Submission Form
Consultation on proposed changes to the Injury Prevention, Rehabilitation, and Compensation (Liability to Pay or Contribute to Cost of Treatment) Regulations 2003

Submissions may be made to:
Email: COTconsultation@dol.govt.nz
Post:
Consultation on Cost of Treatment Regulations change proposals
Health, Safety and Compensation Team
Labour and Commercial Environment Group
Ministry of Business, Innovation, and Employment
PO Box 3705
Wellington
6140

Submissions close at 5pm on Friday 8 February 2013.
Your Details
Name: Marilyn Head	Position: Policy analyst	
Address: 
New Zealand Nurses organisation 
PO Box 2128 WELLINGTON 6140
		
Email (optional):marilynh@nzno.org.nz		

I am responding:
X on behalf of an organisation (please specify): The New Zealand Nurses Organisation (NZNO) 

Please tick to describe the type of organisation:
 Treatment provider group
 Claimant representative
 District health board
 PHO 
 Accident and emergency clinic
 Business representative organisation/industry group
X Trade Union
 Registration Board
X Other (please describe):
Professional organisation	

NZNO is the leading industrial and professional organisation for nurses, representing over 46,000 nurses, midwives, students, kaimahi hauora and health workers on a range of employment-related and professional issues. Te Runanga o Aotearoa comprises our Māori membership and is the arm through which our Te Tiriti o Waitangi partnership is articulated.
NZNO provides leadership, research and support for professional excellence in nursing, negotiates collective employment agreements on behalf of its members and collaborates with government and other agencies throughout the health sector. The NZNO vision is “Freed to care, Proud to nurse”. Our members enhance the health and wellbeing of all people of Aotearoa New Zealand and are united in their professional and industrial aspirations to achieve a safe, sustainable and accessible system of public health care for all New Zealanders.
This submission is informed by consultation with members and staff, in particular members of the College of Emergency Nurses, College of Primary Health Care Nurses, and Nurses for children and Young People Aotearoa, and nursing, policy and research advisers. 
Submission 
Part 1: Increase for general practitioners and nurses for under-six year old consultations
Questions 
1.	Do you support the proposal to increase the rate for under-sixes medical practitioner and combined medical practitioner/nurse visits by $5 per visit?
2.	If not, what are your reasons?	

Yes, insofar as any increase to subsidies can contribute to defraying the cost of care, but not in the sense that we accept that these rate increases will significantly improve access to afterhours health services  for all under six year olds for injuries received as the result of an accident. Current charges for after hours services varies considerably, and fees in excess of $150 , with additional charges for consumables, such as dressings and X-rays, are common and beyond the reach of many people, and are unlikely to be mitigated by this increase. NZNO's CENNZ also notes that the complete, timely and free Emergency Department service often provides a safer, more cost effective treatment pathway than coordinated GP services.  There are other barriers to accessing after hours services across and between regions, besides costs, however. NZNO supports the policy principle of free after hours services as the most cost effective and equitable means of reducing health care costs and demand, but note that these rates are very unlikely to reduce current co-payments for GP visits for normal or after hours care. 
Part 2: Rationalising and updating the dental rates
Proposal 1: contribution rates

Questions 
3.	Do you support the proposal for a new framework for ACC contributions to dental treatment with a more even distribution of payments?
4.	If not, what are your reasons?
5.	Do you support the proposal to reduce the ACC contribution for dental implants while providing more funding for other dental procedures?
6.	If not, what are your reasons?	

3. Again NZNO welcomes  any increase in subsidy and reduction in bureaucracy which will improve access to dental treatment. 
5. We have some reservations. Though we support clinicians being able to exercise clinical judgment as to the most appropriate treatment, there are inherent risks in discretionary funding of different treatments as it offers more opportunity for structural discrimination, which may exacerbate entrenched  disparities.   The Human Rights Commission has document such discrimination in health in their discussion paper on systemic barriers to equality. (Human Rights Commission. 2011.  A fair go for all? Structural Discrimination and Systemic Barriers to Ethnic Equality: a discussion paper by the Human Rights Commission. Accessed February 2013 http://www.hrc.co.nz/wp-content/uploads/2012/08/HRC-Structural-Report_final_webV1.pdf.)
Similarly, a resource booklet prepared for the Medical Council of New Zealand by Māuri Ora Associates states: Even though Māori turn up for GP appointments at the same rate as non-Māori, they obtain fewer diagnostic tests, less effective treatment plans" . (Best Health Outcomes for Māori, Practice Implications:. retrieved February 2013  http://www.mcnz.org.nz/assets/News-and-Publications/Statements/best-health-maoricomplete.pdf). Other evidence is offered in the follwoign papers:

•	Marwick JC, Scott KM, Crampton PR. Utilisation of general practitioner services in New Zealand and its relationship with income, ethnicity, and government subsidy. 2000. Presented at RNZCGP Annual Conference

•	Crengle S, Lay-Yee R, Davis P, Pearson JA. Comparison of Māori and non-Māori patient visits to doctors. NatMedCa Report 6. 2006.

•	Clair Mills, Papaarangi Reid, Rehema Vaithianathan. 2012. The cost of child health inequalities in Aotearoa New Zealand: a preliminary scoping study. BMC Public Health 2012, 12:384. Doi:10.1186/1471-2458-12-384

6.  We are concerned that, in practice, fewer people will be offered implants as opposed to alternative treatments. Reduced co-payments for an inferior treatment will not benefit the patient in the long term, though it may reduce public health costs. We are also apprehensive that further disparities may ensue with some vulnerable people being offered cheaper alternatives because the dentist perceives them to be more at risk of, for example, a tooth being knocked out again.    We note that no evidence has been offered as to the rate of complications ensuing after 10 -15 years (which is not an insignificant period): "some people" is hardly indicative of the need for radical change. And while having more dentists being able to offer alternatives to implants may increase access - better some treatment than none, or a long wait  -  we note that not funding best practice care is one of the major factors influencing dentists' decision to opt out of providing 'free'  dental care: they do not choose to provide an inferior treatment  just because that is what is funded.
Proposal 2: Treatments and their descriptions 
Questions 
7.	Do you support the proposal to rationalise and simplify the list of ACC contributions for dental treatments?
8.	If not, what are your reasons?	
Yes. Another barrier to dentists' participation in school dental care is the significant paperwork associated with it.  

Proposal 3: Treatment for under-18 year olds
Questions 
9.	Do you support the proposal to merge a number of treatments for under-18 year olds with those for adults?
10.	If not, what are your reasons?	

Yes. 
Part 3: Rate increase for treatment providers
Questions 
11.	Do you support the proposal to increase the consultation rate for certain treatment providers by 1.9% under the Cost of Treatment Regulations?
12.	If not, what are your reasons?	

Yes - consistent with Labour Cost Index increases of 1.8 percent to December 2012 (Statistics New Zealand). 

Part 4: Change the name of the Cost of Treatment Regulations
Questions 
13.	Do you support the proposal to change the name of the Cost of Treatment Regulations?
14.	If not, what are your reasons?	

Yes

Part 5: Technical amendment
Questions 
15.	Do you support the proposal to add Items C1 and C2 back into the Cost of Treatment Regulations?
16.	If not, what are your reasons?	
Yes