Primary Health Care

Research & Evaluation of Primary Health Care Strategy (PHCS) initiatives

Overview

The Ministry of Health is managing a portfolio of evaluations as an integral part of the implementation of the Primary Health Care Strategy.

The evaluation portfolio focuses on three key areas:

The implementation of the Primary Health Care Strategy
The impact the Strategy has had on the delivery of primary health care services
Resulting changes in the health of the population

There are a number of projects that are part of the evaluation portfolio. Each focuses on specific aspects of the Primary Health Care Strategy but have a number of common elements:

Evaluations are independently conducted
There is a strong formative component
Consumer and community responses are assessed
There is a focus on intermediate outcomes

The central part of the evaluation portfolio is the Evaluation of the Implementation and Intermediate Outcomes of the Primary Health Care Strategy. The evaluation, being led by Victoria University’s Health Services Research Centre, began in mid 2003 and will be completed in June 2009.

There are a number of projects which look more closely at specific aspects of the Primary Health Care Strategy such as increasing access and improving services for people with chronic conditions. These evaluations and related research will feed into the overall evaluation of the implementation of the Primary Health Care Strategy as well as having stand alone value. These include evaluations of the:

First year of PHOs
Care Plus programme
Primary Mental Health Initiatives
Initiatives to increase access funded through the Reducing Inequalities Contingency Fund
Primary Health Care Nursing Innovations
Intersectoral Community Action for Health (ICAH) initiatives

Most of these evaluations have strong formative components - that is, findings are reported through the implementation with a how the Ministry and DHBs can improve implementation and design features of the Primary Health Care Strategy.

National Primary Medical Care Survey (NatMedCa) Reports

The National Medical Care Survey (NatMedCa) on primary health care providers and patient visits to them was carried out in 2001/02. The research was led by Professor Peter Davis (who also led the WaiMedCa study) with a team from the Centre for Health Services Research and Policy, University of Auckland and academics from other universities. The Health Research Council funded the original research project with input from the Royal New Zealand College of General Practitioners (RNZCGP) and the academic medical departments.

The Ministry subsequently funded nine more in-depth reports on aspects of primary health care delivery. These were:

Family Doctors: Methodology and description of the activity of private GPs;
Primary Health Care in Community-governed Non-Profits: The work of doctors and nurses;
Maori Providers: Primary health care delivered by doctors and nurses;
A Comparison of Primary Health Care Provided by Rural and Non-Rural General Practices
The work of doctors in accident and medical clinics
A comparison of Māori and non- Māori patient visits to doctors;
Pacific patterns in primary health care: a comparison of Pacific and all patient visits to doctors;
A description of activity of selected hospital emergency departments in New Zealand;
Nurses and their work in primary health care.

Read the NatMedCa Reports

Evaluation of the Implementation & Intermediate Outcomes of the PHCS

The central part of the evaluation portfolio is the Evaluation of the Implementation and Intermediate Outcomes of the Primary Health Care Strategy. This evaluation is jointly funded by the Health Research Council, the Ministry of Health and ACC, and is being led by Victoria University’s Health Services Research Centre. The evaluation began in mid 2003 and will be completed in mid 2009.

The Evaluation of the Implementation and Intermediate Outcomes of the PHS: First Reposrt May 2005

This report was based on interviews with more than 160 policy makers, stakeholders, and participants from both within and outside PHOs. It outlined the aims and objectives and methodology and presents early findings. The results showed:

A strong positive response to the goals of the Strategy
Fee reductions seemed to be leading to improved access for key population groups
Some concern about the sustainability of the Strategy
Some preference for targeted funding
Good community representation on PHO boards
Some innovative approaches to primary health care (e.g. increasing role for nurses and community health workers; new services such as clinics and outreach services).

Evaluation of the implementation and intermediate outcomes of the Primary Health Care Strategy (www.victoria.ac.nz)

Evaluation of Primary Health Care Strategy: Practice Data by Dr Jacqueline Cumming and Dr Barry Gribben. September 2007

This report uses quantitative data drawn from the Practice Management Systems of a representative sample of 99 General Practices. The data covers the period between July 2001 (before the Strategy was implemented) and June 2005. At that stage the increased subsidies had been rolled out to all patients in Access Practices and the 0-5, 6-17 and 65+ age groups in Interim Practices.
The report seeks to answer the following questions, for different population groups and funding models:

What changes have there been in the co-payments that patients pay when they use primary health care services since the introduction of the Strategy? How are changes in fees related to government policy objectives?
Since the introduction of the Strategy, what changes have there been in the utilisation of primary health care services by New Zealanders?
Are more patients being seen by nurses?
What changes are there in the pattern of ACC claims made, before and after the Strategy? Are more new ACC claims being made?

That data is analysed to demonstrate:

Co-payment fees paid by patients for GMS consultations
Utilisation rates for a fixed cohort of patients registered 12 months before the change to PHO funding
Proportion of visits recorded with a nurse as the practitioner
ACC claims - the proportion of consultations for which an ACC claim was made
ACC new claims - derived from ACC data

Results are presented by age group, ethnicity and practice funding types.

The report shows that:

Actual fees charged to patients are falling but the amount differs between age groups and different funding models.
Access practices are generally achieving low fee goals but this has been through small reductions in actual fees charged
In Interim practices the greatest reductions are in the 65+ age group.
The data suggests that although the fee reductions were not always as high as desired that overall fee reductions were greater for Māori and Pacific (reflecting their greater enrolment in Access PHOs), patients from lower socio-economic groups (though not always) and those in Access practices. These are the population groups that were more likely to see cost as a barrier.
Reductions in fees were greater for those who had not had a CSC card than those who had, as would be expected
The proportion of ACC claims and the proportion of new ACC total claims do not show any change before and after the introduction of the Strategy. This suggests that practices are not shifting costs to ACC
Consultation rates are raising in all age groups
This pattern is also noticeable in the 18 - 64 age group in Interim Practices where the roll out had not taken place where the roll outs had not taken place at the time of the analysis.
The research focused on actual fees charged rather than scheduled fees for which the Government required.

A number of further reports are expected in 2007. Topics include reports on fees and utilisation over the last five years in 125 practices, governance of PHOs, primary health care nursing, general practices and the impact of the Primary Health Care Strategy on Maori and Pacific peoples.

Evaluation of Primary Health Care Strategy: Practice Data (PDF)

Primary Health Organisations: The First Year (June 2002 - July 2003) from the PHO Perspective

In April 2003 the Ministry of Health contracted Victoria University’s Health Services Research Centre to undertake a small study reviewing the experiences of the first PHOs – those established between 1 July 2002 and 1 April 2003.
The aims of the review were to:

Give an overall description of PHOs, including structures, processes and services
Describe the participants’ experiences of PHO implementation
Describe participants perceptions of the strengths and weaknesses of PHOs at that early stage of implementation

PHOs: The First Year and Appendix 3 from the Health Services Research Centre

Intersectoral Community Action for Health (ICAH) Evaluation: An Overview

In 2001 the Ministry of Health funded four ICAH groups (in Northland, Counties Manukau, Otaki and Porirua) to develop different ways of bringing together community and health sector organisations to improve the health status of Māori, Pacific and Quintile 5 people living in those areas.

The evaluators concluded that each of the ICAH initiatives showed evidence they were working to reduce inequalities, all the projects were working intersectorally, the role and wisdom of the community was vital, the role of the Ministry of Health in the contracting process was generally seen positively and the future of the ICAHs, which were developed before the introduction of District Health Boards (DHBs) and Primary Health Organisations (PHOs), will rely on closer relationship between these groups.

The time covered by the report predates much of the implementation the Primary Health Care Strategy. However it provides valuable examples of ways that PHOs can work with their local DHBs and their community.

Intersectoral Community Action for Health (ICAH) Evaluation: An Overview

Evaluation of Care Plus

Care Plus provides additional funding to PHOs for people who have to visit a GP or nurse more frequently because of significant chronic conditions such as diabetes or heart disease, acute medical or mental health needs, or a terminal illness. Implementation of Care Plus began in July 2004.
Care Plus aims to:

Improve management of chronic conditions
Reduce inequalities
Improve primary health care teamwork
Reduce the cost of services for high-need primary health care users

Review of the Implementation of Care Plus (December 2006)
Prepared for the Ministry of Health by CBG Research

Review of the Implementation of Care Plus

Care Plus: An Overview
This publication explains Care Plus in more detail, how it was developed and contains a summary of the experiences of the three PHOs which trialled Care Plus: HealthWEST PHO in West Auckland (Waitemata DHB); Tihewa Mauriora PHO in Kaikohe (Northland DHB); Canterbury Community PHO (Canterbury DHB).

Care Plus: an Overview (PDF, 103 kB)
Care Plus: an Overview (Word, 107 kB)

Care Plus Process Report (March 2004)
Prepared for the Ministry of Health by CBG Health Research

Care Plus Process Report (Word, 436 KB)
Care Plus Process Report (PDF, 152 KB)

Care Plus Investigation: Estimating Case Loads (December 2003)
Prepared for the Ministry of Health by CBG Health Research

Care Plus Estimating Case Loads (Word, 527 KB)
Care Plus Estimating Case Loads (PDF, 194 KB)

Care Plus Formative Report (September 2003)
Prepared for the Ministry of Health by CBG Health Research

Care Plus Formative Report (Word, 453 KB)
Care Plus Formative Report (PDF, 106 KB)

Evaluation of Primary Mental Health Initiatives

The Ministry of Health is funding 41 PHOs to implement primary mental health initiatives and innovations projects in PHOs through DHBs. The Ministry is also funding an evaluation of the initiatives and innovations programme. The evaluation will collect quantitative and qualitative information and will consider the following areas:

Improving access
Liaison and integration of services
Improving patient outcomes
Education and training
Decision support and IT
Service provision to specified population, for example, Maori, Pacific and youth

The evaluation is being completed by a group of researchers from the University of Otago, and has been extended until June 2008. An interim report will be published in late March 2007, and other reports will be provided throughout the year.

Read more about the evaluation

Evaluation of Reducing Inequalities Contingency Funded (RICF) Projects

In 2002, funding was allocated on an ongoing basis to help providers develop or enhance services aimed at reducing health inequalities. There are 35 initiatives funded through the Reducing Inequalities Contingency Fund to increase access to primary health care services.
The initiatives are diverse in their content and objectives, but can be classified in four groups:

Community Health Workers - the delivery of health care services in the home and community
Free / low cost access to services - various mechanisms are employed to reduce access costs
Centre based activities - the delivery of health care services to particular age groups in non-traditional settings, generally in community facilities owned or used by the target group
Outreach services - these service aim to reach out to people in the community to assist them with their health and social needs

In January 2007, CBG Research Ltd completed a final evaluation of the 35 initiatives.

In August 2003, CBG Research Ltd completed a progress summary report on the evaluation of the projects.

CBG Summary Report August 2003 (Word, 103 KB)
CBG Summary Report August 2003 (PDF, 132 KB)

Evaluation of Primary Health Care Nursing Innovations

Eleven nursing innovations supporting the development of new models of primary care nursing practice and fostering nurse leadership were funded by the Ministry of Health from January 2004 to mid-2006.

There were two main kinds of innovation and the evaluation reports on the varying levels of success across the 11 innovations.

Innovations that fostered the role of the nurse practitioner and services that focus on chronic care management and services for familes, whanau and young people are of particular interest for those planning services for the future.

The Evaluation of the Eleven Primary Health Care Nursing Innovation Projects

Future Reports

A number of further reports are expected in 2007 and 2008. Topics include

Quantitative analyses

Experience of Maori in Maori-led PHOs compared with Maori in ‘Mainstream’ PHOs
Experience of Pacific in Pacific-led PHOs compared with Pacific in ‘Mainstream’ PHOs
Further analysis of data to demonstrate the role of fee changes in relation to utilisation of services
Intermediate outcomes, quality of care (performance management measures)
Repeat of analysis in 2008 to include all age groups over a longer period

Quantitative, qualitative and survey analyses (2007, 2008)

PHOs – Characteristics, Relationships, Roles
Practices – Workforce, Teamwork
Nursing – Roles, Training, Workforce, Teamwork
Financing & fees
Māori health & experience of Māori PHOs
Pacific health & experience of Pacific PHOs
Impact on ACC claims
Population health, Access, Service Delivery and Community Engagement

Economic analyses (2008)

Which groups in the population benefit?
Overall costs
Value for money

Page last updated: 30 October 2007