Introduction:
IPAC welcomes the report of the Ministerial Review Group (MRG),
as a comprehensive and pragmatic approach to achieving more
efficient and effective use of public health dollars. We believe
the recommendations will see significant rejuvenation of clinical
innovation and a stronger focus on clinical outcomes across the
health sector.
We strongly support the major themes of the report, particularly
in the areas of changes to the culture to promote clinical
leadership and improve the integration of primary and hospital
based care.
With regard to structural changes, we support the National
Health Board providing it does not add another layer of
bureaucracy, and will streamline the implementation of policy
across the DHBs. The current arrangement of a large multifunctional
MoH, 21 DHBs, 81 PHOs provides multilayered and fragmented services
for a population of 4 million people and urgently needs
rationalisation.
We make further specific comments as follows:
Report Recommendations
Closer to Home: New Models of Care
• IPAC believes that all health care services should be
provided in a coordinated manner within community settings unless
inpatient services are necessary.
• We support new models of care that are patient centric,
safe, effective, and in particular avoid unnecessary admissions to
hospital.
• We also support the critical appraisal of the role of PHOs,
and whether they, as a separate entity, add value to the health of
communities. The three year time frame is overly generous.
• The ability to share reliable health information across
multiple loci of care in a timely and safe manner is a critical
development in terms of quality outcomes and patient experience of
care. This will involve significant investment in health
information systems architecture, standards development and quality
programme implementation. To ensure success the quality
component should be driven from the "grass roots" rather than
centrally.
Improving Patient Safety and Quality of
Care
The recommendations in this section are excellent.
• IPAC supports the establishment of an independent
national quality agency. We would suggest this agency also
include expertise from other industries (eg. aviation) and
international expertise in health related quality.
• As one of the organisations sponsoring qi4gp we are
committed to the quality agenda for general practice and primary
care, driven by general practice and primary care, and underpinned
by excellent information tools.
• Our experience to date is that the PPP as a top down
"performance" programme has limited general practice engagement and
support, and it cannot succeed without this. It does not measure
"PHO" performance nor does it measure quality in general practice.
It is appropriate that some of this funding should be diverted into
other quality activity that is sector driven and supported, is more
cost effective and is based on educative processes influencing
clinical behaviour.
Identifying the Services People Need: Funding New
Services
• IPAC supports extending the role of Pharmac to purchase
medical devices. We also support the extended role of MedSafe as
recommended.
The Right Service in the Right Place: Changing Service
Configuration
• IPAC supports the development of RSPs and delegated
authority to Chairs and CEOs to make decisions at a regional level
as this will significantly reduce the service inequities that
currently exist within regions.
• Narrowing the scope of MoH's role is strongly endorsed as
the MoH has become increasingly paralysed by its size, functions
and the extent of its internal processes.
Shifting Resources to the Front Line
• IPAC supports the creation of a national shared service
agency to co-ordinate back office functions for DHBs
Annex 2:
Enhancing Clinical Leadership
• IPAC strongly supports the concept of recognising and
rewarding clinical leaders across the sector, as this has never
been done well. We would caution that the incentives/processes put
in place should not be too onerous as this may dissuade busy
clinicians from being attracted to these roles.
Improve Access to Timely Primary and Hospital Services…
• Appropriate, direct access of primary care clinicians to
diagnostics (particularly radiology) would be a welcome boost to
the ability of primary care to manage patients within the
community, and to refer more effectively to secondary care when
necessary. Electronic Decision Support tools in primary care could
assist in determining when such referral is appropriate.
• There needs to be good dialogue and agreed division of
labour between primary and secondary care clinicians if effective
implementation of new scopes of practice and workforce models is to
be achieved.
Establishing and Fostering Greater Clinical Leadership in
Primary Care and across primary and hospital care within DHBs
• PHOs need strong engagement with clinicians if they wish
to take up the new challenges. Where this is lacking, they are of
little relevance.
The Acceleration of National Quality and Safety Improvement
Programmes
• IPAC is of the view that most savings in the health
sector will come from the pursuit of quality in all areas.
The recommendation that an independent national quality entity be
established is excellent in our view.
Annex 3:
Information Technology
• IPAC strongly supports the recommendation around
governance of NSDP and KD projects and a distributed approach to
the safe sharing and transfer of health information amongst
providers.
• Progress around primary care projects has been
disappointingly slow and despite repeated requests for funding to
progress initiatives through external agencies with the capacity
and capability to achieve real progress we have achieved little in
the last five years.
• IPAC would strongly support a new primary care information
system initiative including the listed primary care projects.
We request this recommendation is progressed with some
urgency.
• The PHO Performance Programme is of little value to primary
care as a quality improvement programme and we would question its
value for money. We agree this programme should be scaled
back and investment redirected to a robust primary care quality
initiative such as qi4gp.
• IPAC strongly agrees that an interoperable and connected
distributed approach to the sharing of health information is the
preferred approach. This is consistent with international
learnings, is cost effective and has a much higher expectation of
success.
• IPAC believes the complacency around health information
standards has significantly impeded progress around sharing of
information and requests that standards for the eTransfer of Care
suite and Interoperability are prioritised and development is
accelerated.
Annex 4:
Consideration of the Ministry's Role as a Manager of a
Range of National Operational Functions
• IPAC supports the recommendation that databases and
repositories be moved into the proposed national shared service
agency with its own governance structure.
• We also request access to information within those databases
and repositories be governed appropriately and independently.
Reduce Waste and Bureaucracy and Improve Spending on
Quality and Patient Service
• IPAC agrees the current PHO management fee structure
provides an incentive for multiple small PHOs. This is not
sustainable in an increasingly fiscally restrained health
environment. IPAC supports a re-vamp of the PHO management
fee structure that encourages collaboration and efficiency.
• IPAC strongly supports provider choice around PHOs and PHO
formation on the basis of sound corporate and clinical governance
and community participation.
Reporting and Accountability Processes
• The current reporting and accountability process is
overly bureaucratic and implies distrust of providers. IPAC
strongly supports the formation of a working party to develop a
national framework that focuses on high trust, low bureaucracy and
earned autonomy around reporting and accountability.
Existing Ministerial and Ministry
Committees
• IPAC supports the rationalism of committees, boards and
advisory groups and the inclusion of consumer voices where
appropriate.