Transcript Slide 1

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
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
Financiamiento
Funding of health services:
• Vote Health ($14.4b)
81%
• Out of pocket
14%
• Private insurance
5%
Vote Health has been growing faster than GDP over recent
years.
We spend a similar proportion of GDP on health as other OECD
countries, however our per capita spending is lower than many.
1
2
Comparación Internacional del Gasto en Salud
1980–2010
Average spending on health
per capita ($US PPP)
Total expenditures on health
as percent of GDP
18.0
Australia
Canada
Denmark
France
Germany
Netherlands
New Zealand
Norway
Sweden
Switzerland
United Kingdom
United States
8000
7000
6000
5000
16.0
14.0
12.0
10.0
4000
8.0
3000
Source OECD Health Data 2011
2010
2009
2008
2006
2005
2004
2003
2002
2001
2000
United States
1999
United Kingdom
1998
Switzerland
1997
Norway
Sweden
1996
Netherlands
New Zealand
1995
France
Germany
1994
Denmark
1993
1989
1988
1987
1986
1985
1984
1983
1982
1981
0.0
1980
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
0
2.0
Canada
1992
1000
Australia
1991
4.0
1990
2000
2007
6.0
3
4
CENTRAL GOVERNMENT
Minister of Health
20 DISTRICT HEALTH BOARDS
Buy with Service Agreements
Other Providers
Internal agreements
District Health Board provider arm
(for profit or not for profit private or community
ownership, voluntary, welfare)
• Public hospitals
• Some community services
• Private pharmacy, laboratory, & imaging
• Primary care – GPs, Allied Health, Midwives
• Assessment & rehabilitation
• Private hospital services
• Community services
• Disability support
• Mental health
Health and disability support services
Users of New Zealand health and disability support services
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.
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
Grado de satisfacción medica en el ejercicio de la
medicina
Satisfied
Percent*
Very satisfied
100
75
54
54
66
50
54
49
59
54
68
49
36
25
35
34
35
22
27
30
18
21
8
0
NZ
NOR
NET
UK
SWE
ITA
CAN
FR
15
12
US
AUS
5
GER
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Adultos que informan gozar de buena salud
(2007)
OECD Health Data 2009
Comparación internacional de esperanza de vida al nacer,
algunos países (2009 o último año disponible)
Country
Period
Life Expectancy at Birth
Total
Population
Male
Female
Switzerland
2009
82.3
79.9
84.6
Australia
2009
81.6
79.3
83.9
Sweden
2009
81.4
79.4
83.4
France
2009
81
77.7
84.4
Norway
2009
81
78.7
83.2
New Zealand
2009
80.8
78.8
82.7
Canada
2007
80.7
78.3
83
Netherlands
2009
80.6
78.5
82.7
United Kingdom
2009
80.4
78.3
82.5
Germany
2009
80.3
77.8
82.8
Denmark
2009
79
76.9
81.1
United States
2009
78.2
75.7
80.6
Source: OECD Health Data 2011
1 Estimate
Crecimiento de la esperanza de vida al nacer (1988-2008)
Years
7
Male
Female
8
6.6
6.1
5.7
6
5.6
5.6
5.3
5.3
5
5.2
5.0
4.7
4.7
4.2
4.4
4.3
4.0
4
3.8
4.3
3.9
3.8
3.4
3.4
3.3
3.2
2.7
3
2.1
2.1
2
1
0
NZ
AUS
GER
OECD
Median
FR
UK*
Source: OECD Health Data 2010 (Oct. 2010)
SWIZ
NOR
SWE
DEN
CAN*
NETH
US*
* 1987–2007
Prevalencia de la obesidad en población adulta (2009)
Percent
Measured
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.
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
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
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
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
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
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 undercoordination 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
22
Errores médicos, de medicamentos, o de laboratorio, en los
dos últimos años, con/sin “medical home”
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.
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
1
2
Condiciones crónicas y atención primaria
1. Prevention and early
intervention
Current smoking prevalence* among adults
(15+)
35
33
31
29
Percentage
Address broader determinants
housing/education/employment.
Four main risk factors:
• smoking – good progress
• diet
• exercise
• alcohol
27
25
23
21
19
•
•
•
•
•
use of guidelines
decision support tools
multi-disciplinary teams
self-management/health
literacy
health targets
* 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.
17
8
19 3
8
19 4
8
19 5
8
19 6
8
19 7
8
19 8
8
19 9
9
19 0
9
19 1
9
19 2
9
19 3
9
19 4
9
19 5
9
19 6
9
19 7
9
19 8
9
20 9
0
20 0
0
20 1
0
20 2
0
20 3
0
20 4
0
20 5
0
20 6
0
20 7
0
20 8
09
15
19
2. Early detection and good
management
Year
3
4
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
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
Gracias