Royal New Zealand College of General Practitioners Conference Rotorua

Kia ora koutou katoa.

Thank you very much for asking me to participate in this annual gathering of the Royal New Zealand College of General Practitioners.  It is an honour to be here, and to have been asked to open this conference.

A Governor-General is asked to attend and to open a large number of events.  It is only seldom that I have specialised knowledge of the group's area of work - and today is no exception.  Although my name is irrevocably linked to the report in 1988 on the events at National Women's Hospital it will surprise no one here if I say that I am by no means a medical expert.  So I was relieved to find my name at the beginning of this conference programme, and not at the end. When I looked at the line-up of speakers and workshops, it is obvious why.

During the next two days, you will hear from some of the country's biggest or most influential names in health.  I bow to their knowledge.  I will therefore stand up, welcome you all here, then slide into the background while the experts tackle the big issues for General Practitioners in New Zealand.

As I prepared for my visit here to Rotorua to speak to you, I asked my staff to research the College.  Some of the facts and figures I was presented with bear repeating.

The inclusive nature of the College as an organisation is illustrated by the fact that approximately 3000 general practitioners are members, representing around 95% of all GPs in New Zealand.

In light of this figure, the College's role of providing education and professional development, as well as setting standards for the profession, becomes all the more significant.  So does its task of providing policy and strategic advice in relation to general practice issues in New Zealand.  That is has such widespread acceptance in the profession indicates too that it is a trusted organisation, providing valuable guidance and assistance.  

The College's goal of "improving the health of all New Zealanders through high quality general practice care" is one that ensures that the general practitioners will constantly be challenged, and that the public's health will be the primary focus of your attention.  The public can therefore have confidence that its needs rather than those of the profession, take priority.   That, in practice, requires the continual development of solutions that address both the quality and safety of care provided to patients.  Also, and importantly, this requires ongoing support for all general practitioners who are constantly faced with increasing demands which include contractual, legislative and safety requirements.

That there are ever increasing issues for GPs to confront is undisputed.  The Deloitte report made it clear that there is a huge administrative burden on GPs, and far too much time has to be spent on paperwork, and dealing with what the business world calls compliance costs.  In light of this, it is very much to your credit that the report concluded that GPs give good value for money. 

The hard part is to overcome these administrative challenges and stay focused on the reason you chose this particularly difficult profession - that of improving the health of the people you serve.

Around 15 years ago, during the National Women's Inquiry - and I must say it is so long ago that it seems a bit surreal now - I had a first-hand opportunity to witness the difficulties, technical, and emotional of trying to help those who are very ill.  At the time, I had been asked to chair an inquiry into events at Auckland's National Women's Hospital.

When the Inquiry ended and my Report was presented publicly at a press conference in the Beehive I said "I will never forget the patients".  While that is not entirely true - many of the women I met are now but hazy memories to me - many more I recall clearly down to the way they looked, the extent of their disease, how they spoke of their family, and how they were coping with what was for most, a sudden revelation that, in fact, they had long had a cancer precursor or now, invasive cancer.

Listening to their experiences as part of the evidence heard privately in my room, counsel assisting and I were frequently overcome with grief for what they had experienced and would experience in the future.  The assistant who typed back the tapes would herself be in tears and when evidence about these women was heard in public in the Inquiry room there were a number of occasions when everyone in the room, including the members of the press, were overcome with sadness.

And recently it was driven home again when I spoke to a woman who had been one of the patients during that very fraught time.  She spoke of the informal support group that the women affected by the events at the Hospital had formed and how she was now the only survivor. 

Lest you think that the difficulties of coming to grips with the medical and emotional problems presented by the Inquiry are my only memories, let me tell you that there were many times when I became aware of an equally concerned general practitioner supporting a patient or her family.

The task was extremely difficult for me, and I know that many, many health professionals including general practitioners were often kept unaware of the state of their patients' health leaving them worried, frustrated and helpless to assist.  I know too how much support some of your particular branch of the medical profession gave to gravely ill women.  You are close to the people you serve.  You see their fears and vulnerabilities.  Your patients are not just numbers or interesting cases - they are real people whom you get to know, warts and all. 

I became acutely aware, during that time, of the value that patients place on the need to retain their dignity, particularly those who have diseases of the genital tract, diseases which impact so intimately on their privacy, their family lives and on their self esteem. For many the right to continue to be treated as an individual with all the hopes and fears that all of us nurture was as important as treating the disease.  I was not fully aware of it at the time but there are international standards developed over many years, particularly through the United Nations, for the treatment of patients and for the protection of their rights.  Most in the medical profession will be very familiar with the standards that I referred to in the Report - the Declaration of Helsinki is one example.  But when one examines all of these international standards it is clear they have been developed so that patients' humanity is respected.

And what was so overwhelming to me and to those assisting me, to many of the parties and lawyers at the Inquiry, and no doubt to the General Practitioners left to cope with the consequences of the dubious treatment at the Hospital, was that these women's humanity was not respected.  They were not treated by most of the specialists they met as intelligent, autonomous human beings, entitled to a say in their health care and well able to make informed decisions which took into account all the factors which were important to them, such as the size of their families, their financial position, what sort of treatment, if there were a choice, whose side effects would be preferable to them. The profession lost so much credibility amongst women because they did not respect their basic rights as human beings.  And that suspicion and reduced trust flowed on to general practitioners as well - even when you had not known or been consulted about management regimes, or been advised of the parlous state of the health of many of your patients.

Several years after the Inquiry I was elected to a United Nations Committee concerned with international human rights standards for women.  During that time I thought often of the lessons I learned during the National Women's Inquiry, and much that I learned there has been applied to the development of better human rights' policies concerning health care for women in all parts of the world.  For those who are interested in the broad principles adopted through United Nations machinery and treaty bodies, there are standards for health care of women in the Convention on the Elimination of All Forms of Discrimination Against Women and also in General Recommendation 24 which sets out in more detail the principles in relation to women's health, expected of countries that ratify the Convention. Unsurprisingly they place an equal focus on women's equal rights to health care and to protection of their privacy, dignity as on particular areas such as reproductive health and the need to concentrate on all stages of a woman's life cycle.

It is necessary to emphasise that as I sat listening to the evidence of doctor after doctor, and I considered the ethical implications of what had occurred, I did begin to understand that after years of practice in an atmosphere where patients respect and even fear the professional it is not easy for that professional to remain humane.  The same can be true of other professionals as well. 

The lawyer who does not adequately explain a range of remedies to a client, the Judge who bullies the witness, the doctor who is godlike in directing the patient - these are all familiar figures and all to be deplored.

You may ask yourselves, why am I telling you this?  How is this relevant to this conference? 

I ask you to consider this.  The reason you are here is to discuss a major change in the way you work.  The theme of this conference is "Practicing in a Wired World", a theme that has been chosen to reflect the extraordinary pace with which General Practitioners in New Zealand move towards and adopt new technology.

By international standards New Zealanders are high users of IT, and this also, and maybe particularly, applies to the health sector.  New Zealand has made a healthy industry out of this and is, in some areas, among the world leaders.  Many of the locally developed health software products are world class, and indeed exported widely. 

For GPs, IT is changing from being a useful management tool to one that is also important in changing behaviour.

But in this increasingly interconnected world, how do we juggle the quest for information and the protection of privacy?  Some say that the breathtaking pace of our uptake of technological ability is not matched by similar progress in the simple human values that dictate how we should manage these opportunities.  Important privacy and ethical debates are not proceeding at the same pace as the technological change, and this creates significant risk.

Take this example:  all New Zealanders have a National Health Number (NHI); this means that GPs have the ability to track all health contacts and events, all diagnoses, prescriptions, laboratory tests and results.  This is a wonderful development.  You can now easily identify children who are not immunised.  But what does this mean for patients?  Are there any privacy safeguards for them?   Whose right takes precedence ‑ an individual's right to choose or not choose immunisation, or a community's right to be protected from harm through diseases like such as meningitis.

Another example:  many Independent Practitioner Associations now have the technical ability to produce highly detailed maps that show where health events are clustered, allowing them to target particular markets.  This mapping is so detailed that, potentially, it goes down to the level of single properties.  Again, there is no privacy or ethical framework to guide those using this technology.  

Each individual has a right to privacy, but often the reality is that privacy is not sacred.  In fact, I know that some commentators on the health sector internationally have labelled patient privacy an illusion. 

Let me repeat a little anecdote some of you will already have heard to illustrate my point:  the day after I had presented my Report on National Women's Hospital, I had an appointment for a mammogram.  The night before, television, newspapers and radio were full of stories about the lack of privacy and dignity afforded to women patients at the hospital.  My mammogram over, I was beginning to dress myself again behind the curtain in the tiny cubicle at the clinic when the doctor flung open the curtain, revealing my semi-naked form to an interested waiting room and said "Your mammogram is fine.  You can go home now".

While this may be amusing in hindsight, it certainly was not at the time, and I think this little episode illustrates how easily and unwittingly a doctor can breach a patient's right to privacy.

As you consider the changes that technology will bring to your ability to care for your patients, remember that they will always first be people, with all the quirks and idiosyncrasies that you and I have in abundance.  They cannot be fitted into one standard box, where one treatment fits all.  And nor can they be managed as you would a crate of chickens.  The modern patient sadly lacks the unquestioning compliance that they did only a few short decades ago.  They have their own views and want to help make decisions about their own health care.  And when they are very ill and place their trust totally in you, remember their humanity even more strongly.  That trust is earned, not automatic.  It is at that point that they need you as a person as much as they need the wonders of technology and new forms of treatment. 

I want to say in conclusion that I have enormous respect for the vast majority of the medical profession, and particularly for those who work at the forefront of the health system here in New Zealand - the general practitioner.  So consider the public's needs and do not permit enthusiasm for a project or a desire to do good to blind you as it has done others in the past, to the rights of the patient, particularly when the patient is at the most vulnerable stage. 

There remain those who are patronising or godlike in their dealings with their patients.  Health care like any other service depends on a partnership between professional and patient.  It all comes down to that familiar concept - do unto others as you would have them do unto you.

As for technology, you have a wonderful tool whose possibilities we could only dream about a decade or two ago.  I urge you to use it wisely and with continuing care for the rights of those who cannot protect their own privacy and dignity.

I wish you well for your conference.  I know that you work in an environment that is much more difficult than even a decade ago.  I am a conscious too of the stresses of practices with large numbers of patients, many of whom will be from disadvantaged backgrounds, and the fact that you must be so much more efficient in the administration of your businesses if you are to make an income approaching what your predecessors earned.   I am all too conscious that there is no longer the chance of having a high status in the community to compensate.  But I also know that all of you are better qualified and committed to the health of your patients than ever before. 

I hope you will return home with new insights and enhanced vigour and enthusiasm for your duty.

Tena koutou, tena koutou, tena koutou katoa.