by Kevin Hague
The Government’s announcement that they are moving to achieve the unrealised goals of the Primary Health Care Strategy needs to be taken with a grain of salt.
So far the National Government has virtually ignored primary health and in some areas actively undermined it – so while it would normally be great news to hear that the Government intends to prioritise primary care in 2010/11 - all indications are that Tony Ryall is heading in the opposite direction and has got the priorities all wrong.
Meeting the unmet goals of the Primary Health Care Strategy is a great idea but the Minister’s statement this week bears no relation to the under-delivered parts of the strategy and instead seemed to be signalling the restructuring of Primary Health Organisations.
The Minister’s announcement suggest that he is either unfamiliar with the vision of the strategy and the Vic Uni research just published, or is committed to his own direction, irrespective of them. Some of the Government’s actions have been helpful, such as the bonding scheme for rural health professionals, and the intent to permit a wider range of diagnostic testing to be ordered from primary care, but overall the Minister seems to have missed the point.
If the Government is truly concerned with how we are going to afford to pay for New Zealanders health needs in the future, in the face of aging population, epidemics of chronic disease and increasingly expensive new health technologies, then the role played by primary care will be critical. At the moment the Government is in reverse gear on these priorities (as can be seen in the scrapping of successful diabetes programmes, and healthy eating activities).
The reports published this week from Victoria University confirm that the Strategy has seen a diverse range of Primary Health Organisations (PHOs) develop, with varying approaches. These organisations have been extremely successful in enrolling New Zealanders and giving them significantly cheaper access to primary care, and good progress has been achieved on some of the other key directions.
The priorities for primary health care at the moment should be:
- Improving multidisciplinary teamwork
- Improving health inequalities, especially for Maori
- Working with their enrolled populations to keep them well in the first place, especially preventing chronic conditions like diabetes; and
- A concerted programme to improve quality and safety
But Tony Ryall seems to be ignoring these and instead pushing for restructuring of PHOs.
Published in Environment & Resource Management by Kevin Hague on Fri, September 4th, 2009
Tags: health, Kevin Hague, PHO, primary health, restructuring
More posts by Kevin Hague | more about Kevin Hague
on the trolls and those who are unable to keep on topic
I’ve been frequently amazed at this Government’s ability to say they take something seriously while they’re undermining it in policy by deregulating, and often deregulating at more cost than continuing the policies that were in place.
It’s almost like watching someone with an anxiety disorder desperately trying to avoid the consequences of what they’re doing. Which as an analogy almost makes me sympathetic to them. Until I remember that they’re running down our country’s infrastructure in their self-denial.
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I hear Ryall is planning to harvest the organs of New Zealanders!
Now, when the doctor says,
“Poke out your tongue and say, * ‘Ahh!’ “,
it might be the last you see of it!
* ‘Arrgh!’ for piratical patients.
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To put your words together in a more appropriate sequence . . .
“Meeting the unmet goals of the Primary Health Care Strategy is a great idea but . . . . . .The priorities for primary health care at the moment should be Improving multidisciplinary teamwork, Improving health inequalities, especially for Maori, Working with their enrolled populations to keep them well in the first place, especially preventing chronic conditions like diabetes; and A concerted programme to improve quality and safety”
Something else you say. . . . . .
“So far the National Government has virtually ignored primary health “, not even a year in government and you want them to have EVERYTHING done! Yet a few months ago you were complaining about how quickly the new government was moving with change!
When the Green Party practices ALL the things it preaches, it will be in a position to throw stones, in the meantime, stick to stowing thrones!
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alexaweb! My attention is drawn, you vacuous waste of space!
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Just out of interest, what’s a “Primary Health Organisation”, and why should I care how it’s “structured”? OK, you guys care, but how does this affect my old man’s cataracts not getting fixed because, you know, being blind is “elective”?
Perhaps, I don’t know, less titles so big they need acronyms, more information that regular folk understand. Eh.
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nice article… everyone should give the priority to health becz health is wealth…
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This is one of the Foremost Priorities in NZ Public Service Reformation.
It has been quite easy to deform and turn our Tax-Funded Services into a castle of whispers.
Unfortunately – when you get rid of most Medical Experience around – then overwork the rest – the results ain’t good.
My first 8 years volunteer work in NZ were spent around our Hospitals – unfortunately it is impossible to keep peoples morale up when they suffer from systemic indifference/negligence.
It is also the kind of problem we can’t just fix by throwing bags of money at.
Health is all about caring
or not caring.
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Don’t forget the commitment to Maori health via ti tirritti.
[ Kevin Hague says:
March 9, 2009 at 11:08 am
Essentially there are two major logical steps in the argument jh:
1. The overall health status of a population group is very strongly associated with the relative marginalisation or disempowerment of that group; and
2. The continued failure to honour the Treaty of Waitangi is unquestionably a major source of marginalisation and disempowerment for Maori.
Naturally, sitting behind both of these statements there is a considerable weight of evidence.]
http://blog.greens.org.nz/2009/09/04/primary-health-care-must-be-a-priority/?replytocom=89857#respond
http://blog.greens.org.nz/2008/07/04/kevin-hague-green-candidate-number-7/
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So here’s the real issue with regard to health.
At what level does the responsibility of society stop and that of the individual arise?
The reality of medical science today is that we will reach the point in a few decades where ANYTHING can be cured – at a cost. The question then, and indeed now, is who should bear what cost.
The minimum that we can possible guarantee each other is the existence of life. Any illness or medical situation, including injury, which endangers life, must be treated at public cost. I doubt anyone would disagree (especially as we have ACC to cover the cost of accidental injury).
We need to look at the things that will prolong life that is not immediately under threat. Is it reasonable to expect each of us to contribute to a $150,000 heart replacement (that includes pre- and post-operative care) for someone so their life can be extended by, say, 10 years? No accident. No trauma. Just a heart that is reaching the end of its useful life. Perhaps because of neglect through lack of exercise. Perhaps because of smoking. Perhaps just because it has just worn out? Think carefully about this before you reply, as there are MANY more replacement procedures, at something between $60,000 and $200,000 each, that also need to be on the list.
We also must consider quality of life. There is no doubt that a hip replacement is a miracle in pain relief for those who need and have one; however, the condition that it cures is not life threatening, it’s just at worst painful and at best uncomfortable. For another example, let’s take abortion; in 99.9% of cases it is not carried out because the pregnancy is life threatening, it’s done because a child is life-style changing and that change isn’t wanted. (Personally I would regard pregnancy as a result of rape as an extraordinary case and grant a publicly funded procedure every time; so to me that doesn’t come into this discussion.) There are dozens of examples, of this type of medical procedure, as any doctor for a few examples and they’ll give you a dozen if my daughter is anything to go by. I read recently in an MOH report that the number of breast augmentations done through the public health service had doubled in the last three years; somehow I can’t see these as being to resolve a life threatening situation, nor required because of trauma from an accident!
Do we owe each other extension of life? Do we owe each other quality of life? These are questions we need to have broad discussion on and arrive at consensus about, as a society. If we do, then we need to accept the fact that we (actually you as I’m so close to retirement I’m looking back on it,) will have to pay significantly more in taxes, as science and technology develop more and more ways to enhance life expectancy and quality and today’s costs are seen as ‘cheap medicine’.
Your opinion?
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Biogym
Very terraputic.
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Hi Tussock, fair point!
The links in the post take you to the documentation setting out what PHOs are, and what they are intended to achieve, but it shouldn’t be necessary to have to follow them to find out.
Previously primary care (general practice services and other health services you use in the community without having to be referred to them) were mostly paid for on a fee for service basis by the Government. That means that whenever you or I showed up for an appointment a bill got sent to the Government (and we usually paid one ourselves). Some of the problems with this were that providers were incentivised to see their patients as often as possible, driving cost up, and costs were also increased in referred services like lab tests and pharmaceuticals.
Under the new approach patients enrol with a PHO, which then becomes responsible for providing a set of defined services for them. These are paid for not by ‘fee for service’ but by ‘capitation’. This means that the PHO is paid a fixed sum for each patient enrolled, and is thus incentivised to keep that patient as well as possible and needing the fewest services, as all services have to be paid for within that fixed sum. The PHO provides services by contracts with general practices and other providers.
The theory is that PHOs will keep people well and maximise efficiency by multidisciplinary work (being seen by whoever is most appropriate, rather than the doctor every time because that attracted the biggest fee) etc, and that the funder (DHBs) will have a capped cost, making it easier to control and manage. The major criticism (at least from a patient’s point of view) is that this funding mechanism creates incentives to skimp on quality and to ‘under-service’, hence the need for good systems to monitor quality to ensure this doesn’t occur.
This system isn’t particularly about improving access to ‘elective’ services, but it should help in a couple of ways. First, if cost is controlled in primary care then more is available for other services. Second, as PHOs mature more of them are becoming directly involved in assessing patients for elective surgery and booking those who meet the criteria directly in for surgery. This represents a significant increase in efficiency and should see more surgery done. Some kinds of surgery will also be possible in primary care settings.
Hope that’s a useful explanation.
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Hi Dave,
The questions you raise are, indeed, crucial. Given that the costs of healthcare are being driven up by an aging population, epidemics of chronic conditions, and access to more and more expensive technologies, decisions will increasingly need to be made about what services are and are not paid for by the State. That is why we have supported that particular question being asked in the report of the MInisterial Review Group.
We welcome that conversation and encourage all New Zealanders to be engaged in the conversation about how we best manage this challenge.
What is frustrating though, is that a no-brainer in the debate ought to be reducing the cost we are trying to meet as far as possible. The most cost-effective methods for doing this would seem to be keeping people weller for longer through public (preventive) health and primary care. Public health programmes have been slashed by the current Government, and the progress in primary care is in danger of stalling, with this latest rearrangement of priorities. In other words the challenge is being made more difficult by far.
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DaveS – well said – we all must face up to the fact that health care is, always was, and always will be, rationed, by one means or another.
Seems to me that Politicians are always the last to wish to state such a fact openly. They try to dress it up with euphemisms, or avoid it altogether, whilst ‘promising’ to spend, spend, spend, or in the case of the Nats, cut, cut, cut, as it appeals to their core vote.
It is of course hopeless to ever expect a politician to be honest, open , or fact orientated – after all their primary aim is to get re-elected – so therefore they say what they think their voters & potential voters want to hear. C’est la Vie.
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Yes, thank you Kevin.
“Some of the problems with [the old funding model] were that providers were incentivised to see their patients as often as possible, driving cost up, and costs were also increased in referred services like lab tests and pharmaceuticals.”
Incentivised isn’t a real word, as an aside.
Such cost increases may have come largely from the lengthening waiting lists (and lists for the lists, and whatever else) driving up the cost of primary care over time: as to be reassessed for the lists, you need to visit the GP, to get booked into the specialist, to get more tests done, and you’re often on various pills to manage this and that in the meantime. But that’s just personal experience, you guys have the real data.
I just can’t imagine doctors dragging healthy people in to test and treat them for problems they don’t have, not when there’s so many actual sick people hanging about waiting to get sick enough for their “elective” surgery.
“Second, as PHOs mature more of them are becoming directly involved in assessing patients for elective surgery and booking those who meet the criteria directly in for surgery.”
Well, quite, but I can see the perverse incentives there a mile away. It’s inherently rewarding any office that fakes their own patients to the head of the queue, for an outcome doctors would naturally desire (successful treatment of the ailment and a well patient). Not to mention the risks of a diagnosis for surgery without consulting outside specialists, who presumably exist for good reason.
As to the reports, they say that after funding was increased, patients paid less. Well, duh. They also say consults per patient are up under the PHO model, which was a complaint you levelled at the old funding system, and again, may be more to do with longer queues than funding models.
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Eh ?
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tussock says:
September 6, 2009 at 1:16 am
> Incentivised isn’t a real word, as an aside.
It exists in spoken form as a string of sounds, in written form as a string of letters; and it is used in sentences to express a concept. Sounds suspiciously like a word to me.
Or are you merely complaining that it’s not in your dictionary?
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A couple of points
re
clearly you never watched this system at work, it was terrific. For instance, a woman goes to see her doctor for treatment of a chlorysodumegobber – or some such ailment. Not having a live-in nanny, she takes the three kids with her. At the end of her consultation the doctor puts his hand on top of the oldest child’s head and says “and how is young angelorobertofred today?”, the woman replies, “oh he’s fine!”. Repeat two more times, and there you have FOUR consultations, each worth $65 to the doctor, all over in 10 minutes. Neat eh!
However, capitation arrived well before PHOs, and was embraced by ethical medical practices as an excellent way to have a manageable business with long term dependable income.
Then there is the delight of General Practitioners
. I don’t know that this is something to be proud of, or that I as a tax payer should be paying for. You see, it’s that word “elective” that I object to! Check the dictionary and you will find that it means the patient has decided (elected) to have the surgery, NOT that it is necessary to sustain life.
Finally, let’s look at the “prevention is better than cure” argument for a moment. I am CERTAIN that, if no pensioner had to live in a cold house through the winter there would be less occurrences of flu, common cold, respiratory disease and a myriad of other ailments. So, by the reckoning of this argument the Health Service should pay to install and operate central heating in all pensioners’ homes. Hands up all those in favour of this being paid for out of your taxes (note – beneficiaries should not expect a vote on this question for obvious reasons!)
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Biogym – outdoor physical activity that benefits your health in more ways than ten. Dig for victory! Cultivate your garden. Grow organic food. Cut your own fuel. Plant flax for fibre (weave to confound the Chinese plastic-everything manufacturers)…there are 1000 benefits to membership in Biogym. Costs? Zero. Start date? Today. Go outside now and move!
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Thanks GF
I guess it used to be called “the great outdoors”.
Hope I don’t have to help re-write all the Scouts’ manuals to catch up with the newspeak! (-_-)
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DaveS – if you are doing a re-write of the scouting manuals, you’ll have to include a chapter on avoiding open cast mines (‘Keyholes’ in ‘newspeak’) whenever the troups are out in any of out national parks.
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Given that the cost benefit is huge, meaning we’d save more tax payer money from the health system than spent on prevention, I’d be quite happy. Except that central heating is not the only option. We are already subsidising insulation and clean heat and its a great idea.
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It’s not important, political neologisms just stink a bit.
Regardless, no one “incentivised” anything, contracts aren’t actors, there were just some perverse incentives involved, as there naturally are in all contractual agreements (as there is with the PHOs, and will be with any other funding system).
Adding more rules changes the perverse incentives, but never removes them. Checking for minimum treatment standards means PHO behaviour will naturally converge toward those minimum treatment standards, as it gives them a safe and clearly regulated target for optimal funding.
That they have deliberate incentives to keep people healthy, means they have perverse incentives to dump or ignore sick people, particularly with those chronic illness. It’s how contracts work.
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Dave S says:
September 6, 2009 at 2:34 pm
> I don’t know that this is something to be proud of, or that I as a tax payer should be paying for. You see, it’s that word “elective” that I object to! Check the dictionary and you will find that it means the patient has decided (elected) to have the surgery, NOT that it is necessary to sustain life.
The problem is that that’s not how the term ‘elective surgery’ is used in pracitce. Surgery is defined as ‘elective’ if it can be put off, to the extent that you can ‘elect’ when to have it. It probably won’t kill someone to not have it, but it may well mean the person will end up too sick or disabled to go to work or school, and therefore end up on a benefit. Another thing it might mean is that the person is not well enough to do his or her own cooking or cleaning, and someone else has to be paid to do this for him or her.
people who want to cut finding to public hospitals no doubt find the confusing nature of the term ‘elective surgery’ to be useful.
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“and there you have FOUR consultations”
Occasional check-ups on seemingly healthy young children are, as I understand it, a good return on investment. Obviously, withholding payment from a doctor who keeps his patients well all the time isn’t sensible anyway.
One might almost suggest the national health system should build clinics in, and allocate health professionals and administrators to regions as they’re needed, paying them all a wage.
If one was concerned about perverse incentives, there’s not many there to worry about, other than the constant issues around people not being very good at their job.
“You see, it’s that word ‘elective’ that I object to!”
Ironic quotes are occasionally deserved. What they mean, of course, is that one can elect to give up and go private, or elect to be too poor or too stubborn for that and just hope you don’t die first.
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kahikatea
First thought – newspeak lives! The words mean what we have decided they should mean, not what the language defines them to mean. Ouch.
Second thought – prompted by “It probably won’t kill someone to not have it, but it may well mean the person will end up too sick or disabled to go to work or school, and therefore end up on a benefit.” So OK, we give them a $150,000 surgical procedure instead of $250 net per week – a 15 year recovery period, not taking inflation into account. AND it still feels like quality of life to me – do I owe that, if so can I have some, as defined by me as I’m insured for ‘elective surgery’, please?
Tussock
re “Occasional check-ups on seemingly healthy young children are, as I understand it, a good return on investment”, if the example had been a ‘check up’ I would ave no problem, but under the old pay-per-consultation system simply asking the question “how are you?” gave a GP an additional $65 in gross revenue I would love a job that paid about $22 per spoken word. THere is ZERO return on that investment.
re: “What they mean . . . is that one can elect . . . .be too poor or too stubborn for that and just hope you don’t die first.” If it’s life threatening, I will happily pay for it, my first point was that there is no argument from me that continuity of life should be provided by the system. However, when it’s a may well mean (the ‘well’ is interestingly used in this context (-_-) , ) which can also be reasoned to mean ‘may not mean’, I don’t think the insurance premium is mine to pay. May/may not doesn’t qualify in my bank account I’m afraid!
Ah well, at least two of the kids will earn enough to not be a burden on my pension savings, a third is a lawyer and so will, of course, be rich as well as able to ensure I get every last penny I’m entitled to from the commons. (Or is that common purse? Whatever.) You see, I’ve decided to become a real socialist in my retirement. I have arranged my assets so I don’t have any, and will need substantial help with my rent (yep, the family trust demands I pay rent) as well as a few other things over my nicely extended retirement (I’m looking forward to at least 35 years thanks to being brow-beaten out of smoking, drinking more than 2 glasses of wine in 24 hours, exercising more than my remote control thumb, and a dozen other things that should ensure a long and, thanks to socialism, happy retirement.
Bon
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thank you for this informations..
now i find what i want to know.. thanks
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Dave S says:
September 7, 2009 at 6:32 pm
> If it’s life threatening, I will happily pay for it, my first point was that there is no argument from me that continuity of life should be provided by the system.
You’re entitled to your opinion, but I disagree. I think our health system already spends too much money on keeping people alive, and not enough on relieving suffering.
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To disagree is the greatest benefit of our democracy – and I will fight to the death to allow you to continue to do so – even if you are wrong lol (-_-)
Let’s agree to disagree, as we will change nothing – have a delightful evening.
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