GUEST BLOG: Ian Powell – Health polyclinics for New Zealand?

General Practice New Zealand (GPNZ) is an interesting organisation formed over a decade ago. General practitioner representation is fragmented in Aotearoa New Zealand but GPNZ’s formation did not add to the fragmentation. Instead it provides a voice for networks of general practices rather than individual GPs.

In April 2019, GPNZ published a thoughtful discussion paper. Titled Workforce and resources for future general practice, the paper deliberately does not address specific future business models and governance. In some respects this is disappointing but it does ensure that its main focus is not diluted by these matters

Workforce model and responsiveness

What GPNZ does is describe a model in workforce terms. It lists requirements for responsiveness in order to ensure an improved and comprehensive primary care service for New Zealanders.

These responsiveness requirements are defined as:

• unmet need
• recognition of the changing roles and career expectations of medical practitioners
• building upon emerging workforce roles
• building primary healthcare teams that have a wider range of capability than is currently the norm, and
• articulating an approach that can be implemented widely across different communities, with a high degree of local responsiveness and local variation where appropriate.

Extended primary care team

GPNZ promotes greater integration within a structure it labels “extended primary care teams”. The high-needs Porirua Union & Community Health Centre is used as a current example.

Its model outlines the staff needed for 10,000 enrolled patients. For a general-needs population, this would require 31.3 full-time equivalents; for a high-needs population, 42.5 would be required. The difference would largely be in additional nurse practitioners, GPs, social workers and reception/administration.

The usefulness of this is model is that it indicates the additional workforce investment needed to cater for a high-needs population would be around 35%.

In thinking about the paper generates consideration of other issues. One is integration. Another is governance.

Integration

The current dominant general practice model is limited in its ability to provide accessible and equitable access to quality primary healthcare, as the foundation of a health system intended to produce a universal public good.

GP-owned practices have done Aotearoa New Zealand well, with strengths that should be retained, whichever way primary care evolves. But its small-business structure means there are limitations in its scope to reach out to everybody, particularly those in economically deprived or smaller, isolated communities (ie, high health needs).

Further, largely generationally driven, GP practice partners are declining and upcoming doctors have less interest in purchasing the equity of a retiring partner. There is a limit to the extent existing partners can buy up this equity. Realistically, only corporates can fill this gap if private ownership is to remain the norm.

While improving integration within primary care is essential (as advocated by GPNZ), why stop there? Why not improve integration between primary and secondary care (ie, between today’s GP surgery and hospital) to a level that makes good clinical and wellbeing sense?

Governance

Improving integration within general practices and between it and hospitals leads on to the issue of governance – which GPNZ avoids (understandably, if its paper is seen as part of developmental thinking). Governance should not be left as the elephant in the room.

Consequently, the term “polyclinics” entered my cognitive processes. I had a positive glimpse of them in the Netherlands many years ago.

Over a decade ago, I observed a top-down, one-size-fits-all attempt to introduce them in the National Health Service in England, which included potential private corporate takeover. There was a glimmer of a good idea behind them, but the execution was a shocker. Failure was the outcome.

Cuba

What really prompted my thinking was visiting Cuba in January 2020. There are three main structural tiers to the Cuban health system: community based polyclinics, general secondary care hospitals and sub-specialist tertiary hospitals.

There are nearly 500 polyclinics across the island, each serving defined populations of between 20,000 and 60,000 people. They have a strong neighbourhood flavour about them.

Population size-wise, Cuban polyclinics are comparable with New Zealand’s smaller district health boards (DHBs) such as Tairāwhiti, Wairarapa and West Coast (a little smaller than Whanganui and South Canterbury). It means that they probably know their populations better than most DHBs know theirs. Being well staffed (with doctors and nurses, especially), Cuban polyclinics have the capacity to mobilise to ensure visits to each home annually for immunisation.

Owing to the highly punitive economic blockade from the US, it was necessary for Cuba to develop its own Covid-19 vaccines. Its polyclinics provide better vaccine distribution to their populations than is seen in many other countries.

Polyclinics don’t just provide primary care. They extend into areas of sub-acute hospital care (less so surgery), including outpatient clinics and treatments with the necessary diagnostic support required.

Embryos?

There is no equivalent to these polyclinics in New Zealand. The closest example I can think of is Southern DHB’s Lakes District Hospital, in Queenstown, with the extensive use of rural hospital medicine specialists and visiting specialists from Dunedin and Invercargill. However, primary care is provided by two local general practices. The nearby community trust-run Dunstan Hospital in Clyde is in a similar situation.

It is possible that Taranaki DHB’s initiative to establish a new medical centre in Hawera, staffed by rural hospital medicine specialists and providing a range of primary and secondary care, might have been an embryonic polyclinic.

But the DHB’s engagement with local general practices was a flop. If polyclinics were to be considered in New Zealand, engagement must be of a much higher standard.

Polyclinics in Aotearoa?

Should polyclinics be seriously considered for New Zealand? I think so, provided their structure follows design and the design recognises both the prevalence and provision of quality care of general practices in Aotearoa.

So design should not be one-size-fits-all. Its focus should be on access, not just to primary care but also to hospital outpatient clinics and some other sub-acute work that could sensibly be undertaken in a more local setting. Inclusion of pharmacy and dentistry should not be ruled out, depending on the state of local access.

The growing relatively new branch of specialist medicine known as rural hospital medicine with its emphasis on episodic care offers opportunities that should be considered. Rural hospital medicine specialists can be increasingly found in small DHB or community trust owned hospitals from Northland DHB down to Southern DHB.

But design must also recognise that polyclinics should not compete with privately owned general practices. Cooperation and collaboration have to be the governing ethos.

Governance must be addressed as part of design. DHBs would be the logical statutory bodies to assume overall ownership if the Government were not still foolishly determined to dismantle them in the midst of a raging pandemic!

If DHBs are replaced by the proposed new national health bureaucracy currently called ‘Health New Zealand’, then it should assume ownership (despite its highly bureaucratic centralised nature).

The only other option for polyclinics of this kind would be private corporates. But they are less inclined to invest in less profitable or unprofitable deprived or isolated populations. Given that the Government has little idea what will replace DHBs in community care responsibility there is serious risk of a governance vacuum being created that will allow corporates to suck up and takeover these fragmented bits.

Although the quality of political leadership of the health system does not inspire confidence, this is no justification for not advocating correcting primary care’s pending governance deficit.

[This blog is a revised version of my regular column published by New Zealand Doctor on 10 November 2021]

Ian Powell was Executive Director of the Association of Salaried Medical Specialists, the professional union representing senior doctors and dentists in New Zealand, for over 30 years, until December 2019. He is now a health systems, labour market, and political commentator living in the small river estuary community of Otaihanga (the place by the tide). First published at Otaihanga Second Opinion