Old school

Not so long ago the General Practice (GP) family doctor was part of the whãnau. He, sometimes she, would attend to the health needs of mum, dad and the kids, and often grandparents and grandchildren. He would deliver babies, make house calls, and always make room for an urgent appointment.One such GP is recently retired Havelock North doctor, Colin

One such GP is recently retired Havelock North doctor, Colin Wakefield, who joined the practice of Dr Ian Abernathy in 1976.

“Over 25 years I delivered 1,400 babies, and had five clients who I delivered as babies, and in turn delivered their babies.” Dr Wakefi eld stopped deliveries in 2002 when “the trend was towards independent midwives,” and his patients were aging. “It was thought a safe GP obstetrician should deliver 30 babies a year.”

Childbirth is but one of many changes that has influenced the relationship between doctors and their patients, and the way in which primary care is delivered has needed to adapt to the forces underlying health care reform, which include a chronic shortage of GPs. “The reasons are complex,” says | Dr Wakefi eld. “Enough doctors are being trained but not enough choose to be GPs.”

“The reasons are complex,” says | Dr Wakefi eld. “Enough doctors are being trained but not enough choose to be GPs.”

High levels of medical student debt ($100,000 plus) and the fact a specialist can earn double the income of a GP (around $150,000) discourages students from general practice. A top surgeon in private practice can earn $500,000 per annum and more.

“As a solo GP exiting, it is near impossible to be replaced by another solo GP. My practice had to be amalgamated with one of the three nearby group practices.”

Another long-standing Havelock North GP, Maurice Jolly, already “had an after hours arrangement with Hastings Health Centre”. And it was they who facilitated Colin Wakefi eld’s retirement. “Andrew Lesperance from Hastings Health and Wayne Woolrich from the PHO were wonderfully helpful.”

Dr Wakefi eld says his choice to be a GP was “an ethical service calling”, and he looks back on his career as “a delight to be involved in the health care of my patients”.

The health centre

“We wanted to have a presence in Havelock North and we heard Colin was retiring,” says CEO of Hastings Health Center, Andrew Lesperance. The timing was opportune because “it happened at the same time we merged Maurice Jolly’s practice, so Maurice has moved across the road” (into Wakefi eld’s former surgery).

Originally from Toronto, Canada, Lesperance worked as a specialist cardiac nurse until meeting “a Kiwi girl who bought me home with her as a souvenir”.

Now 20 years in New Zealand, he has held general-manager positions with Southern Cross Hospital in Palmerston North, Cancer Control with the Ministry of Health, and the Marlborough District Health Board, where he was also acting CEO.

“Our intention is to have a two-GP practice in Havelock North. A new appointment is arriving in January.” Until then “a series of locums” will see patients. And he talks of “growing” the practice in the future.

Fundamentally, the Health Centre model sees doctoring run as a business.

The Doctors – with premises in Napier, Greenmeadows, Hastings, and 40 outlets nationwide – is the most obvious corporately-structured health provider in Hawke’s Bay. The owner, Green Cross Health Ltd, also owns the Unichem pharmacy brand, and is listed on the stock exchange with a market capitalisation of $275 million. Doctors and support staff are contracted employees.

Other health centres such as Totara Health, Te Mata Peak Practice, Taradale Medical Centre, and The Hastings Health Centre are limited liability companies. Shareholders are predominantly the doctors involved in the practice, but also include pharmacists, and passive investors. Hauora Heretaunga Medical Centre in Hastings, which provides health  services to enrolled whãnau, is structured as a Trust, with affiliation to Ngãti Kahungunu Iwi Inc.

Chris Ash, Wayne Woolrich and Kevin Snee reshaping HB health care delivery. Photo: Florence Charvin

A unique feature of the Hastings Health Centre is its Urgent Care service. “To have ACC accreditation for Urgent Care we’re required to have X-ray service.” This and other compliance requirements like sterilisation standards “comes at a cost,” says Lesperance. And it is only by “consolidating services” that operating “costs are reduced”.

Today’s health centres offer a suite of integrated health services, which stand- alone doctors, like Colin Wakefield, could not provide, and the notion of the doctor being the first call for primary care is changing rapidly.

Integrated health

“In many parts of the world the contact between GP or clinician and patients is only 40-50% of the time,” says Kevin Snee, CEO of Hawke’s Bay District Health Board (DHB).

Appointed eight years ago when the Board was under statutory management, Snee was recruited from the UK, where he trained as a GP, later specialising in public health, spending his early career “in primary care oversight, commissioning of services, contracting and planning”. One of Kevin Snee’s

One of Kevin Snee’s first initiatives as CEO was to encourage a framework termed ‘Transform and Sustain’. He wrote at the time (2010) this was about “thinking and working differently, and having the time and tools to do this. We must think and act as one system – the Hawke’s Bay Health system – rather than as a DHB, a hospital, or a primary care provider.”

Today, he says, “New technologies and a broadening range of specialist staff ” means instead of seeing a doctor, we’re more and more engaging with other health professionals. Most health centres have in-house “pharmacists who advise on drugs and drug interaction, and assigned nurses for diseases like diabetes”.

Interestingly, Snee says telephone consultation was being trialled when the Havelock North water contamination crisis occurred. “Necessity being the mother of invention,” health providers “phone knocked” their patient lists for consultation. And considering most of those poisoned were at home, that “worked really well”.

From his observation of overseas models, and in response to need, Kevin Snee is keen “to develop how mental health integrates with primary care” … where “clinical mental health professionals, behaviouralists, are part of the primary health care team … not an outreach service, or co-located, as they are here, but full members of the (health centre) team”.

A particular focus of Snee’s tenure as CEO has been shifting resources from the hospital to the community for health promotion and prevention. But it’s not easy. Pressure from Wellington to achieve goals for ‘elective activity’ and funding targeted at particular hospital issues makes it more diffi cult to dedicate resources to primary care.

It’s a Catch 22 situation. “When there are not enough resources in primary care, people end up in the wrong place – the hospital – and because people end up in hospital, we have to put more resources there.”

Addressing this dilemma, and assisting to integrate health care, the DHB has created a new position, Executive Director of Primary Care, the fi rst health board in the country to establish a dedicated role to primary care management.

Primary care

Chris Ash, who holds that position, first came to New Zealand 20 years ago on a gap year between school and university. After completing a business degree he entered a management-training program with the National Health Service (NHS), and his last posting was as director of strategy with Southern Health NHS Foundation Trust in Southampton.

“One of the things that attracted me here was Kevin Snee’s very clear vision that the primary care system in Hawke’s Bay could be even better,” says Ash, whose work experience has included managing services for the elderly, and aspects of social housing in a deprived community.

He says his chief executive “understands that there are numerous communities in Hawke’s Bay, that it’s not one size fits all, and you need services that can respond to the needs of particular populations”.

Communication is key, and Chris Ash says, “The goal is to work with the wider primary care sector, GPs, and non- governmental organisations, to put in place the right structures and incentives for people to work together around the needs of certain patient groups.”

And he says, “Primary care has to be timely, because if a patient has a care need, but it can’t be met in reasonable time, they are more likely to slip into a secondary care situation, or an intervention situation.” From his experience in the UK, Chris

From his experience in the UK, Chris Ash, observes that, “If you construct a service and people don’t engage, then the root of that problem is the way the service is designed, and not the people who use it.” In this

In this context he says, “An interesting concept in developing health policy is this idea of the ‘Universal Care Law’, which states that people who need health services the most are the least likely to access them. It could be cost barriers, it could be distance to access, or the services don’t reflect the need. It could be a feeling you’ll be judged.”

And on the same page as Kevin Snee, he says, “Mental health has been an undeveloped part of primary care globally.” Chris Ash is responsible for administering $240 million of contracts that sit outside the hospital, from a total DHB budget of $520 million. He says large parts of that are transferred directly as part of nationally agreed contracts, as with Pharmac for

Chris Ash is responsible for administering $240 million of contracts that sit outside the hospital, from a total DHB budget of $520 million. He says large parts of that are transferred directly as part of nationally agreed contracts, as with Pharmac for medicines, and the PHO for doctor subsidies.

Money go round

Napier-born Wayne Woolrich has the ideal work experience for his position as general manager at Health Hawke’s Bay, the Primary Health Organisation (PHO) responsible for managing the $40 million subsidy for GP visits.

Previously he was commercial operations manager with Green Cross Health providing funding and operational support to managers at The Doctors; experience that gave him “understanding of the complexities and systems of funding, and the models in operation in general practice”. PHO’s are not-for-profi t organisations with community and provider representation on a Board of Directors and Advisory Groups. They were formed in 2002 and their funding from the Ministry of Health via the DHB is based on enrolments (158,993 people in Hawke’s Bay, 97% of population in October 2017).

“Core funding is capitation (per head) with diff erent rates for diff erent age groups and diff erent demographics,” says Woolrich. The subsidy is “bulk funded on estimated visits regardless of how many times a patient presents”.

Prior to 2002 subsidies were paid per consultation. Dr Wakefi eld recalls being very relieved after capitation funding because “my practice expenses were met when I walked through the door in the morning”, whereas before, “I felt that I worked until two o’clock to pay my expenses, and then I was earning my income.”

As of 1 July 2017, basic annual subsidies ranged from highest for 0-4 year olds with high use cards at $608.69, to lowest for 15-24 year old males with low use cards at $67.55.

The PHO has additional DHB funding streams “to improve access (to health care) for specific catagories”, says Woolrich. Currently, a Whãnau Wellness program is being off ered to low decile Mãori and Pacifi c Islanders. “We work with medical centre providers to identify enrolled whãnau, and to invite them to join a 12 month program of education, and provide health literacy around various topics that aff ect them.”

Wayne Woolrich points to “good relationships with general practice and with our DHB colleagues,” as an important factor, “if we’re to make a diff erence in health outcomes in Hawke’s Bay.” He says, “Part of our culture is to work together on the diffi cult challenges.”

Working together

“What we’ve tried to do is build relationships with both national and local organisations, like the Police and MSD (Ministry of Social Development),” says Kevin Snee, because “often we’re looking after the same group of people with problems of criminality, and health problems, and mental health problems.” He says, “The more we can triangulate and work together to help them, the more we get the synergies, rather than working in silo.”

Chris Ash calls this “the intersectoral component” where “the agendas of several public agencies are fundamentally intertwined”. Six weeks in the job and he has already had “great conversations with some principals of secondary schools, who absolutely get the link between health and well-being and educational outcomes.”

“Employers too,” he says, “can be engaged with the health and well-being of their employees, which leads to less absenteeism, which in turn increases productivity.”

With the recruitment of Chris Ash, CEO Snee is looking forward to “setting up an alliance arrangement” with the PHO and other recipients of DHB funding – pharmacy, aged residential care, community services – to create a greater integration among the different funding streams.

“Sometimes,” he says, “funding streams for similar groups of patients, like long term (chronic) conditions funding in Pharmacy and Care Plus, target the same people, but don’t talk to each other.”

Chris Ash says, “A feature of a high performing primary-care system is a system in which those involved in the caring talk to each other – physically talk to each other.” And he says, “Starting in a new job with the clinical services plan and The Big Listen happening at the same time is a massive blessing for me.”

The Big Listen

A group of about a hundred gather at the Napier Conference Centre for In Your Shoes, an inter-action between healthcare professionals, and the people who use their services, referred to as ‘consumers’.

The word patient is hard to shake, but its time is over. The root is pati, Latin for suffering, and today’s health care emphasises wellness, not disease.

As Kevin Snee pointed out, “Changing language changes the mind set,” and shifting the relationship between users and providers of health care in Hawke’s Bay is a focus of the DHB. The core of this gentle revolution is empowering the community to take ownership of health both individually and collectively.

In Your Shoes forms part of a DHB initiative, The Big Listen, which is described as “about the people side of our workplace and our service,” and invites people “to have their say about what it’s like working in the sector as well as receiving care with us.”

Kevin Snee is taking part in the session, as is freshly-appointed Chris Ash.

We, the consumers, are paired with health professionals, and my confidants are John and Alan. The convener has made it clear that confidentiality is expected, and “anyone who might gossip about what is said today should leave now”.

At first we play a game of snap. The convener asks our opinions of the health system, good and bad. When our answers coincide, it’s ‘snap’, and that happens often.

Later we share more intimate details of our experiences, and I tell my confidants I feel lucky to have had Bertrand Jauff ret as my surgeon.

After he showed me a photo of the “tumor in the mid ascending colon,” I said to him, “Eeew, that’s not very pretty.” Dr Jauff ret replied, “It will look much prettier in a bucket.” And he went on to explain in detail the procedure he would perform.

His humour warmed me. His manner gained my trust. And trust is what I needed most, because that was lost when my doctor mis-diagnosed symptoms I’d been complaining of for three years, at one consultation saying my swollen belly was a sign of aging, and I should consider hormone replacement therapy.

Needless to say I changed doctors.

Now, signed up with a health centre, I’m more likely to see a locum from overseas than my designated GP. Usually my health-care needs are urgent – that day – for bronchitis or a leg infection. When I told an Aussie doctor the bite was from my cat, he said, ‘Then shoot your freakin’ cat’.”

We all have experiences both good and not so good with health care, but all residents of Hawke’s Bay can be assured their current and future health care needs are the intense focus of many well qualified and dedicated health professionals.

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