Dialogue: Primary care best place to start in scramble for money

By MARK WILLS*

The people of Auckland and New Zealand expect unlimited access to expensive and highly skilled secondary and tertiary care.

At the same time many people and health professionals expect easily available and free primary health care in a hospital setting.

Free it may be to the user, but it is dreadfully expensive for the Government and, therefore, taxpayers.

Meanwhile, the real primary health sector, community-based providers of health advice and illness care, otherwise known as general practitioners, practice nurses and other community-based nurses, have battled on, little noticed.

Many GPs have formed groups called Independent Practitioner Associations (IPAs), which have, with skeletal management staff, helped to improve health care and outcomes for many New Zealanders without cost increases.

No payments of millions of dollars have bee made to community-based heath providers as there have been, in vain attempts to lower waiting lists, to hospitals. Yet GPs see 90 per cent of all New Zealanders every year to review their health needs.

Unfortunately, primary health care is not sexy. There are no apparent dramas, no huge edifices, no multimillion-dollar Machines and no world-beating individuals. Politicians do not find general practice captivating, either.

This is a huge travesty, as primary care is the answer to many health system problems of high demand and constrained cost.

One of the main aims of primary care physicians is to keep the people they look after in good health and thus keep them out of hospitals. They do this with tight budgets while having to cope with the spiralling demands of education, accountability, Occupational Safety and Health, ACC and the Health and Disability Commissioner.

Preventive care is an investment in reducing demand for hospital services in the future, and the signals are dire regarding diabetes, heart disease and mental health.

A well-targeted investment in primary care will help manage the risk of these conditions putting even more stress on the health system.

IPAs help GPs to better manage health funding and to improve the quality of services. They assist GPs in attending continuing education and peer group reviews of clinical practice incorporating evidence-based practice, all leading to a more consistent and higher quality service.

One such IPA is ProCare Health, consisting of 370 GPs in the greater Auckland area. These doctors have worked together to find solutions for improved healthcare provision using available money.

Some examples are:

* ProCare GPs and practice nurses have been working with other doctors and nurses from South Auckland GP practices and Middlemore Hospital to explore a different way of managing chronic obstructive pulmonary disease lung damage occurring over a long period. People with this condition are frequently admitted to hospital with acute breathlessness and lung infections.

Patients on the programme for 12 months showed a 60 per cent reduction in the number of days spent in hospital and a significant improvement in quality of life.

* Primary Options for Acute Care is a jointly financed venture between ProCare and other GP groups, and the district health boards in South Auckland and Waitemata. The programme gives ProCare GPs alternatives to hospital admission for those with acute illness.

GPs can arrange diagnostic services such as laboratory tests or free private x-rays, community-based treatment, intravenous therapy or nursing care), and support services such as home care, meals or admission to a rest-home as an alternative to people having to go into hospital. These free services allow people to get better in the community, or in the comfort of their own home.

Of nearly 1200 patients referred to the programme in the past 12 months, 84 per cent were able to be managed in the community without having to be admitted to hospital.

* The ProCare Paediatric Asthma Pathway Programme similarly contributed towards a 40 per cent reduction in asthma attacks requiring hospital admission during the time of the pilot programme.

* ProCare Health implemented a new clinical guideline for the treatment of dyspepsia. This involved an education focus to update practitioners on the treatment of this condition. As a result the waiting list for gastroscopy in the local public hospital was substantially reduced, an improvement in the pharmaceutical prescribing in accordance with quality-based guidelines, greater patient satisfaction and more empowered GPs.

GPs are willing and able to contribute to an improved health system, but often seem to be left out of the loop because of a short- term focus on waiting lists, which could be cut with appropriate GP intervention. Primary care is the security fence at the top of the cliff. The cost of delivering services at the bottom is substantially greater.

The creation, development and maturing of independent practitioner associations such as ProCare Health has provided an opportunity for much more effective management of health services.

Policy makers and funders should take heed of this clinician-initiated advance and join the community-based primary care sector in exploiting the opportunities offered.

The media should become more active in seeking out health success stories, thus bringing them to the attention of politicians, bureaucrats and the public.

* Mark Wills is chief executive officer of ProCare Health.

E-mail: mark.wills@procare.co.nz

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