LOCATING NURSING IN PRIMARY HEALTH CARE:

A REPORT FOR THE NATIONAL HEALTH COMMITTEE

Jenny Carryer, Denise Dignam, Margaret Horsburgh, Frances Hughes and Julie Martin

August 1999 Table of Contents

Executive Summary...... 1

Introduction...... 3

Primary Health Care and Primary Care...... 4

Nursing...... 8

Philosophical Congruence of Nursing with Primary Health Care....11

Primary Health Care Nursing ...... 12

Models of Primary Health Care Nursing ...... 14

Community and family assessment...... 15

Community participation, action and partnerships...... 15

Home visiting...... 17

Surveillance and monitoring...... 17

First Contact Effectiveness...... 18

Funding – Focused on Outcomes...... 18

Community Oriented Primary Care...... 22

Conclusion ...... 23

References ………………………………………………………………...... 24

LOCATING NURSING IN PRIMARY HEALTH CARE: A Report for the National Health Committee

Executive Summary

This discussion paper was prepared for the National Health Committee to provide a perspective on the role nursing could have in New Zealand in the provision of primary health care with particular reference to reducing inequalities in health, improving population health overall, effectiveness of funding mechanisms and identifying barriers to providing population based programmes.

Our intention in the preparation of this paper was to locate nursing in the delivery of primary health care. The focus is on the philosophical and theoretical intent of nursing as being congruent with primary health care. An argument is made for the development of a comprehensive primary health care nursing role rather than the current fragmentation of titles and responsibilities in community based services. We argue that nursing, as a discipline is well prepared for the increasing emphasis the Government wishes to see given to illness prevention and health promotion.

It is proposed that a comprehensive and widely accepted definition of primary health care with an emphasis on disease prevention and health promotion, community involvement and multisectoral cooperation is needed, to distinguish from primary care which is generally referred to as first contact care accessed by self-referral. Primary care is often used interchangeably with primary medical care and this contributes to an emphasis on immediate clinical crises or illness oriented care rather than population health strategies.

The concept of multi-disciplinary teams is supported as being more effective in primary health care than single practitioners, however there are barriers to their effectiveness. Collaboration between health professionals is critical but poor identification of disciplinary skills, confusion over accountability, inequitable workloads, vested interests, role ambiguity, status differentials and struggles with authority and power persist. While nurses have experience with forming partnerships with individuals, families and communities in many community settings and especially within general practice the employer/employee relationship or the notion of delegated medical authority confines nursing to an assistant role and frequently precludes collaboration and the appropriate utilisation of nurses.

1 NZ has considerable investment in nurses and currently subsidises general practitioners to employ the majority who work in primary health care as practice nurses at a cost of $30 million per annum. It is questionable as to whether this now represents value for money or whether it is based simply on history. The practice nurse subsidy is one of several barriers to the development of primary health care nursing.

In addition to practice nurses, primary health care nursing is established in communities at a number of levels and through contributions from various contracts, such as well child services, home health, domiciliary nursing, health promotion, communicable disease screening and management. Not only has this led to fragmentation of service delivery but also there are gaps and duplication of services and confusion surrounding the roles of the various nurses. It is argued that the contract culture has altered nursing to a commodity. This reduces the strength and usefulness of nursing and supports a medical and reductionist health service focus on what are often deeper family and community health problems that would benefit from a more holistic or ‘global’ response.

Nurses understand health as a linear continuum and reject dichotomous notions of health and illness. Holistic concepts of health that recognise the socioeconomic determinants of health are familiar to nurses. From this basis nursing responds to individuals and communities appropriately to their context and their status on the health continuum and works to maximise health and wellness. Nurses have experience in forming partnerships with individuals and communities. As such they are prepared for a primary health care role.

As an example of a model currently proposed as a useful response for the development of primary health care we examine some of the commentary related to Community Oriented Primary Health Care (COPC). This literature notes the need for extensive retraining of medical practitioners to accommodate to primary health care. From a nursing perspective we argue that such immersion would not be needed for nurses who, as a result of nursing’s theoretical orientation towards health and towards partnership would embrace a community empowerment model without retraining. We note however from the available literature that existing examples of COPC have focused on teaching physicians how to adjust to community partnership models rather than consideration of how to utilise the already prepared, well disbursed and often readily available, but frequently underutilised nursing workforce.

2 A recent example of a nurse practitioner led primary health care clinic in New Zealand primary schools is provided to illustrate how nurses can contribute to reducing inequalities in health and improve population health overall in a model which focuses on community partnerships and collaboration with families. This work represents the depth of work required to alter both public and professional perceptions of primary health care. The expertise and skill base of nurses working in primary health care is also illustrated.

Introduction

The National Health Committee (NHC) has in 1999 the objectives

‘To advise the Minister of Health with an independent assessment of primary health care services that would deliver the greatest benefit to the health of population groups, and groups of the population with particular regard to groups at risk or disadvantage and having regard to available resources’; and

‘To decide whether primary health care services funded by the Health Funding Authority (HFA) are a fair and wise use of resources.’

The HFA has signalled population-based programmes as a new direction for general practice in particular (Scott 1998) but this direction has implications for all primary health care providers.

The discussion paper to be presented here is one of six papers intended to provide background to the NHC’s programme of work on primary health care. This paper will provide a perspective on the role nursing can have in NZ for primary health care provision with particular reference to the questions posed by the NHC: · How can primary health care contribute to reducing inequalities in health, ie improve access for the hard-to-reach and so close the health inequality gap between the disadvantaged and more privileged subgroups? · How can primary health care strategies improve the health of the population overall? · What are the most effective funding mechanisms that will best facilitate population health gain in primary health?

3 · What are the barriers to providing population based programmes in primary health care settings?

The Government’s recently released ‘Medium Term Strategy for Health and Disability Support Services’ (Ministry of Health 1999) indicates a move to a health sector that is focused on: · health outcomes rather than outputs; · greater collaboration between providers; · early intervention; and · more community involvement in health.

Such an approach requires a greater emphasis on population health approaches. The Government wants to see increased emphasis on primary care, illness prevention and health promotion to minimise acute episodes of ill health and the potential for injury. This includes improving immunisation rates, achieving healthier lifestyles and better diets, less smoking and enabling New Zealanders to make individual and collective choices that improve their health (Ministry of Health 1999).

In order to achieve this, the Government has indicated that it ‘wants providers and communities to cooperate and collaborate for better care and better service in an integrated and responsive way. This includes better working relationships within the primary sector and between the primary and secondary sectors. The aim is for services to contribute to better health and disability outcomes in the most efficient manner by: · organising services around needs, preferences and overall health status of patients and groups in the community · encouraging early intervention and effective health promotion programmes to prevent disease and disability and to protect and promote health and independence · encouraging local solutions to local problems · making decisions about resource use as close as possible to the point of service delivery’ (Ministry of Health 1999: 11).

Primary Health Care and Primary Care

Government intentions to improve primary health care (in this and other countries) have a long history. It is evident however that making the change from an illness-focused system to a well- established system of primary health care requires significant

4 political courage to make investment at national level even though the solutions will be local. This has yet to happen.

The desire for population based health care and an increased emphasis on primary health care is long-standing. The Ottawa Charter for Health Promotion (Health and Welfare Canada 1986) supported Primary Health Care as being a "driving force in achieving health for all." The directives of the Ottawa charter were reaffirmed in the 1997 Jakarta Declaration (WHO 1997) and the five health promotion action areas of the Charter all fit within a Primary Health Care framework: - To Build Healthy Public Policy - To Create Supportive Environments - To Develop Personal Skills - To Strengthen Community Action - To Reorient Health Services.

Other documents from this era reflect the same direction (Armstrong & Bandaranayake 1995; Kleczkowski et al 1984; World Health Organisation documents, NZ Board of Health 1987, 1987a, 1988, 1988a. The NZ Board of Health (1987) considered the incentives and constraints in primary health care. It is interesting to note the similarity between the issues presented in the NZ Board of Health document to those in the Government’s Medium Term Strategy (Ministry of Health 1999). The similarity suggests there is clear recognition and agreement about what needs to happen but there must be obstacles to realising the goals intended.

Of most interest amongst the recommendations (NZ Board of Health 1987) in terms of continuing relevance are: · incentives should be put in place for keeping people healthy and removed for unnecessary treatments of illness · primary health care should be available near peoples homes or other bases such as workplaces · basic health care teams should be the optimum size for easy communication, personal service and professional support · there should be minimum bureaucratic and administrative costs and the team should be accountable to their own consumers and local community · services should be researched and evaluated by their local health authority · primary health would be better served by skilled generalist community nurses who would incorporate the roles of the present primary care nurses.

5 Examination of these recommendations reveals that few, if any, have been fully implemented. In addition population based health strategies have traditionally been relegated to a more marginal aspect of the health service when compared to personal care or medical services (Armstrong & Bandaranayake 1995). In NZ, historically, this is not surprising when one considers that:

‘For much of the fifty years from 1935 to 1985, New Zealand’s political ideologies were strongly socialist, which saw the rise of a welfare state that emphasised equitable development of social and economic conditions. By international standards, the population enjoyed excellent health as a result of policies leading to adequate housing, high literacy, full employment, improved nutrition and environmental health, family and elderly support, and equitable delivery of public health and medical care services’ (Armstrong & Bandaranayake 1995: 3).

During this era nursing contributed to the delivery of population based primary health care. Community health nurses such as public health nurses, district nurses, and specialist community nurses such as those working for the Royal NZ Plunket Society together with practice nurses were the professional face of health promotion, home based provision of care, prevention and surveillance.

It can be argued that a range of community concerns has remained constant for primary health care, community health nurses. A report from the then Department of Health (Blakey & Bradley 1980) indicated that client concerns discussed with public health nurses were predominately to do with the general health of family members, school based child health issues and specific illnesses or disabilities in school aged children. These dominant issues were closely followed by concerns regarding housing, child behavioural problems, financial hardship and employment. More recent research indicates that these same issues feature in current public health nurse practice (Pybus 1993; Dignam & Alpass 1998). Again there is irony in that these groups of nurses appear to have been those most substantially reduced in the cost cutting exercises inevitable with contracting pressures and health service restructuring.

The demise of the Public Health Commission in 1995 was noted by many as a retrograde step for the advancement of public health or population based health. The caution is now perhaps reflected in increasing attention being given to primary health care within current Government directives.

6 ‘Nations that forget the importance of public health as a condition, and the need for an effective public health service, are left to rediscover its importance over time as declining health among the population becomes evident, or more swiftly as in a national emergency’ (Armstrong & Bandaranayake 1995: 23).

The drive toward primary health care became more overt, and arguably increasingly necessary, in the 1980s. But throughout the 1990s the health reforms have, conversely, supported the growth of primary medical care (Malcolm 1993). The trend toward imbalance is reflected in the current vote health comparison where the investment in personal health and disability support services combined, far exceeds the investment in public health (Ministry of Health 1999a). There is considerable challenge in trying to divert money from the “sponge” of secondary services in order to invest constructively in primary health care initiatives. As nurses we would argue that there might be high levels of over-servicing which arise from the medicalisation of health care and which generate considerable cost. Examples include ultrasound scans for normal pregnancy which have become routine in many instances, the cascade of interventions which characterise medical management of birth, and the excessive prescription of antibiotics which are not clinically indicated.

We suggest that confusion between primary care and primary health care is fundamental to the difficulties in progressing the desired agenda. ‘Primary Health Care (PHC) continues to be plagued by both conceptual confusion and operational uncertainty’ (WHO 1996: 9). McMurray (1999) notes that the confusion between primary care (first line care) and primary health care (inclusive of primary care principles) detracts from recognised international expression.

Currently the National Health Committee (NHC) combines Primary Health Care and Primary Care jointly as,

‘Local, first contact care for people that is accessed by self- referral. It comprises a range of services, delivered by a range of health practitioners, designed to keep people well and out of hospital, from promotion of health, screening for disease to diagnosis and treatment of medical conditions. In contrast, primary medical care refers to assessment, diagnosis and treatment services provided by general practitioners.’

These definitions are restrictive and nursing supports a more comprehensive definition of Primary Health Care as,

7 ‘A conceptual framework for providing public health and primary care services; it includes delivering essential, affordable, accessible, and acceptable health care to the community, with an emphasis on disease prevention and health promotion, community involvement, multisectoral cooperation, and appropriate technology’ (Stanhope & Lancaster 1996: 1100).

Primary care can then be separately defined as,

‘Typically the point of first contact or the entry point into the health care system; emphasises management of commonly occurring diseases or chronic disease’ (Stanhope & Lancaster 1996: 1100).

In the literature there is a degree of confusion in which primary care is often used interchangeably with primary health care when the author(s) really refer to primary medical care. While primary care is covertly understood as primary medical care then community development and health prevention and promotion will be marginalised. Further primary medical care is consistent with the public perception of self-referral to a medical practitioner. Clearly self-referral is an important aspect of access to health care however if it remains the predominant point of entry into health services the health encounter will remain crisis oriented and illness focused. The health episode characterised by self-referral to medical care is a reactive process to a health crisis rather than a proactive intervention for health. Clearly this is not a mismanaged process but rather a response dictated by current delivery parameters.

‘An initial potential obstacle to development is the overwhelming demand led climate within general practice, typified by rapidly shifting agendas, priorities and demands, which tend to be addressed on a “first come, first served” basis. This environment, rather than supporting development, tends to breed a culture which favours immediate clinical action rather than long-term strategic thinking’ (Kilduff, McKeown, & Crowther 1998: 176).

In addition self-referral requires that clients are able to make informed decisions, have motivation, transport, a belief that the service is culturally appropriate and a certain level of private resource to enable access to service. While clients could self-refer to other health professionals their perceived access is based on past experiences and general community awareness.

8 Until there is a change of emphasis from primary medical care to genuine primary health care, ‘… it remains largely a disjointed set of fragmented provider and community groupings with little collective power to influence decision making’ (WHO 1996: 9).

Gough and Richards (1999) point out that pilot sites set up in the United Kingdom under the 1996 Primary Care Act to test ‘new’ ways of delivering primary health care have failed to address a broad approach to primary health care. Rather the focus has continued to be on medical care – personal and general medical services. They suggest that the intent has been to make general practitioner (GP) services more flexible rather than developing a comprehensive approach in order to address health needs. The nurse led pilots have had a similar emphasis and contribute to a reductionist health service.

We argue that a change in emphasis from primary medical care to primary health care together with an overt acknowledgment of the particular skills of a primary health care nurse is needed to address unmet need. Philosophically, the values embodied in nursing are about the enabling of human health potential in a wide range of contexts. This approach seeks to foster optimum health in individuals and communities and is mindful of the particular challenges and impediments that may be present. These values are broader than the curative aspects of health. They include the notion of other influences like social policy, education, unemployment, ethnicity and community culture. The underlying characteristics are social justice and equity, international solidarity, self responsibility and an acceptance of a broad concept of health (NZ Board of Health 1988).

Nursing

In considering the NHC’s questions we acknowledge that no one discipline holds the solution to delivering effective primary health care. However our goal in this paper is to confine the argument to a nursing focus in order to usefully complement the work of other commissioned papers. In so doing we will be negotiating the considerable tension between what nursing is in its theoretical intent and focus and what it has become due to patterns of utilisation. We will also be grappling with the problem that the uptake of nurses in primary health care in NZ does not provide many positive examples from which to draw, with the exception of nurses working in Maori

9 primary health care services. In Northland many of the Maori health initiatives are nurse led services, for example, · Hauora Whanui (KawaKawa) - a comprehensive mobile community service · Hauroa O Te Hiku O Te Ika (Far North) - a nurse led, nurse run primary health care service · Kia Mataara (Far North) - another nurse led, nurse run primary health care service · Te Ha O Te Oranga (Kaipara) - a nurse led community health service · Te Puna Hauora (Awataha Marae, North Auckland) - offers a comprehensive nursing service, home visiting, family assessments and disease management plans.

All of these nurse led services grew to include general practitioner involvement in augmenting the existing services they provide. Only one non-Maori nurse led initiative is funded in this same region.

Walsh and Gough (1999) have argued that the contract culture of the current health market in the UK has altered nursing to a commodity, which is shaped and driven by that market. A similar argument can be made in NZ. We now see nursing work becoming increasingly specific and in effect “broken down” into disease categories or age ranges or even in relation to body parts. This is complicated because on one hand specialisation is useful and allows for the development of a type of expertise. On the other hand it reduces the strength and usefulness of nursing and supports a medical and reductionist health service focus on what are often deeper family and community health problems that would benefit from a more holistic or “global” response. Nurses must cease clinging to their traditional roles and titles and instead, develop the primary health care roles that directly meet the needs of the community they serve. Both generic nursing skills and specialist nursing skills should complement the work of the integrated health care team.

The nursing profession developed undergraduate degree programmes in the 1980s and 1990s with the specific intent of producing graduates who would meet the increased need for community based primary health care as the “bricks and mortar” institutions reduced. Ironically however there appears to have been a steady reduction in the specific contribution of nurses to the community as changes in health services and more latterly contracting pressures have precipitated reduction in numbers of groups such as public health nurses. Anecdotally, the net result of

10 such reductions has been a steady erosion of the confidence of nurses and a growing invisibility around their contribution.

At the same time as we see a reductionist focus in the utilisation of nurses there is an increase in other health practitioners such as strengthening families coordinators, generic health care workers, community workers and a range of support workers. Recently Government has expressed its desire ‘to make it easier to utilise new types of practitioner who can meet patients needs more conveniently or efficiently’ (Ministry of Health 1999:14). This is based, we suspect, on the assumption that nursing can offer nothing tangibly different from a narrow medical focus and therefore the preparation of a new form of worker will provide a new type of service more akin to the requirements of primary health care delivery. If this is true then it is a supreme irony for nursing which has spent years trying to provide a complimentary service with medicine, yet finds that funding and delivery structures continually locate nursing services under a medical umbrella and then seek to replace them with a “new type of practitioner”.

A particular focus within nursing education is an understanding of the complex nature of maintaining health and wellness and the contribution socioeconomic factors make to health experience. Increasingly nursing has developed a theoretical focus not just on the causes of disease and poor health but also on the underlying source of those causative factors in terms of poverty, unemployment and minority ethnicity.

Recent health sector and Government reports1 have posited the intersectoral nature of effective health service delivery and they have also provided clear evidence that there are strong socioeconomic and cultural determinants of both health status and access to health care. For nurses, reading these reports has always provided strong affirmation for the content and focus of our nursing programmes both at undergraduate and postgraduate level. Such reports have also acted as a stimulus to nursing to prepare graduates who have the skills to deliver health care effectively to those who most need it.

For example, nursing has pioneered the teaching of cultural safety in order to produce practitioners who would be acceptable to diverse

1 Ministry of Health (1998b). Making a Pacific difference in health. Wellington National Health Committee. (1998) The social, cultural and economic determinants of health. Wellington Ministry of Health. (1998c). Child Health Strategy. Wellington Ministry of Health. (1998a). Progress on health outcome targets. Wellington

11 and hard to reach groups. Kearns (1997) notes that nursing’s initiative in cultural safety represented one manifestation of a broader trend towards transferring power in health care. He argued that because cultural safety offers both an analysis, and a solution to imbalances of power in society, it can contribute to different ways of seeing and professionally practicing in the community. Cultural safety in practice in community child health nursing has been demonstrated by Heap (1998). However considerable nursing energy was expended in defending this stance both to the public and to Government during the mid 1990s.

In summary, for at least 25 years, nursing has developed curricula which include content relative to, and pioneering in, community care, socioeconomic determinants of health and primary health care skills as well as the more traditional caring/curative arts and skills. But it is noted that our graduate’s skills and knowledge are frequently not recognised nor utilised appropriately or to their fullest expression.

Philosophical Congruence of Nursing with Primary Health Care

Primary health care requires a knowledge and skill set which is qualitatively different than that required for the management of illness and injury. The agenda in primary health care is to work with communities and the people in them to achieve permanent improvement in the quality of their lives. Key principles include equity, access, empowerment, self-determinism, and intersectoral collaboration (McMurray, 1999).

Nurses are familiar with these concepts that go well beyond disease and injury treatment to a strategy of health promotion that includes social and environmental barriers to health. As discussed later this has been the predominant feature of nursing curricula for at least twenty years.

The rhetoric suggests that medicine has also begun to turn its attention towards preparation for primary health care with opportunities for undergraduate medical students to understand communities, the complex nature of health and wellness and focus on population health strategies. The reality however is that the emphasis remains on the bioscientific basis of medicine. The question needs to be asked, whether it is viable for practitioners training in the rigours of biomedicine to add the complexities of

12 population and primary health care to their undergraduate curricula or whether this requires postgraduate training. The suitability and preparation of nurses for a primary health care role on the other hand needs to be recognised and barriers to more appropriate utilisation of the nursing workforce overcome (Ministry of Health 1998).

Regardless however of the designs and desires of disciplinary or health professional groups, the primary responsibility for acceptance and support of primary health care rests with the national level of the health system. The action will be local but it is the national authorities that must launch, fund, evaluate and monitor processes whereby primary health care will become basic to the whole national health system. We argue that Government needs to support the expansion of primary health care. The process we support merges clinical personal health support with a population based public health approach. We believe this will achieve the outcome of self- empowerment for individuals, families and communities to maintaining their own wellness and contributing to decision making when they are sick.

Primary Health Care Nursing

Primary health care as a process is a potential linking mechanism for families who are at risk of ill health. We need to move to more intersectoral partnerships, community development and participation and the development of community. Nurses are able to form a partnership with consumers that shifts health from a curative focus to one of being an empowering change agent for families and communities (Wuest & Stern 1991; Stanhope & Lancaster 1996; Lindsey, Shields & Stajduhar 1999).

We argue for the further development of a primary health care nursing role to redirect the assistive and somewhat compensatory role in which many community based nurses now work. In describing what nurses do, the Ministerial Taskforce on Nursing (Ministry of Health 1998) was aware of the gap between what nursing is in its intent and theoretical foundation, and the reality of nursing in most practice settings. The Taskforce noted that nurses such as practice nurses were frequently unable to contribute as full and equal team members because they had limited access to resources, physical workspace and postgraduate education to maintain and enhance their skill base. The potential of nursing in the community is often subsumed into a role that is little more than assistance with primary medical care.

13 The success of any contribution that a primary health care nurse can bring to a community is dependent on the quality of relationships he/she makes with community members and other health professionals. However, it is not clear in the NZ health system, exactly what individual health professionals each contribute to a primary health care team. They generally work as individuals in a team setting but not as collaborative partners.

In recent years there have been many calls to deliver effective primary and secondary health care through the auspices of the multi-disciplinary team. Many have argued that care thus delivered is more effective than the attentions of a single discipline practitioner (West & Poulton 1997). Clearly however there is confusion about exactly what constitutes a multi-disciplinary team. Two possibilities exist. One is the team comprising a number of individuals contributing from the basis of their different disciplinary identity in order to bring a range of expertise to bear on the delivery of care. The other represents the possibilities inherent in a range of new workers who may bring a range of skills gathered from no particular professional background.

We support the first notion of team as offering the best quality of care. A multi-disciplinary team of people organised to support the needs of a geographic community might include for example, primary health care nurses, medical practitioners, social workers, pharmacists, physiotherapists, midwives and community workers who are mentored and supervised by relevant health professionals. For multi-disciplinary teams to be effective, health professionals must be accountable for their own personal practice and must recognise and respect the contributions of other team members (Toop, Nuthall, & Hodges 1996).

In essence collaboration is essential to the effective functioning of the multi-disciplinary team, but this may be difficult to achieve. Multi- disciplinary teams may also be problematic on a number of other levels. These include the possibility of poor identification of discipline skills, attitudes and contributions, inequitable workloads, the persistence of vested interests, role ambiguity, status differentials and struggles with authority and power.

An excellent example of such problems is reported in Smith, Dickson and Sheaff (1999). According to the rhetoric the development of primary care groups (note terminology) in the UK was to offer nurses a real opportunity to participate in the strategic development of primary care services. Nurses were to be the key drivers for

14 change in the new National Health Service and it was noted that ‘nurses views will be heard and valued, tokenism will not be accepted’ (Department of Health 1997). Primary care groups were heralded as an effective way to put nurses, medical practitioners and (importantly) local communities in charge of managing local health care. Smith, Dickson and Sheaff (1999) report that political lobbying by the British Medical Association and the General Medical Services Committee threatened a policy of non-cooperation unless their demands were met. These demands included a protected general practitioner majority and the right to the Chair of the Board of the primary care group. ‘The language used to describe the process for filling places was significant. General practitioners were to be “elected”, social services “nominated”, nurses “determined” and lay persons “appointed”.’ For nurses the selection process was by short listing, by interview and by measurement against competencies. This situation is a persistent barrier to collaboration and partnership and precludes progress in the development of primary health care.

McEniery (1992) notes that collaboration involves true partnerships in which the power of all members is valued and there is recognition and acceptance of separate and combined spheres of activity and responsibility. This results in the mutual safeguarding of the legitimate interests of each party, and in commonality of goals which are recognised and shared by both parties.

Collaboration between health professionals is critical to the success of primary health care teams. The definition is also relevant to the partnership concept between health professional and the consumer of health services. It may be that these concepts are difficult to embrace for many medical practitioners who have been taught and socialised in hospital settings to believe that they and their knowledge provide natural leadership to any team (Chiarella 1998; Lipley 1998). In many community settings and especially within general practice where current funding structures perpetuate an employer/employee relationship or the notion of delegated medical authority nursing is confined to an assistive role and collaboration and the appropriate expression of nursing is precluded.

Currently there are major obstacles to changing the relationships between medical practitioners and nurses already working in the community. The structures in which ownership and funding of IPAs and general practices is in medical hands and the fact that nurses are inevitably employees is mutually constraining for both groups. Nurses and medical practitioners alike frequently find it very difficult to envisage different ways of working. Many practice nurses for example will actually claim that they prefer the security of

15 their employee status without reflecting on their inability to provide real nursing services from that vantage point.

Within this context there is much confusion about accountabilty with some medical practitioners in the community continuing to believe that they will be held responsible for any clinical errors that nurses may make. The fact that some nurses share this erroneous belief, is demonstrated in that practice nurses as a group have particularly low membership of any professional organisation and thus limited uptake of indemnity insurance (Michel 1997).

Models of Primary Health Care Nursing

This section describes differing models of primary health care nursing as they are applied in communities. First, it is important to note that nursing rejects dichotomous notions of health and illness preferring to regard health as a linear continuum. The concept of health is,

‘A qualitative variable that ranges from poor to good, death to high level wellness, or non- functional to functional performance status’ (Anderson & Tomlinson 1992: 58).

From this basis primary health care nursing responds to individuals and communities appropriately to their status on the health continuum looking to maximise their health experience.

Community and family assessment

In nursing, the construct of family health is a dialectic in which the analysis of family health must include simultaneously both health and illness and the individual and collective (Anderson & Tomlinson 1992). Nursing by its theoretical basis includes family backgrounds and how the family operates as a human social system. Nurses unlike some other health professionals have an advantage because they are involved so intimately with families at the extremities of life and death and in the challenges of parenting, and in situations of loss, chronicity, and disability. Nurses are often at the scene of situations both of tragedy and joy and they share with families, the most basic emotions of happiness and sorrow in a caring context (Friedemann 1989).

16 In carrying out research with nurses working with families in urban areas Appleton (1996) found that nurses are the most likely to identify vulnerable families who are experiencing crisis, ill health and child abuse. The nurse’s ability to support families at risk was found to depend on their being able to utilise six interrelating factors. These factors were; knowledge of the families’ community, reflection-on-action, situations/families which caused the nurse to be concerned, the nurses own knowledge base and experience, past history of the family and a degree of gut feelings and instinct. Working with “at risk” families is an example where the primary health care nurse could also work across sectors with social workers to improve the health and social situation for the family.

The health service requirements of families have to be assessed within the overall framework of the community within which they live. Targeting health services only to families with identified needs, such as a family with a child with asthma, ignores other families who may be equally vulnerable but do not fit the targeted sector. In the same manner free medical care to children under six allows the assumption that this group’s needs are being met, when there are many additional ways of maintaining the health of children which are not included in free medical care.

Community participation, action and partnerships

Primary health care nurses have been shown to work alongside communities to set priorities for health promotion strategies, plan and implement activities that help communities to achieve improved health. ‘At the heart of this process, is the empowerment of communities, their ownership and control of their own endeavours and destinies’ (Tasmanian Women's Health Network 1996). Participation can be described as active involvement of all community subsystems, including individuals, families, and agencies, both government and non-government in comprehensive planning and health promotion. Communities draw on existing human resources and material to support community self-help to take control and participate in the decisions that impact on the health of the people living in their communities (Stanhope & Lancaster 1996).

Community health nurses have explored the processes for developing community partnerships (Lindsey, Sheilds & Stajduhar 1999). Nurses recognise that relinquishing control is an important aspect of community participation. Relinquishing control is not to abdicate responsibility but rather to engage in the professional role of facilitation and coordination that raises the health consciousness

17 of the community. It may be that this less obvious community role contributes to the invisibility of community health nurses (Reutter & Ford 1996). Florence Nightingale in “Notes on Nursing” (1859) wrote that the creation of a healthy environment is not the sole responsibility of the nurse and is better accomplished by involving other persons in the health-promoting activities (Stanhope & Lancaster 1996). Few preventative health strategies can be successful if they are planned in isolation from the community towards which they are directed. If there is an agreed and identified health issue within a community, nurses are in an ideal position to lead as change agents and manage change in collaboration with communities.

The recent media coverage about NZ's low rate of immunisation is an example of where community based nurses could be working more effectively in collaborative strategies with communities where there is basic agreement about the health issue. Effectiveness in this area requires all of the dimensions embedded in nursing practice. These include knowledge about the diseases which immunisation prevents, knowledge about the conflicting evidence available to the public about immunisation, strategies for teaching and information sharing, culturally safe practice and the actual skill of administering injections and managing adverse reactions. Effective immunisation also requires in depth knowledge of the community and its childbearing families if access is to be encouraged. Strategies such as this have been shown to work in Maori primary care services where immunisation rates are higher than in the general population (National Health Committee 1999).

Primary health care as a strategy to work in partnership with communities is supported by the American Nursing Association as the preferred approach to community health nursing practice. The idea of engaging with individuals, families and communities through life events is also linked with a more continuous interaction with clients. This is reflected in the concept of accompanying the client (Hinder 1997).

‘The concept of “accompanying” is illustrated by nurses assisting families by way of support, knowledge sharing, and escorting them through health care processes’ (Hinder 1997: 27).

Home visiting

Home visiting has been a particular feature of nursing services in the community. The American Academy of Paediatrics (1998) provides

18 considerable evidence to support the health benefits of home visiting. The benefits are wide ranging and include direct improvement in birth outcomes, significant maternal health improvements and other long term benefits. The long term benefits were identified in a fifteen year follow up study and included decreased use of welfare, decreased incidents of child abuse and neglect and reduced maternal criminal behaviour. They conclude that health visitation programmes can be an effective early intervention strategy.

The practice area of health visiting, as it is called in the UK, is based on four principles. These are: the search for health needs, the stimulation of an awareness of health needs, the influence on policies affecting health and the facilitation of health enhancing activities (Buttigieg 1995). This aspect of primary health care nursing embraces health promotion, health teaching, monitoring and direct care.

The recognised outcome for home visiting includes prevention of mental, physical and emotional ill health, provision of early detection, mobilisation of necessary resources and provision of care. It seems short sighted that the number of nurses in a position to provide home visits has steadily declined since restructuring. In the absence of workforce data collection and planning, definitive evidence to support this statement cannot be provided. However, it is well known that hospitals and health services have reduced the numbers of public health nurses and The Royal NZ Plunket Society are noting their diminished opportunities for home visiting contact with new mothers and babies.

Surveillance and monitoring

Community nursing also includes aspects of surveillance and monitoring. These are essentially public health strategies to determine efficacy in both individual and population based interventions. Often associated with an epidemiological approach to public health these strategies alone do not form the foundation of community nursing. An epidemiological approach stresses that nursing interventions must be geared towards meeting the health needs of the population. The economic approach is to suggest that meeting all the health needs of the population is impossible therefore it is best to ask how scarce resources can be used to bring about health gain (Robinson & Elkan 1996). A community nurse who implements population health strategies will do so while negotiating the tension between epidemiological approaches,

19 economic approaches and nursing responses to family, community and socio-cultural assessment.

The notion of surveillance is one which produces discomfort for both those required to provide it as well as those on the receiving end (Walsh & Gough 1999). We argue that surveillance is only acceptable as an integral part of overall caring and assistance and that this is a very appropriate role when derived from the skill base of nursing.

First Contact Effectiveness

Previously we have proposed that primary health care is about much more than first contact or self-referral. But we acknowledge that the provision of first contact services is very important and we return to the questions about access and meeting the needs of hard to reach and diverse population groups.

The principle question here is whether or not a primary health care nurse practitioner can provide first-contact primary clinical care as safely and effectively, with as much satisfaction to patients as a general practitioner? Internationally there is evidence that nurses do this very effectively (Spitzer et al 1974; Pearson 1988; Marsh & Dawes 1995; Campbell 1997; Mundinger 1998, 1999; Grandinetti 1999). For example in one study which looked at the effectiveness of nurse practitioners, the nurse was able to function alone in about two thirds of all patient visits (Spitzer et al 1974; Shamian 1997). Many authors also note that patient satisfaction was higher when nurses provide first contact care due to the more collaborative, informative and interactive style of nurses. Given appropriate education, nurses are able to identify conditions and manage a vast range of primary care related events.

The Ministerial Taskforce on Nursing (Ministry of Health 1998) recommended that community health centres be developed in association with polytechnic and university schools of nursing. Funding, it suggested, would be shared between the HFA and the schools of nursing. In effect, the centres would be based around nurse led primary care teams that also provide “contracted” medical services. Such centres would act as an important community resource, while providing a clinical setting for nursing students where students could work under the guidance of experienced nurse practitioners.

20 Funding – Focused on Outcomes

Historically, government funding for primary care services has been paid to general practitioners on a fee for service basis and through co-payments. This means that currently primary care services are mainly funded via the general medical service fee (or fee for service) and from the consumer. Most of this income accrues to the general practitioner in what can not largely be considered a competitive market or a market where there is sufficient evidence in health gain improvements. In addition the general practitioner receives subsidies where consumers are deemed unable to pay due to income (via community services cards) or they are dependent on a medical system (via High User Health Card). General practitioners are therefore in a position with virtually guaranteed demand for the service at virtually guaranteed prices. The question has to be asked - is this best value for both consumer and taxpayer money and does it ensure good quality healthcare?

NZ has considerable investment in nurses and currently subsidises general practitioners to employ the majority who work in primary health care as practice nurses at a cost of $30 million per annum. It is questionable as to whether this now represents value for money or whether it is based simply on history.

The practice nurse subsidy is one of the barriers to the development of primary health care nursing. It was introduced in 1970 to improve the delivery of health services in rural areas. A 1997 review of practice nurse services noted, ‘the reason for the introduction of nurses into general practice has had a profound affect on how they work today. The fact that they have remained employed by doctors has meant that a nursing service with a 27 year history has remained largely unaffected by the changes in the nursing profession over this time’ (Michel 1997: 1). Michel also notes that there is no evidence of health benefit through the use of practice nurses because largely the general practitioners are not accountable for their use. The increased use of practice nurses is related to the subsidy rather than any health benefit to the community.

Per capita payments could well alleviate the problems described above. This would mean that health professional groups or individuals would be paid a lump sum per person enrolled with them. This would require consumers to willingly nominate a service provider. The per capita sum could be for a given or total range of health services. This type of funding could lead to some redirection of resource that currently goes to general practitioners for primary health care nurses. It is this form of funding that is supported by the

21 Ministerial Taskforce on Nursing recommendations (Ministry of Health 1998). The Taskforce recommended that the Health Funding Authority (HFA) could purchase nursing services directly or as part of a joint venture, perhaps with an IPA. Nurses need opportunities to have equal shares in provider organisations offering primary health care and the opportunity to take part in governance of such organisations. Dunham-Taylor et al (1995) provide evidence that where nurses are utilised appropriately, they are a value added and cost savings component of health care.

Over and above the resources that go to the delivery of primary care services, there is a significant amount of resource directed to the provision of community health related services. These services are mainly provided through Health and Hospital Services (HHS) price volume contracts although some services such as Well Child are purchased through organisations such as The Royal NZ Plunket Society and iwi providers. The HHS community related services are currently broken down into Home Health, which provides a range of domicillary nursing and other services, and Public Health, which includes services such as communicable disease screening and management, well child services and health promotion. Purchasing services in this way clearly not only fragments service delivery but results in gaps and duplication of services.

It is not expected that the HFA will purchase nursing services per se as this will only serve to perpetuate the status quo and maintain the “input” rather than the outcome focus. However, more prudent purchasing of primary health care services would in fact be likely to result in many of the current services being delivered more effectively and efficiently and an ability to further develop primary health care initiatives within existing resources. Many of those could be nurse led/nurse managed.

Currently primary health care nursing services are funded in a variety of ways in addition to practice nurses. These include: · Indirectly through contracts to provider organisations · Contracts awarded to Health and Hospital services that employ district nurses, public health nurses and community specialists. · Contracts awarded to non-government organisations such as The Royal NZ Plunket Society, Nurse Maude, and the Asthma Society. · Contracts awarded to Maori and Pacific Island service providers · Occupational Health Nurses are contracted by employers · General Practitioners Þ Nurses are employed mainly through the Practice Nurse Subsidy (PNS), ACC and wages.

22 Þ Nurses are funded through salary in some capitated practices. For example, “Health Care Aotearoa” employ doctors and nurses on a salaried basis. There are also a few individual practices such as “Dargaville Medical Care” that operate similarly. · Independent Nursing Practices

Þ Nurses are funded directly through Health Funding Authority contracts. According to statistics held by the Independent Nurse Practitioner Association there are only five such contracts. Nurses can also charge a fee for service with no access to subsidies. This situation often prevails in women’s health clinics. · Nurses can be funded through subcontracting Þ Opotiki nurses run services from a clinic at Opotiki Hospital on a contract from Pacific Health.

In many of the above examples nurses are not in a position to determine the nature of the service they provide and the outcomes of that service. This restricts their ability to provide a primary health care service, rather they provide only some aspects of a primary health care service.

‘A wide range of community paediatric nursing roles exist which include well child care and other surveillance and prevention activities. Nurses involved include Public Health Nurses, Plunket Nurses, Maori Health Nurses, Maori and Pacific Island Nurse Educators, School Nurses, Ear Nurse Specialist, Enuresis Nurses, Practice Nurses, Midwives and District Nurses. There is very little national coordination of these groups and no overall plan of service delivery’ (1998:37).

The plethora of titles, the general confusion surrounding the role of nurses in community positions and contractual commodification has added to fragmentation and failure to deliver comprehensive primary health care. We emphasise that the simplification of nursing titles within the community to primary health care nurse is long overdue.

We suggest that per capita funding for all or a range of primary health care services that encompasses services currently provided by primary and community providers could result in a more efficient and effective delivery of primary health care services and would address some of the barriers that have been described. Per capita funding would encourage primary health care practitioners to:

23 · focus on identifying and meeting the needs of the population they served · utilise resources and skills more effectively and efficiently.

There have been some recent moves through the HFA to address this in the revised primary health contracts. There is now a requirement for primary care providers to develop health action plans based on the needs of the population. Robust implementation of these health action plans is going to require input from a range of health care providers but because of the way services are purchased it is unlikely that community service providers will be consulted.

This paper does not purport to have the answers related to funding but simply highlights the issues and suggests that there may be better ways to fund in order to encourage and support provision of primary health care rather than the rather fragmented system that currently exists and which tends to favour primary medical care, target only elements of primary health care and inhibit development of the full expression of primary health care.

As noted at the outset of this paper our intention was to locate nursing in the delivery of primary health care. In attempting to do so we have surfaced criticisms not of medical practitioners per se but of the medicalisation of primary health care initiatives. By medicalisation we mean the failure to recognise that the vital contribution and leadership of biomedicine to the management of illness and injury may not transfer usefully into a similar leadership role in primary health care. As a final example of this we will examine some of the commentary related to one of many models currently proposed for the development of primary health care.

Community Oriented Primary Care (COPC)

Community oriented primary health care is being suggested by some as a cornerstone of health care “reforms” and as a useful response to high cost, high acuity health care (Wright 1993). It is being seen as an answer to the need to expand public health services (primary health care) whilst incorporating ecological considerations. Essentially the shift from primary care to community oriented primary care is an approach which adds community emphasis to existing primary medical care (Garr, Rhyne & Kukulka 1993). COPC, in theory, acts as a change agent for the community. The important factor in this equation is that COPC is accountable for the health status of the community it serves.

24 Despite the inherent limitation in its title, COPC is described by Abramson (1988) as involving, epidemiological and community appraisal in order to deliver clinical care and aspects of community “medicine”. Community participation is central to the notion of COPC. This approach recognises that no one health professional working in isolation can produce a healthy society. Nutting and Connor (1986) reviewed evidence on COPC initiatives (as they are currently expressed) in North America and were unable to find clear evidence of its efficacy. They noted then that the extent to which this form of primary health care practice results in improved health status and at what cost remains unanswered.

Pathman et al (1998) argue that the full expression of all of the dimensions of COPC is rare and the title is often inappropriately applied to primary care practices. Pathman et al (1998) state that COPC requires the involvement of medical practitioners in needy communities and then identify a number of barriers which have precluded this from happening. They cite greater cultural distance between the practitioner and their community, more competing demands for the practitioners time, fewer community resources on which to rely and greater professional burnout. Nevin & Gohel (1996) express similar concerns and note particular difficulties in rural areas.

The COPC model identifies a key element in its success as a multi- disciplinary practitioner team. Included in the team are physicians, nurses, social workers, administrators, social scientists and epidemiologists. Accountability for community health status resides with the entire practice, not just with one individual. In order to advance this model Cashman, Fulmer and Staples (1994) note that adequate health training programmes for physicians requires total immersion of some two years duration in a community based site as a useful strategy. ‘Health professionals are taught to work with not on communities, and to respect and value the knowledge, wisdom and expertise of the people they serve’ (1994: 54, italics in original).

From a nursing perspective we would argue that such immersion would not be needed for nurses who, as a result of nursing’s theoretical orientation towards health and towards partnership already embrace consumer empowerment models. We note however from the available literature that existing examples of COPC have focused on teaching physicians how to adjust to community partnership models rather than any consideration of how to utilise more appropriately the already prepared, well disbursed and often readily available but under utilised nursing workforce.

25 Conclusion

There is a significant challenge involved in devising the most useful means of locating nursing appropriately within primary health care in order for nursing to contribute to reducing inequalities in health. We have already noted the successful implementation of largely Maori led nurse services in the far North, where nursing services are improving access for Maori and comprehensive primary health care including population based strategies.

We support any model which moves from a first contact or targetted approach (top down), to a more socially embedded approach that makes use of the ability of community members to establish their own goals, strategies and priorities for health(the bottom-up model) (McMurray, 1999). Within this model the role of the health professional is focussed on health promotion and community development.

‘It is based on the premise that if community members are provided with structural resources and information appropriate to their cultural, social, and physical needs, they will make informed choices to improve their health and the health of their environment’ (McMurray, 1999:262).

A current example of this approach is the development of the nurse practitioner led primary health care clinic within New Zealand primary schools. The proposed pilot project is to be established in a central Auckland primary school. This model has been widely and successful used throughout the United States of America (Clendon 1999a). Key features of this model include,

· the accessibility of the service because it uses an existing community facility and thus optimises its availability to those who most need it

· the focus on collaboration with families rather than individuals

· the potential for reaching at risk children and their families whilst offering a universal service.

The nurse practitioner-led primary care clinic model has been a response to a comprehensive community needs analysis and community consultation (Clendon 1999a). The role of such a practitioner is supported by subsequent work (Clendon 1999b). This more recent research found that key informants believed the concept

26 of a school based clinic would be more effective at meeting the health needs of children and families than the current primary health care services (1999b:72). Of central concern to the participants were the issue of access, and the perception of existing primary care as illness intervention rather than health promotion (1999b:78). This work represents the depth of community involvement required to alter both public and professional perceptions of primary health care delivery. Further the work is an example of the expertise and skill base of primary health care nurses.

27 References

Abramson J.H. (1998) Community-oriented primary care - Strategy, approaches, and practice: review. Public Health Review. 16: 35-98.

Appleton J.V. (1996) Working with vulnerable families: a health visiting perspective. Journal of Advanced Nursing. 23: 912-918.

Armstrong W & Bandaranayake D. (1995) Public health in New Zealand Recent changes and future prospects. Public Health Monograph Series No 1, Otago: Department of Public Health.

American Academy of Pediatrics. (1998) Policy Statement: The role of home visitation programs in improving health outcomes for children and families. Pediatrics. 101(3): 486-489.

Anderson K.H. & Tomlinson P.S. (1992) The family health system as an emerging paradigmatic view for nursing. IMAGE: Journal of Nursing Scholarship. 24(1): 57-63.

Blakey V.M. & Bradley F.V. (1980) Occasional paper no 14. Survey of home visits by Public Health Nurses in Dunedin Health District. Wellington: Research Unit Department of Health.

Buttigieg M.A. (1995) Health Visiting, in Littlewood J. ed, Current issues in community nursing, primary health care in practice. Singapore: Churchill Livingston.

Campbell S. (1997) Nurse practitioners at the cutting edge of today’s NHS. Primary Care. 7(8): 2-4.

Campbell S. (1997) The role of nursing in primary health care, in Salvage J. & Heijen S. eds, Nursing in Europe: a resource for better health. Copenhagen: WHO.

Cashman S.B. et al. (1994) Community Health: Beyond care for individuals. Social Policy. Summer: 52-62.

Chiarella M. (1998) Independent, autonomous, or equal: What do we really want? Clinical Excellence For Nurse Practitioners. 2(5): 293-9.

Clendon, J. (1999a) The nurse practitioner-led primary health care clinic: A community needs analysis, Unpublished Masters thesis. Massey University, New Zealand.

28 Clendon, J. (1999b) Making a difference: Enhancing public health nursing practice, A service development initiative. Child and Youth Team, Child and Family Service: Auckland Healthcare. Auckland, Auckland Healthcare.

Dignam D.M. & Alpass F.M. (1998) Evaluation of the Child and youth team, Child and Family Community Health Services Auckland, Auckland Healthcare. Palmerston North: Massey University.

Department of Health. (1997) The new NHS, modern, dependable. London: HMSO.

Dunham-Taylor J. et al. (1995) Nurses cut health care costs. Nurse Vision Association. 398-410.

Friedemann M.L. (1989) The concept of family nursing. Journal of Advanced Nursing. 14: 211-216.

Garr D. et al. (1993) Incorporating a community-oriented approach in primary care. American Family Physician. 47(8): 1699-1702.

Gough P. & Richards J. (1999) The political and policy context, in Elywn G. &. Smail J. eds, Integrated teams in primary care. Oxon: Radcliffe Medical Press.

Grandinetti D. (1999) What kind of patient would rather see a nurse practitioner? Medical Economics. The Academic Nurse. 8-10.

Health and Welfare Canada. (1986) Ottawa Charter for Health Promotion. Health and Welfare Canada, WHO, Canadian Public Health Association.

Health Funding Authority (1998) Through the eyes of a child, A national review of paediatric specialty services, Community Paediatrics. Wellington: Health Funding Authority.

Heap J. (1998) Community child health nursing: A New Zealand experience. Journal of Pediatric Nursing. 13(3): 189-192.

Hennessy D. (1995) A changing health service requires a changing workforce, in Littlewood J. ed, Current issues in community nursing, primary health care in practice. Singapore: Churchill Livingston.

Hinder G. (1997) Accompanying: the practice of public health nursing in New Zealand. Nursing Praxis in New Zealand. 12(2): 23-25.

29 Kearns R.A. (1997) A place for cultural safety beyond nursing education. The New Zealand Medical Journal. 110(1037): 23-24.

Kilduff A. et al. (1998) Health needs assessment in primary care: the evolution of a practical public health approach. Public Health. 112: 175-181.

Kleczkowski B.M. et al. (1984) Health system for primary health care, a study based on the technical discussions held during the thirty-fourth World Health Assembly 1981. Geneva: World Health Organization.

Lindsey E. et al. (1999) Creating effective nursing partnerships: relating community development to participatory action research. Journal of Advanced Nursing. 29(5): 1238-1245.

Lipley N. (1998) Doctors get controlling role in new primary care groups. Nursing Standard. 12(40): 5.

Marsh G.N. & Dawes M.L. (1995) Establishing a minor illness nurse in a busy general practice. British Medical Journal. 310: 778-780.

Malcolm L. (1983) Growth of primary medical care related expenditure in New Zealand 1983-1993. Wellington: Ministry of Health.

McEniery M. (1992) Collaborating for health care, in Gray G. & Pratt R. eds, Issues in Australian Nursing. Melbourne: Churchill Livingston.

McMurray, A. (1999) Community health and wellness: a socioecological approach. Melbourne: Mosby.

Michel J. (1997) Review of practice nurse services in the northern region. Regional Health Authority. Unpublished report.

Ministry of Health. (1998) Report of the Ministerial taskforce on nursing: Releasing the potential of nursing. Wellington: MOH.

Ministry of Health. (1998a) Progress on health outcome targets, the state of public health in New Zealand. Wellington: MOH.

Ministry of Health. (1998b) Making a Pacific difference in health policy. Wellington: MOH.

Ministry of Health. (1998c) Child health strategy. Wellington: MOH.

Ministry of Health. (1999) The government’s medium-term strategy for health and disability support services. Wellington: MOH.

30 Ministry of Health. (1999a) Public Health Perspectives June. Wellington: MOH.

Mundinger M. (1998) Differentiated practice for better health. The Academic Nurse. 22-25.

Mundinger M. (1999) Can advanced practice nurses succeed in the primary care market. Nursing Economics. 17(1): 7-13.

National Health Committee. (1998) The social, cultural and economic determinants of health in New Zealand. Wellington: The National Advisory Committee on Health and Disability.

National Health Committee. (1999 draft) Review of the wisdom and fairness of the HFA strategy for immunisation of ‘hard-to-reach’ children. Wellington: The National Advisory Committee on Health and Disability.

Nevin J.E. & Gohel M.M. (1996) Community-oriented primary care. Primary Care. 23(1): 1-13.

New Zealand Board of Health. (1987, 1988, 1988a) Primary health care in an area health board context. Discussion papers. Wellington: Standing Committee on Primary Health Care.

New Zealand Board of Health. (1987a) Incentives and Constraints in Primary Health Care in New Zealand. Report to the Board of Health. Wellington: Standing Committee on Primary Health Care.

Nightingale Florence. (1859) Notes on Nursing.

Nutting P.A. & Connor E.M. (1986) Community-orientated primary care: An examination of the US experience. American Journal of Public Health. 76(3): 279-281.

Pathman D.E. et al. (1998) The four community dimensions of primary care practice. The Journal of Family Practice. 46(4): 293-303.

Pearson J. (1988) Quality care in the Alaska bush. Nurse Practitioner. 13(2): 50-56.

Pybus M. (1993) Public health nurses and families under stress, promoting children’s health in complex situations. Special report series 5. Palmerston North: Massey University.

31 Reutter L.I. & Ford J.S. (1996) Perceptions of public health nursing: views from the field. Journal of Advanced Nursing. 24.

Robinson J. & Elkan R. (1996) Health needs assessment: Theory and practice. Edinburgh: Churchill Livingstone.

32 Scott G. (1998) The next five years in general practice. Wellington: Health Funding Authority.

Shamian J. (1997) How nursing contributes towards quality and cost- effective health care. International Nursing Review. 44(3): 79-84, 90.

Smith K. et al. (1999) Second among equals. Nursing Times supplement. 95(13).

Spitzer, W.O. et al. (1974) The Burlington ramdomized trial of the nurse practitioner. The New England Journal of Medicine. 290(5): 251-256.

Stanhope M. & Lancaster J. eds, (1996) Community Health Nursing. NY: Mosby.

Swanson J. & Nies M. eds, (1997) Community Health Nursing: Promoting the health of aggregates. London: WB Saunders.

Tasmanian Women’s Health Network. (1996) Women’s Health and Primary Health Care, Web site, Primary Health Care Unit. Tasmania: The Tasmanian Department of Community and Health Services Library.

Toop L. (1996) Primary care teamwork in the Christchurch area. New Zealand Family Physician. 23: 51-59.

Walsh N. & Gough P. (in press). (1999) From profession to commodity: the case of community nursing, in Springer P. & Hennesy D. eds, Nursing Policy. London: Macmillan.

West M. & Poulton B. (1997) Primary health care teams: in a league of their own, in Pearson P. & Spencer J. Promoting teamwork in primary care: a research-based approach. London: Hodder Headline Group.

World Health Organization. (1996) Integration of health care delivery. WHO Technical Report Series 861. Geneva: WHO.

World Health Orgnization. (1997) The Jakarta Declaration on Health Promotion into the 21st century. Jakarta: WHO.

World Development Report. (1993) Investing in health world development indicators. World Bank, Oxford: Oxford University Press.

Wright R.A. (1993) Community-oriented primary care, the cornerstone of health care reform. JAMA. 269(19): 2544-2547.

Wuest J. & Stern P.N. (1991) Empowerment in primary health care: The challenge for nurses. Qualitative Health Research. 1(1): 80- 99.

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