Localities aplenty from Rawene to Timaru, but will these efforts fit the bill for new networks?

The Government has adopted the Health and Disability System Re­view’s concept of locality networks.

Much remains to be defined for the new shape of primary and community care, but it is clear that PHOs will no longer be the mandato­ry conduit for the bulk of state funding for general practices.

Iwi and Māori providers, general practices, pharmacies, midwives, op­tometrists and other primary and community care services will be expect­ed to form locality networks.

What will induce them to do so hasn’t been explained, but the Govern­ment white paper on the reforms says connections will be tightened be­tween primary and community providers, “so that records and care pathways follow patients between all those contributing to their care”.

Health New Zealand and the Māori Health Authority will commission services based on locality plans informed by communities and iwi-Māori partnership boards.

The Māori Health Authority and Health NZ will fund services through new, as-yet-unspecified contracting methods. Health NZ’s four regional offices will each have about five district offices, tentatively named “pop­ulation health and wellbeing networks”.

Health minister Andrew Little says, in a Cabinet paper, that locality networks could engage a lead provider, or PHOs with a wider focus than at present, to provide management services, or this function could be carried out by Health NZ’s locality commissioning service.

Localities could be based on geographical boundaries, such as those of a local council or an iwi. Or localities could bring together, separately lo­cated groups that have a common feature, such as Pacific peoples. Rural localities too could combine providers in different parts of the country.

Kāpiti got with the localities pro­gramme early. Counties Manu­kau has had a go, also. South Canterbury has a plan. And in the coun­tryside, they’ve been doing it for years.

Martin Hefford has dubbed the Kāpiti Community Health Network, estab­lished last year, a road test of the locality concept.

That was when working as chief ex­ecutive of Tū Ora Compass Health. Now Mr Hefford is on secondment as depu­ty head of the Health and Disability Re­view Transition Unit in the Department of the Prime Minister and Cabinet.

The Kāpiti network works with GPs, pharmacists, aged residential care facil­ities, home and community sup­port services and other providers. Mr Hefford has said the network aims to have some planned care services, including chemotherapy, provided locally.

The network is a partnership of Tū Ora, local iwi Te Ātiawa ki Whakaron­gotai and Capital & Coast DHB. It re­ceives money previously spent by the DHB on the health care home concept.

The DHB has plans for seven more networks like Kāpiti’s. Strategy, plan­ning and performance director Rachel Haggerty says in an interview that the reforms have not stalled these plans.

“They’re definitely progressing,” Ms Haggerty says. “We have a really good working relationship with our PHOs and we had a meeting [recently] talking about how we are progressing.

“With the reforms, it’s about taking things with us that are about the future,” she says.

South Canterbury, population 60,000, is unique in not having a PHO. When GPs lost confidence in Aoraki PHO in 2010, the local DHB set up a primary and community services arm. It gained an exemption to let it directly contract with general practices and other prima­ry care providers and appointed a local GP as chief primary medical officer.

South Canterbury DHB chief execu­tive Nigel Trainor says its direct rela­tionship with providers has worked well and has the makings of a locality net­work. It works closely with primary care to develop new models of care, funds local iwi health provider Arowhenua Whānau Services, and has a Māori health advisory committee.

Consultancy firm EY did a health needs assessment for the DHB, which it is using to develop a locality plan in readiness for the Government’s health system reforms.

The locality plan will be sitting ready for when Health New Zealand takes over

Mr Trainor expects funding models will change to facilitate more commis­sioning of primary and community ser­vices. “That locality plan will be sitting ready for when Health New Zealand takes over.”

A focus will be improving and inte­grating community-based services for older people.

Asked about progress, in the absence of a PHO, in developing new communi­ty-based services beyond general practice, Mr Trainor points to the DHB being one of few in the country without a backlog in ophthalmology. He attrib­utes this to the DHB contracting out­patients ophthalmology to a subsidiary owned by the DHB, and a close relation­ship with optometrists.

It also has a “fantastic model” where the DHB has a subsidiary company, Aoraki Midwives, that employs lead maternity care midwives who care for about 60 per cent of the region’s pregnant women.

Temuka GP Bryan Moore, chair of the district’s Primary Care Alliance, agrees South Canterbury’s non-PHO model works well.

Dr Moore says that’s largely because of the close relationship with the funder. He fears this would be lost with the locality model outlined by the Gov­ernment. The alliance brings together rural and urban GPs, nurses, nurse practitioners and practice managers, along with an iwi representative. DHB primary care and funding staff attend alliance meetings, along with the DHB chair.

Under the alliance model, fund­ing from the Services to Improve Access scheme helped to build Arowhenua Whānau Services, in­cluding the provision of more com­munity mental health services for Māori and the wider community.

Dr Moore says the alliance consulted with, but did not include, non-general practice health services. Unless there is an injection of considerably more fund­ing, he says, it’s hard to see how the full range of community health providers – from aged care to pharmacy – can be brought into a single locality frame­work and work together.

“The practical reality is that you have a limited number of providers. You have to have people willing to engage and you have to make sure that their viabil­ity is not threatened by any new struc­ture that you create.”

More than a decade ago, ProCare Health clinical director Allan Moffitt was a sen­ior manager at Counties Manukau DHB as it set out to establish four localities.

“The Franklin one has always tended to work better, as you find in rural plac­es,” says Dr Moffitt.

“Māngere worked pretty well at get­ting the local doctors talking together. They did some good work on diabetes, and they did some work on renal failure. The East Health one was more about supporting older people.

“Manukau never really worked. There’s a Papatoetoe cluster that con­tinues to meet on their own steam.”

The best things about the Counties Manukau localities, Dr Moffitt says, are better patient access to DHB-provided allied health services and the build­ing-up of multidisciplinary teams.

ProCare has long been exploring the localities concept, initially watching Kāpiti’s slow progress.

“We have a cluster of GPs [in Papa­toetoe] that have been working away with their local community and other providers for a number of years now. That’s one possibility.

“The other one is Kaipara. We have a lot of practices up that way [northwest Auckland]. They operate existing ar­rangements around after-hours care. We are looking at how we might broad­en that out and see how we involve oth­er health practitioners in that network.”

Dr Moffitt says a question needing an answer is the size of Auckland local­ities and the likely need for overlapping boundaries. This is because Auck­landers often seek care near their work, not near their home, or they may have moved to a new home.

Another question is what will encour­age healthcare providers to actually join locality networks. Dr Moffitt assumes providers will remain on current fund­ing formulas and that these won’t be increased.

“And if you want to be part of the new health system and get access to more funds, well, this is how you have to op­erate. It doesn’t have to be financial. It can be about being more efficient, with less paperwork, or doing the right thing for the person in front of you.”

Transition Unit head Stephen McKer­nan has cited the Māori-focused Hokianga Health Enterprise Trust – Hauora Hokianga – as a good example of a locality.

The trust owns and runs a rural hos­pital and provides a wide range of care in the community. This includes pro­viding general practice services for around 7200 enrolled patients at 10 locations, community nursing, physi­otherapy, podiatry, midwifery and Well Child services.

The trust also provides some social services and even has a contract on safe drinking water.

The hospital at Rawene has acute and aged residential care beds and a birthing unit. It is well connected to Northland DHB’s Whangārei Base Hospital, 120km away.

Hauora Hokianga doesn’t have a community pharmacy or provide op­tometry or laboratory services.

Chief executive Margareth Brood­koorn says she has described her or­ganisation as being like a mini-DHB.

“But I’ve corrected myself…It’s more of a locality.”

Hauora Hokianga, itself a Māori pro­vider, collaborates with iwi-based Māori providers to the east and north that offer some services in the Hokian­ga area. It is also part of a whānau ora collective.

Some of Ms Broodkoorn’s main con­cerns are to maintain the independ­ence so highly valued by the Hauora Hokianga board and its community.

She also want to secure more fund­ing for her population, which is largely Māori, has high economic and social needs, and experiences the resulting health problems.

She admits to uncertainty about the shape of the coming localities in the Northland region.

After three months as chief execu­tive, she has had no interaction with the region’s PHO, Mahitahi Hauora, over its thinking on localities.

“In order to bring everyone together, they put us into this mid-north locality.

“In terms of localities, I think the premise behind having the one-stop-shop and the closer-to-home mantra is absolutely ideal.”

And if it means strengthening links with other organisations, “that would be better for our population”.

- Martin Johnston and Fiona Cassie