Developing Nursing in Primary Health Care: The Long Running Saga!

History and Background

In 2002 New Zealand released a long overdue primary health strategy which laid out a plan for giving primacy to primary health care through building services based on community partnership and increased multi disciplinary development. A key statement in the strategy acknowledged the developmental work which would be needed to utilise nursing services appropriately. In 2007 nursing can reflect on how much or how little has been achieved towards the vision which we all shared at the time of the strategy launch especially in relation to workforce development.

Nursing responded early to the impending opportunities and challenges of the strategy and with the full support of the Ministry (guided by the Chief Advisor Nursing of the time) set up a nursing expert advisory group to develop a framework to support the development of the primary health care nursing workforce. A survey commissioned by that group and finally released in 2003 revealed a workforce with fragile capacity, characterised by an older age range than nursing in the secondary sector, widespread reports of significant barriers in access to education and professional development and minimal evidence that new graduates were able to find positions in that sector. The survey revealed a sector not well positioned to support and sustain the demands of the strategy without significant investment and development. At the same time however a comprehensive literature review revealed good evidence of nursing's strongly held commitment to delivering better primary health care service and its appropriateness for delivering the required service. Primary health care, it was noted, requires a knowledge and skill set which is qualitatively different than that required for the management of illness and injury. The agenda in primary health care is to work with communities and the people in them to achieve permanent improvement in the quality of their lives.

In the last five years various people and groups in nursing have worked tirelessly to try and achieve the goals identified in the document “Investing in Health”. This has involved attention to leadership, to education and to models of nursing delivery. It has, of necessity, involved a certain amount of “navel gazing” or professional focus.

Connecting Voices Workshop

At the end of last year (November 21 st ) the Ministry of Health and DHBNZ held a combined workshop attended by a large number of people engaged in primary health from many different locations. Synergia facilitated the day, which was the public face of the planned joint work programme between the Ministry of Health and DHBNZ related to ongoing implementation of the primary health strategy. About 12 nurses were present on the day.

The day began well with presentations by a selected person from each major area - consumer, Maori, PHO and NGO leadership, nursing and medicine. Presentations were revealing of the perspectives and experience of each group and provided an excellent cross section of both input to and impact of the strategy implementation. During the afternoon participants were allocated into ‘perspective' groups randomly rather than by perspective, based no doubt on the notion that it would be good for us to think beyond our usual professional views. The technique was not effectively utilised as generally it requires a period of familiarisation with the group whose perspective is to be explored. The resulting feedback from the “nursing group” caused considerable concern for nursing as it most clearly represented the views of others about nursing rather than being our own analysis of the issues for nursing from a nursing perspective.

The draft document released from the day captured a number of spurious ideas about nursing and failed to capture any of the issues which do concern us. We (the nurses present) collaborated to present a combined feedback to Synergia on the draft report, but as of April we have not seen a final version of the document. That feedback is presented here in full for the interest of readers.

Feedback on the Draft Report of CONNECTING VOICES

Thank you for the opportunity to comment on the Connecting Voices document as compiled by Synergia following the discussion day last November 21st.

This is a combined response from a number of nurses present on the day. We have communicated extensively by email to reach consensus on our response.

1)  Themes

In reference to the themes presented in the document (as pasted below) we unanimously endorse these as being the critical aspects of ongoing development of the Primary Health Strategy.

1.2 )
We request one change and that is, that the word patient is not used here. Patients are people who are already sick and the essence of the Primary Health Strategy is to “catch” people while they are well

• Patient centred – the challenge of developing a health system that is patient centric, where all services support the capability of self-management and well-being within a family/whanau and community context.
• Population focused – supporting the whole population, not just those we see, to reduce disparities and address the demographic and chronic disease challenges.
• Whole system, whole continuum, multidisciplinary response – developing the capacity to meet the needs of patients across the whole continuum of care.
• Care tuned to local community & health system context – that primary care will need to be tuned to meet the needs and context of each community if it is truly to be responsive to the needs of patients and effective in addressing the challenges.
• Service quality, dependability and effectiveness – local tuning is complemented by a focus on evidenced based medicine, ensuring that there is consistency, dependability and safety in service.
• Building our collective knowledge base – that no one party can achieve these outcomes alone, requiring attention to building on common principles, a base of shared understanding, shared resources of information and evidence.

2)  Themes for specific comment

We are asked to comment specifically on further themes as provided by Kim Arcus. In terms of comment we are a little unsure as to what is required. The themes are certainly all important to the implementation of the strategy; the point of interest of course is how we progress them. In brief:

2.1
We strongly endorse the need for mechanisms for shared learning.

2.2
We strongly support improved patient self -management and acknowledge research evidence which shows that people with chronic illness improve their level of self management when receiving structured care from a nurse.

2.3
We strongly support increased community engagement and note that this has not yet been achieved in any degree largely due to the issue of private business ownership within PHOs.

2.4
We see funding systems and structures as the key to behaviour change. Increased integration between primary and secondary care is extremely important if services are to become people centred.

2.5
We argue that a critical change needed is for DHBs to think and act as DHBs addressing the needs of their population group in a coherent and integrated manner which involves as a necessity, a close relationship with the PHOs.

3)  The Minister's Questions

• How do we make the agreed idea of a population health approach to primary care more and more of a reality? How do we change structures, how do we change governance, how do we develop teams, how do we fold in a range of professions and providers who are not currently folded in?
• How do we make the agreed idea of a population approach deliver when it comes to health disparities and inequalities?
• How do we make the agreed idea of a population health approach get ahead of the curve on chronic disease?

These questions were critically important and probably worthy of closer attention than they received on the day.

3.1 Re Governance issues

Both board and clinical governance require a commitment to quality by both health professionals and management therefore team work is fundamental to its success. Constantly focusing on better health outcomes for clients and communities and ensuring real partnership with users can help relationships between different professional groups be developed which will enhance quality service. (Governance Statement NZNO, 2006)

Nursing has argued, since the initial debate on minimum requirements for PHOs, that membership of PHO Boards needed to be carefully managed to avoid a predominance of medical practitioners at the expense of genuine community partnership and appropriate leadership and self determination of nursing and other services within the PHO.

Clearly private business ownership has been and remains a critical factor. We argue that the Minister should intervene to ensure a clear separation between corporate governance or operational issues and the ability of clinicians such as nurses and midwives to have clinical governance over their own services. The reluctance of midwives to see maternity services included in PHOs is a good example of the concern that exists over the current arrangements.

3.2 Funding change managers

We are divided on the issue of change management processes. They are supported in part but not seen as a substitute for addressing key structural issues which inhibit change. We see the major issue inhibiting change as a persistent tendency to think, talk, and fund traditional systems of first contact care for patients based on attendance at GP clinics. This is made evident by confusion or slippage in the document which is reflective of discussion on the day. As nurses, we are strongly committed to primary health care (i.e. the full range of community embedded, pre-emptive and population based services which include but are not limited to first contact care). Frequently discussions which are meant to be about primary health care become limited to primary care (just first contact care) and thus fail to address population health, the challenge of disparities and the challenge of chronic illness.

This is more than semantics and represents a fundamental failure to properly address the strategy, which needs to be about so much more than low cost access to first contact care in general practice. By the time many people access general practice it is too late for prevention of chronic disease.

If change managers are to be funded we strongly support having people with a professional understanding of the context in which change is required.

4) Perspective Groups

The idea of allocating participants into ‘perspective' groups randomly rather than by perspective was potentially a good one because it might have assisted us all to put ourselves in the shoes of others. The technique was perhaps not effectively utilised as generally it requires a period of familiarisation with the group whose perspective is to be explored. While it could have enabled participants to stand in another's shoes it also provided an opportunity for others to declaim how the shoes they would never choose to wear should be worn by someone else. The ‘Synergia' report tends to exacerbate this risk by reporting the groups' feedback as if it is the feedback of the named perspectives. It may have been better to have reported on the technique and the perspectives chosen but reported the feedback as that of eight groups of randomly assigned participants. This would make clear that nursing wasn't expected to own the nursing perspective.

We have a problem now in ‘correcting' the so called nursing perspective because it is not in fact a perspective formed by nurses (see for interest appendix 1). We therefore address the comments as follows:

4.1 Group Action Points

In the nursing section of the document there are three key action points made:

4.1.1) " Change from a profession-centred approach to a patient centred approach, by a significant investment in tools and models of care, which strengthen patient self management and truly reduce inequalities ".

We request this comment be removed from the nursing section of the final version of the document.

A sole non-nurse member in the “nursing” group contributed the comment and we are unsure how and why it has been transferred to the document as a key point.

Nurses do focus very strongly on consumers, hence their immediate, early, well documented approval and adoption of the PHC strategy and its potential and thus their frustration at the failure of the strategy to free up nursing services.  Nurses (as employees of GPs in PHOs) have limited control over their models of care. In "Investing in Health" (2003) we noted our wish to better align nursing serves with community need and we have continued to express frustration at our inability to do so.  Once nursing does not have to struggle eternally to achieve appropriate remuneration, proper leadership structures and taken for granted levels of accessible, affordable, ongoing education, nursing will become even more consumer focused than is currently the case.

We do however strongly support the need for the health sector to develop processes whereby developments are consumer rather than provider driven .

4.1.2) Resource and provide leadership in change management, teamwork and innovation in primary health care.  (Availability of change facilitators)

We have some questions and statements about this point as follows:

From what fiscal source would nursing "resource and provide leadership"?  We have a plentiful human resource but little or no access to the money to make such things happen.

We note that at MCDHB, for example, where there has been significant transfer of money to a newly established primary health nursing leadership structure, this (and more) is exactly what has occurred.

This is a relevant comment but it should be placed in the DHB/PHO section as nursing cannot do it without access to money. It belongs with the important statement already in the DHB section, which recommends the establishment of director of primary health care nursing positions.

4.1.3) " nursing must learn to use capitation effectively".

It is indeed true that the sector still needs to learn to use capitation effectively but it also true that the onus to do so falls most directly on those who own the infrastructure and predominate in the governance of general practice structures. This is not nursing.

We are aware that the Ministry of Health regards capitation as a trigger for behaviour change and is not comfortable with the consistent nursing voice that does not agree that this is happening. We are however clear that if nursing truly did have equal access to capitated funding then behaviour change would be well under way.

Accordingly we want this comment removed from the nursing section and placed where it better belongs.

5) Observations Section

We note the comment that certain issues did not arise in discussion. All three items noted are curiously subjects which nursing regards to be of immense importance both to strategy implementation and to reduction of health disparities. We think they did not arise as:

5.1) Much of the commentary from participants was carefully stifled or “parked”. This may have been because it did not fit an apparent agenda for the day (see appendix for direct participant feedback).

5.2) Nurses did not raise these topics as we feel like a “stuck record” especially around GP ownership. If nursing raises the critical topic of private ownership as a barrier to strategy implementation, nursing is seen as being non-collaborative and critical of medicine and is generally exhorted to focus more strongly on team-work.

5.3) With regard to models of chronic care management, nursing is strongly committed to chronic care management but we are well aware that Chronic Care programmes are not the panacea for many problems and that they should be more broadly implemented.  Such programmes can assist with infrastructure and providing more structured care but there is no clear evidence as yet that any particular model is effective in its entirety or which part of any model is effective. There is limited high quality evidence about the impact of any model and most evidence is US derived. See, for example, Singh and Ham (2006) and the relevant Cochrane review.

6)  Solutions

6.1) We recognise that nursing is but one player in an enormous and complex system. Nursing is, however, the single biggest component of the PHC workforce and it is therefore important to “get it right”.

6.2) We offer this table below, as it represents the core of how nursing is taught and thinks and we believe it also captures the essence of what is intended by the PHC strategy

Crossing the quality chasm (2001). Formulating new rules to redesign health care systems p. 67

If nursing services were to be truly freed up and independently resourced we believe we would see a much quicker transition to the new paradigm behaviours.

6.4) We draw the attention of the MoH and DHBNZ to the document Investing in Health; A framework for activating primary health nursing (MoH, 2003). Four years ago this document, following extensive sector consultation, clearly outlined the necessary process for aligning nursing services with community need and thus facilitating the implementation of the strategy and improving consumer focused services.

The major recommendations or goals (included in appendix 2) are yet to be widely implemented. It is interesting to see how highly pertinent these goals are to current needs for strategy implementation.

Accordingly nursing has now planned to revisit and reactivate this document (in March this year), because it represents a strategic plan for nursing to contribute to achieving the goals of the Primary Health Strategy.

Signed (in alphabetical order)

Geoff Annals, CEO, NZNO
Dr Michal Boyd, NP (Gerontology), Waitemata DHB
Dr Jenny Carryer, Professor of Nursing and Executive Director, College of Nurses
Linda Dubbeldam, RN, Clinical Services Manager, Compass Health
Eldred Gilbert, Director of Nursing and Primary Health Care, CCDHB
Chiquita Hansen, Director of PHC Nursing, MCDHB and Chair, NZNO Primary Health Nurses Council
Denise Kivell, Nurse Leader PHC, Counties Manakau DHB
Rose Lightfoot, RN and CEO, Tai Tokerau PHO
Rosemary Minto, Chair, College of Practice Nurses (NZNO)
Dolly Rewha, Maori Nurse Leader, Te Kupenga O Hoturoa PHO
Helen Snell, NP (diabetes across the life span) MCDHB

Copy to:

Mr Stephen McKernan, Director-General of Health
Mr Chris Clarke, Chief Executive Officer, Hawke's Bay District Health Board

Follow up in 2007

The College and NZNO have worked together drawing on the same group of nurses who attended the combined Care Plus (or management of long term conditions) workshop last year and reported in Te Puawai (November 2006). A strategy group comprised of representatives from both NZNO and the College of Nurses , Aotearoa (CNA(NZ)) met on 6 March 2007 to review the recommendations arising from:

• Ministry of Health evaluation of the Care Plus Programme,
• The Management of Life Long Conditions workshop hosted by CNA (NZ) and College of Practice Nurses, NZNO,
• The report of the National Health Committee (2007) on” Meeting the needs of people with chronic illness “ , and
• The original goals and recommendations of the document Investing in Health (2003). We wished to use these documents as a basis for our deliberations.

Work has been undertaken to produce a brief, focused new version of the original Investing in Health document, which will update key recommendations for setting primary health nursing free. One major challenge of that work was to capitalise on the current Ministry focus on management of chronic conditions whilst at the same time not losing sight of the much greater breadth of primary health nursing including, but not limited to, vitally important work with children, adolescents and families. The draft document will shortly be available on the website for comment.

College members involved in this work include Mary-Jane Gilmor (leader of our Primary Health Nursing Network), Rosemary Minto (also Chair of the College of Practice Nurses), Eldred Gilbert, Dr Michal Boyd, Helen Snell and Dr Jenny Carryer.