The Primary Health Care Strategy
Over five to ten years a new vision will be achieved:
People will be part of local primary health care services that improve their health, keep them well, are easy to get to and co-ordinate their ongoing care.
Primary health care services will focus on better health for a population, and actively work to reduce health inequalities between different groups.
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The table below shows, in broad-brush terms, some of the differences between most existing arrangements and the vision.
| Old | New |
| Focuses on individuals | Looks at health of populations as well
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Provider focused
 | Community and people-focused
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Emphasis on treatment
 | Education and prevention important too
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Doctors are principal providers | Teamwork - nursing and community outreach crucial
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Fee-for-service
 | Needs-based funding for population care
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Service delivery is monocultural
 | Attention paid to cultural competence
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Providers tend to work alone
 | Connected to other health and non-health agencies
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The six key directions for achieving the vision and new arrangements are:
- work with local communities and enrolled populations
- identify and remove health inequalities
- offer access to comprehensive services to improve, maintain and restore people's health
- co-ordinate care across service areas
- develop the primary health care workforce
- continuously improve quality using good information.
These are discussed in detail below.
Work with Local Communities and Enrolled Populations
Primary health care services can best improve the health of the communities they serve by organising services around defined populations – rather than just responding to those individuals who actively seek care.
Primary health care needs to involve participation by people in the communities covered to achieve this. Services will then be more likely to reflect needs and priorities that are set by the people, not just by providers.
Primary Health Organisations will be required to include some members of the community on their governing bodies. They must also be able to demonstrate that they have processes for identifying need and allowing community members and those who use services to influence the organisation’s decisions.
Voluntary Enrolment
The first steps of linking providers to defined groups of people have already begun. Already many general practice organisations, some Maori providers and others keep lists of the people for whom the organisation is taking
responsibility. A system of voluntary enrolment will be introduced to expand these moves across the country.
People will be encouraged to join a Primary Health Organisation in order to gain the benefits associated with this population approach and to improve the continuity and co-ordination of the services that they receive. Most people will enrol with a provider of first-contact services (a general practice or a local health clinic) that is part of the organisation.
Existing lists of the patients who normally attend a practice or health clinic may form the starting point for enrolment but, over the first couple of years, individuals will be asked to make an active choice to join the Primary Health Organisation.
Some Primary Health Organisations will be new organisations rather than ones built up from existing providers. These groups, such as those aimed at particular Maori or Pacific populations, will seek to directly enrol people
in their communities.
The move to comprehensive enrolment will involve a significant change process over several years. The system will work best when the whole population is enrolled; however, enrolment will be voluntary.
Enrolment and Continuity of Care for Patients
Continuity in primary health care means that people have a usual source of care, and can use that source for advice and help over time. People using the service form important relationships with their provider. It may not be necessary to have complete continuity of an individual carer – a small team could be the usual source of care.
Continuity can be shown to result in a number of benefits, particularly where there is a relationship with a particular practitioner. It is associated with:
- better preventive care (Lieu et al 1994)
- patients who feel more able to care for themselves in future (Howie et al 1999)
- better recognition of problems (Gulbrandson et al 1997)
- less recourse to medication as a first-line treatment (Hjortdahl and Borchgrevink 1991)
- better patient compliance with prescribed medication (Becker et al 1974)
- fewer hospitalisations (Weiss and Blustein 1996)
- lower total costs (Flint 1987).
Despite the apparent importance of continuity of care, a number of recent developments in the New Zealand health system have tended to reduce continuity. These include the growth of large-scale out-of-hours arrangements, the increasing number of ‘walk-in’ clinics offering episodic care, and the involvement of a wider range of practitioners in providing care.
However, many of these developments have also brought benefits in convenience and availability of service, and these factors are often more important at the time than the ability to see a known practitioner. A recent review (Guthrie and Wyke 2000) states that ‘it seems likely there will be patients and problems where personal continuity really matters and others where personal continuity is irrelevant or even harmful’.
The future primary health care system will enable people to have continuity of care where it is important, but will not reduce their freedom to choose between different practitioners where this is valuable to them. In the process of enrolling with a Primary Health Organisation, people will also be asked to nominate a practitioner, practice, or provider for continuity of care.4
There will be some national minimum requirements or protocols that will be fully explained to people at the time they make their choice. These might, for example, include ensuring that enrolled people have access to 24-hours-a-day, seven-days-a-week urgent services; that systems allow people to ask to see a particular practitioner; and that, unless people specifically request otherwise, their nominated provider will receive information about consultations or tests with other practitioners. These protocols will build on the work and advances already made by the Health Funding Authority in this area.
Enrolment will not reduce people’s choice of provider. They will be free to seek care wherever they wish regardless of which provider or Primary Health Organisation they have enrolled with. This is important for people’s convenience and to allow them to choose a different practitioner at times when they want a second opinion, a confidential consultation, or to see a practitioner with a particular skill.
If a person chooses not to enrol they will still be entitled to seek care – but they may miss out on some preventive services because they are not in the identified population.
Regardless of people’s nomination for continuity, the enrolment system will allow them to continue to see any primary health carer. The system will also allow people to change their nominated provider without difficulty and without having to explain or seek permission.
Actions
- Primary Health Organisations will be expected to respond to the needs and priorities of their communities, and involve communities in their governing processes.
- People will be invited to join a Primary Health Organisation, usually by enrolling with a provider of first-contact. Enrolment will be voluntary.
- People enrolling with a Primary Health Organisation will be given full information about their options so they can make an informed choice about their nominated practitioner, practice, or provider team for continuity of care.
- Regardless of their nomination for continuity, people will be able to choose any primary health care provider at any time, and will also be able to change their nominated provider without difficulty or explanation.
- National protocols for enrolment will spell out the information people will be given before joining, protections that must be in place to protect confidentiality, and requirements that organisations must meet.
- Information to clearly explain enrolment will be widely communicated to all New Zealanders.
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Most people will enrol with a local practice or health clinic that is part of a Primary Health Organisation. They will gain the benefits of better continuity, co-ordination and more attention to preventive services.
People will be encouraged to nominate a practitioner, practice or provider for continuity of care when they enrol. However, they will still be free to seek care wherever they wish, regardless of which provider they have nominated.
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