Felicity Goodyear-Smith is a General Practitioner and Head of the Department of General Practice and Primary Health Care at the University of Auckland, New Zealand
Primary care in New Zealand
What do populations need?
Populations in the community need a health care provider for first contact, continuity, coordination and comprehensiveness of care. Care needs to be patient- and family-centered, and culturally appropriate.
How does the system provide for these needs?
The New Zealand Primary Health Care Strategy, launched in 2001, focused on local primary health care services to improve people’s health and keep them well with easy access and good coordination of their on-going care. Primary health care services should also focus on better health for a population and actively work to reduce health inequalities. Government-funded District Health Boards pay general practices through their Primary Health Organizations (PHOs), which are tasked with the provision of a set of essential primary health care services to their enrolled populations.
Who pays for the primary care system?
New Zealand has a mixed funding model. Secondary care is free for all New Zealanders, although private specialist and hospital care are also available. Primary care has a combination of government and out-of-pocket funding. Typically, general practices are private businesses owned by general practitioners (GPs), although an increasing number are owned by trusts or communities.
Practices are paid by their PHO using a capitation-based payment system that is based on the number, age, ethnicity and socioeconomic status of their enrolled patients according to needs-based formulae. Although this subsidizes their care, most patients will also pay a fee for service per consultation. Some services may be fully government-funded, such as scheduled childhood immunizations, antenatal care, visits for children under age 6 and consultations with the practice nurse. There are also some special funded projects directed at specific populations, such as chronic care management and services to improve access to help reduce health inequalities.
What are the strengths?
New Zealand general practice is both individual- and population-based. In general, New Zealanders enjoy family- and patient-centered comprehensive care by the same provider. Most of New Zealand’s population (97% of children, 93% of adults) have a primary health care provider. Overall, 79% of children and 81% of adults will see their GP annually, and there is good continuity: 92% of children have the same provider as their parents; 80% usually see the same GP each visit.
Patient information is kept on electronic medical records with a system of secure exchange of clinical information with other organizations in the health sector, such as laboratory and imaging services, and secondary services including sending of patient referrals and reception of hospital discharge summaries.
There is a systematic approach to preventive care, such as screening (71% of eligible women had a mammogram in the last year; 80% of eligible women had a cervical smear in the last three years), cardiovascular risk assessment for primary and secondary prevention with electronic decision support, and provision of childhood and influenza immunizations through practice recall systems plus transfer of information to national registries. Adults aged 64 and older or with at least one chronic illness are entitled to free Influenza vaccine. Most practices send invitations and about 70% of patients take up the offer.
Practices provide health checks for early detection or maintenance of appropriate management. The additional funding for chronic disease management includes programs such as “CarePlus,” which targets people with high health needs due to chronic conditions, acute medical or mental health needs, or terminal illness, and “Get Checked,” which provides every New Zealander with diabetes with a free annual check-up.
What are the weaknesses?
The funding arrangements are complicated, with frequent changes. Copayments are a barrier for some patients. The 2010 Commonwealth Fund International Health Policy Survey found 14% of New Zealanders had gone without some form of health care (not accessed their GP or not collected their prescriptions) because of cost.
Practices receive extra subsidies for socially deprived populations but not individuals — practices with more than 50% Maori or Pacific Island patients are funded at a much higher rate. This can result in inequities, because practices who do not meet the 50% threshold of their enrolled population have to charge much higher copayments to their socially disadvantaged patients than neighboring practices who qualify for extra funding.
Finally, there is generally poor primary–secondary integration. GPs are unable to follow patients once they are admitted to hospital and may receive inadequate information about follow-up management once the patient has been discharged.
Who cares about the maori ? Healthcare should be available for everyone.