HealthWEST Concept Paper

Prepared for the Minister of Health

Practice Nursing - A PHO Salaried Model

The introduction of PHOs has seen the enhancement and development of the practice nursing (PN) roll with the introduction of capitation and new projects under SIA, Health Promotion and Care Plus. Primary care is now seen as a more attractive career path for nurses wanting to work to improve the health status of their enrolled populations.

There are a number of barriers to achieving the potential of primary care nursing which PHOs are starting to consider:

1. The Practice Nurse Subsidy is now absorbed into practice capitation payments. This represents (historically) approximately 33-40% of the total PN salary.
2. PNs remain employees of individual practices which means that the practice determines the level of nursing resource and the scope of nursing within the practices. It is difficult for PHOs to set standards and monitor compliance to these. It can also be difficult for PNs to take practice/professional concerns to their PHO when they are under an employer/employee relationship with their practice.
3. PHOs can provide professional development for practice nurses but need to negotiate release for training/education with the employer practice.
4. It is difficult for PHOs to offer a career pathway and experience for PNs wanting to become Nurse Specialists and Nurse Practitioners.
5. It can be problematic implementing PHO-wide programmes (e.g. Care Plus) through the PN workforce when nurses are employees of practices. PNs are sometimes enthusiastic about implementing PHO programmes, but are unsuccessful without the support of their practice GP(s).

Despite these barriers, HealthWEST has been relatively successful in developing the role nursing within primary care. HealthWEST has a strong Practice Nurse Education (PNE) programme that is free to member nurses. Nurse Cell Groups (peer groups) have been introduced and are now active in determining nursing developments. A number of nurse specialists have been appointed to support practice based nursing. HealthWEST has over 50 practice nurse shareholders with up to two directors on the PHO board.

The Salaried Model

There is a widely held view within HealthWEST that the potential for primary care nursing will not be realised unless nurses are employees of the PHO. The HealthWEST board has approved the development of a business case for a salaried practice nurse model for HealthWEST PHO.

The model will incorporate:

1. Practices nurses employed by HealthWEST and "attached" to member practices.
The PHO will have an employment contract with nurses and a service contract with practices that nurses are attached to.
2. A nursing workforce based on a nurse:patient ratio to be determined by HealthWEST following an analysis of current practice nurse utilisation.
Practices currently determine the level of practice nursing employed within the practice. Progressive practices have employed a higher level of nursing and as a result are better able to respond to PHO programmes such as Care Plus.
3. A career path for primary care nursing.
The career pathway for primary care nursing is limited in the current practice employment model. PHOs can sponsor the development of Nurse Specialists and Nurse Practitioners to work within practices and across the PHO. This will enable the PHO to better support the development and implementation of new population health programmes.
4. PHO nursing professional development and leadership.
A substantial primary care workforce (over 120 within HealthWEST) would justify the appointment of a director of nursing to provide professional leadership and development. PHO provision for locum cover to support nurse rotation and training.
5. Internships, mentoring and training for nurses entering primary care as a career option.
This will enhance opportunities to collaborate with the DHB and the Nursing Schools within Universities to develop internships, mentoring and lecturer/practitioner posts.
6. Leveling based on professional guidelines.
Grading that recognises the seniority of nurses undertaking advanced clinical practice within practices or across the PHO and in teaching/mentoring roles.
7. Employment terms and conditions based on the DHB nursing collective employment contract.
Employment under a PHO CEC that is "harmonized" with the DHB will facilitate the devolution and/or attachment of DHB community nursing services to PHOs and improve integration.

The model will consider various funding options including a mix of the following:

1. A capitation "top-slice" based on the historical PN subsidy component of PHO capitation.

2. A PHO project funding contribution e.g. from programmes such as Care Plus where the PHO delivers the service though a mix of practice and PHO support nursing.

3. Management and infrastructure efficiencies derived through the integration/ attachment of DHB community nursing services.

4. MoH contribution to a PHO salaried nursing "pilot".

The Strategic context for a salaried primary care nursing workforce is the development of Integrated Primary Health Centres (IPHC).

The Model: GPs grouped into larger centres providing a more comprehensive range of primary and community based health services.
An integrated primary/community nursing service (including Practice Nurses, Public Health Nurses, District Nurses, Nurse Specialists and Nurse Practitioners).
Salaried GPs with 'special interest' (sub-specialization) doing outpatient clinics in the centre with visiting DHB specialists and registrars (where appropriate).
An integrated patient information system that links to secondary services.
Outreach services - nursing & CHWs for preventative health, active management and post-hospital support.
Extended hours accident and medical services.
Standardized PHO management/administration support, accounting, IS systems and clinical systems.

Modeling: To develop a Financial Model for an Integrated Primary Health Centre that can be extrapolated to a Primary Health Network for West Auckland. (Ratanui Medical Centre financial accounts for the past two years will be used as a basis for the model revenue and expenses).

Model Variables: Enrolled patients
Consultation rates
General practitioners
Nurses (Practice Nurses, District Nurses, Public Health Nurses)
Community Health Workers
Specialist Clinics
Midwives
Clerical/administration
Allied clinical services (therapies)
Clinical support services (pharmacy, labs, and diagnostics)

Revenue Options: Capitation for enrolled population
Fee-for-service for casual patients
PHO projects (SIA, HP, Care Plus, Get Checked, Terminal Care, etc.)

Expenses: Bases on a full salaried service using the Waitemata DHB collective contracts for Medical, nursing and Allied Health staff.

Facility Capital: Provider and PHO Shareholding

Prepared by Alan Greenslade
CEO HealthWEST
27 April 2004