Primary Health Organisations

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: G-politik in Industrieländern 1

Abstract

As part of it?s policy the elected government in New Zealand (1999), 54 public meetings were held to discuss the Future Shape of Primary Health Care (a document released in March 2000), it invited submissions from interestd groups and from the public meetings. The government documents emphasised the importance of community participation in both the establishment of governance of Primary Health Organisations.

Purpose of health policy or idea

A discussion document entitled The Future Shape of Primary Health Care was released in March 2000 and discussed at 54 public meetings throughout the country.

http://www.moh.govt.nz/moh.nsf/wpg_Index/Publications-The+Future+Shape+of+Primary+Health+Care:+A+Discussion+Paper.

This document invited submissions from interested parties. The final Primary Health Care Strategy incorporated some of the suggestions made in the 290 written submissions and from the public meetings. The official government documents emphasise the importance of community participation in both the establishment of governance of Primary Health Organisations (PHOs). However in practice (to date at least), consumer involvement has been minimal.

 

The main opponents to the policy appear to be some GPs and their umbrella organisations (IPAs). Opposition is based on the following grounds:

Because the higher subsidies will require a significant amount of extra government funding, full coverage of the country by PHOs is likely to extend over 3 - 5 years. In the intervening period, traditional (ie non-PHO) GPs are likely to lose patients and some will go out of business.

The policy has the potential to undermine some of the facets of general practice that GPs have long safeguarded, including the right to extra-bill and to set their own fees.

The government is providing inadequate funding to cover the additional administration, management and compliance costs of PHOs.

The policy is unfair (as least during the establishment phase) because it directs additional funding to all enrollees of PHOs. Therefore wealthier and less-needy people attending a PHO will receive higher subsidies than poorer, more needy people attending traditional GPs. In addition, because wealthier people currently pay higher copayments than lower income people, the reduction in price for higher income people attending PHOs will be significantly greater than that for lower income people. Both of these effects are quite contrary to the stated government aim of reducing health inequalities. The government has responded to this concern by trialling an alternative formula proposed by IPAC (the Independent Practitioner Association Council) in 3 of the new PHOs. This formula retains higher subsidies for individual needy patients within PHOs (rather than for the whole of the enrolled PHO population.)

The emphasis of the strategy appears to be on alternatives to traditional general practice, with nurses in particular being a given a much higher profile.

Nurses and allied health professionals have expressed concerns that the strategy will be captured by GPs in an effort to retain their dominance.

 

District Health Boards are the other key stakeholders, with PHOs becoming important provider organisations within their districts. Most DHBs have been active in assisting in the establishment of PHOs. Most expect to have at least one PHO active within their district by the end of 2003.

 

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

Political and economic background

This policy is a major part of the overall health policy of the current government (a Labour-led coalition, elected Nov 1999). The underlying philosophy contrasts with the market-oriented approach taken by the previous government. The Primary Health Care Strategy (Annette King, of which PHOs are a key plank)  was released in February 2001:

http://www.moh.govt.nz/moh.nsf/49ba80c00757b8804c256673001d47d0/7bafad2531e04d92cc2569e600013d04?OpenDocument .

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

This is a policy that has been prescribed by the Minister of Health. Hence it is entirely driven from the top down. It is not obviously borrowed from elsewhere - although does have some parallels with primary care in some other countries (such as the UK). The main participants in developing PHOs have been (1) District Health Boards, which have worked with groups within their districts towards their establishment as a PHO (2) IPAs - some of which have assisted some of their members to establish PHOs. One IPA has re-organised itself into a PHO. (3) Maori and Pacific providers which have restructured their organisations into PHOs.

Stakeholder positions

A discussion document entitled The Future Shape of Primary Health Care was released in March 2000 and discussed at 54 public meetings throughout the country.

http://www.moh.govt.nz/moh.nsf/wpg_Index/Publications-The+Future+Shape+of+Primary+Health+Care:+A+Discussion+Paper.

This document invited submissions from interested parties. The final Primary Health Care Strategy incorporated some of the suggestions made in the 290 written submissions and from the public meetings. The official government documents emphasise the importance of community participation in both the establishment of governance of PHOs. However in practice (to date at least), consumer involvement has been minimal.

 

The main opponents to the policy appear to be some GPs and their umbrella organisations (IPAs). Opposition is based on the following grounds:

Because the higher subsidies will require a significant amount of extra government funding, full coverage of the country by PHOs is likely to extend over 3 - 5 years. In the intervening period, traditional (ie non-PHO) GPs are likely to lose patients and some will go out of business.

The policy has the potential to undermine some of the facets of general practice that GPs have long safeguarded, including the right to extra-bill and to set their own fees.

The government is providing inadequate funding to cover the additional administration, management and compliance costs of PHOs.

The policy is unfair (as least during the establishment phase) because it directs additional funding to all enrollees of PHOs. Therefore wealthier and less-needy people attending a PHO will receive higher subsidies than poorer, more needy people attending traditional GPs. In addition, because wealthier people currently pay higher copayments than lower income people, the reduction in price for higher income people attending PHOs will be significantly greater than that for lower income people. Both of these effects are quite contrary to the stated government aim of reducing health inequalities. The government has responded to this concern by trialling an alternative formula proposed by IPAC (the Independent Practitioner Association Council) in 3 of the new PHOs. This formula retains higher subsidies for individual needy patients within PHOs (rather than for the whole of the enrolled PHO population.)

The emphasis of the strategy appears to be on alternatives to traditional general practice, with nurses in particular being a given a much higher profile.

Nurses and allied health professionals have expressed concerns that the strategy will be captured by GPs in an effort to retain their dominance.

 

District Health Boards are the other key stakeholders, with PHOs becoming important provider organisations within their districts. Most DHBs have been active in assisting in the establishment of PHOs. Most expect to have at least one PHO active within their district by the end of 2003.

Adoption and implementation

Most of these questions are covered in the sections above. Re what was done to convince opponents, in addition to public meetings throughout the country, the Minister met regularly with key stakeholders, especially the District Health Boards, the NZMA and IPAC (the Independent Practitioner Association Council). While communication with the Minister was described as good, some doubted the effectiveness of the consultation process.

Monitoring and evaluation

The Ministry of Health plans to contract for the evaluation of the formation and some outcomes of PHOs. There will be ongoing monitoring of PHOs in terms of factors such as utilisation rates (by ethnicity and age), services provided, population covered, reported incidence of disease,etc. Presumably, the evaluation will be focussed on the extent to which PHOs are meeting the stated objectives of the Primary Health Strategy.

Expected outcome

The key objective of this policy is to improve access to primary care by reducing the level of copayments. This objective is already being met for those enrolled with the initial PHOs.

Enrollment with PHOs should encourage continuity of care and allow provider to better monitor the health of individuals and their enrolled population overall. However, enrollment is not mandatory for all citizens. Therefore the policy is still unlikely to reach some deprived groups, especially some Pacific Island people who traditionally prefer hospital care to primary care, and itinerants who are unlikely to enrol in a PHO.

During the establishment phase there will be some perverse incentives which undermine the achievement of the policy's stated objectives, especially with respect to equity of access (see 5.2 above).

If GPs continue to be reimbursed by PHOs on a fee-for-service basis, many of the theoretical advantages associated with capitation will be undermined.

Regarding costs, the government has committed $364m additional money over a 3-year period for the establishment of PHOs.. This money is expected to cover both the increase in patient subsidies as well as establishment costs. If funds are inadequate, the deficit is likely to be shifted back on to patients so that copayments may not be reduced as much as expected.

References

Author/s and/or contributors to this survey

Toni Ashton

Empfohlene Zitierweise für diesen Online-Artikel:

Toni Ashton. "Primary Health Organisations". Health Policy Monitor, May 2003. Available at http://www.hpm.org/survey/nz/a1/5