From the editors: challenges and opportunities for sustainable and equitable primary care

In a thoughtful editorial, Professor Jenny Carryer recognises similarities between the aims of the current health reforms and the 2001 Primary Health Care Strategy.¹ The latter have not been achieved, and she doubts that these will be this time round either.² She fears that the many new roles for nurses will result in fragmentation, with an orientation on the provision of disease - rather than holistic person-focused care. Carryer joins a number of other commentators, including Mathieson et al.³ and Tenbensel⁴ in the previous issue of this Journal, expressing concerns about what Te Whatu Ora and Te Aka Whai Ora will deliver with respect to primary health care.

The capitation funding formulas of the primary health care strategy has failed to ensure equitable and sustainable primary care for all. A key issue for the new reforms to address is the funding of practices with high proportions of ‘high needs’ patients to ensure sustainability and provision of quality of care. Using the New Zealand Health Survey,⁵ Hau and colleagues have shown that ‘high needs’ patients are likely to suffer from multi-morbidity, require seven or more GP visits per year, and report barriers to access.⁶ On a very similar note, Dowell and colleagues have used routinely collected primary care data to demonstrate that health risk factors and co-morbidities are clustered in a small number of practices with many ‘high needs’ patients. Considerable challenges, but also opportunities, are afforded to general practice by both the COVID-19 pandemic and the health reforms.⁷ If general practice is to be sustainable, adequate models of care and resources are required to deal with these complex cases and address health inequities.

Te Pae Tata, the Interim New Zealand Health Plan recently released by Te Whatu Ora and Te Aka Whai Ora, identifies that primary and community healthcare requires creation of comprehensive and collaborative teams involving ‘aged care, midwifery, pharmacy, Whānau Ora, mental health, district nursing, allied health and primary care’.⁸ While a team-based integrated approach to community-based care is laudable, mention of general practice per se is completely absent in this document. If general practice workforce shortfalls and funding models to increase equity of access are not addressed, the provision of complex medical care in the community will not be sustainable.⁹

Several studies in this issue address maternal care. A qualitative study by Gauld and colleagues found that Māori women experienced barriers to uptake of maternal pertussis and influenza vaccinations, including sometimes being insufficiently informed by their healthcare providers of the benefits.¹⁰ Solutions include pharmacists assisting in raising awareness of maternal vaccinations and access, early engagement with midwives, and improving accessibility through funding transport. Jardine and others found that pregnant Māori women may experience barriers to engaging with a midwife and are hopeful that the online tool, Best Start Kōwae, will help reduce this equity gap.¹¹ Mobile phones and other digital platforms can deliver a range of health interventions such as smoking cessation and diabetes self-management, as well as maternal services, and have the potential to reduce health inequities between Māori and non-Māori. However, one of the barriers to uptake is having the means and time to enrol in the programme. Txtpēpi is a maternal and child health text-message programme to support māmā (mothers) and family (whānau) to care for their pēpi (babies). Dobson and colleagues found that changing the enrolment to opt-off reduced the sign-up burden, and was an acceptable way to make this low-risk service more accessible.¹²

Other research in this month’s issue looks at various interventions to improve diet or exercise in at-risk populations. The Raising Healthy Kids Health Target recommends that children with high Body Mass Index (BMI) identified in the Before School Check should be referred for assessment and intervention. The success of this intervention is measured by referral numbers. However, an audit conducted by Cave and colleagues has found that while referral rates have been high, actual uptake has been poor, and recommend that the focus should be on preschool children with obesity accessing the programmes.¹³ At the other end of the life spectrum, research of residents in aged care at risk or suffering from malnourishment has found that an oral nutrient supplement successfully increases their BMI and is an acceptable means of addressing malnourishment.¹⁴ Low rates of exercise is often an issue in patients suffering from obstructive sleep apnoea. A feasibility study of a three-arm trial found that either individual exercise prescriptions or personalised text messages were acceptable and feasible means to increasing physical activity in this population.¹⁵ Another vulnerable population are those with pre-diabetes, estimated to affect about a quarter of the adult population. Barthow explains that detecting and managing those with this condition, especially provision of lifestyle modification advice and active management of cardiovascular risk factors, is inequitable, with Māori and Pasifika poorly served. She recommends guidelines should provide targeted interventions, and again expresses concerns about the sustainability of service delivery in primary care.¹⁶

Dew and colleagues have conducted a qualitative study of people who experienced the death of a whānau (family) member during COVID-19 lockdown.¹⁷ Having their loved one die in lonely isolation complicated their bereavement process and prolonged their grief. For future reference, the authors advocate having a way within the rules and restrictions for whānau to able to say goodbye, and provision of bereavement support.

While New Zealand researchers are well served by the Integrated Data Infrastructure which allows linkage of national health, migration, education, justice and other datasets, this does not include primary care data. Pigden and colleagues propose that this is rectified by the national primary care research and surveillance network, and explore the challenges to this being established.¹⁸ Finally, from across the Tasman, a study by Bentley and colleagues finds that many early-career GPs undertake medical work, particularly medical education, in addition to standard clinical practice.¹⁹ It would be good to replicate this study in New Zealand, and this knowledge would help general practice workforce planning policy, yet another piece in the puzzle towards ensuring sustainability of general practice and primary care.

Felicity Goodyear-Smith and Tim Stokes are Editors in Chief of the Journal of Primary Health Care.