Permeable boundaries? Patient perspectives on space and time in general practice waiting rooms.

This paper considers an under-examined space in primary health care - the reception area/waiting room. This space can be challenging to negotiate, particularly for those who experience social marginalisation. We begin by situating the significance of the 'entry into the health care setting' in the patient journey in terms of time as well as space. Through an analysis of interview and focus group data gathered in a New Zealand study, we highlight ways that patients view these spaces as firmly bounded and confronting. In reflecting on the data, we then identify the potential for these spaces to be more permeable. We conclude that this spatio-temporal context need not be one of constraint. Rather, there are ways in which the boundaries of this space can be potentially enabling to those required to pause in the process of enacting patienthood.

The care work of general practice receptionists.

INTRODUCTION The care work of general practice receptionists has received limited research attention, despite receptionists position at the beginning of patients' journeys in many health care systems. We examine receptionists' perceptions of their work and the opportunities and constraints they experience in caring for patients while providing administrative support to practices. METHODS Data were collected in focus group interviews with 32 receptionists from urban and rural general practices in the Auckland and Northland regions of New Zealand. We employed tools from inductive thematic analysis and Straussian grounded theory in interpreting the data. FINDINGS We found that the way receptionists identified with a caring role strongly challenged the pejorative view of them in public discourse. Receptionists provide care in two key ways: for the practice and for patients. The juggling they do between the demands of the practice and of patients creates considerable work tensions that are often invisible to other staff members. CONCLUSION Receptionists have a critical role as the first step in the patient care pathway, bridging health care system and community. For general practice to be patient-centred and improve accessibility for the most vulnerable, the care work of receptionists must be considered core. KEYWORDS Receptionists; general practice; care; New Zealand.

Identifying eHealth Opportunities to Support Medication Adherence - Findings of a Focus Group Study.

BACKGROUND: The burden of cardiovascular disease (CVD) among New Zealand (NZ) indigenous people (Maori) is well recognized. A major challenge to CVD risk management is to improve adherence to long-term medications. OBJECTIVES: To elicit patients' and providers' perspectives on how to support Maori with high CVD risk and low medication adherence to achieve better adherence. METHODS: Analysis of electronic health records (EHR) of four NZ general practices identified medication adherence status of Maori patients with high CVD risk (≥15%, 5-year). A random sample of these patients participated in focus group discussions on barriers to long-term medication adherence. Their primary care providers also participated in separate focus groups on the same topic. RESULTS: A range of factors are identified influencing adherence behaviour, including patient's medication knowledge, patient-doctor communication effectiveness and cost. CONCLUSION: Analysis of barriers to medication adherence in primary care suggests opportunities for health information technology to improve adherence, including patient education, decision support, clinician training and self-service facilities.

The place of receptionists in access to primary care: Challenges in the space between community and consultation.

At the point of entry to the health care system sit general practice receptionists (GPRs), a seldom studied employment group. The place of the receptionist involves both a location within the internal geography of the clinic and a position within the primary care team. Receptionists literally 'receive' those who phone or enter the clinic, and are a critical influence in their transformation from a 'person' to a 'patient'. This process occurs in a particular space: the 'waiting room'. We explore the waiting room and its dynamics in terms of 'acceptability', an under-examined aspect of access to primary care. We ask 'How do GPRs see their role with regard to patients with complex health and social needs, in light of the spatio-temporal constraints of their working environments?' We engaged receptionists as participants to explore perceptions of their roles and their workspaces, deriving narrative data from three focus groups involving 14 GPRs from 11 practices in the Northland region of New Zealand. The study employed an adapted form of grounded theory. Our findings indicate that GPRs are on the edge of the practice team, yet carry a complex role at the frontline, in the waiting space. They are de facto managers of this space; however, they have limited agency within general practice settings, due to the constraints imposed upon them by physical and organisational structures. The agency of GPRs is most evident in their ability to shape the social dynamics of the waiting space, and to frame the health care experience as positive for people whose usual experience is marginalisation. We conclude that, if well supported, receptionists have the potential to positively influence health care acceptability, and patients' access to care.

Cardiovascular disease risk management for Maori in New Zealand general practice.

INTRODUCTION: Maori are overrepresented in cardiovascular disease (CVD) mortality and morbidity statistics in New Zealand (NZ). AIM: To examine cardiovascular risk (CVR) assessment and management for Maori, utilising Caring Does Matter (CDM) initiative data. METHODS: Using 16 general practices' electronic medical records­which include ethnicity data­the rate of CVR screening, CVD medication treatment and adherence levels, and physiological measures for Maori patients at high CVR (≥15% five-year risk of a cardiovascular event) were compared to findings for Pacific and non-Maori/non-Pacific patients. RESULTS: Records for 72,351 adults (10,358 Maori; 14%) showed that Maori patients have a poorer CVR assessment rate (46% at guideline-indicated age) than Pacific and non-Maori/non-Pacific groups; when assessed, a greater proportion of Maori patients (38%) were at high CVR. The proportion of high-CVR Maori patients being treated with oral antidiabetic medication (42%) was lower than for Pacific patients but higher than for non-Maori/non-Pacific patients. Lower rates of antihypertensive adherence were found for high-CVR Maori patients than for non-Maori/non-Pacific patients (although higher than for Pacific patients). The high-CVR Maori patients who adhered to CVD medications had lower blood pressure, total-to-HDL cholesterol ratio and HbA1c than non-adherers. DISCUSSION: The association between higher medication adherence and better control of risk factors suggests that adherence should be further promoted by clinicians. More active CVR assessment, treatment and support of medication adherence in Maori attending general practices is justified, given their high mortality rate from CVD in comparison to the overall NZ population.

General practice ethnicity data: evaluation of a tool.

INTRODUCTION: There is evidence that the collection of ethnicity data in New Zealand primary care is variable and that data recording in practices does not always align with the procedures outlined in the Ethnicity Data Protocols for the Health and Disability Sector. In 2010, The Ministry of Health funded the development of a tool to audit the collection of ethnicity data in primary care. The aim of this study was to pilot the Ethnicity Data Audit Tool (EAT) in general practice. The goal was to evaluate the tool and identify recommendations for its improvement. METHODS: Eight general practices in the Waitemata District Health Board region participated in the EAT pilot. Feedback about the pilot process was gathered by questionnaires and interviews, to gain an understanding of practices' experiences in using the tool. Questionnaire and interview data were analysed using a simple analytical framework and a general inductive method. FINDINGS: General practice receptionists, practice managers and general practitioners participated in the pilot. Participants found the pilot process challenging but enlightening. The majority felt that the EAT was a useful quality improvement tool for handling patient ethnicity data. Larger practices were the most positive about the tool. CONCLUSION: The findings suggest that, with minor improvements to the toolkit, the EAT has the potential to lead to significant improvements in the quality of ethnicity data collection and recording in New Zealand general practices. Other system-level factors also need to be addressed.

Community participation in primary care: what does it mean 'in practice'?

INTRODUCTION: The New Zealand 2001 Primary Health Care Strategy requires primary health organisations (PHOs) to involve communities in their governance and be responsive to communities' needs. It is less clear what the implications of this policy are for general practices. This paper presents key findings from a national study undertaken in the wake of the 2001 primary care reforms on the purpose and process of involving communities in primary health care. METHODS: A three-part qualitative process was employed. Initially, key informant interviews were undertaken with a diverse range of primary care policy makers, funders, practitioners and community stakeholders (n=42). A draft framework for involving communities in primary care was developed, and formed the basis of a consultation phase (n=26). The framework was further developed and then piloted in four PHOs around New Zealand. FINDINGS: Views on community participation varied among different stakeholder groups in the sector. Most described it as a complex process of relationship-building over time, and one that is quite distinct from consumer feedback processes in general practice. For community representatives, it was a process of trust-building and information-sharing between communities and health professionals. These relationships enabled people to feel comfortable seeking care, and professionals to mould services to people's needs. CONCLUSION: This research highlights that community is much more than a setting of care. As citizens, members of disadvantaged communities are partners with general practices and PHOs, working with them to improve health equity by ensuring that services are responsive to their needs.

The health promotion shift into Primary Health Organisations: Implications for the health promotion workforce.

INTRODUCTION: Reconciling the primary care sector's traditional concern for individual health outcomes with a population health approach is integral to the implementation of New Zealand's Primary Health Care Strategy, and a key challenge for health promotion in New Zealand. The purpose of this study was to examine the views of health promoters, their funders and managers toward the implementation of the Primary Health Care Strategy's health promotion agenda. METHODS: Focus groups and interviews were carried out with 64 health promoters and 21 health sector managers and planners and funders over the 12 months beginning March 2008. Interview and focus group transcripts were analysed thematically. FINDINGS: Primary Health Organisations (PHOs) have been perceived as both an opportunity and a threat to health promotion. The opportunity was seen to lie in the development of health promotion responsive to the needs of communities. Yet the numerous PHOs that emerged spread funding and capacity for health promotion thin, particularly amongst smaller PHOs. CONCLUSION: The failure of the Ministry of Health to engage the health promotion workforce in the development and implementation of the Primary Health Care Strategy has led to a clear sense of vulnerability among health promoters. Ideological divisions between primary care and public health have been exacerbated by the restructuring of health promotion funding and delivery. Within non-governmental organisations and public health units concern continues to surround the legitimacy of health promotion approaches undertaken within the primary health care sector.

Educating public health physicians for the future: a current perspective from Aotearoa New Zealand.

Persisting, and in some cases widening, inequalities in health within and between countries present significant challenges to the focus and practice of contemporary public health, and by association, to public health education. As public health physicians and academic educators of medically- and non-medically trained public health practitioners, we call for a radical re-think of current approaches to public health medicine education and training in order to address these challenges. The public health physicians of the future, we argue, require not merely technical knowledge and skills but also a set of values that underpin a commitment to ethical principles, social equity, human rights, compassionate action, advocacy and leadership. Furthermore, while they will need to have their action firmly grounded in local realities they should think, if not speak and act, from an informed awareness of global issues. Drawing from our experience in Aotearoa New Zealand, as well as with marginalised communities overseas, we proffer our suggestions for the process and content of public health physician education and training for the future, with the intention of stimulating debate.

Putting population health into practice through primary health care.

The introduction of the Primary Health Care Strategy has offered opportunities to take a population health approach to the planning and delivery of primary health care. The lack of a common understanding of population health between primary care and public health has been the prompt for a group of academics and practitioners to join forces and produce this statement on a population health approach to primary care, through primary health care. This paper takes the position that the features of a population health approach (such as a concern for equity, community participation, teamwork and attention to the determinants of health) enhance general practice care rather than undermine it. We conclude that the contribution of the health sector towards population health goals can be achieved through collaboration between GPs, nurses, other primary health care workers, and communities, together with health promotion and public health practitioners. Finding common language and understanding is an important step towards improving that collaboration.

Assessing and developing community participation in primary health care in Aotearoa New Zealand: a national study.

AIMS: This study aimed to develop and test a framework and tool for assessing and developing community participation in Primary Health Organisations (PHOs) in New Zealand. METHODS: A qualitative study completed in three phases: semi-structured interviews with 42 key stakeholders in the primary care sector; development of and consultation on a draft toolkit, which included a PHO review process; and piloting the toolkit in four different types of PHOs. RESULTS: A toolkit entitled Community Participation: A Resource Kit and Self-Assessment Tool for PHOs (CP Toolkit for PHOs) was developed, which contains a set of resources for organisational self-review and a framework for community participation under the six headings: Organisational Structure, Maori Responsiveness, Governance and Management Processes, Use of Resources, Links to the Wider Community, and Consultation and Decision-Making. The pilot PHO sites found the CP Toolkit, and the review process contained within it, to be very relevant to the implementation of the Primary Health Care Strategy at a PHO level. CONCLUSIONS: The Community Participation Toolkit for PHOs complements existing quality tools available for clinical general practice and nursing, and supports the further development of primary health care in New Zealand.