Editorial

Te Puawai April 2008

The Primary Health Care Strategy was launched in 2001 as a blue print for the management of unacceptable health disparities in New Zealand and for coping with an impending tidal wave of chronic disease.  The essence of the strategy was to give primacy to prevention rather than treatment, to engage communities in design and ownership of their services and to create a greater seamlessness in services, which would be designed around people rather than service providers.  The strategy was about a great deal more than general practice but eight years into strategy implementation we remain focused on the general practice environment to the exclusion of other important aspects of the strategy.

Undoubtedly, however, it remains critical to focus on what needs to change in general practice as it is indeed a major contributor to services in the community.  There has been a great deal of rhetoric since the introduction of capitation suggesting that it should now be possible in general practice settings for the right person to provide the service rather than perpetuation of the traditional limitations to medical and nursing roles.  Many in the Ministry of Health, especially, have suggested that the playing field has now been levelled allowing for new ways of working to emerge and that further development is contingent on simple behaviour change. 

I regularly listen to nurses in postgraduate classrooms and in numerous national meetings.  It is clear that there are certainly patches of wonderful innovation, a slow evolution of some things changing, but the predominant comment remains one of frustration and a sense of failure in attempting to truly align nursing services with community need.  The voices of those nurses who express frustration are certainly borne out by my own two-year study of people living with chronic illness, which focused in part on participant experience in accessing general practice services.

I read a recent article by Rosemary Minto in the Practice Nurse Journal in which she expressed her extreme frustration about the very many high level meetings she has attended where nurses’ concerns have been succinctly articulated, apparently heard, but no action or response eventuates.  I share her frustration borne of the numerous working parties I too have attended at which nurses have been remarkably consistent in their positioning yet very little has changed to accommodate their views.  As we have said numerous times, nurses embraced the Primary Health Care Strategy with enthusiasm from day one as it connected directly with the exact focus of nursing education for the last 30 or more years.  There remains a persistent disparity between how nurses are educated and how they are able to practise; nursing practice has, in effect, been colonised in the highly medicalised environment predominating even in primary health settings.  That medicalised environment is vigorously sustained, indeed protected, by the Ministry of Health and nursing voices for change have fallen on deaf ears.

As a member (for four years now) of the Ministry Taskforce on Implementation of the Primary Health Care Strategy I am critically aware of the extent to which allied health, NGO and nurse voices are exceptionally congruent.  However it seems that impetus for change is often stymied by any inkling of resistance from medical participants and impetus for change is aborted.

At policy level, implementation of the Primary Health Care Strategy has been dominated by an almost religious belief in the sanctity of the existing model of general practice.  The Ministry of Health has often stated that General Practice is the cornerstone of the Primary Health Care Strategy.  The problem with General Practice in its current form is that it only knows what it knows and sees what it sees and there is a whole world of unmet need, which remains invisible.  Allied health, the NGOs and many (but not all) nurses are painfully aware of that unmet need.  That need is present in people with long term conditions (physical and mental), in people with disability, in people with chronic pain and also ironically in people who can no longer enrol in a PHO because there is no GP available with whom they can register.

It is acutely uncomfortable to say this as I am also aware that the existing general practice workforce works extremely hard, is largely highly dedicated and deals faithfully with the huge volume of presenting problems.  It is not the people I am criticising but the model.  My own research reveals a wide gap between the needs of people with chronic illness, brilliantly outlined in the National Health Committee Report (2007) and the services these people currently receive from general practice.

With the exception of those who were geographically remote, participants in my research almost universally described the accessibility and promptness of general practice services.  Participants were largely content with the service provided, describing it as being there for them whenever they called.  Critically however participants also described a set of needs linked to managing life with a chronic illness, such as desire for education about their conditions, interpretation of care processes, on-going decision support with anticipating and planning for illness related circumstances and managing daily life with levels of illness related disability.  Nurses are largely invisible to these people yet the participants consistently articulate a need for exactly the care and services which we have been teaching in nursing programmes for years.  Interestingly, where participants had had exposure to a specialist nurse or to a well organised Care Plus nursing service their comments changed markedly.

GP leaders have been vociferous in their calls for team-work.  Team-work is important and nurses are generally good team members and value team work highly.  The calls for team-work can also be seen as a seductive disguise for fear of competition and a means of subsuming the autonomy of nurse directed services.  Being a member of the general practice team often precludes the use of full nursing services because the general practice service remains by nature largely reactive, and general practice in itself has poor mechanisms for articulation with allied health and NGOs.  Many practice nurses spend more time “nursing” the practice than the patients and opportunities for the kind of integrated, boundary spanning and proactive care that lies at the heart of nursing are severely limited.

In order to free up nursing services to address critical disparities, meet unmet need and change the focus from reaction to prevention there needs to be a critical examination of the funding streams which, despite Ministry rhetoric:

• Protect the status quo
• Limit primary/secondary integration
• Prevent the development of nursing services
• Prevent the establishment of NP roles despite their clear match with recognised service needs and the looming GP shortage.

In reflecting on the use of capitated funding and the oft-repeated call for behaviour change I am forced to reflect that those with the most to gain have the least power to organise or affect the desired behaviour change.  Arguably patients themselves and nurses most need capitated funding to be used differently but neither group actually has sufficient control of the purse strings to affect change.  This fact is never accommodated or even considered transparently in funding reviews.  It has recently occurred to me while teaching postgraduate nursing students that it would be of great benefit if all nurses based in general practice (or PHOs generally) had an intimate knowledge of the nature and intent of funding streams.  This might encourage them to be more confident in challenging the status quo.

The funding of services needs urgent and in-depth consideration but there are remaining internal issues for nursing which also need attention.  Recently in speaking to the Workforce Taskforce chaired by Dr Robert Logan I suggested that in order to create a nursing workforce to support the nursing service required in primary health care there is a need to:
 

• Closely examine the under-funding of nursing education at under- and post-graduate level, which is directly impacting on the quality of programmes and runs directly counter to workforce need.  See College position paper Funding Master of Nursing (Clinical) Programs under Submissions on the College website (www.nurse.org.nz) for clarification.
• Consider the urgent need for a primary health nursing leadership infrastructure, starting with a high level primary health nursing directorate.  Perhaps this work is in progress with the current DHBNZ project?
• Urgently examine the potential for a move to a four year degree in nursing in which the fourth year is a fully supported entry to practice year (accompanied by provisional registration) with full-time clinical practice in a chosen field of practice - be it primary health care, acute services or mental health.
• Move away from the employment status of nursing services within the private business model of General Practice.

I also commended to the Taskforce the recommendations of the initial Investing in Health (2003) document and the recent 2007 revised recommendations.  These speak directly to the barriers and the opportunities for real change and they need urgent attention.

Professor Jenny Carryer