What is being provided to your patients to complement your work.

I have worked in Clinical Services provision in three PHOs – Procare, Pinnacle and now Tu Ora Compass, for just over one year. Through that experience I have noted there are similarities and differences in terms of the contracts held, the approaches taken, and the outcomes delivered. Not an unusual picture in the New Zealand health system.

A constant has been the potential that Clinical services contract delivery holds in terms of being one of the answers to the pressures and capacity issues that currently face General Practice. The Clinical Services team works, for the most part with people who are enrolled in a general practice and are very happy with the service they receive there, but for a number of reasons, benefit from a clinical service available to them. For example the current Mental Health model which is providing therapists in general practice, supporting easy access for patients.

Additionally, the clinical services team provides the ability to road test numerous innovative ideas and ways of working, which can be subsequently rolled out into daily operation by the clinical services team or become part of general practice day to day work, such as the current Falls project and High Tech Imaging which will be rolled out soon.  

Sexual Health is an example of a community based clinical service. The service is based in Cuba St and is free. As the only secondary sexual health service to be based in the community this highly accessibility can often times result in high volumes of referrals and walk-in patients. To manage this demand we will be working with a very experienced Sexual Health Project Manager from the UK, during October and November, to review and realign the service to ensure the specialist knowledge and expertise, available through this service is utilised in the best possible way for patients.

Lots of opportunities to improve on existing services and introduce new opportunities to support what is already available. Should keep me busy for a few more years.

Bronwen Warren
General Manager Clinical Services

In search of the sweet spot

I was never a good student of economics – a subject I found quite dry. However, one thing I did learn was that there is an inverse relationship between supply and demand – when one goes up the other goes down. Consumers and providers usually find a sweet spot somewhere in the middle which becomes the agreed price. Government funding policy tampers with the natural order of things and when this happens the effects are generally: an increase in use of the product; a decrease in supply; a deterioration of quality; and, the emergence of black markets.

As capitation negotiations between policy makers and Primary Care leaders begin in earnest, it’s timely to reflect on what changes might mean for supply and demand and finding our sweet spot!

Price is constrained by government policy. This is a good thing for the consumer as it aims to achieve affordability at the point of care. However, when this is coupled with policy that is likely to drive up demand the impact on the sustainability of traditional general practice, from both a monetary and workforce perspective is significant.

In Wairarapa we have the highest rate of GP and nurse consults in the country. This is not necessarily a bad thing if it is sustainable for general practice team and results in better health outcomes for our people. The challenge for us is that we are delivering our service in a traditional model and not taking advantage of new ways of working to meet the increased demand.

Like in other markets, price for health service drives not only our demand, but also our supply. We are experiencing reduced supply in terms of our primary care workforce and because funding is not keeping up with demand, the future workforce is less attracted to general practice.

Our workforce is delivering high quality health care, but there are segments of our community who continue to miss out. As primary healthcare teams battle with increasing demand and reduction of supply we face inequities. By increasing capacity in primary care and working smarter, it’s possible to focus more effort on those who need our services most.

The black market of unregulated, unsanctioned health apps and websites are now advising and guiding the care of some of our patients. It is predicted that self-diagnosis technology will have the most significant technological impact on our patients over the next five years. These tools are filling the gap. This is not necessarily a bad thing, but how do we make sure our patients are accessing good quality advice and guidance through these tools?

The answer is to change and adapt, to develop new ways of delivering our service that create capacity, are appealing to the workforce, sustain high quality service provision and support the use of modern technologies.

Later in April, Compass Health will be presenting Health Care Home to Wairarapa DHB. If successful this will enable us to build on the positive experiences of practices in the CCDHB region and invest in new ways of working. Our patients will experience better levels of service, easier access to urgent and unplanned care, more effective proactive care for those with high needs, scheduled routine and preventative care and our practice teams will be working smarter not harder. The platform will be in place to embrace new technologies and support integration of services across the sector.

The time is right for us in Wairarapa. We will avoid the challenges of leading edge implementers and early adopters, yet gain the advantages of the early majority. If we can sort out our supply side, as the policy makers increase demand, we can make Primary Care equitable, affordable and a sustainable future employment option.

Liz Stockley
Director Primary Care, Wairarapa

Release date: 2 October 2017

Kia Ora

In my role as Medical Director I spend time looking a various data reports and quality metrics. It is interesting to see this from the PHO point of view as well as from a practice /practitioner point of view.

For those who have not caught up with this – I work with Compass Health as Medical Director. This is a role complementary to my other primary care related roles as a GP and as a Senior Lecturer at University of Otago Wellington.

I am impressed by the amount and quality of data that the team at Compass Health are able to produce. Great care is taken with the data that it is presented in a clear way with explanation of how and where it was obtained.

Practices have consented to data from their PMS being used as part of the Quality program.
At times Compass Health is asked for other data - for example for research projects and this is produced only with the express consent of the practice involved. This level of care has led to a high level of trust within the network.

Another area in which there is a high level of trust is in the use of comparative data. For a selected number of key quality indicators, practices can see how they compare to other practices. This approach has been well received by practices as they can see where they fit in the PHO and with similar practices. This can help drive quality improvement as practices strive to match others.

In many places around New Zealand the amount and quality of data supplied is much less. The Compass approach has evolved over time, which may not be so obvious to practices and practitioners. In this role, I’ve can see in a practical way, how the volume and quality of data produced by the Compass Health team is focussing quality improvement for both greater Wellington region practices and individual patients, which far exceeds other areas within NZ.

What does this look like?
We can easily go beyond understanding whether Hba1c has been measured or not. The quality of data available means a Compass Health practice team can access a deeper level of analysis. This might mean looking at patients at a practice level; selecting those coded with diabetes to see who have higher HBA1c levels and have not received prescriptions for insulin This enables individual practitioners to review specific patients and work with them to help obtain best clinical outcomes.

The missing patient lists that can at times be a bugbear for practices are also a very useful tool to help practices direct quality improvement.

The practice of medicine has become more complex and the tools we have to help remind a practitioner about who may benefit from clinical intervention are an excellent way to help ensure no patient gets left behind. We can then use our clinical time effectively to work with those in higher need of any interventions, while continuing to support in a less intensive way those who are going well.

Moving ahead, collecting and using the data obtained will continue to assist practices to best care for their enrolled population, combining the date driven science of medicine with the art of applying the information to individual patients at a personal level.

I’m always keen to hear feedback from our Network partners, so please get in touch for any questions about the use for data for quality improvement. What sorts of data would be useful for your practice ?

Ngā mihi

Lynn McBain


Dr Lynn McBain Picture

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.

Martin Hefford
Compass Health