The primary health strategy: Time for a stock take.

The Government’s primary health strategy has been rolling out now for four years. The focus on PHO development is tapering off now as PHO establishment is largely complete and all New Zealanders are theoretically enrolled in a PHO or at least have had the opportunity to do so. So where have we got to in achieving the goals of the strategy given that it was always going to be a ten year plan.

The first interesting question is to ask to what extent the public are aware of any revolution in the way their primary health services are delivered or received . A cornerstone of the strategy was to build partnerships with communities of interest to ensure that health services were owned and shaped by those who would be using them. Such a strategy presupposed that the public had a clear perception of the possibilities inherent in proactive primary health care and could move overnight from using an illness response system to driving and developing a health protection system.

Sufficient to say that despite the obvious and important advantages in cheaper illness care for many, the majority of the public are still rather unclear as to the possibilities inherent in a PHO because they are still accessing much the same sort of service from much the same place. This is not to say that the original intent was not good; an involved active and participatory community is important , indeed critical to successful primary health delivery. As we recover from the rush of PHO establishment we need to renew our attempts to understand and foster participation of communities which I suspect entails a great deal more listening on our part and less designing systems and processes and requesting submissions!

The Non-Government organizations( NGO) are finding it very difficult to work out an appropriate relationship with the PHO funding and structures. In addition I suspect many of them are facing considerable staffing challenges following the successful DHB nurses pay claim. There is a very interesting paper on NGO responses to the primary health strategy and PHO development on the Platform website; it makes sobering reading given how many essential services are being delivered by the NGO sector.

I think that nursing truly understood the implications and potential of the strategy to a degree not shared in many other locations. In nursing minds the goals of the strategy were close to the philosophical approach of nursing itself: addressing partnership with people and communities, support of wellness and prevention of illness through management of environmental, inter-sectoral and personal factors, and care of people in injury and illness based on a therapeutic relationship enriched by awareness of the many facets of cultural difference. Nursing assumed to some extent that its day had come, and expected to serve as partners in establishing and leading the new PHOs as the initial building block of the strategy.

Not surprisingly the rapid and virtually completed PHO development has to date almost exclusively engaged only the general practice component of primary health care services. In this context GPs are the owner/operators of small businesses and have constantly and perhaps understandably articulated the vulnerability of their personal investment in these businesses. As owner/operators they also employ the other members of the team including nurses and although Government has theoretically purchased many million dollars worth of nursing services through the practice nurse subsidy, GP owners have somehow retained the right to significantly determine the nature of those services. Practice nurses, as the employee shadow and non-owner/operator behind general practitioners, have had to struggle extremely hard to be present at the table. As Crampton, Davis and Ray-Lee have argued so eloquently, practice nurses have remained hostage to the fortunes of their GP employers.

At individual general practitioner level there is some willingness to work differently and recognition that there is much that needs to change if we are to deliver effective services. I think there is also considerable frustration that limited work force capacity and funding streams actually limit innovation and change. Recently the Australian Medical Association( AMA) made a press release which caused me to think that we may actually have made considerable progress here in New Zealand. The AMA ( April, 2005) comments were in response to the development of nurse practitioners in Australia. Their spokesperson noted that “ The right way to go is to have nurses complement and assist the work of the GP” and “ general practice nurses help doctors see more patients…but they do so as part of the GP team under the supervision of a GP.” The AMA continues in the same press release to comment that “ Governments endorsing independent nurse practitioners are looking for an easier and vastly inferior solution which is also an irresponsible and dangerous path to follow….a move to independent health practitioners would dumb down the health system” .

Such comments are of course outrageous but neatly capture the entirely outmoded notion that primary health care and community based services are only about medical responses to illness episodes. They also conveniently overlook a wide body of international evidence showing that nurse practitioners provide a comprehensive health focused and entirely safe service in a wide range of settings. In New Zealand there is recognition that the GP work force is dwindling and that whilst GPs are critically important to primary health services for the management of illness and injury, they are only one component of a multi faceted service which must continue to develop an all embracing inter sectoral focus if we are to achieve the health gains we need.

One important limitation has been the artificially imposed divisions within the nursing workforce, as outlined earlier in this chapter. These have ensured that significant levels of nursing expertise and service are located outside the general practice setting and many of them are in the secondary sector. Because the secondary sector has at least maintained some investment in nursing education, the specialist nursing expertise in caring for people with diabetes, respiratory disease, cardiovascular disease, along with pain management and palliative care is much more predominant in secondary care. In addition public health nurses and their population health expertise are still located in the provider arm or attached to hospitals. An important and totally unrecognized nursing work force is also present in the form of school nurses who when present (and not all schools have them) meet essential needs for a vast range of services from school children. By some bizarre lack of logic school nurses are not paid even remotely as much as school teachers despite equivalency of qualifications and more than equivalent responsibility. These factors continue as a barrier to what can even be imagined as the potential integrated health service delivered by a PHO.

The need for further integration of other services should force a critical examination of whether or not the current PHO model is the best it could be. There are compelling reasons to work hard towards such changes because health disparities and current levels of deprivation, suffering, and the increasing rationing of care through the growing disease burden, demand that we deliver population services both better and differently.

Professor Jenny Carryer 2005