Working Together for Better
Primary Health Care
Overcoming barriers to
workforce change and innovation
Report to the Minister of Health
from the Workforce Taskforce
Workforce Taskforce. 2008. Working Together for Better Primary Health Care:
Overcoming barriers to workforce change and innovation. Wellington: Ministry of
Published in September 2008 by the
Ministry of Health
PO Box 5013, Wellington, New Zealand
ISBN 978-0-478-31814-2 (online)
This document is available on the Ministry of Health’s website:
Acknowledgements iv Organisations and groups iv Individuals iv Executive Summary iv Barriers to primary workforce effectiveness v Recommendations for overcoming the barriers v Background 1
Introduction 2 Changes introduced through the Primary Health Care Strategy 2 Workforce implications of the Primary Health Care Strategy 2 Barriers to workforce change and innovation 3 The Funding Model 4 Barriers to change 4 Solutions 5 Organisational Structure and Function 6 Barriers to change 6 Solutions 8 Leadership 10 Barriers to change 10 Solutions 11 Training 13 Barriers to change 13 Solutions 14 Quality Improvement and Assessment 16 Barriers to change 16 Solutions 17 Appendices
Appendix 1: Workforce Taskforce – Terms of Reference for Second Task 18 Appendix 2: Workforce Taskforce Membership 20 Appendix 3: Organisations and Groups Involved in Primary Health Care 22
Working Together for Better Primary Health Care iii
The Workforce Taskforce would like to acknowledge and thank the following organisations,
groups and individuals for their valuable contributions and input in the preparation of this
Organisations and groups
Allied Health Professional Associations Forum Clendon Family Health Centre
Clinical Training Agency
Council of Medical Colleges
District Health Boards New Zealand (DHBNZ) DHBNZ Primary Health Care Steering Group DHBNZ Workforce Group
General Practice Leaders Forum
General Practice Nursing Alliance
Health Care Aotearoa
Independent Practitioners Association Council Medical Council of New Zealand
Ministry of Health
New Zealand College of Midwives
New Zealand College of Practice Nurses
New Zealand Medical Association
Nursing Council of New Zealand
Otara Union Health
Pharmaceutical Society of New Zealand Inc PHO Community Council
Primary Health Care Strategy Implementation Taskforce Royal New Zealand College of General Practitioners Tongan Health Centre
Wellington School of Medicine and Health Sciences
Leanne Arker, Office of the Controller and Auditor General John Baird, DHBNZ
Mary-Anne Boyd, Waitemata DHB
Professor Jenny Carryer, Clinical Chair of Nursing, Massey University
Chrissy Cope, Accident Compensation Corporation Dr Jackie Cumming, Health Services Research Centre Rhoda McDonald, Kowhai Health Trust
David Meates, Wairarapa DHB
Gerald Minnee, The Treasury
Mark Wills, Peak Healthcare Ltd
iv Working Together for Better Primary Health Care
Barriers to primary workforce effectiveness
The Taskforce identified the principal barriers to primary health care workforce effectiveness in the following areas:
? the funding model
? organisational structures
? professional leadership
? quality improvement.
Failure to appreciate the interdependence of all five is itself a significant barrier to achieving greater collaboration and focus on the goals of the Primary Health Care Strategy. The
barriers operate in a context of traditional attitudes, values and ways of working.
Recommendations for overcoming the barriers
In view of the importance to New Zealand of primary health care and rapidly escalating
pressures on its workforce, the Taskforce urges prompt consideration of and action on its
recommendations. The recommendations in this report must be seen as complementary to
initiatives for workforce sustainability.
Recommendation 1: Realignment of funding to enable innovation
That the Director-General of Health review the primary health care funding model in parallel with the review of the funding formulae to ensure that both the model and the formulae:
? achieve the intent of the Primary Health Care Strategy
? create incentives for the organisational changes envisaged in the Primary Health Care Strategy, in particular as they relate to PHOs
? facilitate equitable access to funding by all primary health care providers of first contact services under the Primary Health Care Strategy which recognises that delivery is through teams of health professionals
? support multi-disciplinary working in primary health care service delivery.
Recommendation 2: Structure – investment for expansion and training
That, in order to resolve issues of capital investment for the providers of primary health care: ? the Ministry of Health develop a primary health care sector capital investment strategy which identifies capital investment solutions for expansion, training and retention of the workforce that can be implemented for a variety of ownership structures and adapted for local needs
? the Ministry of Health and primary health care leaders support a group of selected general practices to make an application to the Commerce Commission, for clearance for acquisition under Section 66 of the Commerce Act 1986, in order to get an indication of whether such an amalgamation would be seen as likely to result in a substantial lessening of competition.
Working Together for Better Primary Health Care v
Recommendation 3: Professional leadership and clinical governance
That, to provide professional leadership and clinical governance:
a) the Ministry of Health and DHBs work with professional bodies and the Medical Training
Board to jointly develop an evidence-based vision for the roles of the workforce
providing primary health care which meet service needs
b) DHBs work with the primary health sector to develop a nationally consistent approach
to the development of primary health care nursing
c) the Ministry of Health establish an allied health advisory position to provide expert
advice and lead the development of the allied workforce
d) PHOs be required to promote and support the establishment of effective clinical
governance structures and processes within primary health care providers.
Recommendation 4: Training for primary health care
That, to improve training in primary health care:
a) nurse educators, the Nursing Council of New Zealand, PHO leadership groups and the
Clinical Training Agency (CTA), with facilitation from DHBs, develop an explicit,
nationally consistent career framework or pathway for education and training of nurses
for primary health care practice which:
? takes account of the continuum of learning, including undergraduate preparation,
postgraduate specialisation and continuing education
? includes accessible, affordable and appropriate postgraduate certificate and diploma
programmes for primary health care nurses b) the Medical Training Board and providers of training for other health professionals
identify the capabilities and attributes for collaboration and teamwork to be included in
medical curricula and recommended to trainers of other health professionals c) the Ministry of Health fund and evaluate selected primary health care pilots to assess
the clinical effectiveness of multi-disciplinary learning and collaborative practice and
? the capabilities and attributes required by health professionals to work in multi-
? leadership and team work
? information sharing across professional groups
? partnership with consumers
? recognition of the roles and strengths of the different health professions d) DHBs engage with the Practice Managers and Administrators Association of New
Zealand and other primary health care stakeholders to develop an educational pathway
for practice management.
vi Working Together for Better Primary Health Care
Recommendation 5: Quality improvement – a timely opportunity That the Quality Improvement Committee be asked to lead the development of a consistent
national framework and programme for continuous quality assessment and improvement in
primary health care and:
? assist PHOs to promote a culture of quality improvement based on clinical governance
amongst primary health care providers through meaningful incentives
? work with DHBs and PHOs to implement this national framework with service providers
? establish effective linkages between quality improvement programmes in primary and
Working Together for Better Primary Health Care vii
The Minister of Health agreed that the Workforce Taskforce would focus on the primary health care workforce for its second task. The primary health care sector is in a process of significant change as it responds to influences such as the increasing demands of chronic disease, co-morbidity and an ageing population. The process of change was given added momentum with the release of the Primary Health Care Strategy (the Strategy) in 2001. In the face of increasing shortages of health practitioners, the sector must make the best use of the current workforce and ensure its sustainability.
Discussions with the Ministry of Health, District Health Boards (DHBs), and key organisations in the primary health care sector revealed a concern that some of the workforce related changes envisaged by the Strategy may not be occurring as consistently or rapidly as intended. The Minister of Health therefore requested that the Taskforce identify barriers to the effective use of the primary health care workforce in implementing the Strategy. The terms of reference for the task are included as Appendix 1.
In order to ensure the necessary expertise to undertake the task, the Taskforce co-opted five additional members with specific experience in primary health care. The full list of Taskforce members participating on this task is included in Appendix 2.
In investigating barriers to change in the way the present workforce delivers primary health care services, the Taskforce heard from a wide range of organisations, groups and individuals in the sector. Taskforce members also visited several primary health care providers representing different models of service delivery.
The timeframe for completion of this task was six months. It was not feasible within that time for the Workforce Taskforce to identify and address every barrier to change affecting the primary health care workforce. Rather, the focus has been on the main ones for which clear actions can be taken to overcome those barriers.
The Taskforce has also been unable to consult with all interested parties in the sector or incorporate all perspectives in the timeframe for completion of the report. In the time available, the Taskforce was unable to give adequate consideration to issues specific to Māori,
Pacific and rural populations, and accordingly took a high level approach to the task. Further work is required to identify issues and barriers to primary health care workforce change and innovation that have specific relevance to Māori, Pacific peoples and rural areas.
The Taskforce is aware that there is a considerable amount of work being done relating to primary health care and implementation of the Strategy. In particular, the Ministry of Health and DHBs have a number of work streams and associated groups dedicated to improving primary health care service delivery. It is intended that the recommendations of this report will complement other work in the sector.
Working Together for Better Primary Health Care 1
The Primary Health Care Strategy heralded a radical change to the delivery of primary health care services. The vision of the Strategy is for people to be part of local primary health care services that improve their health, keep them well, are easy to get to and co-ordinate their ongoing care. Primary health care services are now expected to focus on better health for their population and to actively work to reduce health inequalities within their populations.
Changes introduced through the Primary Health Care Strategy
Implementation of the Strategy has a 10 year timeframe and involves the following changes
to the structure and delivery of primary health care:
? a broadening of the focus of primary health care from the health of the individual to include the health of populations
? a shift in focus from the primary health care provider to the community and consumers ? a shift in service delivery emphasis from doctors as the main providers to a teamwork approach involving other health professionals
? broadening of the scope of service from an emphasis on treatment of illness to include prevention of illness and health promotion
? a shift from fee-for-service funding to a blended model of population-based capitation funding and co-payments
? greater connection of providers to other health and non-health agencies rather than 1working individually.
Primary health care delivery was re-structured around Primary Health Organisations (PHOs), which are funded by DHBs to provide essential primary health services. PHOs are not-for-profit organisations and were always expected to vary in their size and structure, according to the needs of their community. Their establishment intended to encourage practitioners to work together across traditional professional boundaries to improve the quality of health care and to engage the community in service delivery.
Workforce implications of the Primary Health Care Strategy
There are a number of workforce implications inherent in the changes to primary health care service delivery brought about by the Strategy.
New ways of working
There is an explicit expectation of a collaborative, multi-disciplinary approach to primary health care service delivery. While GPs and nurses are still seen as the main providers of primary health care, the strategy states that no single practitioner can completely meet an individual’s needs.
Service delivery is expected to be through multi-disciplinary teams which may include other health professionals such as pharmacists, physiotherapists, Māori health workers, health
promotion workers, dietitians, psychologists and midwives. In addition, the health promotion and protection aspects of the Strategy require links with public health services.
1 Minister of Health (2001). The Primary Health Care Strategy. Wellington: Ministry of Health.
2 Working Together for Better Primary Health Care