John Macaskill-Smith: General practice models in New Zealand
Ensuring health for the future
Overview of the NZ Health system• 4.2 million population• 13.8 million GP visits, 65 million prescription items,24 million lab tests, 1 million E.D. attendances• Largely devolved system – Central ministry/ACC ,20 regional Distrist Health Boards, 30 primary carenetworks, large number of PPP (pharmacy, labs,private hospitals, General Practice)• In comparision to most OECD indicators we areperforming well and delivering value-for-money• Growth in NZers’ life expectancy is the highest inthe OECD• 19% of total government spending goes into voteHealth ($14 billion NZD)• Co-payments in primary care
Challenges• Living within our means: our rate of growth in health spend isunsustainable – doubled in the previous decade• Population ageing: increasing demands on health system (44% increasein demand)• Increased chronic conditions – 80% of deaths are a result of heartdisease, cancer, diabetes and tobacco related illness• Increasing expectations from the public on health system performance• Workforce ageing and changing expectations• Fragmentation and differences in service performance across adevolved health and disability system
Drivers for ChangePopulationWorkforceSustainabilityFacilities
Demand increase from existing population+ change in profile
MHN- NGO, not-for-profit- GP owned & governed- 400 GPs- 500 PNs- 100 practices- 500,000 patients- $135 million- Covering 4 DHBs- 100-40% geographical coverage- Holds the contract with the crown,sub contracts members- Regional Alliance contract- GP, acute A&M, community nursing,community mental health, PH, chroniccare
Ensure the future of high quality general practice….Be a vehicle to enable the development of new models,ownership etc to ensure sustainability of high quality GP.Sustainable & leading edge primary care servicesThe way to bring together the founding partners to ensure eachpartner is successfulVehicle to enable single contract/planPinnacleIncorporatedPrimary HealthCare LimitedMidlands HealthNetwork LimitedMidlands RegionalHealth NetworkCharitable TrustRole of Members of the GroupTui OraLimited Integrated health service organisation committed to enhancinghealth and wellbeing.General Practice network – sets the strategic framework, priorities, holdsand controls investment resources, monitors performance – Board electedfrom members – 350 GP members, 500 PN, 97 PMPinnacle provider arm for practice ownership –provides a vehicle to exploreand develop new practice models, supports at risk areasManagement company – employs staff, develops and operatessystems, operates a range of direct to non-GP patient services via providerarm (the engine room for getting stuff done) – Pinnacle/IndependentGovernanceVehicle for connecting with strategic partners + single point for contractingwith Multi DHBs, MoH – Community/Provider/Independent GovernanceMHN Family
New models of care• New way of working required to meet newdemands and capacity requirements• New facilities to support new models of care• Integrated information systems• New contracting arrangements to support newmodels• Retraining the workforce• Resetting the commercial/business model
500,000 lives5 million + encountersHundreds of settingsLife long relationships60 years of unlearning
A new contracting enabler• A shift away from traditional funder/provider roles• Taking experiences from commercial application of risksharing contracting arrangements in construction and oilsectors• Evidence points to better performance of alliancegoverned contracts vs. traditional approaches• Process and patient focused vs. transactional• Driven by front line clinicians• Clinical commissioning in another language
The Alliance Agreement• A nationally determined agreement that is a relationship anddecision making agreement rather than a service deliveryagreement.• The agreement establishes a structure to enable clinicians,alongside managers and others, to make decisions about howto apply resources to specific services to achieve the bestoutcomes. Commissioning & decommissioning• Decisions involve less specification and an emphasis on qualityprocesses and transparency of information to assureaccountability and best value for money.• The scope of the agreement has been broadly developedcollectively around agreed key health areas.• It places the risk and rewards of success on all parties.
Alliance in action• The Alliance Leadership Team is the body for managingchange, not for managing business as usual.• Supported by– The Alliance Agreement– The Alliance Charter– Underlying agreement with Government• Each party to the Alliance retains their role and owngoverance.• Resources around agreed areas are pooled byagreement to support Alliance recommendations• Requires strong senior clinical and managementleadership and committment
The road so far• Long term conditions management– The LTCM is a suite of resources and support designed toenable the general practice team to proactively providetargeted care to patients diagnosed with a LTC• Getting resources upfront– Traditional post hospitalization resources being shifted topreventative roles• Medical Home– Primary care taking broader responsibility for coordinatingcareCo-designed – co-funded
Key components• Planned care: comprehensive assessment and a plannedapproach with a longer term view towards staying well inthe presence of an incurable disease (rather than acutecare for an episode of ill health)• Patient led care with the health care team as the patientsagent• Co-ordinated complete care for people with complexneeds• Commissioning resources to those in greater need• Wider scope of services being available in the patientsHealth Care Home (primary care)• Integrated services that are "seamless" from the patientspoint of view.
The effect to date• Havent had time to measure full impact• Noted increase in clinical leadership• Appears to be a reduction in acute EDpresentations – 11- 7%• Patient satisfaction higher• Workforce satisfaction higher• Improvement in related quality programperformance
HealthyCommunitiesFit for purposeGeneral PracticeModels of CareMDTsIntegrationRight sizingHospitalsSustainabilityHospitalperformanceBSMC ServicesMDTperformanceProactivecareGeneral PracticeperformanceSelf careWhole of system thinking& commissioning
The risk ofdoingnothing….Thechallenge ofchange…
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