Towards integrated care
in New Zealand:
opportunities and challenges
Professor Jackie Cumming
Director, Health Services Research Centre
School of Government
Victoria University of Wellington
Fragmented Care in NZ
• As in other countries, NZ health services are
fragmented
• This results from service users working with a
wide range of health professionals working in a
wide range of organisations
• Lack of information sharing, liaison and team
work are then seen to result in lack of coordination of care
Integrated Care Definitions in NZ (1)
• NZ has a long history of aiming to better integrate care –
at least since the Social Security Act 1938
• ‘Integrated care’ is not always well defined in NZ:
o Achievement of ‘co-ordinated care’ from patient
perspective, i.e. ‘smooth and continuous transition
between services’ and a ‘seamless journey’ for service
users
o Collaboration and co-operation across services, from a
provider perspective
Integrated Care Definitions in NZ (2)
• Linked to good access to primary health care (PHC)
providers, seen to be the lead co-ordinators of care
• Can refer to the linking of key planning, funding and service
delivery activities to support co-ordination
• Can mean integrated service delivery organisations providing
a wide range of services to enrolled populations working
within a single budget
• Integration across a level of care (eg, across PHC) (‘horizontal’ )
• Integration between PHC & secondary (hospital) care (‘vertical’)
• Integration across health & social development services (‘intersectoral’)
Barriers to Integrated Care in NZ
• Separation of roles in planning leading to duplication and gaps;
different criteria for accessing services limiting access
• Barriers to access to PHC, from user fees
• Barriers to PHC providers leading co-ordination, from fees and
private provision
• Lack of information sharing and liaison could see users slip
through gaps, be seen by multiple providers, information not be
shared or go missing, tests duplicated, harm from eg incompatible
medicines, different health advice from providers
• Overall, poor quality of care and waste of scarce health resources
Attempts to Better Integrate Care in NZ (1)
• Many reports on NZ health system noted issues from
fragmentation, proposed better integration
• Many actual reforms emphasised integration of planning and
funding; service budgets; service planning
o Eg, Establishment of Area Health Boards in the 1980s – planning
and funding of pubic health and secondary care
o Eg, Regional Health Authorities / Health Funding Authority –
planning and funding for all health and disability services
• Most emphasis on integrating government-owned
organisations to this point
Attempts to Better Integrate Care in NZ (2)
• NZ seriously began focus on integration for
service delivery / clinical services in 1990s
o Eg, Development of Independent Practitioner
Associations who could integrate care horizontally
across PHC providers and work with hospitals to
vertically integrate care
o Eg, Focus on service delivery and clinical
integration through HFA national integrated care
pilots
Attempts to Better Integrate Care in NZ (3)
• 2000s Primary Health Care Strategy had better integration as a key
objective
o Reducing fees patients pay to improve access to PHC
o Development of Primary Health Organisations to co-ordinate care
horizontally and vertically
o Strengthening role of PHC in the health system
o Encouraging team work and better co-ordination across providers
• However, Primary Health Care Strategy
o Seen to focus on development of new organisations (DHBs and PHOs)
and population health focus
o Insufficient attention to service delivery and clinical integration
o Failure to identify what a comprehensive model of PHC might look like
and how it might be delivered
Attempts to Better Integrate Care in NZ (4)
• At the same time, some policy moves likely
to have increased fragmentation from
expansion of range of providers
• Eg, Deinstitutionalisation in mental health and
older people’s care
• Eg, Growth in independent midwifery
Data and Research?
• Little data and research
• Especially on views of service users
• Hence, not entirely clear where we most
need to pay attention to improve care for
service users
Sicker Adults
Experienced Coordination Gaps in Past Two Years
Percent
80
60
53
40
36
37
39
AUS
NETH
SWE
40
42
43
CAN
US
NOR
56
30
20
20
23
0
UK
SWIZ
NZ
* Test results/records not available at time of appointment, doctors ordered test that had already been done,
providers failed to share important information with each other, specialist did not have information about
medical history, and/or regular doctor not informed about specialist care.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
FR
GER
Any Gaps in Hospital or Surgery Discharge in Past Two Years
Percent
100
80
60
40
26
29
UK
US
48
50
51
SWIZ
CAN
NZ
55
61
66
67
71
73
NOR
FR
20
0
AUS
GER
NETH SWE
* Last time hospitalized or had surgery, did NOT: 1) receive instructions about symptoms and when to seek further care;
2) know who to contact for questions about condition or treatment; 3) receive written plan for care after discharge;
4) have arrangements made for follow-up visits; and/or 5) receive very clear instructions about what medicines you
should be taking.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
Adults
15
Gaps in Coordination of Specialist Care
Specialist did NOT have reason for
visit/tests from regular doctor
Regular doctor NOT up-to-date about
specialist care
Percent
40
33
30
30
26
26
22
22
20
17
13
11
10
15 14
12
11
23
17
16
16
22
20
16
15
10
Base: Saw specialist in past two years and has regular doctor/place of care.
Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
US
UK
IZ
SW
E
SW
R
NO
NZ
NE
TH
ER
G
FR
N
CA
S
AU
US
UK
IZ
SW
E
SW
R
NO
NZ
NE
TH
ER
G
FR
N
CA
AU
S
0
Regular Doctor Co-ordinates Care Received from Other Doctors and Other Places
Percent reporting doctor always/often coordinates or arranges care
100
75
66
68
69
63
55
51
68
69
UK
US
55
50
35
26
25
0
AUS
CAN
FR
GER NETH
NZ
NOR
SWE
Base: Has regular doctor/place of care.
Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
SWIZ
PHC Doctors
Doctor Can Electronically Exchange Patient Summaries
Percent
and Test Results with Doctors Outside their Practice
100
80
60
55
52
49
49
45
39
40
38
31
27
22
20
14
0
NZ
SWE
NET
SWIZ
NOR
FRA
UK
US
AUS
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
GER
CAN
Practice Uses Nurse Case Managers or Navigators
Percent
for Patients with Serious Chronic Conditions
100
80
78
73
68
68
59
60
51
44
43
41
40
20
20
0
UK
NETH
NZ
SWIZ
AUS
NOR
CAN
US
Note: Question asked differently in France.
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
SWE
GER
Primary Care Doctors’ Receipt of Information from Specialists
Percent said after
their patient visits
a specialist they
always receive:
AUS
CAN
FR
GER
NETH
NZ
NOR
SWE
SWIZ
UK
US
Report with all
relevant health
information
32
26
51
13
13
41
26
12
59
36
19
Information
about changes to
patient’s drugs or
care plan
30
24
47
12
5
44
22
13
44
41
16
Information that
is timely and
available when
needed
13
11
26
4
1
15
4
8
27
18
11
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
After Hospital Discharge, Primary Care Doctor Receives Needed Information to
Percent
Manage the Patient Within 48 Hours
100
80
67
56
60
45
42
40
40
36
21
21
20
15
14
CAN
NOR
10
0
GER
NZ
US
NET
SWIZ
AUS
UK
SWE
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
FRA
Proposed New Patient Experience Survey…
Will examine within hospitals,
• Consistency in information provided by different doctors and
nurses
• Explanations about health and health care after arriving home
• Whether service user felt they received enough information to
manage condition on discharge
• Explanation of purposes of medicines that was understood by
service user
• Medication side effects to watch for
• Information to family/whānau
• Sufficient care and assistance after leaving hospital
• Who to contact if have worries after leaving hospital
• Service user receive copies of letters between hospital doctors
and GP
Integrated Care in NZ – The Present (1)
“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’.”
(‘Better, Sooner, More Convenient’)
Integrated Care in NZ – The Present (2)
• Emphasis now on
o Encouragement of joint regional and district leadership and
decision-making
o Devolution of funding and services from hospitals to PHC
settings
o Amalgamations of eg PHOs to strengthen leadership and
capability in service development
o Integrated Family Health Centres
o Improved information systems to share information
o Whānau ora
• But also moves to expand prescribing rights and extend
role of pharmacists
Integrated Care in NZ – The Present (3)
Little is known about these initiatives
• Extent of information sharing
• Extent of co-location of services
• Extent of going beyond the above to agreed
pathways, co-ordination/navigation roles,
team decision-making
• Service users’ views on whether there is
better integration from their perspectives
• Overall impact of changes
We need
• Research on types of integration being achieved or
not being achieved
• Measures to assess integration from both provider
and service user perspectives within and across
service delivery organisations
• Research on impact of integrating processes
• Research on barriers and enablers to better
integration
• Discussion on integration vs expanding access
through new provider roles (role of choice and
competition)
References
Cumming, J. (2011) Integrated Care in New Zealand. International Journal
of Integrated Care (11, 18 November).
Smith, J. (2009) Critical analysis of the Primary Health Care Strategy ad
framing of issues for the next phase. Wellington, Ministry of Health.
Ryall, T. (2007) Better, sooner, more convenient: health discussion paper.
Wellington; National Party of New Zealand.
Russell, M., Cumming, J., Slack, A., Peterson, D., Gilbert, A. (2003)
Integrated care: reflections from research. In Gauld, R. (ed) Health care
management and delivery in New Zealand. Dunedin: Otago University
Press, pp. 201-313.
Health Services Research Centre, Te Rōpū Rangahau Hauora A Eru Pōmare.
(2001) Evaluation of the national demonstration integrated care pilot
projects: overview report. Wellington: Health Services Research Centre.
Commonwealth Fund International Health Policy Surveys:
http://www.commonwealthfund.org/Surveys/ViewAll.aspx?topic=International+Health+Policy