Forum 2019 - Future directions

What do we need to do to deliver a public health and disability system that can best meet the needs of our changing population?

What are the expectations and aspirations of Māori?

What is on the horizon for general practice? What does wellbeing mean in this setting?

What does the future look like?

These are some of the topics that were considered during this session.

Presenters

Tāmati Kruger, Tūhoe leader, Māori advocate and social commentator

Video: Tamati Kruger - Forum 2019 - Future directions

[Tamati Kruger presents to an audience as part of the Future directions session of Forum 2019]

Kia ora koutou katoa.

Pleased to be here. And we say that there's lots of ways to get from birth to death and all of them work.

A lot of our problems, I think, with Maori health, community health I regard not as stop signs, but as guidelines as to what we may do to find solutions. And while death is always news somewhere, but death should never, ever be seen as the nemesis of wellness and being alive. And often, this is the mistake that we make in putting up a standard of what is health? What is good health?

So I represent the Iwi Tūhoe, located around the Te Urewera area. We created a miracle some five years ago, we made a national park disappear. And we're now doing our best, trying our best to reconnect people to nature and to Te Urewera.

For many Maori, well-being is known as Toi ora. well-being, it's having a purposeful life. It's holistic wellness.

On the other side of that continuum, if we were to look at it as a continuum, is a useful concept word called kahupō, which generally means being spiritually blind. And having a life that is meaningless. And to live in a state of dis-ease.

So the opposite, if you like, of toi ora of wellness is not death, but it's being spiritually blind. Not having any purpose in one's life. So toi ora is little bit different from the word that we generally use, which is hauora. Hauora, to many, refers to physical well-being. Whereas toi ora is much broader and it's much more holistic in its view.

Toi ora is also known by many Maori communities, and many Maori as mauri ora. You might have heard of the expression when people get up to do formal speeches, they start off by saying 'te he mauri ora'. This is more of a blessing. It cannot be translated as hi, hello, how are you? It's more of a blessing which is, I wish wellness, I wish well-being, on all of us.

And the well-being is not just pointed at people, but at the environment, at the world, our atmosphere that we all live in, our lifestyle. That is, te he mauri ora, is our connectivity with everything in our universe and in our world. So it's a blessing. It's a saying, te he mauri ora.

So toi ora or mauri ora then, has components, this holistic well-being. These components are interdependent, and they are connected with each other. In no particular order, there is one's wairua, or spirit, and that represents our immortality. It's seen as the imperative for health and well-being.

Then there's the hinengaro, or the intellect. This is metaphysical. And its function is to inform, informing the human being. It's our rational side. A fourth component of toi ora is the whatumanawa, or ngako, the emotional part of a person. It is also metaphysical, meaning it has spiritual qualities and physical qualities to it.

Our emotions are our expressions. It's largely irrational, but irrational is connected to the imagination that we all need and we all have. And then there's the tinana. This is the physical being of a person. This is our mortality. It's all provisional. And this is where we get our pragmatism from.

And so in this country, we tend to focus on the tinana, the physical well-being. Whereas, in the Maori world view, we need to focus on the wairua of the person. And when one can balance, and reach, and connect with one's wairua, the wairua helps with the well-being of the intellect, of the emotions and the physical.

So that's toi ora. All of these elements that, in order to be optimum, in order to have synergy and balance, they must be interconnected. They must be seen together because they affect each other. They are all affective forces to each other.

So for example, if someone is being emotionally abused, none of us here would think that it does not affect the physical well-being of the person, or the spiritual well-being of the person. If someone was being affected physically with illness, then it also touches the spirit, and the intellect, and the emotion part of the person.

So these things, these parts, are not silos independent of each other that we should treat independently, that we go to one source to get well in this component and go to another source to get well in that part. And often, in our country, these things are quite separate. They are territorial and they don't talk with each other.

So all of these elements together is mauri ora. It is well-being, also known as toi ora. So the question is, how do we sustain or restore that well-being? How do we do that when it is depleted, when it is lost, when it's eroded, when it is changed by life? Well, one way-- not the only way, but one way-- is by providing genuine experiences of the vibe of life.

And these can be expressed in the terms wana, which may equate having a gratitude for life, the thrill of being alive, the pleasures and the excitement of being alive. We need that whether you are 99 or nine months old. We all need to feel that we have presence, that we belong, that we are loved and that we can love.

Wehi is another way of feeling and experiencing the vibe of life. Wehi is spoken of as the appreciation for being alive, the wonder of it all, the awe of life. And when we stand in amazement of who we are, where we are, and to whom we belong.

Ihi is the rapture of life. Experiences of bliss, euphoria and delight about life. There are too many people, too many Maori children, who do not have these experiences. For one reason or another, they are denied it, all their lives absent of it. Without wana wehi and ihi, we cannot renew the toi ora. So we then live a life of despair, drudgery and ignominy.

So the illusion is that we must deal with the language of health. What does it mean? What do we mean by it? What do we mean by well-being? Graham Norton, just before the session, advised us that patient comes from the word waiting without complaining.

How sad that patient means a sick person, a victim, a sufferer. And the only words for healer or mender is a physician, a doctor and a therapist. That's quite narrow, in my view. Anyway, there are things that we are doing within my iwi Tuhoē, to do our very best in restoring mauri ora and restoring well-being. We're just starting off with it. We don't have all of the answers. But we are unafraid. So te he mauri ora to all of you. Life, may we all live it well. Kia ora.

[APPLAUSE]

Dr Jeff Lowe, GP, Chair of General Practice New Zealand

Video: Dr Jeff Lowe - Forum 2019 - Future directions

[Dr Jeff Lowe presents to an audience as part of the Future directions session of Forum 2019]

Kia ora. Good afternoon, everybody. And thank you for that welcome and introduction. So my topic is the future of general practice. My challenge is to do that in 15 minutes. So in declaring my conflicts, it really gives you an idea of the perspectives that I bring to this.

I'm the Chair of General Practice, New Zealand. I'm a member of the Federation of Primary Health, New Zealand. I'm on the Alliance Leadership Team here in Capital and Coast DHB. I'm a trustee on our PHO. And, most of all, I'm a GP. And being a GP, I'm a generalist. I'm not a futurist. So most of my remarks and comments are going to be based on my reality, my lived experience.

So why do we need to look at the future? Well, the world we live and play in is changing, and the drivers of that are pretty well established. They are demographic, technological, societal, cultural, and environmental. And that means that the patients-- the people we care for-- are also changing. They're aging and everything that brings. They're becoming more diverse. The expectations of what they expect from the system is changing. And the role that they can play and care-- their own care with knowledge and data-- is changing significantly as well.

And the world we work in is changing also. And Sam this morning talked about that this afternoon very, very well. As a workforce, we're aging. We're becoming more burned out with the complexity of care that we are facing. The demand that's on our day. The demand that fronts up in our waiting rooms.

We're having to adopt emerging technologies into our working day. And at the end of the day, for a lot of GPs and the teams that we work with we're just losing the joy of practice and the work that we do. So the way we operate now is becoming unsustainable. And that's not just general practice. That's the whole of our system. And not only is it unsustainable, but it's no longer fit for purpose. So there's the other why. The why 2,575, which has been very well covered in this conference already so I won't delve into that deeply.

And what's the what? What do we need to do? Well, we know what we've needed to do for over 40 years. If we go back to Alma-Ata, which is 41 years ago now, that talked about health for all, health being a right, having primary care at the focus of health systems and the patient at the center of that.

20 years ago, Barbara Starfield talked about the evidence that stronger primary care at the front and center of a health care system can deliver better health outcomes at a lower cost. And the Declaration of Astana last year called for all health systems internationally to invest in primary care.

In the now, we have the Health and Disability System Review, which brought tears to my eyes. In fact, it brought two tears to my eyes. And what it said of Tier 1 was that strengthening the role of Tier 1 services in the system is critical. This view has been espoused for over 20 years. But progress has been limited.

So we know what to do. We know how to gear up for the future. But we come to the other why. Why is this not happening now? And I would put to you, actually it is happening now. "That the future is here already-- it's just unevenly distributed." That's a quote from The Economist in 2003. Because here's another quote from Ernest Rutherford. "We haven't got the money, so we need to think." And we see organic and innovation developing when resources are most constrained. And boy, have we hit those times over the last 10 to 20 years.

So already we're seeing pilots, proof of concepts, organically developing addressing current needs within the system. We're seeing patient portal and open notes, GP telephone triage, group consultations breaking the confines of the 15-minute appointment being the only way you can interact with your doctor and practice team. We're seeing the tyranny of distance being overcome by telemedicine.

We're seeing care location in different places, in less intensive settings now such as insulin starts in the community here in CCDHB, and infusion services increasingly being delivered in the community. We're seeing better access to diagnostics. There have been pilots on access to MRI performed by ACC and Procare, which is now being rolled out further. We've seen point of care testing, near patient testing, being piloted in Auckland's Regional Rural Alliance.

And we're seeing ultrasound becoming more available. We're seeing ultrasound machines actually being located at rural practices and increasingly in urban practices and after hours facilities. And we're seeing changes in the workforce.

We're now seeing health coaches appear, health improvement practitioners. We're seeing clinical pharmacists working within practices such as the Hawke's Bay. And we're seeing technological changes. Pharmacogenetics is in its infancy. And we see an increasing number of apps and websites such as Health Navigator which are helping patients manage their own care.

So the challenge is, how do we take organic innovation like this, move it with scale and pace, so that, if it's a good idea, it gets spread across the country, it doesn't end up a work-around in a postcode lottery, and these innovations end up smack in the middle of the quadruple aim, rather than disappearing down into the Bermuda Triangle, where most pilots end up? And there's a whole science about how you make improvement happen like that, from letting it happen to helping it happen, to make it happen.

Because at the end of the day, if you want transformation, it needs transportation, something to take it into the future. Do we have examples of that around? Well, I believe we do. And a good example of transformation or a vehicle for that change is the Health care Home and the Health Home Collaborative, a new model of care. So what has that done? It's taken a number of like-minded organizations, who have the hearts, minds, and stomach for transformational change, taken their ideas, taken those building blocks and principles, and moved them forward with scale and pace.

It's taken those building blocks. It's described four different domains of activity, of urgent and unplanned care, proactive care, routine and preventative care, and business efficiency to support that. It's been described a number of elements to make up a model of care which is certifiable, but in short, that it's flexible enough, that it can be applied in a local context and contextualized to our location. And it's ensured-- that key to it ensures that there are benefits to the patient, like giving them access to their records, to their laboratory results, to their doctors, their care teams, ensured that there are also benefits to the general practice themselves. Because none of this occurs without a sustainable workforce.

It gives services such as clinical triage, which value patients' time. If they don't need to turn up to the practice, it can be sorted out over the phone, then that's what we should do. It gives them better access to information, appointment books, their records, their care plans. And it really does, for the first time, give people a chance to not just be recipients of care, but actually participate in their care and be far more self-determining. And it encourages care to be delivered by a team rather than individuals.

So how successful has it been? In three years, we now see 1 in 4 New Zealanders covered by Health Care Home practices. And I would describe that as moving innovation at scale and pace. Does it work? So Midlands Health Pinnacle ran some research in 2017 and again in 2018. And they found, from their analysis, that they found decreased emergency department attendances, particularly for Maori and for the over 65s. They found that there was an improvement in on-day availability of appointments. They also found there were fewer ambulatory sensitive hospitalizations as a result of this model of care.

Does it work in other DHBs and localities? So the challenge for Midlands was workforce and sustainability of practices. They had done a calculation in 2014, that by 2025, they'd be 1 and 1/2 million GP consultations short. At Capital and Coast, there was a different shakeup going on. We realized in about 2012 that there was increasing acute demand on hospital payers. And there was a 4% year-on-year growth in demand and that this would be no longer sustainable. And that this was a problem, not just for the hospital, but for also general practice.

So we embarked on our own Health Care Home journey at that point. Keys to the success for CCDHP have been that it was a joint venture, and there was both PHOs and the DHP were co-invested in this. So both had skin in the game. We already had a functional alliance leadership team with established principles and values, established trust, established leadership. We developed a healthy home support team, which was then tasked to manage the change management, which often gets forgotten in these changes.

Does it work? So within three years, we now have 80% coverage of patients in CCDHP and Wairarapa covered by Health Care Homes, within three years-- again, an example of moving innovation at scale and pace. In evaluating it, it was really important to make sure that we were covering all populations, not just mainstream, but also Maori and Pacific and other priority patients within our DHPs. And in the evaluations, we've seen that appointment availability for high needs patients have come down from somewhere around just under two weeks to get an appointment, a routine appointment with a doctor, down to just under two days. So access has been improved significantly.

And like Midlands, we've seen an improvement in reductions of ED attendances and acute admissions, particularly for Maori and Pacific. And we've also seen a similar downward trend with ambulatory sensitive hospital admissions, as well.

So what next for CCDHP? Can we get beyond 80%? Well, it's still climbing. But the next important bit of work is actually taking clusters of those Health Care Homes and developing health care neighborhoods, if you like, and linking those to the community services that exist in those localities-- so taking and grouping up so that there are populations of around 30,000 to 50,000, developing what we call community health networks and linking general practices and their teams with people who are also delivering care in the community-- care coordination, centered district nursing, allied health, community, pharmacy, geriatric services, and really clustering those services around the people that we care for.

When you've got momentum in the hubs like that, you can then start to develop other services. And one of the services that's been developed in the Kapiti region is the Community Acute Response Service, which aims to try and reduce the number of hospital transfers from Kapiti Coast down to Wellington and Kenepuru emergency departments. And in the first month of operating that, there have been 25 less ambulance transfers-- a huge saving not only to the system, but also the community. It's gifted them back time.

So what next? And what are some of my predictions for the future? I believe the way you interact with your practice will change significantly. There will be an increasing number of channels by which you can talk to your GP and your practice team. And there will be increased bandwidth, in other words, the number of people you can talk to. I think that will be both active and passive, synchronous and asynchronous. And we will see alternatives to face-to-face with other non-face-to-face modes of consultation.

I believe patient portal, in my opinion, has been the most transformational change that Health Care Home is introduced. And I think we'll see that become business as usual. We already see patients who only join practices now who offer patient portal, having been exposed to it. And I believe we will see a growth in telephone consultation, e-consultation, and virtual consultation via video.

Patient participation-- I see that happening at all levels, not only in self-care, but also in service design, design of our facilities, and also patients getting involved in governance, so that they're in the upstream conversations in their care, and that movement, as we've heard up from today, about people self-caring to actually being person-directed and directing the care, choosing who they partner with and how they receive and consume their care. Integration-- I see there being more vertical integration between tier 1 and 2.

Clinical pathways are here now. Currently, we have community pathways. We have hospital pathways. I believe they will become more of a continuum. So pathways have been a really good way of reducing unwanted variation. I believe that, if we join up the pathways, we will see unwarranted variation of care being addressed in terms of where someone presents in the system. So if someone presents with a concussion in general practice or at an after-hours facility or an ED, they will receive the same care.

I see a continued process of specialist knowledge, which is siloed and locked up within a hospital, being driven down through the system, more accessible to community and general practice teams, more available to patients. And I see when something is unpredictable and needs a specialist's attention, that their specialist advice will be available at a more easily accessible and timely fashion. I see alliance leadership teams becoming more mature, more independent, and having a wider membership. And I see more planned devolution of services.

The minister talked about the planned care initiative, which has recently been launched. I see that actually starting to see services being devolved from hospital settings in to community and less intensive settings in a more formal way, with the resource and the support attached to it-- something that we've talked about for years, but it doesn't happen. I see increased data sharing, and we may or may not see an electronic health record platform eventuate in the next 5 to 10 years.

Integration also I see happening horizontally. It's happening to a degree. But bearing in mind that clinical care only constitutes about 20% of a person's health and well-being, we rely so much on what the other sectors offer. And I see the IDI infrastructure as being key to actually informing the system, telling the stories that will allow the right changes to happen in the intersectoral integration space.

Models of care-- I think the models of care around will continue to develop, those such as the Health Care Home whanau order. I think there will be increasing recognition of what complexity drives in terms of the approach that's needed to address high needs populations and the resource that goes with that. I think we will see increasing care delivered in the community, development of community hubs, of those 30,000 to 50,000 groupings, which will allow better planning for localities, and evolving workforce, and a return of the joy in working.

So for the workforce themself, I see a great purposing of our current workforce, people working to the full breadth of scope that they can, new and exciting roles developing. Our workforce will become more multicultural, multi-professional, and I see general practice teams working more closely with community pharmacy, midwifery, Allied Health, and NGOs. They will move from being multidisciplinary to interdisciplinary, where they learn and teach each other; a blurring of the boundaries between who employs people on the team; a movement from those services which are co-located currently, to actually being integrated around patient needs.

And I see a big movement of people actually becoming the MVPs, the Most Valuable People on the care team, as they move from self-care to becoming far more self-determining, armed with knowledge and advice. Business models I see as a hybrid, being a mixture of public, private, and corporate. But I do see the value of practices returning, the joy at work returning to general practice, and in that sense, general practice becoming a more attractive career option for medical graduates. Because we need to attract about 50% of our medical graduates into general practice. And I see increasing interest in ownership of practices, as well.

Digital and data-- I believe, I think there should be a democratization of data. We need data and analytics to be far closer to patients, the information far closest to the end users. And in that way, the value of data is far closer to those it impacts on. So with better data, people can be better informed and can choose and make decisions for themselves. And if they can self-care, that will release capacity within current care teams to do the work that matters the most.

Artificial intelligence is a continuing growing space. And we're seeing that particularly with dermatology, radiology, symptom checking, and triage. And pharmacare genomics is in its infancy.

So if we can do all of that, we might be able to change the paradigm which we work in currently, of people becoming ill, receiving treatment, and being recipients of their care. If we can arm them with that knowledge and change the way we can make them and allow them to become participants in their care. That will give them a chance to actually move towards wellness.

And once people are well, they can then start thinking about prevention. And if they're in that space, finally they might be able to take ownership of their health, become socioeconomically independent and self-determining. And I believe that is what will help them move to a state of wellness. So my final prediction for general practice in the next 5 to 10 years, I hope that I can retire. Thank you.

[APPLAUSE]

Kathryn Cook, Chief Executive MidCentral District Health Board  

Video: Kath Cook - Forum 2019 - Future directions

[Kath Cook presenting to an audience at the Future directions session of Forum 2019]

Tena koutou, tena koutou, tena koutou katoa. Thank you for the opportunity. So here I am. They say that the worst place to be in the speaking slot is the one after lunch, as you're all sort of having your post-prandial snooze. But here I am, standing between you and refreshments. And most importantly, I'm standing between me and refreshments, so I am going to talk quite quickly to get through my few slides that I've got. And it literally is a few.

So today, we're reflecting on equity, health, and well-being. And as Jeff has already said, to some extent, the future is already here. But we certainly cannot wait for it. Our health system, the one that we are all part of, plays a critical role, and will continue to do so into the future, whatever Heather and the team recommend, and, indeed, whatever decisions the government takes.

Our system, and all of us in this system, must continue to support individuals, whanau, and, indeed, our communities towards better health and well-being. So quality living, healthy lives, well communities. So I get to do a DHB perspective, so of course I chose my DHB. That's almost as good as talking about yourself, isn't it-- talking about your DHB?

So this is our vision. This is the vision that our partners, the individuals and our communities, all came together to determine way back in 2016. But all DHB's will have their own story and their own version of this aspiration.

At the heart of our DHB strategy are four key imperatives. Commitment to the treaty underpins each and every one of these imperatives. Achieving equity of outcomes across communities, partnering with people and whanau to support health and well-being. Connecting and transforming primary, community, and specialist care. And of course, quality and excellence by design.

So to give life to this strategy, we've completely transformed the way we organize ourselves. So we don't have a provider arm. We don't have a funding arm. Actually, we have clusters. And these clusters focus on people, or they focus on particular illnesses. So for example, if they're focusing on people, healthy aging, and rehabilitation. For illnesses, it's mental health and addictions. We have a number of clusters.

Each of our clusters are supported by cluster alliance groups. So these cluster alliance groups provide representation from Manawhenua Hauora, which is our Iwi relationship board, consumers, NGOs, primary care-- you name it, everybody has a seat at the table. And those cluster alliance groups are set up to challenge us, to challenge us to be better than we are at the moment.

They are going to help us to determine how we significantly shift our resources, to change the way we both deliver and commission services, so that we can make more of a difference in our community to deliver health and well-being. And to ensure that we achieve equity. At the same time, we've got to ensure, as we disinvest to invest, we make sure our hospital is the best that it can be. But it only does what a hospital needs to do.

So we also recognized, in our district health board, that we needed to get out to our communities and listen to them a lot more than we were. And we did this to get a better understanding of the communities and the people who live there. We wanted to understand the lifestyles, their health needs, their experience of career, their priorities, and aspirations-- not just for health, but for, indeed, their lives, for them, and their families.

Understanding our communities allows us to work in partnership with them, to better design services that meet their needs, and fit all of the needs. It gives us all skin in the game. I think we've already heard that today, skin in the game. Because these are not the district health boards' communities. These are the communities' communities.

So a number of common messages came through, and we have not taken ownership of all of the things that are going to happen in these communities. We have cluster health and well-being plans. We have locality health and well-being plans. And in localities, we have health and well-being groups. And those health and well-being groups are not of the DHB. They are of the community, but they hold us to account. They hold us to account for the more than 250 expectations that they set for us, what they wanted us to achieve in their communities.

So we have five localities, and there was a lot of commonality in the first four localities that we completed our locality health and well-being plans. Firstly, access to health care. So people wanted easy access to health care when they needed it. Mental health and addiction, that was an enduring concern of our communities. They wanted to see improved support for mental health and addiction in their communities.

They wanted better communication and connection, so a district that has quality communication, connections between all of the health services people, whanau, and communities. And they wanted well-communities, communities where everybody supported to have quality living and healthy and active lives. So, on the screen, that's what happened in Tararua when we came together.

The last plan that we developed was in Palmerston North city. They had two further aspirations-- building healthy whanau and communities, a city where people and whanaus feel safe and are supported to make healthy choices and stay well. And wider determinants of health and well-being was a strong feature. They wanted a city where residents have a good quality of life, and everybody has the opportunity to achieve equitable health and well-being outcomes.

The need for improved mental health and addiction support in our communities was a key priority, as I've already said, for every locality. Our communities told us of the desire to know more about where to access mental health services when they needed to. Our communities told us of the need to offer more support to people and whanau, especially our older residents, who feel isolated.

And perhaps most importantly, our communities told us of the need to ensure all of the people involved in the mental health care spectrum work together to support the community. Working together is going to be vital if we're going to change the way we support our communities. For far too long, we have all operated in silos. Silos within the health system, the health sector. Silos between different sectors. Even silos in our own organizations.

The people that we are here to support don't care about silos. They don't care if we're a DHB, if we're primary cares, in-patient, NGO. They don't care about those things. What they care about most is getting the help and support they need. And we must join them in this mindset by changing the way we operate. There is a great deal of pain testing going on in our community, and the strength of the passion as visible.

But if we're going to build on the passion, we need to embrace a more collaborative, whole-of-system approach, and no more so than to mental health. In our district, the approach we're committed to moves away from the individual and towards the collective. All of the partners in our region came together to develop the Waiora health model, which focuses on four main principles-- well-being, resilience, prevention, and recovery. Waiora takes a holistic, whanau-centric approach that begins and ends with well-being.

More recently, the additional concept of flourishing has been identified as an aspirational focus of well-being. The idea that a person living with a mental health condition can flourish requires a fundamental change in the way we've traditionally viewed the concept of wellness. By taking on the Waiora model, we must shift our focus away from the often negative connotations linked with the term well-being, and encompass transformative pathways which enable our people, or whanau, and our communities to flourish.

What we want to do is challenge and inspire people by crafting a vision of a high quality, whole-of-system approach to mental health care. And from Robinson money-- thank you. We're holding out for that bit. Some may believe this to be idealistic, but we also have seen the positive outcomes in our community.

In our community we also have Whanau Ora. Whanau Ora is tangible evidence and a cross-section, collaborative model with a specifically Maori worldview, can transcend sectors to support people and whanau. In the MidCentral community, partners have come together to establish and support Kainga Whanau Ora. Kainga Whanau Ora is a local collective impact pilot focused on whanau, living, and social housing in Palmerston North. The focus is about family, and we all have a place in that. It focused initially on 100 families.

Now, all our whanau live in safe, warm homes. They have pathways to training, education, and employment, and are supported and encouraged to live in safe, loving relationships. People within Kainga Whanau Ora have gained full-time employment. Many have now exited social housing. The pilot has also helped to eliminate gang activity in parts of our community. And it's also helped to improve the lives of children by creating a safe, healthy, non-violent, and drug free environment for them to grow up in.

This is a microcosm of our community, and of all communities across New Zealand. So the question we have to ask ourselves-- and, again, that was the question that Jeff asked us-- is how can we move the pilots, the new approaches and initiatives that we all have where they're working, onto a national level? So what does our future look like?

Well, it looks a lot like now, only different. And we all have a part to play in making that difference. After all-- I think you've heard this before-- it is the right of every individual to live in a decent and caring society, and, most of all, to have the opportunities to enjoy the same levels of health and well-being. Everyone. And when they are sick, to have access to the same specialized levels of care and treatment.

So DHBs are about their communities. They are about all of us, so I didn't want to talk too much about the bit that we often talk about, the patients. So thank you for your time.

[APPLAUSE]

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