Gareth Morgan got it right:

1 January 2009

There is urgent need for change in primary health care, writes

One of the key findings of Gareth Morgan’s book, Health Cheque was that it was the nurses who were largely holding the public health system together. His book published this year is an excellent analysis of the very problems nurses often write about including the wastefulness in the system, workforce challenges, the escalating demand for services and the under-utilisation of community-based, wellness-focused services.

My own research (funded by MidCentral DHB since 2005) studying people living with long-term conditions and the development of chronic care services, exposes many situations where people have their presenting problem of the moment managed reasonably effectively.

But at the same time they are continuously struggling to deal with the challenges to life imposed by a long-term condition and the immense need for coordination of care and services, the need for education and interpretation and the knowledge with which to make plans for their life.

We have found many instances of unmanaged pain, people not referred appropriately to palliative care and people struggling with concerns about sleep, nutrition, exercise, anxiety and many of the other sequelae of long-term conditions. Overarching all of this, nearly 60 per cent of this cohort are living on less that $20,000 (and many on not much more) and even current subsidies (for visits and prescriptions) put regular care out of their reach under the current model.

The good news is that these identified needs remain the concern and focus of nurses and nursing services. There are pockets of innovation and change and some wonderful work being done in various corners of the country where exactly these needs and many others are met by multidisciplinary teamwork and nurse-directed services. But the long talked-about desire to more consistently and genuinely align services with community need, remains elusive and needs continued energy and drive.

Sadly, nurses have struggled to develop a forum to bring together the diverse (but largely aligned) voices of primary health nurse leaders into a group, exerting the kind of authority necessary to ensure the changes we think are needed. The Primary Health Care nursing expert advisory group has come and gone and the hard won revision to the recommendations of Investing in Health decorates all of our shelves.

Recently one multi-disciplinary forum (the Primary Health Care Advisory Council, PHCAC) in which nurses and many other members of the multi-disciplinary team actively participated, was disestablished. This seemingly followed the failure of GP members to agree with all other members of the council on the details of a paper arguing for a new model of primary care service delivery. GP groups often argue that the current model of practice works well as it is, but I and many other nurses worry about the dependence on a diminishing GP workforce and the difficulty in providing truly patient or person centered care within that model.

Recently the College of Nurses along with other groups who were members of the PHCAC engaged in an exercise in which each member organisation developed core principles to underpin service development in primary health care.

In order not to waste that exercise along with all the other work that went into PHCAC, we share them here for consideration by the wider nursing profession and anyone else who is interested. College members developed this set of principles we believe should act as a touch-stone for determining when service development is heading in the right direction. The principles are as follows.

1) Preventive care

evidenced by:

  • people’s increased ownership of health rather than simply attending for illness attention;
  • greatly increased focus on holistic and systematic assessment as a basis for any engagement with health service.

2) Social justice focus

evidenced by:

  • a commitment to ensuring that the most vulnerable and isolated people have equal opportunity to be healthy and can access services of choice.

3) People-centered care

evidenced by:

  • a ‘working with’ rather than ‘doing to’ approach, including increased access and choice of provider, flexibility of appointments and increased email contact;
  • the provision of compassionate and culturally appropriate services to acute and long-term clients.

4) Seamlessness

evidenced by:

  • shared IT services and improved communication between providers;
  • a nurse care coordinator for people with long-term conditions;
  • continuity between primary, secondary, and tertiary services (including residential care).

5) Responsive funding models

evidenced by:

  • funding which genuinely follows and supports people-centered care, rather than provider-centric models;
  • funding which traverses bricks and mortar and professional boundaries.

6) Professional sustainability

evidenced by:

  • Nurses (and nurse practitioners), doctors and allied health staff who use their maximum potential for every health encounter;
  • The presence of support staff to assist appropriately.

The strength of these principles lies in their transcendence of professional boundaries or concerns and they offer significant potential for measuring our way forward in the ongoing saga of primary health care service development.

These principles align rather neatly with many of Gareth Morgan’s concluding comments, including that prevention must be an absolute priority, that we may well see a different model of general practice evolving, that case managers will be important for those with multiple problems, that IT systems are critical and that partnerships between patients and health workers will become the most important relationship in the whole system.

Nursing has no argument with any of that… we just want to get on with it.

Jenny Carryer is executive director of the College of Nurses.