The path to curing a sick system: Primary care at a crossroads without a map

Continuing to use purchasing as the main instrument of sector reform will intensify siloed arrangements

Two approaches could define the future shape of pri­mary and community care. Which one would you choose?

In the first instalment of “Primary healthcare at crossroads without a map”, we proposed two scenarios for a reshaped primary and community care sector.

The first, scenario 1, will disable and/or weaken the role of a dominant provider by broadening the service and commodity-supply avenues.

This approach intensifies the competition between competing professional service and commodity suppliers; relies heavily on digital technologies; and moves people’s entry point to the system, from a generalist with diagnostic and triaging skills, to direct access to discrete aspects of care.

This means health authorities purchase 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.

Scenario 2 takes a comprehensive rather than a siloed approach, driving efficiencies in the rest of the system through providing relational continuity of care, reducing hospitalisations.

Primary healthcare becomes organised into interdiscipli­nary teams. The system’s response to need is applied unequally – its main value is for those patients and communities with complex health and social conditions.

Health-worker focus is on “what matters” to patients and whānau, and what is scientifically proven to improve their health outcomes.

In scenario 1, the arrangements for primary and community care are in stark contrast to that of public hospital care, where no split in responsibility between purchaser and provider will be visible in the new health structures, and where it is acknowledged that the conditions for a competing provider approach are seldom met.

These very different operating conditions for primary and community care, compared with public hospital care, are of real concern.

Te Whatu Ora – Health New Zealand runs the risk, like the DHBs before it, of becoming poacher turned gamekeeper.

DHBs reliably attended to the financial needs of their hospitals and failed to sustain investment in primary and community care, especially when resources were scarce.1 This has contributed to the deep structural differences we now see between the two parts of the sector, such as substantially lower wages and conditions offered for equivalent work.

Te Aka Whai Ora – Māori Health Authority, on the other hand, is better positioned to advocate for a full health system response, inclusive of primary and community care and prevention. The authority is well aware Māori health equity will not be achieved if the main focus is on the risks in the hospital system.

To date, discourse about the effect of competition on healthcare focuses on GPs as owner-operators. It focuses on consequences for the health system of professional dominance in ownership, and associated impacts of professional ownership on technical innovation and suppressing the role of allied health professionals.

This focus misses the growing role of corporate ownership of primary care in all its forms by local and overseas interests, and the consequent impacts on professional practice, including the continuity and comprehensiveness of primary healthcare service and primary care’s role in the wider health system.2,3 Whatever the case, a focus on ownership models ignores the limitations of a competition-based approach to supply.

Scenario 2 sees the core value of healthcare as relational rather than transactional. All technology, from vaccines through to online diagnostics and treatment, is only accepted when trusted by the recipient. The success of both technology and expertise is optimised when it rests on a strong relationship of trust, and a suite of compre­hensive services.

COVID-19 has demonstrated the dire consequences for communities who have lost their trust4,5 in the science underpinning healthcare provision. Transformation will require a mature approach to commissioning, founded on aspiring to the wellbeing of individuals, whānau and communities, as was articulated in the Whānau Ora policy.6 The resulting health-system provision arrangements are then determined by those needs and aspirations, and not by supply-side priorities and market-driven allocation.

Both scenarios see the end of gatekeeping by a single professional group. While scenario 1 does away with gatekeeping, scenario 2 supports doing away with the barriers to getting into the system, while retaining the value of a sophisticated front-line generalist function within primary and community care,7 making sure health resources are applied appropriately, with the patients’ interests paramount.

Both scenarios embrace technological advances, including increased use of virtual care. Both see the relationship between providers as important.

Scenario 1 expects (without evidence) that digital information systems in themselves will be the glue that creates a team approach, despite the team members being in competition. Scenario 2 sees digitalisation as one of many relationship enablers.

Scenario 1 is on a fast track to privatisation, ignoring the strong historical evidence that over-reliance on market mechanisms fails to address health equity, or deliver effective and efficient health services.8–10

Technological advances under these market conditions run the risk of undermining or replacing the relationship of trust at the heart of quality healthcare. Continuing to use purchasing as the main instrument of sector reform will intensify the siloed arrangements – for example, the weak relationships between different parts of primary and community care – that are so damaging.

Continuing to rely on user-pays arrangements reliably denies access for those whose health needs are greatest.

Scenario 1 sees the sector as independently purchasable components that may be joined by IT, but not equipped to address the meta idea of equity and trust in services. On the other hand, scenario 2 identifies the importance of building relationships of trust, especially for those whose needs are greatest.

Scenario 2 may well have the same services as scenario 1, but the organising principles are informed by different values, and by person and equity-centred governance mechanisms.

Many other scenarios are, of course, possible. The current system has elements of both scenarios, but lacks a strategic overview of how this mix needs to change, and how new elements such as digitalisation are incorporated, to reach the system’s goals of health equity and efficiency.

Since 1938, the New Zealand Government has failed to successfully negotiate with primary care provider inter­ests, whether owner operated or corporate owned, to achieve equity of primary care access10 to make the right to health a reality.

The current reforms are an opportunity to address this, with the diagnostic work of the Health and Disability System Review Panel and the Waitangi Tribunal’s report on the Wai 2575 claim gaining broad support from across the sector, particularly to address health equity.

We do not want to, once again, undermine the right diagnosis by the wrong prescription.

There is broad support for change, but the change process needs to be built on an understanding of the complexity of the system, the value that different contributors bring, and a clear roadmap with waymarkers of how we reach our policy goals.

Historically, health systems have arisen out of human capacity for care and compassion, but now we could be facing a future where caring is devalued, and the driving value is consumption.

New Zealand urgently needs a government-supported process to engage with the primary care and community sector on strategic approaches to the challenges it faces. Otherwise, we risk taking a wrong turn at the crossroads, further eroding the right to health for our population.