This is the fourth of a series of six articles
on our health system prepared for the Health 2021 website by
Laurence Malcolm, CDHB candidate.
Providing health services for older people has
been a continuing challenge for all health systems including
New Zealand’s. Three factors have limited progress. Firstly
services have been provided by a wide range of uncoordinated
agencies with little collaboration between them.
This has led to the lack of an effective voice
in priority setting. Acute and long-term hospital care services
have been given a much higher priority. Services for older people
have hence often been referred to as Cinderella services. Thirdly
until recently there has been a lack of an overall local health
authority responsible for the planning and funding of a comprehensive
and integrated service.
Action to address these issues has had a long
history in Canterbury. In the mid-1970s the then North Canterbury
Hospital Board took a key leadership role in promoting coordination.
Much progress was made in developing collaborative and trusting
relationships between agencies. However this progress was lost
during the competitive reforms of the 1990’s.
In the late 1990s clinical leadership from geriatricians
in collaboration with GPs led to what now exists as Eldercare
Canterbury. This has been a successful forum bringing all agencies
together with consumers to express an integrated voice for older
persons health and to develop new services, eg an integrated
stroke management programme. Its ongoing management has been
devolved to Presbyterian Support.
The establishment of DHBs from 2000 initiated
a new phase in the more formal attempts to develop a better
health service for older people. This was developed within the
framework of the Ministry of Health’s Health of Older
People Strategy. In 2004 the Ministry devolved funding for older
persons health to DHBs.
With input from an expert sector group, and wide
community consultation, a Board approved Healthy Ageing, Integrated
Support Strategy was finalized in February 2006. The strategy
acknowledged addressing the needs of an increasing elderly population,
especially in the very elderly group. Furthermore limited control
of institutional admissions had resulted in Canterbury being
over overbedded in its long-term care institutions and hence
over funded.
A key focus of the strategy is providing older
people with community based services that allow them maintain
their independence for as long as possible. The underlying principles
include the need for the strategy to be person focussed and
based on an integrated approach to service delivery. Additional
funding has been provided to enhance service provision (primarily
in the community) and create long-term savings.
Important recent progress has been made in implementing
the strategy. Bed numbers especially in residential care have
been reduced and funding for community services markedly increased.
After many decades of fragmented and unfocused
service delivery we now have established, within the integrated
funding of the DHB, the key components of a comprehensive and
integrated health delivery system for older people. Our Health
2021 team fully endorses this strategy because one of our fundamental
principles is that the health system must focus on keeping people
healthy as well as providing treatment if they become ill.
Primary health care
in New Zealand: a world leader
This is the third of a series of six articles
on our health system prepared for the Health 2021 website by
Laurence Malcolm, CDHB candidate. The purpose of these articles
is to present an up-to-date view of recent developments in our
health system especially those related to Health 2021 policies
and to assist voters in choosing appropriate candidates.
Over the past 10 to 15 years it has been a revolution
in general practice and primary care. For decades GPs had maintained
their autonomy as individual practitioners. The most organized
form of general practice was in larger medical/health centers.
There was little collective action to promote standards and
quality and almost no accountability for resource use, e.g.
the cost of pharmaceuticals and other laboratory tests.
In 1993 the market led reforms at that time had
a positive outcome for general practice. Regional health authorities
had been formed to contract with all health providers including
GPs. Many GPs initially felt threatened by this new development
and as a defensive mechanism formed independent practice associations
(IPAs) to contract with RHAs. IPAs took on accountability for
their members for managing the costs of pharmaceuticals and
laboratory tests with a strong emphasis upon quality, including
personal feedback and guidelines.
In return they retained a proportion of the savings
from the better management of these resources which they put
into improving services to the community. A prominent example
is Pegasus Health Group based in Christchurch. Many new services
were developed including improving immunization rates, the first
free national breast screening programme and the first free
child under three GP services
There was opposition from some GPs to this development.
But IPAs and other forms of general practice organization rapidly
spread so that by 1999 some 84% of GPs were involved. As a consequence
governments after 1999 were able to build on this development
with the National Primary Health Care Strategy in 2002.
The role of IPAs was extended to form primary
health organizations (PHOs) which were more broadly and community-based,
were accountable to the recently formed DHBs in their areas
and would have a key role in improving the health of the community
through a range of primary health care strategies. Patients
would be formally enrolled in PHOs through their general practice
members. The Strategy has been remarkably successful. By 2005
some 96% of the New Zealanders were so enrolled.
There has been a very large increase in government
funding, some $2.2 billion to PHO/GPs, paid on an enrolled patient
capitation basis to improve access to primary care. Whereas
previously patients paid a large proportion of the cost of seeing
their GP this has been halved and patients now pay only $3 instead
of $15 for prescriptions. The average family health bill has
fallen from $940 to $440.
PHOs are now undertaking a wide range of collaborative
strategies with their DHBs including reducing hospital admissions,
better management of waiting lists, improving immunization rates,
and the better management of chronic disease in the community.
PHOs are an almost unique New Zealand development
which puts us well ahead of comparable countries in the organization
and management of GP and related services. In conjunction with
DHBs we are likely to see significant improvements in health
outcomes in the foreseeable future.
From waiting lists to
fairer booking system
Waiting lists have for a long time been an undesirable
but necessary feature of publicly funded health systems. They
provide a safety valve to manage the ebb and flow of acute hospital
demand.
The problem with waiting lists is that they provide
little certainty for patients needing surgery, are unfair and
are subject to manipulation. There was a tendency for doctors,
including GPs to put patients on waiting lists well before their
actual need for surgery. Repeated studies of waiting lists have
shown that patients may have died, had their surgery done in
private or no longer needed surgery.
However in recent years in New Zealand the government
has abolished the old waiting list system. It has been replaced
by a much fairer and well-organized booking system. The new
system attempts to guarantee that all patients referred by GPs
will be assessed by specialists within six months.
If surgery is needed a firm booking is to be offered
to the patient for the surgery to be undertaken within six months.
Patients are assessed on a points system which ensures that
those with the greatest need are given the highest priority,
within available resources.
Unfortunately this means that if resources for
a particular surgical service are not available patients still
needing surgery will miss out and are referred back to GP management.
However a number of other significant changes
have been made to improve access. Firstly the government and
some DHBs have increased funding specifically for elective services.
This has particularly applied to joint surgery and cataracts.
For example in Canterbury the number of hip and
knee replacements this year is more than doubling since 2004.
This has been assisted by the opening of the new surgical services
unit at Burwood Hospital. All patients needing joint surgery
can now be seen and operated on within six months.
New procedures involving GPs and other health
professionals have been put in place to ensure that, as far
as possible, only those who would benefit from surgery are seen
by specialists. For example optometrists, using guidelines,
can decide whether a patient would benefit from seeing an ophthalmologist.
Physiotherapists are assessing patient needs for joint surgery.
A steering committee of GPs and specialists has been established
to ensure the best possible process for patient referral and
ongoing GP management.
In the near future the new booking system, along
with better funding and more organized referral processes, is
expected to offer dramatic improvements in access to elective
surgical services.
How well is our DHB
system working?
Hospital boards, area health boards, crown health
enterprises (CHEs), and now, district health boards, established
by the Labour Coalition Government in 2001. It is widely recognised
that the New Zealand health system has had more recent restructuring
than any comparable system. Does this mean we have now got
it right?
What is clear is that there is little appetite
for further change from political or professional interests.
This is more than just restructuring fatigue. There is a widespread
feeling, both nationally and internationally, that our health
system with its integrated DHBs is probably well in advance
of any similar country. If there is any debate it is that
we may have too many DHBs. But it would take a brave political
effort to challenge local body politics on this issue.
DHBs bring together all health services, primary,
secondary, tertiary, mental health, public health and disability
into one organisation. New Zealand probably now has the most
integrated health system of any comparable country. The only
services yet to be included are private maternity and for
the younger physically disabled. Only ACC operates a separate
funding system.
There is a strong focus upon equity/fairness
with populations being funded according to the needs of their
populations. DHBs have the challenge to get the best possible
value from government allocations based upon population need.
Organised primary health care is emphasised as an alternative
to expensive and often inappropriate hospital based services.
DHBs brought back a democratically elected governance
structure. Although there are continuing concerns about the
effectiveness of this process few would seem to want to revert
to government appointed, secretive and conflict ridden CHE
directorship system which the DHBs replaced. Much progress
has been made in the last six years in building up the skills
and relationships needed for effective governance of this
very complex organisation.
Is the DHB structure working? Yes it is. There
remain huge challenges in health but the Health 2021 team
is supportive of the DHB structure and fully committed to
working within it. It fits our philosophy of building healthy
communities as well as providing excellent health care."
2021 Candidates can
contribute very significantly to progress in Health in Canterbury
In 2000 the Labour led Coalition government brought in district
health boards (DHBs). These were based upon a wealth of experience
built up over many years and rejected the commercially driven but
failed experiment implemented in the 1990s.
Internationally evidence is now accumulating that New Zealand DHBs
are proving to be a most successful way of organizing health services.
DHBs bring together all health services, primary, secondary, tertiary,
mental health, public health and disability into one organization.
New Zealand probably now has the most integrated health system of
any comparable country.
There is a strong focus upon equity/fairness with populations being
funded according to the needs of their populations. DHBs have the
challenge to get the best possible value from government allocations
based upon population need. Organized primary health care is emphasized
as an alternative to expensive and often inappropriate hospital
based services.
Four Health 2021 candidates were elected to Canterbury DHB in 2004.
With close working relationships between them and other board members,
management and clinical leaders they have been able to make an important
contribution to achieving Health 2021 health objectives as follows.
An effective and cooperative health system has been developing
with close working relationships developing between general
practice and specialist services. This is improving access including
to elective surgery and reducing inappropriate hospital admissions.
Improved access with the opening of the Women's Hospital and
the Diabetes and Dialysis Centre.
Radical reorganisation and revitalisation of the child dental
health services plans approved.
Primary health organizations (PHOs) have now enrolled 98%
of the population through their general practices. This is leading
to better quality primary health care and chronic disease management
including cardiovascular disease and diabetes.
A comprehensive strategic plan has been prepared based on
wide community needs assessment and consultation.
A coordinated disability strategy for older persons is being
implemented with progress in providing more community services
to avoid institutional care.
A Maori Health Plan to 2010 is in the final stages of preparation
and places a strong emphasis upon equity and access, PHO involvement
and improving Maori health outcomes involving wide consultation
with the Maori community.
Reduced waiting times in access to elective surgery with the
number of orthopedic operations for hips and knees doubling
with additional funding, better organized services and the opening
of the new Burwood Hospital facilities.
CDHB is now regarded nationally as a leader in more efficient
use of hospital resources with a dramatic reduction in inpatient
length of stay with the Improving the Patient Journey Programme.
Staff relationships have markedly improved and especially
between management and clinical leadership. A new project to
facilitate these developments is being implemented in urology
services as a model for other clinical services development.
New and critically important positions of Chief Medical Officer
and Executive Director of Nursing have been established.
A Quality Council has been formed and there is an increasing
stress upon quality and safety in the provision of clinical
services. Clinicians are encouraged to report adverse events
and treatment injury under a no-blame disclosure policy.
Important progress continues to be made in public health through
a wide range of strategies facilitated by a very active Community
and Public Health Department.
Canterbury DHB has kept within budget with these strategies
and a continuing review of expenditure in all services. It is
expected that initiatives now under way will result in further
efficiencies and savings which can be redistributed to removing
waiting times for elective surgery and improving services generally.
Those elected to the Canterbury DHB in 2007 can expect to participate
in the further implementation of these Health 2021 policies. The
Canterbury community can be confident that major progress has
been made and will continue to be made by Health 2021 in the organization
and provision of its health services.
