New Zealand – Increasing the Pace of Integration 2
Every health system is a series of systems within systems. Common across most health systems is the centrality and power of the hospital sector. This is a comparatively recent phenomena, driven by the rise of novel drugs and expensive medical devices in the 20th century. The hospital system dominates funding and dictates responses to care. The same challenges exist in New Zealand. In some ways, they are even fostered with all Ministry of Health money destined for primary care being allocated to District Hospital Boards first. They in turn handover around 1.5% of their budgets to the Primary Health Organisations created around a decade ago. These PHOs have member general practices to which they in turn deliver capitation funding and centrally contracted allied health and program resources.
On the face of it, such a funding cascade could be dire for primary care. For example, in Australia 6% of the Medicare budget is spent on primary care services so the New Zealand model is currently allocating less to primary care. Perhaps this lean introduction has forced general practice to better utilise nurses and patient profiling to ensure maximum efficiency is achieved with the limited funding envelope.
The funding process also forces the sectors to interact and through special seed funding, form alliances to address areas of high need. It is through this mechanism that New Zealand is starting to emerge as a real pioneer in integrated care. GPs are being upskilled by hospitals to take on specialty work and even provided with hospital employed nurses and allied health to round out their capability. This is giving rise to more and more GPs referring to each other rather than the hospitals when patients have needs in excess of their skills.
Another mechanism for forcing cooperation is the single patient identifier. Reports are provided to general practice by the PHO on the number of patients enrolled at their practice who presented to Emergency Departments or who had a hospital stay over the last quarter. Falling below benchmarks provides reason for the PHO to support the general practice in improving their chronic disease, triage and activity planning approaches. The most recent evolution is the piloting of a predictive screening tool which identifies patients with a 25% or higher risk of attending hospital over the next six months. Practices can then develop improved case management to support these patients before they become frequent hospital flyers.
In the event a patient attends a hospital, clinicians in that system can access the patient record held in general practice in real time. This dramatically reduces the need for repeat tests or assuming blame lies with the GP in the absence of detail on what care has been provided. The hope is to move to a system where every morning in every general practice key clinical representatives have stand up meetings to discuss:
- which patients are on the watch list
- who needs follow up today based on pathology results
- who is being returned from hospital today
- who could be extracted early from hospital if appropriate care could be put in place via virtual medical wards run by general practices nurses and doctors.
The provision of detailed benchmarking and profile reports alongside a central source of funding means that data should increasingly drive resource allocation in New Zealand. Hospitals are still unionised parts of the system with a vested interest in the status quo. However, the mechanisms exist for quickly moving funding, an advantage our tiered system of government does not easily afford. I suspect the Kiwi health system mantra of care close to home, with the patient at the centre, delivered better and cheaper is well on the way to fruition.
Tracey Johnson, General Manager, Inala Primary Care