Critical analysis of the implementation of the Primary Health Care Strategy implementation and framing of issues for the next phase a paper prepared for the Ministry of Health March 2009 Judith Smith Head of Policy,




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Critical analysis of Primary Health Care Strategy implementation

Judith Smith, Ministry of Health, March 2009




Critical analysis of the implementation of the Primary Health Care Strategy implementation and framing of issues for the next phase
A paper prepared for the Ministry of Health
March 2009

Judith Smith

Head of Policy, The Nuffield Trust, London
Visiting Academic Fellow, February 2008 – January 2009

Sector Capability and Innovation Directorate

Ministry of Health
judith.smith@nuffieldtrust.org.uk
Critical analysis of the implementation of the Primary Health Care Strategy implementation and framing of issues for the next phase
Executive Summary

Introduction

This paper represents the first part of a two-stage project ‘Where Next for Primary Health Care Development in New Zealand?’ that was undertaken by Judith Smith, Visiting Academic Fellow in the Sector Capability and Innovation Directorate of the Ministry of Health during 2008-2009. The project’s two elements were as follows:


- an initial phase entailing critical synthesis and analysis of PHCS implementation to date and a framing of the key issues that faced this sector in 2008 and beyond; and
- a second phase that sought to identify options for how primary health care provider development might go forward in New Zealand .
This paper is based on synthesis of existing analysis of the Primary Health Care Strategy (the Strategy) and its implementation, framed within the author’s assessment of this material. In addition, 30 interviews with national primary health care stakeholders were undertaken in order to explore the background to, implementation of, and progress associated with the Strategy.
The Primary Health Care Strategy

The Primary Health Care Strategy was based on two core academic traditions within primary health care research:


- the importance of strong and effective person-focused primary health care service provision as the crucial level for care continuity, co-ordination and integration within a health system (after Barbara Starfield, 1998)
- the importance of primary health care as a fundamental approach to health and community development, and hence in reducing inequalities and improving health (after WHO Alma Ata, 1978)
The analysis set out in this paper is based on an assertion that within the Primary Health Care Strategy, the focus on a health development paradigm of primary health care was predominant as the organising principle for the Strategy and its implementation. This made great sense given the problems that the Strategy was seeking to address in relation to inequalities in health, in access to primary health care services, and a need for greater community participation in health.
It is argued here the Starfield vision of ensuring strong and comprehensive primary care services based on the principle of people receiving continuous, co-ordinated and comprehensive first-contact care has not always received the attention during Strategy implementation that was apparently intended. This assertion is made not on the basis of how funding has been allocated (for the majority of new primary health care funding has gone towards reducing the cost of access to first-contact care) but rather in relation to how the Strategy has been implemented (e.g. the ways in which it has been able to engage and influence general practice and other providers), and where the most impact appears to have been made (e.g. in reducing the cost of access to services, but not being able to lever significant change in models of care at practice and provider level).
International and national evidence on patient views of primary health care indicate that New Zealand scores well (for those who are able to access such care), with timely access to in- and out-of-hours services, longer consultation times, and a sense of involvement in care decisions. This suggests that New Zealand has a strong base of primary health care provision upon which to build as it seeks to extend its primary health care services in line with Starfield’s vision.
Reflecting on implementation of the Primary Health Care Strategy

The Strategy was, by its own admission, intended as a vision to be interpreted locally, rather than a detailed national implementation plan. Progress made in relation to the six key directions set out in the Strategy is reviewed below.


Work with communities and enrolled populations

Population registration is now in place throughout New Zealand, providing the foundation for activity focused on reducing health inequalities and improving public health. Likewise, 80 primary health organisations (PHOs) have been put in place and almost all of the population is registered with a PHO. However, the extent to which the population is aware of PHO functions and services as suggested in the Strategy is open to question, and it seems that people continue to relate first and foremost to their general practice or community provider. PHOs have involved communities in their governance arrangements and are clear about their responsibility to work with communities and the enrolled population in order to try and improve health. The main challenge however is the extent to which PHOs have the actual levers available to them to bring about change in service provision for communities and the enrolled population.


Identify and remove health inequalities

The identification of health inequalities is a key focus for PHOs and district health boards (DHBs), and this issue is regarded by the health system as a core national health priority. There is evidence of improvement in health outcomes in New Zealand over the past decade, together with better rates of immunisation (an indicator that was a key concern prior to the Strategy), and a reduction in inequalities associated with ethnicity in this regard. It is however too early to say whether the Strategy itself has contributed directly to what appears to be a slowing in the rate of increase of health inequalities in New Zealand.


Offer access to comprehensive services to improve, maintain and restore people’s health

Sufficient attention has not been paid to specifying, with the different professions and providers, what different models of comprehensive primary health care services might look like and how they might be realised. The Strategy was ambiguous in relation to the role and functions of PHOs and this compromises PHOs’ ability to assume a strong role in leading change in primary care. Reducing the cost of access to first-contact care has been a key area of success within Strategy implementation – the challenge now is how to sustain this and continue to address inequalities in access. The use of capitation as the basis for allocation of government funding for primary health care has helped to embed a population approach to local planning and funding, but the continuation of significant patient co-payments, together with partial contracting between the government and general practice, means that the potential gains of capitation in respect of a different model of service have largely gone unrealised. There have been many innovations in service provision, but they have not been evaluated and disseminated in a systematic manner. The relationship between the government and general practice was often fraught during Strategy implementation, and clinical involvement in PHOs varies significantly as a result.


Co-ordinate care across service areas

The Strategy set out an ambitious set of aspirations related to the co-ordination of health services within and from primary care, but these need much more attention in the next phase if desired models of integrated care are to come about. PHOs have however used new funding available to them to extend services aimed at better care co-ordination, for example for people with long-term conditions, and they have made progress in developing joint health programmes and initiatives with inter-sectoral partners. International evidence on effective primary care suggests that strong general practice that assures a longitudinal and personal connection between patients and their GP or nurse is critical to co-ordination of services within and beyond the health system. This entails a system where practices are effectively connected (by IT and other management and professional relationships) to a wider range of local diagnostic, allied health care, welfare and public health services. In the New Zealand context, the issue of people having to pay for some services can act as a barrier to the practice performing the role of overall co-ordinator of services.


Develop the primary health care workforce

Whereas in 2001 the Strategy asserted that New Zealand had sufficient GPs and practice nurses (although not distributed appropriately), by 2008, there was national consensus about a shortage of health workforce. Given the known importance of strong first-contact primary health care services in enabling effective co-ordination of an individual’s care, there is a need for national leadership in respect of specifying what primary health care services should look like, with associated minimum standards. Without this, it will be difficult to hold DHBs to account for availability and standards of primary health care. There is evidence of innovation in the development of the primary health care workforce in New Zealand, but concerns remain about the evaluation and spread of such innovation. If new models of integrated primary health care are to be put in place (or where in existence, supported and extended), there is a need for PHOs to have a clearer role in relation to service development, along with appropriate levers and incentives.


Continuously improve quality using good information

The development of patient enrolment has provided a crucial information platform for public health and primary health care interventions. The PHO Performance Management Programme represents an initial attempt to develop national standards for primary health care services, albeit that it focuses on PHOs rather than providers and as such lacks clarity about how practice/provider level performance is to be assessed and incentivised. There is potential to use the PHO Performance Management Programme and the Ten Health Targets to develop a more sophisticated approach to the assessment of quality and performance. This could build on existing professional and community accreditation programmes. What is crucial is that clarity is achieved about the level of the system where performance is to be measured and rewarded (practice, IPA/primary care network, PHO, or DHB).


Challenges for the next phase

Based on this analysis of Strategy implementation, these are the challenges for the next phase:


1) Rebalancing the Primary Health Care Strategy

There is a need for a refreshed Primary Health Care Strategy that ensures attention to the development and extension of first-contact services and a setting out of the direction for the next phase of implementation. As part of this, it might be helpful to work with primary health care stakeholders to paint a picture of what primary health care might look like in New Zealand in say ten to twenty years. Long-term planning such as this needs to take place within the wider context of strategy for the whole New Zealand health care system, making sure that primary care develops to meet the expectations set by national and regional plans for clinical services and networks. This vision for primary care is also needed for the general population who struggle to recognise the scope and potential of primary health care. In doing this, it might be helpful to include a set of national desired outcomes for primary care, and the articulation of ‘simple rules’ for how actors in the system will work together.


2) Working with primary care professionals to plan and implement change

There is an opportunity to build on the strengths of New Zealand primary care by assuring a ‘medical or primary care home’ within plans for the next phase. In taking forward the Primary Health Care Strategy, how the process is developed and managed is as important as what is put in place. With funding roll-outs complete, there is a window of opportunity to frame a new and more constructive relationship with general practice, NGOs, DHBs and other players in the primary health care system. The challenge is to enable strong community and clinical leadership of the next phase of change within primary health care. Furthermore, national PHO organisations need to be fully involved in primary care planning alongside clinical leaders.


3) Clarifying the role and functions of a PHO

There is a need to clarify the role and functions of a PHO within the health system. This could include work to establish a typology of PHOs, accepting that they are a diverse constituency and as such, may have different areas of responsibility and focus appropriate to their form. In any work to pilot different models of integrated primary health care, there should be attention to exploring how the PHO role might operate in different contexts to enable learning about ‘types’ of PHO. PHOs might in future choose to be primary care provider networks, or global planners and funders of primary care for a defined locality – options such as these could be explored within pilot projects. As the future role and function of PHOs is explored, there is a need to determine how far it is important that people have a choice of PHO, and how this relates to people’s ability to exercise choice of primary care practice.


4) Testing out different models of service provision and funding

PHOs find themselves constrained in relation to exerting influence over local practices and other providers, largely on account of primary care funding arrangements that continue to require a significant patient co-payment direct to the practitioner. There is a need for national debate about the nature of the co-payment for general practice, in order to inform future policy about primary care funding and provision. The time is ripe to explore a range of different service models within primary care, including the funding and organiational arrangements that might enable these to be developed by PHOs, IPAs, and providers. In testing out such service and funding models, consideration should be given to exploring new approaches to pooled or locality funding of primary health care, along with contracting and budget-holding by PHOs and/or primary care networks. A range of devolved models of service provision and funding calls for a performance framework that can assure value for money and quality of care nationally.


5) Setting out the expectations of DHBs in relation to developing primary health care

There is a need for a restatement of the role and expectations of DHBs in relation to implementing the Strategy, in parallel to clarifying the role of the PHO. This needs to include an exploration of the pros and cons of DHBs continuing to provide community health services and whether these services should move into PHO management or funding/contracting. A requirement for joint planning between DHBs and PHOs might be helpful in signaling the joint responsibility for Strategy implementation. The performance management framework for DHBs need to emphasise and incentivise the importance of making progress with Strategy implementation, and DHBs need to be closely involved in developing plans for the next phase of Strategy implementation.


6) Strengthening management and leadership within primary health care

There is a need for a management and organisational development plan to be put in place to support the next phase of Strategy implementation. This needs to explore and address the present and future needs for general and clinical management in primary care, at practice, PHO and DHB levels. Such programmes will require funding and long-term commitment to support, network and develop those managing a significant and far-reaching change within the New Zealand health system.


7) Evaluating and learning from the experience of implementation

The analysis by Jonathan Lomas of evaluation and spread of innovation in the New Zealand health system could be used as the basis for developing a stronger framework for evaluating and disseminating change and innovation within primary health care. A review of existing research and evaluation capacity, together with an assessment of current projects under way or completed, would be an important first step in determining a more strategic approach to evaluation and implementation of innovations (where they are proven to be effective). Different approaches to ‘linkage and exchange’ could be trialled as part of the next stage of Strategy implementation, drawing on the experience of Canada, UK and elsewhere.


Conclusion

To conclude, what is needed in the next phase of development is:


- The setting out for the health sector and the population of a vision for effective primary health care services, including a stronger focus on the development of first-contact services as the core co-ordinator of people’s health care, within in an overarching framework of seeking to improve health and reduce inequalities.
- A commitment to work in a more inclusive and collaborative manner with general practice, NGOs, and all other primary care stakeholders as policy is shaped and implemented in a way that builds on the strengths of current provision.
- Work to clarify the current and potential role and functions of PHOs, including the development of plans for how they might assume a more extended role as primary care networks and/or as holders of global budgets for primary and community care services.
- The development of streamlined and different approaches to primary care funding that enable the testing out of new models of integrated primary and community care, within primary care networks.
- A restatement of the role and expectations of DHBs in relation to implementing the Strategy, including in respect of funding, planning, community service provision, and performance management, and how they relate to other actors such as PHOs and community health providers.
- A plan for how management and organisational development support will be provided to the process of strengthening and changing primary and community health care to meet the health and workforce challenges ahead.
- A commitment to evaluate new organisational and service developments in primary care, and to explore new ways of connecting research and practice, drawing on international experience of ‘linkage and exchange’.
This critique is intended as a challenging overview of Strategy implementation to date, together with a framing of issues for the next stage. The Strategy has been at once radical, as evinced by its backing of a community development and population health approach to primary care, and also conservative, in its focus on using government funding to try and reduce co-payments through a subsidy, rather than a contracting approach.
What is clear from the interviews carried out for this analysis is that across the spectrum of primary health care stakeholders in New Zealand, there is a real appetite to move forward and explore in a more collaborative and negotiated manner the potential for different models of care (with associated funding and business models) that will put New Zealand primary health care in a position to meet the twin challenges of rising incidence of long-term conditions and constrained workforce supply. The challenge is to learn from the process of implementing the Strategy to date, attending to the issues related to the lack of an overall implementation plan, the existence of fraught relationships, unclear organisational roles, and inadequate incentives, whilst building on the evident progress associated with developing primary care infrastructure, addressing inequalities in health access and status, and making primary care a key actor in the wider health system. If this challenge is met, New Zealand’s Primary Health Care Strategy will indeed have been radical, successful and of international note.

Acknowledgements

The analysis set out in this paper could not have been carried out without the enthusiastic support and co-operation given to the author by many people within the New Zealand health system and policy community.


Particular thanks are due to Margie Apa, Jim Primrose and Danny Wu at the Ministry of Health who, together with Janice Wilson, Teresa Wall, Deborah Roche and Alan Hesketh oversaw and advised the project.
Peer review comments on an early draft of the paper were made by Nick Mays, Jackie Cumming, Bronwyn Croxson, Jim Primrose, Chris Mules, and Fran McGrath, and these were extremely helpful for the shaping for the final report.
Most of all, I would like to acknowledge the generosity of the many people in the health sector, national professional organisations, national PHO bodies, Ministry of Health, Treasury, and academia who gave their time to talk with me about their views of Strategy implementation, and who forwarded me papers and reports that they had kept from the late 1990s and early 2000s.
The work contained in this paper was carried out during a secondment from the University of Birmingham to the Ministry of Health. The author was asked to carry out this project in order to inform Ministry of Health thinking about next steps in this policy area. The views expressed in this paper are however those of the author alone, and do not represent Ministry of Health policy.

Judith Smith

London, March 2009
Critical analysis of the implementation of the Primary Health Care Strategy implementation and framing of issues for the next phase
Introduction

This paper represents the first part of a two-stage project ‘Where Next for Primary Health Care Development in New Zealand?’ that was undertaken during a one-year secondment as Visiting Academic Fellow in the Sector Capability and Innovation Directorate of the New Zealand Ministry of Health.


The project’s two elements were as follows:


  • an initial phase entailing critical analysis of Primary Health Care Strategy (PHCS, or the Strategy) implementation and a framing of key issues facing this sector in 2009 and beyond; and




  • a second phase that sought to identify options for the development of primary and community health services in New Zealand .

In this first paper, an overview is given of the aims and objectives of the Strategy, in the context it was developed. This is followed by an assessment of the extent to which the aims and objectives of the Strategy have been met over the period 2001-2008, based on synthesis of existing research, evaluation and policy analysis material. This assessment is then used as the basis for identifying the challenges facing the health sector as it takes the Strategy into its next phase of implementation, along with an exploration of how existing policy mechanisms could be used in order to meet these challenges, and where new ones might be required.


Methods

This work represents synthesis of analysis of the Primary Health Care Strategy and its implementation, framed within the author’s assessment of this material. Thirty interviews with national primary health care stakeholders were undertaken (e.g. Ministry of Health officials, GP Leaders’ Forum, Health Care Aotearoa, PHO Alliance, PHONZ, primary health care nurse leaders, and academics who have followed the Primary Health Care Strategy implementation closely), in order to explore the background to, implementation of, and progress associated with the Strategy.

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