New Zealand <Small map of country> WONCA Asia Pacific Meeting, <location>, <month> <Year> Felicity Goodyear-Smith Department of General Practice & Primary Health Care University of Auckland, New Zealand

Demographics of New Zealand’s population Population 4.6 million Distribution >80% urban Ethnicity NZ European 74% Māori 16% Asian 12% Pacific peoples 8% Unemployment rate 4.9% Life expectancy ♀ 83.3 years ♂ 79.6 years Basic demographics: Population Distribution (eg urban / rural / remote) Socioeconomic breakdown Ethnic groups Other relevant characteristics eg religions

Structure primary health care Practices may be owned by GPs, corporates or trusts Government funded capitation and performance payments, with some out of pocket payment for fee for service Medicines & investigations heavily subsidised No fault liability – Accident Compensation Corporation Universal coverage - enrolment in a practice Ownership of practices Coverage of PHC disciplines through health insurance? For whom?

Disciplines working in primary health care in the community GPs, practice & public health nurses, midwives, many allied heath workers Shortage in many rural areas. Many rural GP positions filled by overseas medical graduates, locums Aging medical & nursing rural workforce Which disciplines Constitute PHC (family physicians, nurses, midwifes, allied health professionals) Availability PHC disciplines and distribution in the country

Proportion of general practices integrated in PHC team Solo GPs on the decline, probably now <10% Almost all GPs work with practice nurse, also receptionist & practice manager. Increasing number custom-built group practices, often with community pharmacist, laboratory & radiology services on site. Trend towards integrated centres with allied health & social services (eg mental health, podiatry, nursing & social worker out-reach) Role of PHC teams in provision of primary health care Describe the types of practices operating eg solo GP, group practice, working with practice assistant or practice nurse, or integrated practice with allied health workers and other services (eg laboratory and radiology investigative services), what are the majority and what is the trend?

Community based primary health care in New Zealand Nearly every general practice in NZ is capitated ie looks after a defined enrolled population All Nzers expected to be enrolled in a practice (almost all are) In early all practices, multi-disciplinary collaboration is structured around individual patients, tailored to their needs Are multidisciplinary PHC teams organised around a defined population? If so: what % of GP practices? Is multidisciplinary collaboration in primary health care ad-hoc structured around individual patients and their needs? If so: what % of GP practices?

Relation of primary health care with other community services Whānau Ora Approach that places families at centre of service delivery, requiring integration of health, education & social services Delivered by Māori providers; also available for some non-Māori Other practices more ad hoc All practices belong to Primary health Organisations (PHOs) which may involve consumer consultation & social service integration Relation primary health care and other community services Is there collaboration of primary health care professionals with other community services (social welfare)? To what extent is this structured or ad hoc Are there contacts with community leaders/patient representatives? If so, do they have a formal role or is it ad hoc/informal?

Impact on patient care Whānau Ora outcomes being monitored: Families are self-managing & empowered Families leading healthy lifestyles Families participating fully in society Families economically secure Families cohesive, resilient & nurturing Families responsible stewards of living & natural environments Is there evidence of the impact community-based PHC teams have on patient care and population health? Think of population health, provision of services, effect on overall costs

What are the benefits? Team approach enables GPs, nurses to work at top of scope Devolution of secondary out-patient care into community Capitation enables population-based approaches especially health promotion & prevention PHOs enables collation of data including feedback to outliers eg with prescribing & investigation ordering Positive impact on PHC system, enablers of care Summarise models of success Is there a relation to PHC development (teaching, education, research)?

What barriers are encountered? Funding restraints: 32 PHOs that differ in size, governance, policy Different practice ownership models (eg owned by GPs, Trusts, corporates, District Health Boards) Poor hospital referral back to community care Midwives generally prefer to work independently Present barriers that stand in the way of implementing Community0based PHC teams/centres

How teams support or impede response to community needs Networks of practices (PHOs) hold funds & implement programmes rolled out to all practices Team approach enables systematic approach & high coverage (eg immunisation, cancer & CVD screening, diabetic checks) Well-funded PHOs include social services & community out-reach Ways in which community based primary healthcare teams are a support or impediment to respond pro-actively to health needs in communities

Lessons for other countries In general, family & patient-centred comprehensive primary care Continuity of care Both individual & population-based Often poor communication & transfer of care at primary / secondary interface Summary of what works well and does not work well in community-based PHC teams in this country