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We are thrilled to be able to present this article by Professor Don Matheson, with illustrations by the awesome Bob Kerr, as presented to the Fabian Society.
With thanks and acknowledgements to those mention above.
Please enjoy this thoughtful read.
An address to the Fabian Society of New Zealand
88 years ago a mass migration of economic refugees was occurring in Kurow, North Otago as desperate families moved into the area in search of work from the Waitaki hydroelectric dam. Some even brought their own spades, in case the government did not have enough for them. In fact there was not enough work and an informal settlement formed of desperately poor, unemployed families, on the banks of the river. The local school roll shot from 30 to 300. Andrew Davidson, the local teacher, Gervan McMillan, the local doctor, and Arnold Nordmeyer, the local minister, came together and built a health and its determinants response to the poverty that they saw. It was called the ‘Kurow Cure’ – a scheme based on the concept of justice rather than charity.
Bob Kerr, our Mt Victoria artist, has created these images of that discussion in his work, The Three Wise Men of Kurow. His work summarizes the key concepts behind the health response they envisaged:
So the concept of a free, universal and comprehensive health service for all New Zealanders was born and incubated in Kurow. It became the blueprint for the Social Security Act of 1938, one of the first internationally recorded expression of what today sits within the United Nations Sustainable Development Goals. It is known as Universal Health Coverage, which has been developed by World Health Organisation and the World Bank – with a lot less clarity but the same intent as the Kurow Cure.
So what happened?
In this discussion I will explore what has happened to this vision of health service provision, 80+ years later, especially the last idea, that:
- It should be free, it must be complete and it must meet the needs of all the people
Many aspects of the social security act transformed the health and life chances of generations of New Zealanders, especially free hospital care. However free primary health care for all did not become a reality. This particular provision proved controversial right from the start.
For the next 60 years, attempts by governments to introduce free health care were effectively and passionately blocked by the Medical Profession, then called the New Zealand branch of the British Medical Association (BMA). It was seen as an affront to their right to charge their own fees, and the thin end of the wedge of “socialized medicine”.
Many of the members had come to New Zealand to get away from the NHS. It was also strongly argued that the state should not interfere in the special relationship between the doctor and the patient – both the relationship with the doctor’s wallet and, more broadly, on ‘his’ ability to do the right thing for the patient.
80 years later, the protagonists in this conflict appear to be changing sides.
The NZMA with its 2011 statement on health equity, comes close to repeating McMillan’s mantra, backing accessible care and greater attention to the social determinants of health.
The government, on the other hand, as we have seen by the feedback to the draft NZ Health Strategy, had to be cajoled by the health sector and professional groups to give greater emphasis to health equity.
Changes in the health sector
But the sector ain’t what she used to be. From the 1970s onwards this ‘special’ three-way relationship, between the medical professional providing primary health care, the state and the public, began to change. The formation of group practices, the concept of teamwork with nurses, the introduction of contracts, the appearance of professional ‘managers’ within general practice settings, have all pushed the provision of general practice towards a more complex model of care.
Medical influence on the sector has not entirely dissipated, but evolved into new forms. The MBChB2 leadership for now is being replaced by the MBChB/ MBA3, and soon the MBA. On its own. The obstructive industrial position of the BMA around user charges has been absorbed into new medical corporate entities, IPA4s, which have further evolved into PHO5s. Even more ‘disruptive’, is the recent arrival of medical care companies into the sector, such as Nirvana Health group, Green Cross Health and others springing out of PHOs. These are increasingly shaping the sector – and changing its politics with the dilution of medical power – adding multiple partners to this professional – state marriage and the imperative to deliver a return on investment for shareholders.
So although the equity word is used freely within medical professional circles, the control of the primary health sector is shifting to a series of semi corporate, corporate, and international business entities.
Have we made any progress?
So what progress have we made on bringing free care to those who need it 80 years on?
Various attempts by successive governments have been made to improve primary health care access, including the creation of group practices and trials of capitation in the 70s and 80s. Helen Clark’s first attempt to introduce medical contracts in the late 80s was an attempt to control fees charged to patients. But with a change in government, it was not till the 1997 coalition agreement between National and NZ First that free under six care was successfully introduced.
The early 2000s saw the introduction of enrolment and capitation as a system wide contracting instrument for PHC funding, a sector wide discussion on the meaning and drivers of inequity, and a large injection of government funding into the sector. This funding effectively halved the number of people having difficulty accessing care and, at one stage, had NZ leading world rankings in primary care physician satisfaction ratings.
The 2010s have seen free care for under 6s extended to after-hours care and in 2015 zero fees for under 13s were introduced in New Zealand.
Free care is a no brainer. There is ample evidence that out of pocket payments, particularly for poorer and sick people, adversely impact on their health. Since the Rand study of the 1970s, it has been consistently shown that, faced with increased user charges, people use services less, irrespective of the severity of their condition. This is bad for people and bad for the effective use of health services.
How well are these current instruments working?
According to the New Zealand Health Survey, the answer is not very well. Almost one million New Zealanders report difficulty accessing primary health care services, the majority because of the cost barrier, closely followed by service availability.
The number of conditions appearing in hospitals, which could have been more appropriately treated in primary care, is increasing, with persisting higher rates for Maori, Pacific and people on low incomes.
Even capitation, the funding instrument vital to the delivery of a population approach, has not been applied in an equitable fashion. The introduction of near universal capitation has also not lived up to its policy intent, and is now an instrument that could be making health equity worse. Maori are much less likely to be on a capitation register, with some 10% of Māori currently unregistered. The implications of this, in the age of the Medical Home, is that the community with the greatest need are likely to remain, or become, the medically homeless.
Why do inequalities persist?
Some of the reasons that the policy solutions such as PHOs, DHBs and capitation have so far failed to take equity seriously are worth exploring.
Primary health organisations
The policy of the PHO policy intent was to pursue equity, represent community views and aspirations, and lead a coordinated population health approach. But these organisations have rapidly morphed into provider dominated organisations. They have been consolidated to the point that they have, with some exceptions, lost any relationship with discrete populations, and have weak accountability to communities. PHOs have struggled in many cases to be more than a GP funding post box. Although they are now much bigger they have yet to demonstrate being better than smaller PHOs . Many are focused on buying practices and some are busy plotting the overthrow of their DHB with the talk of fund holding and social investment. Moving the sector towards a population equity focus has disappeared as a priority for many PHOs.
District health boards
The situation for district health boards (DBHs) is more complex. Some in the last decade did take their population health responsibilities seriously, began to invest in their communities, with a measureable improvement in health access for the most vulnerable, and the added bonus of reduction in unnecessary hospitalization. Some even went as far as investing in housing. With the financial squeeze of the global financial crisis, the DHBs have become increasingly brain dead, with an obsessive focus on their end of year financial result, disinvesting in community services, and focusing on Minister defined targets that were reset on a very narrow set of activities that belied the complexity of the organizations they were meant to guide.
A recent Treasury report6 shows that over the last five years most DHBs have shifted financial resources meant for primary care and community services into the hospitals, in attempts to make ends meet. At the same time they have shifted some hospital functions into the community. This amounts to a significant shift in financial resources in the opposite direction to their own planned intent, the policy intent of their organizations under the NZ Health and Disability Act. It has contributed to the failure to address equity of access at the community level. It is also a failure of the existing governance and oversight structures that such a high level of shifting costs onto the community has not been called out.
Having said that, the DHBs and their predecessors, the hospitals, have maintained free access for the whole population, and consistently done this since their inception. While the primary health care sector has failed to achieve equity of access, the hospitals have been much more successful in this regard. This includes effectively fighting off a neoliberal rush of blood to the head in the 1990s when the government of the day attempted to introduce user charges.
Of course the economists, managers, funders and planners all think this is mad. Why would we have access barriers to the front gate and least expensive part of the system, then have free rein for the rest, up to the most expensive offering? It does not make, economic, system, or efficiency sense. However from an equity perspective, it is the continuously open doors of our hospitals that have softened the impact of an inequitable primary health care system for generations of New Zealanders.
The way forward
So what are the lessons learned from the time of the Kurow Cure? The strongest structures in the health sector from an equity perspective and low access barriers remain the public hospital system. It has become part of our culture, or our “socialist streak” in the words of the current prime minister. We have failed consistently to introduce a similar public service culture into the primary health care sector. This sector was built on a small professionally led business model, and is fast becoming a large corporate model, with its focus on shareholder value rather than health equity.
Going forward, my belief is that the institutional instruments such as DHBs, PHOs, and capitation could all be effectively used to reduce health inequalities. But the overall intent is lacking.
At the highest level, the concept of the right to health within a national constitution would help maintain this strategic focus. This would help drive the cultural change required to shift the bureaucracies toward a better balance of economic and human values.
Within the health sector, the revised NZ Health Strategy generally has a much weakened focus on health equity, and is intending to take us into new territory with its emphasis on “social investment”.
The hope here is that with the financialisation of services to the poor, the actuaries and the quants with their algorithms from the insurance world will achieve what the doctors, PHOs, DHBs etc have so far failed to do.
On a more positive note, the strategy does state an intent to promote people-led service design, including for high-need priority populations. This would be a major reversal to recent trends, where community and Maori primary health care initiatives have struggled to survive, overwhelmed by the mismatch between the growing needs of their communities and the resources made available.
At the technical level, what is required is more effective governance and management within some of the existing instruments.
The capitation formula should encompass more of the fragmented funding streams, and have much stronger pro equity bias. VLCA 7should be enhanced, and universalised to all practices, and used to lower access – effective financial incentives should be available for practices that are providing free care. Currently the capitation formula amounts are based on a person’s age. Health needs are greater for Maori, Pacific and low income people, and the formula should be reflecting this.
Free care for under 6s and free care for under 13s now have cross party political currency and should go further to free care for people with chronic conditions, then free care for the elderly.
The availability of primary care services to the highest needs populations needs to be increased. This will require state investment in infrastructure, provision directly, or through community providers.
Fixing the two system holes – the transfer of government resources meant for the community to the hospitals and the failure to enrol the populations with the high needs into the capitation system should be made the highest priority of the system.
Resisting user pays and privatisation
On a broader level, what is it about our hospitals that have enabled them to effectively resist the countervailing forces of user pays and privatisation? Can we replicate these in the further development of the primary health care system? Can we build a sustainable, powerful sector that is patient-centred, values professional leadership, and resists erosion of its social justice focus? We need to harness the protective effect of a strong professional group or groups within the sector that can shape the primary care institutions and maintain a focus on equity.
The Kurow Cure yet to heal
In conclusion, the Kurow Cure as a vision of health care delivery has stood the test of time. A health system built on the concept of social justice vs charity or flawed market mechanisms is as relevant today as it was in the Waitaki riverbed in the 1930s. It is an embarrassment that 80 years later we still have families living in tents and a politically-led public discourse dehumanising the poor.
I’m confident we as a people, and the people of the health system, can do better.
1. Michael Belgrave, ‘Primary health care – Improving access to health care, 1900s–1970s’, Te Ara – the Encyclopedia of New Zealand, http://www.TeAra.govt.nz/en/primary-health-care/page-3 (accessed 26 November 2016)
2. A medical degree
3. A business degree
4. Independent practitioners association
5. Primary health organisations
6. Analysis of District Health Board Performance to 30 June 2015. The Treasury, New Zealand Government, June 2016
7. Very Low Cost Access
This text is from a speech presented by Professor Don Matheson at the launch of the 2016 UCAN Health Charter to the prospective Capital and Coast District Health Board (CCDHB) Board candidates in the 2016 election cycle.
An open letter to DHB Board members.
This letter comes from a network called UCAN that is supporting action being taken to ensure everyone in New Zealand enjoys the right to health.
One area that Boards can make a difference is Primary Care.
We recommend you eliminate access inequalities (increase availability, acceptability, and decrease price barriers) to primary health care services in your DHB area.
This will require differential investment to promote equity of access, by strengthening the primary care providers whose focus is on the provision of care and improved access for people on low incomes, Māori, Pacific, refugees and those with chronic illnesses, including mental illness. These providers may be mainstream general practices, Maori, NGO, or publicly provided services.
In strengthening primary care provision in the Board’s area, support models of care that are responsive to and respectful of the diversity of the Board’s community. One size does not fit all, and a single organisation outside of the public sector, monopolising primary health care provision in the Board’s area is to be avoided.
The DHB can fund this by stopping the current leakage and underspend that for a number of years has been shifting the Board’s resources from the community and primary care to the Board’s provider arm and the hospital. See this report for the situation in your Board. (Analysis of District Health Board Performance to 30 June 2015, Published June 2016, The Treasury, New Zealand Government)
In addition, we recommend you act collectively with other Boards and the Minster to address the national funding mechanism (base capitation formula, Very Low Cost Access, Services to Improve Access) so practices have money available to subsidise fees for patients who currently are struggling to access services. The current capitation formula is not adjusted to meet the high needs found in deprived areas, those on low incomes irrespective of where they live, or amongst Maori and Pacific populations.
That right is being denied to many in Aotearoa/ New Zealand, through poor access to health services, an unfair economic and education system that strongly favours the wealthy over the poor, inadequate and unhealthy housing, poor living environments that alienate vulnerable sections of the community. We have not met our Treaty obligations.
We believe as a nation we can and must do better than this.
The UCAN Charter for Health 2017
Everyone’s right to the health care they need
Free primary medical care available in every community. One million people have an unmet need for primary medical care. The cost of care is the biggest barrier, including the cost of drugs. There is low availability of primary medical care services, particularly in deprived areas. Barriers are bigger for those with chronic conditions, especially mental illness. A primary health care approach with a focus on equity and social justice is required across the health system.
Everyone’s right to a living income
Support a living wage and income for all, including beneficiaries. The gap between the rich and the poor is rapidly growing in New Zealand and this is bad for our health. More and more New Zealanders in work don’t get paid enough to meet their needs, to eat healthy food, and live dignified and healthy lives. Just to survive, many are left with no time for leisure or opportunity to participate in society. In addition, poverty is health damaging reality for many beneficiaries, and especially for 28% of our children who live in poverty.
Everyone’s right to a home
Support affordable, safe and healthy housing. We are failing as a nation to adequately house our children and other vulnerable groups. They are exposed to housing conditions that damage their health and are not fit to live in. You need a Warrant of Fitness for a car, but not a house. People with severe mental illness are often living in substandard temporary housing with insecure tenure. They have been betrayed by a failed market model for housing provision.
Everyone’s right to take part in our society
Support community centres, drop in centres, with free internet connectivity and public transport. We are denying more and more groups the right to actively take part in our society. More people are working are working longer hours, leaving less time for involvement in their communities. We used to house people with severe mental illness in asylums. This role has shifted to the community, but the social contract that community support would be there, has been broken.
Everyone’s right to a safe environment
Support improved access to healthy food, water and air. Regulate and tax foods full of sugar, fat and salt. Ban advertising of unhealthy foods and alcohol. Protect our water and the air we breathe from contamination.. Exposure of children to foods that are harmful to their health, and unrestricted marketing of unhealthy products are now leading causes of later illness. Our water and the air we breathe needs to be protected from contamination, as does the physical environment from which they are generated.
Everyone’s right to education
Support accessible educational opportunities for all. Student loans, unequal and unfair outcomes for children from poor communities, reduced educational opportunities for the elderly and beneficiaries are all opportunities lost.
Questions and Answers
What does a “Right” mean?
An entitlement that humans have by the fact of being human, such as the right to life and the right to be free from torture or degrading treatment. The highest attainable standard of health is a fundamental right of every human being. Health is a reflection of a society’s commitment to equity and justice. Health and human rights should prevail over economic and political concerns.
Can the country afford free health care?
Improved access to primary health care will reduce inappropriate use of hospitals, and help to keep health care costs down overall. Healthier people in the community also has an economic benefit.
What is Primary Health Care?
The main ideas are; that health care is focused on health needs; involves an enduring personal relationship between health workers and the community, particularly for those people with a chronic illness; is comprehensive (not just one illness) continuous (no barriers for patients needing care in both hospitals and the community) and person centred; responsibility for the health of everyone in the community at all stages of life; tackles the determinants of ill-health; and people are partners in managing their own health and that of their community.
Primary Health Care is a social justice and pro equity approach to health care described in the World Health Organisation’s Alma Ata Declaration of 1978 and updated by WHO in 2008. It encompasses primary medical care, hospital care, public health and the wider determinants of health.
Can the country afford a Living Wage?
A living wage has been shown to improve the economy of a country. People are a country’s greatest asset, and our children are our future. Addressing child poverty through supporting a living wage and income is a wise investment in the future.
Can the country afford decent housing?
Housing is not a cost to the economy- it is an asset, an essential piece of infrastructure, as important, if not more so, as a road, or a bridge, or an airport. Once built it has a monetary value, outside of its contribution towards nurturing the next generation.
Can the country afford education that achieve fair outcomes for all?
Like housing, education increases rather than decreases, the overall wealth of the community. Barriers to educational opportunities do not make sense – at any age.
Does the country have enough money for this?
Many of these features will have low cost or even improve the economy. The country has enough wealth to provide for all its citizens if that is made a priority. Currently the country’s wealth is poorly distributed and the provision of basic rights for all citizens is a low priority. The economy has a profound influence on people’s health. Economic policies that prioritise equity, health and social well‐being can improve the health of the people as well as the economy.
Does the UCAN Charter cover all the important issues?
The UCAN charter covers the issues its supporters see as most important at this time. There are a number of other important issues (the right to education, the protection of the planet from global warming) that we support, but are the subject of action led by other groups.
United Community Action Network (UCAN)
The Devastating Effects of Health Care Cuts
“Two tragic events in Wellington’s southern suburbs of Newtown and Kilbirnie calls attention to the devastating consequences of inadequate health funding, including the ongoing health funding cuts, for mental health consumers”, says spokesperson, Debbie Leyland, from the Wellington based health advocacy group, United Community Action Network (UCAN).
“The recent death in the Kilbirnie supported accommodation facility, Mahora House, highlights the dangers caused by continual cuts to health-based funding from Capital and Coast District Health Board (CCDHB) to community based health services” Leyland states.
Mahora House was established in 1985 to support people who were being ‘deinstitutionalised’ from long-term mental health facilities and moving into community-based settings. In 2013 CCDHB 2013 withdrew funding from Mahora House. In March 2016 a resident at Mahora house was fatally assaulted by another resident.
This event follows a similarly tragic event in 2009 at Te Menenga Pai, otherwise known as Mansfield House. The murder of one resident and conviction and imprisonment of another was a traumatic experience for residents, staff, friends and whanau. The Coroner’s investigation found that Mansfield House was chronically short staffed and frequently had an occupancy rate beyond capacity. The report was critical of the role of the CCDHB in its support of a facility with such high need. The Coroner stated that if the controlling health authority, in this case CCDHB, “devolves its responsibilities” to another service then it must continue to ensure ongoing audits ensure that care is delivered appropriately.
“Will an investigation into the recent tragedy at Mahora House present similar findings from the events of 2009? Did the DHB heed the warnings from the Coroner’s report?”, asks Leyland. “The CCDHB has a mandated role to improve, promote, and protect the health of people and communities and to reduce health disparities”
In 2010 the Minister of Health instructed the CCDHB to commence a policy of clawing back savings of $60 million in a three year period. The CCDHB CEO Ken Whelan resigned stating then that he could not “cut costs any further without undermining patient care”. Many of these ‘savings’ came from restructuring funding streams to community based services, ultimately forcing many to merge, reduce the services offered, or to close. Some of the service losses in the Wellington southern suburbs have been advocacy and Midwifery services and drop-in and activity centres.
UCAN calls on the CCDHB to halt all plans to reduce funding to any community-mental health focused services and for an investigation to assess the impacts of the loss of services that have supported the health and well-being of some of the most marginalised and vulnerable within our communities. Are these on-going cuts making inequalities worse? UCAN feels the answer is yes.
“Tragedies hit harder in small communities” says Leyland, “It’s no longer health, it’s Hell”.
For release on Thursday 14 February 2013
The United Community Action Network (UCAN), which was established to protest cuts to community based primary health care services is concerned that the people who need health care the most in this country are becoming less and less able to access it.
UCAN spokesperson, Debbie Leyland says, “The Government keeps telling us that the health of our children is a priority but everything they are doing shows that they couldn’t care less. Free health care for children has been extended but in many communities there is nowhere to get it from.”
“Funding is being slashed to community health providers who work with refugees, migrants and those on low incomes, and many are being forced to cut services. Last year Newtown Union Health lost its midwifery services because of a 7.8 percent cut to it budget.”
“UCAN is not the only group worried about the impact of health equity. Tomorrow the Royal NZ College of General Practitioners is holding a quality symposium with a focus on how to influence improvements in children’s health and at the Living Wage symposium people from all around the country are coming together to make the links between a decent living wage and health and well-being,” Leyland says.
“UCAN believes that there is a clear need for community-based publically-funded health services that are focussed on providing health care to everyone who needs it, when they need it, where they need it.”
“We urge the Minister of Health to walk the talk. Prioritising children means prioritising the health of children and their families. And that means funding the services that will improve the health and well-being of every child, no matter where they live or what their families’ income is.”
News from United Community Action Newtown
Members of the south Wellington community and supporters will be taking to the streets to protest against funding cuts affecting vital primary health services such as the Newtown Union Health Service (NUHS), as the CCDHB attempt to make $20 million of savings this year.
A new community group, United Community Action Newtown (UCAN), has been established to oppose the funding cuts and has organised the protest outside Wellington Hospital at 8:45am on Friday.
UCAN Coordinator Debbie Leyland says Newtown Union Health Service, which works with some of the most vulnerable people in the region, will lose $274,000 this year and expects to face more significant cuts in the year ahead.
“The DHB has indicated the 7.9% funding reduction to NUHS is required to help the DHB save $20 million this year. It has been indicated that the DHB needs to save an additional $20 million over the next two years which will have a serious impact on primary health care.”.
Leyland says the cuts will have serious impacts on patients who have no other option but to access low-cost primary health care, such as NUHS.
“Newtown Union Health is a low cost primary health service that provides vital services to some of the most vulnerable people in Wellington. The funding cuts are dire for the service. Services such as the diabetes program are likely to be cut. There are nurses and doctors volunteering to work for free to keep services going. Wellington Hospital’s A&E will become increasingly cluttered and there will be less ability for accurate assessment of A&E patients due to the extra pressure.”
Leyland says the Government is ultimately responsible for the cuts, and says Health Minister Tony Ryall has refused to meet with community representatives.
“The Government is using a sharp razor to cut services that are vital to the lives of many vulnerable people. We would like to discuss the implications of these cuts with the Minister of Health Tony Ryall so he understands the impacts. Minister Ryall’s office is refusing to meet with us and has told us that he does not meet with members of the community. This shows he is deeply out of touch”.
Leyland believes the cut backs are a poor financial decision and will cost taxpayers money.
“Several dollars are saved in other parts of the health system for every one dollar put into primary health care. These cuts will cost tax payers millions in the long run. The Government should be putting a fence at the top of the cliff, not simply relying on an ambulance at the bottom.” Concludes Leyland.
UCAN has also launched a petition calling for the reinstatement of the funding.
The protest will be taking place from 8:45am on Friday 10th August outside Wellington Hospital, near the A&E department.
Tuesday 5 June
Media release from United Community Action Newtown (UCAN)
In a classic case of David versus Goliath, concerned members of the Newtown community will protest the quarter million funding cut to the Newtown Union Health Service on Friday.
NUHS has been told by the Capital and Coast District Health Board that it will lose $274,000 in funding from July 1, 2012. The frontline primary health care service caters to South Wellington’s most vulnerable communities, looking after people who have difficulty accessing appropriate and affordable health care due to socio-economic deprivation and language barriers.
“These cuts will hugely impact our community,” says NUHS patient and community spokesperson Debbie Leyland. “[NUHS] will have to dramatically reduce the services they offer, which means our most vulnerable communities will have less access to primary health care.”
“Health cuts hurt communities, and they cost us more in the long term.”
The cuts are indicative of wider cuts to public health across the board. The 2012 budget sees the government taking $129 million from the health sector over the next four years.
““The Government is taking a bottom-of-the-cliff approach to our health system,” Ms Leyland says. “These cuts will reduce the well-being of our whole community.”
United Community Action Newtown (UCAN) has formed in response to the cuts, and comprises patients of NUHS and the wider Newtown community. They will protest outside the CCDHB Board Meeting at Wellington Hospital this Friday.
Southern Ward City Councillor Paul Eagle supports the community’s campaign to save Newtown’s primary health service.
“This funding cut will mean no more visits to the doctor for many families. I challenge those unsupportive District Health Board members to hit the streets with me and meet first hand, the very people impacted by this.”
Local politicians will join the community for the protest, which leaves NUHS (14 Hall Ave) to march to Wellington Hospital at 8:30am on Fri 8th June.
Representatives of the community will then present oral submissions inside the CCDHB Board Meeting at 9am.