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July 2005
Jenny Carryer, RN, PhD, FCNA(NZ)
Currently I am deputy chair of this Taskforce which has been convened
to provide strategic advice to the Deputy Director General (Clinical Services)
to assist with implementation of the Primary Health Care Strategy and
with the development of primary health organisations. The Taskforce has
been working on developing a picture of primary health care in 2010 as
an internal working document which can be shared with the organisations
represented on the Taskforce. In this context the document serves only
to identify major issues and scenarios needing wider discussion and deliberation
before such advice can be given. Taskforce members in fact do not specifically
represent organisations but are individuals who bring to the table a range
of experience and expertise across the diversity of primary health care
strategy and practice.
The Taskforce has agreed that its work will be enhanced if there is a
shared vision strongly influenced by the initial Government strategy document
(2001). It is agreed that initial PHO establishment has now occurred and
therefore the vision needs to concentrate on the broader issues of implementing
the wider strategy, which requires “that PHOs will offer access
to comprehensive services to improve, maintain and restore people’s
health”. It is agreed that this will require the involvement of
a broad range of professionals and organisations, and encouragement of
multi-disciplinary and interdisciplinary approaches to ensure client-centred
care.
The full document is not yet agreed to and signed off by the Taskforce
but some key points from the work in progress are shared below.
The achievement of healthy communities and the engagement of communities
in managing health is seen as a key goal of the strategy. Currently it
can be argued that:
- Many individuals and communities still have limited levels of understanding
of actual or potential changes heralded by the implementation of the
strategy. Whilst many people now have good access to cheaper treatment
for illness and injury there is still no observable equity in the degree
of community ownership or participation in directing their local health
services.
- There are some challenges as to how to define relevant communities
of interest for a particular PHO. Need mechanisms to support successful
models.
- Although community participation is not extensive there is much work
being done by a few voluntary but very committed people.
- Many NGOs and other agencies are expressing frustration about how
to work usefully with PHOs to form the necessary partnerships.
- Many general practice teams would like more opportunity to begin
real prophylactic care at a local community level as opposed to their
own practice community.
- Allied health professionals have the knowledge and skills to promote
and maintain health within their communities but current contracts do
not include these activities.
- The recent establishment of the Community Council to advise the Deputy
Director General of Health is an important development.
Co-ordinated care for those with illness or injury is also a goal of
the strategy adopted by the Taskforce.
Current situation
There are initiatives arising from CarePlus and SIA funding to improve
both access and co-ordination but many health practitioners are expressing
concern about lack of workforce capacity to do this properly.- PHOs are saying they have no funding to employ Nurse Practitioners
or other appropriately skilled nurses and allied health practitioners
who could be regarded as the ideal workforce for co-ordination of care
of people with high needs.
- PHOs are having difficulty funding adequate GP levels, especially
locums and after hours services.
- Limited mechanisms exist for communication and co-ordination between
different inter-sectoral and inter-health agencies. Those existing are
still ad hoc or experimental.
- There is a tendency for PHOs to develop new services, which replicate
existing services because of the limited mechanisms for co-ordination
and relationship building.
Funding: It is agreed that funding streams present significant
challenges to developing new ways of doing things and it is agreed that
workforce capacity is also a major area of concern.
Greater flexibility in the funding for community proactive health care
is needed including more flexible targeting mechanisms. Remuneration in
health continues to reward a “doing-to” focus rather than
a “caring about” and preventative focus. Predominant private
business ownership of General Practices raises challenges for operational
and governance issues for PHOs and the artificial constraints between
primary and secondary funding streams need to be eliminated.
It is envisaged that the primary health care workforce core membership
will be always be nurses, Nurse Practitioners, general practitioners,
allied health practitioners and midwives but there may well be greater
flexibility in the way these people are deployed. The recent NZIER report
(2004) identifies a serious health workforce deficit by 2011 from 28-42%
based on differing predictive models. Some particular challenges include
the recently created salary difference between primary and secondary settings
for nurses, undeveloped and some non-existent leadership infrastructures
and many nurses are expressing frustration at artificial constraints on
practice. The general practitioner workforce is ageing and some are experiencing
burnout from high workloads or increased compliance costs. Nurse Practitioners
are being prepared but not employed and there is minimal resourcing for
primary health nurses’ professional development needs. In addition
other key concerns include:
- After hours services are in crisis
- Residential care sector is in crisis
- Limited appointment of nurse leaders in PHOs and those who exist
have limited resource and budget to develop the nursing workforce.
The Taskforce considers that broad strategic relationships in
the sector are especially important to moving forward.
It is important that District Health Boards are clearly understood as
responsible for the health of their population through providing care
for individuals, classical public health services and targeting populations
of need within their area. The PHO is the mechanism by which DHBs deliver
community based services. Within each DHB region, PHOs, NGOs and other
agencies will need to have clearly defined relationships based on providing
effectively and efficiently for individual and community need.
Currently it is felt that the relationship between each DHB and its various
PHOs is currently variable around the country. There is an uneasy tension
between the DHB needing to direct the PHO services but needing to respect
the integrity of GP businesses. The relationship between the Ministry
of Health and DHBNZ is perhaps not well understood in the sector and finally
PHOs and NGOs have no clear processes for sharing resources or co-ordinating
care for clients or patients.
Implications for Primary Health Organisations as discussed by
the Taskforce
- PHOs will need to take a leadership role in the field – they
will need to be catalyst for change, being “enablers and promoters”.
- To facilitate and promote community development, they will need to
represent local communities of interest – not necessarily on a
defined geographical basis.
- They will need to work with a wide range of groups, often undertaking
a “brokerage” role.
- The governance of primary health care will need to be representative
of the population served and the workforce providing that service.
- The population focus will need careful attention especially in the
utilisation of any additional money.
- PHOs will need to acknowledge actively, the imperative to reduce
health inequalities/disparities.
Conclusion of Document
If the goals of the Primary Health Care Strategy are achieved the sector
will demonstrate:
- Emerging evidence of improvements in population health, with reduced
inequalities in care.
- Enhanced engagement with local communities.
- Health care providers working closely together, to deliver integrated
care.
- The introduction of best practice and performance monitoring in primary
health care, and mechanisms to share successes.
- An overall broadening of services delivered at the primary level
with a narrower band of services defined as secondary care.
FOR COLLEGE MEMBERS
It is crucially important that College members continue to use
the electronic discussion group to expose, explore and debate issues
of success, concern, achievement and barriers as they occur. Both
the Ministry Taskforce and the Expert Advisory Group on Nursing
need to be fully advised of the experiences of nurses who are living
and working with the impacts of the strategy implementation and
who are, as the strategy first identified, crucial to its success.
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