Variation in the adoption of patient safety practices among New Zealand district health boards.

OBJECTIVE: To investigate the adoption and impact of quality improvement measures in New Zealand hospitals. METHOD: Structured interviews with quality and safety managers of District Health Boards (DHBs). Correlation of use of measures with adjusted 30-day mortality data. RESULTS: Eighteen of New Zealand's 21 DHBs participated in the survey. Structural or policy measures to improve patient safety, such as credentialing and event reporting procedures, had been introduced into all DHBs, whereas changes to general clinical processes such as medicine reconciliation, falls prevention interventions and disease-specific management guidelines were less consistently used. There was no meaningful correlation between risk-adjusted mortality rates for three common medical conditions and related quality measures. CONCLUSION: Widespread variation exists among New Zealand DHBs in their adoption of quality and safety practices, especially in relation to clinical processes of care.

Pilot study of methods for assessing unmet secondary health care need in New Zealand.

AIMS: In this pilot study, the primary aim was to compare four potential methods for undertaking a national survey of unmet secondary healthcare need in New Zealand (one collecting data from GPs, and three from community surveys). The secondary aim was to obtain an estimate of the prevalence of unmet secondary healthcare need, to inform sample size calculations for a national survey. METHODS: An electronic system was set up for GPs in Christchurch (Pegasus PHO) and Auckland (Auckland PHO) to record cases of unmet need as encountered in clinics. For the community surveys, a questionnaire developed by the authors was administered to people from the same electoral wards as the GP clinics. Three modes of questionnaire administration were trialled: online, telephone and face-to-face interview. Random population sampling from the Maori and General Electoral Rolls was used to identify eligible survey participants until there were approximately 200 respondents for each method in each city. Data collection took place from November 2015 to February 2016. RESULTS: GP reports: Pegasus PHO: 8/78 eligible practices recorded 28 cases of unmet secondary healthcare need in 10 weeks. Auckland PHO: 3/26 practices participated and recorded no cases in three weeks. Surveys: 1,277 interviews were completed (online 428, telephone 447, face-to-face 402). For primary healthcare, 211/1,277 (16.5%) had missed a GP visit because of cost (online 25.0%, telephone 11.6%, face-to-face 12.9%). For secondary healthcare, 119/1,277 (9.3%) reported unmet healthcare need that had been identified by a health professional (online 11.2%; telephone 9.2%; face-to-face 7.5%). Of these, 75/119 (63.0%) required a consultation, and 47/119 (39.5%) required a procedure. Completed interview rates as a percentage of names on the Electoral Roll were low (online 8.8%, telephone 15.4%, face-to-face 13.9%), affected by changed addresses and lack of listed telephone numbers. The response rate for those with valid phone numbers was 47.6%, and for those with valid addresses was 31.5%. CONCLUSIONS: Using the Electoral Rolls to identify respondents is problematic. For a national survey, random population sampling by address, similar to the method employed for the New Zealand Health Survey, but giving respondents a choice between face-to-face and phone interviews, is proposed. Asking GPs to record data on unmet need for secondary care was not successful. Our pilot study suggests there is sufficient unmet secondary healthcare need in New Zealand to merit a national survey.

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.

Rural health care in New Zealand: the case of Coast to Coast Health Centre, Wellsford, an early Integrated Family Health Centre.

INTRODUCTION: Primary health care is critical, particularly in rural areas distant from secondary care services. AIM: To describe the development of Coast to Coast Health Centre (CTCHC) at Wellsford, north of Auckland, New Zealand and reflect on its achievements and ongoing challenges. METHODS: Interviews were conducted with staff and management of CTCHC and with other health service providers. Surveys of staff and a sample of enrolled patients were undertaken. Numerical data on service utilisation were obtained from the practice and from national datasets. RESULTS: The CTCHC provides a wide range of services, including after-hours care, maternity and radiology, across a network of electronically connected sites, as well as interdisciplinary training for a range of health students. General practitioner (GP) recruitment is problematic and nursing roles have been expanded. Staff report positively on the work environment. Consultation rates are higher than in comparable practices, especially consultations with nurses. Rates of hospital admission are relatively low. The development of the CTCHC was assisted by formation of a local primary health organisation (PHO) and by recognition by the local district health board (DHB). Issues with poor coordination of local services, and less service provision than is characteristic in urban areas, remain. Contracting processes with the DHB were complex and time-consuming. The merging of the local PHO into a larger PHO within the Waitemata DHB catchment inhibited progression towards more complete locality planning. DISCUSSION: A dedicated and locally controlled provider was able to generate a more than usually complete community health service for Wellsford and area.

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.

The importance of measuring unmet healthcare needs.

Major restructuring of the health sector has been undertaken in many countries, including New Zealand and England, yet objective assessment of the outcomes has rarely been recorded. In the absence of comprehensive objective data, the success or otherwise of health reforms has been inferred from narrowly-focussed data or anecdotal accounts. A recent example relates to a buoyant King's Fund report on the quest for integrated health and social care in Canterbury, New Zealand which prompted an equally supportive editorial article in the British Medical Journal (BMJ) suggesting it may contain lessons for England's National Health Service. At the same time, a report published in the New Zealand Medical Journal expressed concerns at the level of unmet healthcare needs in Canterbury. Neither report provided objective information about changes over time in the level of unmet healthcare needs in Canterbury. We propose that the performance of healthcare systems should be measured regularly, objectively and comprehensively through documentation of unmet healthcare needs as perceived by representative segments of the population at formal interview. Thereby the success or otherwise of organisational changes to a health system and its adequacy as demographics of the population evolve, even in the absence of major restructuring of the health sector, can be better documented.

Teamwork - general practitioners and practice nurses working together in New Zealand.

INTRODUCTION: Teamwork in primary health care has been encouraged in New Zealand and in the international literature. It may improve work satisfaction for staff, and satisfaction and outcomes for patients. Teamwork may be classified as being multi-, inter- or transdisciplinary and is likely to be influenced by the nature of the work and the organisational context. AIM: To describe and analyse teamwork between general practitioners and practice nurses in New Zealand. METHODS: Data were drawn from a survey of general practices and from interviews with primary health care staff and management. RESULTS: Doctors and nurses in general practice in New Zealand see themselves as a team. Evidence suggests that the nature of the work and the business context most often leads to a multidisciplinary style of teamwork. Some providers have adopted a more intense teamwork approach, often when serving more disadvantaged populations or in caring for those with chronic illnesses. DISCUSSION: Concepts of teamwork differ. This article provides a classification of teams and suggests that most general practice teams are multidisciplinary. It is hoped that this will help personnel to communicate their expectations of a team and encourage progressive team development where it would be of value.

Evaluation of online training for the provision of opioid substitution treatment by community pharmacists in New Zealand.

INTRODUCTION AND AIMS: The role of community pharmacists in the provision of opioid substitution treatment (OST) is pivotal and integral to addiction treatment. An online training program for pharmacists in OST management was piloted in New Zealand in 2010, following recognition of the difficulty in recruitment and retention of community pharmacists to provide OST services. Our aim was to evaluate the OST online training that was made available for any community pharmacist in New Zealand and to establish the feasibility and acceptability of this format of training for community pharmacists. The evaluation explored participants' attitudes, skills and knowledge both pre- and post-training in OST. DESIGN AND METHODS: All pharmacists registering to participate in the training program were asked to complete an evaluation questionnaire immediately before (pre) and immediately after (post) completing the training. Participants were also invited to participate in a brief 10 min structured telephone interview about their training experience. RESULTS: In the first 4 months 190 pharmacists commenced the training; 101 completed both evaluations. Improvements in the confidence and skills of pharmacists were demonstrated through both the quantitative and qualitative analyses. Statistically significant changes in attitudes were also demonstrated. Overall the OST training was well received and the online format was feasible and highly acceptable. DISCUSSION AND CONCLUSION: Online training is an appropriate and economical method of improving pharmacists' clinical skills with respect to this client group, and has the potential to reach a wider audience of pharmacists. Further research is required to investigate OST client experiences in community pharmacy.

The financial impact of clinical task substitution between practice nurses and GPs in New Zealand primary care centres.

AIM: To describe the financial impact on practice owners of increased clinical task substitution between practice nurses and GPs in New Zealand (NZ) primary care settings. METHOD: Case studies of 9 primary health care centres involving: interviews; collation of service and financial information; and nurse and GP diaries covering 1826 consultations. Results were compared with previous NZ large N survey results to develop a model predicting the financial impact of task substitution. RESULTS: The proportion of general practice primary care consultations undertaken by nurses varied from 4% to 46% of total recorded consultations. The actual financial impact for a practice owner of substituting more nursing time for GP time is highly dependent on the following variables: nurse cost per minute relative to GP cost minute; nurse consult duration relative to GP consult duration; nurse consult revenue relative to GP consult revenue; and the proportion of nurse consults also requiring GP time. CONCLUSION: Practice nurses can (and in some practices in NZ, do) provide a broad set of primary care services, including undifferentiated general consultations. For some practices, increasing the proportion of nurse consults and reducing GP consults, would result in significantly improved profitability--for others, the opposite applies. Clinical task substitution is one option to address the forecast increase in demand associated with population aging.

Surgical workforce in New Zealand: characteristics, activities and limitations.

Planning the future surgical workforce is a vitally important activity in which the Royal Australasian College of Surgeons is actively engaged. This paper reports on a survey, undertaken in late 2005, of all vocationally registered New Zealand surgeons. It describes their age and gender distribution, their workload, the distribution of their work hours and limitations on their activities. It is hoped that this will contribute to planning of surgical services for the future. Of surgeons surveyed, 452 (73%) responded. Their mean age was 51 years and 7% were female. Recruitment has been stable at approximately 20 per year since 1990. New Zealand surgeons worked, on average, 48 h per week and could accommodate additional work. Seventy-seven per cent of surgeons took after-hours calls and reported a 55% chance of returning to the hospital each week (30% in the main population centres and 70% in other districts). Overall, surgeons spent 50% of their clinical time in private practice. Most surgeons experienced significant resource constraints in providing surgical care. The current workload of surgeons in New Zealand is acceptable but after-hours duties, especially in secondary hospitals, may be unattractive. Surgical services are currently limited by institutional resources. If there is a substantial increase in the need for surgery in the future, surgical recruitment, which has been stable, should be increased.

Hospital discharges in New Zealand 1991-2005: changes over time and variation between districts.

AIM: This paper describes changes in the rate of hospital discharges in New Zealand between 1991 and 2006, and assesses variation across districts; it contributes to the discussion of the adequacy of the health system. METHODOLOGY: Data on public hospital discharges were obtained from the NZ Health Information Service. Diagnostic Related Groups were used to group and weight cases; domiciliary codes were used to assign cases to districts and as an indication of patients' socioeconomic status. The Intervention Ratio was used as a relative measure of national hospital throughput from 1991 to 2005, and of district service volume. The Coefficient of Variation was used as a measure of overall system variation. RESULTS: There has been an increase of 50.5% in weighted discharges from public hospitals between 1991/2 and 2005/6; adjusted for population change the increase is 17.9%. There has been a modest fall in the degree of variation between districts, but in medicine and surgery 24% of district departments appear to have levels of discharge significantly above or below the national average. CONCLUSIONS: The intensity of public hospital care to the New Zealand public has increased. Where services are provided at a level above or below the national average, local explanations should be sought and corrective action undertaken if warranted.

Projections of surgical need in New Zealand: estimates of the need for surgery and surgeons to 2026.

AIMS: To estimate the volume of surgery that will be needed in New Zealand to 2026 considering current surgical rates, projected growth, and ageing of the population, and un-met need for surgery; to estimate the required size of the surgical workforce; and to estimate the appropriate number of surgical trainees METHODS: An estimate of future surgical need was obtained by applying current age-specific rates of surgery to population projections to 2026. Estimates of un-met need were obtained by applying the surgical rates of favoured districts to all New Zealand. Data on the current surgical workforce was obtained from a survey of the New Zealand Fellows of the Royal Australasian College of Surgeons and vocationally registered non-Fellows who participate in the College's MOPS programme. RESULTS: Overall, with population growth and ageing, surgical need is estimated to increase by between 36% and 59% by 2026, with a central estimate of a 51%. The size of the volume increase varies according to surgical specialty, with cardiothoracic (67%) and vascular surgery (89%) at the high end, otolaryngology (19%) at the low end, and general surgery (50%) and orthopaedics (56%) closer to the average. Un-met need is estimated at 26% of the present volume. To accommodate the population-related increased need, the number of surgeons should grow from 616 to 820; if un-met need were was also to be accommodated by 2026, the number of surgeons required would rise to 1055. CONCLUSION: A long-term commitment to growth in surgical supply is needed if the future surgical needs of New Zealand are to be met and current standards are to be maintained or improved. Surgical needs analyses should be ongoing to assess the effects of factors not included in the present model.

New Zealand general practitioners' non-urgent referrals to surgeons: who and why?

AIM: To describe the clinical and demographic characteristics of patients referred by general practitioners (GPs) to both public and private sectors for non-urgent surgical assessment. METHOD: During 2004, a cohort of 1420 adult patients with the potential to benefit from elective surgery was recruited into the study by their GPs. GPs recorded patient demographics and reasons for referral. RESULTS: 345 out of 828 eligible GPs (42%) agreed to participate in the study and submitted data on 1603 referrals, 2.4 referrals per reporting week. After excluding ACC cases, data on 1420 referrals were analysed. Forty-two percent of those referred were male and 69% were European New Zealanders. The mean age was 55 years. The largest number of referrals were made to general surgery (37%), followed by orthopaedics (19%), gynaecology (12%), and plastic surgery (10%). The modal level of urgency was "routine" and in 24% of cases cancer was a possibility. The GP felt surgery was needed in 47% of cases, while in 73%, assistance with diagnosis and management was sought. In only 3% of eligible cases was no referral made. CONCLUSION: Elective surgical referral makes up a significant proportion of GP workload. In more than half of cases advice on diagnosis or management, rather than surgery, was sought, and in nearly two-thirds the patient was aged less than 65 years. Cancer control was a relatively frequent goal of referral. The very small number of cases where a desired referral was not made suggests that GP and patient expectations are adjusted to service capacity.

New Zealand general practitioners' characteristics and workload: the National Primary Medical Care Survey.

AIMS: To describe the characteristics and workload of New Zealand general medical practitioners (GPs). METHODS: Data were collected from a stratified random sample of GPs as part of the The National Primary Medical Care Survey carried out in 2001. RESULTS: Data were submitted by 244 practitioners; a 62% response rate. Women made up 63% of the GP workforce aged under 40 years, but only 19% of those aged over 50 years. New Zealand graduates made up 69% of GPs; graduates from other areas occupied particular niches in the GP workforce. Each week, GPs worked (on average) 4 days and saw 102 patients. Eighty percent undertook after-hours work, and the average on-call roster was 1-in-8. At least 8% of visits to GPs occurred after-hours. Parameters of workload were lower for women and for those working in community-owned clinics, and higher for those working outside cities. CONCLUSIONS: An increasing proportion of GPs are women, and more GPs are working part time. In addition, if the changes in primary healthcare add to GPs' responsibilities, then more doctors will be needed. At present, GPs' workload is high in rural areas, which suggests inadequate recruitment; the distribution of GPs is a more important workforce issue than absolute numbers.