Experience with Integration Initiatives in New Zealand – A GP Perspective

• Introduction
• Context – the Drivers of Change
• Local Drivers for Integration
• Key Issues
• Incentives for Change
• Integrated Child Health Services in Rotorua
• IPA Activities
• Conclusion
• References

Introduction

The topic of integrated care seems to have been generating a considerable amount of discussion over the last year or so but the debate seems to be occurring in a rather unstructured manner. Part of the problem is a lack of clarity about exactly what is being discussed as integrated care seems to mean different things to different people. For many it seems to conjure a spectre of “an Americanisation of the health service”, with inferences drawn from the experiences of US managed-care organisations, and the controversy that that particular style of integrated care delivery generates. This, and the wide range of issues that integrated care may encompass, makes controversy inevitable.

Perhaps a way forward would be for the medical profession to return to its basic scientific roots and to conduct a more systematic analysis of the issues. Proposed change in the health service that is intended to alter patient outcomes, as is the case here, must be treated in exactly the same way as the introduction of any new therapeutic manoeuvre, operation or pharmaceutical. It should undergo a similar period of rigorous trial and analysis, with exploration of the indications, contra-indications, benefits and adverse effects. Medical practitioners’ ethical obligations about new drugs and interventions are quite clear. How, in principle, are the issues surrounding integrated care any different?

Western medicine’s basic scientific processes have stood the medical profession in good stead over a great many years, and only if debate about integrated care is conducted along these lines will progress be easily made in what will remain a highly controversial area.

Context – the Drivers of Change

A useful starting point might be to consider some of the drivers of change that almost all developed countries are experiencing. What is the context? At a macro level there seem to be many similarities between nations. All are struggling to reconcile the irreconcilable – ever increasing demand for services and an inability of any publicly funded health system to fully meet that demand. The result is, inevitably, an examination of processes that will maximise efficiency, hopefully without compromising effectiveness, and of prioritising care, through more explicit rationing.

The supply side of the health equation is influenced by increasingly sophisticated and often costly technological advances or therapeutics, an increase in the number of providers (who generate costs), funding policies that reward increased service delivery (often with third party payers), and whether or not a particular system has a formalised gatekeeping role.

The demand side drivers are largely the aging population, and increasing consumerism. Older citizens require more medical services, with people aged over 65 requiring, on average, health care costs four to five times the average of the general population, and people aged over 75 years, seven to eight times the average.

There is an increasing awareness of medical matters in the community, and an increasing assertiveness in consumer demand for services. This puts considerable pressure on practitioners to balance their role as advocates for the individual with wider community responsibilities to use scarce public resources wisely.

The result of this inexorable increase in demand is amply illustrated by the American experience. In 1950 health care costs represented 4.4% of GNP; by 1994 they had risen to 14.1%. Between 1965 and 1990 GNP in the US rose by 94%, while in the same period the cost of drugs and payments to dentists rose by 150%, payments to physicians by 250% and hospital costs by a staggering 350%.

Many developed countries have seen health care costs increase as a proportion of GDP, and they continue to grow faster than GDP itself. In the UK spending on health care has increased by 13% greater than the growth of GDP between 1985 and 1991.

This somewhat volatile mix has been compounded by greater difficulty in economic planning – the old adage “the future is not what it used to be applies”.

There is also a growing concern that high technology medicine has failed to deliver on the promise of the early 1960s and 1970s. Communities are no “healthier”: certainly, many diseases can be better managed and treated but there has been inadequate investment in public health or preventive health measures.

Just as many countries appear to have similar problems, so to are similarities in solutions emerging. Many countries are rethinking core strategies of their health services with clearer definitions of national health objectives, policies and responsibilities. Solutions include a greater emphasis on preventive health, the need to ensure equity of access to publicly funded health services for all citizens, greater emphasis on quality and the measurement of quality and health outcomes, and the need for services to reflect the values of the communities they serve.

Several countries have moved to separate the funding of health from its provision – the funder–provider split – and have introduced macroeconomic controls through capping funding, price control of pharmaceuticals and hospital services, greater control of provider numbers and payments, and the introduction or extension of co-payments.

In New Zealand this heady milieu is further enhanced by radical reform and re-thinking of the role of government in public life with a commitment to balance the government budget, the restructuring and stripping back of the welfare state and the corporatisation of numerous government departments. These activities have been moulded in recent years by an apparent belief in the superiority of the market over government of competition over co-operation and a greater emphasis on self-reliance over community responsibility.

Important values such as human dignity, distributive justice and social cohesion have been given second place to the pursuit of efficiency, self reliance, a fiscal balance and a more limited state.  ¹  

This then is the context in which to attempt to think through the issues of integrated care.

Local Drivers for Integration

Rotorua has a population of approximately 65,000. This community is served by a good quality district hospital, primary medical care (42.5 full-time equivalent (FTE) General Practitioners and 27.5 FTE practice nurses), and a large community health sector which includes numerous voluntary agencies, community health agencies such as Tipu Ora and Plunket, and district and public health nursing.

Most of these agencies operate autonomously with varying degrees of co-operation and co-ordination of the care they each provide to their mutual patients or to the wider community. In effect, there are three separate health services each operating independently of the others, yet serving the same populace, and often simultaneously.

There would seem to be (based on biased and unscientific personal experience) potentially significant benefits to be gained from looking more closely at integrated care, if for no other reason than the current services are so hopelessly dis-integrated that there has to be a better way.

Many of the local drivers are a reflection at a local level of the forces at play in the national and international arenas. Demand for health care, the need for it and the inability of the health care service to always deliver are a daily reality. The Rotorua hospital has a fixed revenue and is unable to meet community need and so rationing becomes inevitable. There are also, clearly, opportunities to provide services more effectively either in the community or in general practice, and numerous opportunities to reduce some of the continuing waste and duplication of resources and services.

Key Issues

These are numerous. Perhaps one of the more pressing is inadequate information systems and information strategies. An urgent priority is to develop strategies to understand the Rotorua community’s actual needs, the services currently being provided and to plan the service delivery requirements for the next few years. Currently, virtually all health activity is reactive, with minimal opportunity to measure current or future need or to reflect on how that may be met.

Probably the other single biggest issue is trust – or rather the lack of it. The past few years of “Reform” have damaged relationships between provider groups, and between providers and purchasers, and these will take some time to repair. The competitive model has encouraged providers to focus on maintaining their own autonomy and reinforced a professional “turfism”, reinforced by short-term contracts with no reassurance of renewal. For some of these groups the focus inevitably becomes one of survival. In this environment it is hard to expect organisations to commit to an even more uncertain future in an Integrated Care Organisation (ICO) – whatever that may be.

This leads to another major issue – the lack of strategic direction and leadership. Whilst there is merit in the flexibility of the “local solutions to local issues” approach, it has been evolved in an environment of so much variability in approach yet replication of effort that it has been almost anarchic. There is no discernible strategy, no clear set of rules and no guarantee that investment of local effort will be rewarded.

Consider the recent past. In the last few years, the Hospital Boards have been abolished, the Area Health Boards have been introduced and abolished, and the Public Health Commission, the “competitive model” and user part-charges for hospital services have all entered the picture and subsequently been abolished. Personal health plans were abolished before they could be introduced, the Core Services Committee was unable to complete its task but cleverly underwent a metamorphosis into the National Health Committee with an equally difficult task, but another five years of life. The Transitional Health Authority became Regional Health Authorities before adopting the Pol Pot approach to management with a systematic elimination of anyone with knowledge.

There is no strategy, poor leadership and a workforce that is change-weary and increasingly cynical. What criteria can be used to determine whether integrated care is yet another fad or may offer something more substantial to either patients or providers?

We tend to meet each new situation by reorganising, and a wonderful method this can be for creating the illusion of progress, whilst producing confusion, inefficiency and demoralisation. Gaius Petronius.

Another key issue is the difficulty of moving resources within a community. Basically, hospitals are funded according to the number of procedures or bed stays. There is no incentive for them to keep patients out of their expensive institutions. Similarly, those in general practice know they can keep patients out of hospital, but that requires additional resources that they cannot access.

Health care activities are often considered by purchasers in isolation. Thus spending on pharmaceuticals is viewed as an independent cost centre, and a cost minimisation approach is applied irrespective of whether greater investment in community pharmaceutical use or in laboratory use may reduce the use of secondary services (or even perhaps improve health outcomes).

Finally, change of this nature requires properly resourced change management. It is in effect a major restructuring of the biggest industry that any community has, and that has to be managed properly.

Incentives for Change

Incentives for change can be considered in three groups: professional, commercial and contractual.

Despite the difficulties of the current environment, most providers remain very committed to constantly improving the quality of the service they are providing. The professional incentive to do better has long been a feature of medical care and it remains a strong motivating factor today, although many providers are becoming burnt out by the relentless process of change. Providers are also more aware of the wider issues and realise they need to look realistically at the services they provide in a broader context. They are, perhaps, more open to changes that will preserve or enhance care, provided that the processes are more carefully thought through and supported than has been the case in recent years.

There also need to be commercial realities for individuals and for organisations. Financial rewards are important and can be used as both an incentive and a reward for practicing a more integrated form of care.

Finally, contractual details can also play an important part in whether organisations wish to remain in isolation or to work in a more co-operative and co-ordinated fashion. Currently many organisations are funded for autonomy, not for independence, and many of the incentives effectively encourage organisations to remain independent even if they can see the need for increased integration.

Integrated Child Health Services in Rotorua

For the last few yeas a considerable amount of effort has gone into developing an integrated child health project in Rotorua. This has involved representatives from the hospital, a general practice Independent Practitioner Association (IPA) and key child health community providers such as Tipu Ora and Plunket, as well as public health nurses, midwives and consumer representatives.

This group is attempting to develop a model of integrated care that would see all children in Rotorua enrolled with a family health team. This team will usually comprise a GP, practice nurse, Plunket nurse, Tipu Ora and other services.

Information about the child will flow between the secondary sector, the primary medical sector and the community through the family health teams in an attempt to reduce duplication of effort but also to identify gaps and try to target services more effectively at those who need them most and receive them least. This project is intended to be supported by KidZnet – an information strategy to improve this communication and support child health services that is being developed within a joint venture between Health Waikato and the Rotorua GP group.

Three types of information appear to be necessary. Firstly, well-child information, which would record basic demographic details and a limited data subset of well-child events such as routine checks and immunisations. It is likely that this information would be available to authorised members of the various agencies involved.

The second type of information relates to better disease management for children with established health problems. This is largely an expansion of the current information flows that occur between the primary and secondary sector, but ways of improving this interface are being explored with the intention of extending it yet further to the people who need to know about it in the community sector. This is part of embracing a more comprehensive disease management strategy for these children.

Finally, population-based data is needed that looks at overall community morbidity. This would require information that can help identify needs and service provision and look for gaps between the two so that services can be planned.

As part of this project, two child-health co-ordinators – one an ex-practice nurse and the other coming from a community health background – and a GP paediatrician have been appointed to the project. It is hoped these people will be able to co-ordinate the delivery of services in the community. That is not to take on a provider role themselves, but simply to conduct the orchestra of providers already in place.

The key issues that this group has faced really reflect the ones already listed above and, in particular, the issues with relationships. It is hard for any agency to take a broader, and perhaps more altruistic, medium-to-long-term view whilst they are consumed with seeking funding to ensure their own survival in the immediate term. There is a degree of suspicion about motives of other players, both purchasers and providers, some cynicism and some burnout but overall a strong sense of commitment that something must be done to improve the child health statistics.

At this stage, the project is probably about half completed. Although it is too soon to be able to report definitive results, progress so far is encouraging. There is a Stakeholder Group which represents all the key players involved in child health in the Rotorua community, and for the first time all the member agencies are meeting regularly to discuss how to work together to improve child health services. This group has already identified a few opportunities for improvement, including better, structured referral of pregnant women by GPs to lead maternity carers and subsequent referral of new born children to well-child providers, and the establishment of a rheumatic fever register to monitor secondary penicillin prophylaxis. However, it is the very fact of meeting and starting the process of working together that is the most encouraging.

IPA Activities

The local IPA has been very active over the last few years in a comprehensive programme of patient enrolment so that there is now a total of 65,717 patients enrolled with general practitioners. Basic accuracy of demographics about these people is high as this is required for capitation purposes and all but two general practitioners in Rotorua are now members of this capitated network.

Knowing who makes up the population is an essential pre-requisite to understanding the services that the community requires. The appointment of an Information Technology (IT) manager has seen the development of a much more cogent IT strategy for the whole IPA.

This strategy includes rationalising of practice management software systems (previously five systems were used within the town, now moving towards one or possibly two); standardisation of hardware solutions and a check on the adequacy of the cabling and hardware configurations; and training and adequate support for the whole community of providers. The IT manager will be available to work with all the child heath providers in order to embrace a wider community of providers with agreed computer hardware, software and communication solutions.

The next phase of the project will see the establishment of a disease register. All providers will be encouraged to use Read codes during consultations and will certainly be strongly encouraged to record a number of the diseases that are currently important because of high morbidity, high cost or a gap between ideal and current treatments.

The nature of repeat prescribing means that most patients with chronic disease re-attend at a practice every three months for new prescriptions. As patients re-attend, the practice management disease registers will be maintained and this will give a tremendous opportunity for the establishment of a community-wide distributed disease register covering each of the major diseases. Secondary providers, pharmacies and others can then work together to approve quality of service delivery and patient management for these conditions by using the well established tools of medical audit, peer review, feedback, targeted continuing medical education (CME) and so on. Within a relatively short time it would become apparent, for example, how many patients with diabetes have had retinal photoscreening, how many still require it, what the implications are for planning of those services, and so on. It is only by a consistent strategy and the integration of effort amongst providers that this type of rationalisation of services and planning of services can effectively occur.

This opportunity partly arises because of the increasing sophistication of the electronic medical records that many GPs now have. The adoption of electronic records has been high in New Zealand relative to many other western countries, and there are a variety of very sophisticated products in the market place. Another advance is in the ability of integrated networks to operate in a distributed fashion so that the key information resides on the provider’s own computer system. Only very limited information needs to leave that system, and that will happen by a process that carefully safeguards the privacy and ethical requirements of the patients.

Conclusion

A somewhat intuitive conclusion is that integration has to be better than dis-integration, which describes much of our current health service. Experience in other industries has shown that for change to be successful those driving it should enlist the support of those who are required to make the change, and then empower them to lead it. The health sector is no different. The providers up and down New Zealand have to experience a day-to-day reality that seems far removed from that of planners and purchasers. In order to achieve the kind of change that integrated care requires, and to realise the opportunity it offers, thinking and effort must first be integrated at all levels; not only between providers, but between planners, policy makers, politicians, purchasers, the public and providers. The crucial requirements are strategy and stability, knowledge and leadership and – perhaps above all – trust.

References

1. Boston J, Dalziel P [eds]. The decent society?: essays in response to National’s economic and social policies. Auckland, New Zealand: Oxford University Press, 1992.