The costs, barriers and enablers of providing PGY2 placements in general practice in Aotearoa New Zealand: a mixed-methods study.

Introduction Few mandatory community-based attachments for postgraduate year two doctors (PGY2s) in Aotearoa New Zealand are hosted in general practices, due to space, time and remuneration barriers. Aim This study aimed to explore the costs, barriers and enablers to general practices of hosting PGY2s. Methods A cost analysis for four general practices beginning to host PGY2s was undertaken, including time spent supervising and supporting PGY2s, revenue impact including subsidies and cost of providing clinical space. Interviews with these practices and seven experienced PGY2 host practices were conducted and analysed thematically. Results The estimated mean cost of hosting PGY2s excluding room cost was NZ$4907 per 13-week placement (range $890-$9183), increasing to $13 727 per placement (range $5750-$24 715) when room rental was included. Four themes were identified: working within a small business model; a new learning environment for PGY2s; providing positive experiences for the PGY2s; the relationship between practices and district hospitals that employed the PGY2s, including job sizing. Discussion Tension exists between the small business model of general practice and providing positive experiences for PGY2s in a new learning environment. Guidance and support structures for PGY2 hosting should be developed nationally, and communication and cooperation between practices and employing hospitals needs improvement. Out-of-hours work should be included in community-based attachments so PGY2s' remuneration is consistent. General practice teams are willing to be part of creating a sustainable workforce. However, the time taken to host and costs of providing training in primary care are barriers. There is urgent need to increase funding to general practices for hosting PGY2s.

How did New Zealand's regional District Health Board groupings work to improve service integration and health outcomes: a realist evaluation.

OBJECTIVES: In Aotearoa New Zealand (NZ), integration across the healthcare continuum has been a key approach to strengthening the health system and improving health outcomes. A key example has been four regional District Health Board (DHB) groupings, which, from 2011 to 2022, required the country's 20 DHBs to work together regionally. This research explores how this initiative functioned, examining how, for whom and in what circumstances regional DHB groupings worked to deliver improvements in system integration and health outcomes and equity. DESIGN: We used a realist-informed evaluation study design. We used documentary analysis to develop programme logic models to describe the context, structure, capabilities, implementation activities and impact of each of the four regional groupings and then conducted interviews with stakeholders. We developed a generalised context-mechanisms-outcomes model, identifying key commonalities explaining how regional work 'worked' across NZ while noting important regional differences. SETTING: NZ's four regional DHB groupings. PARTICIPANTS: Forty-nine stakeholders from across the four regional groupings. These included regional DHB governance groups and coordinating regional agencies, DHB senior leadership, Maori and Pasifika leadership and lead clinicians for regional work streams. RESULTS: Regional DHB working was layered on top of an already complex DHB environment. Organisational heterogeneity and tensions between local and regional priorities were key contextual factors. In response, regional DHB groupings leveraged a combination of 'hard' policy and planning processes, as well as 'soft', relationship-based mechanisms, aiming to improve system integration, population health outcomes and health equity. CONCLUSION: The complexity of DHB regional working meant that success hinged on building relationships, leadership and trust, alongside robust planning and process mechanisms. As NZ reorients its health system towards a more centralised model underpinned by collaborations between local providers, our findings point to a need to align policy expectations and foster environments that support connection and collegiality across the health system.

Impact of health system governance on healthcare quality in low-income and middle-income countries: a scoping review.

INTRODUCTION: Improving healthcare quality in low-/middle-income countries (LMICs) is a critical step in the pathway to Universal Health Coverage and health-related sustainable development goals. This study aimed to map the available evidence on the impacts of health system governance interventions on the quality of healthcare services in LMICs. METHODS: We conducted a scoping review of the literature. The search strategy used a combination of keywords and phrases relevant to health system governance, quality of healthcare and LMICs. Studies published in English until August 2023, with no start date limitation, were searched on PubMed, Cochrane Library, CINAHL, Web of Science, Scopus, Google Scholar and ProQuest. Additional publications were identified by snowballing. The effects reported by the studies on processes of care and quality impacts were reviewed. RESULTS: The findings from 201 primary studies were grouped under (1) leadership, (2) system design, (3) accountability and transparency, (4) financing, (5) private sector partnerships, (6) information and monitoring; (7) participation and engagement and (8) regulation. CONCLUSIONS: We identified a stronger evidence base linking improved quality of care with health financing, private sector partnerships and community participation and engagement strategies. The evidence related to leadership, system design, information and monitoring, and accountability and transparency is limited.

The place of rural hospitals in New Zealand's health system: an exploratory qualitative study.

INTRODUCTION: In Aotearoa New Zealand (NZ) there is a knowledge gap regarding the place and contribution of rural hospitals in the health system. New Zealanders residing in rural areas have poorer health outcomes than those living in urban areas, and this is accentuated for Maori, the Indigenous people of the country. There is no current description of rural hospital services, no national policies and little published research regarding their role or value. Around 15% of New Zealanders rely on rural hospitals for health care. The purpose of this exploratory study was to understand national rural hospital leadership perspectives on the place of rural hospitals in the NZ health system. METHODS: A qualitative exploratory study was undertaken. The leadership of each rural hospital and national rural stakeholder organisations were invited to participate in virtual semi-structured interviews. The interviews explored participants' views of the rural hospital context, the strengths and challenges they faced and how good rural hospital care might look. Thematic analysis was undertaken using a framework-guided rapid analysis method. RESULTS: Twenty-seven semi-structured interviews were conducted by videoconference. Two broad themes were identified, as follows. Theme 1, 'Our place and our people', reflected the local, on-the-ground situation. Across a broad variety of rural hospitals, geographical distance from specialist health services and community connectedness were the common key influencers of a rural hospital's response. Local services were provided by small, adaptable teams across broad scopes and blurred primary-secondary care boundaries, with acute and inpatient care a key component. Rural hospitals acted as a conduit between community-based care and city-based secondary or tertiary hospital care. Theme 2, 'Our positioning in the wider health system', related to the external wider environment that rural hospitals worked within. Rural hospitals operating at the margins of the health system faced multiple challenges in trying to align with the urban-centric regulatory systems and processes they were dependent on. They described their position as being 'at the end of the dripline'. In contrast to their local connectedness, in the wider health system participants felt rural hospitals were undervalued and invisible. While the study found strengths and challenges common to all NZ rural hospitals, there were also variations between them. CONCLUSION: This study furthers understanding of the place of rural hospitals in the NZ healthcare system as seen through a national rural hospital lens. Rural hospitals are well placed to provide an integrative role in locality service provision, with many already long established in performing this role. However, context-specific national policy for rural hospitals is urgently needed to ensure their sustainability. Further research should be undertaken to understand the role of NZ rural hospitals in addressing healthcare inequities for those living in rural areas, particularly for Maori.

The cost savings of the rural accelerated chest pain pathway for low-risk chest pain in rural general practice: a cost minimisation analysis.

Introduction The rural accelerated chest pain pathway (RACPP) has been shown to safely reduce the number of transfers to hospital for patients who present with chest pain to rural general practice. Aim This study aimed to estimate the costs associated with assessing patients with low-risk chest pain using the RACPP in rural general practice compared with transporting such patients to a distant emergency department (ED). Methods This was a retrospective cost minimisation analysis. All patients with low-risk chest pain that were assessed in New Zealand (NZ) rural general practice using the RACPP between 1 June 2018 and 31 December 2019 were asked to participate. The costs incurred by patients were determined by an online survey. Patients were also asked to estimate the costs if they would have been transferred to ED. System costs were obtained from the relevant healthcare organisations. The main outcome measure was the total cost for patients who present with low-risk chest pain. Results In total, 15 patients (22.7% response rate) responded to the survey. Using the RACPP in general practice resulted in a median cost saving of NZ$1184 (95% CI: $1111 to $1468) compared with transferring the same patient to ED. Discussion Although limited by low enrolment, this study suggests that there are significant savings if the RACPP is used to assess patients with low-risk chest pain in rural NZ general practice.

Corrigendum to: The cost savings of the rural accelerated chest pain pathway for low-risk chest pain in rural general practice: a cost minimisation analysis.

Introduction The rural accelerated chest pain pathway (RACPP) has been shown to safely reduce the number of transfers to hospital for patients who present with chest pain to rural general practice. Aim This study aimed to estimate the costs associated with assessing patients with low-risk chest pain using the RACPP in rural general practice compared with transporting such patients to a distant emergency department (ED). Methods This was a retrospective cost minimisation analysis. All patients with low-risk chest pain that were assessed in New Zealand (NZ) rural general practice using the RACPP between 1 June 2018 and 31 December 2019 were asked to participate. The costs incurred by patients were determined by an online survey. Patients were also asked to estimate the costs if they would have been transferred to ED. System costs were obtained from the relevant healthcare organisations. The main outcome measure was the total cost for patients who present with low-risk chest pain. Results In total, 15 patients (22.7% response rate) responded to the survey. Using the RACPP in general practice resulted in a median cost saving of NZ$1184 (95% CI: $1111 to $1468) compared with transferring the same patient to ED. Discussion Although limited by low enrolment, this study suggests that there are significant savings if the RACPP is used to assess patients with low-risk chest pain in rural NZ general practice.

What is important for high quality rural health care? A qualitative study of rural community and provider views in Aotearoa New Zealand.

INTRODUCTION: While the general principles of healthcare quality are well articulated internationally, less has been written about applying these principles to rural contexts. Research exploring patient and provider views of healthcare quality in rural communities is limited. This study investigated what was important in healthcare quality particularly for hospital-level care for rural communities in Aotearoa New Zealand. METHODS: A pragmatic qualitative study was undertaken in four diverse rural communities with access to rural hospitals. Data were gathered through eight community and indigenous (Maori) focus groups (75 participants) and 34 health provider interviews, and analysed thematically. RESULTS: Two study sites had large Maori populations and high levels of socioeconomic deprivation, whereas the other two sites had much lower Maori populations and lower levels of socioeconomic deprivation, but further travel distances to urban facilities. Rural hospitals in the communities ranged from 12 to 80 beds and were both government and community trust owned. A theme of the principles of high quality rurally focused health services was developed. Nine principles were identified: (1) providing patient- and family-centred care that respected people's preferences for where treatment was provided; (2) providing services as close to home as could be done well; (3) quality was everybody's job; (4) consistent care across settings, with reduction on unwarranted variation; (5) team-based care across distance, with clear communication and processes between different facilities working together; (6) equitable health care particularly for Maori, and then for the whole rural community; (7) sustainable service models, particularly for workforce, as a counterbalance to 'closer to home'; (8) health networks to improve patient flow, and reduce waste; and (9) value was more than value for money, and including valuing respectful, timely care. Another theme around rural and urban healthcare quality was developed. While the nature of care was different in different settings, patient experience should be the underlying measure of quality, and quality measures needed to be interpreted in the context of local circumstances, with rural-specific quality measures where appropriate. CONCLUSION: The researchers developed principles of healthcare quality specific to rural communities regarding patient and family preferences for where care was received, a broader focus on value beyond value for money and a strong focus on equity for indigenous people. These principles add to the rural principles previously described. Patient experience should be the underlying focus of quality, while noting that the nature of health care provided in rural and urban settings is different. The present study's findings support the concept that quality measures should be interpreted in the context of local circumstances, with the development of rural-specific measures. The authors hope the findings, when locally contextualised, will assist health policy makers, planners, providers and community leaders as they strive to improve the quality of health services for their rural communities.

New Zealand Pae Ora Healthcare Reforms 2022: Viable by Design? A Qualitative Study Using the Viable System Model.

BACKGROUND: The New Zealand (NZ) Pae Ora (Healthy Futures) health reforms came into effect in July 2022 with the establishment of Health New Zealand (HNZ) (Te Whatu Ora) and the Maori Health Authority (MHA) (Te Aka Whai Ora) - the organisations charged for healthcare provision and delivery. Given these changes represent major health system reform, we aimed to conduct an early evaluation of the design of the reforms to determine if they can deliver a viable and sustainable NZ health system going forward. METHODS: The evaluation was informed by Beer's viable system model (VSM). A qualitative exploratory design with semi-structured interviews and documents analysis using thematic analysis was used. We conducted 28 interviews with senior healthcare managers and reviewed over 300 official documents and news analyses. RESULTS: The VSM posits that for a system to be viable, all its five sub-systems (operations; co-ordination; operational control; development and governance) need to be strong. Our analysis suggests that the health reforms, despite their strengths, do not satisfy this requirement. The reforms do appreciate the complexity of the healthcare environment: multiple stakeholders, social inequalities, interdependencies. However, our analysis suggests a severe lack of detail regarding the implementation and operationalisation of the reforms. Furthermore, resourcing and coordination within the reformed system is also unclear. CONCLUSION: The health system reforms may not lead to a viable future NZ health system. Poor communication of the reform implementation and operationalisation will likely result in system failure and inhibit the ability of frontline health organisations to deliver care.

How to Best Develop and Deliver Generic Long-Term Condition Rehabilitation Programmes in Rural Settings: An Integrative Review.

People living rurally frequently experience health disparities especially if living with a long-term condition (LTC) or multi-morbidity. Self-management support is a key component of LTC management and commonly included in rehabilitation programmes to enhance ability to self-manage health and encourage physical activity. Such programmes are however often condition focussed and despite evidence for their effectiveness, are not always feasible to deliver in rural settings. Generic programmes are arguably more optimal in the rural context and delivery can be face to face or remotely (via telehealth). The aim of this explorative integrative review was to collate and present international evidence for development, delivery, integration, and support of community-based, generic LTC group rehabilitation programmes delivered rurally in person, or remotely using telehealth. Electronic databases were systematically searched using MeSH terms and keywords. For inclusion, articles were screened for relevance to the aim, and practical information pertaining to the aim were extracted, charted, and organized deductively into themes of Development, Delivery, Integration, and Support. Within each theme, data were synthesized inductively into categories (Theory, Context, Interpersonal aspects, and Technology and Programme aspects). Fifty-five studies were included. Five studies contributed information about community based programmes delivered via the internet. Development was the only theme populated by information from all categories. The theme of Support was only populated with information from one category. Our review has drawn together a large body of diverse work. It has focused on finding practical information pertaining to the best ways to develop, deliver, integrate, and support a community-based generic rehabilitation programme for people living with long-term health conditions, delivered rurally and/or potentially via the internet. Practical suggestions were thematically organized into categories of theory, context, interpersonal aspects, and technology and programme aspects. While the findings of this review might appear simple and self-evident, they are perhaps difficult to enact in practice.

New Zealand's rural hospitals in 2021: findings from an exploratory questionnaire survey.

Introduction There is a gap in our knowledge of the place and contribution of rural hospitals in the New Zealand health system. There is no current description of rural hospital services, no national policies and little published research regarding their value. Aim To explore rural hospital leader perspectives of the role of rural hospitals. Methods An on-line survey of rural hospital leaders conducted to capture perspectives on areas including facility nomenclature; access and equity; funding and the health reforms. Results Fifty-five rural hospital leaders representing 19/24 rural hospitals responded. 'Rural Hospital' was the most common term used to describe facilities with 80% of respondents indicating this as their preferred term. Other descriptive terms varied widely from primary through to secondary care. Respondents indicated that the loss of rural hospital in-patient beds would be unacceptable to communities (median 0, IQR 0, 1). Scores on questions about 'range of services' (median 7, IQR 6, 8), 'accessibility' (median 7, IQR 6, 8) and how rural hospitals were addressing health equity (median 6, IQR 5, 7) were variable. The process for allocating funds to rural hospitals was perceived as lacking transparency (median 3, IQR 2, 5). National strategy and 'local governance and control' were both rated as important (median 9, IQR 7, 10 and median 9, IQR, 8, 10) for a rural hospital's future. Discussion By capturing a collective national rural hospital leadership voice, this study facilitates the understanding of the rural hospital concept. The findings inform subsequent research needed to gain a clearer picture of New Zealand rural hospital provision.

Implementation of the Diabetes Community Exercise and Education Programme (DCEP) for the management of type 2 diabetes: qualitative process evaluation.

OBJECTIVES: To examine context-specific delivery factors, facilitators and barriers to implementation of the Diabetes Community Exercise and Education Programme (DCEP) for adults with type 2 diabetes (T2D) using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework. DESIGN: A qualitative evaluation embedded within the DCEP pragmatic randomised controlled trial. Data collected via focus groups and interviews and analysed thematically. SETTING: Community-based in two cities (Dunedin and Invercargill) in the lower south island of New Zealand. PARTICIPANTS: Seventeen adults diagnosed with T2D attending DCEP and 14 healthcare professionals involved in DCEP delivery. INTERVENTION: DCEP is a twice weekly session of exercise and education over 12 weeks, followed by a twice weekly ongoing exercise class. RESULTS: While our reach target was met (sample size, ethnic representation), the randomisation process potentially deterred Maori and Pasifika from participating. The reach of DCEP may be extended through the use of several strategies: promotion of self-referral, primary healthcare organisation ownership and community champions. DCEP was considered effective based on perceived benefit. The social and welcoming environment created relationships and connections. People felt comfortable attending DCEP and empowered to learn. Key to implementation and adoption was the building of trusting relationships with local health providers and communities. This takes time and care and cannot be rushed. Training of staff and optimising communication needed further attention. To maintain DCEP, delivery close to where people live and a generic approach catering for people with multiple chronic conditions may be required. CONCLUSIONS: For success, lifestyle programmes such as DCEP, need time and diligence to build and maintain networks and trust. Beyond frontline delivery staff and target populations, relationships should extend to local healthcare organisations and communities. Access and ongoing attendance are enabled by healthcare professionals practicing in a nuanced person-centred manner; this, plus high staff turnover, necessitates ongoing training. TRIAL REGISTRATION NUMBER: ACTRN12617001624370.

Developing a national primary care research network: a qualitative study of stakeholder views.

Introduction Primary care research is critical to address Aotearoa New Zealand's (NZ) health sector challenges. These include health inequities, workforce issues and the need for evaluation of health system changes. Internationally, primary care data are routinely collected and used to understand these issues by primary care research and surveillance networks (PCRN). NZ currently has no such infrastructure. Aim To explore health sector stakeholders' views on the utility of, and critical elements needed for, a national PCRN in NZ. Methods Twenty semi-structured interviews and a focus group were conducted with key stakeholders, representing different perspectives within the health sector, including Hauora Maori providers. Data were analysed thematically. Results Six themes were identified that included both challenges within current primary care research and ideas for a future network. The themes were: disconnection between research, practice and policy; desire for better infrastructure; improving health equity for Maori and other groups who experience inequity; responding to the research needs of communities; reciprocity between research and practice; and the need for data to allow evidence-informed decision-making. Improving health equity for Maori was identified as a critical function for a national PCRN. Discussion Stakeholders identified challenges in conducting primary care research and translating research into practice and policy in NZ. Stakeholders from across the health sector supported a national PCRN and identified what its function should be and how it could operate. These views were used to develop a set of recommendations to guide the development of a national PCRN.

Medication risk management and health equity in New Zealand general practice: a retrospective cross-sectional study.

BACKGROUND: Despite an overt commitment to equity, health inequities are evident throughout Aotearoa New Zealand. A general practice electronic alert system was developed to notify clinicians about their patient's risk of harm due to their pre-existing medical conditions or current medication. We aimed to determine whether there were any disparities in clinician action taken on the alert based on patient ethnicity or other demographic factors. METHODS: Sixty-six New Zealand general practices from throughout New Zealand participated. Data were available for 1611 alerts detected for 1582 patients between 1 and 2018 and 1 July 2019. The primary outcome was whether action was taken following an alert or not. Logistic regression was used to assess if patients of one ethnicity group were more or less likely to have action taken. Potential confounders considered in the analyses include patient age, gender, ethnicity, socio-economic deprivation, number of long term diagnoses and number of long term medications. RESULTS: No evidence of a difference was found in the odds of having action taken amongst ethnicity groups, however the estimated odds for Maori and Pasifika patients were lower compared to the European group (Maori OR 0.88, 95 %CI 0.63-1.22; Pasifika OR 0.88, 95 %CI 0.52-1.49). Females had significantly lower odds of having action taken compared to males (OR 0.76, 95 %CI 0.59-0.96). CONCLUSIONS: This analysis of data arising from a general practice electronic alert system in New Zealand found clinicians typically took action on those alerts. However, clinicians appear to take less action for women and Maori and Pasifika patients. Use of a targeted alert system has the potential to mitigate risk from medication-related harm. Recognising clinician biases may improve the equitability of health care provision.

The views of New Zealand general practitioners and patients on a proposed risk assessment and communication tool: a qualitative study using Normalisation Process Theory.

BACKGROUND: Communicating risks of medication harm and obtaining informed consent is difficult due to structural barriers, language and cultural practices, bias and a lack of resources appropriately tailored for the health literacy of most patients. A decision support tool was proposed to alert prescribers of risk and provide tailored information for patients to facilitate informed decision-making with patients and their whanau (family) around medication use. Patient and prescriber co-design was used to ensure the tool was designed to best meet the needs of end-users and avoid increasing health inequity. This paper describes the first stage of the co-design process. METHOD: Normalisation Process Theory (NPT) was used to prospectively evaluate the tool. Semi-structured interviews were held with fifteen patients (five Maori, five Pasifika and five NZ European) and nine general practitioners (two Maori and seven European). RESULTS: Three themes were identified, which related to the three NPT concepts most relevant to developing the tool. Theme 1 (coherence: meaning and sense making by participants) explored participants' understanding of prescribing safety, medication harm and risk, which is based on experience. Patients want as much information as possible about their medications and risk, but doctors find it difficult to communicate that information. Theme 2 related to the NPT concept of cognitive participation (commitment and engagement by participants) explored what participants thought about a prescribing decision support tool. Participants were cautiously optimistic, but worried about potential harm arising from its use. They also identified requirements for the tool and features to avoid. Theme 3 describes the collective action required for successful implementation of the tool; namely, culturally safe and trustworthy doctor-patient relationships. CONCLUSION: Patients and general practitioners provided different perspectives when prospectively evaluating the proposed risk assessment and communication tool. This co-design research identified important pre-requisites for the tool and features to avoid and novel ideas for the proposed tool. Overall participants supported the development of the proposed risk assessment and communication tool, but identified the important role that doctor-patient relationships would play to ensure successful implementation. The use of Maori and Pacific languages in the proposed tool may enhance engagement and understanding.

Health Care Utilisation and Health Needs of People with Severe COPD in the Southern Region of New Zealand: A Retrospective Case Note Review.

We examined health care utilisation and needs of people with severe COPD in the low-population-density setting of the Southern Region of New Zealand (NZ). We undertook a retrospective case note review of patients with COPD coded as having an emergency department attendance and/or admission with at least one acute exacerbation during 2015 to hospitals in the Southern Region of NZ. Data were collected and analysed from 340 case notes pertaining to: demographics, hospital admissions, outpatient contacts, pulmonary rehabilitation, advance care planning and comorbidities. Geometric mean (95%CI) length of stay for hospital admissions in urban and rural hospitals was 3.0 (2.7-3.4) and 4.0 (2.9-5.4) days respectively. More patients were from areas of higher deprivation but median hospital length of stay for patients from the least deprived areas was 2.0 days longer than others (p = 0.04). There was a median of 4 (range 0-16) comorbidities and 10 medications (range 0-25) per person. Of 169 cases where data was available, 26 (15%) were offered, 17 (10%) declined, and 5 (3%) completed, pulmonary rehabilitation at or in the year prior to the index admission. Patients were less likely to be offered pulmonary rehabilitation if they lived >20km away from the hospital where it took place (odds ratio of 0.12 for those living further away [95%CI 0.02-0.93, p = 0.04]). There were deficits in care: provision and uptake of non-pharmacological interventions was suboptimal and unevenly distributed across the region. Further research is needed to develop and evaluate strategies for delivering non-pharmacological interventions in this setting.

New Zealand general practice registrars' views on their academic learning needs during vocational training: online survey.

Most doctors working in New Zealand general practice undertake vocational training through the Royal New Zealand College of General Practitioners. We aimed to explore general practice registrar views on their academic learning needs during and following vocational training. An online survey of all current NZ GP trainees in 2019 was completed by 314 registrars (54% response rate). The majority (88%, 275/314) were completing RNZCGP Fellowship only, and of these half (55%, 152/275) were planning a further postgraduate qualification. A minority (12%, 33/275) indicated a desire to undertake a masters or PhD degree. Almost all (99%, 310/314) intended to work in general practice; 9% (8/314) intending to also work as rural hospital doctors. The five most common areas of interest for further training were clinical skills (68%), practice-based teaching (66%), specific clinical conditions (63%), age or life-stage specific (47%) and non-clinical areas (41%). There is a considerable gap between completing RNZCGP Fellowship, intending to undertake further (formal postgraduate) education and actually enrolling. This is concerning given the need for lifelong learning and critical evaluation of practice and health service delivery. The future New Zealand general practice workforce needs GPs to be diverse and highly skilled members or leaders of expert teams.

Protocol for a mixed methods realist evaluation of regional District Health Board groupings in New Zealand.

INTRODUCTION: Achieving effective integration of healthcare across primary, secondary and tertiary care is a key goal of the New Zealand (NZ) Health Strategy. NZ's regional District Health Board (DHB) groupings are fundamental to delivering integration, bringing the country's 20 DHBs together into four groups to collaboratively plan, fund and deliver health services within their defined geographical regions. This research aims to examine how, for whom and in what circumstances the regional DHB groupings work to improve health service integration, healthcare quality, health outcomes and health equity, particularly for Maori and Pacific peoples. METHODS AND ANALYSIS: This research uses a mixed methods realist evaluation design. It comprises three linked studies: (1) formulating initial programme theory (IPT) through developing programme logic models to describe regional DHB working; (2) empirically testing IPT through both a qualitative process evaluation of regional DHB working using a case study design; and (3) a quantitative analysis of the impact that DHB regional groupings may have on service integration, health outcomes, health equity and costs. The findings of these three studies will allow refinement of the IPT and should lead to a programme theory which will explain how, for whom and in what circumstances regional DHB groupings improve service integration, health outcomes and health equity in NZ. ETHICS AND DISSEMINATION: The University of Otago Human Ethics Committee has approved this study. The embedding of a clinician researcher within a participating regional DHB grouping has facilitated research coproduction, the research has been jointly conceived and designed and will be jointly evaluated and disseminated by researchers and practitioners. Uptake of the research findings by other key groups including policymakers, Maori providers and communities and Pacific providers and communities will be supported through key strategic relationships and dissemination activities. Academic dissemination will occur through publication and conference presentations.

Creating sustainable health care systems.

PURPOSE: In order to create sustainable health systems, many countries are introducing ways to prioritise health services underpinned by a process of health technology assessment. While this approach requires technical judgements of clinical effectiveness and cost effectiveness, these are embedded in a wider set of social (societal) value judgements, including fairness, responsiveness to need, non-discrimination and obligations of accountability and transparency. Implementing controversial decisions faces legal, political and public challenge. To help generate acceptance for the need for health prioritisation and the resulting decisions, the purpose of this paper is to develop a novel way of encouraging key stakeholders, especially patients and the public, to become involved in the prioritisation process. DESIGN/METHODOLOGY/APPROACH: Through a multidisciplinary collaboration involving a series of international workshops, ethical and political theory (including accountability for reasonableness) have been applied to develop a practical way forward through the creation of a values framework. The authors have tested this framework in England and in New Zealand using a mixed-methods approach. FINDINGS: A social values framework that consists of content and process values has been developed and converted into an online decision-making audit tool. RESEARCH LIMITATIONS/IMPLICATIONS: The authors have developed an easy to use method to help stakeholders (including the public) to understand the need for prioritisation of health services and to encourage their involvement. It provides a pragmatic way of harmonising different perspectives aimed at maximising health experience. PRACTICAL IMPLICATIONS: All health care systems are facing increasing demands within finite resources. Although many countries are introducing ways to prioritise health services, the decisions often face legal, political, commercial and ethical challenge. The research will help health systems to respond to these challenges. SOCIAL IMPLICATIONS: This study helps in increasing public involvement in complex health challenges. ORIGINALITY/VALUE: No other groups have used this combination of approaches to address this issue.