System review panel seeks more accountability, ambition, wellness from primary care

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System review panel seeks more accountability, ambition, wellness from primary care

Virginia
McMillan
Childhood
A refocus on promoting wellness rather than treating sickness is sought
The public system may need to take a more deliberate approach to how it funds general practice services The health system faces another round of

Comments

Who was the GP on the Simpson panel?

What about a fit for purpose funding model? What about a universal, targeted funding formula with the abolition of VLCA? What about making the profession attractive?

A glimpse at the report looks ominous for the sector. 

This is it? This is what Ms Simpson and panel came up with? Are you serious? The words "clueless", "ignorant", "unimaginative" and "incompetent" spring to mind. 1.46% of Government Health spending goes to Primary Care which already delivers 93% of health contacts in NZ and the response is "Primary Care needs to do more". Ms Simpson you should be embarrassed. No, actually, upu should be ashamed.

I’m going to devote a bit of time to reading the actual report. There is so much literature on the social determinates of health, with healthcare access making such a small contribution that it seems unfair that health care providers are blamed for poor health outcomes. At the same time, I’m open to exploring ways that I can change things in my own part of the world. This report is really just a teaser, in 6 months the full report will be released. The pessimist in me feels like I’m being softened up for bad news. The optimist will read the report herself. 

There is a pretty simple equation here. It costs around $40 running costs for a 15 minute accredited clinic appointment and with escalating compliance the costs go up and up steadily. Someone has to pay for that (Govt, clients, ACC, PHO's etc etc) or we will simply bail out and wait for our superannuation. We are not greedy, we just expect at least as much as our collegial salaried hospital specialists from that premium over the $40, even though we generally work far longer hours. And Heather seriously thinks "we" need to be doing more prevention. Seriously. The future (5 minute Balkanised walk-in Bums-on-Seats) services won't be able to provide that for sure. And now they are lamenting the failures of Capitation. 

Ah of course, more preventative measures. Logan's Run anyone? Just stop people getting old. 

Isn;t control of lipids and blood pressure and getting people to stop smoking preventative? The immunizations the nurses in general practices give not preventative enough?

This whole 'we can prevent illness and symptoms' is such a myth. There is huge pile of pathology out there that will occur irrespective of our prevention strategies. More on the way with the aging population. We at GP physicians are diagnosing and treating organic disease and illness every day. I sometime think that the powers that be forget about the need to treat someones suffering in the here and now...

Absolutely Richard. The real issue is that us GPs are to blame for everything, including aging and all disease. Why should our issues get fixed or we get adequately funded when we can't fix these things?!

Agreed Richard. I made the suggestion to one of our leading epidemiologists that the problem was people getting older and the whole thing seemed lost on him. 

"We need to prevent illness and you need to do it". Right. "We need to reduce our suicide rates, you need to do it". Do you understand the problem? The evidence suggests that more than 80% of suicide attempts are made within 15 minutes of the decision. 15 minutes to intervene. If you seek help you are less likely to attempt suicide. Do they seek intervention in those 15 minutes or do they look for a means? Many, if not most, of the contributing factors are not medical but social. Are we expected to redress the social inequities too? Do you think we don't try to? More "advice" from the Chardonnay Socialists is what we need. It is easy to crusade for change, it is not so easy to understand what those changes should be and how they could be implemented. This shows no indication that they even understand the problem to begin with.

On that odd graph, what is the X axis supposed to be?

The graph at the top.

 

Ta.

 

I think it is more a figure, than a graph, so there is no real X-axis meaning.  It certainly has more information and meaning than the usual "circles and bubbles" that dot DHB and MoH reports.  However the Y-axis would have more meaning if it was in proportion.  According to this figure, only about 2% of funding comes from private health insurance whereas the latest review indicates 35% are insured (see https://www.health.govt.nz/system/files/documents/publications/private-health-insurance-coverage-2011-15-nzhs-oct16v2.pdf ).

Also, one presumes this shows only what can be classed as primary care as private and public secondary, hospital and non-GP Specialist care is not mentioned and yet that, along with over-management, is where health dollar spending is mainly going and will continue to grow unless some of these reports recommend removing most of the PHO/DHB/MoH management duplication (ie stopping wasting so much money on meaningless reports from armies of non-medical managers) and reduces secondary costs by valuing General Practice and addressing determinants of health outside GPs' ability to control.

Hey, some fire in the discussions at NZ doctor at last :-)

 

The review spent much time using charts and data to demonstrate the inequity of outcomes for Maori and Pacific.

They did not use any data from the Integrated Data Infrastructure (IDI) that collates information from any government sources and has the ability to identify the whanau who would benefit most from targeted services and funding.

The database also creates a platform for whole of Government action which will be required to address many of the emerging problems including the issues of equity.

It is difficult to understand why this unique resource was not mentioned.

The IDI gets a brief mention on page 254 of the report, in an item about the People's Project. The comments appear to confirm the IDI can be used to improve health outcomes.

Hi Virginia

I found the reference to the IDI on page 264 of the report. I still feel that the IDI has not been given the prominence it deserves. It is a unique collection of data that has the potential to identify whanau with the greatest risk of intergenerational damage. In turn this would support the targeting of services and funding to those with the greatest capacity to benefit. This is a form of personalised health and social care that works at the level of the individual/Whanau and so much more accurate than public health analysis.

It makes sense to me that this data could be used to identify those most at risk within our communities and those most subject to inequity. I believe that it is these individuals who habitually "fall through the net" and suffer adverse outcomes but how do we use this data and engage without breaching privacy in some way? Isn't the only reason that this data can be collected because it is "de-identified"? This tells us that there is a problem - and intuitively we know this - but then we can't find out who has the problem so we cannot target the resources appropriately. Will those who have suffered inequity trust us enough to allow us to "re-identify" the data because, frankly, can we or the system ever be trusted enough to redress the inequity we created? That we need to do this is perfectly obvious, in fact I believe it is imperative, but how do we do this? Or do we change our approach and start building a system that everybody can trust and will engage with from the ground up? How do you do this when political agendas repeatedly interfere - especially when political agendas determine the resources available? Frankly this whole review smacks of a political agenda and not doing the right thing because it is the right thing to do.

It certainly is an amazing resource. As alluded to by Dr Moore, privacy and stigma concerns about using it have been raised. It’s interesting – cops, teachers and GPs can probably still tell you who many of these families are, but that doesn’t mean anyone is necessarily reaching out to help them or even knows how best, or who best, or when to do so. In the next issue of New Zealand Doctor, GP Bryan Betty says it is really important to overcome fragmentation. This will be hard; perhaps the review’s final report will advise stripping away some of the structures that reinforce it? We humans’ left hands often don’t know what our right hands are doing!