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This month’s edition of Healthcare Review – OnlineTM is the third in a series focussing on integrated care.
This edition overviews the roles of policy in the development of integrated care and provides viewpoints from some of those people who are most influential in the development of integrated care in New Zealand.
The first contribution is from Dr Gay Keating, Senior Advisor, Policy Branch, at the Ministry of Health, and focusses on the role of policy and the Ministry of Health in the development of integrated care in New Zealand.
She presents a comprehensive overview of integrated care, exploring issues, discussing the various policies and outlining the potential role of integrated care organisations. In addition she presents suggestions on who should be involved in the development of integration, and thoughts on how further progress is likely to be made. The view is optimistic. Integrated care is seen to offer solutions to some health care delivery issues through the achievement of improved co-ordination of services in a way which will lead to gains in health and independence within the funding available.
In Dr Keating’s view, the role of the Ministry of Health is to support developments in the health sector and to support Government in establishing policy that manages risks posed by integration and ensures the delivery of the health gain benefits that integrated care offers. This contrasts with the role of the Health Funding Authority (HFA) which, while supporting developments in the health sector, must also balance the potential of new developments against the limitations of the current situation, and take calculated risks on new unproven ventures.
Integrated care is very much on the agenda of the HFA; the integration of health and disability support services is seen as a key strategic direction. Demonstration projects which cover a wide range of approaches to integrated services will test key questions about integration. Formal evaluation of the demonstration projects will examine the contribution of integration projects to improving health and independence and will assess the impact of the proposed policy.
This process is intended to give the people of New Zealand, providers, the HFA, the Minister of Health and the Ministry of Health a chance to examine the implications of the policy and engage in a discussion as to the most appropriate developmental strategy for this type of purchasing.
Ms Cindy Kiro, Department of Social Policy and Social Work, Massey University Albany has more broadly reviewed the importance to primary care and Maori providers of managed care {integrated care} and the role of Government in its development.
Questions are raised relating to the motivation of Government in developing these policies, suggesting that there is reason to believe that primary motivation arises from controlling health expenditure and managing political risk rather than managing health.
The formation of managed or integrated care organisations is viewed as a logical next step in the process of removing Government from health services provision. But the transition to integrated care is not seen to absolve Government from addressing certain fundamental issues associated with health care within New Zealand such as how much money Government should spend on health and what is the nature of the contract between Government and its citizens in respect of health.
She highlights the lack of clear evidence from the USA of the benefits of moving to managed care, and draws attention to the style of competition in health services that occurs between competing integrated care organisations.
Ms Kiro considers that Maori interest in co-ordinated care is because it is seen as a means to increase direct control over health services by Maori for Maori, and also raises issues associated with Iwi-led integrated care organisations, such as ethical conflicts of interest.
Ms Loraine Hawkins, who is currently working in HM Treasury, provides some background to the two papers above by reviewing the role that policy has played in the past in developments in integrated care in New Zealand.
Her paper reviews the policy rationale and track record for proposals for integration of funding streams and integration of service delivery in New Zealand and comments on some similarities and differences in the English reforms of the 1990s.
She reviews relevant health reforms directed at integrated funding: the reforms of the 1980s which created Area Health Boards and the next wave of reform starting in 1991 which focussed on integrated management of the total health care needs of a client population.
The 1991 Policy Statement outlined the intention of the integration of funding streams, and their management by the then Regional Health Authorities, (RHAs) to lead to integrated service delivery: better co-ordination and management of patient care across different settings.
A number of subsequent policy statements have also emphasised integrated care under its various titles. However, the policy rationale for pursuing integrated service delivery was perhaps less clearly articulated than the rationale for integrating funding streams.
Evidence regarding the ability of integrated funding to address problems arising from fragmented funding and some positive experience in the USA and UK exists but there is a lack of strong evidence about models of integrated care: the best configuration of primary and community health services and the best way to organise the interface with secondary care.
The resultant lack of clarity from policy makers regarding the desired end point of integrated care is cited as a possible reason for the slow timeframe in the development of integrated care. But it is also pointed out that the Government lacks the power to re-organise the private independent practitioners and NGOs that make up the primary and community health services and must rely on the initiative of providers themselves to respond to the opportunity. Financial incentives are lacking and administrative or political obstacles have been significant.
Further difficulties are created by a lack of national policy resolution of some controversial issues, for example mandated use of unique patient identifiers. The lack of national policy has meant that the former RHAs have made progress on difficult issues from different views.
She identifies the role that central Government has played in restricting funding of integration, noting that these interventions have not always been transparently outlined, in policy guidelines, policy statements etc, but that explicit Government decisions in these areas would have divided the health professions, inviting a campaign for policy reversal.
Thus, policy, and indeed lack of policy, are cited as only one of various ways in which Government influences the development of integrated care.
The next edition in the integrated care series of Healthcare Review – OnlineTM will review the role that funding and development processes play in integrated care development.
Subsequent issues will consider delivery systems in integrated care, with reviews of experience from primary and secondary care providers in both public and private sectors, and the influence of technology on the development of integrated care.
Earlier editions in the integrated care series of Healthcare Review – OnlineTM introduced integrated care and outlined ethical issues associated with its delivery.
The first edition provided an introduction to integrated care from Professor John Ovretveit, Professor of Health Policy and Management at the Nordic School of Public Health in Goteborg, Sweden. Professor Ovretveit’s paper provides a valuable overview of integrated care and outlines five models around which integrated care systems can be based.
The second edition reviewed the role of ethics in integrated care, both the influence of ethics on the development of integrated care and the ethical issues around integrated care for the delivery of health care. Papers, from Dr Colin Feek, Chief Medical Advisor, Ministry of Health, Sir John Scott, Professor Emeritus of Medicine, University of Auckland, Professor Grant Gillett, Otago Bioethics Centre, University of Otago, and Professor George Salmond, Director of the Health Services Research Centre, Victoria University of Wellington, addressed ethics issues from different perspectives based on the contributors’ various clinical, bioethical and policy experience.
