prescriptions, review their test results and receive recalls, as well as have virtual consultations with their GP or nurse through secure messaging. The internet now gives people access to health education ranging from health-promotional activities to information on specific conditions, participation in support groups, and a raft of interventions, such as e-therapy teaching cognitive behavioural therapy skills to address depression. A caveat here is that there is considerable unreliable and poor-quality information available on the world wide web, with potential for harm. The web can never replace the function of a trusted health provider who can help people navigate the web, critically appraise the accessed material, and address inaccurate, misleading and potentially dangerous information.

There is also the expanding Internet of Things. In the medical context, this enables medical devices and sensors to connect with people’s phones or with their medical practice. There are many possibilities here, ranging from tracking people’s activity and monitoring blood pressure, continuous glucose levels, heart rate or clotting time (to inform adjustment of anti-coagulation therapy) through to complex emergency response systems. Connected implantable, wearable and in-home medical devices enable the sensing, storing and tracking of biometric measurements over time, and this data can be reviewed by the individual, and also shared with their families, carers and health providers. Doctors can monitor and manage the healthcare of patients remotely, reducing the need for clinic visits for check-ups, and supporting the elderly to remain in their own homes. The Internet of Medical Things is an area of rapid expansion, and can be expected to reduce health costs and improve people’s quality of life in many ways.

Telemedicine via the internet can help reduce disparities in rural regions; patients can connect remotely with their doctors, and perhaps attend nurse-led clinics without physical access to a GP. This could extend to telesurgery, enabling a surgeon to operate on a patient in a geographically remote location using a robotic teleoperator system via the internet. Treatments will become much more precise and personalised, tailored to an individual’s predicted response or risk of disease, particularly on the basis of their genetic profile. The uptake of tools such as smart phones and other smart devices will help.

Medical research has dramatically progressed our ability to provide effective and efficient care over the past few decades. However, one unintended consequence is the development of evidence-based guidelines for preventing and treating single diseases. As people develop new conditions, more drugs may be added. This has led to a situation where, for example, people may be prescribed drugs to decrease their blood pressure, lower their cholesterol, thin their blood, treat their diabetes, reduce stomach acid, prevent gout, manage their arthritis and improve their mood. Moreover, the clinical trials on which the current evidence is based largely excluded elderly people, and older people may not get the same benefits as the younger people evaluated in the studies. These cocktails of drugs have a range of possible adverse effects, as well as the potential for many interactions. Elderly people may end up taking 15 or more medications, some of them several times a day. They may be prescribed more pills to treat side-effects. Many of these drugs may no longer be needed, but reducing or discontinuing medications occurs far too rarely. New Zealand needs a robust campaign to encourage and support doctors to de-prescribe safely, and to educate older patients that this is in their best interest. Reducing polypharmacy may have many positive health outcomes, such as reducing falls and improving cognition, and may lead to an overall better quality of life, as well as saving many millions of dollars in unnecessary drug costs. And, as mentioned earlier, PHARMAC’s independence must be respected, with no government interference undermining its decisions in response to public advocacy.

Providing optimal healthcare for New Zealanders going forward will be challenging. There must be a focus on keeping people healthy, as well as looking after them when they become unwell. This includes mental and social well-being, building resilience, and supporting people to live happy and meaningful lives, and thus preventing suicide. We need to address the secondary/primary, affluent/poor, and urban/rural divides, and improve communication and collaboration between medical and all other healthcare practitioners.

The Māori wellness paradigm Te Whare Tapa Whā, with its holistic approach to physical, mental, spiritual and family health, is a model for all New Zealanders, as is the principle of whānau ora, with health, education and social services integrated around people and their families. The best outcomes will be achieved when doctors, nurses, other health and social care providers, patients and their families are all members of the team. Our team may also include virtual assistants. We need to further embrace technology, and to welcome smart phones and smart systems as tools to assist us. We have reached a turning point, and we require wise and brave people in authority to choose the right direction of travel towards an affordable and high-quality New Zealand healthcare system.