|Implemented in this survey?|
The government is supporting the establishment of new Integrated Family Health Centres which house a wide range of primary health and social services. The aim is to shift some services (such as minor surgery and first specialist assessments from the hospital setting into the community, thereby reducing pressure on public hospitals and providing a more accessible and streamlined service for patients. Consolidation of Primary Health Organisations is also being encouraged.
In September 2009, the government called for proposals for the establishment of Integrated Family Health Centres (IFHCs), which would be administered by Primary Health Organisations (PHOs). IFHCs will be large centres housing general practitioner (GP) practices, specialists, radiology and laboratory testing as well as allied health professionals such as pharmacists, physiotherapists and dentists. Selected social services would also be offered. The IFHCs are expected to operate extended opening hours, house observation beds and offer minor procedures.
The policy aims to confront an aging population and doctor shortages and to lighten the load of hospital emergency departments by bringing services out of secondary care and "closer to patients". The objective is to offer a streamlined service involving improved cooperation between health professionals and more convenience for the patient.
The government also wishes to achieve closer cooperation between primary and secondary care. Smaller PHOs are being encouraged to merge with larger ones in order to reduce duplication and waste of administrative functions. The number of PHOs is expected to halve from around 80 to 40 .The plan is also to achieve the previous Labour government's objective of making PHOs less centred around general practice and more multi-disciplinary.
Those PHOs which operate the IFHCs would receive extra funding to manage the change process. The government also plans to provide a small fund as dollar for dollar seeding money for feasibility studies to support small general practices to consolidate into Integrated Family Health Centres (IFHCs) if they wish.
Primary Health Organisations, Primary health care providers, Patients
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
In essence, this policy is an attempt by the government to accelerate the speed of development of primary care centres which provide a more comprehensive set of primary health services. Some such centres already exist. Plus family centres are common in many other countries. This policy can therefore hardly be described as "innovative". There are, however, some aspects of this policy that are quite new to New Zealand, including the provision of more surgical procedures in the primary care setting and more integrated patient records.
While this policy has not as yet attracted much attention from the general public, public visibility will undoubtedly increase as the IFHCs are set up and the services become available to the public.
Prior to the 1990s most GPs in New Zealand were sole private operators who were paid government subsidies on a fee for service basis with the ability to charge patients co-payments. During more-market style health reforms under a National (i.e. conservative) government in the 1990s, GPs began to organise and group together into Independent Practitioner Associations in response to new contracting arrangements. This enabled them to have increased bargaining power but was encouraged by the government of the time because it improved negotiating efficiency. These associations negotiated new modes of funding, experimenting with capitation funding for some services, and making savings which were invested into activities such as health promotion. They also introduced new health prevention initiatives, prescribing guidelines and quality monitoring.
In 1999 a centre-left coalition government was elected into power. The new government embarked on a set of wholesale reforms to focus the public health care system on primary care, aligned with the principles of the Alma-Ata declaration of the World Health Organisation. The 2001 Primary Health Care Strategy involved the formation of Primary Health Organisations (PHOs), funded on a capitation basis. The intent was for the PHOs to include a range of primary care providers, such as psychologists and practice nurses, and to be community owned and governed. They were to focus on population health gain by organising health promotion and other public health strategies (see Survey 3/2004: Primary Health Organisations: Establishment).
These primary care reforms were implemented in a top down fashion and have resulted in a complicated array of funding arrangements and a range of organisations that differ in their abilities to improve population health. There are currently around 80 PHOs which vary greatly in the number of patients registered with them. Smaller PHOs have limited budgets and management capacity and therefore struggle to offer certain services . A recent evaluation of the Primary Health Care Strategy recommended more collaboration within the primary care sector and a clarification of PHO roles, as well as a focus on development of services at the first point of contact (Smith, 2009).
In 2008 a new centre-right government was elected into office. Prior to the election, the National Party had released a health discussion document entitled "Better, Sooner, More Convenient ". The primary health care component of the manifesto was an update of the Primary Health Care Strategy. The government believes that the Strategy is not progressing at an acceptable pace and that integration between primary and secondary care needs improvement. The National Party recognises the importance of the primary health care sector but is using a clinician-led approach rather than a community-led approach to attempt to achieve the goals of the strategy. The vision is for doctors and nurses to become more actively engaged in the planning and running of health services. At the same time, this government is placing less emphasis than the previous government on the need to consult with communities on the planning of health services.
This policy follows a change of government from centre-left to centre-right in 2008.
The policy aims to speed progress towards the objectives of the 2001 Primary Health Care Strategy.
|Implemented in this survey?|
The idea to set up IFHCs is being led entirely by the government. While a new concept for New Zealand, integrated centres of this type can be found in many other countries. From an international perspective, New Zealand lags behind other countries in terms of comprehensiveness of services provided in the community, with many services - such as minor surgery, specialist consultations and xrays - usually being provided in the hospital setting.
The approach of the idea is described as:
Primary Health Organisations: Large PHOs whose expressions of interest to establish an IFHC have been selected are generally enthusiastic about the prospect of new opportunities and the devolution of some services to them from District Health Boards. When the reform was first announced the feeling was that the concerns of clinical leaders in primary care were being heard and that they would be able to implement the changes that they felt would make the PHCS more effective. As the process has evolved however, there is concern that PHOs are required to make large scale changes with minimal extra funding. One large team of providers (comprising 274 general practice teams, 11 PHOs and 3 District Health Boards) has abandoned the idea of establishing multiple IFHCs, proposing instead to develop a small number of 'community health hubs'. Smaller PHOs are concerned about the potential loss of connection to their communities, which they see as the key to improving the health of their patients. They are also nervous about the government's directive for PHOs to merge into larger organisations. In spite of these reservations, PHOs remain broadly supportive of the general concept of improving integration across service providers and continue to work towards meeting this objective. It therefore seems likely that new types of health centres will be developed over time. However, some of these are likely to be somewhat different in structure from the IFHCs that are being proposed by the government.
District Health Boards (DHBs): District Health Boards contract with PHOs to provide a range of primary health services. They are also responsible for secondary services, including hospital services. Many DHBs have worked in partnership with PHOs to develop proposals for IFHCs. DHBs see problems with the primary health care strategy as it currently stands. In particular, intended changes to service orientation (to a 'wellness' approach) or delivery (more interdisciplinary) have not been successfully implemented. They are therefore broadly supportive of the proposed changes, citing the benefits of more secondary services being closer to patients as well as encouraging more innovative models of provision. DHBs are also keen to see pressure on emergency departments relieved and are supportive of increased financial risk sharing between DHBs and primary care providers as a result of devolution. Some DHBs have voiced concerns over whether primary care providers performing minor procedures will result in a loss of efficiency.
General practitioners: The response of GPs has been mixed: some see IFHCs as offering new opportunities while others have expressed concerns about the potential disruption to existing professional relationships.
Patients: IFHCs should improve access for patients and smooth the pathway of care through multiple providers. However, to date the proposal has not been widely published to the general public.
|National Party||very supportive||strongly opposed|
|Primary Health Organisations||very supportive||strongly opposed|
|General practitioners||very supportive||strongly opposed|
|District Health Boards||very supportive||strongly opposed|
|Patients||very supportive||strongly opposed|
|National Party||very strong||none|
|Primary Health Organisations||very strong||none|
|General practitioners||very strong||none|
|District Health Boards||very strong||none|
The Government applied a tendering process to the implementation of this initiative, calling for a first wave of expressions of interest from primary health care providers. These could include PHOs, nursing organisations, allied health, mental health and social service providers. The tender gave priority to organisations capable of targeting populations of more than 50 000. The proposals to form IFHCs are to be implemented within three years, be large scale and transformational, with the objective of implementing innovative new models of care for up to 30 percent of the country's population. Proposers were invited to suggest changes to funding pathways, with money coming from DHBs in exchange for devolution of services and an expectation of capital coming from the private and NGO sector.
70 proposals were submitted in response to the government's tender but only nine of these were invited to develop a business plan. Establishment of the first IFHCs is expected to commence from July 2010, once their business plans have been fully assessed and approved.
The process is being led by PHOs, with DHBs providing a support and advisory role. The success of implementation will hinge on the skills of PHOs (which are relatively young organisations) to plan and operate the IFHCs and provide a new range of services within the funding available. Good relationships between primary and secondary care providers as well as those within primary care - for example between GPs and dieticians or nurse practitioners - will also be important for the success of this policy.
There are no indications thus far for formally evaluating the implementation of the policy. However, the primary care providers will be required to give information to the public regarding their services and to seek community and consumer input.
As was the case with the introduction of PHOs, the plan to create IFHCs is being driven from the top down rather than by the providers themselves. The success of this policy therefore depends crucially on it attracting the support of both primary and secondary care providers. The additional money offered by the government was intended only to manage the change, not to finance new facilities (Johnston, 2010). A lack of funding is therefore likely to be a barrier to implementation of the policy.
The fact that the largest group of providers has already withdrawn from the idea of creating IFHCs - in part due to lack of funding - does not bode well for the nation-wide implementation of this policy as originally proposed. The policy may, however, result in the establishment of some IFHCs, especially in rural areas, and encourage the development of other models of practice in larger centres which still meet the government's main objective of shifting some hospital-based services into the community.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
It is very early days to make any judgment about the success (or failure) of this policy because as yet, no IFHCs have been established and any impact on the quality, equity or efficiency of services will depend crucially on details of their funding, structure and management. Shifting more services out into the community does have the potential to improve access, reduce waiting times and possibly also reduce the cost of some services. However successful implementation will require close collaboration by a range of actors. This will be challenging and could result in some unexpected responses.
Kim Letford, Toni Ashton