The Waimarino Review
A discussion document prepared by the Health Funding Authority and Good Health Wanganui
March 2001 Published in March 2001 by the Ministry of Health PO Box 5013, Wellington, New Zealand
ISBN 0-478-24329-4 (Book) ISBN 0-478-24332-4 (Internet)
This document is available on the Ministry of Health’s Web site: http://www.moh.govt.nz
Contents
Introduction 1 Overview 1 Have your say! 2
Background 4 Contract 4 Waimarino 4
Review Process 6
Community Input 7 Service issues 7 Stakeholder meetings 7 Hui 7
Demographic Analysis 9 Age structure 9 Mäori population 10
Socioeconomic Information 12
Review Findings 14
Recommendations 15
Implementation Process Outline 18
Appendices Appendix 1: Waimarino Stakeholders Group Terms of Reference 19 Appendix 2: Current HFA Funded Waimarino Services 20 Appendix 3: Primary Services Options and Issues 22 Appendix 4: Proposed Waimarino Health Services Advisory and Monitoring Group 27 Appendix 5.1 29 Appendix 5.2: Expected GHW Outpatient and Community-based Services for Waimarino Population 31 Appendix 5.3: Non-GHW Health Providers, Waimarino Region 35
iv The Waimarino Review
The Waimarino Review v
Introduction
The purpose of this document is to inform the people and service providers in the Waimarino of recommended changes to health service delivery at the Waimarino Health Centre in Raetihi, and of proposed new services for the region. The need for these changes has been identified through a review process that is described in the document.
Overview
The principal recommended change is to enhance existing service provision and establish new primary care services using the funding formerly applied to the inpatient service at the Waimarino Health Centre. This proposed change will provide a better match of service provision against priority health needs for the area. The proposed new services will include: ?? an additional GP ?? a telephone triage and assessment service ?? an enhanced transport and accommodation policy for people travelling to Wanganui for services previously provided at the Centre ?? establishment of a school clinic at Ruapehu College ?? support for a local health service advisory and monitoring group to advise the funder and otherwise influence and ensure coordination of health service provision in the Waimarino.
Potential also exists for: ?? enhanced public health/health promotion activities ?? enhanced mental health services (in conjunction with a rural mental health service delivery pilot project).
It is not proposed to change the current provider of existing outpatient, maternity, therapeutic and diagnostic services at the Health Centre. However it is possible that the information in this document may initiate some changes in volumes or methods of delivery of these services.
This document has been distributed to all those who attended the stakeholder meetings held during the review process, other interested parties, and to all health service providers in the Waimarino area.
Copies will also be available at the Health Centre in Raetihi and the Ruapehu Information Centre in Ohakune. Additional copies can be obtained from the Ministry of Health website (www.moh.govt.nz) or from the contact addresses and phone numbers overleaf.
The Waimarino Review 1 Have your say!
We would appreciate your opinion on the recommendations in the report and on the proposed new services. You can let us know your opinion by coming to the public meetings or hui that will be held in the area (dates and locations will be advised separately).
You can also contact us by mail, e-mail or phone at the following addresses and numbers.
Mail address FREEPOST 152367 MINISTRY OF HEALTH PO BOX 4212 WHANGANUI
e-mail address [email protected]
Phone Marilyn Rimmer at either of these numbers: - 06 345 2900 025 924 312
Please include in your written or e-mail response: ?? your (or your organisation’s) name, address and contact details (so we can ask you for more details if necessary) ?? whether you are happy for your (or your organisation’s) name to appear in a list of responses to the final document ?? how many people were involved in the preparation of your response.
Please make sure that we receive your responses by
th 5 pm on Thursday 12 April 2001
This will ensure that we have time to consider them before issuing the final report and recommendations.
Notes: Throughout this document ‘HFA’ means the Health Funding Authority – the government body that purchased services from GHW and other providers.
‘GHW’ means Good Health Wanganui, the Hospital and Health Service (HHS) responsible for the Waimarino during the time this document was being prepared.
With the enactment of the New Zealand Public Health and Disability Bill the HFA ceased to exist, and the Whanganui District Health Board came into existence.
The HFA’s responsibilities in regard to the implementation of changes proposed in this document have been taken over by the Ministry of Health and the Whanganui District Health Board.
2 The Waimarino Review
The Waimarino Review 3 Background
Contract
In 1999 the HFA and GHW signed a three-year contract for rural health services. Part of the contract provided for a 24-hour seven-day inpatient service at the Health Centre in Raetihi, as well as a range of outpatient clinics and some other services.
The contract agreement included provision for a review of both GHW rural health services (Waimarino and Taihape) during the 1999/2000 financial year.
Waimarino
The Waimarino district consists of the three small rural communities of Raetihi, Ohakune, and Tangiwai. National Park forms the northern boundary. The current population is approximately 4000. Waimarino has a relatively young population, and in Raetihi, where the Health Centre is located, Mäori make up around 50 percent of the population. The population structure, and how it varies from the GHW mean, is shown later in the demographic analysis.
For a long time the Waimarino district has been served by the local GPs, a rural hospital in Raetihi and base services for more complex cases at Wanganui. The present Health Centre in Raetihi was commissioned in 1994 to replace an older facility. It was built to house a three-bed medical inpatient service open 24 hours seven days a week, a two-bed birthing unit, and a wide range of outpatient and visiting clinical specialist facilities.
In 1996 access criteria were changed to exclude admissions to the Centre for social reasons. In the case of children, since the 1990s only patients with very minor conditions have been admitted to the Centre because of concerns about clinical safety issues in this isolated facility.
As a result of these changes the inpatient nurses in the Centre often had no patients to look after. The occupancy rate averaged 23 percent for the year 1999/00 with only one GP using the inpatient service for admissions. In addition, a GHW audit found that many of the admissions that the inpatient service did have were clinically inappropriate being minor problems not usually managed through inpatient admission.
Two GPs practice in the area, one each in Ohakune and Raetihi. However some local people have been using the Health Centre as a default GP service for minor injuries and medical problems despite the fact that GHW is not contracted or funded to provide a service of this type.
4 The Waimarino Review All of these factors had a significant impact on GHW’s ability to attract staff and retain them in Waimarino. Nurses felt there was little chance of being able to develop, maintain, or use appropriate clinical skills in this limited situation.
On 31 May 1999 GHW advised the HFA that it would have to reduce medical inpatient services due to staff leaving and an inability to recruit replacements. From June 1999 the medical beds closed from 3 pm Saturday until 8 am on Monday, continuing to provide 24 hour availability through the week.
The HFA agreed to waive any contract penalty in the interim but required GHW to ensure that appropriate communication and support systems were established to minimise the risk to the community. GHW was also instructed to report progress to the HFA every two months.
In August 1999 GHW advised that despite an extensive recruitment drive the staffing issue remained unresolved and that the reduced operating hours would need to remain.
On 18 October 1999 GHW signalled that the review of rural health services was now urgent as the registered nurse staffing levels at Raetihi had reduced to 1.8 full time equivalents (FTE) from the full establishment of 5.0 FTEs. By the end of October 1999 the Centre opened only five days a week, from 8 am until 5 pm. The HFA agreed that GHW could provide a reduced inpatient medical service on a temporary basis.
GHW is still technically contracted to provide a 24-hour seven-day inpatient service at Waimarino. To maintain this the Centre would need to have 3.2 FTE additional registered nurses to meet the minimum safe staffing level required by the Ministry for 24-hour operation. Despite regular advertising over a 20-month period GHW has been unable to attract the necessary staff for the Waimarino inpatient service.
The HFA acknowledges that GHW has attempted to address the situation in the Waimarino, and that recruitment and retention of suitably qualified clinical staff in rural areas is a major national and international issue.
The Waimarino Review 5 Review Process
The overriding principles for the review process were: ?? to ensure the future services are responsive to the Waimarino community ?? to ensure equity of access, funding and costs, and opportunities ?? to ensure greater accountability for all public health expenditure ?? to ensure cost effectiveness, sustainability and clinical safety of services ?? to encourage innovation.
To these ends the HFA adopted a process designed both to ensure community buy-in and support for future service provision in the area, and to develop a profile of services for the area.
The HFA discussed the proposed review process with key individuals and groups including GHW, local providers and community representatives. Apart from a few concerns with the timing there was general support for the review.
Nominations were sought for a key stakeholder group. The HFA also asked for advice from Taumata Hauora, our Treaty partner, on the process for involving Mäori in the review, and implemented their advice by inviting their suggested members onto the stakeholder group. See Appendix 1 for the stakeholder group terms of reference.
The HFA identified the services currently provided (see Appendix 2). The HFA used the stakeholder group, chaired by the Ruapehu Mayor, Mr Weston Kirton, to validate information.
The HFA also produced a demographic analysis of the area to assess the local population’s probable demand patterns. This was combined with the feedback from the local community, and used to develop the new services proposed for the region.
6 The Waimarino Review Community Input
Three stakeholder meetings were held, on 30 November 1999, 16 December 1999, and 17 February 2000.
A hui was held at Raetihi on 18 May 2000 to gain local Mäori input independently of the stakeholder meetings.
Two principal concerns became apparent during the review process – with the services that were being provided, and with governance issues around service delivery.
Service issues
It is unlikely that the Waimarino population is fully aware of the range or the volumes of health services that the HFA currently contracts for their region. The expected volumes based on a pro-rata division of GHW’s total contracted services, and some of the volumes that GHW is currently providing can be found in Appendix 5.2. Non-GHW services are in Appendix 5.3.
Stakeholder meetings
The ‘wish list’ derived from the stakeholder meetings included: ?? improved community nursing services ?? improved transport and accommodation allowances ?? proactive integrated GP services, with 24-hour emergency callout.
Hui
At the hui several people voiced concern over the reduction in the inpatient service. However the most valued part of the inpatient service appeared to be the 24-hour availability of the inpatient nurse for minor injury and other GP level cares, even though this was never a part of GHW’s contracted services. The prospect of losing this service was a very real concern.
There were also concerns over perceived high needs for Alcohol and Drug services and child health issues.
The summary of issues from the hui included perceived needs for: ?? a local community mental health nurse
The Waimarino Review 7 ?? improved alcohol and drug services ?? whänau/family targeted education programmes, such as parenting and anger management ?? social worker/s in schools ?? improved oral health needs ?? sexual health services ?? sexual abuse support services ?? improved district nursing services ?? improved midwifery services ?? enhanced Mäori mental health services ?? improved cultural awareness and cultural safety for services delivered to Mäori ?? Whänau Ora programme ?? improved GP support and after hours services, and after hours access to the centre for ancillary services.
There was a general desire for services to be more responsive to Mäori needs, and the principle of ‘services for Mäori delivered by Mäori’ was voiced. The lack of formalised local involvement in the way services are delivered was felt to be a significant issue.
8 The Waimarino Review Demographic Analysis
The Waimarino area comprises census area units Tangiwai, Ohakune and Raetihi (census area unit codes 554900, 555000, 555100). The total normally resident population in these areas at the 1996 census was 3967. This population figure has been agreed with GHW.
Age structure
The census provides details of the age structure of the population in five year bands ie, 0–4, 5–9 and so on up to 80–84. After age 84 the whole population is reported as 85+.
In the first chart below the age structure of the Waimarino population is compared with the age structure of the whole GHW population. The solid line is the Waimarino population, and the dotted line represents the GHW population.
This chart clearly shows that the Waimarino population has more young people and fewer elderly people than the GHW population as a whole.
Clearly this will influence the services needed by the Waimarino region, as different age groups have widely varying needs.
Waimarino population structure and GHW whole population structure Source census 1996
12% Waimarino population Whole GHW population
10%
8%
6%
4% Percentage of popn in age group
2%
0% 00-04 05-09 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Age Group
The actual variation between the Waimarino population and the whole GHW population in percentage terms can also be found. This is shown in the first chart on the next page.
In this chart the horizontal base line marked 0%, about two-thirds of the way up the chart, represents the whole GHW population. The population variation can be read from this line
The Waimarino Review 9 as plus or minus a percentage for each age group – for instance, there are about 20 percent more children in the 0–4 age group in the Waimarino than there are in the general GHW population. The use of ‘normally resident’ figures in this analysis probably caused the apparent dip in the adolescent population, as some of these would have been away from home at boarding school at census time.
Waimarino/GHW whole population per centage variation Source census 1996 30%
20%
10%
0% 00-04 05-09 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+
-10%
-20%
-30%
-40% % variation (+/-) Waimarino/GHW whole population
-50%
-60% Age group
Mäori population
The proportion of Mäori in the Waimarino population is significantly greater than the national average, especially in the younger age groups.
10 The Waimarino Review Waimarino review - percentage of Maori in whole population
100%
90%
80%
70%
60%
50%
40% Percentage in population 30%
20%
10%
0% <1 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 >85 Age group
The localities vary, with Raetihi having the highest proportion of Mäori.
Waimarino Review - percentage of Maori in population by area
100% Tangiwai 90% Ohakune Raetihi 80%
70%
60%
50%
40% Percentage of Maori
30%
20%
10%
0% <1 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 >85
Age group
The high proportion of Mäori in the Waimarino means that Mäori providers would have sufficient volumes of patients for effective delivery of some services. While specialist services should remain with GHW, an opportunity may exist for Mäori providers to develop or extend community-based services in the area.
The Waimarino Review 11 Socioeconomic Information
Tangiwai Ohakune Raetihi New Zealand
Demographics Average (mean) age 32 31 31 35 % people of Mäori ethnicity 30 35 54 15 % people aged less than 15 years 29 28 30 23 % people aged 65 years and over 7 6 11 12 % people not in the labour force 23 27 37 35 % households with children <5 years old 17 22 23 16 % households with one or more 17 12 20 23 superannuitants % households with at least one sole 15 22 31 17 parent family
Income % people receiving Income Support 34 32 43 38 % people gainfully employed full time 55 54 43 46 Average (mean) personal income $20,679 $21,276 $17,645 $21,634 Median personal income $14,946 $16,251 $13,276 $15,603 % with personal income >$30,000 19 24 16 24 Average (mean) household income $36,907 $38,572 $32,675 $43,341 Median household income $30,369 $34,591 $28,141 $34,707
Access % families with no motor vehicle 7 11 27 7 % families with no phone 14 14 21 7
Overall the population is somewhat poorer than the national average, with a greater disparity in Raetihi than in Ohakune or Tangiwai. In the region as a whole there is a higher than average proportion of families without telephones or cars.
These factors, coupled with the remoteness of some localities (especially West of Raetihi) can cause difficulties with access to health services, and indicate that there will be a significant need for mobile services and travel and accommodation assistance.
The young population combined with the areas of relative poverty indicates that there will be significant demand for services used by the children, youths and young (<40) adults. The services most often utilised by these groups are: ?? all paediatric services ?? child and adolescent dental services ?? school health services ?? sexual and family health
12 The Waimarino Review ?? mental health, including acute intervention and crisis respite care ?? alcohol and drug services ?? emergency services.
The high proportion of Mäori in the population needs to be taken into account when choosing service providers.
The Waimarino Review 13 Review Findings
The picture that emerges from the review is one of an area with significant health needs where service provision needs to be more closely matched to the priority health needs of the population.
Primary health services are undersized for the population, access to services can be difficult and cost may be a barrier to service access for many people.
Ngati Rangi, the Pipiriki Health Service and Plunket provide health promotion and illness prevention services, but otherwise the existing health services tend to be reactive in their approach.
A significant number of the local people feel they have no ability to influence the services provided, or the delivery of those services.
The high proportion of Mäori in the area means that Mäori providers would have sufficient volumes for an economic delivery of some services, and that all services need to be culturally safe and presented in an acceptable manner.
14 The Waimarino Review Recommendations
Taking all information into account, we recommend health service changes as detailed in the table below.
Recommendation Rationale
Enhance existing service provision ?? New and enhanced services will better match the and establish new primary care priority needs of the population services using the funding formerly ?? Inpatient services were not used in any volume when applied to the inpatient service at they were available the Waimarino Health Centre. ?? The clinical safety of many admissions was doubtful Enhance access to inpatient because of facility and staffing issues. services at Wanganui base hospital ?? Satisfactory staffing of small isolated rural inpatient units is no longer realistically possible ?? The significant amount of funding allocated to this service can be used to provide enhanced primary services
Service enhancement: ?? Mäori form approximately 40% of total Waimarino Improved responsiveness to Mäori population needs ?? Mäori population recognised as having significant Development and implementation health needs of an action plan that addresses: ?? Mäori representatives identified the need for enhanced ?? continuing commitment to a responsiveness to Mäori needs during review process partnership relationship with providers and key stakeholders ?? cultural awareness and safety ?? Mäori health gains ?? communication and consultation ?? integrated approaches to service delivery
New service: establish a 24-hour ?? People in remote areas have difficulty gaining access telephone triage and assessment to advice or services to help in determining the service urgency of a medical problem or the most appropriate actions to take ?? This service would enhance health outcomes by reducing unnecessary travel, assisting in determining the urgency of the problem and advising on the most appropriate actions
The Waimarino Review 15 Recommendation Rationale
New service: provide a third GP for ?? There is a significant need for enhanced GP services the area, capitated and based in in the area. Raetihi ?? A capitated service could provide primary care at low See Appendix 3 for some issues cost to patients who would otherwise experience cost and options for GP services. barriers to service ?? A capitated practice can operate innovatively and proactively to meet the primary health needs of the local area ?? A purpose built facility is available as a base (the Waimarino Health Centre) ?? A minor assessment and treatment service would operate as a routine part of GP services
New service: establish an ?? Inpatient services will be centralised to Wanganui, so appropriate transport and many people will have to travel to and stay in town accommodation policy (note that ?? Enhanced transport and accommodation allowances the HFA is currently engaged in will help to reduce rural/urban inequities national consultations about transport and accommodation policies)
New service: establish a school ?? School clinics are an effective way of improving clinic at Ruapehu College adolescent health by enabling young people to easily access health services
New service: establish a local ?? Local people need to feel in control of their health health service Advisory and services Monitoring Group, able to influence ?? The service funder for the Waimarino area needs service providers and service expert advice and feedback from local representatives provision in the Waimarino area to guide the provision and development of services See Appendix 4 for more details ?? Local area knowledge and experience will ensure that about the Advisory and Monitoring service provision is better matched to demand Group. ?? The Advisory and Monitoring Group will know what services are contracted for the area, and by whom, and will be in a position to ensure that services are delivered appropriately ?? The provision of services will be directly monitored at the local level ?? Rapid feedback on the provision and acceptability of services will enable service providers to fine tune service provision appropriately ?? Faster responses to changing local needs will be possible ?? Service acceptability will be enhanced by direct local input into control of health resources
16 The Waimarino Review Recommendation Rationale
The DHB should consider further ?? AMG local knowledge of the population and population service enhancements for the area, health needs will provide guidance for the DHB in after taking advice from the AMG. prioritising further service developments These enhancements could ?? DHB establishment philosophy embraces local input include: into development of solutions ?? a mobile minor surgery unit ?? further enhancement of oral and dental services ?? other needs as identified by the AMG
The Waimarino Review 17 Implementation Process Outline
6t March 2001 Circulate review document for comment and submissions
Dates to be advised Public meetings and hui
5 pm, Thursday 12 April Final responses received 2001
Tuesday 22 May 2001 Issue final review document, incorporating responses and comments from Waimarino stakeholders Issue formal notice of service changes as appropriate
June 2001 Implementation of service changes
December 2001 Implementation complete
18 The Waimarino Review Appendix 1: Waimarino Stakeholders Group Terms of Reference
Purpose a) To act as a conduit for accurate information flow during the review process between the HFA and the communities of Raetihi, Ohakune, and Pipiriki. b) To provide advice on how to best meet the priority health needs of the local community. c) To assist in consultation between the HFA and the community.
Roles and responsibilities a) To attend scheduled meetings. b) To confirm current information relating to health services in the area. c) To assist in identification of gaps in service/needs of the communities d) To assist in identification of best option for future health service delivery. e) To assist in community consultation as determined in the Communication Plan. f) Comment on draft proposals and plans. g) Be available to advise HFA on issues during development of strategies.
Meeting schedule
It is anticipated that there will be two meetings: - ?? during week ending 3 December 1999 ?? during week ending 19 December 1999.
In addition it is considered important that group members make themselves available for February as part of a local consultation process
Note: There were in fact three meetings, the extra one being held on 17 February 2000. In addition to these meetings a hui was held at Raetihi on 18 May 2000.
The Waimarino Review 19 Appendix 2: Current HFA Funded Waimarino Services
For some service volumes see Appendix 5.2.
Provider GHW Ngati Rangi Plunket Pipiriki Other/ Community Health independent Service Health Services providers Centre
Alcohol and drug counselling ?
Asthma ? ? ? ?
ATR (assessment and treatment of ? over 65s, DSS assessment)
Child health nurse ? ? ?
Dental ?
Dietician ?
District nurses ?
Facilitation services (child health) ? ?
General Practitioner services ?
Inpatient (service suspended) ?
Maternity ?
Men’s clinic
Mental health (including Crisis team) ?
Occupational therapy ?
Palliative care ?
Physiotherapy ?
Podiatrist ?
Social worker ?
Specialist nurses (asthma educator, respiratory, cardiac, diabetes, ? continence, oncology)
Specialist outpatient clinics (orthopaedic, medical, paediatric, ? gynae/obstetrician, ENT, general surgeon)
Tamariki Ora (Well Child) ? ? ?
Well Child checks ? ? ? ?
Well women’s clinic ? ?
Whänau Ora (well families) ? ?
X-ray ?
20 The Waimarino Review St John Ambulance provides ambulance services for the area. Services are partly funded by the HFA, with other funding coming from the ACC and donations from private individuals.
The Waimarino Review 21 Appendix 3: Primary Services Options and Issues
The Waimarino region currently has two GPs, one in Ohakune and one in Raetihi. Both practices operate on a fee for service (FFS) basis (see ‘notes’ at the end of this section for an explanation of this, and of the capitation system).
The recommended ratio of GPs to population is 1/1400. With the local population at around 4000 the Waimarino is underserviced by GPs.
It is proposed to establish another GP in the area. This will obviously impact on the existing GPs, although if the process is properly managed the impact can be beneficial rather than otherwise.
Some advantages and disadvantages of various GP service models are detailed below.
GP service models Advantages Disadvantages
Current model ?? GPs retain business ?? Area remains underserviced (Two independent independence, current patients ?? High burnout risks because of FFS GPs) and current income onerous on-call rosters ?? Arrangements for existing ?? Limited ability to take advantage patients who are satisfied with of inservice education or services remain in place upskilling ?? No or limited ability to provide integrated services ?? Difficulties in securing payments from some patients ?? Patients with outstanding bills may not access services ?? Gaps or service inconsistencies in primary service provision (immunisation, diabetes, asthma)
22 The Waimarino Review GP service models Advantages Disadvantages
Two FFS GPs as ?? GP/population ratio corrected ?? Most negatives above still exist now, plus a new ?? Arrangements for existing for independent FFS GPs capitated practice patients who are satisfied with ?? Existing FFS GPs may lose in Raetihi services remain in place patients and income ?? More choice for patients ?? May lose one or both existing ?? Capitation could allow services GPs to be provided at lower cost to patients, for example a maximum $5 copayment for a GP visit, with free nurse clinic visits ?? Capitated service will be able to function pro-actively rather than responding to patient demand ?? Potential for mutual cover, but this may be difficult as business structures are different
All three GPs ?? GP/population ratio corrected ?? Existing GPs will have to capitated and ?? Arrangements for existing change business structure and operating patients who are satisfied with practices independently services remain in place ?? Existing GPs retain income ?? More choice for patients ?? Capitated services may provide services at lower cost to patients, as above ?? Capitated services will be able to function pro-actively rather than responding to patient demand ?? Enhanced ability to provide mutual cover, as business structures are similar
All three GPs ?? All above advantages, plus: ?? Existing GPs will have to capitated and ?? Additional management fees to change business structure and operating as an be shared among practices practices IPA, not necessarily in the same ?? Enhanced ability to develop premises. (See proactive programmes notes for an ?? Enhanced ability to develop explanation of ‘IPA’) integrated services and programmes as IPA ?? Possibility of budget holding for radiology, pharms and labs
The Waimarino Review 23 GP service models Advantages Disadvantages
Three capitated ?? All above advantages, plus: ?? Existing GPs will have to GPs, operating as ?? Additional funding from change business structure and an IPA in shared management fees practices practice with ?? Economies of scale from use of ?? Ohakune patients would have to shared facilities travel to Raetihi and holding shared facility and supports budgets for pharms ?? Could be co-located with or and labs near to Health Centre ?? If co-located, nurses could provide support for Health Centre operations and community nursing operations as well as practices
Notes
Fee for Service (FFS) system In the Fee for Service system, the HFA pays all or part of the cost of a consultation for any patient who is eligible for a general medical services subsidy (GMS).
The GMS subsidy is available for: ?? any person holding a Community Services Card (CSC), and that person’s dependants ?? any person holding a High User Health Card (HUHC) ?? any child of a non card holder, up to the age of 15 for all children, and up to the age of 18 where the child is still dependant on the parent/s.
The amount of the GMS subsidy the HFA will pay for these consultations is set nationally. The GP may claim the subsidy for a consultation with any patient in the above categories, and may also charge the patient an additional ‘copayment’ fee. The copayment fee is set by the GP.
For children under six, the HFA pays an amount that usually (but not always) covers the entire fee, and it is expected that the GP will not usually charge anything on top of the HFA fee. This means that GP consultations for any child under six should normally be free.
The GP will charge the whole consultation fee for patients who are not in the categories above. The fee charged is up to the GP.
GPs also receive various other subsidies. For instance, the influenza vaccinations that are free to people of 65 and over are paid for by the HFA, with the GP claiming an agreed amount for each vaccination that he/she performs. Other subsidies include child immunisations, part of a practice nurse’s salary, and free maternity care.
The Fee for Service system means that the more patients a GP sees, the more subsidies, patient copayments, or consultation fees he/she can claim or charge. In this system there is
24 The Waimarino Review little real incentive for a GP to practise pro-actively, as this may reduce the number of consultations that he/she can claim or charge for, so reducing the practice income.
Capitation This system is a method of population based funding. The funding available under this method of payment is not full reimbursement of the cost of providing all general practice care.
The amount paid to a GP is equivalent to the expected average annual GMS and other subsidies that would be claimed by a GP for the practice population that is being served. The amount the HFA pays is adjusted for the size, socioeconomic, and demographic profile of the practice population using a national standard payment model.
In most capitated schemes the GP is still allowed to charge patients in some categories a copayment fee – although with suitable arrangements the copayment may be lower than would otherwise be the case.
With capitated funding, practice income is no longer directly coupled to the number of patients seen by the GP. The means that a GP can practice innovatively and proactively without reducing his/her practice income. There is an increased incentive to provide health education and promotion services to the practice population, and to ensure the population remains well.
This system also encourages the use of practice nurses to run clinics or provide services to patients, often enabling these services to be provided at lower cost than would otherwise be the case.
IPA (Independent Practice Association) Independent Practitioner Associations (IPAs) are legal entities set up by groups of GPs and other primary providers. IPAs are usually a Limited Liability Company, an Incorporated Society, or a Trust. They may vary in size from only a few members to hundreds. The HFA sponsors and supports IPA development.
IPAs provide a legal entity with which the HFA can negotiate contracts on behalf of a group of primary practitioners. This supports provision of innovative and more integrated health care services, which primary practitioners would not be able to provide on their own.
IPAs also enable and encourage the development of consistent standards of practice among their members, and enable and encourage on-going practitioner education and upskilling, which enhances the quality of care provided.
Some IPAs hold and manage their own budgets for laboratory testing and the provision of pharmaceuticals. Savings may be made through providing improved information and development of guidelines to members on the appropriateness of prescribing or lab testing, innovative patient management, or proactive care. IPAs may keep an agreed proportion of any budget savings they achieve, to be used to improve and expand the range of health care services provided by the organisation.
The Waimarino Review 25
The HFA pays IPAs management fees up to a maximum of $6,300 per year per GP member, according to the functions the IPA takes on.
IPA membership is voluntary, and there is no obligation for health providers to join one. However well over 80 percent of New Zealand GPs are IPA members.
26 The Waimarino Review Appendix 4: Proposed Waimarino Health Services Advisory and Monitoring Group
This appendix describes a Waimarino Health Services Advisory and Monitoring Group (AMG) that could be established by the HFA or DHB. This Group would cover all health service providers in the Waimarino area. The functions the group could perform include:- ?? promoting enhanced accountability of service providers ?? information transfer both ways (from community to providers and vice versa) ?? networking ?? input into needs assessment for the local region ?? exploring local solutions to health needs ?? input to annual and strategic DHB plans ?? input to service planning, service coordination and service changes ?? monitoring of and reporting on: – service provision – the general state of health services in the Waimarino region – the utilisation, provision and management of services by and for Mäori – staffing, skill, and workforce development issues – areas of particular need ?? acting as a conduit for concerns about services and service delivery ?? promoting greater public understanding of health service delivery in the area.
The AMG should report as a matter of urgency should unexpected events or unforeseen developments jeopardise the safety, security, capacity or delivery of health services in the region.
It is recognised that health outcomes for Mäori are poorer than for the general population. AMG activities could contribute directly to improving health outcomes for Mäori by ensuring the coordinated delivery of services to Mäori. It could also contribute to the quantification of health gaps and provide information to enable services to be more closely focused towards Mäori, reducing the disparity between Mäori and the general population.
Options
The AMG could take many forms, for instance: ?? a new management committee or management group, supported by an existing organisation ?? an extension or a sub-group (enhanced as necessary) of the existing stakeholder groups or community groups, and supported by them
The Waimarino Review 27 ?? an independent trust or similar body, either self-supporting or supported by an existing organisation.
The key to the AMG’s effectiveness would be that it is seen to be an independent body, representative of all stakeholders in the region, and fully integrated into the health service network with real powers to influence service providers and the service funder/s.
The AMG would have to develop and maintain functional links with, and foster links between all stakeholders in the region, including: ?? primary sector providers and clinicians ?? PCOs and IPAs ?? secondary/tertiary sector providers and clinicia ns ?? MDOs ?? iwi ?? Mäori organisations ?? other ethnic and cultural groups and organisations ?? health service consumer organisations ?? service funding agencies.
If the AMG were to be supported by an organisation that also provided services in the area the funder would need assurances that it was transparently independent of the support organisation in its functioning.
Because of the potential for conflicts of interest the AMG should not in itself be a service funder or provider.
28 The Waimarino Review Appendix 5.1
This section describes how the following pages should be interpreted.
Appendix 5.2, columns 1–4, describe the outpatient and community services that should be available from GHW for people in the Waimarino region. Note that not all of these services are appropriate for delivery at or through the Waimarino Health Centre.
Column 5 shows the total GHW contract volumes for these services. Some services are purchased as a block contract, and it is not possible to develop volumes of interventions for Waimarino. However where services are purchased on a volume basis, this figure is shown.
Column 6 shows the simple pro-rata share of the total contract volumes. The Waimarino population is 7 percent of the total GHW population, so the Waimarino ‘share’ is the total GHW volume multiplie d by 0.07.
Column 7 shows the known volumes delivered to the Waimarino population at or through the Waimarino Centre in the 1999/00 financial year. Note again that it is not necessarily appropriate that all services are delivered at or through the Centre. Also some volumes of these services may have been delivered at Wanganui, and will not be shown here.
Appendix 5.3 gives a brief description of services provided to the Waimarino by other health service providers in the region.
The Waimarino Review 29
Appendix 5.2: Expected GHW Outpatient and Community-based Services for Waimarino Population
Notes: Purpose of this schedule is to inform consumers of range and nature of services provided by GHW and other providers to the Waimarino. All volumes are annual figures from 2000/01 GHW contract, except Column 7 volumes which are actual GHW figures for the 1999/00 year. Presence of a GHW clinic or service on this schedule does not imply that the clinic or service should be provided at the Waimarino Centre. Outpatient clinic location must consider logistics, expected clinic volumes, local demand and transport assistance costs. Mental health provision is funded as a block contract. Waimarino population: 7% of all GHW.
1 2 3 4 5 6 7 Service Purchase unit description Purchase unit Notes Total GHW Waimarino 1999/00 volumes provided at code contract pro rata or through Waimarino volumes volumes centre
Specialist Ear nose and throat – first S25.02 679 48 26 medical attendance (OP) Ear nose and throat – S25.03 764 53 13 services subsequent attendance
General medicine – first M00.02 900 63 10 attendance General medicine – M00.03 1,500 105 1 subsequent attendance
General surgery – first S00.06 1,790 125 79 attendance General surgery – subsequent S00.07 1,808 127 59 attendance
Gynaecology – first attendance S30.02 350 25 22 Gynaecology – subsequent S30.03 600 42 22 attendance
The Waimarino Review 31 1 2 3 4 5 6 7 Service Purchase unit description Purchase unit Notes Total GHW Waimarino 1999/00 volumes provided at code contract pro rata or through Waimarino volumes volumes centre
Ophthalmology – first S40.03 Currently not provided by GHW 900 63 Not provided attendance – no ophthalmologist Ophthalmology – subsequent S40.03 1,620 113 Not provided attendance
Orthopaedics – first attendance S45.02 750 53 3 Orthopaedics – subsequent S45.03 2,900 203 26 attendance
Paediatric medical outpatient – M55.02 322 23 14 first attendance Paediatric medical outpatient – M55.03 1,237 87 33 subsequent attendance
Vascular surgery outpatient – S75.02 56 4 No information first attendance Vascular surgery outpatient – S75.03 178 12 No information subsequent attendance
Fracture clinic – first S45.04 Not offered by GHW at 485 34 Not offered at Waimarino – attendance Waimarino provided by GPs Fracture clinic – subsequent S45.05 Not offered by GHW at 1,504 105 Not offered at Waimarino – attendance Waimarino provided by GPs
ED service Emergency department – ED03.01 ED services provided at GHW. 16,500 1155 Not offered at Waimarino Level 3 Emergency service provided by GPs and St John’s.
Radiology Community radiology (HHS) CS01.01 Plain films two days per week 9,973 698 552 service and mobile ultrasound provided monthly
32 The Waimarino Review 1 2 3 4 5 6 7 Service Purchase unit description Purchase unit Notes Total GHW Waimarino 1999/00 volumes provided at code contract pro rata or through Waimarino volumes volumes centre
Sexual and Sexual health – first contact SH01.01 Specialist service at Wanganui 528 37 No information reproductive Sexual health – follow up SH01.02 Specialist service at Wanganui 650 46 No information health services Family planning services SH01.03 Specialist service at Wanganui 750 53 No information Specialist Cardiac education and M10.04 Two monthly plus cardiac 1120 78 No information nursing management support group services Diabetes education and M20.06 Two monthly (includes 388 27 No information management dietician) plus weight control support group Palliative care – community M80.05 Provided by DN, FU by 104 7 No information services oncology nurse as required
Community Community services – DOM101, DOM102, Professional services, 1 Block contract services professional services DOM103, DOM104, including home oxygen, stomal DOM110 service, continence service, orthotics
Community Community services – home DOM1.05 Assessment by DN. Local 8,227 576 303 support help provision. services Community services – meals DOM1.06 Assessment by DN. Local 31,644 2,215 457 on wheels provision. Community services – DOM1.07 Assessment by DN. Local 6,973 488 No information personal care provision.
Maternity Pregnancy and parenting W01.02 LMC midwife and LMC GP 63 4 12 education Maternity facility – fee for labour W02.01 46 and delivery <199 births Maternity facility – fee per W02.04 44 postnatal <199 births
The Waimarino Review 33 1 2 3 4 5 6 7 Service Purchase unit description Purchase unit Notes Total GHW Waimarino 1999/00 volumes provided at code contract pro rata or through Waimarino volumes volumes centre
Child health Well child – school aged C01.02 Public health nurses based in 15,388 1,077 No information services (5–18 years) Wanganui
Dental School dental services D01.03 Two school dental nurses 12,910 904 N/A Outpatient dental treatment D01002 Provided at Wanganui 1,550 109 N/A
Mental Eating disorders services MHCS009 Mental health services block No information health contract community Community alcohol and drug MHCS01.A, As above No information services MHCS01.B Advocacy peer support MHCS021 As above No information Maternal mental health MHCS028 As above No information Community mental health MHCS06.A, As above No information teams MHCS06.B Children and young people MHCS08.A As above No information Home-based support MHCR901 As above No information Crisis respite MHRE01.1 As above No information Planned respite MHRE01.2 As above No information Kaupapa Mäori MHCS019, As above No information MHCS020
NB: Rural mental health service delivery pilot project being considered.
34 The Waimarino Review Appendix 5.3: Non-GHW Health Providers, Waimarino Region
1 2 3 4 5 6 Service PU Description PU Description of Provision Current Services Comments/Service Description/Change
Plunket Plunket services Post natal services including 0.4 FTE Plunket Nurse time, No change Plunket line and facilitation 0.5 FTE Kaiawhina dedicated to services. Funded from GHW area Waimarino region (= 0.9 FTE Plunket contract Plunket person)
Ngati Rangi Mäori Community Whänau Ora, Tamariki Ora, Well Provided for about 1200–1300 No change Community Health service child facilitation service, Whänau Mäori people in the Ohakune/ Health Centre support. Raetihi region
Pipiriki Health Mäori Community A range of general health Provided for about 80 whänau in No change Services Health service education/and promotion, advisory, the Pipiriki area liaison and co-ordination activities
Ambulance St John Primary response by local GPs Funded partially by Central contract Establishment of telephone triage, Ambulance under contract to St John with St John ambulance, and assessment and minor treatment Ambulance service. Ambulance partially by ACC service operated by GPs and vehicles based in Taihape and nurses. Ambulance service Waiouru. contract and ACC need to be incorporated into scheme.
Other primary Primary care HFA and HBL payments for Two GPs Establish third GP in the area care services services pharmaceuticals, laboratory, immunisation and other benefits and subsidies
The Waimarino Review 35