Evaluation of initiatives to improve access to Primary Health Care: inadequate data or unanswerable

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Evaluation of initiatives to improve access to
Primary Health Care inadequate data or
unanswerable questions?

• Antony Raymont
• Health Services Research Centre
• Victoria University of Wellington

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2. Content of Presentation

• New Zealand Primary Health Care (PHC)
• DHBNZ PHC Access project
• Outline aspects of completed literature review
• Defining access
• The range of interventions
• Approaches to evaluation
• System approaches
• Controlled trials
• Local Programmes
• Conclusions for New Zealand

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3. New Zealand PHC

• Ministry of Health
• 21 District Health Boards (40-400K pop.)
• Planning and funding all health care for district
• Running hospitals
• 81 Primary Health Organisations (6-300k pop.)
• Planning organising /- service provision
• About 1100 general practices ( many NGOs)
• Note variation in size (?capacity ) and in PHOs
  function (?provider ?overlap) Context

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4. DHBNZ Primary Care Access Project

• Review of literature on Improving Access to
  Health Services for Vulnerable Populations
• Implementation and evaluation of an intervention
  to improve access
• Training practices to be welcoming
• Nurse outreach
• Being undertaken by CBG Health Research Ltd with
  Mauriora Associates

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5. Components of Access(Penchanskys 5As,
Anderson et al.)

• Availability the service is provided
• Accessibility users must be able to get there
• Accommodation convenience
• Affordability OK for user
• Acceptability positive experience

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6. Other Components of Access

• Predisposition of potential patients
• Beliefs about medical care
• Health literacy
• Debts, language, social status
• Appropriateness of care
• Interactional and clinical skills
• Secondary services (doctor variation)
• These are other examples of variable context

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7. Range of Interventions

• Funding amount and type
• Creation of New Health Centres
• New arrangements
• IPAs, Divisions of General Practice
• Cultural change
• Friendly trustworthy staff ethnic matching
• Community partnerships
• Options to use a different professional
• Outreach (GP, PN, CHW)

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8. Wider Context

• Local history
• What are people used to?
• How have relationships been in the past?
• Staff availability and quality
• National and State differences
• Australia vs NZ vs Canada vs UK
• cost and availability of primary care
• These are all further examples of variable
  context.

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9. Approaches to Evaluation

• Controlled trials
• System comparison
• National and District
• Before and after comparisons
• Change in local outcomes with multifaceted
  interventions

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10. System Evaluation

• Barbara Starfield, Shi and Macinko and PHC
• Comparison by district/state/country
• Outcomes
• Mortality rates
• Childhood and mental health indicators
• Subjective wellness
• Screening and prophylaxis rates
• Appropriate use of hospital services
• System cost

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11. Good primary care

• Characteristics
• person-focused care
• long-term (gt2 years) personalized care
• family and community orientation.
• first contact access for each new need
• comprehensive and coordinated care

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12. PHC-focussed system

• Characteristics of PHC-focus
• equitable distribution of services
• long-term (gt2 years) personalized care
• universal, publicly accountable, financial
  coverage
• low or no co-payments for services
• incomes of primary care physicians close to that
  of specialists
• Conclusion There is good evidence that these
  PHC and system characteristics improve population
  health and reduce healthcare cost.

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13. Results of Access Reviews

• Improving access to primary care for Maori, and
  Pacific peoples Helena Barwick, 2000.
• Stated that there was lack of robust evidence.
• Access to Health Care by Gulliford et al, 2001,
  (UK).
• Reviewed six recent innovations and was only
  able to come to a few tentative conclusions.
• These results may be weak because the researchers
  were looking for controlled trials

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14. Controlled Trials

• Require standardised interventions
• In a consistent context
• Often unavailable, therefore
• Results are often ambiguous
• Positive results may not transfer
• Limited application to primary health care
• We hope that the Nursing outreach and staff
  training project will qualify

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15. Local Solutions

• Often mentioned that multi-faceted interventions
  are most likely to succeed
• Improving attendance at GPs surgery
• Health education of the public and
• Reducing fees and
• Improving friendliness of providers etc.
• Reducing ambulatory sensitive admissions
• Improving GP attendance
• Resourcing acute care at home
• Improving access to out-patient specialty care
  etc

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16. Evaluating local solutions

• System approach comparing before/after
• Process targets EG
• Improved attendance at surgery
• Appropriate use of hospital emergency dept.
• Outcome targets EG
• Population satisfaction with health care
• Population wellness
• Reduced avoidable mortality

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17. NZ System changes (MoH)

• Adequate supply of health workers, including
  doctors, nurses, managers and community health
  workers.
• Expanded role of nurses and pharmacists.
• Equitable distribution of health resources.
• Reduced patient fees.
• Incentives to improve access (as well as
  quality).
• Funding for locally developed initiatives.
• Maintain data bases of primary care activity and
  health outcomes, and evaluate change over time.

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18. NZ District changes (DHB)

• Support for, and oversight of, Primary Health
  Organisations.
• Protect those serving disadvantaged populations.
• Structure PHOs so that the population each serves
  is clearly defined by geography and/or ethnicity
  and/or level of need.
• Forestall negative incentives of capitation
  funding.
• Undertake surveillance of health status and
  access to care.
• Monitor the performance of secondary services.

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19. NZ Provider changes (PHO/Practices)

• Form partnerships with the community.
• Assess population health problems and health
  service access as a joint community/provider
  activity.
• Facilitate culture change in practices (ensure
  that those most in need experience a warm
  welcome.
• Implementing service outreach initiatives.
• Utilize community health workers.
• Continue practice support (clinical, managerial
  and infrastructural).

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20. Conclusions

• Controlled trials of standardised interventions
  are of limited application in PHC.
• Improved access to PHC and better population
  health usually require multifaceted
  interventions.
• These may be situation specific
• The nature of these and the likelihood of success
  depends on local conditions
• Generalised outcome measures should be adopted
  (and monitored)