The New Zealand Health Strategy

Full text version

Date of publication: December 2000This is the full text online version of this document. You can also download this publication in PDF format.

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Chapter 4:
Priorities

These are priority areas that the Government wishes the health sector to pay particular attention to in the short to medium term. These priorities are in three groups:

• population health objectives – to highlight particular areas where the Government wishes to see outcomes improved

• objectives to reduce inequalities in health

• service priority areas – to highlight particular services that are important in addressing the two previous groups and also impact upon Government priorities.

Priority population health objectives

Of the 61 objectives, 13 population health objectives have been chosen for implementation in the short to medium term. The Government intends focusing Ministry of Health and District Health Board attention to this list of priority population health objectives.


These priorities have been selected according to the degree they can in the short to medium term:

• contribute to important overarching Government initiatives such as reducing inequalities
• improve the health status of the population
• engage the health sector and enhance the focus on outcomes, specifically preventive services
• engage other sectors, reflecting the scope for national and local intersectoral action
• encompass all groups within society (such as age groups)
• ensure continuity with significant existing policy and programme initiatives
• provide focus and direction for the District Health Boards
• reflect the intent of the Treaty of Waitangi.

These priorities will provide a direction for action on health. Selecting priorities for action does not mean other services will cease or be downgraded. However, it does mean increased emphasis will be placed on action on these priorities over time: an evolutionary rather than revolutionary process.

The importance of these priorities will be recognised in the Minister’s expectations of the Ministry of Health, the Minister of Health’s funding agreements with District Health Boards, and District Health Boards’ funding agreements with providers.

As circumstances change over time, so priorities for action will also change.

The rationale for selecting these particular objectives is given below.

Reducing smoking

Tobacco smoking is the major cause of preventable death in New Zealand. Each year about 4700 of all deaths are attributable to smoking (Ministry of Health 1999b).

Parental tobacco smoke and environmental tobacco smoke are related to several conditions (for example, sudden infant death syndrome (SIDS) and the childhood risk of croup, pneumonia and asthma). There is good evidence that morbidity and mortality can be substantially reduced using preventative approaches.

The reduction of tobacco smoking will be achieved by the implementation of a comprehensive mix of initiatives under the National Drug Policy in each of the following areas: smoking cessation services; health promotion; tobacco taxation; and legislative development and implementation.

Improving nutrition

Cardiovascular disease, cancer and stroke have been identified as the three leading causes of death for New Zealanders, and nutrition plays a major role in all of these (Ministry of Health 1998).

Recent data show that the majority of adult New Zealanders had nutrient intakes that met or exceeded their requirements and consumed the recommended quantities of vegetables.

However, while the proportion of energy intake from fat has decreased, adults are still consuming more fat, in particular saturated fat, than recommended by the Ministry of Health. A significant number of New Zealanders, especially Māori and Pacific households, report running out of food or being unable to eat properly because of lack of money (Ministry of Health 1999a).

The Ministry of Health is committed to promoting good nutrition and undertakes surveys to monitor the food intakes and nutrition-related body measurements of New Zealanders. The Ministry also provides nutrition guidelines and policies to address the nutritional needs of New Zealanders throughout their lives.

Reducing obesity

Recent data show that 15 percent of males and 19 percent of females are obese, and 40 percent of males and 30 percent of females are overweight (but not obese) (Ministry of Health 1999a). These prevalences are likely to increase. Obesity is one of the most important avoidable risk factors for a number of life-threatening diseases and for serious morbidity. The prevalence of obesity for Māori is 27 percent for males and 28 percent for females; while 13 percent of male and 17 percent of female New Zealand Europeans and others are obese. For Pacific males and females, the prevalence of obesity is 26 and 47 percent respectively (Ministry of Health 1999b).

Current work in this area includes a stocktake of obesity prevention programmes in New Zealand as well as an evidence-based review of successful international programmes.

Increasing the level of physical activity

Lack of regular physical activity is a modifiable risk factor for major heart conditions such as heart disease, stroke, hypertension and premature death. At least one-third of New Zealand adults are insufficiently physically active, and lack of physical activity is estimated to account for over 2000 deaths per year (Ministry of Health 1999b). There is good evidence that 30 minutes of moderate exercise each day reduces risk.

The Ministry of Health will continue to support the Hillary Commission’s work in the development of strategies such as Push Play and Green Prescription.

Reducing the rate of suicides and suicide attempts

New Zealand’s youth suicide rate is one of the highest in the OECD countries. There are differences in the rates of completed and attempted suicides, with females having a higher rate of attempted suicide but a lower rate of completed suicides than males.

In order to reduce the rate of suicides and suicide attempts, a range of population-based and targeted approaches are required.

These include initiatives that: reduce the development of risk factors common to suicide; strengthen resiliency/protective factors; provide early identification, support and treatment for those who have risk factors or are suicidal; provide support after a suicide; restrict access to lethal means of suicide; and encourage the ‘safe’
portrayal of suicide in the media.

Minimising harm caused by alcohol and illicit and other drug use to individuals and the community

Over 80 percent of adult New Zealanders consume alcohol. At some time in their life, nearly one in five New Zealanders will suffer an alcohol use disorder. Alcohol abuse is a risk factor for some types of cancer, stroke, and heart disease. Alcohol abuse also significantly contributes to death and injury on the roads, drowning, suicide, assaults and domestic violence.

The abuse of illicit drugs also harms some New Zealanders. Of particular concern is the risk to public health from the transmission of blood-borne viruses through the sharing of needles and syringes, and cognitive impairment. People who experience both drug and mental health problems have particularly poor health outcomes.

Intersectoral action plans will be developed under the National Drug Policy to minimise the harm caused by alcohol and illicit and other drugs. A broad range of strategies is essential and will include initiatives in: information, research and evaluation; health promotion; assessment, advice and treatment services; law enforcement; and policy and legislative development.

Reducing the incidence and impact of cancer

Cancer is the second leading cause of death (27 percent) and a major cause of hospitalisation (7 percent) in New Zealand. There are about 17,000 new registrations of cancer each year, with the highest rates in the middle and older age groups.

To address this priority, a co-ordinated approach is being developed across prevention activities, early detection (particularly screening), treatment and rehabilitation.

Reducing the incidence and impact of cardiovascular disease

Cardiovascular disease is the leading cause of death (accounting for about 40 percent of deaths) and morbidity in New Zealand.

Early detection of those at risk and early intervention through primary care are two of the key approaches to controlling cardiovascular disease.

Reducing the incidence and impact of diabetes

Diabetes is estimated to cause about 1200 deaths per year (Ministry of Health 1999b), and diabetic complications (such as heart disease, blindness and kidney failure) are major contributors to the burden of disability experienced by people from middle age, especially in Māori and Pacific communities. Projections are for a significant increase in the prevalence of diabetes in the next 10 years.

To address this area, there will be roll out of the Diabetes 2000 strategy and the nationwide adoption of local diabetes groups to support improved quality of care. There will be a particular emphasis upon the high risk populations of Māori and Pacific peoples.

Improving oral health

Diseases of the teeth and gums are among the most common of all health problems and are experienced by all New Zealanders at some stage of their life. Dental problems cause much pain and discomfort and can often contribute to a loss of self-esteem. It is now apparent that there are significant inequalities in oral health status between different population groups. In particular, Māori and Pacific children and adolescents have worse oral health than non-Maori
and non-Pacific children.

To improve oral health, initiatives will include support for the fluoridation of reticulated water supplies, increasing preschool and adolescent attendance, and increased health promotion and clinical prevention for lower socioeconomic groups, including Māori and Pacific peoples.

Reducing violence in interpersonal relationships, families, schools and communities

In many countries violence is recognised as a key public health issue. Child abuse, sexual violence, family violence, school bullying and elder abuse are all preventable forms of harm and social disruption.

To reduce violence in those areas, health professionals and providers require protocols and training to allow them to recognise and respond to the family violence and abuse. Public health campaigns are also important.

Improving the health status of people with severe mental illness

The Government’s major priority for mental health is focusing on improving outcomes for people who have a severe mental disorder – about 3 percent of adults and 5 percent of children and young people. Addressing this issue goes beyond provision of treatment services in secondary and primary settings. It is also requires intersectoral action to address issues concerning education, housing, stigma and discrimination to help ensure people’s full range of needs is met.

Major initiatives to address this priority include: the continued implementation of the Blueprint for Mental Health Services in New Zealand; improving the responsiveness of services to Maori; a greater focus on recovery; and improved co-ordination between the health sector and other social service sectors.

Ensuring access to appropriate child health care services including well child and family health care and immunisation

Many indicators of child health show that New Zealand has a low international ranking of child health (for example, high rates of unintentional injury). Vaccine-preventable diseases are an important cause of morbidity and mortality for all communities. New Zealand has a relatively low immunisation rate and there is an ongoing cycle of epidemics of vaccine-preventable diseases such as whooping cough (pertussis) and measles.

In terms of immunisation, the adoption of the National Health Committee advice on immunising children most in need by outreach services is an essential component, along with ensuring that each newborn child has a well child provider.



Reduce inequalities in health status

As well as the 13 population health objectives identified above, the Government seeks to reduce inequalities in health status by ensuring accessible and appropriate services for all New Zealanders, including Māori and Pacific peoples.

All of the initiatives described above will help to reduce inequalities, especially for people of lower socioeconomic status. More details of how the Government seeks to reduce inequalities for Māori and Pacific peoples are given below.

Māori advancement in health

Improvements in Māori health status are critical, given that Maori, on average, have the poorest health status of any group in New Zealand. The Government has acknowledged the importance of prioritising Māori health gain and development by identifying a need to reduce and eventually eliminate health inequalities that negatively affect Māori.

Working towards reducing inequalities will involve government departments and agencies working co-operatively across sectors, community engagement, and community development.

The progress of achievements since the mid-1980s must continue. Some examples include:

• growth and upskilling of Māori providers

• expansion of the Māori workforce at all levels of the health sector

• enhancement of mainstream providers’ ability to meet Māori needs and expectations

• increased Māori participation at all levels of the public health sector.

A Māori Health Strategy will be available by June 2001 (see Appendix 2 for more details) and will provide the details unable to be captured within the New Zealand Health Strategy.

Reducing inequalities for Māori in the short to medium term includes, but is not limited to:

• attention on addressing He Putahitanga Hou objectives relating to rangatahi health, disability support services and alcohol and drug services

• improving the quality and effectiveness of health promotion and education programmes targeted at Maori

• forming effective partnerships at all levels under the Treaty of Waitangi

• enhancement of mainstream providers

• increased Māori participation at all levels of the public health sector

• improving an established matrix of relationships vertically and horizontally throughout the health sector

• increased participation and involvement of Māori health providers across the health sector

• improved mental health services to Maori, which take into account Māori healing

• an increased number of Māori in the health workforce, particularly in mental health

• promotion of smoking cessation programmes

• increased resources for Māori health providers delivering sexual and reproductive health services.

Existing Māori health gain priority areas will continue to receive attention. The eight priority areas are:

• immunisation

• hearing

• smoking cessation

• diabetes

• asthma

• mental health

• oral health

• injury prevention.

Improving Pacific peoples’ health

As described in Chapter 2, Pacific peoples’ health status is lower than that of many other New Zealanders. In addition, there are specific issues in relation to access to services and the provision of culturally appropriate services.

The specific aims to reduce inequalities in health for Pacific peoples include but are not limited to:

• strengthening primary health initiatives for Pacific peoples

• improving the health of Pacific children

• improving mental health services for Pacific peoples

• enhancing screening programmes to improve the health of Pacific peoples

• increasing the number of Pacific peoples in the health workforce.

A Pacific Health and Disability Action Plan is being developed within the Ministry of Health. For more details, see Appendix 2.


Service priorities

The previous sections concentrated on health outcomes. Clearly the services that deliver health care are also important, and the Government is committed to ensuring all health providers deliver high quality and culturally appropriate services.

As with the priority population health areas, the Government has identified a small number of service priority areas for the sector to concentrate on. This means that these are areas which should be considered first if extra funding becomes available. The five areas are:

• public health

• primary health care

• reducing waiting times for public hospital elective services

• improving the responsiveness of mental health services

• accessible and appropriate services for people living in rural areas.

These areas are discussed in more detail below.

Public health

Public health professionals and service providers take a leading role in improving population health outcomes and reducing inequalities in health status through disease prevention, health promotion and health protection programmes.

For example, they have a role in ensuring the safety of the air we breathe, the water we drink, and the food we eat. Public health programmes focus on enabling people to make individual and collective choices which improve their health.

These programmes address issues such as mental health promotion, reduction in harm from drug use (including alcohol and tobacco), and immunisation promotion.

Public health experts also play a role in promoting healthy public policy through submissions to central and local government agencies on key issues relating to population health, and assessing public policies for their impact on health and health inequalities.

Improving the impact of public health services will require:

• further development of Māori public health providers and organisations

• development of Pacific peoples’ public health services

• increased delivery of health promotion initiatives in community and primary care settings

• increased focus on health education

• increased co-ordination with Territorial Local Authorities and other agencies that play an important role in public health

• improved access to public health protection services in rural areas, with a focus on clean water, sewerage and housing.

Primary health care

Primary health care is critical to improving health and reducing inequalities in health status for all New Zealanders including Māori and Pacific peoples. Primary health care is delivered close to communities with their participation and is a key to improving and maintaining health through programmes to promote health, prevent disease and provide early diagnosis and treatment of illnesses to prevent complications developing.

A wide range of providers deliver primary health care, including general practitioners, nurses, health educators, counsellors, Māori health providers and Pacific health providers. To achieve the aims of the Strategy, it will be important to increase co-ordination between these providers and between primary health care providers and public health and secondary services providers.

An increase in the number and variety of Māori primary health care providers and the emergence of Māori development organisations are essential components of an effective primary care sector. Priority will be given to ensuring existing successful Māori providers are consolidated and developed. This will ensure that options and choices become a reality for Māori and that issues such as equitable access begin to be addressed.

Similarly, improved primary health care services are essential to meet the needs of Pacific peoples. Pacific providers will need support to grow and develop further. It is also important that mainstream providers of services deliver their services in a culturally appropriate way to Māori and Pacific peoples.

Therefore, a key priority for District Health Boards is to ensure comprehensive primary care coverage and quality primary care services in both urban and rural areas. The Government is currently preparing a Primary Health Care Strategy that will incrementally change the way services are delivered. (For further details, see Appendix 2.)

Reducing waiting times for public hospital elective services

A key priority for the Government is reducing waiting times for elective (non-emergency) hospital surgery and treatment. Appropriate access to elective services is highly valued by the public and therefore important for ensuring confidence in the public health system generally.

Providing elective surgery to patients who have the greatest ability to benefit from treatment also helps to improve health outcomes and reduce health disparities for all New Zealanders including Māori and Pacific peoples.

District Health Boards will need to place priority on reducing elective waiting times, giving patients certainty about timeframes, and ensuring appropriate care for patients seeking elective services. Specifically, the Government’s strategy for reduced waiting times includes four key objectives for access to elective services:

• national equity of access to elective services so patients have similar access regardless of where they live

• a maximum waiting time of six months for the first specialist assessment

• a maximum waiting time for surgery of six months for patients who are offered publicly funded treatment

• delivery of a level of publicly funded service which is sufficient to ensure access to elective surgery before patients
• reach a state of unreasonable distress, ill health and/or incapacity.

The seven strategies for achieving these objectives are:

• nationally consistent clinical assessment

• increasing the supply of elective services

• giving patients certainty

• improving the capacity of public hospitals

• better liaison between primary and secondary sectors

• actively managing sector performance

• building public confidence.

A particularly important consideration for District Health Boards will be ensuring the maximum contribution to improved health and reduced inequalities from its investment in elective services. Three key initiatives are required to achieve this.

• Ensuring the patients with the greatest need and ability to benefit are offered treatment first. This needs-based approach helps to reduce health inequalities as people from populations with the poorest health status, such as Maori, stand to gain improved access to elective services. There is already some evidence of this trend occurring in some services, for example, cardiac surgery.

• Providing a smooth and timely pathway through to treatment. Where treatment is offered, it should be provided within the next six months, and patients should be given certainty about this maximum waiting time.

• Ensuring that the best care and support available is provided to patients seeking elective surgery. In particular, patients who cannot be offered treatment within six months may require regular reviews of their condition if it is likely to deteriorate, and also access to pharmaceuticals, community support services and other available care. Such care and review mechanisms should be included and documented in the patient’s care plan.

Improving the responsiveness of mental health services

The level and quality of specialist mental health services have improved over recent years.

Significant gains are still required to ensure services meet the full range of needs of people who experience mental and psychological distress. The Government is committed to continually improving mental health services through implementing the Mental Health Commission’s Blueprint, which draws on the objectives of Looking Forward (Ministry of Health 1994) and Moving Forward (Ministry of Health 1997).

This will result in comprehensive services that lead to:

• people with mental illness being treated fairly, with respect and with dignity

• people with mental illness having the opportunity to participate fully in their communities free from negative discrimination

• more services that are easier to access and that are able to respond to a diverse range of needs more quickly

• a better quality of services that are able to identify and respond to needs in a way that promotes recovery.

Improvements are needed in all mental health services, but there must be emphasis on improving mental health services for children and young people, older people, Māori and Pacific peoples.

At a local level, there will be other service priorities (for example, services for people with alcohol and drug problems, including methadone services; services for people with multiple, complex and high support needs).

Collaboration between providers of mental health services is imperative. Hospital-based and community-based services must collaborate with each other as well as with non-governmental providers and primary health care services.

All are integral to improved co-ordination of mental health services. Equally importantly, there needs to be appropriate referrals, assessments and comprehensive strategies with other sectors (such as housing) to ensure that people’s full range of needs is met.

Accessible and appropriate health services for people living in rural areas

One in four New Zealanders lives in rural areas or small towns. Rural areas have a higher percentage of children and older people living there.

Thirty-two percent of Māori live in rural areas (consisting of a higher proportion of children and young people) compared with 23 percent of non-Māori. Of particular concern is the significantly poorer health status of rural Māori compared with rural non-Māori and urban Māori. Ensuring comprehensive, quality service coverage is therefore a key priority for District Health Boards that include rural areas.

There are still considerable variations in the levels of services available in different parts of rural New Zealand. Reasons for this include:

• the accessibility of general practitioners, nurses and other primary care providers, community health providers and public health providers in rural areas (including transport costs)

• viability of services

• ongoing difficulties in recruiting and retaining health care providers in rural areas

• distances from secondary care units and specialist services.

There needs to be improvements in the range and consistency of services for rural New Zealanders to ensure that they have certainty about access. Improvements will be achieved by policies and programmes for:

• ongoing clinical education, and training for rural health care practitioners

• a bonus for providers in rural areas

• funding for locum support

• the ongoing promotion of community-based initiatives in rural areas through innovative methods of co-ordinated service delivery involving primary and secondary health care providers

• expanding the skills and roles of service providers such as nurse practitioners and Māori health care providers to undertake a wider range of tasks in association with general practitioners

• the promotion of collaborative acute-care networks to ensure that people ‘get the right care, at the right time, in the right place from the right person’. This will involve strategies to guarantee methods of transfer to the nearest hospital capable of providing definitive care, to maximise the skills and integration of service providers and to maximise the current expertise and skills of rural practitioners

• the further promotion of the role that new technology (for example, Healthline) has in increasing rapid access to services and providing certainty

• directors of rural health in North and South Islands.

Specific issues concerning primary care in rural areas will be covered in the Primary Health Care Strategy.

There is clearly a strong relationship between these areas and the population health priorities. All of these areas are to a greater or lesser extent inter-related. Some of these linkages are shown in the table below.

	Public health	Primary health	Waiting times	Mental health	Rural health
Māori health
Pacific health
Smoking
Nutrition
Obesity
Physical activity
Suicide
Alcohol and drugs
Cancer
Cardiovascular
Diabetes
Oral health
Violence
Mental illness
Child health