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- Abstract
- Introduction
- Overview of the First Health and PrimeHealth Organisations
- The Primary Health Care Strategy
- Impact of the New Zealand Primary Health Care Strategy
- First Health/PrimeHealth and the Coalition Government’s Health Policy
- References
Abstract
The First Health and PrimeHealth organisations emerged from a pilot project funded by the Health Reforms Directorate and the Department of Health in 1992/3.
The primary health care network, established as a result of the pilot, was intended to drive change. The network was designed to be a new platform for primary sector organisation and change management and also a platform for primary/secondary sector integration.
Given the possibility of rapid change in the political environment, network structures were built on sound principles and values that would outlive any such changes.
An examination of how the current First Health/PrimeHealth organisations fit in with the New Zealand Primary Health Care Strategy requires consideration of the approach of the First Health/PrimeHealth organisations alongside key points from the Primary Health Care Strategy.
The Primary Health Care Strategy reflects consistent health policy held by the Labour Party for the past 30 years. However, there is a number of significant problems with the strategy. Some relate to funding and to enrolment. In addition, there is an 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. The foundation of a primary care lead integrated health sector is well organised, high quality general practice teams. Ignoring any reference to this reflects persistent attempts to marginalise and ignore a key asset in the form of well-organised general practice teams linked into IPAs and primary care networks.
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.
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.
Introduction
The purpose of this article is to examine how the current First Health/PrimeHealth organisations fit in with the New Zealand Primary Health Care Strategy 1.
Overview of the First Health and Prime Health Organisations
First Health and PrimeHealth emerged from a pilot project funded by the Health Reforms Directorate and the Department of Health in 1992/3.
The project examined the feasibility of establishing a primary care network in Tauranga. It was constructed on the best evidence available about the then health reform trends both in New Zealand and overseas.
The Tauranga Primary Health Care network ("the Network"),which was established as a result of the pilot, was intended to drive change, not to maintain the status quo. The Network was designed to be a new platform for primary sector organisation and change management but also a platform for primary/secondary sector integration.
Because the political environment can change rapidly, it was important to create the network structures on sound principles and values that would outlive any such changes.
Values, Goals and Missions
The overall goal of the Network was to improve the health of New Zealanders who were public health patients in Tauranga. The three values that informed all decision-making were:
• quality
• equity
• accountability.
It seemed to the Network steering committee that using high quality as the main standard for every activity would focus those working in the Network in a way that would be acceptable to medical professionals, the general population and politicians alike. Quality was chosen as it is the easiest way to promote change amongst health professionals and coincidentally also appeals to consumers.
The Network’s mission statement, containing values that clearly reflect those of the recently released Primary Health Care Strategy, is:To provide comprehensive, high quality care to a registered population, delivered by a team of professionals in a way that respects a patient’s choices, autonomy and culture.After the mission statement was agreed, it became possible to create a primary care network that could move on address the issues driving change and reflecting those changes:
1. Continuous quality improvement. 2. The need for greater professional accountability. 3. The need in society for greater equity in health outcomes. 4. The increased importance of health service consumers and their effect on service delivery. 5. The development of multi-disciplinary primary care teams to deliver shared care. 6. The information/communications revolution and the emergence of the electronic health record. 7. The development of the concept of a responsibility for the population at risk as well as the individual contact involved in delivering personal health care. 8. Defining the practice population and obtaining the denominator for the measurement of practice activities. 9. The development of constructive relationships with management; it was important for the health professionals setting up the pilot to deliver an environment where there was an effective partnership with management. 10. Delivering health services more flexibly, particularly for Maori and Pacific Islanders. 11. To move from a "sickness" model of health care to a "wellness" based model. 12. To move towards incorporating the principles of the Ottawa charter and its concepts of healthy cities and community development.
These were the Network’s objectives as originally developed in 1992/3. It is interesting to see how little they have changed, despite being developed during a time when "the market" was used as the model for health service structures; they are still effective today when the market no longer has a role and health service delivery is seen as a "public good" delivered by the State.
The strength of the primary care network approach was two-fold:
1. The partnership between general practitioners, practice nurses and practice management staff, ie, the multidiciplinary approach 2. The clear values and direction that were informed by evidence and not by sectional interests. The most controversial action taken after the initial pilot project had been completed at the end of the first year was the development of a joint venture between the Network and the insurer, Aetna Health (NZ) Ltd. The joint venture was intended to allow the creation of a high quality management support organisation that could, in turn, create, a transportable management structure that could be offered to other networks and multi-disciplinary teams in the same area or in other parts of New Zealand.
The theory was that this would ensure the existence of high quality management systems that were affordable. The more groups that used the systems, the lower the transaction costs and the less resource would be diverted from delivering health services.
By the end of the pilot project, the Network group had identified four barriers to moving forward which related to the need to understand:
1. how to achieve integrated care
2. how to develop information systems
3. how to handle risk
4. how to raise sufficient capital to create integrated systems.
The joint venture provided answers to these questions. Aetna Health (NZ) Ltd set up an affiliate company, First Health Ltd that became the joint venture partner with the Network.
The services that First Health provides are:
1. Management support services.
2. Contract negotiation and maintenance.
3. Quality framework/clinical governance framework.
4. Outcomes management.
5. Disease management programmes.
6. Information framework.
7. Communications framework.
8. Treasury.
9. Risk management.
10. Health services management support.
11. Business analysis and business plan development.
12. Marketing expertise.
13. Commercial support.
14. Access to best practice.
The acquisition of budgets that were "at risk" caused some anxiety within the New Zealand health professional environment. In taking risk, the joint venture developed an approach with the then, Midland Regional Health Authority to manage the total risk of the pharmaceutical and laboratory testing budgets. Over time it has been demonstrated that such risk can be managed in a way that adds value to the sector, reduces variance in health professional behaviour and uses evidence-based best practice to drive change.
First Health now works with eight networks across the North Island. These involve 300 doctors, 300 practice nurses and 500,000 enrolled and capitated patients.
The Primary Health Care Strategy
In February 2001, the New Zealand Government released its Primary Health Care Strategy. It came as no surprise. The Labour Party has had consistent health policies for the past 30 years.
The themes of Labour Party policy have been:
• The integration of the publicly funded system.
• Population-based funding.
• The development of primary health care teams.
• The extension of the role of nurses within the health system.
• More health promotion and disease prevention.
• Locality based services.
• Integrated service delivery.
• Greater community involvement in health service design and delivery.
These policies have existed since a Labour Party White Paper 2 developed in 1974. Subsequently, the Labour Party established Area Health Boards and in 1989 attempted to have general practitioners put on contracts that lead to capitation and a team approach incorporating health promotion.
None of these initiatives succeeded. However, with the introduction in 2000 of District Health Boards (DHBs) and the recent Primary Health Care strategy its seems more likely that the time has come for these ideas.
Impact of the New Zealand Primary Health Care Strategy
The strategy give a high level vision of the primary sector. This is an improvement on the pre-existing policy vacuum.
However, there are significant problems with the strategy:
- It is a very high level document with little direction as to how the desired structures may be attained and what the drivers to attain them might be.
- The words ’general practitioner’ (GP) and ’Independent Practitioner Association’ (IPA) are conspicuous by their absence. Without GPs and IPAs the strategy would not be able to be implemented. The foundation of a primary care lead integrated health sector is well organised, high quality general practice teams. Any reference to this has been ignored. This represents the persisting attempts to marginalise and ignore one of our key assets in New Zealand, ie, the well-organised general practice teams linked into IPAs and primary care networks
- The idea that voluntary ’enrolment’ will allow population-based funding is naïve. Compulsory enrolment is the prerequisite for population based funding.
- The concept of enrolment with the Primary Health Organisation (PHO) is a curiosity as no-one can define or understand the nature of these PHOs. How will the public understand why they are to register with PHOs and not their doctors?
- The PHOs could well emerge as single entities that are owned by DHBs, if this were the case then enrolment would, in effect, be with the DHB. Would this not make the DHB a Health Maintenance Organisation? Is this in keeping with government policy?
- If the PHO was, indeed, a sub-set of the DHB and co-ordinated the various primary care organisations, the question arises as to what was the purpose of IPAs, Maori Development Organisations and other organisations, that might now appear to be anunnecessary layer of administration. If so, the DHB could take over and bureaucratise the primary sector. International experience has shown that this approach does not work well.
- As the initial public meetings of the DHB take place, it is becoming clear that the DHBs are underfunded and lacking capacity to perform the functions for which they are designed. The underfunding will lead to reduction of service capacity in many DHBs. In turn, this will clash with the public’s increasing expectations of the newly created DHBs.
- With the arrival of the newly elected DHB members at the end of 2001, this conflict between actuality and expectation will become more severe.
- The challenge will be to manage through this very difficult transitional phase to deliver the integrated health delivery system so desperately required in New Zealand. There is no choice but to manage resources in a more effective, patient-centred way. The chaos of the next twelve months may allow primary care networks to work with the Government to change the model.
- The absence of funding is not an overwhelming barrier, provided that it forces primary care networks to find original solutions to our health delivery problems
First Health/PrimeHealth and the Coalition Government’s Health Policy
The most significant change in First Health has been the merger with Southern Cross Healthcare. As a result of this merger, First Health has been made a part of the Southern Cross Hospitals Trust and is a not-for-profit company. This change has allowed all the other features of First Health’s activities to be recognised within the health care sector. Previously, the association with a US-based for-profit company was not seen to be acceptable in the New Zealand context.
| Primary Health Care Strategy | First Health/PrimeHealth | ||||||||||||||||||||||||||
| Work with communities and enrolled populations | First Health/PrimeHealth have worked with communities from the beginning. They have:
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| Voluntary enrolment | All First Health/PrimeHealth practices have worked with voluntary enrolment since 1993. There are 500,000 capitated patients. | ||||||||||||||||||||||||||
| Maori health |
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| Pacific Island services | The South Auckland Network works extensively with South Seas, (a Pacific Island health care provider) to develop innovative services and improved health outcomes for the local population. | ||||||||||||||||||||||||||
| Identify and remove inequalities | There is extensive need analysis capacity using the capitated database and good demographic data. Using agreed READ codes, the disease burden in communities can be understood. | ||||||||||||||||||||||||||
| Comprehensive services Improving health Maintaining health Restoring health |
• Health promotion/immunisation rates >85%. • Patient centred disease management programmes. • Call centre | ||||||||||||||||||||||||||
| Funding services according to needs |
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| Best use of therapeutic support services and referrals | Pharmacist facilitators are employed. Their role is to promote the use of best practice for the use of pharmaceuticals and laboratory investigations. | ||||||||||||||||||||||||||
| Removing barriers to accessing appropriate services | Practices have received funding to remove or reduce access barriers where appropriate. | ||||||||||||||||||||||||||
| Primary care services will be not-for-profit | First Health is a not-for-profit company whose beneficiaries are the people of New Zealand. | ||||||||||||||||||||||||||
| A broad intersectoral approach |
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| Collaborative, interdisciplinary approach | There are Practice Nurse Development Officers in the networks. This develops the interdisciplinary working of the network groups. | ||||||||||||||||||||||||||
| Rural workforce | There are networks in Northland, Eastern Bay of Plenty, Tairawhiti and rural Taranaki. These groups are supported in developing local solutions to their health care delivery issues. | ||||||||||||||||||||||||||
| Continuous quality improvement | The whole direction of First Health/PrimeHealth has been to manage change by working towards better quality of services. | ||||||||||||||||||||||||||
| Financial risk | Collective responsibility has been taken for the quality of clinical care, value has been added to the health sector and best practice implemented at the same time as reducing costs. | ||||||||||||||||||||||||||
| Effective infrastructure for information collection and sharing | First Health created an effective infrastructure for managing primary sector information using:
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| Evaluating the impact of new arrangements |
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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.
First Health and PrimeHealth are evidence- and performance-based organisations that represent the largest funded health care population in the country.
The demographics of the enrolled patients offer the most extensive modelling for population-based funding formulae. The networks operate in some of the most deprived population areas in New Zealand (Northland, South Auckland and the East Coast).
The experience of working with information to transform it into useful, practice-level information that can stimulate change has been the most significant achievement of this project. Patient and community involvement and improving Maori and Pacific Island health outcomes have also been at the core of the values of the two organisations.
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.
