Bright prognosis for new health centres

The new clinics will have facilities similar to hospitals, equipped for minor surgery, lab tests and specialist consultations. Photo / Sarah Ivey

Michael Lamont, for one, is excited at the thought of what can be achieved under the latest change to the health system.

"Integrated family health centres - absolutely," enthuses the head of the Mangere Community Health Trust, then adds "we're building one."

Just as many of you may, or may not, have got your heads around the existence of PHOs (Primary Health Organisations) brought in under Labour, entities called integrated family health centres are to be the latest buzz in health under National.

These new centres - Auckland could get up to 12 - are to be set up as a main plank of the Government's better, sooner, more convenient policy for primary health care.

The Government came up with this policy, it says, to confront major challenges in health - the ageing population, the drain of doctors overseas and to lighten the load on hospitals which groan from patients arriving at accident and emergency departments when they could have avoided becoming so ill had they got treatment sooner.

National wants to have more services closer to patients and plans to devolve more of the things you go to the hospital for to the new centres, one of which should pop up some time soon nearer to your own backyard.

The options, say health professionals keen on the concept, are myriad: from specialists on hand, to doctors performing minor surgery, to better co-ordination and wider ranging care. But some health professionals in the smaller PHO's we spoke to are concerned. They say they already provide many of these services and fear they will be swallowed up in a big new entity.

Their patient groupings of the most vulnerable, from refugees to the homeless, could become lost in the crowd, they say.

Lamont, however, who heads a PHO in an area of high need, couldn't be more positive.

"We've been waiting for this for the last 30 years," he says.

He envisages innovation in streamlining systems, and patients walking in to see a doctor, popping next door to see a specialist, getting the x-rays or tests they need on the spot and perhaps even popping in to the dentist or pharmacy, all in the one building.

He expects the Counties-Manukau GP shortage to be improved by young doctors wanting to work in innovative centres, and though he says maybe not all problems will be solved "it will at least put the people under the same roof and they might have a cup of tea or lunch together and talk about some common things".

You won't have to quit your local GP under the new system, he says, but you just might find things working better.

Say your GP says you have a melanoma on your cheek, he explains. Through an electronic system, that GP might be able to see there is a free space at 3pm at the new local integrated family health centre and you can go in and get it removed pronto.

"There should be that sort of facility so you can provide treatment, rather than saying I'll (the GP) write a letter to the hospital, and they'll (the hospital) write a letter to you at some stage and tell you to come in on the 9th of July at 10.30am, and you say I'm not going to be here then..."

Or, perhaps your child gets injured playing sport at the weekend. Instead of getting an ambulance and the child hanging around in pain at a frantic hospital A & E department, they could be taken to the local centre which will have an extended hours service.

"They'd be able to come in the front door, get their x-ray, get their plaster on and their fracture managed."

To be fair, the primary health system has been fairly quiet for the past decade, but each time there is a change of Government the new leadership inevitably has a go at trying to fix health.

Health Minister Tony Ryall is no exception, through the announcement of integrated health networks, which is also part of the Government's promise to cut layers of bureaucracy from public systems.

Ryall says the changes he is introducing in health are really finishing off the plan Labour brought in in 2001 when it unveiled the centrepiece of its policy for the primary sector, the Primary Health Care Strategy.

This set the stage for the introduction of the primary health organisations (PHOs), universal patient subsidies and the development of primary care into much more than doctor-led general practice.

Labour spent more than $2 billion on the strategy, which was intended to strengthen the links from primary care to hospital services and reduce, or at least constrain, the number of people going to hospital.

Both parties are keen on the idea that keeping people well in the community, or treating them before they become seriously unwell, will reduce hospital demand.

The evidence is mixed on whether the PHO system has worked, possibly because better primary health care has picked up more chronic illness that previously went untreated.

Labour clearly succeeded in the creation of PHOs and cutting of patient fees. There are around 80 PHOs and more than 80 per cent of New Zealanders are enrolled in one, whether they know it or not.

The average fee came down to around $25, although it is creeping up.

But Ryall points out that despite Labour's achievements in these areas, it made little progress on the rest of the strategy.

The bulk-funding of PHOs and the increased state funding that permitted reduced fees, even for the wealthy, became so popular National realised it was politically foolish to return to fee-for-service healthcare with targeted subsidies based on low income, age and high health needs.

Thus National committed itself to retaining PHOs, in reduced numbers, even though they are an extra layer of bureaucracy to channel funding from district health boards to primary care clinics, and will retain the fees review process designed to control increases.

The scheme has the potential to fix after-hours care - the weeping wound of the 2001 strategy - but whether it does will depend on the will of DHBs and the Government.

The primary care sector and the Labour Government never agreed on whether PHO bulk-funding covered after-hours and despite top-up arrangements, many areas still have limited and pricey services.

While Ryall's changes are broadly in line with the 2001 strategy, he wants a reduction in the number of PHOs - to save money by avoiding duplication - and he is dismissive of the community involvement the strategy required.

However, some small PHOs serving high-needs areas argue that their size and the community representation in their governing structures are at the heart of their success, demonstrated, for instance, in child immunisation rates that are above the national average.

Justine Thorpe is one who is worried. She runs the South East and City (SECPHO) PHO in Wellington which has a strong focus on community involvement, and says why change a system which is working well.

Her PHO caters for patients who speak 30 different languages and who are mostly on low incomes.

They are refugees and migrants from the Middle East and Africa, Pacific and Maori, and one practice within the PHO cares for much of Wellington's homeless population.

The GP practices in the PHO are reaching these people and she fears for them if the PHO is pushed or cajoled to join one of the new networks.

" I mean, we're quite proud of the fact that we've got really high vaccination rates for 2-year-olds, and that's not because we sit back and wait for them to come to us.

"We have a very active outreach service and make it accessible and I guess that's our concern, that sort of pull it all into one big centre... yes, people could access everything under one roof, however, our community isn't really one to go to a big centre and become part of this big thing."

She fears these patients, who are the majority population in her PHO, will become a minority in a big new centre.

"We have community leaders on our boards, we have community leaders working for us as well, so our ability to vaccinate all those children is because we have relationships."

General Practitioner Kathy James is on the board of SECPHO and is clinical adviser for Health Care Aotearoa, a national network of 55 community-driven primary health care services.

She shares Thorpe's concerns. Instead of making health care more accessible, she fears for some it could become less accessible.

It is unclear yet how far people may have to travel to a new clinic, and in rural areas this needs to be looked at closely, she says.

"Because, are they going to look at closing the small rural hospitals and collapsing services into one polyclinic and people are going to have to travel further?"

And what is the guarantee that services remain free, she asks.

"If they are going to be commercially run, how will they be paid for?

"These are all unanswered questions. Are they going to be run for a profit? I would say probably."

Contrast her concerns with Professor Cindy Farquhar, the steering group chairperson for the Greater Auckland Integrated Health Network bid which has been given the nod to proceed to the business case stage.

Farquhar uses the term "hospital in the community" and says the new centres will be able to offer more, and, importantly, take the load off struggling public hospitals.

She agrees the Greater Auckland proposal is huge - 12 new centres, 311 general practice teams, 11 PHOs, three district health boards and 1.25 million patients - but does not see why services would become impersonal.

You can continue to go to your own GP, she says, but you can get the follow-up treatment you need faster, and for more complicated issues you can still go to hospital. There are very interesting proposals coming out of primary care, she says.

Counties Manukau, for example, has already brought in a system where patients who are acutely unwell but not necessarily needing a hospital bed instead receive nurse visits to their own home.

"It was a way of saying we understand this patient is too sick to be left on their own but not quite sick enough to be left in the hospital."

In Farquhar's own area, women's health, at any time at National Women's at Auckland Hospital there are four to six women with severe morning sickness who need to come in for IV fluids.

An integrated family health centre could do that, she says.

"There are all sorts of possibilities. I think, you know, it's really quite an exciting approach...

"This is about, in my view, working smarter, streamlining services and thinking about the patient's experience from beginning to end.

"At the moment, we've got general practice over here, secondary practice over there and they really don't talk to each other that much - when you think about it for long enough, you think 'gosh, why haven't we tried to work this way before'."

COUNTDOWN TO CLINICS

* The Ministry of Health has provisionally accepted nine bids from consortia of district health boards and PHOs to set up new centres.
* Formal business cases are due with the ministry next month and it is planned the new centres would start being set up from July.
* They will vary around the country, but the kinds of services they could provide include 24-hour accident and medical care, the taking of blood samples for testing at a laboratory, clinical psychology, midwifery clinics, minor surgery, assessment during an asthma attack, consultations with visiting hospital specialists (the front door to elective surgery), and referral for diagnostic imaging.
* Many centres are also likely to provide daytime general practice care but this will depend on nearby practices deciding to shift in.