Student: Dulia Halliday
Supervisors: Les Toop Dept Public Health & General Practice, Co-Supervisors: Kelly Maw and Shelley Frost [Pegasus Health]
Sponsor: Partnership Health Canterbury
Introduction
The New Zealand Primary Health Care Strategy (PHCS) was implemented in 2001. It changed the funding of primary health care from the “fee for service” model to capitation. The “fee for service” model paid the general practice a general medical subsidy (GMS) when the general practitioner (GP) attended to the patient. Fee for service meant that there was no subsidy if the patient was only seen by the practice nurse (PN). Therefore the PN was limited by always having to involve the GP in their patient care for the practice to receive the GMS. Capitation funds a general practice on the basis of its enrolled population. The capitation payment is worked out from the average amount of times patients of a certain demographic see the GP in a year. It is thought that the change to capitation would allow for the PN to have a more autonomous role in the practice. This project aimed to explore how successful GPs and PNs felt the PHCS had been in improving teamwork and what issues (positive or negative) had arisen as a result.
Method
A postal survey was sent out to all GPs (273) and PNs (286) belonging to Partnership Health Canterbury Primary Health Organisation (PHO). The first set of questions asked how the GP and PN workload in different areas of patient care had changed in the past ten years and what issues this had bought to the practice. These questions were for both GPs and PNs and asked them about their own workload and that of their colleague. The next question asked how the GPs and PNs wanted their workloads to evolve in these areas of patient care and what would need to be done to obtain their desired workload. The rest of the questions were text based. They asked for their individual opinion on: the positives and negatives of capitation and enrolment; the communication between other members of the primary health care sector and their overall opinion (positive, negative or neutral) to patient care in the past ten years.
A recorded focus group was also run with 7 GPs and 9 PNs. The GPs and PNs talked freely for 90min with minimal interjection from those running the group. This allowed a more in depth discussion of the changes in primary health care in the past ten years.
Results
Questionnaire
Overall 234 questionnaires were returned. Of these 226 were completed with the other 8 not being filled out due to working in general practice for less than 6 years. The final response rate was 45% for GPs and 40% for PNs. 75% of respondents said that the PNs were involved in more patient care than ten years ago, with greater utilisation of their skills. Even with this increased workload, 96% of PN respondents wanted to do more or were happy with the amount of patient care they were doing. In order for this welcome trend to continue they felt they needed more space, education, employed hours and greater support from the GPs. Only 3 percent of PNs felt their skills were under utilised in providing patient care.
Two thirds of respondents thought that GPs spent more time caring for patients. Taken together it is clear that, on the whole general practice is busier than ten years ago with more patients being seen and needing longer consultations. 60% of GP's were happy with their patient care workload. Around 75% of GP's thought that they were spending more time managing chronic diseases and on extended care of serious illness while only 20% of GPs thought they were spending more time on minor illness. This suggests that there is a change in the nature of work that GPs are doing.
The perceived downsides of the PHCS were financial with an ever more complicated multiplicity of funding streams and a more controlling, bureaucratic government requiring unnecessary reporting. Of these it was evident that the greatest single concern for both the GPs and PNs was the huge and increasing paperwork occasioned by the new reporting requirements of the PHCS. These transaction and opportunity costs were seen as getting in the way of time available to spend on patient care. Over half of GPs thought that capitation had improved funding or income. The PNs thought that capitation and enrolment had improved continuity of care with patients. Both GPs and PNs expressed their concern for the lack of or poor communication with midwives. They thought that this undesirable negative attitude towards each other was harmful to patient care, business and workload.
Overall respondents felt (by 5 to 1) that patients had benefited from the changes. GPs and PNs felt that the positive change had come through the increased funding making it more affordable for patients to be seen and that the services provided now are better than ten years ago.
Focus group
PNs and some GPs agreed that there is an increase in PN autonomy. The GPs, as business owners, were primarily focused on financial matters. There was a wide range of views expressed on the best and most efficient way to run a general practice as a successful small business whilst maximising patient care.
Discussion
The results show that PNs are spending more time on patient care and are very positive about this change. With the PN having increased autonomy and an extended role in general practice this increased teamwork allows for a shared workload and for the GPs to focus their time and knowledge on providing more specialised patient care. PNs feel more work satisfaction, respect and appreciation when trusted with an increased workload. With the ever-growing workload of primary care it is vital that those with clinical training are utilised effectively. With more clinical work for the PN this should allow for a more efficient workforce and it will be increasingly needed with the projected decline in GP workforce.
The GPs major concerns regarding the changes in the past ten years involve the invading government control. The majority of GPs are practice owners, which gives them the financial responsibilities of the business. Like other business owners GPs invest time and money into their businesses, but unlike other businesses general practices are under the financial control of the government. The government puts little trust in the integrity of GPs not realising that GPs, as well as being concerned for their business, also want to provide a fair, accessible and complete service to their patients. The more government demands control over general practice, the more GPs become vulnerable to financial losses. The government demeans GPs integrity by not trusting them with the result that GPs resent the government and therefore fewer GPs will want to buy into general practice when they are at such a financial risk.
The poor communication between midwives and the general practice staff is a huge concern to primary health care. Poor communication leads to fragmentation, duplication and vital information falling between the cracks. With midwives it is more than just poor communication. There is a lack of trust, respect and common ground between the two professional bodies. Because there is no midwife opinion in this study, there is a bias to the general practice opinion, which is one of concern for patient health, efficient care and desire to work in greater collaboration with midwives.
There are a number of limitations to this study. The poor return rate (42%) means that the data may not accurately represent the whole Partnership Health Canterbury general practice team. This low return rate was expected though because the survey was sent out just prior to Christmas. It's possible that some of the survey questions were ambiguous and this may have affected the accuracy of the results. Question one asked both GPs and PNs about the changes in workload for the GP. Around 15% of PN comments suggested that they did not understand this question and answered it according to their workload or that of the practice. Question 8 asked if they thought that the changes in the past ten years were positive, negative or neutral for patient health. Some of the comments suggested that the answers for this question took into consideration themselves or the practice. The focus group was very PN lead, which may have hindered the GPs ability to talk freely, though the PNs may have felt similar.
Conclusion
It appears from these results that the PHCS has been successful in allowing PNs to work more autonomously and has increased their time spent on patient care. The majority of GP and PN respondents found these changes to be of benefit to patients. However, the emergence of complex and multiple funding streams in addition to the capitation payments, together with the attendant additional paperwork, are reducing time available for patient contact and are damaging morale. It would be wise to give more consideration of the general practice workforce needs and concerns.