This document provides a comparative analysis of primary health care policies in the UK, Australia, and New Zealand since 2000. It summarizes the key policies implemented in each country, including the introduction of primary health organizations and capitation funding in New Zealand, practice-based commissioning and pay-for-performance in the UK, and Medicare reforms and preventative health strategies in Australia. The document concludes that primary health care is better developed in the UK based on metrics like quality of care, access, costs, coordination, and patient satisfaction. This is attributed to the NHS system's greater integration, financial incentives for providers, and focus on chronic disease management and nurse-led care.

1. 1
A COMPARATIVE ANALYSIS OF THE PRIMARY HEALTH
CARE POLICIES IN UK, AUSTRALIA AND NEW ZEALAND
INTRODUCTION:
Primary health care has been a key strategy in improving health
outcomes and reducing health inequalities in recent years in several countries.1 This paper
provides a brief overview of the range of policies implemented towards primary health care
in United Kingdom, Australia and New Zealand since 2000 and analysing the comparative
effectiveness of the reforms introduced.
A BRIEF OVERVIEW OF THE GOVERNMENT POLICIES FOCUSSED ON
PRIMARY HEALTH CARE POST-2000:
NEW ZEALAND
The Labour government which came to power in 1999, aimed to
restructure the health care system with the introduction of Primary Health Care Strategy
(PHCs) in 2001 to strengthen the role of existing primary care.2 As a result three major policies
were introduced. First, the government encouraged the formation of primary health
organisations in order to address health inequalities2 by reducing patient co-payments4 and
provide a population based service delivery.2 Second, a significant change introduced in the
funding model, with a transition made from fee-for-service funding towards capitation
funding at the practitioner level in all the Primary Health Organisations (PHOs). Third, the
government encouraged patients to use the services provided by PHOs by providing
additional funding and subsidising patient fees for primary health services.2,3 Two new
funding arrangements were introduced for PHOs under the capitation based funding model.
The first one was the “access” formula aimed reduce patient co-payments and strengthen the
financial incentives provided by the government with over 50 percent of the enrolment for
Maori and Pacific people. The second type of funding was based on “interim” formula in order
to maintain the existing subsidies along with some additional funding to support new
government policies.4
A national programme called the ‘Care Plus’ programme was introduced by the
government in 2004 as part of the primary healthcare strategy. Under this programme, the
nurses provide Care Plus services independent of General Practitioners (GPs) to patients with
chronic health conditions, with patients receiving free or low cost services on follow-up
visits.16 Another key policy change introduced in 2006 was the ‘PHO Performance
Management Programme’. The intention behind the programme was to introduce ‘pay for
performance’ programme in the primary health care to assess the performance of GPs against
a set of targets and indicators similar to the ‘QOF’ system in UK targeting especially the “high
needs population” including Maori and Pacific community.17

2. 2
In recent years, the current government proposed a series of initiatives to
integrate primary health care across PHOs, District Health Boards and other organisations in
the health sector through the formation of Integrated Family Health Centres (IFHCs) to
develop greater co-ordination and co-operation of healthcare services.14 In 2009, the Ministry
of Health took initiatives to develop “Better, Sooner, More Convenient” (BSMC) healthcare in
order to integrate funding, healthcare services and staffs across various fields in primary and
secondary healthcare. The main idea behind BSMC demonstration programme was to deliver
affordable healthcare services outside of hospitals such as access to rural areas, easy access
to GPs and nurses via phone and emails, employing specialists in general practice clinics and
other healthcare delivery services.14
UK
In UK, primary health care provided by the National Health Service (NHS),
suffered a major setback before 2000, due to low quality of care and poor working conditions
reported by GPs and other health care professionals.5 The government increased the funding
for NHS from 6.7% of the GDP to 8% in 20005 and established the NHS Modernisation Agency
in 2001 in order to support and improve patient outcome.8 In 2003, the government
introduced “FT” (Foundation Trusts) in order to create a patient-led approach to NHS services
by raising funds for providing hospital services to the local population.8 In addition, a new
system termed “PbR” was introduced in addition to FTs as means for paying hospitals.
Practice Based Commissioning (PBC) was launched in 2004 to engage all GPs and other
healthcare professionals in the commissioning of healthcare services provided.8 A new
contract agreement towards general practice was introduced by restricting the core hours of
practice from 8 a.m. to 6.30 p.m. New Primary Care Trusts were established for providing
after-hours patient care.5 The NHS took over the responsibility of providing “out-of-hours-
care” starting from 2004 and care was provided by GPs and nurses at purpose-built
commercial organisations rather than at patient’s home.6 Another significant policy change
in 2004 was the introduction of “pay-for-performance” scheme, which comprises a set of
indicators, the ‘Quality and Outcomes Framework’ (QOF) to assess the quality of patient care
provided.6
The NHS Modernisation Agency was replaced by the ‘NHS Institute for
Innovation and Improvement’ in 2005 which led to an increase in day-care surgeries,
reduction in the length of hospital stay and increased access to diagnostic procedures.8 Under
the Health Act 2007, a ‘Commissioning Framework’ was established to create a joint
commissioning of services between health and the local authorities to allow greater freedom
of power to health authorities over allocation of funding for healthcare services.8 In recent
years, there have been various initiatives to increase accessibility to primary healthcare
centres with the emergence of “walk-in polyclinics”, “one stop primary health centres” and
“health and well-being centres” which offer a wide range of services including antenatal and
postnatal care in addition to several diagnostic and outpatient services.7 Of late, the
government has introduced ‘GP-led commissioning’ with the establishment of over 250
clinical commissioning groups which comprises primarily of GPs who will undertake the

3. 3
responsibility of holding around £60 billion of the health budget in order to purchase health
services at the local level. The rationale behind this policy initiative is to decentralise
healthcare by abolishing primary care trusts and develop a more community based approach
to healthcare services within the NHS.15
AUSTRALIA
Healthcare in Australia is provided under the universal health insurance
coverage (Medicare) with subsidies on primary healthcare access, GP consultations and
pharmaceuticals.11 In 1999, the government introduced incentives to increase private health
insurance coverage in order to shift the demand for healthcare services from public to private
hospitals.9 The increase in private health membership form 30% in 1998 to more than 45% in
2000 raised a major policy concern regarding the supply and demand for doctors between
private and public health sector. The government also introduced tax rebate for private health
insurance in order to address adverse selection among the insurance members and to
encourage young people to take up private health membership. However raise in out-of-
pocket expenditure and increased healthcare expenditure costs led to a decline in
membership among younger age groups. As a result, new policy changes were introduced in
2005 in order to increase the affordability of cover and reduce the out-of-pocket expenditure.
The government increased the tax rebate by 5-10% for people aged 65 and over. A new
“Medicare Plus” package was introduced in 2004 in order to minimise out-of-pocket
expenditure costs. Under this package, the Medicare rebate was increased for all concessional
patients which led to increase in access to GP and other health care services. In addition, the
introduction of “safety net” scheme provided further protection by containing the individual
out-of-pocket expenditure.9
In 2009, the Australian nursing federation announced a new policy with
support from commonwealth fund in order to shift the focus for primary healthcare from a
hospital based approach towards prevention and health promotion approach encouraging
greater participation from nurses and midwives.12 In addition, a new National Preventive
Health Strategy has been developed by government in order to shift the focus of primary
healthcare towards prevention and increase community participation.13 The Australian
government released the first National Primary Health Care Strategy in 2010. One of the key
initiatives proposed is that, the government will undertake the entire responsibility of funding
the primary healthcare in particular, the public hospitals. In addition, initiatives have been
made to reform primary healthcare with the evolution of “Divisions of General Practice into
“Medicare Locals” and a nationwide electronic health records system.10 The rationale behind
the introduction of Medicare Locals is to provide a backbone for primary healthcare through
integration of services within primary healthcare and other health related sectors in addition
to improving 24/7 access. In 2011, the Ministry of Health announced the establishment of
Local Hospital Networks (LHNs) in order to address the healthcare needs of the local
population which will work in conjunction with Medicare Locals.11

4. 4
WHY GOVERNEMNT POLICIES TOWARDS PRIMARY HEALTH CARE IS
BETTER IN UK COMPARED TO NEW ZEALAND AND AUSTRALIA?
Of the three countries, the National Health Service (NHS) in UK is the
first to launch a primary health care model with GPs functioning as a gatekeeper to primary
health care.18 Patient access to healthcare services, health initiatives based on a population
based approach are widely channelled through Primary Care Trusts in UK, with GPs playing a
central role in fundholding.18 Similar to NHS model, New Zealand has a primary care system
led primarily by GPs however, only 60% of the primary care is funded by the government with
the remaining funding received via patient co-payments.19 In contrast, the Divisions of
General Practice which has been the principal provider of primary care services in Australia
was largely funded by the government.20 In addition, the Australian government has taken
the entire responsibility of funding PHCs under the new primary health care strategy.10 In
contrast to NHS where Practice Based Commissioning is well established, no initiatives were
made in New Zealand or Australia in the commissioning of healthcare services, so they lack
the financial authority of funding provided through Primary Care Trusts.18
The method of payment for primary care is unique to each of the three
countries. For instance, General Practitioners in New Zealand are paid partly based on a fee-
for-service model with the remaining payment made on a capitation basis. Since 2004, GPs in
UK receive payments through capitation method in addition to supplementary fees provided
based on the pay-for-performance assessment scale. The Australian healthcare lacks a pay-
for-performance scheme and GPs are paid primarily on a fee-for-service basis although the
payment model is not well integrated in the healthcare system.21 The provision of capitation
funding and limitation on co-payments have lowered the cost of access to primary health care
in New Zealand. In addition, the recent introduction of Performance Management
programme and pay-for-performance model has placed a hold on GPs in assessing the efficacy
of treatment provided and the quality of care.18 In UK, the blend of capitation payments and
pay-for-performance model21 with performance measures assessed through QOF have
resulted in increase in the rate of quality improvement with reduction in socioeconomic
inequalities.6 Compared to UK and New Zealand, the fee-for-service model for GPs
maintained through the Medicare insurance funding although proved favourable towards
patient access to healthcare the system failed to address socioeconomic inequalities with
poor services to rural areas and indigenous population.18
In the context of democratisation of primary care, third sector has been
dominant in the role of democratisation in New Zealand, with PHOs being non-profit based
and independent organisations in delivering healthcare with wider participation from the
community especially from Maori and Pacific population. In contrast, the Primary Care Trusts
which have been the primary provider of primary health care in UK and the Divisions of
General Practice which dominated the health care services in Australia were both strongly
provider driven.18 The funding for co-ordinating structure for primary care, the Australian
General Practice Network (APGN) is funded solely by the Australian government in contrast

5. 5
to the Independent Practitioner Associations (IPAs) in New Zealand and the GP commissioning
and fundholding in UK which are funded by members of the primary care organisation.20
In UK and New Zealand, primary health care is well integrated through the
use of electronic medical records with over 95% of the physicians in primary care adopting
the e-health system.22 In contrast, Australia lacks an universal electronic health record system
which remains a major barrier to integration of primary health care23 although, the current
government has proposed new policy initiatives to introduce this system.10 Cost remains a
significant barrier to access primary health care services in New Zealand in particular, patient
co-payments.4 In contrast to UK, where dental care is included in the basic public program
and funded by the government, adults in New Zealand and Australia need to fund their own
dental care which deters many people from visiting a dentist.19 In both New Zealand and UK,
care for patients with chronic diseases such as diabetes and hypertension has been a key
concern under primary health care strategy.24 In contrast, albeit introduction of Practice
Incentives Program (PIP) and Enhanced Primary Care program (EPC) management of chronic
illness has always been a challenge in Australian healthcare system, a major reason being the
dominance of fee-for-service model and lack of multidisciplinary approach to patient care
within general practice.25
Consumer focus has been central to primary care in the NHS healthcare
system. Aggressive performance management targets and funding boosts by the government
had resulted in drastic reduction in excessive waiting lists for patient treatment while long
waiting lists for specialist care and surgical cases have been persistent problems in UK and
New Zealand.27,31 The ability of nurses to provide healthcare services independently outside
of GPs control is well established in UK in contrast to New Zealand and Australia where
independent nursing care is less well developed,18 although recent initiatives to involve
nurses in providing patient care independent of GPs, have been initiated in Australian
healthcare system in the field of chronic care management.12 The introduction of “Nurse
Practioners” (NP) into primary care in UK made significant improvements in primary health
care. NPs had the right to prescribe medications for patients with long term illness with
minimal involvement of GPs. The nurse-led approach allowed GPs and other specialists to
concentrate more on patients who needed urgent care and those who were critically ill. The
key driver behind the expansion of nurse-led care was the introduction of incentives by the
government to GPs and nurses to improve the quality of healthcare services provided through
NHS. In contrast, nurse-led care in general practice is not well established in New Zealand and
Australia leading to underutilisation of practice nurses with persistent inequalities in the
healthcare provided among different ethnic groups.26
In a nutshell, NHS has come a long way in implementing successful primary
health care strategies in UK through various policy measures and the outcomes have proved
to be consistently better in all the key determinants of PHC performance measures including
organisation, patient satisfaction, access to health care, transaction costs, patient care

6. 6
coordination and quality of care27-30 justifying why primary health care in UK is better than
New Zealand and Australia.
Figure 1: The table below shows the key outcomes in relation to primary health care in UK, New Zealand and Australia
Key Indicators UK New Zealand Australia
Rated quality of care as “excellent”
or “very good” by medical home27
88% 83% 79%
Problems paying medical bills in the
past year27
1% 11% 8%
Had a medical problem but did not
visit a doctor in the past year27
7% 18% 17%
Did not fill prescription or skipped
doses in the past year27
4% 12% 16%
Out of pocket spending in the past
year (more than US $1000)27
1% 13% 39%
Access to doctor or nurse when sick
or needed care (same or next day
appointment)27
79% 75% 63%
Difficulty getting after-hours care
without going to the emergency
room27
21% 40% 56%
Waited less than a month to see a
specialist27
80% 68% 59%
Test results/records not available at
appointment or duplicate tests
ordered27
13% 15% 19%
Did not have arrangement made for
follow-up visit27
12% 31% 31%
Any medical medication or lab
errors27
8% 22% 19%
Overall patient engagement in care
management for chronic
condition27
69% 45% 48%
Has a medical home27 74% 65% 51%
Primary Care Doctors’ use of
Electronic Patient Medical
Records28
89% 92% 79%
Doctors can receive financial
incentives29
89% 80% 65%
Patient satisfaction based on
Financial Incentives for Primary
52% 2% 5%

7. 7
Care Doctors targeted on Quality of
Care28
Needed Dental Care but did not see
a Dentist due to cost (below
average income)30
16% 46% 43%
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