Delegates at the RNZCGP conference's Sunday morning session with Palmerston North GP David Hill were grateful for the ample supply of free coffee to keep up with his challenging address.
They were taken through recent and distant history, the interregnum following the English Civil War, then Brexit, Trump and the corrosive effects of bureaucracy.
Dr Hill warned GPs they might find some of what he had to say about the inherent dysfunction of health systems "uncomfortable". It could have been positively depressing if he hadn’t leavened it with his vision for a brighter future.
Dr Hill describes his Palmerston North Health Hub Project as "a brainchild of frustration", a reaction to dealing with the bureaucracies of the Ministry of Health, DHBs and PHOs.
"We learn to live in mutual incompatibility," he says. "A lot of the time our interests do not meet. How do we get from a bureaucratic-driven medical system, which is what we have, to a value-driven medical system? If we get individual healthcare right, we get population health care right."
One of the biggest challenges is in medical education, he says.
"We are selecting people who will operate well in the current system, even though we know the current system is not operating well. Our trainees are selected to work in dysfunctional organisations, why wouldn’t they be dysfunctional?"
He likens the health system’s "morbid symptoms" to the interregnum of Cromwell’s time following the English Civil War.
When systems fail, people may blame the Government, which can result in "turkeys voting for Christmas", as happened with Brexit, he says.
Dr Hill argues that New Zealand’s determinants of poor health are indeed a failure of government.
"How can we possibly allow 27 per cent of our children to live in poverty? Fourteen per cent of people over 65 live in poverty. Ten percent of New Zealanders own more than half the wealth.
Nowhere is that more transparent than in Auckland."
"Inequity is institutionalised in New Zealand."
He urged colleagues to challenge these failures "and be radical in our solutions".
One way is to break down the system of silos, which carves up funding into primary, secondary and tertiary care. Increasing demand and expectations will require a greater focus on keeping well, which he says is the approach of the Health Hub Project.
"I would have to challenge the assumption that training more doctors is the solution to demand. All you’re doing is driving your costs up. We need a distributed system of care, not just doctors at the top of the pyramid."
He says GPs may be tempted to sit back and retire, thinking it doesn’t really matter. "And maybe I should have done that, in hindsight."
Instead, he has poured his energy into the hub, which he describes as a distributed integrated family health centre, with three practices in Palmerston North linked through a common database, and working with social organisations to improve mental, physical and social well being of individuals.
The focus is on continuity of care.
"We’ve got something that’s designed to work for us in the way we want to work. In our institution, there are no managers."
They have also changed the way they are funded because capitation and the copayment weren’t enough to support what they were trying to do, Dr Hill says.
He and his partners have convinced local investors to get involved in a social enterprise investment model, with the business part-owned by a charitable trust.
"It’s helped us massively," he says. “Not only from a cash flow point of view, but also making sure we keep a business focus on what we’re doing."
Article by Cliff Taylor (ctaylor@nzdoctor.co.nz) New Zealand Doctor