PLANIFICACIÓN DE LOS EXPERIMENTOS

In reviewing implementation of the Primary Health Care Strategy it could be said that the goals of Labour’s primary health care reforms were laudable and placed New Zealand ahead of most developed countries (Gauld, 2009a). Implementation of the Strategy has led to a number of achievements including:

 A reduction in cost of access to primary health care

 Increased utilisation of primary health care services

 The identification and appreciation of health inequalities

 A wider range of health promotion services at primary health level

 An extension of a range of primary health care services (Cumming et al, 2005; Cumming & Gribben, 2007, Gauld, 2008; Smith, 2009).

While there may have been small pockets of change in general practices which have embraced the vision of the Strategy, overall primary health care development has been disappointing and many of the features of health services have remained unchanged (Ashton & Tenbensel, 2010; Gauld, 2009a). In addition, DHBs have performed on a par with previous structures and the historical disconnect between primary and secondary care continues to exist in many settings (Gauld, 2009a).

The Primary Health Care Strategy was a far reaching ambitious set of aspirations for the coordination of health services within and from primary health care (Smith, 2009). It carried a high degree of uncertainty making it less likely to be adopted. It did not take into consideration the effect on existing institutions and structures, the shape of the primary health care sector, or the capacity to deliver the intended goals (Gauld & Mays, 2006). Sufficient attention was not paid to specifying what different models of comprehensive primary health care services might look like.

The proposed change necessitated breaking down traditional barriers, professional boundaries, and employment practices. Existing values, beliefs and norms were counterproductive to Primary Health Care Strategy implementation. Nursing however signalled its absolute desire to change right from the outset. Prior to the release of the Strategy, Carryer et al. (1999) wrote a report for the National Health Committee on locating nursing in primary health care. Further evidence was the work undertaken by the Expert Advisory Group on Primary Health Care Nursing (2003) in developing the framework for activating primary health care nursing in New Zealand. Members of this group were nurses from New Zealand nursing organisations, NGOs and Iwi providers, as well as schools of nursing.

The complexity of the proposed changes meant that the Primary Health Care Strategy was difficult for some to understand and use. Rogers (2003) concurs that a potential adopter’s perception of complexity unquestionably affects the rate of adoption. Little consideration was given to the fundamental differences in values, beliefs, and behaviours between the DHBs and their various PHOs. The Crown recognised that the business decisions of contracted parties such as PHOs may also differ from those of the DHB (The Treasury, 2009). However, the attempt to restructure primary health care through PHOs was ambitious given the government neither owned nor fully funded these structures. The ambiguity in relation to the role and functions of PHOs also compromised their ability to assume a strong role in leading change within local health systems(Smith, 2009).

Each DHB was tasked with developing a local strategy which allowed the expression of local variation. Nonetheless, lack of national consistency in the varying interpretations across the country significantly impacted on the configuration of service delivery (Walker & Collins, 2009). For some DHBs primary health care development was taken seriously, in others it was business as usual (Barnett & Barnett, 2004a; Cordery, 2008; Smith et al., 2008). Gauld (2009a) expressed concern that only one third of DHBs understood that an investment in primary health care could make a real difference to the health of a population and reduce the need for secondary care.

The organisational design of DHBs generated numerous tensions (Adam, 2003). Cumming and Mays (2002) question whether DHBs had the right incentives to make the best use of the available resources to meet the needs of their local communities. Funding constraints forced some DHBs to focus on maintaining crucial hospital services curtailing hospital overspend (Gauld 2009a). Gauld (2009a) also stated that tight central government control over decision-making meant DHBs did not have full authority to relocate funds from one area into another. This then reduced DHB capacity to invest in strategies to attend to the broader determinants of health.

The rate at which the reforms took place also resulted in a number of unintended consequences (Gauld, 2008). Much of the implementation effort went into lowering fees and the formation of a large number of PHOs rather than achieving the intent of the Primary Health Care Strategy. Accordingly the complexity and duplications in planning and purchasing were considerable (Ashton & Tenbensel, 2010; Barnett & Barnett, 2004a; Gauld, 2012). Twenty DHBs and over 80 PHOs could be considered excessive for a small country such as New Zealand. Administration costs of PHOs tied up funding that could have been better used to remove patient fees and improve health outcomes.

The labyrinth of funding and organisational systems each with variable capacity supports the notion that there were significant flaws in both design and implementation of the Strategy (Gauld, 2009a). Gauld (2009a) questions whether the development of PHOs was necessary given that the same outcomes may have been achieved through working closely with the existing IPAs, increasing GP subsidies and instigating other primary health care developments such as Care Plus. Instead, a significant number of PHOs simply passed on their capitation payments to general practices without requiring the change expected (Ashton & Tenbensel, 2010; Barnett & Barnett, 2004a; Cordery, 2008; Finlayson et al., 2011; Gauld, 2009a). The funding approach necessitated the incentivising of desirable outcomes (Primary Health Care Advisory Council (PHCAC), 2009).

Reviewing the situation in 2008, Smith et al. argued that greater lucidity was still required around the role of the PHO in shaping services that can deliver and improve population health (Smith et al., 2008). Cordery (2008) identified that PHOs still faced three main challenges:

1. The change from an illness to a wellness focus

2. The management of a short-term funding regime and government

demands

The Primary Health Care Advisory Council (PHCAC) (2009) identified “the importance of primary health care planning taking place within the wider context of health system planning” (p.3). Recommendations from the working group included service models based on a person/whanau centred approach and multidisciplinary/interdisciplinary working together in the best interest of the patient. There was acknowledgment that teamwork and leadership must be developed and nurtured. This required awareness of the wide range of health practitioners who contributed to primary health care. Consumer and community voices must be heard in the development of service models, especially in meeting the needs of Māori. The importance of integrated information technology systems was recognised as needing to be progressed alongside the development of technical tools to accommodate the wide scale service change expected. A review of the current funding models was considered necessary in order to bring about the desired change.

The Minister of Health disestablished the PHCAC late in 2009. The PHCAC was originally set up in 2008 to replace the previous PHO Task Force; its function was to provide timely and quality high-level advice to the MoH and DHBs. The mandated membership represented a wide cross section of the primary health sector. It appears illogical that this voice was considered unnecessary given the issues identified through various evaluations of the Primary Health Care Strategy (Barnett & Barnett, 2004b; Cumming & Gribben, 2007; Cumming et al., 2005; Raymont & Cumming, 2003).

3.7 Concluding statement

What this chapter demonstrates is that a number of conventional enablers and constraints heavily predisposed the trajectory of changes that took place in New Zealand following the release of the Primary Health Care Strategy. Resistance and numerous impediments in the health sector meant the Strategy was rich in vision but, as detailed throughout this chapter, the operational decisions were in some measure at odds with this vision. This in turn negatively impacted on the effective deployment of primary health care nurses. Understanding such complexities is the epitome of case study research

programme (Yin, 2003). Next, Chapter Four presents the philosophical and methodological location that underpins this research.

Chapter Four: Philosophical