Annual Review Debate — Health

Thank you very much, Mr Chair, and can I just acknowledge the Minister who’s taken the chair, Andrew Little, and thank him for his time tonight. I want to start with mental health. You heard from a range of DHBs who talked about the growing waiting list for child and adolescent mental health services over the last three years. DHB representatives who appeared for their annual reports highlighted that they wanted a system-wide response. They believe the ministry needs to take a leadership policy and investment role. Even the Director-General of Health acknowledged this as a sector-wide issue and has called for a response. What is the Minister’s response to deal with those ballooning wait times for child and adolescent mental health services?

Thank you, Mr Chair.

💬 Matt Doocey: Point of order, Mr Chair. I thought this new approach to annual reports was for the caller to ask a succinct question so the Minister would get up and answer.

💬 Hon Chris Hipkins: Mr Chairman, this is a committee stage. It does allow the opportunity for members to make speeches, it allows opportunity for members to ask questions or multiple questions if they wish to. As with other committee stages, Ministers can accumulate a number of questions before they choose to answer them. It does mean that the member should still be able to expect to get an answer to his question.

CHAIRPERSON (Adrian Rurawhe): That was actually my fault, I should have given the call, the first call, to Dr Liz Craig as the chair to make her statement, so I apologise to the committee. We’ll go to Dr Liz Craig to give the speech that should have started this debate, and then if the Minister would like to consider Mr Doocey’s question, he can do that after that.

💬 Matt Doocey: Point of order, Mr Chair. Can I just have some clarity on what the Leader of the House has said. It was my understanding that the caller could engage in direct question and answer and not be interrupted.

CHAIRPERSON (Adrian Rurawhe): Yeah, both are correct.

💬 Hon Member: Oh, great political answer.

CHAIRPERSON (Adrian Rurawhe): Well, it is correct. Both the member and the chair can create that dialogue if it’s appropriate. But what should’ve started this part of the debate is the speech from Dr Liz Craig.

Thank you, Mr Chair. As Health Committee chair, I’d like to just provide a brief overview of the annual reviews for this year in the health sector and talk through some of the key themes emerging from the reviews that we did.

So our sector comprises a number of entities, and this year we did annual reviews in depth on eight district health boards, along with the Ministry of Health, Pharmac, and the Cancer Control Agency. So some of the DHBs that we reviewed included Counties Manukau, Capital and Coast, Hutt Valley, Waikato, Hawke’s Bay, Canterbury, South Canterbury and Southern DHB.

We started off with the Minister of Health, Andrew Little, appearing before the committee. Some of the discussions that we had included talking about the health and disability sector reforms, the upcoming review of Pharmac, and the Government’s inquiry into mental health and addiction, and some of the implementation that happened there.

Then that was followed by the Ministry of Health, and we had some discussions there around the financial performance of DHBs, strategies to improve Māori and Pacific health, and also COVID-19 vaccines. I think in the discussions we noted a range of things, including that a significant proportion of the DHBs were having deficits, but a large proportion of that was also considered with non-compliance of the Holidays Act, and so the need to set aside some funds for that.

The Minister also spoke about some of the work under way in terms of expanding the mental health workforce, and also just acknowledged some of the workforce shortages, for some, particularly areas like psychologists and psychiatrists, the long pipeline, up to seven years for training. Also just talking about the shortage of mental health specialists, nurses and other specialists, and also people in terms of those skills in talk therapies. So the Minister just outlined a range of workforce developments in that area, including 350 full-time equivalents, providing talk therapies through the access and choice programme in primary care.

We also heard from the Cancer Control Agency. This was our first review with the agency because they were only established in December 2019. Their role is to provide that national leadership in cancer care. Most of the agency’s first year had been around operational issues, developing the operational model vision, and recruiting key staff. But we were also incredibly pleased to hear about the role they’d played during the COVID response the previous year, and in particular developing up some consistent guidelines, so that while some of our screening had not happened during level 3 and level 4, much of the treatment had gone on because of the guidelines that they developed, and that was incredibly positive.

We also heard from Pharmac. Basically the annual review predated the announcement of the terms of reference for the Pharmac review. But what we did discuss was the work that Pharmac had done in relation to the disruption to global manufacturing and supply chain pharmaceuticals, and the work that they’d been doing there to make sure we had a steady supply of pharmaceuticals.

And then finally, looking at some of the key themes emerging from the DHBs that we reviewed. As I mentioned there were a range of DHBs who had deficits, and though many of them had actually then talked about how they were going to come back to break even over the next one to two years, and just looking at the impact of the Holidays Act and plans for addressing that. But also the role of population growth and acute demand increases on their workforce and workflow.

Mental health services was another common theme. A range of DHBs were expanding mental health service delivery or opening new units but also acknowledging increased demand, and particularly for child and adolescent mental health, some of the longer waiting times that we were seeing there. Also, talked to DHBs about COVID-19 vaccine and their plans for roll-out.

So overall, it was a very busy year for the health sector. But also I just want to end by saying thank you very much to those working in the health sector. The incredible response we saw from the sector and those working in it for COVID-19, making sure they responded both to COVID, but keeping business as usual and delivery of care happening during the same period. Thank you.

Thank you, Mr Chair, and I thank the chair of the Health Committee, Dr Liz Craig, for her comments and endorse parts of what she said.

I thank my colleague Matt Doocey for his opening question. The issue of infant, child, and adolescent mental health services is a growing issue for New Zealand, like the rest of the world. There has been a significant increase in demand for services, and that has pushed our waiting times for New Zealand mental health services in the region of between 5 and 7 percent in most cases. So the measures that DHBs are held against for infant, child, and adolescent mental health services are an expectation that 80 percent of people will be referred to specialist services within three weeks, and 95 percent of those referred to services will be seen within eight weeks. Most DHBs are not meeting that target.

As part of the revamped mental health services and the investment that went into services in 2019—that $1.9 billion spending programme over four to five years—a number of investments have been made. We now have specialist, or youth-specific, primary mental health and addiction services in 10 DHB areas now setting up and operating. We’ve recently expanded Mana Ake, which was a programme that started in Canterbury primary schools. It’s now been—or will, from the beginning of next year, be extended to five additional DHB areas and then will be expanded beyond that over time. We’ve expanded the school-based health services to all decile 5 schools; that will assist in alleviating some of the pressure on the DHB-provided mental health services. And, as a result of COVID and the investment in COVID-related services, additional investment went into telehealth or remote services and a number of online programmes that young people can get access to. We know they’ve been well-used, and that has alleviated some pressure too, but it is not a complete answer to the challenge DHBs still have with the waiting times for those particular infant, child, and adolescent mental health services.

Thank you so much, Mr Chair. What information has the Minister received in regards to the delay in development and publication of the Office of the Director of Mental Health and Addiction Services annual report?

Thank you Mr Chairman. I thank the member for her question. The report of the Office of the Director of Mental Health and Addiction Services was a report that originated from a verbal recommendation from the Auditor-General in roughly 2003; the first report was produced in 2005. There is a statutory role in the ministry, which the Director of Mental Health, and that statutory role, that director, has responsibilities under a number of pieces of legislation, but principally the Mental Health (Compulsory Assessment and Treatment) Act. The Auditor-General of the day considered that it was appropriate for the Director of Mental Health to report on regulatory action taken and statutory powers exercised under the legislation which he or she was then required to exercise powers under. Over time, that report grew and it became a very generalised report, not only on powers exercised and regulatory actions taken but it became a general report on a number of aspects of our mental health services, and the report was often quite late after the reporting period.

When the report came to be prepared for the 2018 year—it typically takes about a year to prepare; it took a little longer than that—it was all but ready to go in 2020 when the pandemic struck, COVID-19 struck, all the efforts of relevant ministry personnel were redirected to the COVID-19 effort and so the report was delayed. At the point of which it was ready for reporting, it was considered that it would be appropriate to combine the 2019 data, so there’d be one report covering 2018 and 2019. That was compiled, and released again late early this year. I think members opposite and others had noted that the report, once published, did not contain the same data and the same breadth of data as had appeared in previous reports. I think the ministry is justifiably open to criticism for changing the content and format of the report without foreshadowing that publicly, and indeed, I might add, without foreshadowing it to the Minister. It is a matter that has been taken up with the ministry.

But in any event, the report has been produced, and much of the content that had appeared in previous reports, but did not appear in the 2018/19 report, is otherwise available through other sources. Recently, for example, the ministry released information related to what is called section 132 deaths, so deaths of people in the care of our mental health services while under a compulsory order. That should have appeared in the 2018/19 report, and it wasn’t there. The ministry has since released that and made a public statement that it is publicly available.

There is another aspect of the data that didn’t appear in the latest report; that is section 95 inquiries. They are inquiries that the Director of Mental Health is empowered to make for a serious incident for somebody under a compulsory order. There hasn’t been an inquiry since 2016, so the data would have simply been a big fat zero, and it was considered by those compiling the most recent report not to report on a zero result, so that didn’t occur.

But in all other respects, the relevant data on the Director of Mental Health’s powers and the exercise of those powers and the regulatory actions taken under relevant legislation, and that legislation is the Mental Health (Compulsory Assessment and Treatment) Act, as I’ve said, but also now the Substance Addiction (Compulsory Assessment and Treatment) Act 2017, a more recent piece of legislation. That report covers actions under those pieces of legislation and is, by and large, correct.

Thank you, Mr Chair, and I’d like to thank the Minister for joining us tonight and for taking these questions. I have one question arising from the Pharmac and Cancer Control Agency annual review and then a set of questions from the Ministry of Health.

I think the first question from the Cancer Control Agency and from Pharmac is a discussion arising out of processes and decision making from Pharmac. In particular, I’m seeking a response to the challenge that I’m putting to the Minister in those Pharmac decision-making processes to not remove the Pharmac exemption for children receiving cancer medicines in DHBs. It seems to me that it would be cynical to remove an exemption for children with cancer to simply harmonise policy. Why would we want to double down to the lowest common denominator and remove Pharmac medicines from children with cancer when, in fact, maybe we should double up and explore maybe increasing that scope for children who don’t have cancer? So I challenge the Minister to maybe address that and give some thinking as to how he might show some leniency towards that position.

I’d then like to address the annual review from the Ministry of Health, where we talked around a restructuring, and the 30 or so Māori health questions that went to every DHB, and weave those two together into a sequence of questions. The first part would be around the restructuring. I’d ask the Minister: does he have any sense of the cost to disestablish DHBs and establish Health New Zealand? Does he have any idea as to what that might be?

The second point I’d raise is that I have grave concerns for two separate health systems. And I agree with the leader who calls it “separatist” when describing two separate health systems: one with a veto—a Māori health authority—and then, Health New Zealand. Spilling out of that, then, are the questions: what is the cost of setting up a Māori health authority? How much funding will a Māori health authority receive? And I say that in the context of officials who stood on stage last weekend and said that the funding would be “modest”—modest. So I’m wondering if he has a sense as to what funding the Māori Health Authority might receive.

I’m concerned that there will be unhealthy competition between a Māori health authority and Health New Zealand, and I’m looking for some reassurance as to how the Minister might address that. Have they thought of that? Do they see it as a risk, as well? How might that be managed?

I raised a question earlier today, and I’d ask it again because I’m trying to understand how this works. If I’m in my general-practice mode and I have a person coming toward me who is co-commissioned from a Māori health authority and also has some work involving Health New Zealand, how do I manage that? How do I account for it? Is part of the consultation under a Māori health authority commissioning - sort of umbrella, and another part under Health New Zealand? Am I invoicing two? It just alludes me. If he could add some clarity from a general-practice perspective how that would look with a person coming towards you, when there’s co-commissioning from a Māori health authority and still responsibilities under Health New Zealand.

I’m wondering if he could, sort of, confirm if he’d had any discussions or communications about aligning the Māori health authority with He Puapua; not whether he has read the document, I understand that he hasn’t, but I’m interested in any discussion as to how this all aligns with the strategy at He Puapua.

I’d look back and question whether he is familiar with the health restructuring reforms in the late 2000s, under the strategy “meeting the challenge”, where the Ministry of Health had a policy arm and it had a funding arm. I’m wondering if he has taken into account any findings—or learnings, if you like—that might have come from that, that might inform the break-up of the Ministry of Health, because it would be a shame to, sort of, not learn from what was done around about 2009, actually.

I’m interested—and I’m trying to not overwhelm the Minister writing, because I would also be the same—will funding of the health restructuring be in this year’s Budget? Can we anticipate a Budget line?

Second to last question: can he give an example of where the Māori Health Authority can veto national planning of health services. I’m trying to understand this. I understand it is co-signing approval. If he could just give an example as to how that veto might deploy. In what instance might it be used?

And, finally, and it may be a rhetorical question, but I’ll place it anyway to get a view: does he expect consultation between the Māori Health Authority and Health New Zealand to be useful in improving Māori health inequities? Does he expect consultation between the Māori Health Authority and Health New Zealand to be useful in improving Māori health inequities? Thank you, Mr Chair.

I’ll try to take the member’s questions seriatim, and if I’ve forgotten anything, the member will have to remind me in a later call and I may need more than one call to do this. In relation to Pharmac and the recent issue about decision making, particularly in relation to paediatric oncology, I make this point. Pharmac had commenced a review on that issue in 2019. It had seen, and had had drawn to its attention, that even though its decision making and the number of patients it is making decisions about is very small when compared to the whole range of things Pharmac has to deal with, and the budget is comparatively small compared to the now over a billion-dollar budget a year that Pharmac deals with—it nevertheless considered there was an inconsistency in the way it was making decisions about those medications compared to everything else. It didn’t regard it as particularly urgent because of the numbers, but it nevertheless commenced the review; COVID interrupted, and it suspended the review. It then resumed the review once it got notification of an allegation of discrimination that was made to the Human Rights Commission, and the Human Rights Commission commenced an investigation.

As that member will know and would expect, if a Government agency is under investigation for a claimed breach of its statutory duties, it is at the very least morally obliged to act appropriately. In this case, it was to resume its review of its decision-making actions and powers to ensure that they were compliant, or at least not in breach of its obligations under the Human Rights Act. Notwithstanding that the Human Rights Commission has yet to make a finding on that, and I should point that out. No decision has been taken about how Pharmac might treat paediatric oncology in the future, although it appears from its public comments to consider that it feels obliged to try to regularise its decision making.

I would add a couple of riders to that. I have sought assurances and Pharmac has given assurances through officials to me and publicly that any treatment that is currently funded by Pharmac, whether it’s been approved by Pharmac or not, or gone through the exemption process, will continue regardless and will continue to be available now and in the future. So the issue will be about new treatments, and whether or not it changes its process for new treatments is yet to be determined.

But the second point I would make is to the extent that some people are concerned that the time that Pharmac often takes to make a decision can be very lengthy, that is precisely the objective of the review that we’ve commissioned in relation to Pharmac, which is to look at the timeliness and agility of its decision making. I think there is some justified criticism of Pharmac not making decisions in a timely enough way when new technologies are available, and we want to see improvement in that regard. But let’s wait to see what the outcome of that review is before we get too concerned about them.

Moving on to the health and disability reforms, which is the theme of the member’s remaining questions, in particular about the Māori Health Authority, let me go through some of the questions. The cost to disestablish DHBs and establish Health NZ: obviously, when you are in transition from one system to another one, there will be some cost. To date, I think the cost of the transition unit has been a little over $1 million, and there will be additional cost to be incurred as the transition unit gears up to be an implementation unit and goes through the process of transitioning DHBs and parts of the Ministry of Health into Health NZ. There will be a cost to that, and the member will, in two weeks’ and two days’ time, see the Budget, and it will be provided for in the Budget yet to be handed down.

The member asks about two separate health systems, one with a veto. Well, he’s got that wrong. Both parties to the system have a right of veto. What this is about is reaching agreement, and I’m not quite sure why the member refers to it as two separate health systems. There is only one system, but there will be two partners to it, and the member confuses independence with separatism. The member will understand there are plenty of relationships in which there are independent parties who come together, two independent parties who are capable of thinking separately for themselves but joined together in a common ambition, in a common set of principles, and a common endeavour, and a common enterprise as it’s sometimes referred to, who act in partnership. That is what we are doing. That will be the New Zealand health system of the future—a Māori health authority, under which Māori can provide leadership for their people and their issues. Because the reality is, as they and many others have pointed out, the performance of our health system as it is at the moment is leaving Māori woefully behind. That’s not acceptable any more.

Our forebears signed up to the Treaty of Waitangi. It had a very clear principle about partnership, about equality, and that is what we must strive for and we must find vehicles and arrangements to achieve that, and this is what we are trying to do. This is what this is about. It is not two separate systems; it is one system with two partners.

The member asks, “How much funding?” That is yet to be determined. There are future funding issues, largely looking at current funding models. That is the next big chunk of work, and decisions on that will be 12 months or so away.

The member asked about competition between Health NZ and the Māori Health Authority, and I reassure the member there is no competition. This is a system which will require agreement between the Māori Health Authority and Health NZ, because we all enter this on the basis of the Treaty principle of partnership. We all have the same ambitions. We all have the same aspirations about the health of New Zealand and the health of New Zealanders. We are all in this and Māori will provide leadership for their people. Health NZ will be the other part of the system. Those entities will reach agreement for the benefit of the whole system and all our people, and they will make great decisions and they will reach agreement. And that will be the health plan and that will be the basis, too, on which decisions are made.

The member asked, if he is in general practice and he does some work under Health NZ and some under the Māori Health Authority—it does not work that way. So the way a locality planning network operates is that all relevant partners in that area, health providers, iwi, other community representatives—and they will be local body representatives—will come together to work up the health plan for that locality, and that would be the basis of the commissioning decision by the regional branch of Health NZ. Commissioning decisions will be made to ensure good health services are available to all New Zealanders. And whether it’s a kaupapa Māori health provider who is providing health services to a region, as happens now, to Māori, Pākehā and anybody else, that will continue. Nothing will change in that respect. Ngāti Hine health doctors do not sit there thinking, “Oh, how much of a Ngāti Hine are you? How much of tangata tiriti are you?” They don’t make that call now and they won’t in the future.

The member asked about alignment with He Puapua. I have to say, in all my considerations with my colleague Peeni Henare, I have not considered He Puapua. I have not read the document. I do not know what it says and no doubt I will eventually get to have a look at it.

I haven’t considered the health restructuring from the late 2000s or 2009. That was under a different Government of a different hue. But if they restructured in 2009, I mean, let’s look at it now, because it ain’t working. It’s not working for Māori and it’s not working for a lot of the rest of New Zealand either.

Is there going to be funding in the 2021 Budget? Well, that is a question for two weeks’ and two days’ time, and the member will see that then.

Can I conceive of a situation which the Māori Health Authority would exercise a veto? No, because I don’t have to, because the Māori Health Authority and Health NZ will be reaching agreement. That is what the system will require. And they will reach agreement because we all have the same ambition. We want a healthy New Zealand, and we want the populations in New Zealand to be healthy. And we want Māori to exercise their rights under the Treaty, and the Crown to fulfil its obligations under the Treaty, which is to allow for tino rangatiratanga, some leadership, some control, some decision-making rights. That is the direction we’re going.

Do I expect consultation between the Māori Health Authority and Health NZ to be useful to, I think, improve Māori healthcare? Absolutely. Because when you look at the health outcomes for Māori at the moment—shorter life expectancy, the fact that more Māori struggle to get access to healthcare, and those who do get inferior results as a consequence—that’s got to change. And that will change when the brilliant Māori health leaders that I know are right across New Zealand get a chance to exercise some leadership and do great stuff.

Thank you, Chair, and thank you, Minister Little, for receiving questions. I have limited time so it’s going to come out as a shopping list—not intended.

So a couple of questions. The first thing is, as you know, Māori have the worst outcomes for all cancers other than melanoma. Will the Government commit to immediately funding more accessible cancer screening for Māori, including human papilloma virus self-testing kits and lowering the cancer screening age for Māori by 10 years to reflect the shorter life expectancy?

The next question—Pharmac. The annual review of Pharmac showed that $50 less is being spent per person for Māori than non-Māori. What is the Minister doing to address inequity in Pharmac funding for Māori and to improve Māori access to lifesaving pharmaceuticals?

The third question—mental health. Will the Government adopt He Ara Oranga’s recommendations in suicide reduction and invest in a targeted approach to suicide prevention for Māori?

The fourth, Minister—we are extremely supportive of Te Tiriti - focused Māori Health Authority this Government is taking. You’ve already said it will have legislative powers to act as an independent voice. Will the new Māori Health Authority have budgetary control?

And our final question please, Minister—racism. What will the Minister do to protect Māori from the backlash of racism when establishing the Māori Health Authority and asserting tino rangatiratanga in Aotearoa? Kia ora. Thank you.

Kia ora to Debbie Ngarewa-Packer. Thank you for those rapid-fire questions. I will respond to them as quickly as I can.

Just on the last question: what am I going to do about the potential for a racist backlash? Keep arguing the case. Keep asserting the point. I’m very confident that what Peeni Henare and I have come up with as a vision for New Zealand health—

💬 Hon Aupito William Sio: Change leadership on that side.

—is the right thing for New Zealand. We’ve got support from this side of the House and I hear the member expressing support. We have to do this because in the 21st century, 181 years from the Treaty, we start to fulfil the Crown’s obligations, and we can all do that together. So you have my commitment. I’m standing firm and fast alongside my colleague Peeni Henare.

In relation to cancer treatments for Māori, I don’t want to concern the member unduly but we have a Budget coming up and the Budget will lay out specific proposals, whether it’s for the Minister of Health or Pharmac, and there will be measures in relation to that and the member will see what is in there.

In relation to the second question about Pharmac—and the member is absolutely right, Pharmac spends $50 per person less on Māori on average than for other New Zealanders. That is unfair. So that is an issue that Pharmac is now actively addressing in the way it makes its decisions and it’s a fact that I expect the current review to also be considering when it considers its recommendations for future decision making by Pharmac.

The next question about mental health, and particularly suicide reduction for Māori—the member is correct that there is an elevated risk for Māori, particularly for young Māori. That is why part of the suicide prevention and postvention programme is initiated specifically for Māori. So there’s already specific funding gone out to kaupapa Māori services dealing with those dealing with suicide prevention and dealing with the suicide bereaved, and that, obviously, will continue.

Finally, in relation to the Māori Health Authority—what might the budget be? I’ll just reassure the member that that is work that is under way now, because one of the things we have to do is look at current funding models. What has become apparent, and it was referred to in the Health and Disability System Review, is that current funding formulas are too blunt to take account of levels of disadvantage, socio-economic disadvantage, race disadvantage, and other measures that we need to rethink as we put together funding formulas for the future health system.

Thank you, Mr Chair. Just before, a question was raised from the other side by my colleague Dr Shane Reti, who’s a general practitioner. In my life as a general practitioner, and now in my new life as a member of Parliament, my patients and my constituents have asked about cochlear implants, and I was wondering if the Minister could tell us a little bit about any recent announcements he’s made on cochlear implants.

Thank you, Mr Chair, and thank you to Gaurav Sharma for that question. I think last year we announced additional funding for cochlear implants, which means that we can fund an additional, I think, roughly 60 cochlear implants. I have to say that I had an amazing story relayed to me just a few days ago of a person whose 51-year-old brother, who’s been profoundly deaf, got a cochlear implant recently, and did so because he wanted to hear the sound of his grandchildren. Because of that additional money put in last year, he had the procedure recently, and as you would imagine, it has profoundly changed his life. She was telling me that she’d got a phone call from him the other day saying he was off to the beach so he could listen to the waves—things that we take for granted. So that is the profound impact that is happening. We have a waiting list of, I think, roughly 240 cochlear implants at the moment in New Zealand. We need to work very hard to reduce that, and we will continue to do so, but being able to do that as one-off extra funding appropriations makes a difference, and we will continue to look for opportunities to make that difference for cochlear implants.

Thank you very much, Mr Chair. Look, I’ve got five primary questions for Minister Little relating to DHB workforce, infrastructure, operating deficits, and holiday pay. First question: during the annual reviews, we consistently talked with DHBs highlighting the lack of workforce, so I’d be interested to hear how many fulltime-equivalent vacancies we had across all the DHBs as at 30 June 2020, and of that, how many were for nurses.

Second question: during the annual reviews, we heard consistently around the infrastructure deficit crisis within the health sector. What I’m interested in is what the estimated capital deficit or investment deficit is over the next 10 years as of 30 June 2020 for all DHBs. My third question: in regards to closing that infrastructure deficit, we’ve obviously got the aspect of dealing with growth. So in addition to that, what is the outlook in terms of the next 10 years from the end of June 2020 for growth and capital investment?

Fourth question: we discussed at length around operating deficits within our DHB environment—basically, where costs are exceeding revenue. Can he articulate what the total deficit was across all DHBs for the year ending 30 June 2020, and does he expect that to be bigger or smaller as we come to the end of this financial year? Lastly, a large portion of those DHB deficits relate to holiday pay provisions. What I’m interested in from the Minister is what DHBs, if any, received a qualified audit opinion in 2019/20 because they could not reliably measure their holiday pay liability. A supplementary to that is: in the annual reviews, we heard from Waikato DHB that they noted that they were instructed to make balance sheet provisions for holiday pay. To your knowledge, were there any DHBs instructed by the Ministry of Health or your officials to make balance sheet provisions for holiday pay? Thank you, Minister.

Thank you, Mr Watts, for those questions. I will get through them as quickly as I can. In relation to the workforce issues that the member refers to, I’m not quite sure what the number of vacancies on a fulltime-equivalent basis is. What I can say is that this is a Government that in the last couple of years alone has added funding for over 3,000 fulltime-equivalent roles within the DHB network alone, and we’ve added on more in previous years to that. We know that there are nurse vacancies. Part of the challenge we’ve got is workforce development, so investing in more training. Creating a new nurse is a multi-year challenge in terms of getting the training, the on-job, and getting up to spec, so that will take some time.

One of the benefits of the health reforms and of Health New Zealand is that they will have a dedicated workforce planning and development mandate. That means that they can do the long-term planning, engage with the training institutions, work up the training programmes, and start to really plan and work out that long-term pipeline of health talent and skills that we need. I think part of the problem has been that under the DHB model it has been way too disaggregated and a bit haphazard and a bit ad hoc, which explains the shortfall in health skills that we have at the moment.

In relation to the infrastructure deficit, I thank the member for the question. He might want to talk to some of his colleagues who’ve been around a little longer, particularly those who were in Government, because there were two years—I think 2015 and 2016—when there was no money spent by the Government of the day on health infrastructure. You look at the graph and it’s just blank in those two years. We have a major catch-up job that we’re doing, which explains why this Government has allocated close to $5 billion in health infrastructure in the time that it has been in Government.

Of course, what we’re discovering is that you can make that decision, but getting the planning and the design and getting construction under way takes a bit of time, as well. So there is a programme. I think the four northern DHBs have done a plan—I think their infrastructure deficit just over the next 10 years is something like $10 billion. So this is what we’re talking about, and when you’re rebuilding almost an entire hospital in Dunedin, which is a nearly $1.5 billion building project, you start to see the scale of the problem that we are fixing—that we are fixing.

How to deal with growth, as well—the member raises an interesting point, and I think one of the challenges we see, and one of the things I expect to see out of the health reforms, is that stuff that is currently done in hospital—some treatments that are currently done in hospitals—we need to be finding ways to push out into community settings. There are some types of chemotherapy that don’t need to be done in a hospital setting—could be pushed out into a properly equipped and staffed community setting. More opportunities to do that, so that we focus our hospitals on the serious end of healthcare that’s needed, and those things that people don’t have to travel hours and hours for that can be done close to where they live and to their communities—we want to find opportunities to do that. So I think the member might expect, over the next few years, to see a slight reorientation of the capital works programme to move away from just the big, grand hospital campus renewal stuff to other facilities in a more community-oriented sort of basis.

In terms of deficits, the total deficit at 30 June 2020 was just over a billion dollars. That did include Holidays Act accrual, as well as some COVID spending, and, indeed, there are deficits being recorded for the DHBs at the moment that still incorporate those two elements. It will be bigger this year, but the DHBs will be supported in terms of meeting their Holidays Act liabilities, and they will also be supported to meet their additional COVID-19 response costs.

Thank you, Mr Chair. Thank you to the Minister for his many answers, especially with the health reforms with the Māori Health Authority, which we are excited about, where the collaboration will be more focused on equity rather than competition, as well, with the provider level. My question to the Minister is: what details were announced in relation to Pharmac this year?

I thank the member for the question. Pharmac, as many people have seen, has been a very good model for medicines procurement. It does all the procurement for all our DHBs. It now procures over a billion dollars a year in medicines for New Zealanders. Those medicines are provided to—I think the last figure I saw was 3.7 million New Zealanders; a lot of New Zealanders getting a lot of medicines. But there have been, I think, justified criticisms about the speed with which Pharmac sometimes makes its decisions, particularly with new medical technologies. So we have commissioned a review of Pharmac and its decision making. Pharmac is required to work within the budget that it gives. That is what it says in its statute: that it must work within its budget. That budget is set independently of Pharmac, as you would expect. It is the Government of the day that sets the Pharmac budget, but Pharmac has to work within it and make the best decisions that it can.

If I just talk tangentially for a moment about cancer treatments, this Government set up the Cancer Control Agency because we were concerned, like many New Zealanders, that there was inconsistency in diagnosis times and inconsistency in treatments of cancers, depending on where you lived in New Zealand. So the Cancer Control Agency is now there to provide leadership and monitoring and to drive some consistency in cancer diagnosis and treatment. One of the reports they are currently preparing is a report on cancer treatments available in New Zealand, and to compare that to countries we like to compare ourselves to, like Australia, the UK, and Canada—all countries with significant public health systems. I think that would be a useful starting point on the debate about cancer treatments we should be having, including those we don’t currently have, and that, I think, will inform future decisions by Pharmac. But we need to make sure that Pharmac is set up in a way and equipped to be able to respond agilely and quickly where new technology becomes available and make good purchasing decisions at that time.

Thank you, Mr Chairman. In the review process, we heard of concerns around the equity of care for disabled persons, our elderly, and mothers and babies, and I have five questions for the Minister relating to these concerns.

Firstly, does the Minister consider the daily payment rates for disability respite carers of $76 a day for 24-hour care, equating to $3.16 per hour, as appropriate?

Secondly, how many day centres for people with disabilities were closed by disability service providers throughout New Zealand in the 2019/2020 financial year?

Is the Minister aware of the 15 percent gap identified by the Disabled Persons Assembly (New Zealand) between the funding of day services to disability service providers and the cost of provision of services for people with disabilities by the service providers?

In the 2019/2020 financial year, what was the range, in points scored across the DHBs, which enabled a hip-joint replacement, and does he consider it appropriate for a score of 50 points in the Canterbury DHB area enabling hip-joint replacement surgery while a person in Invercargill must reach a score of 70 points?

And, finally, does the Minister believe there is any correlation between length of stay in hospital after birth, and mother or baby’s readmission within the first 1,000 days of a baby’s life?

In relation to the daily payment rate and whether or not it is appropriate, I think we all want to make sure that the support given to caregivers, whether they’re family or not, is appropriate and is fair and, I might say, is consistent across funding streams. And that is a big piece of policy work that needs to take place.

In relation to how many day centres for disabled have been closed in the year under review, I cannot answer that question. I do not know.

In relation to the 15 percent gap between funding of day services and the cost of services, I appreciate the member providing that figure to me. I think that and the previous earlier question about the daily payment cover the point that the Health and Disability System Review didn’t, sort of, get to but which we have committed to, which is we actually need to unpick disability support services and funding arrangements and remove it from the health focus, because it is not just a health focus, there are other social supports that are relevant to them. And we need to have and explore a regime, the Government’s regime, that I think is respectful of the full breadth and all dimensions of the needs of the disabled community, and that kind of covers off the points that the member has been raising.

I’m glad the member has drawn attention to the points system in different DHBs—for example in relation to hip-joint replacement—because it wasn’t something that was addressed by the previous Government. It is one of the postcode lottery issues that infects our current health system. And it is precisely because of that sort of thing that a unified, coherent, consistent health system under a Health NZ with a nationwide mandate can actually start to seriously address—we can actually put in place some common standards of diagnosis and treatment across all hospitals, regardless of where you are. And, actually, we can manage patients’ treatment through a hospital network, not going to say, “Well, if you can’t get it at that hospital that’s part of some DHB, you’re going to struggle to get it somewhere else.” ACC actually provides an interesting model, because they are a funder of healthcare, they can pick and choose where across the public health system they can get procedures done, and they do that. Well, you know, if it’s good enough for somebody who’s suffered an injury by accident, and they’ve got a financial backer who can pick and choose where they get their treatment so it’s faster than somebody who is getting treatment that is not by reason of injury by accident, actually, Health NZ can provide an answer to that problem.

Finally, the correlation between the length of stay in hospital of a new mum and readmission, I don’t know the research on that—and I’m sure my colleague Dr Ayesha Verrall, who covers this area, would be fully familiar with the statistics in it. But it wouldn’t surprise me if the point that the member is making is correct.

Thank you, Mr Chair, and thank you to the Minister in the chair, Andrew Little. Look, I just want to go back. We kind of started this process talking about mental health, and youth mental health in particular, and I wondered if the Minister could talk a little bit further about specific announcements that have been made in regard to youth mental health just over the last year.

One of the objectives of the Government’s response to He Ara Oranga and the $1.9 billion package we announced in Budget 2019 is not just to provide more services, which we are currently doing, and growing them for those with mild to moderate health conditions, but to have specific packages for young people. So we have funded now in 10 DHB areas specific youth mental health services, mainly in the form of youth one-stop shops, because we know that for a lot of young people who need support and assistance through mental health challenges—actually, there is an environment in which that works best, where they’re getting attention not only to the mental health issues but to other health issues and other social issues that they might have, as well. So we’ve put a lot more funding into that.

We’ve also added funding to the school programmes for health, not only social workers in school but in some cases nurses in schools, so that that healthcare and support is available at that age and at that stage in school. As well as that, we’ve also got specific and targeted funding for young Māori and for Rainbow youth as well, targeted funding for those areas. We’ve put $1 million into Youthline—Youthline, never had public funding before; it’s having public funding, and that will be continuous—and we have supported the availability of online mental health services through a number of different apps, which are being well used by young people.

Speaker