New Zealand Public Health and Disability Amendment Bill — Third Reading 
New Zealand Public Health and Disability Amendment Bill — Third Reading 
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New Zealand Public Health and Disability Amendment Bill 
Third Reading 
Hon TONY RYALL (Minister of Health) 
: 
 I move  
That the New Zealand Public Health and Disability Amendment Bill be now read a third time 
. I will start by thanking the chair of the Health Committee Dr Paul Hutchison and the members of the committee and its staff for their work on this bill. I also acknowledge the Parliamentary Counsel Office and the Ministry of Health for their support to the committee. 
The bill and its supporting regulations provide the statutory environment to improve the coordination of resources across the district health boards reduce bureaucracy improve front-line health services and improve value in the public health and disability sector. The bill is consistent with the Government’s pre-election commitments where we said we would make improvements to the public health service without the distraction of massive restructuring. This bill does that. 
We can indeed be proud of our public health service in New Zealand and its many achievements as evidenced by the recent improvements in the nation’s health targets. Emergency departments are seeing more patients faster. In the last year the number of patients admitted to or discharged or transferred from an emergency department within 6 hours jumped from 81 percent to almost 90 percent. District health boards delivered 105 percent of their target for elective surgery and record numbers of patients are now getting surgery. There are shorter waiting times for cancer treatment and 99 percent of all patients received their radiation treatment within 6 weeks of their first specialist assessment. In the third quarter of 2009-10 11 district health boards achieved 100 percent in the fourth quarter 17 district health boards achieved 100 percent and next year this target moves to 4 weeks. Immunisation rates have increased. The national immunisation target of 85 percent for 2009-10 was exceeded with 87 percent of New Zealand’s 2-year-olds fully immunised and in the last year the rates for Lakes District Health Board jumped by 22 percent MidCentral District Health Board increased by 13 percent and Waikato District Health Board increased by 12 percent. 
There has been better help for smokers to quit. There were significant gains over the past year in district health board staff providing smoking cessation support to hospital patients who smoke. However there is still plenty of room to improve. The results for the diabetes and cardiovascular services showed a steady improvement with the biggest annual improvements shown by Whanganui District Health Board by 14 percent and Counties Manukau District Health Board by 10 percent. 
But as noted in the ministerial review group’s report there are a number of major challenges facing the public health and disability sector: an ageing population health workforce issues service vulnerability financial sustainability and cost growth. The system itself set up under the New Zealand Public Health and Disability Act 2000 and inherited by this Government can at times hinder performance improvement. It does not provide the levers needed to optimise value for money and deliver a health service that meets the needs of New Zealanders into the future. It actually stands in the way of system-wide change and it slows coordination between district health boards which is needed if they are to significantly improve their performance. It has encouraged localism at the expense of overall coherence and performance. There is too much fragmentation with 20 district health boards reinventing the wheel 20 times and that has frustrated both this Government and the previous Government. 
We need to get the public health and disability system to act as one system with hospitals working more closely with each other and with primary-care and community services. Hospitals must collaborate better across regions and nationally. Decision making must become less fragmented and must be made at the right level in the health service so that there is better prioritisation nationally and more efficient and effective use of our limited resources. In particular we need more cooperation across district health board boundaries. 
This bill will help by firstly improving sector planning and decision making by supporting district health boards to undertake smoother more effective and better balanced planning across the service at national regional and district levels. Better national and regional decision-making supports rational and cohesive service and capacity planning. District health boards will then be better placed to grow and protect the vulnerable health services. 
Secondly the bill accelerates improvements to quality and safety by establishing an independent Health Quality and Safety Commission. The Health and Disability Commissioner is reported as saying progress in this area has been slow and patchy under the present arrangements. The new commission will be led by clinicians and it will help organisations across the whole health service to improve patient safety and service quality at the secondary primary and community levels public and private. A Peter Davis study found that 13 percent of people admitted to hospital suffer an unintended injury caused by health care that resulted in some disability. Even a 20 percent reduction in errors could save us approximately $100 million a year—money that could be reinvested into front-line services. We want gains in better and safer care—better results better patient experiences—and we want clinicians to lead this. 
The bill will also minimise administration costs and reduce bureaucracy and waste in the public health service by supporting shared administrative support and procurement services across the public health service. That will reduce the cost of district health board back-office functions with estimated savings of up to $700 million over 5 years. That money will be crucial to help us maintain and improve front-line services over the next few years. Specifically the bill amends the district health boards’ objectives and functions so that district health boards are required to work collaboratively to meet national regional and local service needs. It creates a new planning framework which supports district health boards to plan across national regional and district levels. It provides the Minister of Health with the power to direct district health boards in regard to how administrative support procurement services within the service should be obtained and who must provide those services. That is so we can make sure that there are no hold outs to our national approach. 
The bill provides the Minister of Health with the power to give direction to all district health boards to comply with stated requirements for the purpose of supporting Government policy on improving the effectiveness and efficiency of the public health and disability sector. It provides dispute resolution measures to support district health boards to work collaboratively. As I said the bill establishes the independent Health Quality and Safety Commission which will advise the Minister on health epidemiology and quality assurance matters determine quality and safety indicators lead and coordinate work with the purpose of monitoring quality and safety across the sector and perform the other functions of quality and management that are assigned to it from time to time. The bill also enables district health board elected members to be appointed to other district health boards. 
The Government and indeed all New Zealanders want a strong and sustainable public health service: one that works successfully at both a local a regional and a national level where the planning and the service delivery is well coordinated and where we can enhance the quality of health care and reduce the duplication of corporate and administrative work. 
This bill will help us to change administrative functions and the way the health service works to reduce bureaucracy and to provide a greater focus on more important priorities. I commend the bill to the House. 
Hon RUTH DYSON (Labour—Port Hills) 
: 
 I am very pleased to stand in support of the third reading of the New Zealand Public Health and Disability Amendment Bill. I begin by commending the way in which the Health Committee considered matters during its deliberations on this bill. The select committee has three parties represented: National the Green Party and Labour. On many issues we have worked I think in an exemplary fashion. We should actually be given a gold star by the Clerk of the House and probably by the Speaker for the way in which we intelligently and seriously consider submissions. It is to the benefit of legislation that that is able to happen in the select committee process. 
I also commend the officials who assisted us with this bill. There were some political tensions in relation to both the major parts of this bill. The advisers took those issues very seriously particularly given that the concerns raised by both the Green Party and the Labour Party were backed up by an overwhelming majority of the 13 submitters. I think the advisers were really helpful in that regard. I also acknowledge the submitters. 
There was no disagreement on the two primary purposes of the bill. The first one was to establish the Health Quality and Safety Commission. My recollection is that every single submitter who commented on the establishment of the commission supported it. The second primary purpose was to give a mandate for collective purchasing across district health boards or arbitration when district health boards had any conflicts or disputes over shared services and a mandate for the Minister of Health to require district health boards to plan in unison. So that is a much more centralised directive from the Minister in regard to purchasing and planning between the district health boards. Once again every submitter said that that was an important step forward. The district health boards have made considerable progress in that regard voluntarily but if there was one that was not happy to be part of that united picture then that really held up progress so having a clear legislative back-up for that desire is a good thing. Those are both good aims and Labour supports the intent of the legislation. 
As I said concerns were raised about both of the primary purposes. The first was in relation to the Health Quality and Safety Commission. I guess I could sum up by saying that submitters the Greens and Labour felt that a commercial model just was not a suitable model for the commission. That was the funding model in the original legislation; it is no longer in the legislation. I pay huge tribute to my colleague Kevin Hague from the Green Party for his tenacity in not only having his typescript amendment submitted during the Committee of the whole House but also his ability in persuading every other party in this House to support it. Kevin Hague’s amendment was passed unanimously. I think that was an excellent move. I am sure that he will speak to it further. It is not a very common occurrence that a member from a smaller party gets through a quite significant change to a funding model in legislation. This was clearly a different ideology from what the Minister had intended and it got unanimous support from this Parliament last week. So I acknowledge Kevin Hague’s work and congratulate him on it. 
At an earlier stage of the bill the Minister commented that the primary purpose or overall aim—not its specificity—was to ensure that we had better planning for a more efficient health system whereby we would reduce waste and deliver better services. Who could argue with that? But my concern is that the statement is frankly just not true and the bill will not deliver what the Minister sets out. We have heard a lot of this stuff before from the National Government. We have heard a lot about the delivery of more front-line services but in the last 23 months we have seen about 110 cuts to front-line services. There have been well over 100 cuts to front-line services whereas the Minister promised to improve front-line services. So how do those two statements—the opposite in terms of facts—relate to each other? The answer is that they do not. 
We have also heard the Minister say on numerous occasions that the Government will cut down on bureaucracy as part of getting more of these services to the front line. However we have seen not only cuts to front-line services but also an increase in bureaucracy. There is a huge new bureaucracy in Wellington called the National Health Board. It has really undermined the Ministry of Health even though the health board is technically a unit of the Ministry of Health. The National Health Board is calling the shots. We know that the Minister has appointed people who favour his ideology rather than favouring independent Public Service advice. We know that the people who run the National Health Board and the people who used to be employees of the Ministry of Health—who are now consultants to the National Health Board—are costing us huge amounts of money. 
We know that Murray Horn was being paid $1500 a day to prepare a report that was basically laughed at by the health sector as being a massive leap backwards. When it comes to saving money and decreasing bureaucracy let alone getting more services to the front line where people in New Zealand badly need them this Minister achieves zero out of three on all three counts. He has failed miserably. It is very obvious from the increase in public concern about cuts to front-line health services that people are becoming very annoyed and feel that this is not what they voted for and that it is not what the Minister promised. It is exactly the opposite. 
In question time today I raised my concern about an entire service that is being exited from the Capital and Coast District Health Board. The Minister did not seem to be aware of that issue. He started saying that the Capital and Coast District Health Board is now in the same league as every other district health board. But that is not true because the Capital and Coast District Health Board has said that elderly people who get no personal support at all but just get home support for laundry meal preparation or house cleaning will have their home support cut from their assessment. That practice will be rolling out from 1 December. That is exactly what has been happening in Otago and Southland. Members of Parliament from that region will tell this House that it has been an absolute nightmare for them in terms of elderly people coming to them with deeply distressing stories of their unfair treatment at the hands of the Minister of Health. Those people had been getting only 1 or 2 hours of home support a week—$30 worth—but that tiny bit of help makes the difference between those people being able to stay happy well and safe in their own home or having to go reluctantly into a rest home which would cost the taxpayer around $1000 a week. 
Although the intent of this legislation is good in theory we have been waiting for 2 long years to see some responsibility shown by the Government and some delivery on its promises. We are frankly sick of seeing the opposite of what National promised before the election. We have seen no reduction in bureaucracy. We have seen hundreds of front-line services cut. We have seen nurses community health workers social workers and mental health support teams lose their jobs. We have seen home support cut. We have seen over a hundred other front-line health services cut at the same time as the Minister is saying the Government is bringing this bill in so the sector can be more efficient and deliver more front-line health services. The question that remains—and it was certainly not answered by the Minister when he read that dreadful speech just prior to my taking the call—is how this move will be judged. Nothing at all in this legislation holds the Minister accountable for the promises he made. We have heard those promises before from a National Government. We saw cash registers in public hospitals in the 1990s. We are seeing a creeping move to privatisation by stealth in our health system now and we are seeing cuts to front-line health services. Those are the concerns that submitters raised about this legislation. We have heard nothing from the Government to reassure us. 
Dr PAUL HUTCHISON (National—Hunua) 
: 
 It gives me great pleasure to speak on the third reading of the New Zealand Public Health and Disability Amendment Bill. It is somewhat disturbing to see the shroud-waving of the previous speaker Ruth Dyson and to hear the misinformation about the extraordinary advances in productivity efficiency and efficacy in this health service. 
Hon Ruth Dyson 
: Name one. 
Dr PAUL HUTCHISON 
: I will. There have been 18000 more elective surgery cases per year—18000 more per year. 
But I will just for a moment agree on one thing which was that during the submissions to the Health Committee the committee did collaborate very well and indeed collaboration in the New Zealand health services is something that we as the National Government want to promote. It was something very lacking under the previous Labour Government. I too want to thank the officials for their very helpful assistance. 
In the true spirit of the efficiency and effectiveness that this legislation wishes to promote in the New Zealand health services the parliamentary Committee stage of this bill went through in absolutely record time. In fact it was a historical record that certainly in my time I have never witnessed. During that time Kevin Hague of the Greens managed to pass an amendment—relating to the funding of the Health Quality and Safety Commission—that even he was surprised went through. I say: “Good on you Kevin!”. 
This bill is indeed about ensuring that the New Zealand public health service becomes efficient and effective and that every health dollar is spent well because that certainly did not happen during the 9 years of the Labour Government. Treasury showed extremely clearly that under Labour the level of productivity in the health sector was abysmal but this bill is one of the instruments that will certainly effect change. 
This bill is about improving coordination at the local regional and national level. Again that is something that has just not been there during the last 9 years under Labour. So busy was Labour with its massive restructuring and with its massive building up of a bureaucracy that it forgot about the aim of the original health and disability Act to ensure good coordination. This National Government is doing something about that. 
The bill is also about making the best of procurement opportunities and technology arrangements. It is about ensuring that back-office procedures are streamlined and that resources are used for front-line services. Again that has been badly needed for many years. 
This bill is about ensuring that health services are led by clinicians and that clinical networks are again led by clinicians so that we have a patient-centred health service that is largely driven by our very important nurses doctors and technicians etc. who work so ably throughout our health service. It is about ensuring the very highest quality in our health services and about continuously seeking to improve quality; it is tremendous that we have someone like Professor Alan Merry leading the independent Health Quality and Safety Commission. 
But it is profoundly important that this bill was supported by all 13 submitters and indeed by all the parties in this Parliament. One would not have thought that though when one heard the speech from Ruth Dyson. It is profoundly important because we have seen tremendous turbulence in the health service over the last 30 years due to successive Governments causing restructuring. So it is time—and timely—that some legislation is agreed upon across the board that will allow sustainability within our health service. 
It is extremely relevant that this time the National Government has brought in legislation that has been very carefully considered and that has been very carefully crafted and that true to our word the legislation is evolutionary rather than the massive restructuring we have seen in the past. The genesis of this bill of course goes back firstly to the 2008 election manifesto that National brought out  
Better Sooner More Convenient 
 followed by the ministerial review committee so ably led by Murray Horn. 
Perhaps one of the only controversies during the Committee stage was the issue of consultation with regard to strategic planning but it is somewhat ironic that the Hon Ruth Dyson forgot to bring in any amendments regarding that during the Committee stage. She was either clearly in agreement with the Government or just too lazy to bring in changes. That is similar to the record that we have seen of the Labour Government during its previous 9 years in Government. I know that even the Greens were expecting Labour to bring in an amendment with regard to consultation. As it happens the changes regarding consultation are very much fit for purpose. The previous rules were very prescriptive and not efficient or appropriate for changes significant to particular groups. In contrast the bill allows regulations to impose requirements for consultation on plans that will reflect the complexity and materiality of the changes. That is absolutely relevant and appropriate. 
After 30 years of turbulence in the health sector and after 9 years of fragmentation poor productivity and poor value for money I cannot overstate how important it is that this health legislation is supported by all parties and all submitters. This means that the Government can concentrate on improving the efficiency and productivity of the New Zealand health sector well into the future. 
IAIN LEES-GALLOWAY (Labour—Palmerston North) 
: 
 It is a pleasure to speak in support of the New Zealand Public Health and Disability Amendment Bill. Dr Hutchison alluded to the fact that it appears that all parties will support the third reading of this bill but I would like to address the concern Dr Hutchison raised about some of the material that Opposition members are covering and why we have spoken so forthrightly against some of the myths that the Government is creating about the health system. 
The Minister and Dr Hutchison spoke at length about value for money and about productivity and indeed this bill supports shared procurement and is an attempt to reduce costs in the health system. It is a good thing; it has noble objectives and the Opposition supports it. However it is based on the premise that New Zealand’s public health system costs too much has too much bureaucracy and is inefficient and unresponsive. Indeed all the Government’s spin Dr Hutchison’s speech and the Minister’s speech are all based on that premise. Much as we support any moves to make the public health system more responsive and more efficient we must dispel this ridiculous myth that the Government is espousing. 
In my second reading speech on this bill I offered up the amount of money spent per capita on health care in New Zealand as a way of measuring how New Zealand ranks internationally in terms of the total cost of health care and New Zealand ranks very well by that measure. It spends less per capita than Australia the United Kingdom Canada Germany and of course the United States of America where costs really have blown out due to that country’s total reliance on private providers and multinational health insurers and due to the influence of the lobbyists from the pharmaceutical industry. The United States of America is a country that needs to take a serious account of cost blow-outs in the health care system. 
There are however a number of other measures by which we might look at how New Zealand compares internationally. Life expectancy is one measure. Not only do we compare very very well in terms of life expectancy but when we measure life expectancy against how much we spend per person we see that we do even better. If we look at the cost of purchasing pharmaceuticals we see that New Zealand just about outranks every other country in the world thanks to Pharmac. The use of technology and information technology is another area where we do very very well internationally. I bet most people in New Zealand will be surprised by this one: satisfaction rates amongst primary-care physicians in New Zealand are absolutely astronomical in comparison with those of many overseas jurisdictions. 
The New Zealand health system does very very well yet this Government seems to insist on pushing the message—and it does so through this bill; it has built a burning platform—that the health system is in absolute crisis. Yet when we look at it in real terms we see that there is a lot of good to be said about our health system but— 
Michael Woodhouse 
: Ruth says there is nothing right and Iain says there is nothing wrong. 
IAIN LEES-GALLOWAY 
: —there are places where we can improve. My friend Mr Woodhouse is getting a little bit concerned but I ask him not to worry because I am getting there. There are areas where we can improve. But this bill is just tinkering; it is small stuff. The real savings in health care are to be found in tackling the really big issues—the things that really cost our system. 
Diabetes is one area where we do appallingly internationally. Youth suicide is probably one of our biggest shames internationally. Cardiovascular disease and diseases related to alcohol abuse to tobacco use and to the abuse of other drugs are all things that cost our system. If the Government was serious about cutting costs it would not be dilly-dallying with this bill. Instead it would have a serious strategy to take on those things—a strategy for wellness in New Zealand. 
All those issues affect those who are most deprived in a far more destructive way than they affect those who are least deprived. So the single biggest thing that this Government could do if it was serious about reducing costs in the health system would be to have a serious strategy to reduce inequalities. What have we actually seen? We have seen tax cuts that increase inequalities. We have seen an increase in GST that affects those who spend the majority of their income on the basics in a far greater and more destructive way than it affects those who have more disposable income. 
This Government is actively increasing those disparities and it is undermining the good work that our physicians our nurses and our specialists are trying to do to clean up the mess left at the bottom of the cliff. This Government has no strategy for prevention. It does not care for prevention and it does not care for reducing inequalities. We can see this in the jack-up of the Horn report. The Horn report begrudgingly mentions the previous Government’s strategies for prevention and the effect they have had. It states: “New Zealand’s relatively strong commitment to prevention and public health has helped improve life expectancy delayed the onset of disability associated with chronic disease and reduced inequalities.” 
Hon Steve Chadwick 
: 9 years of Labour. 
IAIN LEES-GALLOWAY 
: Yes 9 years of Labour and the Horn report had to admit that that was the outcome of the Labour Government’s strategies. It goes on to state: “Opinion is divided however on the much narrower question”—the much narrower question—“of the extent to which further spending in this area at the expense of more immediate health needs might help reduce future health costs or improve the country’s economic performance thus making future health spending more affordable.” That narrow focus is what this Government is focused on. 
Hon Steve Chadwick 
: Sleight of hand. 
IAIN LEES-GALLOWAY 
: It is sleight of hand; it is smoke and mirrors. The Government is not interested in the big picture. It is not interested in where our health system might get to in 2020 or 2030 or in improving outcomes for our children. It is interested in the very narrow focus of the here and now. 
Do members know what? I am prepared to concede that that politically this bill makes some sense for National. People who habitually vote for the National Party do not tend—I am talking about tendencies here—to suffer from social deprivation. They do not suffer from the effects of low income. They do not suffer from diseases such as diabetes cardiovascular disease and everything else. They certainly do not tend to suffer from rheumatic fever. So politically a focus on the here and now and on the health system’s ability to respond to people who are fundamentally well makes sense for National. If National was truly interested in all people in New Zealand and if it really had a strategy that encompassed the whole community in New Zealand then it would not be faffing around with this bill and it would not be faffing around with the kinds of recommendations from the Horn report. Instead it would be focused on a true preventive public health strategy—and do members know what? That is what Australia is doing. 
We are very focused on the catch-up with Australia on trying to close the wage gap and on catching up economically with Australia. The Government is failing abysmally on that as well. Australia’s big priorities are obesity tobacco and alcohol. Australia has not come up with just a few bullet points and a catchy slogan. On each of those issues it has an overview a road map of how to get to its final goal and technical papers that deal with the guts and the details. Australians have a plan and they know where they want to be in 2020. The Labor Government in Australia has a real strategy for encompassing everybody in the community and for wellness in the whole community. 
The Opposition supports the objectives of this bill. It certainly does no harm so we are happy to see it pass through the House. But there is a problem with our health system: it is not what the Government is offering in terms of problems; it is how the Government treats those who are most deprived and most vulnerable in our community. This bill does not address that problem and it is about time we had a Government that was prepared to put up something that does. 
KEVIN HAGUE (Green) 
: 
 Hear hear! Iain Lees-Galloway made a great speech. 
I begin by echoing the comments made by both Paul Hutchison and Ruth Dyson—and indeed by me in my second reading speech—praising the other members of the Health Committee for their work and also the officials and the submitters; it was a great experience to be part of. 
It was a shame that the Minister of Health in his speech to open this debate could not resist the temptation to talk about what he sees as the achievements of this Government in the health sector. Inevitably that opens up the territory to members like me who see this Government’s achievements in health as particularly negative. 
For example I need to respond to the Minister’s comments by pointing out that in its two Budgets so far this Government has slashed funding for health services in real terms. In this year’s Budget we are at least $150 million down on what is required for the health sector to tread water in real terms. That is being measured right across the sector and services that are being cut are struggling now to maintain parity with the task that has been set for them. 
We have also seen the Government whittle away the targets that the health sector has and focus those targets on particular areas of performance. For example Paul Hutchison talked as the Minister did about increased elective surgery. Well elective surgery is one of the few targets left in the health sector so that is what the sector chooses to focus on rather than everything else. As it happens elective surgery makes up about 5 percent of what we ask the health sector to do and if we asked most of the experts in health they would say it is the least important 5 percent. And it is occurring at the expense of the most important aspects of the health sector which are public health and primary care. 
We have not seen from this Government any kind of coherent plan for dealing with the crisis in rural and provincial health services. Indeed just 2 weeks ago we heard from Murray Horn who chairs the National Health Board comments along the lines of “when” hospital services for West Coast people are centralised in Christchurch. Well for West Coast people that is an alarm bell because it suggests that the Government in fact has made a decision about the future of health services and the future of rural hospital services is to be centralised in city hospitals. That is certainly one of the options but I think most rural people were hoping that the Government would instead support the retention of hospital services in rural areas and would have something sensible to say and do about the retention of primary care services in rural areas also. Sadly no. 
It is early days but as yet we have not seen any kind of coherent plan for dealing with the crisis in the health sector workforce. We certainly look forward to the Minister having something to say about that issue. We have a Ministry of Health that is currently in disarray and there is critical erosion of capability largely as a result of the significant change that is occurring leaving the ministry effectively in irons. I could go on but I make these criticisms as I said because the Minister himself opened up this territory. 
Collaboration is an important area and it is one that the Green Party has advocated strongly for. Collaboration between district health boards and between other entities in the health sector enables us to have a health sector and a health service that is able to respond in an intelligent way to the fact that some services need to be organised very much at a local level while others require a regional or national focus. So the effect of this bill the New Zealand Public Health and Disability Amendment Bill in enabling better collaboration between entities in the health sector is good and a far far preferable alternative to restructuring the sector once again and forcing mergers between district health boards and other entities. I do not need to say anything more about that. 
The Health Quality and Safety Commission is also a really important advance. Debates on earlier stages of this bill have highlighted the enormous potential to extract gains in the health sector from improving aspects of quality such as accessibility of services the acceptability of those services their effectiveness their efficiency and the safety of services. The potential for gain is very great indeed. 
It will be important when the commission begins work that it focuses right across the sector on all aspects right from public health at one end—those services intended to keep people well—through primary care secondary care tertiary care and even quaternary services and also disability support services and aged-care services. It is also important that it not only deals with those aspects of health services that are about the interaction between individual clinicians and individual patients but also reflects on and works to create improvements in system-wide effects—the systemic effect of health services and the systemic situation of those people using health services. Iain Lees-Galloway referred to the effect of inequality on health and that will have an important impact on the work that this commission does. 
I thank both Paul Hutchison and Ruth Dyson for their kind remarks about the amendment to this bill that I brought to the House. Indeed I congratulate the House and all of its parties everyone represented here on the unanimous support for the amendment. I probably do not need to go over the arguments which have been well-rehearsed in the House save to say that had the self-funding model that originally appeared in the bill been allowed to stand the consequence would have been perverse incentives that would have produced suboptimal outcomes and indeed hamstrung the commission in its work. I think it is to the House’s credit that that model has not been allowed to stand. Instead we have a rational and sensible basis for funding the service. 
I want to finish by referring to a couple of the next priorities. As Gareth Morgan pointed out in his book  
Health Cheque 
 some of the real outstanding priorities for the New Zealand health sector are firstly to massively increase the investment and focus of the sector on public health services—those services intended to keep people well in the first place and prevent illness and disability. As Gareth Morgan points out those services have far and away the best return on investment. The second thing that Gareth Morgan says we should be doing is leading a focused debate amongst New Zealand citizens on how we should make decisions about allocating the limited dollars and resources that are available to the health sector. On the first of those priorities we have a Government that is currently moving in the wrong direction. It is taking money away from public health and putting it into the more specialised end of services. That is absolutely wrong. On the second of those priorities we are still waiting to hear from the Minister about the progress that is being made in reforming the National Health Committee and the Public Health Advisory Committee to actually undertake precisely that task that Gareth Morgan suggests is important which is to start a national conversation about how we best prioritise scarce health resources. 
This bill is an important start but we now need to move on to the really important work that lies before us. Thank you. 
Hon HEATHER ROY (ACT) 
: 
 I rise to speak to the third reading of the New Zealand Public Health and Disability Amendment Bill on behalf of the ACT Party. We will be supporting the bill as I think every party in the House is. I congratulate the Minister of Health on this bill. I think it makes some very pertinent changes to the public health sector. 
The initiatives in the bill have been pretty well traversed by many of the speakers who have preceded me and I will mention a few. The establishment of the Health Quality and Safety Commission is a very good move and I think we can expect to see some good things come out of it. It allows elected district health board members to be appointed to other district health boards. It makes a good deal of sense and we have already seen some people be appointed to more than one district health board because they have the right skills ability and experience in the health sector to make meaningful decisions and in many respects lead the discussions that need to be had. 
The bill amends district health board planning requirements to provide for planning and accountability frameworks that take into account national regional and local requirements. The speaker who preceded me the Green member Kevin Hague mentioned that very pertinent things are happening at a local level but there are times when regional and national initiatives are needed usually because of geography or because of the sheer size of the issues being looked at. 
The bill increases ministerial powers to direct district health boards to enhance the use of shared services in the health system. For many years now we have been seeing boards cooperating and collaborating to establish shared services. The result is nearly always greater efficiency and a much better utilisation of scarce resources particularly financial resources and we want to see much more of that. 
We are seeing much better cooperation and collaboration between district health boards particularly since the change in Government. We have seen a significant emphasis on the regionalisation of services where that is appropriate and it too has brought greater efficiency to the sector. As a result patients are being seen in a much timelier manner and waiting lists in many areas have been reduced. That is exactly what we need to see. I think there is a lot of scope yet. 
This bill has brought about much better cooperation between the public and private sectors. The private sector is able to gear up when it has certainty of contracting to be able to provide services particularly where there are significant gaps long waiting lists or whatever in the public system. We should not get caught up in the debate or the philosophical blinkering of the ills of the private sector or the ills of the public sector; we should be striving day in day out to break down those barriers so that we consider health care health services and the health workforce as an umbrella. It does not really matter to a patient who is ill where the services come from as long as that patient is able to receive timely quality services. That should be the aim. 
The health sector workforce was also mentioned by the Green Party member. If he had not mentioned it I was going to launch into that. We have seen in the last week a report saying that shortages of health professionals in the short and long term are significant issues. One of the things that I talked about a lot when I was the health spokesperson for the ACT Party in Opposition was the fact that we are very good at training health professionals from physiotherapists and occupational therapists to nurses and doctors but we are not good at keeping them in New Zealand. I used to talk about training our health professionals for export. Sadly there is far too much of that happening and we need to find ways to combat that phenomenon. Recruitment and retention are still significant issues for the health sector and will be increasingly so looking into the future. 
Iain Lees-Galloway talked about Australia. There are some impressive things happening in Australia. He talked particularly about primary care and I think there are some lessons to learn there. He talked about the focus on obesity tobacco and alcohol. But he did not tell the House about the other side of that equation—that is the Australian private health sector has much greater involvement in the overall health picture. More Australians belong to health insurance schemes. The Australian Government also makes a significant effort to contract with the private sector. Those things make a significant difference to waiting lists or waiting times—whichever we want to use as a measure—and they are much better at matching quality medical services with patients in a timely manner. 
We have to pay attention to our economy. This Government is making significant gains in this area. I think we could be making faster significant gains if we were prepared to make some tougher decisions particularly about tackling Government spending but that is really a matter for another day. 
I am in favour of this bill; the initiatives are very good but I wonder whether the initiatives are just about tinkering with the public health sector rather than looking to make significant and meaningful change. One of the things that I think has been a lost opportunity with this bill is related to grappling with the way that we elect and run district health boards. We have just had local government and district health board elections and one of the questions that I would like the Minister to address is why we have district health board elections. Most people have absolutely no idea whom they are expected to vote for. There is a cost to the elections; I asked the Minister in the House the other day what the cost was of running the elections to select people for district health boards and what the cost was of running the boards. I think we need to look at the sense in doing that. I ask whether we need 11-person boards when in fact a three- or five-person committee might do just as good a job. I ask whether it would do the job more efficiently. I ask what the saving to the taxpayer would be and how much that saving would translate into health services. That is something we need to look at very seriously. What is gained by having elections? What is the percentage of people who actually voted? The figures are not in yet from the latest round of district health board elections but we need to look at the percentage of people who voted. Do voters know anything about whom they are voting for? Are we electing the right people or are the district health boards heavily reliant on the Minister’s four appointees to each board for the skills that are needed? Personally I think we would be much better off with a three- or a five-person committee appointed by the Minister to run each of the district health boards and that would bring about significant savings. 
I will finish there. I reiterate that the ACT Party supports this bill; we think that these are good initiatives that make a good deal of sense particularly in relation to the running functions and organisation of district health boards but the bill is an opportunity lost because it could have been an opportunity to look at whether things could be run much more efficiently. 
I acknowledge the points that the Labour and Green members made about looking to the future in terms of our health services. We need to take seriously the workforce issues and the use of the public sector particularly in promoting primary care. We need to take seriously those issues as our population continues to age and I look forward to continued debates on those issues. Thank you. 
RAHUI KATENE (Maori Party—Te Tai Tonga) 
: 
 At the second reading of the New Zealand Public Health and Disability Amendment Bill I raised the issue of district health board public consultation requirements. The House will recall that the Health Committee’s view was that the bill would likely weaken the consultation element of the Act that is being amended. In essence the core objection the Maori Party had to the bill was directly related to the Treaty clause in the New Zealand Public Health and Disability Act which we see to be of crucial importance. A Treaty clause is also included in Crown funding agreements with district health boards. Although there is a standardised Treaty clause some differ depending on the agreement with the provider. The general thrust of the Treaty clause is the statement: “The DHB has a responsibility to assist the Crown in fulfilling its obligations under the Treaty of Waitangi and are guided in that responsibility by the NZPHD Act and other policy directions from the Crown. The Act requires DHBs to take active steps to reduce health disparities by improving health outcomes for Maori.” 
For all those prone to anxiety about how symbolic intent translates into implementation let me assure the House that the strength of the principal Act is that it provides specific and pragmatic assurances about how these obligations can be fulfilled. For example Crown funding agreements with district health boards state: “DHBs must establish and maintain DHB processes to enable Maori to participate in and contribute towards strategies for Maori health improvement. This recognises and respects the principles of the Treaty of Waitangi. References to the Treaty of Waitangi and the principles of partnership participation and protection in DHB accountability documents and agreements between the Minister and the Crown derive from and should therefore be understood in this context.” 
I want to be really clear about just how important this Treaty framework is and for all providers to understand how to enact the founding document of our nation. A Treaty clause is used in Ministry of Health contracts with providers primarily to fulfil and comply with section 4 of the New Zealand Public Health and Disability Act 2000. The Act recognises the importance of the Treaty relationship in facilitating Maori involvement in Maori health provisions and outcomes. For the record I remind us all of the wording of section 4 of that Act which has become a benchmark for the way in which we can truly respect and adhere to the aspirations that all our ancestors had when they signed up in 1840: “In order to recognise and respect the principles of the Treaty of Waitangi and with a view to improving health outcomes for Maori Part 3 provides for mechanisms to enable Maori to contribute to decision-making on and to participate in the delivery of health and disability services.” This is a vital reference point for the bill as an entirety and specifically in relation to the concerns I have raised in the House previously in relation to consultation. 
I pay credit to my colleague the Hon Tariana Turia for the leadership she demonstrated back in 2002 with the introduction of  
He Korowai Oranga: Maori Health Strategy 
. That strategy says outright that the Government is committed to fulfilling the special relationship between iwi and the Crown under the Treaty of Waitangi. It goes further outlining how the principles of partnership participation and protection derived from the Royal Commission on Social Policy will continue to underpin that relationship. They are threaded throughout  
He Korowai Oranga.  
Partnership will be demonstrated in working together with iwi hapu whanau and Maori communities to develop strategies for Maori health gain and appropriate health and disability services. Participation will be illustrated in involving Maori at all levels of the sector in the decision making planning development and delivery of health and disability services. Protection will be evident as a priority when the sector collaborates and cooperates to ensure that Maori have at least the same level of health as non-Maori and that Maori cultural concepts values and practices are safeguarded. 
The foundation that I have laid out today is critical to understanding why we have raised concerns about the vital need to enhance and articulate the detail in consultation. An overarching aim of the health and disability sector is the improvement of health outcomes and the reduction of health inequalities for Maori. How else are we to do this other than with the active involvement of whanau hapu and iwi? We in the Maori Party want to see the active involvement of manu whenua to facilitate Maori access to services the provision of appropriate pathways of care which might include but are not limited to matters such as referrals and discharge planning and ensuring that services are culturally competent and are provided to meet the health needs of Maori. It is expected that there will be Maori participation in the decision making about and the delivery of the service. 
When I spoke to this bill at the second reading I raised my concerns from the select committee’s view that the bill would likely weaken the consultation element of the Act. Presently the Act requires the same standard of consultation as section 83 of the Local Government Act 2002. The bill requires consultation but the standard of consultation is not defined. When I spoke I said that that worried us and it continues to worry us. The local body elections held over a week ago have provided even further reason why we need to be vigilant about the issues of representation and participation of Maori in the health sector. Around the country we saw that Maori were unfairly inequitably and disproportionately under-represented on elected councils including district health boards. 
Section 29(4) of the Public Health and Disability Act 2000 requires the Minister of Health to ensure that Maori membership of the board is proportional to the number of Maori in the district health board’s resident population and that there are at least two members on the board. Despite the legislative measures in place all our experience and anecdotal evidence tells us that there are still far too many district health boards that fail to meet even those most minimum requirements. We want to be absolutely sure that we have every base covered and that we maintain a determined resolve to ensure that Maori membership of the district health boards is both proportional to its Maori population and a minimum of two members. We will be insisting that robust and comprehensive consultation processes are in place to enable Maori to contribute to decision making on and to participate in the delivery of health and disability services. 
Finally I do not want to leave the impression that it is district health boards only where Maori representation is an issue. I refer the House to the report to the Minister of Local Government on the review of the Local Government Act 2002 and the Local Electoral Act 2001 special topic paper on representation February 2008. They reveal that in Wellington and Dunedin only 1 percent of the members on local councils are Maori; in Blenheim there are none. Clearly there is a much bigger picture surrounding Maori participation and representation. It is an issue that we want to fully canvass in the upcoming constitutional review. 
We will support this bill at its third and final reading but we will be looking to the Minister to provide us with more confidence on the capacities of district health boards to consult and fully involve mana whenua. 
NICKY WAGNER (National) 
: 
 I rise to support the New Zealand Public Health and Disability Amendment Bill at its third reading. All parties in the House support this bill which is designed to increase efficiency and effectiveness in the public health system. We all know and are concerned about the increasing costs of care throughout the world and in New Zealand and faced with an ageing population and increasing demand for new technologies and services it means that focusing on cost-effectiveness and high-quality services is essential. 
This bill is based on the recommendations of the expert ministerial review group which was commissioned when National came into Government. The bill provides a framework to introduce national and regional cooperation and to reduce duplication of back-office functions. It also supports a greater focus on patient safety across the health sector and responds to the call from health professionals for an independent commission and an agency to step up quality involvement across the whole sector. The bill received very positive support from the 13 submitters. They supported the moves to improve the coordination of planning at local regional and national levels and there was also support for an enhanced quality of health care and the reduction of duplication. 
The bill also establishes a new Crown entity called the Health Quality and Safety Commission. Its function is to promote and support better quality and safety in health and disability support services to determine quality and safety indicators and to advise the Minister on any health epidemiology and quality-assurance matters. There is very good support for improved quality and for an improvement in the coordination of health services and in the level of cooperation and collaboration between health sector agencies. There is also support for the need to drive better value for money in the public health sector given the tight funding environment and the inexorable increase in demand for health care services. 
The Nurses Organisation supported the direction of the bill and saw it as “filling the gaps in the current health framework without the need for major restructuring”. It also noted that it was the intention of the bill to improve the functioning of the health system to deliver better sooner more convenient health services for all New Zealanders. The Association of Salaried Medical Specialists commented on the need to increase collaboration between district health boards and to reduce the unnecessary duplication of resources in such a small country. It is hoped that the opportunity that this bill provides for district health board members to sit on more than one district health board will increase understanding between boards and foster closer working relationships. The bill also provides rules for mediation and arbitration to cover disputes between district health boards. 
This is an important bill. It has been well supported in the Health Committee and in the House and it will help the health sector to deliver better-quality and more cost-effective health services across the country. I commend it to the House. 
LYNNE PILLAY (Labour) 
: 
 I join my colleagues and indeed the whole House in supporting the New Zealand Public Health and Disability Amendment Bill but I put on record that I do so with some caution. No one would question the purpose of the bill which is to establish the Health Quality and Safety Commission and provide a mandate for collective purchasing which as the Minister says will save—I think the claim is—some $700 million. Certainly those sound like very appropriate purposes. The bill also allows for a system of arbitration where there is conflict over shared services. 
In terms of planning of health services within our hospitals no one in this House would argue about the need for efficiency. In fact when in Government Labour made many moves to ensure that the health system was more efficient. But we on this side of the House express some caution—and it is very appropriate caution given National’s history and its record in just this term of Government. 
I congratulate Kevin Hague as my colleagues have done on his successful amendment that went through. In fact it was agreed to without debate because it was so well-supported. The amendment removed the requirement for the commission to be self-funding. I quote Kevin Hague when he stated a concern that “usually with the best of intention there could be an incentive for service providers if they have to pay for quality improvement programmes and also have a constrained financial position”—which is indeed the case under this Government—“then they may well choose not to pick up all of the programmes and whilst we hope that service providers would usually prioritise quality and safety over financial cost the reality is that this will only occur through the ethics of the providers and their personnel because the incentives are generally set up in the system to focus on the dollar.” 
I say to Kevin Hague that that is very wisely put and I certainly agree. When we consider some of the cuts to programmes that we have seen in the short time this Government has been in power I agree with Kevin Hague and I reiterate how important it is to have those checks and balances. In terms of consultation I say that along with the checks and balances in terms of providing the best-quality health services which are what every New Zealander is entitled to I am in agreement with Women’s Health Action which was really concerned that “Consultation with communities should not be viewed as a nicety but rather as a fundamental part of the public health and disability system that ensures health and disability services are appropriate for and responsive to those who use them.” 
The purpose of my address this afternoon is to put the Government—and I say this along with my colleagues—on notice that Labour members will be watching we will be monitoring and we will be ensuring that we do not see this legislation brought in at the cost of consultation and at the cost of provision of quality services to people. 
One may ask why we would have these concerns. Well I think we only have to look at National’s record and we see a distinct change under this Government. The previous Labour Government was about promoting wellness in health and the very successful primary health organisations ensured that doctors’ visits across the board within primary health care were affordable and were contained at an affordable level. It is very disappointing that that is now not the case and we see the cost creeping up. 
We have seen real cuts to primary health initiatives that promote wellness and prevent major financial cost to say nothing of the cost to people’s quality of life later on or indeed the ultimate cost the cost of their life. Those supports the promotion of health initiatives have not been there at the important times. If members in the House or the Government were to ask where that could be seen I would have to ask for an extension to this speech to go through all the cuts that have occurred. 
If we look at the issue of obesity we on this side of the House are not of the view if we can go back that in terms of promoting wellness— 
Mr DEPUTY SPEAKER 
: This is a third reading speech. 
LYNNE PILLAY 
: Promoting wellness is very much part of what should happen in primary health care or in our health system. I know that district health boards are responsible for funding many of these health care programmes whether they are about drug or alcohol abuse whether they are about dependency or whether they are about things like smoking cessation programmes which are absolutely vital in terms of the health and safety of our nation. The cuts in these areas are to the mental health services and we know that due to the dramatic cuts in funding in those areas we will be paying the price much further along the way. With the best will in the world with the purpose of this bill to establish the Health Quality and Safety Commission many of these cuts have been at the cost of health and safety to all New Zealanders. So there is a certain irony there. 
The mental health service is really important to invest in as well as healthy eating programmes. If we look at initiatives that are often provided or funded through the district health board we see the cuts to healthy eating programmes in school such as Fruit in Schools to sexual and reproductive health services and to support for Alzheimer’s disease. All of these services are effectively getting the chop. There is some misgiving and much concern—I see Paul Quinn over there sharing his concern as well. Paul Quinn is someone who often does not act entirely in a partisan way. He often has the courage to speak out and say that he agrees with the Opposition in some instances when there are concerns about what is being cut certainly in the area of health care. 
We in Labour are putting the Government on notice. We will be monitoring this efficiency. We believe that if we got our calculators out and looked at the millions in savings at the moment that this Government has brought in we would see that the savings are from cuts to services—cuts to vital services that should be provided. These savings of efficiency cannot be at the cost of quality. 
So certainly this bill is supported and it is enhanced by the Green Party’s amendment. I congratulate Kevin Hague; he has had lots of accolades today in the House and I think that is very fitting. So along with my colleagues I do support this bill but certainly give notice that Labour members and I know the very hard-working members on the Health Committee will be taking a real interest in this bill. Thank you very much. 
Dr JACKIE BLUE (National) 
: 
 I am very pleased to speak in the third reading of the New Zealand Public Health and Disability Amendment Bill. This bill is the result of proposed changes that came about from the recommendations of the ministerial review group. I believe that it was a landmark document from the ministerial review group. It really discovered that the public sector was not working well. It was working in a siloed way and the group was concerned about the 21 different ways of doing things in the 21 different district health boards. Essentially there was competition and very little collaboration in some instances. This bill is not a major restructuring of the health system. It is about making things work better and making people work more collaboratively. The proposed changes will result in better value for money in our public health sector will enable greater national cooperation in the sector and will reduce duplication and bureaucracy. 
The ministerial review group comprehensively assessed the sector and I think it did an excellent job. I congratulate the group on the extremely impressive work that it did. It made 170 recommendations on how to reduce bureaucracy improve front-line health services and improve value in the public health and disability sector. This bill is about progressing some of those areas. 
The public health sector faces many challenges. New Zealand has an ageing population with more long-term and chronic health problems and it has a health workforce that has been dependent largely on staff trained overseas. This all comes with the backdrop of international workforce shortages. There are district health boards struggling to be financially sustainable there are concerns about the quality of care and preventable errors and there are concerns about the health indicators that we have had which have been quite a mixed bag when New Zealand is compared with other OECD countries. This bill is about ensuring that the public health system is better positioned to meet the growing need and demand for it while the world remains in an economically challenged position. 
There have been a number of amendments to the principal Act and I would like to deal with the establishment of the Health Quality and Safety Commission in Part 1 of the bill. The ministerial review group was very concerned about the quality of care and in particular about preventable and avoidable errors. It is estimated that avoidable and preventable errors—adverse events—cost around half a billion dollars each year which is staggering. This bill proposes the establishment of a stand-alone commission which could save up to $100 million each year. The commission’s objectives are to monitor and improve the quality and safety of health in the disability support sectors and to help providers to make improvements. New section 59B inserted by clause 11 of the bill defines the functions of the commission which cover the areas that were previously undertaken by the National Health Epidemiology and Quality Assurance Committee. The committee’s functions all relate to quality and safety indicators reports and the promotion and dissemination of information. 
Huge inroads have been made in productivity in the health area all under the leadership of our Minister of Health Tony Ryall. I will talk a wee bit about the six health targets which have been at the front of people’s minds in the public health sector and I believe that is important. It keeps the issues at the front of the mind of clinicians and district health boards so that they know what they critically and urgently need to be focused on. We have seen improvements in many areas and elective surgery is one outstanding area. The target for elective surgery was an increase in volume by an average of 4000 procedures. In the last year despite swine flu and the recession that target was exceeded by over 12000 procedures. That is a staggering result. 
There have been shorter emergency department waiting times. Emergency departments are the shop fronts of district health boards. The target is that 95 percent of people should be treated within 6 hours and it is pleasing to see that district health boards are stepping up. That target has been increasingly achieved by district health boards around New Zealand. I visited Counties Manukau District Health Board when it celebrated its achievement of that target. It did not happen just overnight. It was about consultation. Everyone from the orderly to the reception staff and the clinical team was involved and consulted. They were told exactly why it was important to reach that target. The issue was all about collaborating consulting and talking and that is how that district health board achieved that. 
The waiting times for cancer treatment are something that is particularly dear to my heart. Radiation oncology times have improved markedly since the previous term of Parliament. Virtually every district health board is achieving improvements. Every cancer centre is achieving the 6-week target and under Tony Ryall’s leadership not one person has had to go to Sydney for treatment. By December this year that target will be down to 4 weeks and there is every expectation that the cancer centres will achieve that target. That is also a fantastic result. 
Immunisation is another success story. The target is to have 85 percent of 2-year-olds fully immunised. We have achieved that. That was achieved 3 months sooner than had been expected. 
We have had a fragmented public health system and along with that district health boards have had to cope with significant financial and clinical challenges. There has been too much duplication and poor regional and national performance. This bill will go some way towards ensuring that the public health system is better positioned for the future. Thank you. 
Hon DAMIEN O’CONNOR (Labour) 
: 
 What a pleasure it was to hear particularly the last parts of that speech from Dr Jackie Blue. Dr Blue who is a good member of the Health Committee pointed out that there is duplication in the health system. Indeed I think that most of us would agree that there has been much of that. Indeed it was set up in the 1990s by the previous National Government which thought that having Crown health enterprises competing against one another would be efficient effective and market-driven. Well blow me down National members have finally discovered that a little bit of collaboration and coordination is actually good particularly in a system that has the potential to consume huge amounts of money and can have an unlimited demand for its services depending on the technology. 
The New Zealand Public Health and Disability Amendment Bill is a good bill but it offers us the opportunity to raise a few questions. As has been said it establishes a Health Quality and Safety Commission. No one could argue with the objective of trying to improve health and safety in the health system or to improve public safety. We need to get better at every opportunity and that is great. 
The bill has also introduced a mandate for collective purchasing across district health boards—that is having a Pharmac-type body that has some grunt some muscle to negotiate better prices for services goods and consumables in the health system which can get a better deal and lower the costs for everyone. It is smart; it should have been happening. 
In fact the previous National Government brought in Pharmac and I applaud it for that but when National came back into Government John Key said that Pharmac might be up for renegotiation because the US - New Zealand free-trade agreement might require some reconsideration of Pharmac’s role. Well because I have not heard that being said for a while I hope that the Prime Minister is being guided by the collective wisdom of his colleagues. He has not been there for long—I can accept that—but his colleagues know that Pharmac is the single best thing that National did when it was last in Government—I have to say that. It is acknowledged throughout the world as being the way to control the cost of pharmaceuticals. This bill allows for coordination across district health boards and that is good. 
This Government talks about customer focus market drivers user-pays and all those wonderful commercial terms. Normally customers should be able to have a say in the services they get. That occurs in this system through consultation between the district health boards and the people in their regions. These are taxpayers who fund the public health system. They expect to have a good public health system in their regions and they expect to have it delivered by the district health boards. But this bill removes the obligation for district health boards to consult the public and that is a backward step. 
Clause 10 repeals section 38 of the New Zealand Public Health and Disability Act and substitutes new section 38. That new section removes any obligation to consult. That is quite bizarre. I can state categorically that the people of the West Coast have different expectations and needs from those of the people of Manukau. It is important that the senior managers of the district health board consult the community to get a steer on what it expects from its public health system because it is not as easy as that to define. 
As members will understand another silly exercise conducted by National was the core health services review. The previous National Government thought it could identify what core health services were. It was going to define them and say that they were what the public health system should deliver that all the rest would be up to the private sector and if people wanted to purchase those services or get insurance then they could do that. 
After a couple of years—2 or 3 years; it was a long process—National discovered that one cannot define core health services. Why? Because they are different for every part of the country and for every single community. Yet this bill removes the obligation for the people in charge of literally hundreds of millions of dollars’ worth of expenditure to talk with their communities. That is a silly piece of this legislation. [ 
Interruption 
] I ask the member who spoke for National to explain why he thinks that removing the obligation to consult is a good thing. 
This bill is also about Tony Ryall’s claim to efficiency and effectiveness in front-line services and all the rest of it. We hear the figures dribbling off the tongues of the National members quite regularly. We hear about elective surgery etc. We have seen cuts being made to the investment side of health to pay for those elective surgery procedures. No one would deny that new hip replacements new knees etc. are necessary—no one would deny that. There have always been waiting lists. Because of technology and the fact that there are more things we can do in health there is always a demand. But if we invest in that end where we can easily count the procedures and take the money from the investment input end—that is preventive health care and having better knowledge in the communities—it is a zero sum game because over time it costs the Government and each and every one of us as taxpayers more and more money in health care. 
Labour had a huge commitment to primary health care. We invested literally hundreds of millions and yes we were crucified by National for doing that. We invested it at the preventive end. But right from the moment that National came in we have had cuts and cuts and cuts. Tony Ryall said that he would cut $700 million from the health system. Well he is doing pretty well. He has reversed healthy food guidelines— 
Michael Woodhouse 
: He never said that. 
Hon DAMIEN O’CONNOR 
: He made a song and dance about them and said they were silly things. Then he cut things like sending the breast cancer bus to places like Westport. People now have to travel 100 kilometres whereas the bus used to come to them. National has cut home support services in Southland and Otago—$10 million was cut from home support services. These are people in their homes who need 1 or 2 hours’ help a week to maintain their hygiene and their good health and Tony Ryall has cut those services. National members have cut anti-obesity funding oral health care funding and mental health care funding at a time when we have acknowledged the obesity epidemic. 
Jo Goodhew 
: No they have not—oral health funding has not been cut. 
Hon DAMIEN O’CONNOR 
: There is the member for Timaru. Well Timaru Hospital cut services. It said it had to cut 5000 people from coming into the emergency ward at Timaru Hospital. One just cannot do that without squeezing access to services for many many people particularly in Timaru. Radiology services in Timaru were cut by 10 percent. That means that the people who needed those services either had to travel to Christchurch or they did not get access when they should have. There have also been cuts to services for the elderly in South Canterbury in that member’s electorate. Those cuts were to achieve Tony Ryall’s $700 million of tax savings. If that member wants to go out and explain to the elderly why she has cut 1 hour or 2 hours from their home-care services then good luck to her. I think she will find out the effect of those cuts next year in the election campaign. 
This goes on and on. I could list literally hundreds of cuts across the health sector. The member for Rangitata says those cuts were in the area of low-value spending but they were not. Those areas of expenditure were in the preventive investment side of health care to improve the health status of the population across the board. When the district health board went out to consult it picked up where the most effective areas were to make those inroads. Was it in oral health care? Was it in the area of good eating or obesity? 
This bill has some good components in collective purchasing but the removal of the ability and the obligation by district health boards to consult communities is a very backward step and we will pay for that dearly in the long run. 
MICHAEL WOODHOUSE (National) 
: 
 One of the most important parts of the democratic process is the ability to debate the merits of a policy or a bill. Most of that happens in this Chamber or at select committees. That is the pointy edge of democracy I guess. So although there appears to be unanimous support for this bill we have heard a number of members on the other side of the House say that it is tinkering or that it does not go far enough and they want to ask the Minister this that and the next thing. If that is of such concern to those members where on earth were they at the stage of the bill when they could do just that—the Committee of the whole House? Although it is very rare to have a public health and disability bill passed unanimously through the House I am absolutely certain it is unheard of that such a bill is passed unanimously without a single word being said or question being asked of the executive by the Opposition at the Committee stage. 
It really does lay bare the empty rhetoric that we have heard including from the member who has just resumed his seat about all the concerns about cuts which frankly I would be very happy to refute emphatically. It is simply empty rhetoric none more so than what we heard in the call from the member Mr Lees-Galloway which I would describe as very articulate nonsense. He talked about there being no true public health strategy for prevention and he even accused National voters and supporters of not having diabetes heart disease or any other chronic illnesses. It was absolute nonsense. But here is what I would like him to do. I would like him to go to the 75000 homeowners who have had their houses insulated under the Warm Up New Zealand programme 55 percent of whom have a community services card and ask them whether the National Government has a public health strategy. When we had 30 percent increases in the price of tobacco— 
Hon Member 
: That was the Greens. 
MICHAEL WOODHOUSE 
: That programme was a joint initiative no doubt but it did not happen under Labour; that is the point I am trying to make. National came up with the money. What else did not happen under Labour is 30 percent increases in the price of tobacco; again that is unprecedented in this country. If Mr Lees-Galloway thinks that this Government is in the pockets of the tobacco lobby and if he stands as the champion for Labour in tobacco cessation rates then he needs to explain why Labour when in Government did not take the same bold steps as a public health initiative. 
Thanks to the efforts made under this Government nearly 90 percent of our children are now fully immunised against vaccine-preventable diseases. Thanks to the Health Committee’s recommendations which will come out of the inquiry into how to improve childhood immunisation rates I have every confidence that that rate will go to 95 percent. It is absolutely unprecedented in this country and again certainly no public health initiative by the previous Government matched it. It is just a fallacy to say that this Government is not focused on public health. I suspect that Mr Iain Lees-Galloway cannot see the wood for the public health trees. 
There have been some changes. We might have dispensed with a few poster campaigns and we might have stopped funding a particular Internet programme that did not actually add any value because the Minister of Health has made it very clear that our limited resources have to be spent on services that will add value and I think a few of them did not. But it is not true to say that this Government does not fund public health. I think Mr McCully in his capacity as Minister for Sport and Recreation summed it up when he said that we could spend a lot of money on these poster campaigns or Internet campaigns or we can just give kids a bat and ball and send them out into the playground to exercise. I think that is where the merits of this Government lie. 
We heard from Ms Dyson that there was nothing from the Minister to reassure the public that their health needs will be met. Well the extra 25000 elective surgeries are a good start the reduction in cancer treatment waiting-times is a good start the really good performance in emergency department throughputs is a really good start as are our immunisation rates our improvements in our health workforce the voluntary bonding scheme—I could go on. The very fact is that much as the Opposition do not like to admit it this Government has managed to get a lot more for a little more. I think that is very commendable. I commend the bill to the House. 
Bill read a third time.