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Evaluation of the Implementation of The Primary Health Care Strategy

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Better access to health care for individuals. Care of identified populations (not walk-ins) ... Nikki Coupe and Fiva Fa'alau. 7 . Research Team. Auckland (Nursing) ... – PowerPoint PPT presentation

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Title: Evaluation of the Implementation of The Primary Health Care Strategy


1
Evaluation of the Implementation of The Primary
Health Care Strategy
2
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
3. PHCSE The Project
  • Antony Raymont / Jackie Cumming
  • Health Services Research Centre
  • Victoria University of Wellington

4
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
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
6. Research Team
  • Host organisation
  • Victoria University of Wellington
  • Health Service Research Centre (VUW)
  • Jackie Cumming and Antony Raymont
  • Anne Goodhead, Mariana Churchward, Janet
    McDonald, Mahi Paurini
  • CBG Health Research Ltd (Auckland)
  • Barry Gribben and Carol Boustead
  • Nikki Coupe and Fiva Faalau

7
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
8. Governance - Steering Group
  • Constitution
  • Four research managers, Four funder
    representatives (1 ACC), and HRC as chair
  • Function (serially)
  • 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
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
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
11. Research Themes III
  • The impact on primary health care services for
    Maori.
  • 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
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
13. Structure of the Research
  • Key Informant Interviews
  • A Postal Survey
  • Quantitative assessment
  • Economic analysis
  • Time line (three years)
  • Phase I to June 05 Phase II to Dec 06

14
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
  • Interview 1 Mid 2004 (Report April 05)
  • Interview 2 Jan June 2006

15
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
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
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)

18
18. Quantitative Assessment
  • Analysis plan
  • Barry Gribben
  • CBG Health Research Ltd

19
19. What are we evaluating
  • 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
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
21 Attribution difficult
  • Regard PHCS as a single entity encompassing many
    interventions
  • Some clear cut components - fees
  • Qualitative data critical to interpretation

22
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
23 National data 1
  • PHO upload data
  • 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
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

25
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
26. Sample to date
  • Small numbers practices involved so far (50)
  • So analyses are illustrative only
  • Are not estimates of national rates
  • but show trends over time
  • 29 practices
  • 220,000 patients
  • 4 million consultations

27
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
28. Key Informant Interviews
  • Phase One (formative)
  • Antony Raymont

29
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.
  • Practice Nurses
  • Medical Practitioners
  • Community Representatives
  • Managers and CEOs
  • Bureaucrats from IPAC to MoH

30
30. Numbers
  • 77 primary care organisation identified including
    PHO, incipient PHO and PCO
  • Characteristics of PHO
  • Focus - Maori 18, - Pacific 9
  • Funding Acs 51, Mix 16, Int. 32
  • Site - lt 100k 60 - gt100k 38
  • Size - Small lt20k 49 (11 popn.)
  • - Large gt20k 50 (89 popn.)

31
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
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
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
34. Qualitative results
35
35. Positive Response
  • Better access with reduced fees
  • More flexibility with capitation funding
  • Nurse visits, phone FU, proactive care
  • Ability to identify and care for population
  • Small Ethnic PHO to City PHO
  • Rejuvenation of General Practice
  • Higher income

36
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
37. Implementation I
  • Problems
  • Payment processes
  • Data errors
  • Detection of duplicates
  • Treatment of casual visits
  • Context
  • Rapid uptake three levels of data

38
38. Implementation II
  • Problems
  • Targeting of subsidy
  • Well off in Access practices or 65
  • Context
  • Multiple targeting are in use on the way to
    universal coverage
  • Access (geographical) Age groups CarePlus
    (health need)

39
39. PHO Governance
  • Boards included representation of
  • Community including Maori and Pacific people
  • Medical and Nursing professionals
  • Community reps - shoulder tapped, nominated or
    elected by community groups
  • Problems
  • Commity development vs Medical/Corporate
  • Community uninterested (Size related)

40
40. PHO Management
  • Focus on setting-up
  • Now moving to new initiatives
  • Small PHO capacity issues
  • Management fee
  • Efficiencies of Scale
  • Larger (ex IPA) PHO
  • Benefit of changes (esp. population approach,
    community involvement) less obvious

41
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
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
  • Team work (vs being in charge)
  • Salaried employment (vs business worries)
  • Independent practice (vs handmaiden role)

43
43. PHCS Nursing
  • Margaret Horsburgh
  • School of Nursing
  • University of Auckland

44
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
45. Nursing perspective Implementation
  • Uneven development
  • Development depends largely on preferences of
    general practitioners
  • Focus on primary medical care versus primary
    health care

46
46. Challenges
  • Dominant private business model
  • Employer/employee relationships
  • Differentiating nursing role
  • Leadership

47
47. Way forward
  • Articulating primary health care nurse role
  • Career pathway
  • Recruitment and orientation to primary health
    care including mentoring
  • Nationally recognized standards of practice
  • Financial recognition for skill level
  • Increasing training opportunities
  • Reducing barriers to education

48
  • 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
    nurse-doctor employment arrangement is often a
    barrier

49
49. New Services
  • Great variability by PHO and Practice

50
  • Greater accessibility and 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
  • 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
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
52. Referred services
  • Labs and Pharms
  • - focus on historical mal-distribution
  • - need for devolution of budgets
  • Hospital services
  • - incentive to use EDs

53
53. Quality
  • Incentives for better focus of care with
    capitation and population identification
  • Quality programme in process
    (IPA programmes on hold)

54
54. Information
  • Population data much improved
  • (Reporting more complete but individual visit
    data not required)

55
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
  • Maori, Pacific, Low SES
  • Large
  • Well resourced 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
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
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

58
  • 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)
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