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)

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 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 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. 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 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) Phase I to June ’05; Phase II to Dec ‘06

14. Key Informant Interviews

PurposeUnderstand 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. Postal Survey

PurposeTo investigate the issues raised during the key

informant interviews so that their extent and distribution can be specified.

TimelineTo follow each phase of the informant interviews

16. Quantitative Assessment

In summaryWill 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)

18. Quantitative Assessment

Analysis plan

Barry Gribben

CBG Health Research Ltd

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. 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 / qualityNMDS ED / OP national databases

Practice surveyConsultation ratesConsultation typesCo-paymentsRoles

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. National data

PHO DateReg Ethnicity Gender Quintile AgeGrp Quarter Cohort with NHI ALL PAH ASH DM Asthma IHD CX Mamxxx yyyyqq Maori M 0 0-4 qtr cnt n n n n n n n n

Pacific F 1 5-17Other 2 18-44

3 45-644 65+5

• Link PHO databases and NMDS

• Get excellent data from NMDS

• But NHI not 100% on registers

• Can examine non-PHO data “by subtraction”

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)

24 PHOs chosen representing different types

Random sample of practices, but min 1 each typen=81

All 5 invited to participate

n=5

14 ineligible8 declined

leaving n=59

Data collected

n=30

5 non-PHO practices recruited for interviews

2 ineligible1 declined

leaving n=2

Practice or PHO considering approving participation

Data returned successfullyn=27Access 5Interim 22

Data returned successfully

n=2

Data returned successfully Final data set n = 29

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. 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. 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 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

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. Wariness

GPs noted Threats to viability of practices Compliance, bureaucratic, cost increase

without clinical benefit Devaluation of medical roleOthers mentioned Failure to realise full benefitsGradual increase in trust

37. Implementation I

Problems Payment processes

Data errors Detection of duplicates Treatment of casual visits

Context Rapid uptake; three levels of data

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. 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 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

Management fee Efficiencies of Scale

Larger (ex IPA) PHO 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

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

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 nurse-doctor employment arrangement is often a barrier

49. New Services

Great variability by PHO and Practice

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. 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

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)