An Open Letter to Tony Ryall, Minister of Health, New Zealand.

Dear Mr. Ryall,

It’s funny, everything here in New Zealand is so informal--up to and including patients and physicians calling each other by first names--that I almost feel like I should begin this letter with “Dear Tony”. After all, we met briefly at the rural general practitioners network conference in Christchurch in March and since then, I have been participating in New Zealand Locum’s “roving locum” program, so that would seem to almost count as the basis for informality in New Zealand. But I don’t feel comfortable with such a salutation. You have an important and honorable position and I would like to formally take a moment to give you some professional feedback and advice based on my 30 years in primary care and on my 3 months here in New Zealand.

Before we get started however, I must weigh in on the above photo. Maybe it “goes”, but I’m not sure all the stripes really work for you. Just a thought from a casual observer. But I don’t really want to go into sartorial issues with you, I think it’s healthcare that occupies us both.

From the very outset, I’d like to thank you and your fellow New Zealanders for affording me with the opportunity to participate in your care and become part of your communities, if only briefly. To say that the experience has been rewarding and reinvigorating would to be an understatement. I had the privilege of practicing in four different locations and I was uniformly impressed with the common sense, intelligence, industriousness, respectfulness, and dignity of the people I met.

In a broad sense, as part of your enormous political responsibility, you are tasked with caring for these people as well.

In recognition of that fact, I thought I’d share a few thoughts with you as to how I think you may better accomplish this lofty mission.

1. Continue to push for more primary care physicians and to generally support primary care, especially in rural settings. GP’s are the base of the health care delivery pyramid and if you look at almost any measure of health outcomes, countries that have a robust primary care network deliver better, more cost effective care. Your ROMPE program (rural origins of medical preference entry) is an innovative and proactive way to address the workforce needs of the country in the future. As is the Voluntary Bonding Scheme whereby students can benefit from debt relief if they practice in rural areas. And finally, your recognition that Integrated Family Health Centers may offer a means to provide more care for rural patients in the community setting is forward thinking. Anything you can do to further support and retain the hardworking GPs of New Zealand will benefit everyone.

2.Think about further modifications to or outright abolition of co-pays in the GP offices. To be frank, I’m not sure how you would do this financially, particularly given the philosophical approach that underpins the recently promulgated National Party budget. But here’s some food for thought: the preponderance of research shows that co-pays or upfront fees, particularly at the primary care portal of access, constitute an impediment to accessing care, especially for those who are most socially vulnerable. In three months, I witnessed several occasions when patients were actually turned away from a primary care practice for inability to pay upfront. Quite aside from the ethical quandary that this poses, it doesn’t make financial sense in the long run as patients are effectively shunted from cost-effective primary care to more expensive portals of entry such as the A&E department (ER).

3. ACC. Now this is a topic everyone loves the warm up to. I must say, that the ACC accident and compensation scheme is a brilliant way to fund and run a no-fault insurance program. It effectively almost eliminates litigation, and circumvents those who have a self-interest in fanning the flames of such. Unfortunately, because of the presence of user fees as discussed above, patients occasionally invoke an injury or accident to justify their physician visit. As with any type of insurance, the gray areas on the margins always seem to become a battleground. If New Zealand had a comprehensive bona fide single-payer system, like, for example, Canada’s, the need for differentiating an accident or injury from a medical problem would be obviated. Just a thought.

4.Procedure Wait Times. So as not to be repetitive I refer you to my recent blog post about this. (http://kwisecondopinion.blogspot.com). I just can’t help but think that a better approach to some of the unacceptable wait times in the public sector is to put more organizational effort, and yes, if necessary, money, into improving that sector of care. “Better, sooner, more convenient”, right? The tacit or surreptitious promotion of private insurance and private sector health care will ultimately prove divisive and uncontrollably problematic. You need look no further than the ongoing chaos in the USA for a harbinger of your future should you continue to promote this misguided approach.

5. Pharmaceutical policy. I would strongly encourage you to abolish direct-to- consumer advertising by the pharmaceutical industry--and for that matter, the health supplements industry as well, with their flagrantly unsubstantiated health claims. There is only one other country in the OECD that allows this sort of thing and again, I suspect that you would not like to be subject to the type or magnitude of political power and economic clout enjoyed by the pharmaceutical industry in the USA. Oh, and while I’m at it, please ask Pharmac to list drugs by their chemical, or generic names, rather than trade names in the published list of approved medicines. (Or has this been some sort of bargaining chip in the price negotiation process?)

I could go on, but those are pretty much the highlights of what I feel could be improved in the New Zealand health system at least from a primary care perspective.. Some of it, I know, it’s politically or economically untenable but that’s always what’s been said in the past about many reform proposals.

Probably most importantly of all, however, is that I simply wanted to ask you to be ever mindful of your responsibility to care for your fellow New Zealanders. Because even in the short time I was here, I was struck again and again by the fact that your fellow countrymen are indeed an extraordinary group of people. As the health minister for these people, you have a solemn obligation to care for them in the best possible way.

I wish you luck in this endeavor and I hope in some small way that this constructive feedback helps you attain that goal.

Best regards,

Ken Fabert, M.D.