Towards integrated care in New Zealand:

opportunities and challenges

Professor Jackie CummingDirector, Health Services Research Centre

School of GovernmentVictoria University of Wellington

• As in other countries, NZ health services are fragmented

• This results from service users working with a wide range of health professionals working in a wide range of organisations

• Lack of information sharing, liaison and team work are then seen to result in lack of co-ordination of care

Fragmented Care in NZ

Integrated Care Definitions in NZ (1)• NZ has a long history of aiming to better integrate care –

at least since the Social Security Act 1938

• ‘Integrated care’ is not always well defined in NZ:

o Achievement of ‘co-ordinated care’ from patient perspective, i.e. ‘smooth and continuous transition between services’ and a ‘seamless journey’ for service users

o Collaboration and co-operation across services, from a provider perspective

Integrated Care Definitions in NZ (2)• Linked to good access to primary health care (PHC)

providers, seen to be the lead co-ordinators of care• Can refer to the linking of key planning, funding and service

delivery activities to support co-ordination• Can mean integrated service delivery organisations providing

a wide range of services to enrolled populations working within a single budget

• Integration across a level of care (eg, across PHC) (‘horizontal’ )• Integration between PHC & secondary (hospital) care (‘vertical’)• Integration across health & social development services (‘inter-

sectoral’)

Barriers to Integrated Care in NZ• Separation of roles in planning leading to duplication and gaps;

different criteria for accessing services limiting access• Barriers to access to PHC, from user fees• Barriers to PHC providers leading co-ordination, from fees and

private provision• Lack of information sharing and liaison could see users slip

through gaps, be seen by multiple providers, information not be shared or go missing, tests duplicated, harm from eg incompatible medicines, different health advice from providers

• Overall, poor quality of care and waste of scarce health resources

Attempts to Better Integrate Care in NZ (1)

• Many reports on NZ health system noted issues from fragmentation, proposed better integration

• Many actual reforms emphasised integration of planning and funding; service budgets; service planningo Eg, Establishment of Area Health Boards in the 1980s – planning and

funding of pubic health and secondary careo Eg, Regional Health Authorities / Health Funding Authority – planning

and funding for all health and disability services

• Most emphasis on integrating government-owned organisations to this point

Attempts to Better Integrate Care in NZ (2)

• NZ seriously began focus on integration for service delivery / clinical services in 1990s

o Eg, Development of Independent Practitioner Associations who could integrate care horizontally across PHC providers and work with hospitals to vertically integrate care

o Eg, Focus on service delivery and clinical integration through HFA national integrated care pilots

Attempts to Better Integrate Care in NZ (3)

• 2000s Primary Health Care Strategy had better integration as a key objectiveo Reducing fees patients pay to improve access to PHCo Development of Primary Health Organisations to co-ordinate care horizontally

and verticallyo Strengthening role of PHC in the health systemo Encouraging team work and better co-ordination across providers

• However, Primary Health Care Strategyo Seen to focus on development of new organisations (DHBs and PHOs) and

population health focuso Insufficient attention to service delivery and clinical integrationo Failure to identify what a comprehensive model of PHC might look like and how

it might be delivered

Attempts to Better Integrate Care in NZ (4)

• At the same time, some policy moves likely to have increased fragmentation from expansion of range of providers

• Eg, Deinstitutionalisation in mental health and older people’s care

• Eg, Growth in independent midwifery

Data and Research?

• Little data and research

• Especially on views of service users

• Hence, not entirely clear where we most need to pay attention to improve care for service users

Sicker Adults

Experienced Coordination Gaps in Past Two Years

UK SWIZ NZ AUS NETH SWE CAN US NOR FR GER0

20

40

60

80

20 2330

36 37 39 40 42 43

53 56

Percent

* Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share important information with each other, specialist did not have information about medical history, and/or regular doctor not informed about specialist care.Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

UK US SWIZ CAN NZ AUS GER NETH SWE NOR FR0

20

40

60

80

100

26 29

48 50 51 5561

66 67 71 73

Percent

* Last time hospitalized or had surgery, did NOT: 1) receive instructions about symptoms and when to seek further care; 2) know who to contact for questions about condition or treatment; 3) receive written plan for care after discharge; 4) have arrangements made for follow-up visits; and/or 5) receive very clear instructions about what medicines you should be taking.Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

Any Gaps in Hospital or Surgery Discharge in Past Two Years

Adults

15

11 1310

17

11

22

12

26

15 14 16

0

10

20

30

40

AUSCAN FR

GERNETH NZ

NORSWE

SWIZ UK US

Gaps in Coordination of Specialist Care

16

22 2017

15

3033

2623

16

22

AUSCAN FR

GERNETH NZ

NORSWE

SWIZ UK US

Specialist did NOT have reason for visit/tests from regular

doctor

Regular doctor NOT up-to-date about specialist care

Percent

Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.

Base: Saw specialist in past two years and has regular doctor/place of care.

66 68

51

63

35

69

55

26

55

68 69

0

25

50

75

100

AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US

Regular Doctor Co-ordinates Care Received from Other Doctors and Other Places

Percent reporting doctor always/often coordinates or arranges care

Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.

Base: Has regular doctor/place of care.

PHC Doctors

NZ SWE NET SWIZ NOR FRA UK US AUS GER CAN0

20

40

60

80

100

55 52 49 49 4539 38

31 2722

14

PercentDoctor Can Electronically Exchange Patient Summaries

and Test Results with Doctors Outside their Practice

Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

PercentPractice Uses Nurse Case Managers or Navigators

for Patients with Serious Chronic Conditions

UK NETH NZ SWIZ AUS NOR CAN US SWE GER0

20

40

60

80

100

7873

68 6859

5144 43 41

20

Note: Question asked differently in France.Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

Primary Care Doctors’ Receipt of Information from Specialists

Percent said after their patient visits a specialist they always receive:

AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US

Report with all relevant health information

32 26 51 13 13 41 26 12 59 36 19

Information about changes to patient’s drugs or care plan

30 24 47 12 5 44 22 13 44 41 16

Information that is timely and available when needed

13 11 26 4 1 15 4 8 27 18 11

Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

GER NZ US NET SWIZ AUS UK SWE CAN NOR FRA0

20

40

60

80

100

67

56

45 42 40 36

21 2115 14 10

PercentAfter Hospital Discharge, Primary Care Doctor Receives Needed Information to

Manage the Patient Within 48 Hours

Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

Proposed New Patient Experience Survey…

Will examine within hospitals,• Consistency in information provided by different doctors and nurses• Explanations about health and health care after arriving home• Whether service user felt they received enough information to

manage condition on discharge• Explanation of purposes of medicines that was understood by

service user• Medication side effects to watch for• Information to family/whānau • Sufficient care and assistance after leaving hospital• Who to contact if have worries after leaving hospital• Service user receive copies of letters between hospital doctors and

GP

“New models of care which see the patient rather than the institution as the centre of service delivery and which aim to promote a more seamless patient journey across community, primary, and hospital sectors, greater use of primary and community care, and the shifting of care ‘closer to home’.”

(‘Better, Sooner, More Convenient’)

Integrated Care in NZ – The Present (1)

Integrated Care in NZ – The Present (2)

• Emphasis now ono Encouragement of joint regional and district leadership and

decision-makingo Devolution of funding and services from hospitals to PHC settingso Amalgamations of eg PHOs to strengthen leadership and

capability in service developmento Integrated Family Health Centreso Improved information systems to share informationo Whānau ora

• But also moves to expand prescribing rights and extend role of pharmacists

Integrated Care in NZ – The Present (3)

Little is known about these initiatives • Extent of information sharing• Extent of co-location of services• Extent of going beyond the above to agreed

pathways, co-ordination/navigation roles, team decision-making

• Service users’ views on whether there is better integration from their perspectives

• Overall impact of changes

We need• Research on types of integration being achieved or not

being achieved• Measures to assess integration from both provider and

service user perspectives within and across service delivery organisations

• Research on impact of integrating processes• Research on barriers and enablers to better integration• Discussion on integration vs expanding access through

new provider roles (role of choice and competition)

ReferencesCumming, J. (2011) Integrated Care in New Zealand. International Journal of Integrated Care (11, 18 November).Smith, J. (2009) Critical analysis of the Primary Health Care Strategy ad framing of issues for the next phase. Wellington, Ministry of Health. Ryall, T. (2007) Better, sooner, more convenient: health discussion paper. Wellington; National Party of New Zealand.Russell, M., Cumming, J., Slack, A., Peterson, D., Gilbert, A. (2003) Integrated care: reflections from research. In Gauld, R. (ed) Health care management and delivery in New Zealand. Dunedin: Otago University Press, pp. 201-313.Health Services Research Centre, Te Rōpū Rangahau Hauora A Eru Pōmare. (2001) Evaluation of the national demonstration integrated care pilot projects: overview report. Wellington: Health Services Research Centre.Commonwealth Fund International Health Policy Surveys: http://www.commonwealthfund.org/Surveys/View-All.aspx?topic=International+Health+Policy