New Zealand's independent practitioner associations: a working model of clinical governance in primary care?

Establishing clinical governance model in primary health care: A systematic review

Clinical governance is a systematic approach to enhancing the quality of primary health care and ensuring high clinical standards, responsiveness to performance, and continuous improvement in service quality. The objective of the current study was to investigate the global experiences of clinical governance in primary health care. In the present systematic review, relevant articles from different countries were searched in various databases such as MD PubMed from Medline portal, Emerald Springer link, ProQuest, Cochrane, Scopus, Web of Science, and Consult until April 2019. The searched articles were checked through CASP and PRISMA checklists, and their results were extracted. Of the 17 selected studies, 16 belonged to developed countries, including England (13), Australia, Italy, and New Zealand, and one was from Turkey. The findings were divided into three general categories: (1) principles of effectiveness and risk management, (2) deployment requirements such as structural and organizational needs, resource and communication, and information management, and (3) barriers of clinical governance toward providing primary health care. it is recommended that a suitable framework or model be developed and designed adapted to the local culture and taking into account all effective dimensions for a proper establishment and implementation of clinical governance in primary health care.

Engaging general practitioners in pay-for-performance scheme design

Purpose

Policymakers implementing pay-for-performance schemes within general practice should seek to design schemes which work with rather than against the professional values and goals of general practitioners. In this way, schemes are more likely to enhance the practitioners' engagement. The purpose of this paper is to show how this was done in two case studies of pay-for-performance design and present the lessons from this study for policymakers.

Design/methodology/approach

A Most Similar Systems collective case study of the design of two pay-for-performance schemes for general practitioners, the United Kingdom's Quality and Outcomes Framework (QOF) and the New Zealand’s Performance Management Programme (PMP) was undertaken, involving 26 semi-structured interviews with policymakers, documentary and literature analysis.

Findings

Innovation in processes was found in both case studies which facilitated engagement by general practitioners in the formulation and implementation of these schemes. These were careful selection of highly skilled design teams, use of principle-based negotiation techniques and academic mediation of indicator selection. In addition, in England the majority of members in the combined QOF design team were general practitioners. The evidence from these two case studies reinforces approaches to scheme design which seek to harness rather than challenge medical professional values and which maximise the participation of general practitioners in the design process. Achieving funder/practitioner collaboration should be a key goal in the policymaking process.

Practical implications

Pay-for-performance scheme designers can improve their ability to engage general practitioners in scheme design and scheme uptake by adopting approaches which actively engage general practitioners as designers and users of such schemes.

Originality/value

This study compares two contemporaneous processes of pay-for-performance scheme design and implementation in similar systems of general practice funding and delivery at the national level, offering a rare quasi-experimental opportunity for learning lessons from comparative analysis.

New Zealand health system: universalism struggles with persisting inequities

New Zealand was one of the first countries to establish a universal, tax-funded national health service. Unique features include innovative Māori services, the no-fault accident compensation scheme, and the Pharmaceutical Management Agency, which negotiates with pharmaceutical companies to get the best value for medicines purchased by public money. The so-called universal orientation of the health system, along with a strong commitment to social service provision, have contributed to New Zealand's favourable health statistics. However, despite a long-standing commitment to reducing health inequities, problems with access to care persist and the system is not delivering the promise of equitable health outcomes for all population groups. Primary health services and hospital-based services have developed largely independently, and major restructuring during the 1990s did not produce the expected efficiency gains. A focus on individual-level secondary services and performance targets has been prioritised over tackling issues such as suicide, obesity, and poverty-related diseases through community-based health promotion, preventive activities, and primary care. Future changes need to focus on strengthening the culture and capacity of the system to improve equity of outcomes, including expanding Māori health service provision, integrating existing services and structures with new ones, aligning resources with need to achieve pro-equity outcomes, and strengthening population-based approaches to tackling contemporary drivers of health status.

Clarification of Safe Delivery by Iranian Experts Based on Clinical Governance: A Qualitative Study

OBJECTIVE

To clarify the principles of a safe delivery based on Clinical Governance Criteria, as recommended by the pertinent experts.

MATERIALS AND METHODS

The current study was part of a qualitative research conducted by content analysis method in 2013 and purposive sampling, performing 24 in-depth interviews based on semi-structured questions and analyzed using thematic content analysis. The participants in this research included midwives, obstetricians, managers, and hospital doctors. The data were under continuous consideration and comparative analysis in order to achieve data saturation.

RESULTS

The main concepts derived from interpretations of the pertinent experts include: Patient & Public involvement; Risk Management; Education; Clinical efficiency; Clinical audit; Personnel & Management.

CONCLUSION

In a safe delivery, there is a vicious cycle of causes the elimination of which is only possible through benchmarking patterns that attend to most aspects of a safe delivery. Changes to services require utilization of appropriate change management strategies.

The World Health Report 2008 - Primary Healthcare: How Wide Is the Gap between Its Agenda and Implementation in 12 High-Income Health Systems?

BACKGROUND

The World Health Organization's 2008 report asserted that the focus on primary healthcare (PHC) within health systems should increase, with four sets of reforms required. The WHO's PHC advocacy is well founded, yet its report is a policy document that fails to address adoption and implementation questions within WHO member countries. This paper examines the prospects for the WHO PHC agenda in 12 high-income health systems from Asia, Australasia, Europe and North America, comparing performances against the WHO agenda.

METHODS

A health policy specialist on each of the 12 systems sketched policy activities in each of the four areas of concern to the WHO: (a) whether there is universal coverage, (b) service delivery reforms to build a PHC-oriented system, (c) reforms integrating public health initiatives into PHC settings and (d) leadership promoting dialogue among stakeholders.

FINDINGS

All 12 systems demonstrate considerable gaps between the actual status of PHC and the WHO vision when assessed in terms of the four WHO reform dimensions, although many initiatives to enhance PHC have been implemented. Institutional arrangements pose significant barriers to PHC reform as envisioned by the WHO.

CONCLUSIONS

PHC reform requires more attention from policy makers. Meanwhile, the WHO PHC report is perhaps too idealistic and fails to address the fundamentals for successful policy adoption and implementation within member countries.

Can clinical governance deliver quality improvement in Australian general practice and primary care? A systematic review of the evidence

OBJECTIVES

To review the literature on different models of clinical governance and to explore their relevance to Australian primary health care, and their potential contributions on quality and safety.

DATA SOURCES

25 electronic databases, scanning reference lists of articles and consultation with experts in the field. We searched publications in English after 1999, but a search of the German language literature for a specific model type was also undertaken. The grey literature was explored through a hand search of the medical trade press and websites of relevant national and international clearing houses and professional or industry bodies. 11 software packages commonly used in Australian general practice were reviewed for any potential contribution to clinical governance.

STUDY SELECTION

19 high-quality studies that assessed outcomes were included.

DATA EXTRACTION

All abstracts were screened by one researcher, and 10% were screened by a second researcher to crosscheck screening quality. Studies were reviewed and coded by four reviewers, with all studies being rated using standard critical appraisal tools such as the Strengthening the Reporting of Observational Studies in Epidemiology checklist. Two researchers reviewed the Australian general practice software. Interviews were conducted with 16 informants representing service, regional primary health care, national and international perspectives.

DATA SYNTHESIS

Most evidence supports governance models which use targeted, peer-led feedback on the clinician's own practice. Strategies most used in clinical governance models were audit, performance against indicators, and peer-led reflection on evidence or performance.

CONCLUSIONS

The evidence base for clinical governance is fragmented, and focuses mainly on process rather than outcomes. Few publications address models that enhance safety, efficiency, sustainability and the economics of primary health care. Locally relevant clinical indicators, the use of computerised medical record systems, regional primary health care organisations that have the capacity to support the uptake of clinical governance at the practice level, and learning from the Aboriginal community-controlled sector will help integrate clinical governance into primary care.

Clinical significance of clinical interventions in community pharmacy: a randomised trial of the effect of education and a professional allowance

Objectives

To assess the clinical significance of clinical interventions undertaken by community pharmacists, and to explore the effect of providing education and/or remuneration on the clinical significance of interventions.

Design

Randomised trial involving four groups of community pharmacists; expert panel to assess the clinical significance of the interventions.

Methods

The “proactive” clinical interventions undertaken by community pharmacists during the trial were reviewed by an expert panel for assessment of avoided adverse health consequences and clinical significance. The panel used a validated assessment instrument developed from the existing research literature and a pilot study by the authors.

Data analysis

Agreement between experts was determined using the kappa statistic. In addition, the results of the expert panel were analysed for cases where the majority of experts provided the same assessment of clinical significance (ie, consensus).

Results

Overall, there was no statistically significant difference in the clinical significance of clinical interventions undertaken by the four study groups. However, there were significant differences (95% CI) in the types of proactive interventions undertaken, with the two groups that received an educational intervention being more likely to engage in more complex intervention areas, such as drug/drug interactions and adverse/side effects. Analysis of consensus revealed that 52% of proactive clinical interventions were deemed to be “clinically significant” and 2% were deemed to be either “clinically very significant” or “potentially life-saving”. When extrapolated to national Australian prescribing figures, a mean of 3,752 potentially life-saving interventions by community pharmacists could be expected per year (95% CI 454 to 13,554).

Conclusion

The results of this study provide the first estimates of the potential clinical benefits associated with clinical interventions in Australian community pharmacies. The study contributes evidence on the value of pharmaceutical services to the health care system. As such, it is expected that the study findings will provide a platform for discussion and decision-making.

The unintended consequences of New Zealand's primary health care reforms

In 2001, the New Zealand government commenced a program to reform the organization of publicly funded primary care services. While there have been several positive results of this reform, including the reduction of patient co-payments and the extension of the range of primary care services, the government's program was a hastily implemented attempt to place primary care, the delivery of which is dominated by private doctors, under firm state control. It was also an attempt to override preexisting arrangements. As such, the government succeeded in its goal of establishing new primary health organizations (PHOs), but there were also significant unintended consequences. As detailed in this article, these consequences include (1) the creation of a labyrinthine funding and organizational system with a variable capacity to deliver on the government's reform objectives, (2) an increase in the power and scope of preexisting doctor organizations combined with a government unable to wrest control over the setting of patient co-payment levels, and (3) an emerging lack of clarity about future directions for the primary health care sector.

Shifting clinical accountability and the pursuit of quality: aligning clinical and administrative approaches

This paper presents a narrative review of the literature on clinical accountability, and draws particularly on England's experience establishing "clinical governance" as a base to examine the establishment of a clinical accountability framework for cancer services in Ontario. The review suggests that clinical governance and accountability approaches that actively mesh clinical and administrative approaches at both system and local levels are more likely to be effective in improving quality of care.

New Zealand's health system: national policy goals and decentralized service planning and delivery

To inaugurate the fifth year of its publication, The American Heart Hospital Journal (AHHJ) focused its Winter 2007 issue on health care systems from around the world, with 8 articles contributed by national leaders in their respective countries. Due to the interest and wide range of expertise in the international cardiac community, we will continue to publish Special Reports throughout 2007 on this topic. We invite members of the international community to share with readers of the AHHJ, their insights on the strengths and weaknesses of their respective health care and cardiac care systems, as well as their ideas and aspirations for future change.

Primary care organizations in New Zealand and England: tipping the balance of the health system in favour of primary care?

This paper examines the experience of developing primary care organizations (PCOs) in New Zealand and England, exploring how far these new institutional forms have been able to 'tip the balance' of their host health system in favour of primary care. The original objectives for establishing PCOs in the two countries are assessed using published research evidence on the impact of PCOs covering: efficiency and cost containment; the development of clinical engagement and leadership; the development of primary care; and the purchasing of secondary and referred services. It is concluded that in both countries, progress has been made in aligning more closely the individual focus of general practice with the population perspective of the wider public health system. The New Zealand approach of using non-governmental PCOs is judged consistent with harnessing the professional culture of general practice towards community-based public health. By contrast, English primary care trusts (PCTs) are at risk of becoming remote from their origins as purchasers in primary care and general practice, unless the re-introduction of practice-level purchasing can provide GPs with new enthusiasm for local planning and service development.

Are New Zealand's new primary health organisations fit for purpose?

Attempts to make New Zealand's health care more equitable have resulted in rapid change. But the reforms are largely untested and their effects difficult to predict

Does community-governed nonprofit primary care improve access to services? Cross-sectional survey of practice characteristics

This study compared community-governed nonprofit and for-profit primary care practices in New Zealand to test two hypotheses: (1) nonprofits reduce financial and cultural barriers to access; and (2) nonprofits do not differ from for-profits in equipment, services, service planning, and quality management. Data were obtained from a nationally representative cross-sectional survey of GPs. Practices were categorized by ownership status: private community-governed nonprofit or private for-profit. Community-governed nonprofits charged lower patient fees per visit and employed more Maori and Pacific Island staff, thus reducing financial and cultural barriers to access compared with for-profits. Nonprofits provided a different range of services and were less likely to have specific items of equipment; they were more likely to have written policies on quality management, complaints, and critical events, and to carry out locality service planning and community needs assessments. The findings support the shift to nonprofit community governance occurring in New Zealand and elsewhere.

General practice and the New Zealand health reforms--lessons for Australia?

New Zealand's health sector has undergone three significant restructures within 10 years. The most recent has involved a Primary Health Care Strategy, launched in 2001. Primary Health Organisations (PHOs), administered by 21 District Health Boards, are the local structures for implementing the Primary Health Care Strategy. Ninety-three percent of the New Zealand population is now enrolled within 79 PHOs, which pose a challenge to the well-established Independent Practitioner Associations (IPAs).

Although there was initial widespread support for the philosophy underlying the Primary Health Care Strategy, there are concerns amongst general practitioners (GPs) and their professional organisations relating to its implementation. These centre around 6 main issues:

1. Loss of autonomy

2. Inadequate management funding and support

3. Inconsistency and variations in contracting processes

4. Lack of publicity and advice around enrolment issues

5. Workforce and workload issues

6. Financial risks

On the other hand, many GPs are feeling positive regarding the opportunities for PHOs, particularly for being involved in the provision of a wider range of community health services. Australia has much to learn from New Zealand's latest health sector and primary health care reforms.

The key lessons concern:

• the need for a national primary health care strategy

• active engagement of general practitioners and their professional organisations

• recognition of implementation costs

• the need for infrastructural support, including information technology and quality systems

• robust management and governance arrangements

• issues related to critical mass and population/distance trade offs in service delivery models

[Clinical governance]

The direction of health organisations requires the coordination of diversified competencies, notably in administration, management and care. In France, for university hospitals, the law (decree) of 1958 is pivotal. Other approaches have been developed in other countries, depending on their history, traditions, and the organisation of their respective health care systems. These models can enlighten our current reflexions at a time when in France, the question of a new definition of governance for university hospitals is raised.

Comparison of private for-profit with private community-governed not-for-profit primary care services in New Zealand

OBJECTIVE

To compare the characteristics of patients, their disease patterns, and the investigation and referral patterns in private community-governed not-for-profit and private for-profit primary care practices in New Zealand.

METHODS

Observational study using a representative survey of visits to general practitioners in New Zealand. Practices were categorised according to their ownership: private for-profit or private community-governed not-for-profit. Patient socio-demographic characteristics, treated prevalence and other characteristics of presenting problems, morbidity burden, numbers of investigations and referral patterns were compared.

RESULTS

Compared with for-profit practices, community-governed not-for-profit practices served a younger, largely non-European population, nearly three-quarters of whom had a means-tested benefit card (community services card), 10.5% of whom were not fluent in English, and the majority of whom lived in the 20% of areas ranked as the most deprived (by the NZDep2001 index of socio-economic deprivation). Patients visiting not-for-profit practices were diagnosed with more problems, including higher rates of asthma, diabetes and skin infections, but lower rates of chest infections. The duration of visits was also significantly longer. No differences were observed in the average number of laboratory tests ordered. The odds of specialist referral were higher in for-profit patients when confounding variables were controlled for.

CONCLUSIONS

Community-governed not-for-profit practices in New Zealand serve a poor, largely non-European population who present with somewhat different rates of various problems compared with patients at for-profit practices. The study highlights for communities, policy-makers and purchasers the importance of community-governed not-for-profit practices in meeting the needs of low-income and minority population groups.

Fundholding: learning from the past and looking to the future

Australian trials of healthcare initiatives that included fundholding models have not produced convincing quantitative evidence of health gains, but there is qualitative evidence of improved patient well-being and significant changes in service mix, which may produce longer-term health gains. Fundholding is most likely to improve patient outcomes when implemented within a broader healthcare initiative that has the potential to be more effective if financed outside existing funding structures. The most appropriate fundholder organisation depends on the nature of the initiative and the type of stakeholder engagement required, but technical and organisational skills will always be needed for balancing financial viability and additional patient services. Stakeholders' willingness to engage in fundholding depends on the anticipated budget impact, how they will use the savings generated, and whether workforce needs will be fulfilled. Before including fundholding in healthcare initiatives, there must be realistic prospective analyses and community debate. Monitoring and evaluation frameworks must also be in place to provide ongoing evidence of quality of care, health and well-being outcomes and financial implications for fund contributors.

Cross sectional study of primary care groups in London: association of measures of socioeconomic and health status with hospital admission rates

OBJECTIVES

To calculate socioeconomic and health status measures for the primary care groups in London and to examine the association between these measures and hospital admission rates.

DESIGN

Cross sectional study.

SETTING

66 primary care groups in London, total list size 8.0 million people.

MAIN OUTCOME MEASURES

Elective and emergency standardised hospital admission ratios; standardised admission rates for diabetes and asthma.

RESULTS

Standardised hospital admission ratios varied from 74 to 116 for total admissions and from 50 to 124 for emergency admissions. Directly standardised admission rates for asthma varied from 152 to 801 per 100 000 (mean 364) and for diabetes from 235 to 1034 per 100 000 (mean 538). There were large differences in the mortality, socioeconomic, and general practice characteristics of the primary care groups. Hospital admission rates were significantly correlated with many of the measures of chronic illness and deprivation. The strongest correlations were with disability living allowance (R=0.64 for total admissions and R=0.62 for emergency admissions, P<0.0001). Practice characteristics were less strongly associated with hospital admission rates.

CONCLUSIONS

It is feasible to produce a range of socioeconomic, health status, and practice measures for primary care groups for use in needs assessment and in planning and monitoring health services. These measures show that primary care groups have highly variable patient and practice characteristics and that hospital admission rates are associated with chronic illness and deprivation. These variations will need to be taken into account when assessing performance.