Primary and community health services are lagging
According to a recent news item, District Health Board deficits are set to expand to around $500 million for the year, a substantial sum on a total annual health budget of about $20 billion.
Perhaps this is to be expected after a decade of a funding squeeze, and the current Government is to be applauded for its larger Budget allocations to health.
But is the money going to the right places in the health system?
Hospital services seem to be the main beneficiaries, and yet there is a very substantial and important primary and community sector that has lagged well behind in funding and staffing. This points to a weakness in our funding system.
This is not only a funding system issue. It also relates to a delivery model. We need to become less reliant on costly hospital structures, and move to a model that can provide the same services — but “closer to home”, at the level of family doctor, health centre, and other services between hospital and community.
This approach is already working overseas. Denmark — a country of a similar population size — has reduced the number of hospitals over the past 20 years from 98 to 32. This involved moving to a greatly expanded primary care system.
Britain’s National Health Service uses more than three times the number of acute hospital bed days for over-65s compared with the Kaiser Permanente in the US, a large non-profit, primary careled organisation that uses active clinical management by co-operating specialists and primary care doctors.
As it is, apart from emergency and acute admissions, most of our public hospitals have much-reduced operational capacity at weekends, which suggests some reallocation of services outside hospitals is possible. So, how could this work in practice? I suggest the following.
Improve the capacity of the primary and community sector by grouping up, combining multidisciplinary teams, enhancing the deployment of upskilled practice nurses, and providing local diagnostic facilities together with intermediate-level services such as observation and social-care respite beds, and care delivered in the home.
Reduce hospital admissions by targeting disorders that can be treated in the community and by providing a comprehensive, affordable “after-hours” care service.
Move those in-hospital procedures that can be so treated to a day-stay approach, and, where possible, shift outpatient visits either to family doctors or to mobile and “virtual” specialist and nursing services.
Develop common contract terms and shared clinical pathways across the sector, and reduce inter-sector competition and boundaries to increase the availability of flexible solutions.
Ensure IT services that can work across sectors and systems, telephone triage services, along with IT innovations such as shared electronic records (with patients too) and comprehensive practice enrolment systems that facilitate prevention, screening and health maintenance.
There are elements of all of these operating at present, but we need to bring it all together.
A major part of that would mean committing to a more functional alliance framework between the hospital sector and the Primary Health Organisations, putting them at the front of health service delivery — a requirement that should be written into district health board chief executives’ performance expectations.
Also, Government needs to look again at the primary care funding formula to facilitate new and more efficient models of care while retaining continuity of care.
And, if we are looking for an area where this reinvigorated alliance framework might start its work, “after hours” care is an obvious field of common interest between the primary/community and hospital sectors.
Auckland consumers should not have to resort “after hours” to expensive commercial facilities or inconvenient hospital emergency departments for conditions that they would normally take to their family doctor.
This could be the testing ground for a new health and social care alliance in the region. Once proven, it could then be repeated for other services that can be brought “closer to home” and better tailored to Ma¯ ori, Pasifika and other populations with inequitable outcomes.