The concentration of complexity: case mix in New Zealand general practice and the sustainability of primary care
Anthony Dowell
1 * , Bryan Betty 2 , Chris Gellen 3 , Sean Hanna 4 , Chris Van Houtte 3 , Jayden MacRae 5 , Dipan Ranchhod 3 , Justine Thorpe 3
1 Department of Primary Health Care and General Practice, University of Otago, Wellington, New Zealand.
2 The Royal New Zealand College of General Practitioners, New Zealand.
3 Tū Ora Compass Health Primary Care Network.
4 Ora Toa Health Services, Porirua, New Zealand.
5 Datacraft Analytics.
Journal of Primary Health Care 14(4) 302-309 https://doi.org/10.1071/HC22087
Published: 13 October 2022
© 2022 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of The Royal New Zealand College of General Practitioners. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)
Abstract
Introduction: New Zealand general practice and primary care is currently facing significant challenges and opportunities following the impact of the coronavirus disease 2019 (COVID-19) pandemic and the introduction of health sector reform. For future sustainability, it is important to understand the workload associated with differing levels of patient case mix seen in general practice.
Aim: To assess levels of morbidity and concomitant levels of socio-economic deprivation among primary care practices within a large primary health organisation (PHO) and associated Māori provider network.
Methods: Routinely collected practice data from a PHO of 57 practices and a Māori provider (PHO) of five medical practices in the same geographical area were used to compare a number of population health indicators between practices that had a high proportion of high needs patients (HPHN) and practices with a low proportion of high needs patients (Non-HPHN).
Results: When practices in these PHOs are grouped in terms of ethnicity distribution and deprivation scores between the HPHN and Non-HPHN groups, there is significantly increased clustering of both long-term conditions and health outcome risk factors in the HPHN practices.
Discussion: In this study, population adverse health determinants and established co-morbidities are concentrated into the defined health provider grouping of HPHN practices. This ‘concentration of complexity’ raises questions about models of care and adequate resourcing for quality primary care in these settings. The findings also highlight the need to develop equitable and appropriate resourcing for all patients in primary care.
Keywords: case mix, clinical workload, complexity, equity, general practice, multi‐morbidity, primary care, risk factors.
References
[1] Health and Disability System Review ‐ Final Report ‐ Pūrongo Whakamutunga [Internet]. Wellington: HDSR; 2020. Available at https://systemreview.health.govt.nz/assets/Uploads/hdsr/health‐disability‐system‐review‐final‐report.pdf [accessed 22 September 2022][2] New Zealand Government. Major reforms will make healthcare accessible for all NZers. Wellington; 2021. Available at https://www.beehive.govt.nz/release/major‐reforms‐will‐make‐healthcare‐accessible‐all‐nzers [accessed 22 September 2022]
[3] Millar E, Stanley J, Gurney J, et al. Effect of multimorbidity on health service utilisation and health care experiences. J Prim Health Care 2018; 10 44–53.
| Effect of multimorbidity on health service utilisation and health care experiences.Crossref | GoogleScholarGoogle Scholar |
[4] Mercer SW, Zhou Y, Humphris GM, et al. Multimorbidity and socioeconomic deprivation in primary care consultations. Ann Fam Med 2018; 16 127–31.
| Multimorbidity and socioeconomic deprivation in primary care consultations.Crossref | GoogleScholarGoogle Scholar |
[5] Crampton P, Dowell A, Woodward A. Third sector primary care for vulnerable populations. Soc Sci Med 2001; 53 1491–502.
| Third sector primary care for vulnerable populations.Crossref | GoogleScholarGoogle Scholar |
[6] Marmot M. An inverse care law for our time. BMJ 2018; 362 k3216
| An inverse care law for our time.Crossref | GoogleScholarGoogle Scholar |
[7] Stirling AM, Wilson P, McConnachie A. Deprivation, psychological distress, and consultation length in general practice. Br J Gen Pract 2001; 51 456–60.
[8] Hart JT. The inverse care law. Lancet 1971; 297 405–12.
| The inverse care law.Crossref | GoogleScholarGoogle Scholar |
[9] Baird B, Charles A, Honeyman M, et al. Understanding pressures in general practice. London: King’s Fund; 2016.
[10] Hochman M, Asch SM. Disruptive models in primary care: caring for high-needs, high-cost populations. J Gen Intern Med 2017; 32 392–7.
| Disruptive models in primary care: caring for high-needs, high-cost populations.Crossref | GoogleScholarGoogle Scholar |
[11] Yarnall KSH, Pollak KI, Østbye T, et al. Primary care: is there enough time for prevention? Am J Public Health 2003; 93 635–41.
| Primary care: is there enough time for prevention?Crossref | GoogleScholarGoogle Scholar |
[12] Gopfert A, Deeny SR, Fisher R, et al. Primary care consultation length by deprivation and multimorbidity in England: an observational study using electronic patient records. Br J Gen Pract 2021; 71 e185–92.
| Primary care consultation length by deprivation and multimorbidity in England: an observational study using electronic patient records.Crossref | GoogleScholarGoogle Scholar |
[13] Wallar LE, De Prophetis E, Rosella LC. Socioeconomic inequalities in hospitalizations for chronic ambulatory care sensitive conditions: a systematic review of peer-reviewed literature, 1990–2018. Int J Equity Health 2020; 19 60
| Socioeconomic inequalities in hospitalizations for chronic ambulatory care sensitive conditions: a systematic review of peer-reviewed literature, 1990–2018.Crossref | GoogleScholarGoogle Scholar |
[14] Jackson G, Tobias M. Potentially avoidable hospitalisations in New Zealand, 1989–98. Aust N Z J Public Health 2001; 25 212–21.
| Potentially avoidable hospitalisations in New Zealand, 1989–98.Crossref | GoogleScholarGoogle Scholar |
[15] Harris R, Tobias M, Jeffreys M, et al. Effects of self-reported racial discrimination and deprivation on Māori health and inequalities in New Zealand: cross-sectional study. Lancet 2006; 367 2005–9.
| Effects of self-reported racial discrimination and deprivation on Māori health and inequalities in New Zealand: cross-sectional study.Crossref | GoogleScholarGoogle Scholar |
[16] Jones PG, Thornton V. Does cost drive primary care patients to New Zealand’s emergency departments? A systematic review. N Z Med J 2013; 126 15–24.
[17] Hobbs FDR, Bankhead C, Mukhtar T, et al. Clinical workload in UK primary care: a retrospective analysis of 100 million consultations in England, 2007–14. Lancet 2016; 387 2323–30.
| Clinical workload in UK primary care: a retrospective analysis of 100 million consultations in England, 2007–14.Crossref | GoogleScholarGoogle Scholar |
[18] Croxson CH, Ashdown HF, Hobbs FR. GPs’ perceptions of workload in England: a qualitative interview study. Br J Gen Pract 2017; 67 e138–47.
| GPs’ perceptions of workload in England: a qualitative interview study.Crossref | GoogleScholarGoogle Scholar |
[19] Gray B. The Cynefin framework: applying an understanding of complexity to medicine. J Prim Health Care 2017; 9 258–61.
| The Cynefin framework: applying an understanding of complexity to medicine.Crossref | GoogleScholarGoogle Scholar |
[20] Dowell AC, Menning L, MacDonald N, et al. An evolution in thinking to support the post 2020 global vaccine strategy: the application of complexity and implementation science. Vaccine 2019; 37 4236–40.
| An evolution in thinking to support the post 2020 global vaccine strategy: the application of complexity and implementation science.Crossref | GoogleScholarGoogle Scholar |
[21] Manning E, Gagnon M. The complex patient: a concept clarification. Nurs Health Sci 2017; 19 13–21.
| The complex patient: a concept clarification.Crossref | GoogleScholarGoogle Scholar |
[22] Fisher G. The complexity of severe and multiple disadvantage. London: Synthesis and Lankelly Chase; 2015.
[23] Lanham HJ, Leykum LK, Taylor BS, et al. How complexity science can inform scale-up and spread in health care: understanding the role of self-organization in variation across local contexts. Soc Sci Med 2013; 93 194–202.
| How complexity science can inform scale-up and spread in health care: understanding the role of self-organization in variation across local contexts.Crossref | GoogleScholarGoogle Scholar |
[24] Watkins JM, Mohr B. Appreciative inquiry: change at the speed of imagination. Organ Dev J 2001; 19 92
[25] Nelson P, Martindale A-M, McBride A, et al. Skill-mix change and the general practice workforce challenge. Br J Gen Pract 2018; 68 66–7.
| Skill-mix change and the general practice workforce challenge.Crossref | GoogleScholarGoogle Scholar |
[26] Pullon S, McKinlay E, Dew K. Primary health care in New Zealand: the impact of organisational factors on teamwork. Br J Gen Pract 2009; 59 191–7.
| Primary health care in New Zealand: the impact of organisational factors on teamwork.Crossref | GoogleScholarGoogle Scholar |
[27] Dowell A, Stubbe M, Macdonald L, et al. A longitudinal study of interactions between health professionals and people with newly diagnosed diabetes. Ann Fam Med 2018; 16 37–44.
| A longitudinal study of interactions between health professionals and people with newly diagnosed diabetes.Crossref | GoogleScholarGoogle Scholar |
[28] Crengle S. The development of Māori primary care services. Pac Health Dialog 2000; 7 48–53.
[29] Keating G, Jaine R. What supports are needed by New Zealand primary care to improve equity and quality? J Prim Health Care 2016; 8 312–5.
| What supports are needed by New Zealand primary care to improve equity and quality?Crossref | GoogleScholarGoogle Scholar |
[30] Naper J, Manetto L, Wiren D. A project to improve the quality of care for overweight and obese patients in a Nelson general practice. J Prim Health Care 2017; 9 321–7.
| A project to improve the quality of care for overweight and obese patients in a Nelson general practice.Crossref | GoogleScholarGoogle Scholar |
[31] Dalbeth N, Dowell T, Gerard C, et al. Gout in Aotearoa New Zealand: the equity crisis continues in plain sight. N Z Med J 2018; 131 8–12.
[32] Mercer SW, Fitzpatrick B, Gourlay G, et al. More time for complex consultations in a high-deprivation practice is associated with increased patient enablement. Br J Gen Pract 2007; 57 960–6.
| More time for complex consultations in a high-deprivation practice is associated with increased patient enablement.Crossref | GoogleScholarGoogle Scholar |
[33] Matheson D, Reidy J, Keenan R. Bringing primary health and community care in from the cold in the New Zealand health reforms? Tracing reform recommendations to budgets and structures. J Prim Health Care 2022;
