Reform and counter reform: how sustainable is New Zealand's latest health system restructuring?

Hospital avoidance: an integrated community system to reduce acute hospital demand

Background:

Growth in emergency department (ED) attendance and acute medical admissions has been managed to very low rates for 18 years in Canterbury, New Zealand, using a combination of community and hospital avoidance strategies. This paper describes the specific strategies that supported management of acutely unwell patients in the community as part of a programme to integrate health services.

Intervention:

Community-based acute care was established by a culture of close collaboration and trust between all sectors of the health system, with general practice closely involved in the design and management of the services, and support provided by hospital specialists, coordination and diagnostic units, and competent informatics. Introduction of the community-based services was aided by a clinical guidance website and an education programme for general practice teams and allied health professionals.

Outcomes:

Attendance at EDs and acute medical admission rates have been held at low growth and, in some cases, shorter lengths of hospital stay. This trend was especially evident in elderly patients and those with ambulatory care sensitive or chronic disorders.

Conclusions:

A system of community-based care and education has resulted in sustained gains for the Canterbury health system and freed-up hospital resources. This outcome has engendered a sense of empowerment for general practice teams and their patients.

Barriers to cervical screening among Pacific women in a New Zealand Urban Population

BACKGROUND

In Aotearoa/New Zealand cervical screening programmes have reduced cervical cancer; however, half of cervical cancer cases among Pacific women are found among clients who had not attended cervical screening. Hence, we set out to determine health provider perspectives on barriers that prevent their services reaching Pacific women within Aotearoa/New Zealand.

MATERIALS AND METHODS

Twenty semi-structured interviews were conducted with health care providers, Pap smear takers and community workers in the Wellington region. Participants were asked their views on factors that enabled and/or constrained the participation of Pacific women in their cervical screening services.

RESULTS

Six interrelated themes influencing participation in cervical screening among Pacific women in the Wellington region were apparent: the funding and practice of service delivery; family always coming first; the cost of screening services; type of employment; the appropriateness of information; and attitudes to self and screening.

CONCLUSIONS

Determining specific ethnic group actual health needs and meeting them contributes to overall improvement in New Zealand's health status. The results identified the need for improvements to the delivery of screening services including adapting cervical screening services to the requirements of Pacific women through more outreach services at alternate clinic hours; culturally appropriate practitioners; the ability to take up opportunities for health checks and foster long-term relationships; as well as appropriate monitoring and evaluation of approaches. Funding and reporting relationships also need to be compatible with the goal of improving outcomes for Pacific women. Further research into client voices for their particular needs to compliment the service provider perspective as well as minority groups is called for.

Stresses experienced by psychiatrists and their role in burnout: a national follow-up study

BACKGROUND

Many studies have looked at sources of stress in psychiatrists, yet the role played by different factors in the causation of burnout in psychiatrists remains unclear. We had two aims, first, to develop a predictive model for the onset of burnout. Second, we aimed to study the differences in the perception of what caused stress between psychiatrists who rated themselves high on Emotional Exhaustion compared to those who rated themselves as low on Emotional Exhaustion.

METHODS

A previously described questionnaire that identified stressors relevant to consultant psychiatrists was mailed out to 426 psychiatrists, with 240 replies. Scores on the Emotional Exhaustion dimension of the Maslach Burnout Inventory were available for 131 respondents.

RESULTS

Based on an earlier literature review, the Sources of Stress Questionnaire (SOS-Q) used in the study had 45 factors, categorized into predisposing, precipitating, perpetuating and protective factors for burnout in psychiatrists. Of these, factor analysis identified 11 non-correlated factors which were used in the final analysis of this study. Four factors emerged as associated with burnout in psychiatrists in New Zealand: too much work; working long hours; an aggressive administrative environment; and lacking support from management. Two factors negatively correlated with Emotional Exhaustion were a high level of job satisfaction and/or enjoyment, and low pay compared to other countries.

CONCLUSIONS

Most factors associated with burnout are preventable and can be managed jointly between psychiatrists and administrators. Service providers need to address burnout seriously.

New Zealand's Primary Health Care Strategy: early effects of the new financing and payment system for general practice and future challenges

Since 2001, implementation of a New Zealand's Primary Health Care Strategy (the Strategy) has led to an increase in the proportion of primary health care services which are publicly funded, the development of 82 primary health organisations (PHOs) to oversee primary health care services and universal public capitation funding of PHOs. This approach has replaced the previous system of fee-for service targeted public subsidies paid to individual general practitioners (GPs). Patient copayments, although at a reduced level but still set by individual practitioners, have remained a core feature of the system. This paper focuses on the implementation and impact of key policy changes over the first five years of the Strategy. Although patient copayments have fallen and consultation rates have increased, the new funding and payment system has raised a number of unresolved issues - whether to retain the new universal funding system or revert to the former targeted approach; how to achieve the potential gains from capitation when GPs continue to receive their income from a variety of sources and in a variety of different ways; and how to manage the potential for 'cream skimming'. Recent improvements in access may, in time, improve health status and reduce inequalities in health, but there is no guarantee that a universal system will necessarily improve average health or reduce inequalities. Much depends on the services being delivered and the populations that are benefiting most - something New Zealand needs better evidence on before determining future policy directions in primary health care.

Reforming primary health care: is New Zealand's primary health care strategy achieving its early goals?

Background

In 2001, the New Zealand government introduced its Primary Health Care Strategy (PHCS), aimed at strengthening the role of primary health care, in order to improve health and to reduce inequalities in health. As part of the Strategy, new funding was provided to reduce the fees that patients pay when they use primary health care services in New Zealand, to improve access to services and to increase service use. In this article, we estimate the impact of the new funding on general practitioner and practice nurse visit fees paid by patients and on consultation rates. The analyses involved before-and-after monitoring of fees and consultation rates in a random sample of 99 general practices and covered the period from June 2001 (pre-Strategy) to mid-2005.

Results

Fees fell particularly in Access (higher need, higher per capita funded) practices over time for doctor and nurse visits. Fees increased over time for many in Interim (lower need, lower per capita funded) practices, but they fell for patients aged 65 years and over as new funding was provided for this age group. There were increases in consultation rates across almost all age, funding model (Access or Interim), socio-demographic and ethnic groups. Increases were particularly high in Access practices.

Conclusion

The Strategy has resulted in lower fees for primary health care for many New Zealanders, and consultation rates have also increased over the past few years. However, fees have not fallen by as much as expected in government policy given the amount of extra public money spent since there are limited requirements for practices to reduce patients' fees in line with increases in public funding for primary care.

The unintended consequences of New Zealand's primary health care reforms

In 2001, the New Zealand government commenced a program to reform the organization of publicly funded primary care services. While there have been several positive results of this reform, including the reduction of patient co-payments and the extension of the range of primary care services, the government's program was a hastily implemented attempt to place primary care, the delivery of which is dominated by private doctors, under firm state control. It was also an attempt to override preexisting arrangements. As such, the government succeeded in its goal of establishing new primary health organizations (PHOs), but there were also significant unintended consequences. As detailed in this article, these consequences include (1) the creation of a labyrinthine funding and organizational system with a variable capacity to deliver on the government's reform objectives, (2) an increase in the power and scope of preexisting doctor organizations combined with a government unable to wrest control over the setting of patient co-payment levels, and (3) an emerging lack of clarity about future directions for the primary health care sector.

Burnout and job satisfaction in New Zealand psychiatrists: a national study

OBJECTIVES

To estimate the prevalence of burnout and the level of job satisfaction among New Zealand psychiatrists, and to ascertain relationships between socio-demographic variables, job satisfaction and burnout in the target population.

METHOD

In phase one of the study a postal survey was mailed out to every practising psychiatrist on record as well as all doctors working in psychiatry without specialist qualifications (MOSS). Three questionnaires were used: a socio-demographic questionnaire, the Maslach Burnout Inventory (MBI) and a Job Diagnostic Survey (JSS). Regression analysis was performed on returned data sets using socio-demographic characteristics as explanatory variables and score components of the MBI and JDS as the outcome measures.

RESULTS

The results showed that the prevalence of burnout in New Zealand psychiatrists is cause for concern. Two-thirds of all psychiatrists described moderate to severely high levels of emotional exhaustion, with a similar proportion describing low levels of personal accomplishment. Depersonalisation did not appear to be a major problem in the population. Job satisfaction remained relatively high despite the high prevalence of burnout, although there was a relationship between burnout and job satisfaction scores.

CONCLUSIONS

This study has demonstrated a high prevalence of burnout and factors associated with it among New Zealand psychiatrists. Further research is needed to ascertain why job satisfaction remains high in the presence of burnout, and factors predisposing to, or protective of, burnout.

Psychiatrists in New Zealand: are they burning out, satisfied at work and, in any case, who cares?

OBJECTIVE

To explore possible contributing or mitigating factors for burnout in New Zealand psychiatrists as well as future research directions in this area.

METHOD

A selective review of the literature pertaining to burnout and reports regarding New Zealand's medical workforce.

RESULTS

Possible factors contributing to burnout in New Zealand psychiatrists include rapid changes in the country's health system, the challenge of recruiting and retaining psychiatrists, poor distribution of staff and funds and difficulties in psychiatric training. Potential protective factors against burnout include lifestyle factors, long experience in psychiatry, proposed long lengths of career in New Zealand and potentially positive changes in the health system. Research challenges include subject recruitment, the lack of exploration of personal protective factors and completing longitudinal studies.

CONCLUSIONS

Given the current state of knowledge, it would be difficult to accurately know whether New Zealand psychiatrists were burnt out or satisfied with their work. Carefully designed studies would help to clarify this issue.

Continuity through change: the rhetoric and reality of health reform in New Zealand

New Zealand, like most other developed economies, has struggled to establish the best way of organising and delivering publicly financed health care services. Before the 1990s, hospitals and some related services were planned and provided by regionally based, locally elected health boards. This system was replaced in 1993 with a quasi-market structure in which separate organisations were responsible for the purchasing and provision of services. This in turn was replaced in 2001 by a system of locally elected boards that is remarkably similar to that which existed in the 1980s. The change to and subsequent abandonment of the quasi-market structure implies major changes to the way that health services are organised in New Zealand and suggests policy U-turns in (at least) three key areas: from cooperation to competition (and back); from integration of the roles of purchaser and provider to contractual arrangements (and back); and from local decision-making to centralised decision-making (and back). The aims of this paper are to examine the depth of system change in practice and to consider the extent to which the stated goals of reformers have disguised the degree of continuity between reform eras. We conclude that simplistic distinctions between structural approaches often fail to capture salient influences upon decision-making. New Zealand has not, in fact, been "to market and back" as the rhetoric would have us believe. Key aspects of the health system have endured throughout the reform period and these arguably have more importance for system functioning and performance than the high-level structural changes.

Clinicians' reported use of clinical priority assessment criteria and their attitudes to prioritization for elective surgery: a cross-sectional survey

OBJECTIVES

To explore the attitudes of clinicians working in New Zealand publicly funded hospitals towards prioritizing patients for elective surgery, and their reported use of clinical priority assessment criteria (CPAC).

DESIGN

A cross-sectional study using a postal questionnaire. The questionnaire drew on themes identified from an earlier qualitative study. Questions were closed and information was sought about perceptions of the need to prioritize patients, effective ways of doing so and the use of CPAC.

SETTING

New Zealand.

PARTICIPANTS

A national sample of cardiologists, cardiac, general and orthopaedic surgeons, and registrars.

RESULTS

Three hundred and thirty-two clinicians responded to the survey (74.1%). Respondents generally agreed that a nationally consistent method of prioritizing patients for surgery was required but felt their clinical judgement was the most effective way of prioritizing patients. Current CPAC were considered to be administrative tools and there was marked variation in their reported use. Consistent use of CPAC using the constructs provided was more likely to be reported by cardiac specialists than general or orthopaedic surgeons. Other features of the hospital system in which surgeons worked also had a major impact on access to elective surgery.

CONCLUSIONS

Clinicians recognized the need for a nationally consistent method of prioritizing patients. Although most did not consider current CPAC were effective in achieving this, many felt there was some potential in further development of tools. However, further development is problematic in the absence of objective measures of need and ability to benefit.

New Zealand's psychiatrist workforce: profile, recruitment and retention

OBJECTIVE

New Zealand is suspected of sharing other countries' difficulties of having inadequate numbers of practising psychiatrists and attracting psychiatrists to work outside its main urban centres, but there is no contemporary data on the socio-demographic and professional practice profile of its psychiatrists. This paper highlights some interesting trends about New Zealand's psychiatric workforce.

METHOD

A postal questionnaire was sent to all actively practising vocationally registered psychiatrists with a New Zealand mailing address requesting information about basic demographic data, professional training experiences, current professional status, practise intentions, why they chose to work where they do and what factors might influence them to leave for another region of New Zealand or overseas.

RESULTS

Of the 277 doctors on the vocational register for psychiatry, 159 responded, giving a response rate of 59.8%. Most psychiatrists were male (n = 102; 64.2%), European (n = 144; 90.6%), aged between 41 and 60 (69.2%), born overseas (n = 90; 56%), had English as their primary language (n = 142; 89.3%) and were in a long-term relationship with dependent children (n = 99; 62.3%). Nearly all (n = 149; 95%) did their psychiatry training in a metropolitan area and most (n = 108; 67.9%) held the Fellowship of the Royal Australian and New Zealand College of Psychiatry (FRANZCP). Most worked in a metropolitan area (n = 136; 85.5%) and either wholly or partly in the public sector (n = 145; 93%). Nearly one-quarter expected to retire over the next decade. Professional factors were rated more important as a reason for staying by metropolitan psychiatrists compared with their non-metropolitan counterparts (p < 0.001). Psychiatrists who did not have an FRANZCP (57%vs. 27%, p = 0.05), those who had spent more than 50% of their professional life in New Zealand (86%vs. 74%, p = 0.02) or those who had obtained their primary medical degree outside New Zealand were more likely to be in non-metropolitan areas (81%vs. 49%, p = 0.04). Metropolitan psychiatrists rated personal and social reasons more highly than non-metropolitan psychiatrists did for factors which might induce them to leave for another area, whereas professional development was ranked lower.

CONCLUSIONS

This is the first contemporary study of New Zealand's psychiatric workforce and it highlights some interesting trends and has significant implications for those concerned with the recruitment and retention of psychiatrists. Further investigation is suggested, as a more complete picture of New Zealand's specialist psychiatric workforce would be gained by including psychiatrists who are not vocationally registered.

Romanow, Kirby and Courchene: Canada's health system--a moral or a business enterprise?

This paper examines Thomas Courchene's argument that Senator Kirby was closer to the truth than Commissioner Romanow when Kirby argued that Canada's healthcare system is only sustainable though introducing more private investment. The paper finds that Romanow's position, and indeed the nature of Canada's healthcare system, have been misrepresented by those seeking a larger private market share. The paper concludes the balance of evidence supports Ramanow, not Kirby.