The silence of a policy void

This future scenario sees primary care as a collection of saleable health commodities and services.

The purchasing public is perceived as not having easy access to these commodities at the moment. This, it’s said, is because of the gatekeeping role played by GPs and general-practice businesses – whether solo or group practices or sharemarket-listed entities – and because of the professional arrangements they use (PHOs and capitation payments, for example).

So, this model focuses on competition and the market to govern where and how care is provided, and seeks to change the gatekeeper role, because it frustrates market values of competition and choice.

The solution is to disable and/or weaken the role of a single dominant provider by broadening the service and commodity supply avenues.

Broadening supply will be achieved through purchasing arrangements that level the playing field, and by intensify­ing the competition between competing professional service and commodity suppliers, eg, nurse practitioners, pharmacists, physiotherapists, midwives and occupational therapists.

Digital technologies, such as telehealth, virtual doctor visits, online diagnostic and treatment services, and e-prescribing, will replace face-to-face and resource-intensive, in-person modes of care. This will move the entry point to the system from a generalist with diagnostic and triaging skills, to direct access to discrete aspects of care.

This solution can best be achieved through purchasing each aspect of primary and community care separately, using a locality-based purchaser for government-sourced funding, avoiding government funds flowing through GP-controlled organisations like PHOs.

Funding will flow through other mechanisms (insur­ance, out-of-pocket payments), so the influence of locality purchasing will vary according to the wealth of the community.

A key enabler of this change is the integrative potential of health IT platforms through which providers in separate organisations use a common source of patient-related data. Technology and the market approach will thereby grow the non-GP elements of the primary care sector.

Technology will also broaden the scope of services that can be offered by each part of the sector, increasing the public’s access to a greater range of services, including social support. This solution will also enable records-sharing and easier engagement with the social agencies such as the Ministry of Social Development, Department of Corrections and police, and NGOs, including whānau ora commissioning agencies.

In the US, the acquisition by retail giant Amazon of a primary healthcare organisation is an indicator of how this scenario could well evolve into a health system where distribution of health commodities dominates.

This future scenario sees primary care having a relation­ship of trust at its core: a relationship between a health worker (who is part of a primary healthcare team) and a community and its members.

If nothing else, our COVID-19 experience has reminded us of the primacy of relationships, and the importance of trust in health services.² Through trusting relationships, the health team’s response is informed by knowledge of the patient, their family and their social conditions. A person’s health conditions are viewed in terms of time – sometimes over generations – as well as place and social context.

Primary and community care is the first point of contact between the patient/community and the health system. The health team has the necessary relationship, skills, technologies and approaches to address the majority of health needs for their community. The health team also has the agency to mobilise additional effective system response when required, such as hospitalisation or social care and support.

In this model, the skilled health workers are in direct contact with the patient, because they have the knowledge to make the best clinical decisions about and with the patient, in the patient’s context. It enables a comprehen­sive rather than a siloed approach. This drives efficiencies in the rest of the system through providing relational continuity of care,³ reducing hospitalisations.⁴

Scenario 2 organises primary healthcare into interdisci­plinary teams, with team members holding the skills required to respond to the specific and unique needs of each community member or whānau. This relationship of trust and the ability to marshal the required system response is applied unequally: its main value is for those patients and communities with complex health and social conditions, where their needs outstrip the individual’s and their whānau’s ability to navigate an appropriate health-system response for themselves.

Fundamental to the health worker’s role is their focus on “what matters” to the patients and whānau⁵ and what is scientifically proven to improve their health outcomes.

The patient focus should not be secondary to pecuniary interest in specific treatments or service offerings, or disinterest in what really matters. Technology advances such as telehealth are designed and deployed to strength­en and enable the relationship between the patients and the trusted health worker, not substitute it.

Scenario 2 can best be achieved by alignment of values across health workers, the health system and the commu­nity, and a shared sense of the health outcomes to be achieved.

Team approaches will be embedded in the way health workers are trained and incentivised. The system is government funded without out-of-pocket expenditure, as has been modelled during COVID.

Under the second scenario, where provision through private-market competition has failed for decades, services will be provided by government, for example, in high-need and rural communities.

Where Te Tiriti o Waitangi commitments have been made, services are governed, owned and may be provided by Māori organisations. Where both government and private provision has failed, community-owned provision is supported, for example, Pacific communities, union health and youth health.