This case study describes how PHOcus on Health provided full management services for a PHO.
What you have to know about primary care on the West Coast:
- it has a sicker & poorer population on average than the rest of NZ
- there are huge geographical distances involved, & consequent isolation
- it has difficulties attracting & retaining health care professionals
- the DHB has stepped in as provider of last resort and owns/operates some practices
A rocky start
The West Coast PHO was one of the first half dozen established in New Zealand. Unusually, it was initially established by the DHB, before being ?handed over? to South Link Health Inc (SLH). SLH essentially had three roles: they provided the management services for the PHO, they supported the general practices in their traditional role as an IPA, and they were the ?appointing body? for the PHO?s Trustees. In this latter role, over time SLH implemented a model of governance incorporating good local representation from runanga, district councils, the Maori health provider and the PHO?s health professionals.
After four years of operation, the PHO had made little progress in implementing the Primary Health Care Strategy (at least as far as the DHB was concerned), with the West Coast public largely unaware of, and uninterested in, the PHO. There was little direct relationship or connection between the PHO Board and its practices, and the PHO had little in the way of local presence, resources or staffing.
Under pressure from the DHB over the PHO?s performance, the PHO board in 2005 issued an RFP for management services. PHOcus on Health responded with a proposal, and were successful in obtaining a three year contract. Initially, there was concern, particularly from private general practice owners, over the PHO Board opting for an outside organization, rather than continuing with SLH, an organization known to, and trusted by, the GPs.
Credibility gained through focusing on practice support
PHOcus on Health, because of its intimate knowledge of, and commitment to the importance of, general practice, quickly gained credibility with and the support of local general practices. GPs could see that the PHO was not going to become a threat to their businesses; if anything the PHO would be offering even more business & revenue opportunities to the practices than before, and certainly than many of them had expected.
PHOcus on Health, because of its equally unequivocal support for the PHO, its obvious commitment to the development of local capacity, and its lack of interest in building its own infrastructure, also quickly gained credibility with the DHB, leading to further business opportunities coming the way of the PHO and, therefore, to the PHO?s practices.
Different options for MSO arrangements
PHOcus on Health had offered the PHO two options for management services:
- supporting the PHO Board to employ their own CEO and develop their own capacity to administer the organization, with support from PHOcus on Health
- PHOcus on Health acting as and for the PHO, in a more traditional MSO type arrangement
The Board opted initially for the second approach, judging it was not yet ready for option 1. As a result, PHOcus on Health began recruiting a Manager and other staff, secured on office, opened a PHO bank account locally, and secured the services of a Greymouth-based accounting firm. The PHO grew from no staff at 1 Jan 06, to employ four staff by Sep 06, and nine by 30 Jun 07. Of the 9 staff at that point, one was involved in administration and the remaining eight were clinical/service delivery staff.
Focus on health outcomes
At the first strategic planning session run by PHOcus on Health in April 06, the PHO board adopted a half page statement of its purpose and priorities that unashamedly focused on improved health outcomes, and equity in those outcomes, as the organisation?s main goal. This provided good guidance for the development of the organization in its first year of operation, and particularly focused the PHO on establishing clinical programmes that would improve patient outcomes, rather than becoming too focused on the bureaucracy and systems of running a PHO. Clincial programs in place within the PHO by July 07 were:
- Chronic disease: Care Plus, diabetes annual reviews, retinal screening, diabetes pharmacy reviews, diabetes self management education groups, cardio vascular and diabetes risk assessments, cardiovascular annual reviews, practice based smoking cessation, Flinders self management
- Mental health ? assessments, training, advice and brief intervention
- Cancer navigation support services and palliative care
- Youth ? sexual health, confidential health advice team support
- Health promotion; training, men?s hui, community collaborative events, healthy lifestyle ambassador awards, youth health, breast feeding support, Performance Management Programme
To support practices with these initiatives the PHO has provided;
- funding for each practice to establish a Quality Improvement Committee
- detailed reports from Performance Management Programme
- a local professional development programme for all staff
- access to funds for conference / course leave
Health outcomes; equity in health outcomes; population health
The West Coast PHO has boundaries more or less contiguous with those of the West Coast DHB, the West Coast Regional Council, and the three District Councils that make-up the West Coast region: Westland in the south, Grey, and Buller in the north.
This means the PHO is able to use census data for the region as a denominator against which to measure its own enrolment and other data.
One of the first things a comparison of PHO data with census data led to was a realization that Maori appeared to be missing out on, and/or were not engaged with, the PHO?s services.
Maori were less likely to be enrolled in the PHO than their non-Maori neighbours. And those Maori who were enrolled, were less likely to attend the PHO?s medical centres ? whether for routine general practice care, or for any of the PHO?s various free or subsidized initiatives ? diabetes annual reviews and retinal screens, for example.
When this data was further broken down by district, it became apparent that Maori were also differentially engaged in the PHO in different sub-parts of the region. In the Westland District, where the local Maori health provider was based, and where the local medical centre had good relationship with that provider and had made a concerted effort to engage Maori, Maori were well engaged with the PHO. Conversely, in the district furthest away from Hokitika, over a third of Maori identified in the census, appeared to not be enrolled in the PHO.
This led to the PHO board approving a business case for the use of SIA funds, to employ a kaiawhina/kaihautu (community health work/navigator) to work with Maori and the medical centres in the Buller region to increase Maori enrolment, engagement, attendance and accessing of services & entitlements. The kaiawhina started in Feb 07.
Subsequent PHO enrolment data shows significant increases in Maori enrolment over the next few quarters. It is, as yet, too early (to expect) to see differences in health outcome measures for Maori as a result of this initiative.
Other initiatives around inequalities that the PHO has implemented include using the HEAT assessment tool for all new clinical programmes and funding practices to audit the charts of enrolled Maori patients to ensure that they have been offered all the services and programs to which they are entitled.
A shift to greater local control
At the second strategic planning session in early 2007 the Board made the strategic decision to move towards taking on more responsibility for their own operations & administration. The first step in this shift was the recruitment of a CEO, who would be employed directly by the PHO, rather than by PHOcus on Health.
A CEO was recruited and commenced in Aug 07. At the same time, a move to larger office premises was made, as the organization continued to grow. By Sep 07, the PHO employed 16 staff (3 administration, 13 clinical/service delivery). Staff who had previously been employed by PHOcus on Health moved to become employees of the PHO, with PHOcus on Health thereby being able to step back from direct involvement in, and responsibility for, the day to day administration of the PHO.
PHOcus on Health's role then focused on supporting the CEO and Board at a strategic level.
Subsequently, in late 2009, when the CEO resigned, PHOcus on Health was asked to help out again. This morphed into an arrangement in which PHOcus on Health was contracted to provide its own staff as Chief Executive of the PHO. Succession planning was undertaken as part of this role and, in March 2013, Helen Reriti, the PHO's then Clinical Manager and 2ic, stepped up into the Executive Officer role, with PHOcus on Health again reverting to a support role to the local leadership.