Background
New Zealand’s 1938 Social Security Act was the world’s first attempt to create a “national health service”, but doctor resistance meant this was never achieved. A series of policy compromises mean that, today, public hospitals salary all staff and are free of patient charges. General Practitioners mostly practice privately and act as gatekeepers. They receive considerable government subsidies but charge most patients a fee per consultation, creating an access barrier [37]. There is a strong tradition of family practice and focus on primary care within the health system. Yet, the arrangements set down in the post-1938 compromise mean GPs and public hospitals work largely separately from one another. Government contributes around 80% of total health expenditure. Around 40% of public hospital specialists have a separate private practice. The parallel private system means patients of better means are able to circumvent public hospital waiting times when referred by their GP, or to access treatments considered to be lower priority in the constrained public sector [49]. |
A general practice that is part of a PHO can enrol a patient in Care Plus if they are assessed by a doctor or nurse at the general practice as: |
• being able to benefit from intensive clinical management in primary health care (at least 2 h of care from 1 or more members of the primary health care team over the following 6 months), and |
• having 2 or more chronic health conditions, as long as each condition is one that: |
• is a significant disability or has a significant burden of morbidity; and |
• creates a significant cost to the health system; and |
• has agreed and objective diagnostic criteria; and |
• requires continuity of care and where a primary health care team approach has an important role in management; or |
• requiring intensive clinical care because they: |
• have a terminal illness (defined as someone who has advanced, progressive disease whose death is likely within 12 months); or |
• have had 2 acute medical or mental health-related hospital admissions in the past 12 months (excluding surgical admissions); or |
• have had 6 first-level service or similar primary health care visits in the past 12 months (including emergency department visits); or |
• are on active review for elective services. |
Methods
Design and sampling
Data collection
Data analysis
Results
Category | Participants, n (%) |
---|---|
GP and PCN participants
|
16 (100)
|
Profession: | |
General Practitioner (GP) | 12 (75) |
Primary care Nurse (PCN)a
| 4 (25) |
Sex: | |
Female | 7 (44) |
Male | 9 (56) |
Ethnicity: | |
New Zealand European | 11 (69) |
Other (including: Asian, Other European, African, etc.)b
| 5 (31) |
Years in clinical practice: | |
0–5 years | 1 (6) |
6–10 years | 3 (19) |
11–20 years | 3 (19) |
20 years + | 9 (56) |
General Practice demographics
c
|
15 (100)
|
Practice Size: | |
1–4 GPs | 6 (40) |
5–9 GPs | 4 (27) |
10+ GPs | 5 (33) |
Practice Location: | |
Urban | 9 (60) |
Rural | 6 (40) |
Practice location New Zealand Deprivation Index | |
1–3 | 4 (27) |
4–7 | 10 (67) |
8+ | 1 (6) |
Clinical decision making
Complexity
That's a multi-morbidity, I can think of where there's a complex array of medical conditions which prevents that person from being able to cope alone at home, bringing on confusion with the number of medications that the person is on, and so on and so forth. It's like a big waterfall. (Participant 1 GP)
It’s like people come in with their shopping list and they want a repeat of their 15 different interacting medications for their 6 six different pathologies. (…) (Participant 6 GP)
I think often they've got their agenda of what they want to talk about. You've got your idea that, okay, you want your prescriptions, but I also have to check a number of other things. Trying to focus on what they've actually come in for, which may not be the most urgent thing but is obviously the thing that's worrying them the most, and picking at there's nothing particularly dangerous that you're missing like the ones who at the end of the consult say, "Oh by the way, I've been having chest pain for the last six weeks." (Participant 2 GP)
Then of course you make a rod for your own back because I think by giving people more time and addressing more problems than you should, word gets around, people change to you because a friend recommends you. I've even had people change from doctors within the practice saying that they don't like Dr. So-and-So because he's always in such a hurry and so brusque and efficient, and your heart just sinks because you think, well yes, I will try and do a good job and give more time, but that comes at a cost to me and to my other patients, so you run later and later. (Participant 9 GP)
Inadequacy of single disease guidelines
Whereas if you have got one person with diabetes, it’s fairly straightforward to follow the guidelines. People with multiple conditions, there are guidelines for each of them, and it’s impossible…, it’s not beneficial to the patient to stick to 4 guidelines for 4 conditions (Participant 7 GP).
Addressing clinical decision making in multimorbidity: “satisficing” and relational continuity of care
I think, not perfectly managed, but managed well enough within that person’s individual parameters. (Participant 6 GP)
I think it comes down to agreed management plan and I think that's really the point. There's some things you're going to agree and some things you don't. I think that's probably the point. It's an agreed management system, which is again why the imposition of targets and the imposition of a certain way of doing chronic disease management doesn't work. (Participant 4 GP)
So, although, in an ideal world I would say he should lose 20 kg and be completely pain-free from his back problems and not take any painkillers and not take this group of several medications that he's on, I think it's not a bad situation in that we're managing it and it's stable and relatively well-managed. (Participant 9 GP)
Sometimes if they've got a whole list of things you have to just sort of divide the list up and say, "Look, we'll do this today and maybe we can, we need to do something about these things, but then you can come back and we'll do the other thing," (Participant 2 GP)
… with the people with multimorbidity you see frequently it’s not just one 15 min time slot, it’s just carrying on from where you left off last time. You build and build and build on that. In the year, you’ve had an hour and probably more. (Participant 6 GP)
I work kind of half hour appointment. I aim for the first 10 min to be the patient introduction … you know let them talk about whatever they would like to talk about and then I would bring it round to the last 20 min to hone in on specifically what I would like, tied in with what they would like. But I do have a lot of time with my patients and that's [how] you know I get to know them, what they've been up to, has anything happened in their lives recently, what are they worried about, you know, “how is the pet?. So we cover the social aspect and we just gently move around to the diabetes side of things (Participant 8 PCN)
It's repeating the message, but repeating it in different ways. Sometimes I'll dwell on the medication management, other times I might dwell on their lab results, another time … well I always talk about the lifestyle really. Just putting the stress on different things and finding out what clicks to people. Trying to find something that's sort of like, you know what it’s like yourself. People can tell you the same thing but in one day someone will say it slightly different and you think oh! (Participant 3 PCN)
Health care delivery
Primary care funding model
I think New Zealand is in many ways the most difficult [setting to practise GP] because you have two customers scrapping for the same amount of time thinking that they're your exclusive customer. You've got the funding from the ministry of health through the PHOs … [who] are not going to pay you if you don't tick [their] boxes. You've got your patient with their A3 list, and both of them want 20 min at least of the 15 min appointment. There's 40 min. Two customers fighting for the same time window. (Participant 16 GP)
They [Patients] will say, “Oh, this, this, and this.” I’ll say, “Well look, we can deal with this and deal with this, but the other, that sounds really important and I don’t want to dismiss it. You will need to make another appointment to come back.” That’s very difficult, because I’m very aware that we charge [NZD] $39 for a consultation. I am very aware that a significant number of people in our area, that’s a big portion of the money that they’re getting that week. It’s not easy. It’s not easy to do that. (Participant 10 GP)
Use of Care Plus
Once they've registered with a nurse they then are entitled to three appointments with the GP for [NZD] $15.50 and they can use that as they choose. It has to be about their medical problem. (Participant 8 PCN)
We've identified people in our practice who qualify under the Care Plus funding scheme or the High User Health Card, to have regular input free of charge to them. We use that money, we don't charge our patients and they get two hours of free nursing time a year. Usually in four half an hour visits, but we can tailor it to the individual needs. And they are assigned a specific nurse. We have a care plan screening questionnaire, a good assessment of them, where they're at and what their needs are and what help they've got. And the nurse assigned to that particular patient, the idea is that we build a relationship with them and if they have a hospital admission or their spouse has a hospital admission or one of them is ill, or the circumstances change, or just to support people better. (Participant 3 PCN)
What we've been trying to do for years is actually use the Care Plus funding in some way, which is actually quite difficult, as you're probably aware …. rather than [it] just be … an extra on top of people's care, to actually to use it to fund chronic disease management per se and to pull that in as a funding element for a new system … But it didn't work, A) because that's an enormous task, and we didn't have the resources and the ability to do that, B) there was no direct funding for that [chronic disease management] (Participant 4 GP)
Care Plus is a pretty crude tool. You only need two long-term health conditions. It could be hypothyroidism and hypertension, you know, pretty straightforward conditions, really, so you get these people who are basically well, coming in every three months for their pills, and then people with eight conditions, who really need it. (Participant 10 GP)
For example, if I say, "Come back in two weeks to get your blood pressure checked," it's quite likely that they will just wait until the next routine visit, when their pills are running out, and then once again they'll use a Care Plus visit and get it cheaper. (Participant 9 GP)
Fragmentation of health care provision
We had a blood pressure clinic and you [practice nurse] did your blood pressure. The respiratory clinic, and you did your respiratory, and so on. You only did a little bit of this, that, and the other. You didn't see the whole picture. (Participant 13 PCN)
I think the concept of chronic disease management is a laudable prospect that should be delivered in primary care should be supported. I think rolling more of those ancillary services that are really designed for chronic disease management … needs to come into that area [primary care] … we need a philosophical shift as well..” (Participant 4 GP)I think it's actually early days in the whole scheme of it [chronic disease management] - at the moment [we are] trying to change the culture of the separate conditions. (Participant 13 PCN)
The trouble is at the moment there’s no viable model about sharing which would allow us to proceed and obviously because we’ve got two different kinds of systems and not really kind of integrated so it’s a difficult one. (…) The trouble is that specialist medicine doesn’t appreciate a shared model of care really. (Participant 12 GP)