Dr Jim PrimroseChief Advisor

Atención de Salud PrimariaSeminario en Sistemas de Salud

Nueva Zelanda

ChileDec 2011

El mundo visto desde Nueva Zelanda

Neozelandeses

Total 4.4m

European 68%

Maori 14%

Pacific 7%

Asian 10%

76% live in North Island

Sistema de Salud y Discapacidad

Caracteristicas principales

• universal access

• largely funded from taxation

• comprehensive range of services, increasingly based on strong community and primary care services

• fixed budgets

• prioritisation

Providers – mix of public and private ownership

Financiamiento

Funding of health services:

• Vote Health ($14.4b) 81%

• Out of pocket 14%

• Private insurance 5%

Vote Health has been growing faster than GDP over recent years.

We spend a similar proportion of GDP on health as other OECD countries, however our per capita spending is lower than many.

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1000

2000

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6000

7000

8000

1980

1981

1982

1983

1984

1985

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1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

Australia

Canada

Denmark

France

Germany

Netherlands

New Zealand

Norway

Sweden

Switzerland

United Kingdom

United States

Comparación Internacional del Gasto en Salud1980–2010

Average spending on healthper capita ($US PPP)

Total expenditures on healthas percent of GDP

4321

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2.0

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6.0

8.0

10.0

12.0

14.0

16.0

18.0

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

Australia Canada

Denmark France

Germany Netherlands

New Zealand Norway

Sweden Switzerland

United Kingdom United States

Source OECD Health Data 2011

CENTRAL GOVERNMENT

Minister of Health

20 DISTRICT HEALTH BOARDS

Users of New Zealand health and disability support services

Internal agreementsBuy with Service Agreements

Other Providers

(for profit or not for profit private or community ownership, voluntary, welfare)

• Private pharmacy, laboratory, & imaging

• Primary care – GPs, Allied Health, Midwives

• Private hospital services

• Community services

• Disability support

• Mental health

District Health Board provider arm

• Public hospitals

• Some community services

• Assessment & rehabilitation

Health and disability support services

Atención de Salud Primaria– la consulta medica privada

96% of New Zealanders are enrolled with general practice, their medical home.

New Zealand has 1100 general practices with:

• 3,200 General Practitioners (GP: Population ratio 1:1400)

• 5,200 Practice nurses

• almost all practices use electronic patient records.

Practices are mainly owner operated small businesses and function within larger groupings/networks – Primary Health Organisations.

Funding at practice level is blended, a mix of government funding (capitation) and patient fees - which vary.

People rated care received from regular doctor as very good/ excellent

Source: 2010 Commonwealth Fund International Health Policy Survey in 11 Countries

Opinión de pacientes en Nueva Zelanda sobre consultas medicas

35 3522 27 30

18 218 15 12 5

54 5466 54 49

59 5468 49

3634

0

25

50

75

100

NZ NOR NET UK SWE ITA CAN FR US AUS GER

Satisfied

Very satisfiedPercent*

Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

Grado de satisfacción medica en el ejercicio de la medicina

OECD Health Data 2009

Adultos que informan gozar de buena salud

(2007)

Comparación internacional de esperanza de vida al nacer, algunos países (2009 o último año disponible)

Source: OECD Health Data 2011

Country Period Life Expectancy at Birth

   Total Population

Male Female

Switzerland 2009 82.3 79.9 84.6

Australia 2009 81.6 79.3 83.9

Sweden 2009 81.4 79.4 83.4

France 2009 81 77.7 84.4

Norway 2009 81 78.7 83.2

New Zealand 2009 80.8 78.8 82.7

Canada 2007 80.7 78.3 83

Netherlands 2009 80.6 78.5 82.7

United Kingdom 2009 80.4 78.3 82.5

Germany 2009 80.3 77.8 82.8

Denmark 2009 79 76.9 81.1

United States 2009 78.2 75.7 80.6

1 Estimate

2.12.1

2.7

3.23.33.43.43.83.8

4.04.34.2

4.7

3.94.3

4.74.4

5.05.2

5.65.35.3

5.65.76.1

6.6

0

1

2

3

4

5

6

7

8

NZ AUS GER OECDMedian

FR UK* SWIZ NOR SWE DEN CAN* NETH US*

Female Male

* 1987–2007Source: OECD Health Data 2010 (Oct. 2010)

Years

Crecimiento de la esperanza de vida al nacer (1988-2008)

15

Prevalencia de la obesidad en población adulta (2009)

Note: BMI estimates based on national health interview surveys (self-reported data) are usually significantly lower than estimates based on actual measurements.

Percent

* 2008** 2007

Source: OECD Health Data 2011 (June 2011).

Measured

Self-reported

Mejorando la satisfacción de la gente con los servicios

System features:

Engagement/participation – at all levels

• governance – DHBs and PHOs

• service design

• public reporting - increasing

• self care + health literacy – needs more work

Primary Care

• enrolment - 96% of people enrolled with general practice

• long term relationships - continuity and responsiveness

• choice of provider

Mano de obra calificada

Currently we have• reasonable numbers of General Practitioners (GPs) and Practice Nurses, but the workforce is ageing and not well distributed• practice based teams of GPs and Practice Nurses are universal, but broader multi-disciplinary teams less common

There’s • a voluntary bonding scheme - for communities with low GP/nurse numbers• continuing professional development• and involvement with clinical governance is increasing

– multi-disciplinary

Mano de obra calificada – dirección futura

We aim for more multi-disciplinary teams in local communities – GPs/nurses/pharmacists/allied health.

In particular to

• have health professionals working to the full scope of their practice

• expand roles eg primary care nurses managing more chronic conditions, pharmacists prescribing & immunising

• have greater flexibility within existing roles, as well as new roles Clinical assistants

Care coordinators/navigators

• build a strong generalist workforce with effective specialist support

Farmacéuticos y servicios de diagnóstico

Pharmaceuticals

• Medsafe – assesses medicines for use in NZ - is part of the Ministry of Health

• Pharmac – decides which medicines to fund and promotes their optimal use – within a capped budget

• Dispensing of medicines through 960 community pharmacies

This means

• most medicines fully funded by the government – a $3 copayment applies

• our rate of pharmaceutical use is similar to other countries

• our per capita pharmaceutical spend is about 50% of the OECD average

Farmacéuticos y servicios de diagnóstico

Laboratory services

GPs order a wide range of laboratory tests from local community laboratories (privately owned)

• there are no patient fees

• results are returned electronically to practice computer systems

Radiology

GPs order these investigations from

•public hospitals - no patient fees, but some waiting

•or community Radiology clinics (privately owned) – fees apply

Next step = improving access to radiology services

Can it improve quality and save money?

“yes it can”

• Prevent hospital admissions

• Identify patients most at risk of deterioration and ensure they receive coordinated care and self-care services

• Counteract the increasing fragmentation of services

• And its possible that those who suffer most from under-coordination are people who are poor and/or members of ethnic minority groups

Coordinación clínica e integración

Does clinical coordination improve quality and save money? – Dr John Ovretveit, The Health Foundation

22

Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

Errores médicos, de medicamentos, o de laboratorio, en los dos últimos años, con/sin “medical home”

Base: Reported medical mistake, medication error, and/or lab test error or delay in past two years.

Percent

Coordinación clínica e integración

Key aspects

• requires clinical leadership

• change based on the patient journey - the right thing to do

• enabled by flexible funding and permissive policy environment

Building blocks

Enhanced primary care capacity & capability

• workforce – changing scopes of practice + multi-disciplinary teams

• facilities – larger health centres

• information capability – safe sharing of electronic health records

Service shift from hospitals to communities

Condiciones crónicas y atención primaria

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Current smoking prevalence* among adults (15+)

* The definition of current smoker is the WHO one of a person who has smoked more than 100 cigarettes in their life and smokes currently at least once a month.

1. Prevention and early intervention

Address broader determinants housing/education/employment.

Four main risk factors:• smoking – good progress• diet• exercise • alcohol

2. Early detection and good management

• use of guidelines• decision support tools• multi-disciplinary teams• self-management/health

literacy• health targets

Metas de Salud (Health Targets)

• Shorter Stays in ED Departments

95 percent of patients will be admitted, discharged, or transferred from an Emergency Department (ED) within six hours

• Improved Access to Elective Surgery

The volume of elective surgery will be increased by an average 4,000 discharges per year (compared with the previous average increase of 1400 per year).

• Shorter waits for cancer treatment radiotherapy and chemotherapy

Everyone needing radiotherapy will have this within four weeks

• Increased immunisation

95% of two year olds will be fully immunised

• Better help for smokers to quit

95 percent of hospitalised smokers will be provided with advice and help to quit smoking

• More Heart and Diabetes Checks

90 percent of the eligible adult population will have had their cardiovascular disease (CVD) risk assessed in the last five years

“To improve health care we require not better professions, but better systems of work. A “system” in this sense is a set of elements interacting to achieve a shared aim. Here is the trick: to improve the performance of the system you need to attend more to the inter-actions than to the elements. Great health professionals inter-acting well with all of the other elements of the healthcare system make great health care.”

Don Berwick, “Medical Associations: Guilds or Leaders?BMJ, Vol 314, 564-1565

Mejorando la atención de salud…

Gracias