Dialogue: Health revolution focuses on avoiding hospital admissions

Primary care is playing a bigger role in public health strategy. KAREN POUTASI* outlines an approach aimed at making a difference to New Zealanders' wellbeing.

Talk about the public health system and most New Zealanders will assume you're talking about hospitals.

After all, that's what we hear about most, whether the news of the day be staff shortages, patient complaints, waiting lists or whatever.

In healthspeak, we refer to hospitals as providing secondary care or, in the case of the main-centre hospitals, tertiary care.

But while hospitals continue to garner the headlines, there is lots happening in primary health care which could make a far greater difference to New Zealanders' well-being.

This quiet revolution is not making the news yet, but when the changes take effect we will see a new look in this part of the health sector and, more important, a discernible improvement in health status.

Primary care is where most of us get our health needs met, most often from the traditional family doctor and practice nurse.

Nurses have long offered community-based primary care - as Plunket nurses, district nurses or public health nurses. Recent law changes will mean the advent of the independent nurse practitioner.

As well, many Maori and Pacific services providing primary health care for their own people have been set up in the past few years, and there has been growing innovation by some independent practice associations.

Even so, a large number of those who turn up in hospital could have stayed out had they seen a primary care professional earlier.

My health and independence report last year showed a steady 3 per cent a year increase in admissions to hospital from diseases and conditions that could be prevented by early primary health care.

This type of admission was 58 per cent higher for Maori and 89 per cent higher for Pacific Islanders than for Pakeha New Zealanders.

There is nothing new in the argument that better access to primary care could cut hospital admissions. International evidence shows that a strong primary care system can achieve better results and lower overall costs.

But it has proved hard to reach the sort of person who typically turns up at accident and emergency departments quite ill, and to persuade him or her to go to a primary care provider first.

The changes, signalled in the New Zealand Health Strategy, then fleshed out in last year's Primary Health Care Strategy, incorporate a variety of approaches to address this problem. And they will take place within a framework which has already been adjusted to make improved health more attainable.

District health boards are already assessing the needs of the people in their constituencies.

And, for the first time, the boards have been told how much money they can expect to get from central Government for the next three years.

The combination of the two gives them a far better basis for planning effective programmes than they have had in the past.

Planning the programmes, however, isn't what is going to make the difference. Matching them with the people who need them is. And to do that, primary care providers will increasingly be grouping together and offering their services in a different way.

We can expect more primary health care out in the community.

New primary health organisations will spearhead the change. They are expected to be more multi-disciplinary than many existing practices, and their approach to a community problem such as diabetes could, for example, include nutritionists running healthy eating classes at a local high school, gym instructors taking exercise classes and optometrists doing regular eye checks.

Primary health organisations will also differ in another important respect. They will be paid according to the number and characteristics of the patients enrolled with them. This will make primary care more affordable for those most in need.

The great advantage of enrolment is that it makes it a lot easier for the practitioners to follow up patients - for recall notices, reminders and so on.

So elderly people who, in the past, may have had their influenza develop into pneumonia, which has put them into hospital, may instead be contacted and invited to have a flu jab.

The first primary health organisations are expected to be up and running this year. Logically enough, they're likely to appear first in the areas of greatest need.

It's not all new. I've already alluded to the work over the past decade of some independent practice associations and Maori and Pacific Island providers.

Undoubtedly it was some of their work we see reflected in New Zealand's rise from 20th to 13th in the latest OECD life-expectancy ratings.

Primary health organisations will build on this work and will be the key to boards' ability to improve the health status of their communities.

New Zealanders are increasingly gaining an international reputation as innovators - in fashion design, biotechnology, wine and food and film-making.

If we do primary care right, our health system can also be up there with the best in the world.

* Dr Karen Poutasi is the Director-General of Health.

* Brian Rudman is on leave.