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Dr Jim Primrose Chief Advisor

Atención de Salud Primaria Seminario en Sistemas de Salud Nueva Zelanda. Dr Jim Primrose Chief Advisor. Chile Dec 2011. El mundo visto desde Nueva Zelanda. Neozelandeses. Total 4.4m European 68% Maori 14% Pacific 7% Asian 10% 76% live in North Island.

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Dr Jim Primrose Chief Advisor

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  1. Atención de Salud Primaria Seminario en Sistemas de Salud Nueva Zelanda Dr Jim Primrose Chief Advisor Chile Dec 2011

  2. El mundo visto desde Nueva Zelanda

  3. Neozelandeses Total 4.4m European 68% Maori 14% Pacific 7% Asian 10% 76% live in North Island

  4. Sistema de Salud y Discapacidad Caracteristicas principales • universal access • largely funded from taxation • comprehensive range of services, increasingly based on strong community and primary care services • fixed budgets • prioritisation • Providers – mix of public and private ownership

  5. Financiamiento • Funding of health services: • Vote Health ($14.4b) 81% • Out of pocket 14% • Private insurance 5% Vote Health has been growing faster than GDP over recent years. We spend a similar proportion of GDP on health as other OECD countries, however our per capita spending is lower than many.

  6. 1 2 3 4 Comparación Internacional del Gasto en Salud1980–2010 Average spending on healthper capita ($US PPP) Total expenditures on healthas percent of GDP Source OECD Health Data 2011

  7. CENTRAL GOVERNMENT Minister of Health 20 DISTRICT HEALTH BOARDS Buy with Service Agreements Internal agreements • Other Providers • (for profit or not for profit private or community ownership, voluntary, welfare) • Private pharmacy, laboratory, & imaging • Primary care – GPs, Allied Health, Midwives • Private hospital services • Community services • Disability support • Mental health • District Health Board provider arm • Public hospitals • Some community services • Assessment & rehabilitation Users of New Zealand health and disability support services Health and disability support services

  8. Atención de Salud Primaria– la consulta medica privada 96% of New Zealanders are enrolled with general practice, their medical home. • New Zealand has 1100 general practices with: • 3,200 General Practitioners (GP: Population ratio 1:1400) • 5,200 Practice nurses • almost all practices use electronic patient records. Practices are mainly owner operated small businesses and function within larger groupings/networks – Primary Health Organisations. Funding at practice level is blended, a mix of government funding (capitation) and patient fees - which vary.

  9. Opinión de pacientes en Nueva Zelanda sobre consultas medicas People rated care received from regular doctor as very good/ excellent Source: 2010 Commonwealth Fund International Health Policy Survey in 11 Countries

  10. Grado de satisfacción medica en el ejercicio de la medicina Percent* Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

  11. Adultos que informan gozar de buena salud (2007) OECD Health Data 2009

  12. Comparación internacional de esperanza de vida al nacer, algunos países (2009 o último año disponible) Source: OECD Health Data 2011

  13. Crecimiento de la esperanza de vida al nacer (1988-2008) Years Source: OECD Health Data 2010 (Oct. 2010) * 1987–2007

  14. Prevalencia de la obesidad en población adulta (2009) Measured Percent Self-reported * 2008 ** 2007 Note: BMI estimates based on national health interview surveys (self-reported data) are usually significantly lower than estimates based on actual measurements. 15 Source: OECD Health Data 2011 (June 2011).

  15. Mejorando la satisfacción de la gente con los servicios • System features: • Engagement/participation – at all levels • governance – DHBs and PHOs • service design • public reporting - increasing • self care + health literacy – needs more work • Primary Care • enrolment - 96% of people enrolled with general practice • long term relationships - continuity and responsiveness • choice of provider

  16. Mano de obra calificada • Currently we have • reasonable numbers of General Practitioners (GPs) and Practice Nurses, but the workforce is ageing and not well distributed • practice based teams of GPs and Practice Nurses are universal, but broader multi-disciplinary teams less common • There’s • a voluntary bonding scheme - for communities with low GP/nurse numbers • continuing professional development • and involvement with clinical governance is increasing – multi-disciplinary

  17. Mano de obra calificada – dirección futura • We aim for more multi-disciplinary teams in local communities – GPs/nurses/pharmacists/allied health. • In particular to • have health professionals working to the full scope of their practice • expand roles eg primary care nurses managing more chronic conditions, pharmacists prescribing & immunising • have greater flexibility within existing roles, as well as new roles • Clinical assistants • Care coordinators/navigators • build a strong generalist workforce with effective specialist support

  18. Farmacéuticos y servicios de diagnóstico • Pharmaceuticals • Medsafe – assesses medicines for use in NZ - is part of the Ministry of Health • Pharmac – decides which medicines to fund and promotes their optimal use – within a capped budget • Dispensing of medicines through 960 community pharmacies This means • most medicines fully funded by the government – a $3 copayment applies • our rate of pharmaceutical use is similar to other countries • our per capita pharmaceutical spend is about 50% of the OECD average

  19. Farmacéuticos y servicios de diagnóstico • Laboratory services GPs order a wide range of laboratory tests from local community laboratories (privately owned) • there are no patient fees • results are returned electronically to practice computer systems Radiology GPs order these investigations from • public hospitals - no patient fees, but some waiting • or community Radiology clinics (privately owned) – fees apply Next step = improving access to radiology services

  20. Coordinación clínica e integración • Can it improve quality and save money? • “yes it can” • Prevent hospital admissions • Identify patients most at risk of deterioration and ensure they receive coordinated care and self-care services • Counteract the increasing fragmentation of services • And its possible that those who suffer most from under- coordination are people who are poor and/or members of ethnic minority groups Does clinical coordination improve quality and save money? – Dr John Ovretveit, The Health Foundation

  21. Errores médicos, de medicamentos, o de laboratorio, en los dos últimos años, con/sin “medical home” 22 Percent Base: Reported medical mistake, medication error, and/or lab test error or delay in past two years. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

  22. Coordinación clínica e integración • Key aspects • requires clinical leadership • change based on the patient journey - the right thing to do • enabled by flexible funding and permissive policy environment • Building blocks • Enhanced primary care capacity & capability • workforce – changing scopes of practice + multi-disciplinary teams • facilities – larger health centres • information capability – safe sharing of electronic health records • Service shift from hospitals to communities

  23. 1 2 3 4 Condiciones crónicas y atención primaria • 1. Prevention and early intervention • Address broader determinants housing/education/employment. • Four main risk factors: • smoking – good progress • diet • exercise • alcohol • 2. Early detection and good management • use of guidelines • decision support tools • multi-disciplinary teams • self-management/health literacy • health targets Current smoking prevalence* among adults (15+) * The definition of current smoker is the WHO one of a person who has smoked more than 100 cigarettes in their life and smokes currently at least once a month.

  24. Metas de Salud (Health Targets) • Shorter Stays in ED Departments 95 percent of patients will be admitted, discharged, or transferred from an Emergency Department (ED) within six hours • Improved Access to Elective Surgery The volume of elective surgery will be increased by an average 4,000 discharges per year (compared with the previous average increase of 1400 per year). • Shorter waits for cancer treatment radiotherapy and chemotherapy Everyone needing radiotherapy will have this within four weeks • Increased immunisation 95% of two year olds will be fully immunised • Better help for smokers to quit 95 percent of hospitalised smokers will be provided with advice and help to quit smoking • More Heart and Diabetes Checks 90 percent of the eligible adult population will have had their cardiovascular disease (CVD) risk assessed in the last five years

  25. Mejorando la atención de salud… • “To improve health care we require not better professions, but better systems of work. A “system” in this sense is a set of elements interacting to achieve a shared aim. Here is the trick: to improve the performance of the system you need to attend more to the inter-actions than to the elements. Great health professionals inter-acting well with all of the other elements of the healthcare system make great health care.” • Don Berwick, “Medical Associations: Guilds or Leaders?BMJ, Vol 314, 564-1565

  26. Gracias

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