This issue of the NZMJ reports the experience of Counties Manukau District Health Board (CMDHB) in implementing a series of integrated care projects. However, the papers published today really represent the culmination of a process that started five years ago, when key individuals decided to adopt a systems approach to the imminent crisis facing healthcare in South Auckland. We tend to use words like “crisis” so often that they have become devalued. But there is no other way to describe an annual growth in secondary care utilisation of 9% over a 10-year period, when the population, albeit the fastest growing in New Zealand and one of the poorest, is experiencing growth of only 2% per annum.

If the increase in secondary care utilisation in Counties Manukau had continued, a new secondary care facility costing $400M would have been required within five years. Patient care, especially in winter, was already being compromised, and patient and staff satisfaction were declining. Many admissions to secondary care could have been avoided by enhanced and more timely primary care. The health status of the Counties Manukau population, particularly that of Maori and Pacific people, was unacceptably worse than that of the general population.

The key features of CMDHB’s response are described in the first paper of this issue by David Clarke et al.1 The approach taken was one of systems analysis. Independent advice was sought from international health systems experts, and recognised leaders in integrated care and disease management were visited. A clear description of the shortcomings of healthcare provision in South Auckland was compiled. Broad consultation was undertaken and a strategic plan developed.

These steps had been taken before, and almost read like a page from Sir Humphry’s memoirs, however the next step was somewhat unusual. Rather than launch into the traditional rounds of planning, refining, and interminable meetings that so often ensue the establishment of some good principles, CMDHB adopted a blitzkrieg approach. A large number of different integrated care projects were immediately funded, implemented and evaluated. New primary care facilities were funded for Maori and Pacific people. Significant management resource was devoted to making sure the DHB monitored projects closely. Monthly reporting was required from all projects. Most importantly, if a project was not performing it was terminated or stopped, and resources reallocated.

Auckland Uniservices and CBG Health Research Group were contracted to evaluate 21 of the projects. At the end of the first year of evaluation, three projects stood out – Primary Options for Acute Care (POAC), Diabetes Chronic Disease Management, and Congestive Heart Failure Chronic Disease Management. These projects were well received by patients and providers, and looked like producing a strongly positive return on investment.

Many other smaller projects, not reported in this issue, have also had a significant impact, improving primary/secondary care integration and slowing growth in demand for hospital services. A dyspepsia project run in the ProCare IPA radically improved the quality of referrals, and reduced the number of inappropriate gastroscopies. Research into growth in emergency department attendances suggested strategies for encouraging better use of GP services. Other projects have developed innovative systems for monitoring care. A well child project established the feasibility of using an electronically updated immunization register to track children who are not immunized.

Sophisticated IT systems have been a critical supporting feature of many projects. Counties Manukau invested a lot of time and money in setting up this infrastructure. However, integrating hospital and general practice systems has been difficult at times, due to a lack of incentive for Practice Management Systems (PMS) vendors to provide the necessary functionality. Communications protocols and messaging systems needed to be established as a result.

The problem of integrating hospital and general practice systems is a recurring theme in integrated care. The Hepatitis B Screening Programme experienced significant delays because PMS vendors were slow to provide necessary modifications. A useful advance would be the agreement of formats and variable names for all systems, so that a single set of interfaces can handle all GP systems. Unfortunately, there appears to have been little real progress on implementing the WAVE recommendations. This remains a major barrier to improving integrated care. Sooner rather than later, the Ministry of Health needs to adopt a policy of “no comply, no pay” on the provision of National Health Index on all transactions. There is no reason why the New Zealand Medical Council cannot immediately form the basis of a national provider index, which is crucial in determining clinical responsibility.

It is always prudent to be cautious when predicting the future based on what is in effect a single data point. In addition, the Hawthorne effect is very powerful, perhaps especially so with regards to general practitioners who appear to be relishing the opportunity to take over expanded roles and greater resources. The results to date from these CMDHB projects are promising, but are not yet proven to be sustainable, or even generalisable. The unique circumstances of CMDHB may well have been responsible for the impact of the initiatives. The POAC project was based on a similar project in Canterbury; a subsequent pilot in Waitemata has been less obviously successful.

However, at this point in time, the combined impact of all the measures detailed in this issue is best reflected by acute admissions data from Middlemore Hospital. After 10 years of sustained annual 9% growth, last year the growth in admissions was zero. That result is unlikely to be a statistical aberration.

Author information: Barry Gribben, Senior Research Fellow, Department of General Practice and Primary Health Care, University of Auckland, Auckland

Correspondence: Dr Barry Gribben, Department of General Practice and Primary Health Care, University of Auckland, Private Bag 92019, Auckland. Fax: (09) 373 7006; email: barry.gribben@cbg.co.nz