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In this edition of Healthcare Review – OnlineTM, we consider health care strategy in New Zealand, both the recently released Primary Health Care Strategy [Feb 2001; available at the New Zealand Ministry of Health’s website] and the New Zealand Health Strategy [Dec 2000; available at the New Zealand Ministry of Health’s website].
The Primary Health Care Strategy follows on from the New Zealand Health Strategy and the New Zealand Disability Strategy. According to the Ministry of Health, The New Zealand Health Strategy sets out principles, goals and objectives for the health system and these have guided the development of the Primary Health Care Strategy. The New Zealand Disability Strategy, which is still being developed, has also helped to shape the Primary Health Care Strategy.
A strong primary health care system is central to improving the health of New Zealanders and, in particular, tackling inequalities in health. There is considerable evidence available about the specific contribution primary health care can make to improved health outcomes and a strong direction for primary health care development is essential to allowing this to be fulfilled.
Dr Jonathan Simon, Director of Health Services Management, First Health/Southern Cross, considers the Primary Health Care Strategy from the perspective of the First Health primary health care network. The First Health organisation emerged from a pilot project funded by the Health Reforms Directorate and the Department of Health in 1992/3.
This primary health care network, established as a result of the pilot, was designed to be a new platform for primary sector organisation and change management and also a platform for primary/secondary sector integration.
Simon begins with an overview of the First Health and PrimeHealth organisations outlining the overall goals and structure of these organisations.
Against this background he considers the primary health care strategy. In his view the strategy reflects consistent health policy held by the Labour Party for the past 30 years. However, he highlights significant problems with the strategy that include issues related to enrolment, funding and the absence of the use of the terms ’general practitioner’ (GP) and Independent Practitioner Association (IPA), both of which are vital to the implementation of the strategy. He notes that the foundation of a primary care lead integrated health sector is well organised, high quality general practice teams and refers to persistent attempts to marginalise and ignore this asset.
Simon reviews the approach of the First Health/PrimeHealth organisations alongside key points from the Primary Health Care Strategy. He concludes that there is a very clear relationship between the values and the achievements of First Health and PrimeHealth over the past decade and the government policy on primary health care for New Zealand. He considers that the Primary Health Care Strategy gives First Health and PrimeHealth the opportunity to continue to work with professionals and communities to create new partnerships and to deliver better health outcomes. Against this positive must be weighed the areas of concern with the strategy, particularly in relation to issues with respect to enrolment, funding and recognition of the role of existing primary care structures in implementation of the strategy. These issues will need to be addressed in order to move forward with the strategy as set out.
Dr Dave Graham, MBChB, DCH, FRACP, Community & General Paediatrician, Health Waikato, Hamilton New Zealand, considers the New Zealand Government’s New Zealand Health Strategy and the Primary Health Care Strategy and reflects on the health system in relation to child health in New Zealand.
Graham describes the shifts that have occurred in the New Zealand health system since the early 1990s from a structure based on a Department of Health, area health boards and hospitals through to the "purchaser-provider split" environment, and subsequent changes to the structure of purchasers and public providers within that system.
Graham notes that unplanned side effects of this planned and imposed evolution in the health system have included, in particular, an increase in private health insurance.
In addition, the changes imposed on the health system have not occurred in isolation. A number of other changes occurring simultaneously have also had tremendous impact on the New Zealand health sector, including increasing complexity of the health system and increased numbers of new health care provider groups.
The most recent shift has been to a system of District Health Boards (DHBs), hospitals and other health providers. This change has been accompanied by a strategic rethink in a number of health care delivery areas, a good example of which is the Primary Health Care Strategy.
Graham highlights concerns related to the DHB-based system, including an apparently top heavy management system and a contracting and funding system that significantly restricts the ability to assess the requirements for and provide specific services at a local level.
The Ministry of Health, not the DHBs, will hold funds for the period November 2000 to November 2001. During that time, the keys for clinicians to effectively work within the system will be to:
• know the Ministry people
• identify key board members
• identify key board subcommittees
• become involved in the election process
• become involved in regional analysis.
In considering the New Zealand health system and child health, Graham notes that, despite the changes and the associated expansion of the Ministry of Health, New Zealand still lacks a service in the Ministry of Health that is specific to children. In addition, children are not clearly represented in some other key ministries. Poverty and the poor health of certain ethnic groups contribute to child health issues. These circumstances should be, but often are not, taken into consideration within the health system structure.
Other concerns that he raises with respect to the Primary Health Care Strategy relate to enrolment and an apparent "demonising" of anything that is not the "new" model, without recognising current naturally evolving models.
Whilst the Primary Health Care Strategy has worthy goals and proposes using population enrolment with primary care providers to reach these goals, the voluntary nature of enrolment is likely to lead to failure. Certainly the groups at most risk are the groups least likely to enroll in a voluntary primary care system.
At both the DHB level, and using the Primary Care Strategy as a specific example, there is a sense that worthy goals and sensible principles are being hamstrung in the details of their implementation.
