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 ($14.4b) 81% Out of pocket 14% Private insurance 5% Vote Health has been growing faster than GDP over recent years. We spend a similar proportion of GDP on health as other OECD countries, however our per capita spending is lower than many.
8000 7000 6000 5000 4000 3000 2000 1000 Comparación Internacional del Gasto en Salud 1980 2010 Average spending on health per capita ($US PPP) Total expenditures on health as percent of GDP Australia Canada Denmark France Germany Netherlands New Zealand Norway Sweden Switzerland United Kingdom United States 18.0 16.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0 0 1 2 3 4 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Australia New Zealand Norway United Kingdom United States Canada Denmark France Germany Netherlands Sweden Switzerland Source OECD Health Data 2011
CENTRAL GOVERNMENT Minister of Health Buy with Service Agreements 20 DISTRICT HEALTH BOARDS 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 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 Percent* 100 Satisfied Very satisfied 75 50 25 0 54 54 66 54 49 59 54 68 49 36 34 35 35 22 27 30 18 21 15 8 12 5 NZ NOR NET UK SWE ITA CAN FR US AUS 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 Source: OECD Health Data 2011 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 1 Estimate
Crecimiento de la esperanza de vida al nacer (1988-2008) Years 8 Female Male 7 6.6 6 5 4 3 2 4.7 4.2 6.1 4.3 5.7 4.0 5.6 3.8 5.3 3.8 5.3 3.4 5.6 3.4 5.2 3.3 5.0 3.2 4.4 2.7 4.7 2.1 4.3 2.1 3.9 1 0 NZ AUS GER OECD Median FR UK* SWIZ NOR SWE DEN CAN* NETH US* Source: OECD Health Data 2010 (Oct. 2010) * 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? Prevent hospital admissions yes it can 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 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 * 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. Percentage 35 33 31 29 27 25 23 21 19 17 15 Current smoking prevalence* among adults (15+) 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 Year 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
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