Evaluation of the Implementation of
The Primary Health Care Strategy
2. Presentation Outline
 Introduction to the project
 Dr Antony Raymont
 Quantitative Findings
 Dr Barry Gribben
 Qualitative Findings
 Dr Antony Raymont
 Nursing Issues
 Prof. Margaret Horsburgh
 Discussion
 Jon Foley on continuity of care
3. PHCSE: The Project
Antony Raymont / Jackie Cumming
Health Services Research Centre
Victoria University of Wellington
The Primary Health Care Strategy
 Published February 2001
 Aims
 Better access to health care for individuals
 Care of identified populations (not walk-ins)
 Better co-ordination (community and second)
 Means
 Increased subsidisation of primary health care
 Capitation funding (with enrolment)
 Primary Health Organisations
5. Set-up of Evaluation
 “The Strategy [] will be supported by ongoing
research during its implementation” (p.26)
 Funded by MoH, ACC & HRCNZ (2003)
 Health Research Council of New Zealand
called for proposals
 Selection followed the usual HRC process
6. Research Team
 Host organisation
– Victoria University of Wellington
 Health Service Research Centre (VUW)
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Jackie Cumming and Antony Raymont
Anne Goodhead, Mariana Churchward,
Janet McDonald, Mahi Paurini
 CBG Health Research Ltd (Auckland)
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Barry Gribben and Carol Boustead
Nikki Coupe and Fiva Fa’alau
7. Research Team
 Auckland (Nursing)
 Margaret Horsburgh and Bridie Kent
 Wellington Medical School (GP)
 Tony Dowell and Roshan Perera
 Canterbury (PH and GP)
 Pauline Barnett
 Ministry and Treasury
 Bronwyn Croxson, Durga Rauyinar
 International
 Nick Mays and Judith Smith
8. Governance - Steering Group
 Constitution
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Four research managers, Four funder
representatives (1 ACC), and HRC as chair
 Function (serially)
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Discuss and comment on the project plan and
research instruments
Monitor progress and review and approve any
variations in the project plan
Review reports and publications
9. Research Themes I
 The relationship between the Ministry, DHBs,
PHOs and PCOs.
 Governance and internal financial arrangements of
PHOs.
 Changes in the role of consumers and local
communities in the development and management
of primary health care services.
 Enrolment processes and efforts to address
population care.
10. Research Themes II
 Efforts to identify and correct inequities in access
to health services.
 The development of new services, other changes
in service provision and the achievement of
comprehensiveness in primary care.
 Efforts to improve service quality.
 Developments in information collection and
quality.
11. Research Themes III
 The impact on primary health care services for
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Māori.
The impact on primary health care services for
Pacific peoples.
Changes in the primary health care workforce.
The development of multidisciplinary teams
within PHOs particularly the role of nurses.
Moves to coordinate services between PHOs and
other organizations
12. Research Themes IV
 How the PHCS has increased access, and
reduced inequalities in access, to services.
 The impact of the PHCS on health status and in
reducing health inequalities.
 The impact of the implementation of the PHCS
on injury care provision.
 Changes in the quality of primary care services
(including use of drugs, laboratory tests and
referrals).
13. Structure of the Research
 Key Informant Interviews
 A Postal Survey
 Quantitative assessment
 Economic analysis
 Time line (three years)
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Phase I to June ’05; Phase II to Dec ‘06
14. Key Informant Interviews
 Purpose
Understand the experience and activities of
Primary Health Organisations and their
member practices in responding to the
Strategy
 Time line
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Interview 1 – Mid 2004 (Report April ’05)
Interview 2 – Jan – June 2006
15. Postal Survey
 Purpose
To investigate the issues raised during the key
informant interviews so that their extent and
distribution can be specified.
 Timeline
To follow each phase of the informant interviews
16. Quantitative Assessment
 In summary
Will use data from administrative data sets and
from practice PMS to assess
patient costs
rates of consultation
use of nurses
changes in ACC claiming
 Results will be presented by Barry Gribben
17. Economic analysis
 Will use national and practice level data
 Assess net cost of the Strategy
 Evaluate distribution of expenditure by
Population group
(pop. vs govt.; low/high SES)
 Service type
(primary vs secondary)
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18. Quantitative Assessment
Analysis plan
Barry Gribben
CBG Health Research Ltd
19. What are we evaluating
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What is the PHCS exactly
PHOs / pop health focus
Improved funding
SIA / RICF / CarePlus
NIR / BSA / NCSP
Improved 1º / 2 º care integration DHBs
IPA-led quality initiatives / HCA
RNZCGP MOPs programmes
20. Original plan
 PHCS = PHO / funding / pop health focus
 Evaluate with a cohort study with control
group of non PHO practices
 But PHO sign up too rapid – much faster than
we expected – now 3.8M pats
 Potential control group too biased
 Plan B = analysis of longitudinal data from
PHOs
21 Attribution difficult
 Regard PHCS as a single entity
encompassing many interventions
 Some clear cut components - fees
 Qualitative data critical to interpretation
22. Data sources
 National data sources
PHO data – registers / utilisation / quality
NMDS
ED / OP national databases
 Practice survey
Consultation rates
Consultation types
Co-payments
Roles
23 National data 1
 PHO upload data
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PHO register structures
Utilisation data – first submitted Oct 2004
Quality Indicators – not yet implemented
 No data prior to PHCS
 Long phase in with incomplete data capture
for first few cycles
24. National data
• Link PHO databases and NMDS
• Get excellent data from NMDS
• But NHI not 100% on registers
• Can examine non-PHO data “by subtraction”
PHO DateReg
xxx yyyyqq
Ethnicity Gender Quintile AgeGrp
Maori
M
0 0-4
Pacific
F
1 5-17
Other
2 18-44
3 45-64
4 65+
5
Quarter Cohort with NHI ALL PAH ASH DM Asthma IHD CX Mam
qtr cnt n
n
n
n
n
n
n n
25. Practice data
 Sample of 60 practices in a before / after
design, from PHOs participating in evaluation
 Sufficient power to detect changes in
utilisation rates / copayments of 10%
 Complete data collection of register / visits /
copayments / role of provider (Dr/nurse)
26. Sample to date
• Small numbers practices
involved so far (50%)
• So analyses are illustrative
only
• Are not estimates of national
rates
Practice or PHO
considering
approving
participation
24 PHOs chosen
representing
different types
5 non-PHO
practices
recruited for
interviews
Random sample
of practices, but
min 1 each type
n=81
All 5 invited to
participate
14 ineligible
8 declined
2 ineligible
1 declined
leaving n=59
leaving n=2
n=5
Data collected
n=30
• …but show trends over time
•29 practices
•220,000 patients
Data returned
successfully
n=27
Data returned
successfully
Access 5
Interim 22
n=2
•4 million consultations
Data returned
successfully
Final data set
n = 29
27. Next stages
 Much more analysis to do reconciling PHO
start dates / capitation funding / subsidy
increases in a single analytical framework
 Complete national data extraction
 Explore interesting features qualitatively in
next rounds – eg low ACC copayments in
Interim practices
 Expand practice sample
28. Key Informant Interviews
Phase One (formative)
Antony Raymont
29. Appreciation
 Thanks to all those in sector who have been
badgered for information, interviewed and
asked to reveal their experiences with the
implementation of the Strategy.
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Practice Nurses
Medical Practitioners
Community Representatives
Managers and CEOs
Bureaucrats from IPAC to MoH
30. Numbers
 77 primary care organisation identified
including PHO, incipient PHO and PCO
 Characteristics of PHO
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Focus - Maori 18%, - Pacific 9%
Funding – Ac’s 51%, Mix 16%, Int. 32%
Site
- < 100k 60%
- >100k 38%
Size - Small <20k 49% (11% popn.)
- Large >20k 50% (89% popn.)
31. Selection of PHO
 PHO partitioned on key characteristics
(Focus, funding, size and urban/rural)
 One in three chosen from each group
(So as to equalise region, age and overlap)
 26 PHO chosen (interviews done at 23)
(1 not established, 1 disestablished, 3 refused, 2
of these replaced)
 Essentially no PCO at time of interviews
32. Interviews Undertaken
 PHO(8) – CEO/Manager or Chair
- Maori, Pacific, Community reps.
- General practitioner rep.
- Nursing rep.
 Practices (Approx. two per PHO)
- GP and P Nurse (Separately)
 Independent practices
 Other Informants (MoH and GP Orgs.)
33. Process
 Semi-structured interview guides
 Interview recorded and noted
 Issues abstracted with supporting quotes
 Interviewee asked check the record
 Issues partitioned into themes – iterative
process starting with proposed list
 Themes described with supporting quotes (no
interpretation at this stage)
34. Qualitative results
35. Positive Response
 Better access with reduced fees
 More flexibility with capitation funding
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Nurse visits, phone FU, proactive care
 Ability to identify and care for population
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Small Ethnic PHO to City PHO
 Rejuvenation of General Practice
 Higher income
36. Wariness
GPs noted
 Threats to viability of practices
 Compliance, bureaucratic, cost increase
without clinical benefit
 Devaluation of medical role
Others mentioned
 Failure to realise full benefits
Gradual increase in trust
37. Implementation I
Problems
 Payment processes
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Data errors
Detection of duplicates
Treatment of casual visits
Context
 Rapid uptake; three levels of data
38. Implementation II
Problems
 Targeting of subsidy
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Well off in Access practices or 65+
Context
 Multiple targeting are in use on the way to
universal coverage
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Access (geographical); Age groups; CarePlus
(health need)
39. PHO Governance
 Boards included representation of:
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Community including Maori and Pacific people
Medical and Nursing professionals
 Community reps - shoulder tapped,
nominated or elected by community groups
 Problems
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Comm’ity development vs Medical/Corporate
Community uninterested (Size related)
40. PHO Management
 Focus on setting-up
 Now moving to new initiatives
 Small PHO capacity issues
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Management fee
Efficiencies of Scale
 Larger (ex IPA) PHO
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Benefit of changes (esp. population approach,
community involvement) less obvious
41. Other Organisations
 Co-operation between PHO
(Large interim PHO and small access one)
 Difficulties in case of overlap
(Patient and practitioner poaching)
 Various moves towards combined work
with eg WINZ, Schools, Police etc.
42. Primary Care Workforce
 Fears of inadequate capacity
 Issues and solutions
 Address income disparity (docs and nurses)
 Ensure adequate training
(Spaces in FMTP; financial support PNs)
 Changing expectations – eg benefits of
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Team work (vs being in charge)
Salaried employment (vs business worries)
Independent practice (vs handmaiden role)
43. PHCS: Nursing
Margaret Horsburgh
School of Nursing
University of Auckland
44. PHCS : Nursing
 Expanded role for nursing
 Strengthen and enhance phc team
 Teamwork and collaboration
 Aligning nursing practice with community
need and service delivery
 Population and personal health strategies
45. Nursing perspective:
Implementation
 Uneven development
 Development depends largely on preferences
of general practitioners
 Focus on primary medical care versus
primary health care
46. Challenges
 Dominant private business model
 Employer/employee relationships
 Differentiating nursing role
 Leadership
47. Way forward
 Articulating primary health care nurse role
 Career pathway
 Recruitment and orientation to primary health care
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including mentoring
Nationally recognized standards of practice
Financial recognition for skill level
Increasing training opportunities
Reducing barriers to education
 I think there is the potential to achieve an expanded
role, and it is happening particularly in rural areas
where there are not enough GPs to provide services
 Nurses are really struggling at the moment to see
how they fit into the whole structure. Some of them
have embraced the idea then been knocked back by
the PHOs who are really GP dominated
 It depends on the attitude of the GPs, and the nursedoctor employment arrangement is often a barrier
49. New Services
 Great variability by PHO and Practice
 Greater accessibility and
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acceptability
Extended opening hours
Whole family visits
Recruitment of a female
practitioner
Home visiting
Medical clinics at schools
Assistance with transport
Information for new immigrants
24hour PHO Helplines
Cultural training
Interpreter services
Secondary care liaison
ED liaison services
Acute illness home care
Specialist availability in practice
Podiatry
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Focused clinics
Care plus related activities
Diabetes and nutrition clinics
Asthma nurse clinics
Smoking cessation
One-stop-shop for youth
Free sexual health clinics
Cervical and breast screening
Programmes for mental health
Programmes for disabled persons
Extra-practice services
Radiology
Retinal screening
Refraction
51. Care of Injury
 No change in actual care of injuries
 Awareness of conflict between capitation and
fee-for-service systems
 Incentive in favour of medical care for
patients (higher co-payments with ACC)
 Incentive in favour ACC claims for
practitioners (second diagnosis)
52. Referred services
 Labs and Pharms
- focus on historical mal-distribution
- need for devolution of budgets
 Hospital services
- incentive to use EDs
53. Quality
 Incentives for better focus of care with
capitation and population identification
 Quality programme in process
(IPA programmes on hold)
54. Information
 Population data much improved
(Reporting more complete but individual visit
data not required)
55. Typology of PHO
Small
Inadequate management
resources
Access funded
Low co-payments
Previous capitated NGO
Salaried doctors
Increasing use of nurses
Established community
governance
Low material investment
Māori, Pacific, Low SES
 Large
 Well resourced
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management
Interim funded
Higher co-payments
Previous fee/service IPA
Doctors own practice
Nurses underused
Establishing community
governance
Established IT, premises
General population focus
56. Distribution
(Current data)
 37 Small – 8 Interim (22%)
 41 Large – 11 Access (27%)
(Guesstimate)
 37 Small – 11 IPA (30%)
 41 Large – 32 IPA (78%)
57. The Future
 Need to ensure that the goals of
Strategy are reached:
 Inexpensive care
 Expansion of primary health care team
 Population focus
 Inclusion of the community
 Co-operation with other services
 Monitoring outcomes
 We [said] that if you are just doing this to
reconfigure general practice you are wasting
your time and money, it needs to be a bigger
more audacious goal than that and that is about
bringing in other services [and functions].” (DHB)