Primary health care: walking backwards into the future?

The Māori whakataukī (proverb) ka mua, ka muri is expressed in English as ‘walking backwards into the future,’ and mirrors Spanish philosopher George Santayana’s warning ‘those who cannot remember the past are condemned to repeat it’.¹ Heeding the lessons of the past when reconfiguring Aotearoa New Zealand’s (NZ) health system remains a pressing need. We will shortly be facing a general election with current opinion polls predicting a change of government, which would inevitably bring with it a change in primary health care policy.

Ka mua, ka muri is the theme of our guest editorial from Professor Sir Mason Durie.² He begins by highlighting that one of the key outcomes of the 2022 Labour government health reforms (Pae Ora Health Futures Act)³ was the establishment of Te Aka Whai Ora (Māori Health Authority) and Iwi Māori Partnership Boards. In doing so, the government signalled that Māori health is key to delivering health equity in NZ. Durie then goes on to chart the antecedents of Te Aka Whai Ora, beginning with Te Rangi Hīroa’s Māori Advisory Committee in 1920 and ending with the Waitangi Tribunal Health Services and Outcomes Inquiry (Wai 2575) set up in 2016 to hear all claims concerning grievances relating to health services and outcomes of national significance for Māori.⁴

Health care inequities for Māori remain prevalent. The need to address Māori (& Pacific) inequities in uptake of maternal vaccination against influenza and pertussis is addressed by Macredie and colleagues in their kaupapa Māori-aligned qualitative study.⁵ They interviewed Māori and Pacific hapū mama (pregnant mothers) and found that building and maintaining trust and giving mother’s time and autonomy to make a decision on being vaccinated was essential.

Chronic pain is commonly seen and managed in primary care and is a topic which features prominently in this issue. In an Australian study Shebeshi and colleagues⁶ looked at factors associated with the rate of general practitioner (GP) visits related to pain in patients with chronic pain, using data collected by adult specialist pain management services (SPMS). They found that more than half of these patients had greater than three GP visits in the 3 months before referral to SPMS, and that patients who used opioids were more likely to visit a GP than those who were not using opioids. The issue of the use of opioids in chronic pain in primary care, which is problematic, is further explored in a Canadian study. Lam and colleagues⁷ used qualitative methods (focus groups) to explore primary care provider perspectives on a modified routine opioid outcome monitoring (ROOM) tool used by community pharmacists. They found that the modified tool was reported as supporting collaboration between community pharmacists and primary care providers. Low back pain (LBP) specifically features in two papers. Tennant and colleagues⁸ addressed the issue of inappropriate spinal imaging for LBP. They found that in Australia most patients with LBP referred for surgical opinion have diagnostic radiological investigations regardless of whether these are indicated by clinical guidelines. They suggest that Australia would benefit from adopting NZ’s Accident Compensation Corporation (ACC)’s strategy of increasing GP access to subsidised magnetic resonance imaging when requested in accordance with clinical guidelines. The role of ACC in LBP is explored in a retrospective audit and descriptive analysis of ACC funded, non-public hospital healthcare service use by Hill and colleagues.⁹ They conclude that the cost of ACC-funded LBP health care services continues to increase despite ongoing attempts to reduce prevalence and the cost of managing symptoms.

Prescribing further features in this issue, in the context of polypharmacy and antimicrobial resistance. Polypharmacy is a particular challenge for older adults and Liu and colleagues⁹ have developed and validated PolyScan, an information technology triage tool, to identify potentially inappropriate prescribing in this population. Registered Nurse (RN) designated prescribers now have prescribing authority, but little is known about their antimicrobial stewardship role. Lim and colleagues¹⁰ explored this question using qualitative methods and found that RN designated nurse prescribers had an awareness of the importance of their antimicrobial stewardship role. RNs are well placed to implement approaches to reduce antimicrobial resistance, and the authors advocate for all nurses to receive education in this area.

The Waikato health region is the setting for two studies looking at quality of care. Becker and colleagues¹¹ cover otitis media with effusion in children and analysed referral rates to secondary care (otorhinolaryngology) over a 2 year period. Interestingly they found that both referral rates and tympanostomy and ventilation tube insertion rates were greater for Māori than for NZ European children, a finding they hypothesise has a number of potential explanations, including progress towards reducing inequities. Melanoma diagnosis and treatment is the focus of a clinical audit by Na and Oakley.¹² They found compliance against agreed melanoma (MelNet) quality statements was poor, notably in relation to hospital care, where there were long delays for treatment. A further study looked at improving the quality of care for big bodied patients receiving end of life care, through addressing the ‘one size fits all’ current approach to hospital gowns. Phillips and colleagues¹³ interviewed hospice staff on their views of gowns designed for big bodied patients and found they can potentially enhance the care and dignity for these patients as well as making it easier for staff to give respectful care. Moving on to this issue’s quality improvement report, Gu and colleagues¹⁴ reviewed clinical medical student case-based teaching material used in general practice teaching at the Otago Medical School (Dunedin). Their aim was to see if it was representative of the NZ population and whether there was potential for implicit bias. They found that cases typically represented majority population norms and conclude that representation of diversity, and hence cultural safety, can be improved though review and revision of written teaching cases.

Comprehensiveness is considered a core attribute of primary health care, but it lacks a consistent definition in the literature. Baughman and colleagues,¹⁵ from the American Board of Family Medicine Foundation, conducted a scoping review with the aim of unifying definitions of comprehensiveness. They found comprehensiveness consists of three interrelated aspects: whole-person care, range of services, and referral to specialty (secondary) care. Lastly, we have a Cochrane Corner which looks at whether it is worth spending extra for blue-light filtering glass in spectacles,¹⁶ and a Charms and Harms exploring the benefits and harms of the mushroom Ganoderma lucidum.¹⁷

Conflicts of interest

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