On The Nation: Health Debate

Headlines:

Neither National Health Spokesman Jonathan Coleman nor Labour’s Health Spokesman David Clark will commit to a specific target for reducing suicide, although both say they are open to it and will have further discussions on it if they are elected.

Despite record suicide figures, Dr Coleman refuses to describe the situation as a crisis, saying instead calling it a challenge.

Dr Coleman insists funding for health is increasing per capita, but won’t say whether demographic factors such as an ageing population are accounted for.

Patrick Gower: Well, health is one of any government’s’ big-budget items. Billions a year are spent on hospitals and subsidising drugs and GP visits, but Labour says the National government has been underfunding the system and it can’t deliver the way it should. Meanwhile, mental health has pushed its way - thrust its way - to the top of health policy platforms of both major parties, as demand for services skyrockets. I’m joined now in the studio this morning by National’s Health Spokesman, Jonathan Coleman, and Labour’s Health Spokesman, David Clark. Good morning to you both.
David Clark: Morning, Patrick.
Jonathan Coleman: Morning, Patrick.
I do want to start today with mental health and, in particular, suicide. News this week, Jonathan Coleman, that 606 people have died from suicide in the last year – a record; a shameful record; a sad record. Is it a crisis?
Coleman: Well, look, that’s a figure we all collectively have to do something about, and that’s why we’ve increased mental health funding by $300 million, why there’s $100 million in the last Budget – latest Budget – for new ways of doing things. Look, this is a challenge internationally, but it’s a challenge for the whole of society. It’s not something the government by itself can answer; it’s got to be answered by families, by sports clubs, people in workplaces. It is something we’ve all got to attack together, because we’ve got to get that number down – no question.
Sure, but the question was – is it a crisis? Is it a crisis now?
Coleman: Look, one death is one too many. You can call it what you like; 600 deaths is way too many, and we want to get that down, and that’s what I’m totally committed to as Health Minister.
So it seems that you’re calling it a challenge rather than a crisis, because that’s the word you used.
Coleman: Doesn’t matter what you call it; death is a tragedy. I feel totally for those families. There could be nothing worse than losing a child or a loved one to suicide. We’ve got to do absolutely all in our power to prevent that, and that’s what I’m absolutely committed to doing.
Okay. David Clark, is it a crisis? Are you happy to put that word on it?
Clark: It is absolutely a crisis. We have the worst teen suicide rate in the world – in the Western world – and that is just completely unacceptable. Jonathan’s right; one death is one death too many, but what I’m afraid of is that things are going to get worse before they get better. There is no plan in place that marks out a way to get around where we are now. We need the whole of society in the debate, yes, for sure, but there are things we can be getting on with now, and the initiatives the government’s rolled out are tinkering on the sidelines. The amount they put into the Budget is less than one-tenth of 1%. They’re refusing to review it, and when people bring evidence to them, they call it left-wing, anti-government activists. They’re out of touch. This is an issue that matters to New Zealand. Every New Zealander I speak to up and down the country is telling me they know someone in their family or their circle of friends who’s affected by a mental health issue, and the government’s not been taking it seriously. We won’t take nine years to take mental health seriously.
Okay. So what will you do then? What will you do when you actually get in there? What will Labour actually do about it that’s different to what the government’s doing?
Clark: Absolutely. So, straight away, we’ve said we’ll put a nurse in every single secondary school in the country, and that is going to make sure that we make a difference. It’s been done in decile 1 and 2 schools, but mental health isn’t just in decile 1 and 2 schools. We want to roll it out to every school in the country. We’ve looked at what the University of Auckland’s evidence says about the programme that’s in place now, and we’ll roll out the successful one to every school.
Okay. So, that’s fine, but will you commit to a target? And I’m going to bring this question to you as well. Will you commit to an actual target of reducing suicide?
Clark: In government, we will. We will work with the sector to find a target that is achievable. Government does have a role to play here. Sure, the community does—
Will you commit now? Will you commit to a target?
Clark: Today I will not commit to it, because it’s got to be done with the sector in consultation.
Because the sector wants 20% in 10 years. That would be saving around about 120 lives. Will you commit to something like that?
Clark: Well, I think that that’s a sensible target, personally, but I want to have the conversation with the sector before we set it.
Is it a sensible target, Jonathan Coleman? 20% over 10 years, 120 lives a year, and we’re talking here about brothers, sisters, uncles, family members, friends.
Coleman: I think we do have to be aspirational about it. I’ve moved my thinking on a target. I think that sounds like a reasonable target, but what I have said is that after the election, if we’re re-elected, we will look at this issue again. But that doesn’t sound an unreasonable target. We’ve got to do better on this.
So neither of you are actually committing to a target here, though.
Coleman: Well, what I have said previously is that we have now shifted our thinking and that after an election, if we’re re-elected, we will look at that target again. Look, I’ve met with international experts. What they’ve said to me is even having an aspirational target, it makes a difference around the culture of the workforce. I don’t think there’s any harm in having a target. We’ve got to do better on this.
It sounds to me—
Clark: The challenge is the Treasury says that the Ministry of Health doesn’t understand the sector and it doesn’t know what an effective intervention looks like. We’ve actually got to get in there and get cooperation with the sector, set a target and put our money where our mouth is and get on with it. We need to review the sector – short, sharp review; doesn’t need to take a lifetime – we need to fund it properly, and then we need to make sure that we get on with education and give it independent oversight as well – a mental health commissioner, like we used to have, who holds governments to account of both stripes, because the situation we’re in is not one we should have as a country, and we should be ashamed of where we are now.
Okay. I’m just going to come back to you, Jonathan Coleman, because it sounds like you are committing to setting a target at around about this sort of 20% reduction over 10 years – 120 lives a year – but you’ll do it after the election. You’re basically committing today to setting a target but after the election.
Coleman: So, I’m not committing to an exact figure today. What I’ve said is that sounds reasonable. I dispute what David Clark says. Look, actually, the ministry has a very clear—
Yeah, but just on your change of thinking, you’ll commit to a target after the election and it’ll be around about 20%?
Coleman: I’ve said I’m o—No, I haven’t said the exact number. What I’ve said is I think, actually, a target now would be a good idea. It has to be aspirational and has to galvanise the workforce and the sector, but I’ve said all along that is now something we’ll look at after the election.
Clark: Over the past decade, there has been a 60% increase in the number of people accessing mental health services, and funding’s gone up by less than half of that. It’s taken the government nine years to even realise there’s an issue here. We need some urgency around it.
Coleman: Well, that’s not correct. Funding’s gone up by $300 million. 150 extra psychiatrists. 600 more mental health nurses. That’s a fact.
Clark: There are more people working, but it’s not keeping up with demand. That is the fundamental point.
Coleman: It is, actually.
Clark: If you put one or two extra nurses in, that’s a good thing, but you actually need to put more in than that because we’ve got to keep up with demand. This is a serious crisis for New Zealand, and we need to take it seriously; we need to get on with making solutions. And one of the other things we’re going to do, Paddy, is we’re going to start with 400,000 of the most vulnerable people and make sure they have a mental health coordinator in their GP practice. When you visit that GP, the consultation will be free, and then there’ll be a mental health coordinator who can refer on or who can talk with you, who can follow up, check how your meds are going, whether you’re having any adverse side effects. This is something the PHOs have recommended. Those at the coal faces know what the solutions are. And we just need to get on and implement them.
Coleman: Can I just make the point – all these promises are being made on the fly. So they’ve said they will put in $856 million to health next year. There’s $550 million of hospital pressures. There’s $300 million for their general practice plan. They have promised $30 billion of new things right across the board, you know, right across not just health.
Clark: I’m happy to discuss funding, Paddy. Happy to discuss funding and be completely transparent.
And we will come back– We’re going to spend a lot of time talking about funding later in the debate, but right now we’re on mental health. And here we go. We’re going to talk about the numbers, but we can also talk about why isn’t the funding ring-fenced at the moment? We’ve got a big problem here. Why isn’t the funding ring-fenced at the moment?
Coleman: No, we do have ring fence. That’s totally incorrect. 7% of DHB baselines, no question about that.
Yeah, but why don’t you ring-fence more of it? Why don’t you bring it back to what it was?
Coleman: It’s always been ring-fenced.
Clark: Yeah, and the issue with the ring-fencing is the government hasn’t funded to the ring fence. And we know in Canterbury, for example, they spend $43 million a year more than they’ve been funded for. They’re funded below the national average despite what’s gone on with the Canterbury earthquakes. Kids are waiting forever to see someone when they need help, even the mild to moderate end. 45% of kids under 12 are waiting more than three weeks to see somebody. In Nelson Marlborough, there are people who are waiting two weeks – who are suicidal – for a psychological assessment. That’s not okay.
Coleman: Yeah, I dispute all those statistics. We put an extra $106 million into Canterbury to support health in Canterbury after the earthquakes.
Clark: They’re your statistics, minister. Please. They are your statistics from your own Ministry of Health website. And when they say clearly that children are not getting the care that they need, I don’t think they’re making it up unless you’ve got an issue.
Let’s agree here that we’ve got problems in mental health, because we can agree on that. But what is the cause? What do you think, David Clark, has been the cause of the increase in demand in mental health services?
Clark: Well, look, I think part of it is growing inequalities in our society. The OECD came out with a report in 2014 that said we have inequalities growing in New Zealand faster than any other Western country. We’re not the most unequal yet, but we’re on the path there. We’ve got people who are under financial stress. We’ve got a cultural issue that’s broader as well. And I think a good, crisp review will shed more light on that too.
Jonathan Coleman, it’s not just David Clark saying this. People we’ve spoken to have talked about the stresses of homelessness, the pressures of poverty. All of these kinds of issues of inequality are helping lead to this mental health problem. Do you agree that that’s what caused it?
Coleman: Well, actually look, inequality is lessening, not growing, but we live in a very complex society. Right, so, increased social media creates a lot of pressure on people, social isolation, changes to family structures – this is what is being seen internationally. This rise in demand from 96,000–
Clark: Can I just leap in there, because I agree with what Jonathan’s saying there, but one of the issues is–
Coleman: Can we speak one at a time, though, seriously? Patrick, we do need to be able to speak–
Well, finish it off, then. Let him hear what the cause is, if it’s not poverty, if it’s not homelessness, if it’s not inequality.
Coleman: At the same time, which is a good thing, more people feel that they can seek help. So the excellent work Sir John Kirwan has done around destigmatisation means, actually, it’s okay to seek help. That is a good thing, but it’s caused an increase in demand for services. So that’s why we’ve produced this $100 million package, which is doing things in a new way – an innovative approach to increase access in communities, to strengthen mental health services in schools and also, very importantly, electronic and distance counselling. That’s an evidence-based approach.
It sounds like by saying that, you know, John Kirwan is responsible for this upsurge in–
Coleman: I’m not saying that; I’m just talking about a range of factors in society.
Yeah, but if you look at that, it sounds like you’re saying there’s not an increase in need; there’s just an increase in awareness. Is that your argument?
Coleman: No, it’s a number of factors – increase in need, increase in awareness, the changing social dynamics. It’s all contributed to an uptick in demand. And that’s what we’re seeing internationally. And that’s why we have this new approach – social investment, early investment, looking at building childhood resilience. Look, 50% of mental health problems are apparent before the age of 14. I’ve seen this as a doctor. It’s very important, actually, to give people the skills to cope–
As a doctor, there’s caseloads of 110 high-need patients put on some doctors. Is that too high? And I want your medical opinion on this, not just–
Coleman: Well, Patrick, it’s just not clear what you’re talking about. You’d have to define what you mean by 110 caseloads.
110 high-risk, high-need patients for psychiatrists.
Coleman: What you’re saying just doesn’t make sense. Honestly, I think you better clarify exactly what you’re saying because I just cannot answer that question because there’s no definition around what you’re saying.
There’s no definition around what a high-need–?
Coleman: Well, what do you mean 110 high-risk patients are being seen by psychiatrists? I mean, do you mean that one psychiatrist is seeing 110 a day? That’s just not happening.
Not a day. On their caseload.
Clark: There are a lot of people waiting for services, and I think that goes to the point.
Coleman: Well, it’s not quite clear what you’re saying. Look, waiting times have decreased, access has increased, the money has increased, and we’re doing things differently. But, of course, like everything in health, we’ve got more to do.
Right. Now we need to get to a break. We’ll come back.
Clark: Wait patiently. I just want to say, Paddy, we’re not keeping up with demand. That is the issue.
All right. Well, stay with us, because there will be more from David Clark, as you can see, and Jonathan Coleman will have a lot more to say after the break.

Well, welcome back to our health debate with National’s Jonathan Coleman and David Clark from Labour. I want to come to you again, Jonathan Coleman, because you are overseeing at the moment a health system that is attracting negative headlines on a daily basis – DHBs with money worries. Now, the question for you is are they out of money, or are they simply not doing a good job managing what they’ve got?
Coleman: Look, their deficits are less than a fraction of 1% of their total budget. They’re producing the results – 50,000 more operations, 150,000 more appointments, and 6900 more doctors and nurses in the system. On top of that, we’re going to be funding $18 GP visits. And I can tell you this is a well-costed plan which is affordable. It’s not like Labour’s made-up $30 billion of promises right across all areas of all portfolios, which they’re going to have to put a capital gains tax, a land tax, a water tax, a higher-income tax in place to fund.
Okay. All right, all right, all right. It’s a health debate, remember. But I just want to summarise your answer there. I asked you are DHBs doing a good job or whether they don’t have enough money. You’ve basically said everything’s— So in summary, you’ve said everything’s fine. What’s your take on that?
Clark: We have committed to putting an extra $8 billion in more than National over the first four years. And we’ve funded that. We’ve got a fully transparent fiscal plan, and Jonathan knows that. He’s making mischief there. It’s absolutely all lined up. We’ve said clearly that we’re not backing the tax cuts, that tax package skewed towards the wealthy. That gives us $2 billion. On top of that, we’ve done a families package, under which 70% of families—
I think we’re all forgetting it’s a health debate here. And I’ll come back to you—
Clark: No, the point I want to make, and it’s important, is that it is all costed, and we’re putting an extra $8 billion in, and we want to get value out of that, because right now the system is under-funded. On the mental health wards, police are being called in. That’s not how it used to be. And the Minister needs to commit, next election— if he’s still there after this election as Minister – to commit to fully funding for cost pressures in his first budget $554 million, according to the Ministry of Health formula. Will he commit to that? We will. We will fund Health as it needs to be funded.
Yeah. What about this question, then – I mean, more money’s great, okay. That’s one solution. But what’s one other thing that you would do as Health Minister that would actually change the way the system’s working that doesn’t involve more money?
Clark: Good question. Good question, Paddy. Well, that doesn’t involve more money – most of these things do. You put money upfront. But one thing that doesn’t cost money – we’ve already said we’re going to give everybody a $10 discount on their GP fee. But we’ve also said we’ll review—
That costs money. That costs $300 million.
Clark: Importantly, we’ve said we want to review the way that service is delivered. And that is the thing that the Minister has shied away from. The sector has asked for it, and it makes a real difference. There are people who cannot afford to go to their GP. Half a million Kiwis, according to the Minister’s figures, last year could not afford to go to their GP.
So you couldn’t come up with one thing to help the system that doesn’t cost money.
Clark: I did. A review. That has been asked for—
A review. A review.
Clark: That has been asked for by the sector, because they think it could work better.
Okay. Jonathan Coleman, can you come up with one thing that doesn’t cost money that will help the health sector?
Coleman: Well, look, everything costs money, and that’s why we’ve put an extra $5 billion into it.
That’s not true. Good ideas don’t cost money.
Coleman: Well, we’re going to be implementing that strategy which we rolled out 18 months ago. It’s all about getting people to the doctor earlier, care in the community. That’s why we’ve got fully costed $18 GP fees. 2.5 million New Zealanders will be getting either free or very cheap GP fees. And the problem with Labour’s plan is, you know, he is promising everything—
Clark: $10 cheaper for every New Zealander, Jonathan.
Coleman: And that’s going to cost $300 million.
Clark: And that’s because right now our ED departments are full. People are getting treated in corridors,…
Coleman: No, that’s not true.
Clark: …because the primary care system is not keeping up with demand. We’ve also promised to fund extra doctors so we can keep that demand out of the emergency departments.
Coleman: And how much will that cost you?
Clark: It’s about doing sensible things. $30 million over three years. And that’s what Tim Malloy has asked for at the Royal College of GPs. You know that that demand is there. We know that Patea can’t get a doctor for love nor money. All round New Zealand, rural communities are missing out. There are under-served communities in Auckland. We can do so much better for our people, and health should be a priority – affordable healthcare, quality for all New Zealanders.
All right. I’m going to bring Jonathan Coleman in here again, because let’s talk about funding, because you’ve said a couple of times here this morning that you’re actually putting more money in the health system year on year.
Coleman: Yeah, $5 billion.
Yeah. Okay. But what you’re not taking into account when you do those sums is demographics, like an ageing population. Older people need more health spending. You can see that if you go to the doctor yourself how many old people are in there, and you’re not keeping up with that.
Coleman: No, that’s not true. If you look back over the last nine years, we’ve fully funded inflation and population growth.
Clark: But not demographics.
Not demographics.
Coleman: Treasury can show you the facts. An extra $5 billion. We focused on results. 50,000 more operations. 150,000 more appointments. Hundreds of services across the—
Clark: Well, tell that to Doug Pike. There was a guy, Doug Pike, who needed knee surgery, said it was so painful he wanted to chainsaw off his leg. He waited eight years, sold his house to get that surgery and only received news three days after he’d sold his house that finally his public surgery had come through. I mean, what does the Health Minister say to Doug?
Coleman: Well, look, I don’t know Doug personally, but we’ve increased electives by 50,000 a year.
Clark: There’s a guy in my electorate, Dave Laing, who’s been turned away three times by the hospital. He needs knee surgery. He needs a walker to get round. He’s on pain relief. What do you say to that guy? This is happening. We asked Infometrics to independently analyse the Treasury data and see how much more money would have needed to go in since 2009 to deliver the same level of care for New Zealanders, and they estimated $2.3 billion. Now, that’s not small. That’s why you have to be more disabled now to get eye surgery – people are going blind – or knee surgery or get into a mental health facility.
Let’s pick up on that – elective surgery –which you mentioned before, which you say you’re doing well on.
Coleman: Look, there’s always more to do, but we’ve dramatically increased it.
And, you know, it may be that he becomes Health Minister. How easy is it to lie to the public with these statistics? Because when we look at your elective surgery statistics, they show that a number of elective surgeries – in fact, 60% of them – were actually eye injections that could be performed by nurses, which most Kiwis, to be frank, would not view as elective surgery.
Coleman: Patrick, that’s completely incorrect. So, 50,000 more operations per year. 20,000 of those are very important eye procedures, eye injections, and, actually, skin excisions as well for things like malignant melanoma – some of them done under general anaesthetic. So if you took out every important operation, you’d get down to zero. Even if you decided to take out skin and eye, you’ve still got 30,000 more operations.
Clark: Patrick, if you took skin and eye out of the big DHBs, like Waikato, like Auckland, like Bay of Plenty, they’re actually now performing fewer surgeries than they were the year before. Once you take out those things that used to be done mostly in primary care, they’re doing fewer surgeries despite a growing population.
Do you think it’s a rort putting these eye sur—?
Clark: I absolutely think it’s a rort.
So if you become health minister, would you take that out on day one?
Clark: I think we need transparency around that stuff. We need the transparency because New Zealanders are not getting the healthcare they used to get. They have to be more disabled before they get health services.
Coleman: They’re getting more access to healthcare all the time. All those health services are improving, and access is being increased. More people are able to get an operation or a specialist appointment than ever before. We are the first government—
Clark: 60,000 didn’t get the specialist assessment that their GP recommended, and Pippa Mackay says that doctors have stopped referring them because the statistics are worse than that.
Coleman: 95% of people referred by their GP get to see a specialist. That’s a huge amount. Well over 550,000—
Clark: GPs. I was talking to a GP last week who told me she’d stopped referring people on because they’re just not getting the treatment any more, so they’ve even given up referring to the hospitals.
Coleman: Well, that is not correct.
Clark: Pippa Mackay says it’s true too, and she’s the president of the Medical Association.
Well, we’re going to have to leave it there. That’s been a great debate. Thank you very much, both of you.
Coleman: Cool. Thanks very much, guys. Thanks, Patrick.
Clark: Thanks, Paddy.

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