The glue that Primary Health Organisations provide primary care

The fortnightly publication New Zealand Doctor Rata Aotearoa is a must read for anyone interested in the state of primary care in Aotearoa New Zealand.

Much of its material is also published online either in advance (daily) or concurrently with print editions.

It has a team of experienced quality journalists led by a very competent editor in the form of Barbara Fountain. Their articles are strong on issues as they evolve, twist and in turn.

A case in point is a recent paywalled article by Martin Johnston (27 October): Clinic for unenrolled patients helps with closed general practice books.

Due to workforce shortages the three general practices in Masterton, the biggest town in Wairarapa, had to close their books for new enrolled patients.

This is not an uncommon situation. It is one of the most serious features of the crisis that New Zealand’s health system now finds itself in for reasons beyond its control (although within the control of political leaders).

Enter Tū Ora Compass, a Primary Health Organisation (PHO) based in the Greater Wellington region) Wairarapa along with Kāpiti Coast, Porirua, Hutt Valley and Wellington).

The PHO believes that general practice workforce pressures in Wairarapa have been higher than elsewhere in the wider region.

Fortunately Tū Ora Compass was able to organise a temporary reprieve for these Masterton unenrolled by providing a special virtual clinic for unenrolled patients.

Where necessary the largest of the three practices, Masterton Medical Centre, provides further support.

This was through a service which began being rolled out in Masterton in July. Its full title is ‘Telehealth GP service Practice Plus’.

‘Practice Plus’ is jointly owned by Tū Ora Compass and Pinnacle, another PHO based in Waikato. It provides a four-hour GP session, with 12 to 16 appointments, on weekdays along with an after-hours service.

The PHO has a collaborative relationship with Health New Zealand (Te Whatu Ora) which has worked well. The latter provides funding to help make ‘Practice Plus’ affordable for patients.

Martin Johnston describes how ‘Practice Plus’ works as follows:

Patients of the Unenrolled Clinic have a telehealth consultation with the Practice Plus GP unless they need an in-person assessment, such as an electrocardiogram or other physical examination. Those are done at Masterton Medical with a health care assistant or physician assistant from the clinic supporting the telehealth GP.

Tū Ora Compass Chief Executive Justine Thorpe considers that the unenrolled clinic “…is temporarily filling the gap – very successfully – until there is sufficient practice capacity and its patients can be enrolled…” in a Masterton practice.

PHOs have an interesting in history. Prior to the New Zealand Public Health and Disability Act 2001, general practices were paid, through the health ministry, a fee for service (subsidy) for providing primary care to patients.

In the early 1990s, in the context of a subsequently unsuccessful endeavour by the then National government to turn the public health system into competitive market, general practitioners began to join together into independent practitioners associations (IPAs).

This was in in order to enhance GPs negotiating position with government. But it also provided a stepping stone for government to consider moving to capitation (population-based funding) instead of uncapped fees for service.

The Public Health and Disability Act did not create PHOs. They are not statutory bodies. But the Act enabled their creation through its Primary Health Care Strategy thereby replacing the IPA system.

The first PHOs were formed in July 2002. By 2008 there were 82. Former health minister Tony Ryall (2008-14) initiated a pragmatic ‘rationalisation through mergers’ process. Today there are 30 PHOs operating.

Tū Ora Compass is not the only PHO operating within Greater Wellington but it is by far the largest and the only one dedicated to the whole region.

PHOs are usually not-for-profit trusts. Their overall goal is improving their population’s primary health. They received government capitation-based funding via the district health boards (DHBs) until July 2022. Now it is from Te Whatu Ora.

As they aren’t statutory bodies PHOs can simply be changed or removed by government policy.

In 2020 the Heather Simpson led review of the health and disability system recommended that geographic based localities be established to gradually replace PHOs over around five years.

However, localities were not the same as PHOs. DHBs would assume the latter’s organisational and funding roles. Localities would have been like community-based health networks working with and supported by their DHB.

This was overturned by the Labour government’s decision in April 2021, without public or health system consultation, to abolish DHBs. Consequently, the localities established under the Pae Ora Act 2022 have only marginal similarity with the Simpson review.

I have discussed this in my article published by BusinessDesk (5 May 2023): Localities in chaos and confusion.

Since then it has become clear that localities will be little more than a geographic map determined top-down by Health New Zealand.

Further, once the new government is formed, it is expected that localities will quietly disappear from the scene.

From my perspective there are three main lessons that can be learnt from my above narrative – the importance of innovation, being relational, and PHOs.

First, innovation in health systems mainly comes from closer to where most healthcare is provided. In this case it was by Tū Ora Compass which used its knowledge of primary care in Wairarapa to come up with a practical temporary fix.

Second, health systems are labour intensive. Further, much of the expertise and experience on how to respond to challenges and innovate rests with those closer to where healthcare is provided rather than with those at the top of a vertical structure.

Relationships are critical to whether things work well or otherwise. Consequently, a relational culture is critical. This culture is evident in the relationship between Tū Ora Compass and GPs in Masterton.

Being relational is also evident in the PHO’s relationship with both Te Whatu Ora (most of whom were previously DHB employed) and Pinnacle.

Third, particularly with the absence of DHBs and the level of systemic crisis, it highlights the critical importance of PHOs to the health system.

Aside from the workforce, PHOs have proven to be one of the few bits of glue that are holding the health system together.

PHO functions and role have migrated under the health system restructuring from being covertly to overtly indispensable.

Something for the anticipated incoming health minster Dr Shane Reti to contemplate.