Official thoughts on primary care revealed, belatedly

In a discussion about “reimagining” primary care, Te Whatu Ora board committee members expressed their concerns about the number of general practices with closed books.

There is little sense of the crisis in general practice when one reads the section headed “Strengthening General Practice” in the minutes of the Te Whatu Ora board committee on public health, community and primary care, held last 9 March.

“…the number of GP practices with closed books is concerning, and this needs to be addressed promptly. The committee is also concerned about our ageing population as well as the ageing GP workforce.”

But it’s likely the crisis will have been explained to the committee by the likes of independent member and The Fono chief executive Tevita Funaki, specialist GP and ProCare clinical director Allan Moffitt, at the time the Te Whatu Ora interim clinical director of commissioning, and board member Jeff Lowe, a specialist GP.

Since last July, New Zealand Doctor Rata Aotearoa has been wrestling with Te Whatu Ora for access to board committee minutes. Minutes up to then of the public/primary committee and its successor, the health services committee, arrived in February following an investigation by chief ombudsman Peter Boshier and an effusive apology from Te Whatu Ora over repeated delays. The minutes, shorn of their accompanying briefing papers, can be vague, but they offer nuggets of knowledge on official views.

PHO funding questioned

The committee and its renamed successor, the health services committee, both commented on not knowing where the money goes once it’s gone to PHOs.

The earlier committee said: “…there is a lack of transparency of funds after they have been allocated and paid to the Primary Health Organisations (PHOs). If we are providing funding to the PHOs, the committee wants visibility of the flow of funds from PHOs to the practices.”

And the newer committee said in a discussion last April of proposed funding increases in national community and primary care contracts: “The committee has no visibility of whether the uplifts will be passed on through wages as PHOs are not specifically required to do so.”

Bryan Betty, the chair of PHO representative group General Practice NZ, says he is puzzled by those comments.

“All PHOs are required to report against contracts and produce financial reports and annual reports to demonstrate how the funds are used,” says Dr Betty, a specialist GP. “Te Whatu Ora has not raised directly with us any transparency concerns, and we’re working very closely with them on multiple areas on the role of PHOs going forward…

“This is [nearly] a year ago now that these meeting notes were produced. Hopefully, any concerns that the committee had at that point have been addressed internally.”

The director of the agency’s living well commissioning division, Martin Hefford, says in an email response, regarding last July’s 5 per cent capitation rise, the contract Te Whatu Ora has with PHOs doesn’t have specific requirements about wage increases, but it’s expected as much as possible goes to frontline staff.

“We recognise that decisions on budgets and remuneration are for providers to make,” Mr Hefford says, adding that, like the committee, the agency has “no visibility” if annual increments are passed on as wages.

“However, primary care providers operate in a competitive market, and anecdotally we know that primary care wage rates and GP subcontract rates generally increase proportionate to annual adjustments. We are not aware of issues in relation to PHO uplifts being passed through as wage increases.”

Future of primary care

The March meeting appears to have been given a paper on the potential future of primary care, including some analysis of current general practice ownership models. New Zealand Doctor is seeking the paper.

“The committee acknowledged that corporate general practice models are different and point out the primary health organisation purchasing practices are not reflected [in] the paper,” the minutes say.

The committee also acknowledged an “opportunity for future mixed models and would like to test what the fit-for-purpose model looks like”. Members emphasised communication with the sector was important, including “key milestones and messaging for the next three to six months”.

“…it is important to frame the communications to reflect Te Aka Whai Ora journey with Te Whatu Ora on reimagining and design[ing] the new primary care system to achieve equity”.

Comprehensive Primary Care Teams, which are now being set up with government funding in some practices with significant numbers of high-needs patients, were discussed in March. The minutes say data on scheme trials is needed to show the funding and delivery model is correct. Members want to understand the effectiveness of different models to determine the future path.

Teams funding limited

In January last year, the public health/primary care committee discussed the strictly time-limited funding of Comprehensive Primary Care Teams, something that has become widely known in the sector only now as more of the teams are established. The $102 million, announced in Budget 2022, runs out in June next year.

“The committee…noted funding is not sustainable and the ongoing resourcing for the Comprehensive Primary Care Team roles will be subject to future Budget bids or other funding sources.”

Also noted was the constraint of the very specific Budget 2022 wording: “…it may be best to consider pilots of how this important aspect of delivery might work to contribute to localities.”

Locality and iwi boundaries

How to draw the boundaries of localities and iwi Māori partnership boards occupied the public/primary care committee in September 2022. Overlapping iwi Māori partnership boards territories was an issue, and “iwi/rohe do not neatly align with health boundaries”.

One suggestion was to follow local government boundary lines, adjusting them in line with views expressed by affected communities. “The committee discussed local government involvement and the need to avoid getting captured in the bureaucracy.”

Another issue was the public’s divided loyalties to more than one place. “Factors such as where they work, socialise and their sense of community all impact where they are likely to access services.”

Revising guidance

The future of localities may be in doubt now under the Coalition Government, but the concept got plenty of airtime in the committee minutes released up to last July.

This includes that the committee wanted “more flexibility in how we structure and define localities”. Members feared the current approach and the “guidebook” on locality creation may be too prescriptive. The guidebook documentation was to be redrafted.

Progress was good, and the goal in January last year was to have provisional locality boundaries published for half of New Zealand by last July, with the rest of the country included by July this year. “The committee questioned whether this timeframe is too long as many ‘localities’ wanted to move now.”

At a presentation by national commissioning director Abbe Anderson, the committee was brimming with questions about localities. Are there mandates for the locality plans, members asked, are there clear timelines for delivery, what will be their relationship with PHOs, and how will they link to other parts of the health system?

In January 2023, officials explained how hard establishing localities would be. It’s an extensive change programme, and they had to “create alignment” and “manage expectations both internally and externally”.

Members felt there wasn’t a strong relationship with PHOs, “which must change”.

The April meeting heard that a definition of localities would be supplied.

“The committee advised that localities should endeavour to work closely with primary care and are a possible solution to the pressures they face.”

The June health services committee meeting proposed, to the board, boundaries for 22 new localities, subject to local authority approval. In September, New Zealand Doctor reported the 22 were set for sign-off. But then the general election in October changed the likely future of localities, and there has been no further word of the 22.

Equity funding adjustment

In January last year, the public/primary care committee said that the money for equity adjustments to capitation – Budget 2022 provided $86 million over four years from July 2022 – “is insufficient to sufficiently address equity”.

Also, officials wanted the equity funding to be “much more broadly applied to capitation, rather than targeting a small number of practices, indicating a start to addressing fundamental issues with the capitation formula”.

But the version announced by Labour ministers Ayesha Verrall and Peeni Henare in April distributed $37 million over two years to a specific group of 153 primary care operators, namely Māori and Pacific providers and practices with a high number or majority of Māori and Pacific people on their patient list.

General practice leaders complained that this disadvantaged the many Māori and Pasifika at most practices and ignored the broader problems of capitation.

Telehealth review

In June, the health services committee noted the board had commissioned a review of telehealth services in April. “…in order to provide a more comprehensive understanding of the efficacy of telehealth services, further work will be undertaken through the review of telehealth services and resultant strategy development…”

In April, the public/primary care committee discussed the rapid reduction in funding in a section on telehealth and COVID-19. It was “time to take stock on [a] national telehealth approach” and compare it against other contracted services.

Public health voice silenced

The committee in September 2022 picked up on the public spat in which then health minister Andrew Little criticised Te Whatu Ora public health specialist Gary Jackson for urging, on the agency's letterhead, MPs to support Chlöe Swarbrick’s alcohol control bill.

Dr Jackson withdrew his urging in a second letter. The episode raised the question of how the 12 regional public health units, now wrapped into the new agency’s National Public Health Service, could retain their public health advocacy role.

The committee suggested switching from talking about making a “submission” to offering “advice”, via the national service and the Ministry of Health, to MPs considering bills.

But it was a wider issue than just national legislation, the committee noted: “...staff also need to advocate on regional issues and we need to provide clarity to keep staff safe.”

Sugar levy discussed

Committee members in June discussed if a sugar levy or removal of GST from fruit and vegetables could be a future policy, but noted this would be up to the Government.

“…currently there is no Te Whatu Ora, Public Health Agency, or government formal plan to reduce obesity in New Zealand...”

Legislation and policy are the “most cost-effective interventions” to address the obesity and dietary risks responsible for 17.5 per cent of health loss in New Zealand.