Mind The GapDr Nick Chamberlain

Domain Highest performer Lowest Performer New Zealand ranking (out of 11 countries)

1. Care process United Kingdom Sweden 3

2. Access to care Netherlands United States 7

3. Administrative efficiency

Austria France 2

4. Equity of care United Kingdom United States 8

5 Health care outcomes

Austria United States 7

OVERALL RANKING United Kingdom United States 4

Ranking of Health Care Systems,

Commonwealth Fund

Drawn up by the International

Conference on Primary Health Care,

Alma-Ata,USSR, 6-12 September 1978Primary health care is essential health care based on practical,

scientifically sound and socially acceptable methods and technology

made universally accessible to individuals and families in the

community through their full participation and at a cost that the

community and country can afford to maintain at every stage of their

development in the spirit of self-reliance and self-determination.

It forms an integral part both of the country’s health system, of which

it is the central function and main focus, and of the overall social and

economic development of the community. It is the first level of

contact of individuals, the family and community with the national

health system bringing health care as close as possible to where

people live and work, and constitutes the first element of a continuing

health care process.

The Primary Health Care Strategy

Hon Annette King, Minister of Health

February 2001

• People will be part of local primary health care

services that improve their health, keep them well,

are easy to get to and co-ordinate their ongoing

care.

• Primary health care services will focus on better

health for a population, and actively work to reduce

health inequalities between different groups.

Six key directions for primary health

care will achieve this vision:

•work with local communities and enrolled populations

• identify and remove health inequalities

•offer access to comprehensive services to improve, maintain and restore people's health

•co-ordinate care across service areas

•develop the primary health care workforce

•continuously improve quality using good information.

Old NewFocuses on individuals Looks at health of populations as

well

Provider focused Community and people-focused

Emphasis on treatment Education and prevention

important too

Doctors are principal providers Teamwork – nursing and

community outreach crucial

Fee-for-service Needs-based funding for

population care

Service delivery is monocultural Attention paid to cultural

competence

Providers tend to work alone Connected to other health and

non-health agencies

.

• The Strategy outlines a new vision for primary health care. It does

not contain details of implementation, which will involve

evolutionary change to protect the gains already made.

Involvement and collaboration with the primary health care sector

will be a key feature of the implementation process in the coming

months and years. This is crucial to ensure that all issues are

considered in developing the new arrangements.

• To achieve this involvement, working parties of providers,

communities, District Health Boards, and the Ministry of Health will

be formed around key areas of work. Consideration may also be

given to developing a primary health care advisory group to help

guide developments in the sector.

Evaluation – Jackie Cumming

Primary Health Care Strategy had better integration as a key objective

• Reducing fees patients pay to improve access to PHC

• Development of Primary Health Organisations to co-ordinate care horizontally and vertically

• Strengthening role of PHC in the health system

• Encouraging team work and better co-ordination across providers

However, Primary Health Care Strategy:

• Seen to focus on development of new organisations (DHBs and PHOs) and population health focus

• Insufficient attention to service delivery and clinical integration

• Failure to identify what a comprehensive model of PHC might look like and how it might be delivered

• Failure to hold DHBs and PHOs accountable for delivering the strategy

(‘Better, Sooner, More Convenient’)

Better Sooner More Convenient

“New models of care which see the patient rather than the

institution as the centre of service delivery and which aim to

promote a more seamless patient journey across community,

primary, and hospital sectors, greater use of primary and

community care, and the shifting of care ‘closer to home’.”

Then There was IPIF – Integrated

Performance and Incentive Framework

So what was wrong with IPIF?

Nothing, absolutely nothing!

System level measures

NZ Health Strategy

Primary Care Working Group report

• Funding - follow individual rather than practice

• Models of Care

• Workforce sustainability

• Develop a Primary Care data and monitoring programme with

accountability for equity

• Primary Care Funding review - Funding follow individual rather than

practice

• Consolidated DHBs and PHOs - size allows both to take on more upside

and downside risk.

• Separate DHB dual functions of funder and provider

• New model of care - Updated Evaluation needed. Healthcare Homes

promising but primary secondary silos a limitation. Support financial and

org policies that bind together

• MOH - Develop implementation plan from the NZ Health Strategy with

specific outcomes. Improve engagement with sector

Primary Healthcare Evaluation - Amy

Downs (Fullbright/ Ian Alford Fellow)

supported by Treasury

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The Evidence Base for Primary and

Community Interventions

Note: many of these interventions are already underway across our Region in some form.

Ten evidenced-based community interventions to avoid hospital care

Hospital

activityQuality Cost

Hospital

activityQuality Cost

Improved GP access to specialists

including e-communication

Support for self-care for specific

conditions

Remote monitoring for certain long-

term conditions

Ambulance / paramedic triage to

community

Condition specific rehabilitationSupport to people in nursing / care

homes

End-of-life care in the communityExtensivist model for high risk

patients

Rapid access clinics for urgent

specialist assessmentSystematic Secondary Prevention

Key: Relatively good evidence that the intervention can do this Mixed evidence with studies coming to varying conclusions on this dimension

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A Health System for our Future

Populations

• The Nuffield report “Shifting the Balance of Care” suggests new

ways of working in primary and community care to curb the growth

of activity in hospitals and other high cost per unit settings. These

include:

− Transferring certain hospital activities into primary and

community settings including people’s homes

− Utilising collaborative, multidisciplinary teams supported by

technology to provide alternative methods of consultation and

engage with patients, to empower them to take ownership of

their health and collaborate in the formation of their care

pathways.

• This approach has been found to:

1. Improve the productivity of primary care providers

2. Reduce pressure on GPs

3. Reduce unnecessary utilisation of health care services

Community vs. Hospital Investment

Neighbourhood Healthcare Homes

Neighbourhood Healthcare Homes (NHH) are a collaboration

between NDHB and the Northland PHOs. The model is defined as:

“A team based health care delivery model led by primary care

clinicians that provides comprehensive and continuous health and

social care with the goal of supporting individuals to obtain

maximised, equitable health outcomes”

NDHB anticipates improvements in the areas of:

• Timely acute and unplanned care for patients

• Proactive care for high needs patients

• Excellent routine and preventative care

• Improved business efficiency.

NHH Model Core Elements

• Call Management

• Clinical Triage (Right person, right day, right preparation)

• F2F for those who need it most

• Alternative options (Portal, Virtual Consults)

• Matching supply to demand

Timely Unplanned Care

• Standardisation, Visual Management, LEAN Flow, Continuous Improvement

Business Efficiency / LEAN

• Patient Register for those with complex needs

• MDT, Integrated Care planning approach

• Patient centred care, Multi Disciplinary meeting Proactive Care

• Proactive health plan for everyone – system initiated contact

• MCA pre consult work up

• Community Health Workers

• Telephony outbound campaigns

Routine Preventative Care

Q U A L I T Y & S A F E T Y

E Q U I T Y

Consumer

Engagement

Quality and Safety in Primary Care

• What is Clinical Governance in General Practice/ Primary Care

• Who is accountable for Patient Safety and Quality in General Practice/ Primary Care

• “A marvel to get through the morning without any mistakes but a miracle to get through the afternoon as well”

• Don’t know error rates, but likely to be as high as 20%

• Adverse drug events are the fourth largest cause of admissions to ED in USA.

• Use of Global Trigger tools?

• Greater PHO accountability?

Primary Care Strategy 2018

• Let’s not! We don’t need another Strategy. Learn from History,

revisit 2001, modernise it with a bit of BSMC and the NZ Health

Strategy, Working group recommendations, Primary Health Care

Evaluations, evidence of what works, and then this time, LET’S DO

THIS!

• National Consistency and Local Innovation

• An Implementation plan - a Portfolio with Programmes of work and

multiple Projects with resource for change

Strategy is easy, Change and

Implementation is the hard part!