Towards integrated care in New Zealand: opportunities and challenges Professor Jackie Cumming Director, Health Services Research Centre School of Government Victoria University of Wellington

As in other countries, NZ health services are fragmented This results from service users working with a wide range of health professionals working in a wide range of organisations Lack of information sharing, liaison and team work are then seen to result in lack of co- ordination of care Fragmented Care in NZ

Integrated Care Definitions in NZ (1) NZ has a long history of aiming to better integrate care – at least since the Social Security Act 1938 ‘Integrated care’ is not always well defined in NZ: o Achievement of ‘co-ordinated care’ from patient perspective, i.e. ‘smooth and continuous transition between services’ and a ‘seamless journey’ for service users o Collaboration and co-operation across services, from a provider perspective

Integrated Care Definitions in NZ (2) Linked to good access to primary health care (PHC) providers, seen to be the lead co-ordinators of care Can refer to the linking of key planning, funding and service delivery activities to support co-ordination Can mean integrated service delivery organisations providing a wide range of services to enrolled populations working within a single budget Integration across a level of care (eg, across PHC) (‘horizontal’ ) Integration between PHC & secondary (hospital) care (‘vertical’) Integration across health & social development services (‘inter- sectoral’)

Barriers to Integrated Care in NZ Separation of roles in planning leading to duplication and gaps; different criteria for accessing services limiting access Barriers to access to PHC, from user fees Barriers to PHC providers leading co-ordination, from fees and private provision Lack of information sharing and liaison could see users slip through gaps, be seen by multiple providers, information not be shared or go missing, tests duplicated, harm from eg incompatible medicines, different health advice from providers Overall, poor quality of care and waste of scarce health resources

Attempts to Better Integrate Care in NZ (1) Many reports on NZ health system noted issues from fragmentation, proposed better integration Many actual reforms emphasised integration of planning and funding; service budgets; service planning o Eg, Establishment of Area Health Boards in the 1980s – planning and funding of pubic health and secondary care o Eg, Regional Health Authorities / Health Funding Authority – planning and funding for all health and disability services Most emphasis on integrating government-owned organisations to this point

Attempts to Better Integrate Care in NZ (2) NZ seriously began focus on integration for service delivery / clinical services in 1990s o Eg, Development of Independent Practitioner Associations who could integrate care horizontally across PHC providers and work with hospitals to vertically integrate care o Eg, Focus on service delivery and clinical integration through HFA national integrated care pilots

Attempts to Better Integrate Care in NZ (3) 2000s Primary Health Care Strategy had better integration as a key objective o Reducing fees patients pay to improve access to PHC o Development of Primary Health Organisations to co-ordinate care horizontally and vertically o Strengthening role of PHC in the health system o Encouraging team work and better co-ordination across providers However, Primary Health Care Strategy o Seen to focus on development of new organisations (DHBs and PHOs) and population health focus o Insufficient attention to service delivery and clinical integration o Failure to identify what a comprehensive model of PHC might look like and how it might be delivered

Attempts to Better Integrate Care in NZ (4) At the same time, some policy moves likely to have increased fragmentation from expansion of range of providers Eg, Deinstitutionalisation in mental health and older people’s care Eg, Growth in independent midwifery

Data and Research? Little data and research Especially on views of service users Hence, not entirely clear where we most need to pay attention to improve care for service users

Sicker Adults

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

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

Adults

15 Gaps in Coordination of Specialist Care Specialist did NOT have reason for visit/tests from regular doctor Regular doctor NOT up-to-date about specialist care Percent Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries. Base: Saw specialist in past two years and has regular doctor/place of care.

Regular Doctor Co-ordinates Care Received from Other Doctors and Other Places Percent reporting doctor always/often coordinates or arranges care Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries. Base: Has regular doctor/place of care.

PHC Doctors

Percent Doctor Can Electronically Exchange Patient Summaries and Test Results with Doctors Outside their Practice Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

Percent Practice Uses Nurse Case Managers or Navigators for Patients with Serious Chronic Conditions Note: Question asked differently in France. Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

Primary Care Doctors’ Receipt of Information from Specialists Percent said after their patient visits a specialist they always receive: AUSCANFRGERNETHNZNORSWESWIZUKUS Report with all relevant health information Information about changes to patient’s drugs or care plan Information that is timely and available when needed Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

Percent After Hospital Discharge, Primary Care Doctor Receives Needed Information to Manage the Patient Within 48 Hours Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

Proposed New Patient Experience Survey… Will examine within hospitals, Consistency in information provided by different doctors and nurses Explanations about health and health care after arriving home Whether service user felt they received enough information to manage condition on discharge Explanation of purposes of medicines that was understood by service user Medication side effects to watch for Information to family/whānau Sufficient care and assistance after leaving hospital Who to contact if have worries after leaving hospital Service user receive copies of letters between hospital doctors and GP

“New models of care which see the patient rather than the institution as the centre of service delivery and which aim to promote a more seamless patient journey across community, primary, and hospital sectors, greater use of primary and community care, and the shifting of care ‘closer to home’.” (‘Better, Sooner, More Convenient’) Integrated Care in NZ – The Present (1)

Integrated Care in NZ – The Present (2) Emphasis now on o Encouragement of joint regional and district leadership and decision-making o Devolution of funding and services from hospitals to PHC settings o Amalgamations of eg PHOs to strengthen leadership and capability in service development o Integrated Family Health Centres o Improved information systems to share information o Whānau ora But also moves to expand prescribing rights and extend role of pharmacists

Integrated Care in NZ – The Present (3) Little is known about these initiatives Extent of information sharing Extent of co-location of services Extent of going beyond the above to agreed pathways, co-ordination/navigation roles, team decision-making Service users’ views on whether there is better integration from their perspectives Overall impact of changes

We need Research on types of integration being achieved or not being achieved Measures to assess integration from both provider and service user perspectives within and across service delivery organisations Research on impact of integrating processes Research on barriers and enablers to better integration Discussion on integration vs expanding access through new provider roles (role of choice and competition)

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