Shape-up call for primary health care

1 September 2012

New Zealand Nurses Organisation policy advisor Jill Clendon took a look at the New Zealand general practice model of primary health care and found it lacking at the recent primary health care nurses conference.

She also spoke of nurses’ ethical obligation to be advocates on the socio-economic issues impacting on their patients’ health.

Delivering primary health care through general practices is not working for those who need it most – the country’s poorest, says Jill Clendon.

She told the conference that the business model and funding of general practice needs to be addressed as one way of addressing disparities in health between the rich and poor, white and brown in New Zealand. Also needing addressing were the social determinants of health – like employment, housing and education – that she says research has shown to be more influential on population health outcomes than medical care.

Clendon began her presentation by clarifying what she saw as the fundamental differences between the terms primary health care and primary care. She says primary health care is a broad philosophy of care intended to redress inequities in health (with a key principle being social justice). Primary care, on the other hand, she says, is just one part of primary health care and generally revolves around the type of individualised care provided in general practices.

“In this presentation, I would like to look at ways that nurses can include a primary health care perspective in their primary care practice.”

She told the conference that in terms of equity New Zealand ranked poorly in a number of measures when compared to other OECD developed countries, particularly in child poverty and child mortality. Also, it was known that Māori live at least 8 years less than non-Māori in this country, and life expectancy for Pacific males was 6.7 years less than total males and Pacific females 6.1 years less than all females. Latest research has also shown clear ethnic and social inequalities in infectious diseases in New Zealand.

“The gap in health between white New Zealand and brown New Zealand has actually widened, as has the gap in health between those considered well off and those who live in poorer socio-economic conditions. Quite simply put, this is unfair, and it is wrong.”

She says the 2001 Primary Health Care strategy was intended to address many of these disparities, but after more than a decade, New Zealand health care statistics in terms of equity were no better, and in some instances worse, than in 2001.

“How can this be in a country that once prided itself on its egalitarian ethos and which now has one of the biggest rich/poor gaps in the OECD?” asks Clendon. “One of the reasons is because our PHC system is delivered primarily through general practice, and quite simply, this isn’t working for those who need it most.”

She says costs remains a major barrier to accessing GP services, and while there were some moves in the right direction – like free care for under-sixes and the very low cost access scheme – these were just “tinkering around the edges”.

The strategy had in some cases freed up funding for different services delivered in different ways, including a number of nurse-led initiatives, but it had also created another layer of health bureaucracy, and the business-driven model for general practice meant people missed out on care.

She says the primary health organisation (PHO) structure in theory was “excellent” but she was not convinced that PHOs truly understand what primary health care is with only a few PHOs – including Māori providers who ‘get it’. The challenge also remains in getting funding for primary health care nursing, so the profession could help meet the goals of the PHC strategy

Clendon also got spontaneous applause and calls of “hear hear” when she commented on the PHO and government emphasis on measuring outcomes like immunisations and cardiovascular checks. “Do such indicators truly measure health outcomes? I think not …”

Ethical obligation to act

Clendon says the business model in general practice needs to be addressed, but this would only resolve part of the health disparity problem. The other reasons for health disparities – the social determinants of health – also needed to be addressed to ensure an equitable PHC system develops.

She says researchers have shown that 14 determinants of health, including employment, income, education, and race have been shown to have larger effects on health than the effects associated with physical exercise, diet, or alcohol and tobacco consumption.

“While the role of nurses in addressing issues such as smoking, diet, and exercise is clear, what is less clear is how nurses can address these social determinants of health – aspects that have an even greater impact on health. How can we address levels of education or housing issues?”

She says if improvements in these areas have a far greater effect on health outcomes than anything we do on the shop floor, then nurses must do something about them. “We have an ethical and moral obligation to.”

Clendon says, firstly, nurses can assess for the social determinants of health by asking appropriate questions during patient assessments to ensure, for example, a person has a warm house, food in the cupboard, or transport to their appointment, so issues can be identified and appropriate support or referrals made. Having a resource list in your practice of the agencies that may be able to help and support your clients can be useful in helping you make quick links and referrals.

Secondly, nurses can play a key role in advocating for health equity in their own practice, local nursing school, interaction with student nurses, and supporting your professional group in their lobbying and advocacy roles.

Also, nurses can look at how to change the current primary care business model and advocating for a shift to better models.

“Some models of primary care do work better than others, and we should be advocating for a shift to better models. Primary care should be centred on patient need, not provider income for a start.”

She says some such models exist – like union health centres, some community health centres, and Māori and iwi providers – but funding remains an ongoing battle.

*Jill Clendon was a keynote speaker at Shaping the Flow, the Inaugural Conference of the NZ College of Primary Health Care Nurses NZNO held in Hamilton, August 2012