The NZMA's advocacy focuses on strengthening the medical profession and delivering an effective health service to our patients. We meet with Government health officials and other agencies at the highest levels. We also exert influence writing submissions on a wide range of topics, and regularly speak out in the media.
Our high profile and influence places us in a strong position to advance core health issues, such as addressing medical workforce shortages and achieving the best value for expenditure on health services. The opinions and input of the NZMA are sought at all levels of policy development and review.
The NZMA has a long and proud history, but as an organisation we are always looking to the future and we remain proactive in our efforts to achieve a world-class health system. We have a successful track record of effecting change and making a difference to our profession and the lives of patients.
Scroll down the list of our current advocacy issues, or click on a heading to go straight to the detail of that issue.
- Child health and welfare
- Clinical research
- Doctors' health and well being
- End-of-life care
- Evidence-based medicine
- Health equity
- Health literacy
- Health policy formulation
- Healthy environment
- Legislative developments
- Maori health inequity
- Medico legal issues
- Mental health
- New roles and task substitution
- Population-based Funding Formula
- Primary care funding
- Professionalism and clinical leadership
- Public health
- Role of the Doctor
Child health and welfare
There is currently significant community and political interest in children’s health and wellbeing and the prevention of child abuse.
- The Health Committee Inquiry into improving child health outcomes and preventing child abuse with a focus from preconception until three years of age made 130 recommendations for practical and evidence based health and social interventions to break cycles of disadvantage and improve child health outcomes. All of these recommendations are supported by the NZMA and we seek to have as many as possible adopted and will work constructively with the Government to implement them.
- The Vulnerable Children Act came into force on 1 July. The NZMA is a member of the Children's Action Plan (CAP) Workforce Advisory Group and has ongoing involvement with this. We also made a submission on a core competency framework for the children’s workforce.
- Our position statement on water fluoridation highlights child oral health issues
- The NZMA's alcohol policy briefing contains recommendations on alcohol consumption during pregnancy and discussion on:
- alcohol use by children
- impact of alcohol on wellbeing of children
- exposure to alcohol marketing
The key message for the NZMA is that—beyond the advancement of health, economic benefit etc—the opportunity to participate in clinical research is a significant workforce issue for senior clinicians both in respect of professional development and job satisfaction. As per the Cranleigh report (commissioned by the select committee) :
- Specialist clinicians involved in clinical trials have increased education and the opportunity to have a global presence in their specialist field.
- Top clinicians seek to engage in clinical research and are likely to stay within New Zealand if offered the opportunity to conduct clinical research as an integral part of their employment.
- Doctors in training who are involved in clinical trials often go on to be leaders in their field of medicine.
- Recognising clinical trial activity would assist in retaining New Zealand clinical researchers and scientists.
- A culture of cutting edge medicine and innovative practice allows New Zealand to retain the most able and creative doctors.
- Clinical trials are important for the retention and recruitment of senior clinicians.
Doctors' health and well being
NZMA continues to find significant opportunities to provide leadership on issues of doctors' health and wellbeing without necessarily being a provider of services or getting into industrial matters. Good research is available on the link between doctor wellness and patient outcomes and data may also be available on health system productivity and the wellness and vitality of the health workforce.
The NZMA’s Doctors’ Health Wellbeing and Vitality position statement makes recommendations for doctors and students, employers, medical schools, colleges and the Government. Each of these recommendations will be pursued during 2015 and opportunities sought to reinforce the importance of optimal health for the medical workforce.
The NZMA’s greater involvement with the Medical Benevolent Society is an opportunity to achieve a higher profile for this fund and improve its reach to doctors and families in need.
End-of-life services are resource intensive. The NZMA supports Advanced Care Planning and provides resources for Advance Directives and resuscitation orders. The NZMA Code of Ethics also provides guidance for doctors in giving effect to advanced care plans and, more generally, recognises the rights, autonomy and freedom of choice of patients.
End of Life Care advocacy issues include:
- public awareness of ACP and tools
- training and support for health practitioners
- equity of access to end of life care and support services
- role of good communication and information systems
- workforce—including specialist palliative care
System issues (including IT) and funding are seen as barriers to the implementation of APC at a practice and a whole-of-sector level. However there is an opportunity to learn from health services that are doing this well, eg, CDHB
The public debate tends to centre on individual experiences and wishes, and rarely considers the issue from a societal or ethical perspective. The NZMA’s position on euthanasia is clear and well publicised. It may, however, need to be restated to particular audiences and we must ensure that terminology and meaning is clear.
NZMA Chair Dr Stephen Child has done a number of media interviews on this issue recently, and has met with ACT party leader David Seymour about his private member's Bill.
There is a need to educate the media and public on what evidence-based medicine is and why it is important. Health literacy and how to interpret evidence is part of this.
Evidence-based decision making should also apply to policy development and implementation and, wherever possible, the NZMA will underpin its representations with research and evidence.
The Natural Health and Supplementary Products Bill awaits its third reading. If passed and enacted in 2015 it will regulate complementary medicines but not as stringently as the NZMA would have preferred.
Dr Stephen Child has given media interviews supporting evidence-based medicine, relating to homeopathy and vaccination, and has been interviewed on the medicinal use of cannabis.
Health equityThe NZMA Health Equity statement provides core principles and messages that continue to be incorporated in most of our advocacy work.
Multi-sector initiatives that address vulnerable communities are emerging and can be leveraged to support wider policy change. We referenced this in our response to the Productivity Commission Issues paper, and in submissions on climate change targets and Living well with diabetes.
Healthy environmentThe NZMA supports doctors playing a wider role in the community. This includes issues such as cycling as a healthy option, and the role of public transport, as well as broader issues like the health impacts of climate change and conflict.
- The NZMA made a submission on Auckland Council's Long Term Plan
- The role of environmental factors was highlighted in our submission on the National Respiratory Framework
- We made a substantive submission to the Ministry for the Environment on climate change targets.
Health literacy is the ability to obtain, process, and understand basic health information and services in order to make appropriate health decisions. Health literacy includes how an individual navigates and interacts with our complex health system. Health literacy also includes people’s expectations about health and well-being, and their understanding of health messages, medicine labels and nutrition information, as well as their ability to fill out medical forms and talk with their doctor.
While the NZMA has limited scope to improve health literacy directly, we can emphasise the importance of good health literacy and the impact poor literacy has on health outcomes and service utilisation. We will seek political and wider social interest in this, and advocate for government, sector and community programmes to improve health literacy.
We also need to ensure that health professional and system performance meets different levels of health literacy.
- We have made a submission to the Health Literacy Project that recommended:
- the framework be rewritten in plain English
- it reference non health players eg education
- specific reference to those groups who are known to have poor health literacy
- We have included consideration of health literacy issues in our response to the Productivity Commission issues paper on More Effective Social Services, and in our submission to the Medical Council on its better data discussion paper.
Health policy formulation
The NZMA has been concerned for some time that agencies are too focused on implementation activities and with not enough attention paid to the front end (research, analysis, consultation, policy development) and the back end (evaluation and review).
We have raised with this the Ministry of Health and others, and we welcomed Sir Peter Gluckman’s report The Role of Evidence in Policy Formation and Implementation (Sept 2013). This report provides a number of recommendations that, if implemented, will improve the quality of policy development in health and more widely. In addition to pursuing this implementation, we could also seek to have this form part of SSC and Auditor General evaluation of government agencies.
Integration, both vertical and horizontal, remains a key objective politically and at a system level. Basic concepts of integration centre on collaboration and coordination to improve the delivery of services in a ways that work for patients.
Most of the work towards integration is being driven from primary care, however DHB alliance agreements and the proposed Integrated Performance and Incentive Framework are designed to facilitate and encourage primary and secondary integration.
The NZMA recognises the benefits of integration but needs to consider enablers, barriers and unintended consequences, and advocate accordingly.
Key legislative developments in 2015:
- Health Practitioner (Replacement of Statutory References to Medical Practitioners) Bill—has undergone its first reading and is likely to go to Select Committee.
- HPCA Act review
- Vulnerable Children Act—implementation issues have been extensively canvased by the NZMA, with information regularly made available to members. We addressed issues with delays in police vetting with the Ministry of Health and an interim position was agreed.
- Natural and Supplementary Products Bill—awaiting 3rd reading
- TPPA—Submissions made (written and oral) to the Select Committee examining the Korean FTA as an opportunity to raise issues that are likely exist with the TPPA. We have also called for an independent comprehensive health impact assessment of the TPPA. Our concerns have been noted in a number of media articles on this issue.
- Coroners Amendment Bill—NZMA made a submission on this and spoke to the Select Committee
- Smoke-free Environments (Tobacco Plain Packaging) Bill
- Medicines Act—a full review is under way and consultation is likely before the end of the year.
With the decision to cease work to establish a joint regulatory authority with Australia for therapeutic products the Minister directed the Ministry of Health to develop a comprehensive regulatory scheme for therapeutic products in New Zealand stating that it is important we modernise our regulation of medicines, devices and cell and tissue therapies under a single cost-effective regulatory framework.
Maori health inequityWhile the health equity position statement remains the cornerstone of what we do, the health of Māori generally needs to be reflected throughout all the advocacy themes. The Treaty of Waitangi makes us unique as a nation and is reason in itself to have Māori health inequity reflected as a separate item in the advocacy themes.
The NZ Health Strategy review may provide an opportunity to put more emphasis on Māori health equity and social determinants.
Medico legal issues
Medico legal issues—including naming of doctors and other health professionals as part of coronial processes—continue to be an area of concern for members. The Coroner's Office is now sending the NZMA all health sector-related decisions.
HDC investigation processes and timeliness also create concerns from time to time. The NZMA will keep a watching brief and maintain regular contact with the Commissioner.
The NZMA was called by Parliament's Justice Select Committee to discuss issues of consent and information sharing, in response to a petition about parents being advised before minors undergo procedures.
The NZMA's submission on the Coroners Amendment Bill supported changes to:
- ensure coroners' recommendations are specific to the case and evidence before the coroner, as well as clear about how the recommendations will reduce the likelihood of future deaths in similar circumstances
- ensure coroners consider which individuals or organisations have an interest in the death and to ensure those individuals or organisations have the opportunity to give evidence or consider any recommendations that may be directed to them before the coroner finalises his or her decisions.
Mental wellness links strongly with social determinants and equity, and there is an opportunity for this to be an area of proactive advocacy for the NZMA: “There is no health without mental health” - WHO
In our 2012 response to the draft Mental Health and Addiction Service Plan (2012-2017), the NZMA endorsed measures to:
- improve integration of care
- ensure early intervention
- address disparities in health outcomes
- provide better access to services for children and youth.
Issues of concern centred on funding models and priorities, particularly if a redirection of resources opens up gaps in existing services.
There is a growing acknowledgment of the link between mental health and physical health. People with mental health conditions typically have poorer physical health status and conversely those with poor health may often experience mental health issues.
Dr Child attended an 'Equally Well' summit
New roles and task substitutionThis will continue to be a theme in 2015, with the Health Practitioner (Replacement of Statutory References to Medical Practitioners) Bill having its first reading. This is ostensibly about removing legislative “barriers to innovation”.
The NZMA position statement on Principles for Health Workforce Redesign provides a platform to consider these and other workforce initiatives and needs to be further promulgated in the sector (particularly the medical colleges).
The NZMA has made a number of submissions relating to this issue, including:
- on the Medicines Action Plan, reiterating concerns around non-medical prescribing and the importance of diagnostic considerations, referencing our position statement on non medical prescribing.
- on the 53rd agenda of the Medicines Classification Committee, reiterating concerns about pharmacists selling oral contraceptives and Nitrofurantoin (increased fragmentation, compromised safety, undermined therapeutic relationship with GP). The MCC subsequently decided not to allow these sales to proceed. Dr Child was interviewed by the media on this topic.
- on a proposal to extend the scope of practice for nurse practitioners.
Population-based Funding Formula
The Population-based Funding Formula (PBFF) determines the share of funding allocated to each District Health Board, but does not determine the overall level of funding. The aim of the PBFF is to fairly distribute available funding between DHBs according to the relative needs of their populations and the cost of providing health and disability support services to meet those needs. The PBFF formula has not been reviewed since it was introduced in 2003, apart from some minor adjustments following the 2006 census.
A review has been signaled and scoping work started at the Ministry. While the sector would like a comprehensive review that looks at the formula itself to determine whether allocations are fair and reflect current health needs, the Minister has signaled that this is unlikely.
Primary care fundingFunding issues in primary care are multifaceted, ranging from capitation formula, to co-payments, to incentive frameworks, to VLCA and GMS.
NZMA advocacy is likewise multifaceted and can involve anything from policy discussions to contracting issues. Changing business models and the integration agenda are also involved.
At a policy level, the NZMA will pursue improved targeting of primary care funding, based on the principles of proportionate universalism.
Proportionate universalism describes a service that that is delivered to all, because of evidence that all will benefit, but provides additional assistance to those who need and will benefit from more.
Professionalism and clinical leadership
Both are core principles within the Role of the Doctor statement.
Professionalism is central to the NZMA’s work via the Code of Ethics and our advocacy activities, and professional regulation is likely to feature in 2015 if the review of the HPCA Act is progressed.
Professionalism describes the skills, attitudes and behaviours we expect from individuals during the practice of their profession. It includes concepts such as maintenance of competence, ethical behaviour, integrity, honesty, altruism, compassion, service to others, adherence to professional standards, justice, respect for others, and self-regulation. External challenges to professionalism include policy and management influence (bureaucratisation), commercialism and systems that erode clinical autonomy. Internal challenges include the willingness to uphold the professional concepts noted above and addressing unprofessional behaviour.
The Government’s In Good Hands report (2009) signalled a desire to improve clinical leadership and clinical governance in the health system. Clinical leadership encompasses national influencers, institutional leaders, service leaders and frontline clinicians who are leaders during the course of their clinical work. Clinical leadership is most effective when clinicians are the key drivers for change. In addition to leadership role opportunities, enablers of clinical leadership include the nurturing of prospective leaders and support from peers. Barriers can include lack of time and resources, organisational culture, lack of meaningful influence, lack of incentives and scepticism.
The NZMA has a role in supporting clinical leaders and ensuring that clinical leadership is embedded meaningfully in the health system and enabled across all of the domains noted above.
Ethics and professionalism have been reflected in our position statements on Third Party Funding Arrangements and on the procurement of non-clinical goods and services.
In the past weeks Dr Child has been interviewed on the issue of Australian doctors threatened with jail for speaking out about refugee conditions, and Dr Baddock on cheating issues at RNZCGP.
We made a comprehensive submission on the concept of publishing surgical and other data.
Professionalism, trustworthiness, altruism, unity were discussed at meetings with Hon Jonathan Coleman, Associate Health Minister Dunne and MP Kevin Hague.
The NZMA has asked the Government to make Public Health policy a coherent and clear national priority. Action taken at a population level can protect and improve the health of the population and that the Government has the opportunity to further influence a large number of factors that affect the health of New Zealanders, including interventions such as water fluoridation, increasing tobacco and alcohol control, and implementing measures to curb the environmental drivers of the obesity epidemic.
Preventive health links strongly with the second part of our mission statement. Major policy areas are obesity, tobacco and alcohol.
The NZMA last year published the Obesity policy briefing paper recommending key policy initiatives.
- We will continue to pursue tobacco control polices and support the goal of Smokefree by 2025, and have made a submission in favour of a protocol to eliminate trade in tobacco products.
- Alcohol policies remain a focus for the NZMA, at both central and local government levels. We received extensive media coverage for our Alcohol policy briefing paper. We also supported PHA’s Don’t Know, Don’t Drink campaign on drinking in pregnancy with a media release.
- Other public health issues we are pursuing include folate, fluoride, iodine and psychoactive substances.
- We have made a submission to the Health Select Committee supporting the Health Protection Bill, which recommends a ban on sunbeds for those under 18. We support the Cancer Society's call for a ban on commercial sunbeds.
The NZMA believes that quality considerations are fundamental to good health policy, systems and delivery. Quality drives excellence in the delivery of health services and helps ensure patient safety and optimal outcomes. Sound quality principles and frameworks are required to support and guide doctors in their work and decision making.
The pursuit of quality therefore underpins the NZMA’s advocacy and all sector developments are critically examined through a quality lens.
The NZMA supports the development of quality measures in health but has some concerns regarding hard indicators both in respect of their strength as quality markers and the risk that indicators will transition from useful measures to inform safety and quality improvement initiatives, to drivers of process and that sensible care decisions and patient outcomes will become secondary to meeting the target.
The NZMA therefore needs to have confidence that the indicators selected and processes employed are:
- appropriate for the purpose of monitoring and promoting quality and safety in healthcare
- meaningful and scientifically sound
- practical in terms of complete and accurate data collection without undue additional compliance burden for the sector
- audited to ensure that there is evidence that ‘improvements’ against indicators do in fact lead to improvements in clinical care and patient outcomes
- used for the purpose intended and not as a tool to police performance at a individual or organisational level.
Role of the Doctor
The NZMA's Role of the Doctor statement is referenced in much of our advocacy and has particular relevance to clinical leadership, integration and role substitution advocacy. It also backs up our interest in wider societal issues such as health equity. A focus on professionalism is a natural extension of the Role of the Doctor statement.
Particular aspects of the RoD that will be emphasised in the current environment include:
- the meaning of diagnosis
- the right of doctors to be able to speak out.
The values of the profession must underpin any discussion of the role of the doctor. Key concepts are altruism, service and compassion.
Compassion is fundamental to the relationship between the patient and the doctor, and is defined as a deep awareness of the suffering of another, coupled with the wish to relieve it.
- The Role of the Doctor statement was referenced in our submission on MSD's proposal to extend the ability to complete Work Capacity Medical Certificates to other health practitioners, arguing that the term 'medical' needs to remain the remit ofg medical practitioners.
Workforce strategy in New Zealand is currently highly fluid, and is likely to move to an environment with fewer vacancies.
HWNZ has signalled that this will enable:
- a shift in reward, recognition and remuneration for doctors from one with focusing on recruitment and retention to one focusing more on quality and productivity
- better geographical, demographic and disciplinary distribution of the medical workforce to meet provincial, rural and urban demand
- a move in the balance of New Zealand-trained medical graduates to overseas-trained medical graduates from the current 60:40 ratio to an 85:15 ratio
This will also create pressures within the workforce pipeline and may mean the government taking a more directive role in career choices and location of doctors in training.
Ongoing monitoring of workforce initiatives for the wider health workforce is needed, particularly as these tend to be developed solely within a “workforce strategy” context rather than within a wider health policy framework.
- We are represented on the HWNZ Medical Workforce Governance Group and continue to review the support material produced by HWNZ to ensure it meets student and RMO needs. We have also had significant input into the implementation of community experience placement requirements for prevocational trainees.