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Cunliffe: Primary Care Implementation: Next Steps


David Cunliffe

12 September, 2008
Primary Care Implementation: Next Steps

I would like to acknowledge Dr John Martin, World Health Organisation; Pat Snedden, ADHB; Dr John Wellingham, Royal New Zealand College of General Practitioners; Dr Kathy James, from Health Care Aotearoa; Dr George Salmond, former Director General of the Ministry of Health; Dr Don Matheson, former Deputy Director-General of Public Health; Stephen McKernan; organisers Dr Pat Neuwelt and Professor Alistair Woodward, AK University.

Introduction
It’s a great pleasure to join this distinguished audience today for what I believe will be an important opportunity to discuss future of primary healthcare. I want to recognise up front that many of you were passionate advocates for primary care, before we even had a Primary Healthcare Strategy. I see a very eminent group of quite likely suspects in the room. Folk like Peter Glensor, Hutt Valley DHB and Pat Sneddon, Auckland DHB who have gone on from being pioneers to become some of the most senior leaders in the sector.

I know that last night you reflected on the Alma Ata Declaration of 1978 and its relevance to the present day. For me the Alma Ata Declaration’s focus on social justice achieving equity, taking a broad approach to health and primary health, and its emphasis on people participating in planning and implementation of their health care is still relevant.

I also want to acknowledge the role of the World Health Organisation in helping to shape healthcare policy worldwide and once again to welcome Dr John Martin to the forum.

The Alma Ata Declaration was the highlight on the health calendar in 1978. Let’s reflect on some of the other key events that took place that year – for everyone in the room under 30, it was the year that Ashton Kutcher was born. And for the geeks in the room, let’s not forget it was the year the Rubix Cube hit the shelves.

Here in New Zealand, Hello Sailor won album of the year and Dennis O’Brien was our most promising male singer (who?). Some things don’t change – 1978 was the year that Fair Go won ‘Best Information Show’.

In health, we are in a constant state of change. New technologies, medicines and procedures become available, improving and saving lives through medical advances. In the last 30 years, in no small part through your efforts:
• Life expectancy for New Zealand women has increased from 76 years to 82 years, for New Zealand men from 69 years to 78 years.
• Infant mortality in New Zealand has decreased from 13.8 per 1000 live births to 5.3.
• Deaths from cardiovascular disease in New Zealand have been reduced from 171 per 100,000 in 1979 to 63 per 100,000 in 2004.
• The percentage of New Zealand adults who are daily smokers has been cut in half from 36 percent to 18 percent in 2007.

While we can be proud of these achievements the time has now come to plan the next stage of our future. And just as many of you have grown from being pioneers at the frontiers of healthcare practice in New Zealand I believe it is time to build on the organic, emergent nature of that pioneering change to more systematically leverage local strengths.

We need to ensure that the systems and processes through which we deliver primary healthcare more fully give effect to the original vision of the Strategy. I do so because like you, I’m passionate about the opportunity to build a healthier and more just society.

Outline and Context
Since 2000 the government has made a concerted effort in primary healthcare. This morning I would like to describe what we have done to achieve our vision for primary care and importantly, what we need to do to take the implementation of this cornerstone strategy to the next level of effectiveness.

It is appropriate to reflect on what has been achieved in primary health care, and where we need to head from here.

This is one of a series of key speeches that I will use to lay out a package of strategy work that Cabinet has recently agreed, to ensure full implementation - and the next wave of innovation - in the New Zealand Health and Disability Strategy. Others will include next steps in the evolution of the DHB System, a new approach to workforce development, a nationwide agenda for clinical quality improvement, next steps for the Health Information Strategy, and other key components of the core health system.

In parallel, I expect to bring forward new measures to underpin the effective provision of Aged Care and Disability services, and to report on work in progress to address current issues in key clinical areas.

It is crucial to note that while the government is confident that excellent progress is being made to deliver better health care to all New Zealanders – we are ambitious to do even better and are determined to innovate and improve services wherever possible.

Good public and primary healthcare is not primarily about ideology – it is about common sense measures to understand the drivers of health of our population, to take steps to promote good health through health promotion and disease management, and to provide affordable and equitable access to early diagnosis and appropriate intervention to address health needs.

However Alma Ata also reminds us however that this can never be divorced from the socio-economic context of the population, nor the political economy of the processes that seek to serve it. In this regard, and in the integrated approach to linking public health and primary care, Alma Ata and its WHO successors have been seminal in the development of New Zealand's approach to primary health strategy.

Accordingly, it is appropriate today to summarise:
• First, what has been achieved since the launch of the Primary Health Care Strategy, in light of the direction set by the Alma Ata Declaration
• Second, to honestly confront the remaining barriers to the full and consistent implementation of the strategy; and
• Third, to provide a clear outline of the direction of travel for the sector under this government over the next sever years.

The Journey to Date
When we took office nine years ago we inherited a health system with high entry costs to primary care, few people enrolled with long term conditions management programmes, excessive waiting times for electives and gross inequalities for Maori and Pacific peoples.

New Zealand had experimented with marketising health care and a hospital-centric health system, with disastrous results. Access was uneven and inequitable. Population and primary health strategy was largely missing.

What the system lacked was a comprehensive focus on population health goals and reducing those inequalities. By 1999 it was clear that New Zealanders were losing trust and confidence in their health system.

The 2001 health reforms and the establishment of District Health Boards represented a marked change in the provision of health services in order to address these challenges.

Our new model of health care delivery emphasises population health improvement, reducing inequalities in health status, better integration of services, and greater community involvement in health system governance.

In other words we were seeking to embody the same principles as the Alma Ata Declaration.

We continue to have a strong focus on primary health because for most people it is their first level of care and it can make a real difference to health outcomes. It can be the difference between people staying well longer and being better supported to manage chronic conditions.

Primary Health Care Strategy
The Primary Health Care Strategy, which was launched in 2001, set out a ten-year vision for primary health in New Zealand that was:

People will be part of local primary health care services that improve their health, keep them well, are easy to get to and co-ordinate their ongoing care. Primary health care services will focus on better health for a population, and actively work to reduce health inequalities between different groups.

The Strategy identified six key directions to achieve this vision:
• work with local communities and enrolled populations
• identify and remove health inequalities
• offer access to comprehensive services to improve, maintain and restore people’s health
• co-ordinate care across service areas
• develop the primary health care workforce
• Continuously improve quality using good information.

Implementation
The government has put its money where its strategy is. Since 2002/03 we have invested an additional $2.2billion in primary health care.

Seven years into the Strategy implementation, it is valuable to examine the extent of progress on the six key directions. The health sector can point to many successes. The shift in emphasis from a hospital-centric and market-driven approach to health care to an integrated population and primary health care approach has been one of the hallmarks of health policy under this government.

Accordingly I am pleased to report:
• The establishment of more than 80 primary health organisations
• Enrolment of approximately 95% of the New Zealand public in these PHOs
• Increased community engagement in decisions about their local primary health services through representative
• Lower cost access to general practice and pharmaceutical services, more than 1 million enrolees pay no more than $16 per visit, and no more than $3 per prescription, and this is improving some of the pricing dynamics in the broader primary care market

Not surprisingly, more people are using primary care services than ever before, including increased use by Maori and Pacific populations
• 74 percent of enrolled children under six years are receiving free standard consultations through the Zero Fees for Under Sixes programme – a high percent of Maori and Pacific populations are benefiting
• Between 2002/2003 and 2006/2007, the number of adults reporting an unmet need for GP services was cut in half

Involvement in long-term conditions management programmes, which are based in primary care, has increased:
• Through the performance management programme, there are early signs of improvement in areas such as breast cancer screening and influenza vaccinations for the elderly
• The number of people enrolled in Diabetes Get Checked programme increased by 10,000 in the last year, reaching more than 70% of known people with diabetes;
• enrolments in Care Plus, our structured management programme for those with multiple chronic illnesses, increased by 30,000 in the last year, and
• the uptake of publicly-funded statins, to reduce cardiovascular disease risk, is now at levels comparable with Australia
• in the last year the proportion of those with a long-term mental illness who also had a relapse prevention plan in place increased from 35 percent to 64 percent

In keeping with the emphasis the government has given to the Primary Health Care Strategy, we have invested above the OECD average in the areas of prevention and public health. Examples include:
• Our HEHA programme - education on improving diets and increasing physical activity
• Outreach services to increase uptake of childhood immunisations, including meningococcal and pneumococcal vaccines, and the recently introduced HPV vaccine that offers the potential to prevent up to 70% of cervical cancer.
• cancer screening coverage, particularly for Māori and Pacific women, and,
• media campaigns aimed at reducing smoking in the home or car.

As a result, there is strong evidence that lifestyle risk factors have improved.
• We have had one of the biggest decreases in the OECD in tobacco consumption. Smoking prevalence in 14 and 15-year-olds has dropped 42 percent for girls and 56 percent for boys since 1999.

Hospital mortality rates have been steadily declining and patient satisfaction with hospital services remains high.
• The average length of stay in hospital is reducing while the rate of readmissions to hospital remains steady. Taken all together these factors indicate the quality of service in our hospitals keeps on improving.

This has been matched by growth in electives services volumes while maintaining relatively short waits. Over the last six years we have seen the number of case weighted discharges increase by over 12 percent.
• We have delivered over 8000 additional joints and over 4000 additional cataracts since 2004/05.
• This year we have further increased electives funding at national prices and have introduced more flexibility to allow clinicians to address areas of highest electives need.

Progress has been made to support the primary health care workforce.
• Across the sector more than 2000 nurses and 1000 new doctors have been employed during the life of this government. (We welcome the Opposition's non time-bound commitment to another 750 health care workers, but will try not to slow down to that level of increase).
• We have increased doctor and nurse salaries in recognition of the fact that we are competing in a world market for health professionals
• Early signs that there are expanded roles for nurses in care coordination and delivery of preventive services.

We recognise that primary care must operate in conjunction with appropriate levels of primary and secondary level infrastructure. Accordingly in the last six years over $2.3 billion of capital expenditure has been undertaken and new hospitals and primary clinics have opened the length and breadth of the country.

As noted, to fund all of this and much more, Vote Health has increased at a much faster rate than GDP annual growth, on average 9 percent nominal growth per year. In part, this increase has been to fund services where there was an under-investment in the 1990s.

Stocktake: Progress and Challenge

The launch of the Primary Health Care Strategy therefore signalled the most significant changes to, and increased investment in, primary health care services in over 50 years.

Many countries are recognising that harnessing the potential of the primary health care sector is vital to improving health outcomes.

But this government, like this sector, having achieved much, is not content to rest on our collective laurels. We are ambitious and determined to fully realise the aims of the Strategy.

Central to that challenge is the way care is delivered. The way we deliver primary care hasn’t changed much since the inception of the Strategy. Most care is still delivered by GPs in practices that are not sufficiently integrated with other community health services or with secondary or tertiary services.

While the care and dedication of these GPs has to be admired, challenges to the full implementation of the Strategy remain, including:
• Lateral integration with public health services, well-child, maternity, pharmacy, physiotherapy, radiology and laboratory;
• Vertical integration with hospital-based speciality care, and day surgery;
• Integration of clinical information creating unified medical records where information can be shared with other clinicians as required;
• Workforce training opportunities so that future doctors and nurses and allied health professionals have a strong primary care footing; and,
• Prevention models well grounded in the community, including linkages with NGOs and social marketing.

A key factor holding back new service delivery models is the continued influence of patient co-payments. Despite the shift to capitation and the fact that under the Very Low Cost Access scheme more than a quarter of New Zealanders benefit from very low cost access, there are still too many practices that derive one half or more of their income from patient co-payments.

This reinforces a model of care delivery where: GPs are the dominant practitioners because they command higher co-payments; episodic care is rewarded over preventive and longitudinal care; and small practices not well integrated into the overall health system remain the norm.

In May this year I received the Logan Report of the Primary Health Workforce Taskforce. While it pulls no punches I believe it is a valuable and constructive document. I have agreed to the vast bulk of its recommendations and charged the Ministry of Health with the expeditious implementation of recommended change.

As Minister I have also directed the Ministry to go beyond Cabinet's formal reporting requirements on the implementation to date of the Primary Health Care Strategy, and propose a series of reforms, that Cabinet has now accepted, that will take implementation of the strategy to the next level.

The strategy was always designed to be evolutionary, in order to encourage innovation and customisation at a local level. As a sector we are on a journey – a journey that in many ways can be traced back to Alma Ata. The balance of my remarks today aims to provide a clear indication of the future direction of travel.

Criteria for Success

To set the context for this future direction, I want to emphasise three key factors that will continue to guide successful implementation:
• Sustaining low cost access
• Better linking public and community-based providers, and
• Developing and rolling out new service delivery models.

Sustaining low cost access

Reductions in user co-payment charges have been a major achievement of the Primary Health Care Strategy. The Very Low Cost Access (VLAC) programme in particular has not only radically cut access costs for a million Kiwis, but is reported to be having a beneficial effect on pricing in primary health care markets.

We must continue our journey towards free or very low cost access for even more New Zealanders. I never again want to see Kiwi parents having to choose between doctors visits for sick kids and food on the table.

Low cost or free primary care, together with Working for Families, income-related rents and healthy housing schemes, are providing a sound basis for improved public health and are cutting child poverty.

But there is more to do and this government is not satisfied yet. Barriers and inequalities remain for too many health care consumers.

For example, the New Zealand Health Survey shows that Maori are more likely to experience cost as a barrier than non-Maori. We must explore options for removing remaining cost barriers and ensure that gains are not eroded through undue increases in user co-payment charges.

In some cases user co-payment charges are already rising. There is growing evidence that the profitability of general practices is rising ahead of inflation.

A Fees Review Framework is in place that sets benchmarks for annual GP user co-payment increases. Let me state very clearly that the government remains determined that the fees review process is essential and will remain.

Increases provided through the Fees Review Framework consistently exceed future funding track increases, and are likely to continue to do so given multiple inflationary pressures.

Nor has the process yet addressed the wide variance in user co-payment charges that predated the Fees Review Framework.

Incentives to keep cost increases low need to be part of primary health care funding systems. Development of new service models that make better use of the primary health care workforce could also assist to manage primary health care costs.

Better linking public and community providers

Improving the health of our population cannot be achieved through general practice alone.

There is a need to address the broader determinants of health such as improving nutrition, increasing exercise, shoring up housing stock, and further educating the public about the value of prevention and early intervention.

This requires a focus on populations and communities reinforced by messages delivered by health practitioners delivering care to individuals. Public health units and NGOs such as Plunket need to be more closely integrated with PHOs and PHOs providers to enable this change in focus to occur.

There are examples of this integration occurring through PHOs and PHO providers:
• In the Wairarapa, the PHO, which serves the whole district and works closely with the District health Board, has enlisted the support of the Maori Women’s Welfare League to identify families with children who have not been vaccinated. This has resulted in improved vaccination coverage rates for the district.
• In the South Island, BreastScreen South has an agreement with general practitioners whereby GPs are paid an annual fee to enrol eligible women into the programme. This linkage with general practice has resulted in breast screening rates for Maori and Pacific women in this region well above the national average.

Developing new service delivery models

Targeted funding initiatives have stimulated new approaches to service delivery. For instance:
• better coordinated care for people with multiple chronic conditions (Care Plus)
• improved outreach to high need populations (Services to Improve Access)
• population-based health interventions (Health Promotion), and
• improved access to services for people with mild to moderate mental illness (Primary Mental Health Care).

We aim to build on what has been achieved through these initiatives.

It is difficult for primary health care providers working in isolation from each other and the wider health system to develop effective interfaces with other services across a locality or a district.

However, much can be achieved if we can successfully build on the leadership and coordination roles of DHBs and PHOs.

I believe that PHOs, working in partnership with DHBs and primary healthcare providers, need to be supported and incentivised to lead progress toward new service delivery models in primary health care.

Getting those incentives right, and rigorously monitoring the quality and consistency of primary health care implementation through those relationships, will form a critical part of the next phase of the strategy.

Future Direction: A Bold Vision

Let me lay out a clear challenge - to take the implementation of the Primary Health Care Strategy to the next level, nationwide.

To do this we must identify and replicate examples of best practice; better align incentives and clarify the roles of key players in the system.

In particular we must clarify the "vertical" relationships between DHBs, PHOs, and front line providers, to create stronger incentives for the consistent, population-based delivery of the Primary Health Care Strategy.

DHBs must better manage the devolution of primary care implementation through local networks of representative PHOs, which will support multi-disciplinary teams working in primary health care service delivery.

PHOs must promote a population health approach to primary care – in the spirit of Alma Ata and in line with WHO best practice. PHOs must build a culture of quality improvement based on clinical governance amongst primary health care providers, supported by appropriate incentives and a nationwide framework for health quality improvement.

The appropriate development of a broad-based primary care workforce, including nurses at all levels and a full range of other health professionals alongside GPs, is essential. Workforce planning and equitable access to funding for frontline services must support this integrated, team-based approach.

The Ministry of Health is charged with overseeing the acceleration of this shift to a more integrated approach to implementation. The government will hold the Ministry accountable for outcomes and expects it to play an appropriate leadership role in the sector.

Having got your attention with this shorthand summary of the intended direction of travel let me explain the content in a little more detail.

Positioning PHOs to lead change

Primary Health Organisations are critical to implementation of the Strategy and to leading change.

As noted in the Logan report, primary health care delivery was restructured around Primary Health Organisations (PHOs), which are not-for-profit organisations funded by DHBs to provide essential primary health services. PHOs were always expected to vary in their size and structure, according to the needs of their community.

Their establishment was intended to encourage practitioners to work together across traditional professional boundaries to improve the quality of health care and to engage the community in service delivery.
I think it is fair to say that a minority of PHOs are already fulfilling their expected role in leading implementation of the Strategy.

Lake Taupo PHO is one such PHO. Let's briefly explore this example as an archetype of the kind of PHO that we would like to see more of across the sector.

Lake Taupo PHO currently employs eight clinical staff including a social worker, dietician and community based Nurse Practitioners. It delivers a range of services such as fitness, primary mental health, physiotherapy, medication review services and traditional Maori therapies.

It has developed Healthright, a holistic, patient focused approach to the management of long term conditions, That includes additional case management funding for nurse led clinics, community nursing and a strong lifestyle intervention and preventative approach including exercise, nutrition and smoking cessation.

The introduction of integrated solutions for information technology and information sharing has also been a priority for this PHO. Not bad for one PHO!

Generalising from a range of PHO innovations, we can see that the greatest advances for the sector have occurred where:
• PHO roles and goals are closely aligned with the Strategy
• DHBs are well engaged and have close geographical alignment with a limited number of PHOs or a single PHO
• there is meaningful engagement of DHBs, PHOs, providers, professionals and communities in planning for primary health care development
• PHOs have strong leadership – manifest in the capacity to build effective working relationships with funders and providers, and to lead service model development across a diverse range of providers and communities.

Increasing DHB engagement in primary health care development

Some DHBs have recognised the importance of the Strategy to their success.

This is exemplified by the approach taken by the MidCentral DHB This established four geographically determined PHOs, with a single management service organisation to support the PHOs. Working closely with its PHOs, MidCentral has, over the last three years, invested significantly in the development of primary health care. In December 2005 the DHB approved $7million sustainable funding for primary health care development.

This has included the establishment of Chronic Care Teams which link several initiatives across the diabetes, cardiovascular, respiratory, and cancer plans. The multidisciplinary teams, which were developed with input from primary and secondary health care providers, are available at the community level and are coordinated through local Primary Health Organisations.

MidCentral Health’s investment in primary health care has included approximately 70 additional positions. Twenty five of these are nursing but the investment programme has also seen a diversification of the clinical skill sets available within primary health care.

New positions have included dieticians, podiatry, physical activity, smoking cessation, physiotherapy, health promotion, cardiologist, cardiac technicians, and psychology.

There has also been additional investment in diagnostic technology available within primary health care including echocardiogram, ECG machines, defibrillators, exercise treadmill and spirometry. The DHB has also invested in decision support software and additional data analyst capacity within PHOs and the DHB.

This investment is recent and it will be some time before results are fully realised, but positive outcomes are already evident, such as:
• 1000 cardiovascular disease risk assessments completed in first 3 months
• 22,000 visits to chronic care teams in primary care settings in 12 months
• 21% Maori participation rates against 14% for the population as a whole, indicating successful targeting of high needs populations
• diabetes screening rates improved from 45%-65% over 12 months.

There is too much variation in DHB involvement in the development of primary care.

I expect all DHBs to work closely with their PHOs to produce district-wide primary health care development implementation plans in collaboration with DHB provider arm services, NGOs, providers and communities.

Increasingly, DHBs should build partnerships which increasingly devolve primary health care services to local networks of PHOs, who in turn become primary implementing agents in their areas.

Funding Incentives

We must ensure that funding models and policy settings, and in particular the substantial First Contact funding stream, achieve maximum leverage on development of service delivery models.

Complexity of funding and accountability arrangements should be reduced, and a better alignment achieved between the strategic primary care role of DHBs and the lead implementation role of fully equipped, broad based PHOs.

There should be a clear hierarchy of accountability from the Crown (through the Minister and the Ministry), to DHBs, and then to PHOs and primary care providers and NGOs.

In some cases, flexibility to offer global budget rather than siloed funding streams to DHBs and PHOs is an option that should be explored, while maintaining traction in priority areas such as long-term conditions management and primary mental health care.

A commonly reported impediment to the development of more integrated service delivery is lack of access to one-off transition funding. I want the Ministry to work with the sector to identify and develop options for accessing transition funding and capital investment funding.

It is also essential to maintain Government’s achievements in removing cost as a barrier to access for many New Zealanders, and to continue to explore options for removing remaining cost-barriers that continue to impede access for the most disadvantaged.

I have asked the Ministry of Health to examine as a priority the underlying cost drivers and the financial incentives faced by providers; the mix of universal and targeted funding streams; appropriate mechanisms for improving access for those people for whom user co-payments are a barrier; and the ongoing affordability for Government.

This work also needs to identify opportunities for incentivising the development of service delivery models that have potential to better manage cost drivers.

Strengthening performance accountability

To effectively leverage performance, alignment must flow through all players in the health system, including:
• the Ministry, which holds the Crown Funding Agreements and funds DHBs
• DHBs, which hold the agreements with PHOs
• PHOs, which hold “back to back contracts” with providers
• providers, comprised predominantly of general practices and some Non-Government Organisations (NGOs)

The PHO Performance Programme uses performance-based payments to incentivise performance improvement against a range of high priority nationally consistent indicators, such as influenza vaccination coverage for older people. I am currently investing more money in incentive payments for performance in the areas of long-term conditions and reducing inequalities and improved alignment with health targets.

Looking further forward I want to see existing performance initiatives aligned and a comprehensive and closely aligned performance management system developed across DHBs, PHOs and providers. This will ensure performance management is more consistent between DHBs, PHOs and providers and that it is more focused on measuring outcomes, rather than inputs.

The Ministry will ensure that DHBs are held accountable for performance against implementation of the Primary Health Care Strategy, using a defined set of performance indicators.

I want the Ministry to take the following actions to improve the level of cooperation and collaboration between DHBs, PHOs and providers:
• Firstly, to support the further development of district health networks that work across hospital and community service boundaries to improve patient outcomes. Early evidence indicates clear advantages to geographically based or demographically targeted PHOs in this regard.
• Secondly, by requiring DHBs to work with their PHOs to collaboratively develop comprehensive district primary health care development plans that demonstrate how better devolved service delivery models will be implemented
• And thirdly, explore options for the development consistent quality management approaches by PHOs, supported at a framework level by the ministerial Quality Improvement Committee and locally by DHBs.

I will also require that PHO and practice-level performance information is publicly available. This will increase the financial and reputational incentives to improve quality.

The Ministry of Health

The Government has recently revised its requirements of the role of the Ministry in the sector, as I first indicated in May this year.

The Ministry will be held directly accountable for outcomes in the sector, alongside the ongoing direct statutory responsibility of DHB boards to the Minister, to ensure an enhanced and streamlined chain of accountability.

The Ministry will need to engage actively with DHBs, PHOs and NGOs as work proceeds apace to realign funding and monitoring practices to support the full implementation of the Primary Health Care Strategy.

In doing so it will need to re-examine how the expectations of PHOs are specified in contracts, and ensure that enrolment lies with PHOs rather than with individual providers. PHOs can then make funding decisions that are in the best interests of their enrolled populations as intended under the Strategy.

Funding and planning responsibility for a wider range of primary health care services, and more flexibility in how funding is deployed will also enhance the ability of PHOs to lead implementation by developing service delivery models that span the breadth of primary health care.

Additionally, making PHOs and their providers financially accountable for the referrals they make should lead to more efficient resource allocation decisions and has considerable potential for changing service delivery models.

Other options that have the potential to open up the scope for development of service delivery models include:

• PHO ownership of services (e.g., where a general practitioner might be salaried rather than own their own business)
• co-location of a range of health and social services in one place, taking advantage of the benefits of scale in integrated "one stop shop" primary health centres
• use of information technology to facilitate patient-centred e-health initiatives, including such basics as e-mail and telephone triage

Many of these models are already being tried in some places.

The Ministry of Health is working with the sector to maintain the momentum of innovation while improving the quality of evaluation and reporting of results.

I want the Ministry to identify those situations where the desired primary health care service delivery model is being achieved; evaluate the factors that have been key to their success; and, provide incentives for other providers to replicate these successful models.

Building on this work, I have asked the Ministry in collaboration with the Primary Health Care Advisory Council to develop a model for multi-disciplinary family health centres to be tested in locations beginning in 2009/10.

Development of the model will build on best practice principles learned from examples such as Lake Taupo PHO.

Conclusion

Today's symposium comes at a critical time for the sector. At a general political level there is a growing bipartisan consensus on the importance of strong primary health care strategy.

So today we have considered the evidence of success in what the strategy is already delivering – more equitable and lower cost access to care; successes in disease management and public health campaigns; the emergent development of extensive and innovative primary care infrastructure through PHOs and enhanced primary care practices.

But I have been equally realistic about the remaining gaps and the future challenges. I am not content to rest here. There is so much more good that we can do, building on the best delivery models we have seen – like Lake Taupo PHO and Mid Central DHB.

To achieve that we need to be more systematic about clarifying roles, aligning incentives, managing the rollout of best practices and holding all relevant players appropriately accountable.

As was boldly stated in the Alma Ata Declaration, primary care “relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community.”

The health workforce is the heart and soul of the primary health care. None of the goals we have outlined can be achieved unless the need for change is embraced by GPs, nurses, midwives, physios, pharmacists, community health workers, dieticians, occupational therapists and others.

We must include all health workers in planning and implementing the changes required for improving services, health outcomes and reducing inequalities.

This must be complemented by refining the roles of the Ministry, DHBs, PHOs and other providers to ensure that the structures and processes of primary health care implementation support the goals of the strategy and the passion and dedication of this workforce.

Thank you.


ENDS

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