Compass Health Blog 1: This blog is entirely the opinion of the author and does not represent the position of the Compass Health Board.

If I were Minister of Health: A Policy Prescription for Primary Health Care

Ten weeks to the election and the public-sector policy wonks are being told to put down their pens on any matter that might be seen to be party political; but they can use the intervening time to work on briefings for the incoming Minister.  Not being public servants, we can still say what we like.   I was very disappointed in the lack of support for primary care in the last budget.  Rather than complain, I have decided to use this first Compass blog to outline what I think primary care friendly health policy would look like.   I’m not greedy, my list includes only 3 items…

1.     Immediately support affordable general practice for those with low incomes

Most of us spend more on our hairdresser than we do on our GP.  It’s true, a recent survey[i] showed that the average kiwi spends $71 per hairdresser visit and visits 4 times per year, whereas they visit their GP about 3.8 times a year, and spend less than $50 per visit.  But we also know that for over 530,000 low income NZers[ii] the cost of GP services is a barrier to accessing care – and not going to your GP when you have a health need is considerably more important than putting up with split ends.  Good access to general practice improves equity, health outcomes, and overall health system value for money[iii]. 

A new government could, by July 2018, offer practices an extra subsidy for their enrolled patients who have a community services card, or who are living in the most deprived areas, in return for lower copayments for this group.  Such a policy need not impact on VLCA practices – that bulk arrangement could stay in place (and be strengthened) for those with high concentrations of very high need patients. 

Such a subsidy will not help practices financially; it is purely a patient benefit, since the practice gains extra capitation, but loses co-payment revenue.  So, we also need to …

2.     Invest in sustainable general practice

Capitation rates were set some 15 years ago.  They need to be reviewed to better reflect patient need and complexity.  Some adjustments I would like to see:

• move to single year age bands to recognise more exactly the way that average use changes by age – an 82-year-old is different to a 66-year-old and should be funded accordingly;
• recognise ethnicity and deprivation in the capitation rate as a proxy for complexity – Maori and pacific people suffer from long term conditions such as diabetes and heart failure on average considerably younger than Pākehā, and have more socioeconomic complications. An adjustment would help struggling VLCA practices, and also those non-VLCA practices with many high needs patients (Titahi Bay and Featherston come to mind); 
• open up more registrar and nursing-entry-to-practice places to ensure we have enough new GPs and practice nurses being trained to cope with the ageing population and expected retirements.   

3.    Invest in Comprehensive, Patient-centred Primary Health Care

It’s time we got serious about creating comprehensive primary health care teams including GPs, nurses, physiotherapists, clinical pharmacists, health care assistants, midwives, social work, district nursing, mental health therapists, coordination services and so on. One way to enable this would be for a set of ‘modular’ add-ons to the PHO agreement, whereby practices that met certain criteria could opt to provide, for instance, physiotherapy, podiatry, maternity, mental health, well child, etc, with support from their PHO.  The amount for each service could be negotiated nationally.  The wider team would then become part of the PHO network.

This would also require investment in changes to the model of care in general practice, to offer better use of new technology, a focus on patient convenience, and use of lean processes (along the lines of the Health Care Home model).   A funding arrangement that split the cost of providing patient centred services 50:50 nationally and locally would help get PHO and DHB buy in to the changes needed.  It would also recognise the foresight of DHBs such as Capital and Coast that trying to invest in the future while struggling to pays today’s bills.

What would it cost nationally? Affordable access might cost $70 million, sustainable general practice and comprehensive health care perhaps another $200 million a year.  It seems a lot – though it is less than 2% of the current health budget.  Perhaps a better question is: what will it cost if we don’t do it?  What is the impact if primary health providers can’t cope with the silver tsunami or the mental health epidemic?  Just in the Wellington region alone we will need another 200 or so hospital beds by 2031 to cope with the aging population if we don’t actively pursue these changes now.