Nz General Practice

Transcript

Your guide to New Zealand general practice 1 Acknowledgements Thank you to Martin London for the work he has contributed to this resource. Compiled originally by Lynn Saul and reviewed by Dr Sue Crengle, Shahrazad Abdul-Ridha, Ian St George, Iain Hague, Sue Hancock, Joe Scott-Jones and Dene Egglestone. Revised in 2005. Cover Photo: Lawrence Smith/PhotoNewZealand.com Version 3, July 2005 Published by The Royal New Zealand College of General Practitioners, New Zealand, 2005. ISBN: 0-9582429-1-7 © The Royal New Zealand College of General Practitioners, New Zealand, 2005. The Royal New Zealand College of General Practitioners owns the copyright of this work and has exclusive rights in accordance with the Copyright Act 1994. In particular, prior written permission must be obtained from the Royal New Zealand College of General Practitioners for others (including business entities) to: • • • • copy the work issue copies of the work, whether by sale or otherwise show the work in public make an adaptation of the work as defined by the Copyright Act 1994. 2 Contents Introduction .............................................................................. 4 Section 1 Requirements to work in New Zealand as a general practitioner ........................................................... 6 Section 2 General practice overview ....................................................... 15 Professional development ........................................................ 20 Doctor/patient relationship ...................................................... 24 Section 3 Health of New Zealanders ....................................................... 29 Health care sector overview ..................................................... 35 Regulatory requirements .......................................................... 39 Orientation to general practice ................................................ 45 Practice orientation ................................................................. 58 Appendices Appendix 1: Subsidies ............................................................. 66 Appendix 2: Glossary .............................................................. 69 References ......................................................................... 70 3 Introduction Intending immigrant family doctors or general practitioners (GPs) overseas who may be considering New Zealand as an option may find it difficult to access advice or information on how to get started in New Zealand general practice. The Royal New Zealand College of General Practitioners has brought together in this resource the sort of information you will need. We intend it to be a living document, and it will be updated as the sector changes or regulatory requirements alter. The College provides advocacy and support for general practice and practitioners, delivering post-graduate education, professional development and quality tools – all aimed at supporting and strengthening our members’ practice. We set out in this resource first, the requirements you will need to work as a GP in New Zealand. Second, a general practice overview includes the sort of professional development a GP is expected to maintain, and what is expected in this country of the doctor/patient relationship. Third, the New Zealand health environment, with detail on how the sector is structured, including the regulatory requirements that face each GP Finally, templates which you may use when . your planning becomes more detailed. These offer questions you will need answered. 4 The Medical Council of New Zealand provides resources that cover important information for doctors. If you do not already have a copy, we suggest you contact the Medical Council to obtain a copy of: • Cole’s medical practice in New Zealand (2005) • Good medical practice. 5 SECTION 1 Requirements to work in New Zealand as a general practitioner Work in the medical profession is covered by legislation entitled “The Health Practitioners Competence Assurance Act 2003.” This determines the registration and scope of practice of a general practitioner. To work in New Zealand as a general practitioner you will need: 1. 2. 3. 4. Medical registration Confirmed job offer Work permit Either work with a practice as part of a Primary Health Organisation (PHO), or a Section 88 notice entitling payment of subsidies for some patients. Under the legislation, the Medical Council of New Zealand is the authority that determines the scope of practice and the registration of general practitioners. The College advises you to contact the Medical Council for information on this as soon as possible. 6 Medical Council of New Zealand Level 12 Mid City Tower 139–143 Willis St P O Box 11 649 Wellington Website: www.mcnz.org.nz Email: If this is your first enquiry, [email protected] : Enquiry regarding current application, [email protected] Tel: +64-4-384 7635 The Medical Council has specified three broad scopes of practice in which general practitioners may be registered. • • • General scope of practice Vocational scope of practice Special purpose scope of practice. Particular conditions may also be placed on these differing types of registration. Which one is right for you will depend on a number of factors, including: • • • Whether you intend to reside permanently in New Zealand Where you trained and qualified as a doctor What experience and/or training you have in general practice and in which country that experience and training was obtained General scope of practice A medical practioner registered within a general scope of practice is authorised to work within the Council’s definition of “the practice of 7 medicine”, but must work within a collegial relationship and also ensure appropriate continuing professional development takes place. Provisional general scope of practice This requires the medical practioner to work in a position approved by the Council for a minimum of 12 months under the supervision of an approved registered medical practitioner, in which time the medical practitioner must complete the Council’s requirements for registration within a general scope. Vocational scope of practice A medical practitioner registered with a vocational scope of general practice works within that scope as defined by the Medical Council (“General practice is an academic and scientific discipline with its own educational content, research, evidence base and clinical activity, and a clinical specialty oriented to primary care. It is personal, family and community oriented primary care that includes diagnosis, continues over time, is anticipatory as well as responsive”), has the qualifications, training and experience to obtain Fellowship of the Royal New Zealand College of General Practioners (FRNZCGP) and must participate in an approved Continuing Professional Development (CPD) programme to maintain competence. Provisional vocational scope of practice A medical practitioner applying for registration within a vocational scope of practice must, if not registered within a general scope, work under supervision for a minimum of 12 months, and during this period complete the requirements for registration with a vocational scope. 8 Special purpose scope of practice Medical practitioners who are in New Zealand for defined or limited reasons, including teaching, sponsored training, research, working as a locum tenens for up to six months, or assisting in an emergency or other unpredictable, short-term situation, will be registered within a special purpose scope. This scope does not lead to permanent registration. The practitioner must work under supervision, and the Council must approve the institution where the practitioner works. Qualifications The Medical Council has prescribed in detail the qualifications for the various scopes; the recognised academic institutions, and the necessary training and experience for registration. There may also be a requirement for an English language test. The full description of the scopes and the details of the qualifications are obtainable from the Medical Council, and are laid out in the New Zealand Gazette No 120 of 15 September 2004, pages 2920 to 2928. All medical practitioners must also hold an Annual Practicing Certificate (APC) issued by the Medical Council. These registration requirements came into effect on 18 September 2004, and there are some transitional provisions that apply until 19 September 2006 for some practitioners who held registration under the now repealed Medical Practitioners Act 1995 at the time the new requirements came into effect. Work Permit After a confirmed job offer has been obtained, a practitioner must obtain a work permit from the New Zealand Immigration Service, which will also require evidence of medical registration. The Immigration Service 9 has branches in New Zealand and around the world. Medical practitioners are on a priority list for immigration into New Zealand to address longterm skill shortages. For questions, including assistance with locating a branch nearest to you, call the National Contact centre on: • 914 4100 for callers with the Auckland toll-free region • 0508 558 855 for callers outside the Auckland toll-free region. The immigration website (www.immigration.govt.nz) provides comprehensive information and will help locate the branch nearest to you. Confirmed job offer The confirmed job offer must meet Medical Council requirements for supervision and collegial relationships. Most vacancies for GPs in New Zealand are advertised in at least one of the following two medical publications. You may also wish to place your own advertisement. The New Zealand Medical Journal New Zealand Medical Association P O Box 156 Wellington Tel: +64-4-472 4741 Fax: +64-4-471 0838 Email: [email protected] Website: www.nzma.org.nz New Zealand Doctor CMPMedica (NZ) Ltd P O Box 31-348 Auckland 1330 Tel: +64-9-488 4266 10 Fax: +64-9-488 4284 Email: [email protected] Website: www.nzdoctor.co.nz Locum employment New Zealand has two Government-funded rural locum schemes: Northern Rural General Practice Consortium (covers north of Warkworth) P O Box 57 Kerikeri 0470 Tel: +64-9-407 3561 Fax: +64-9-407 3571 Email: [email protected] Website: www.ruraldocs.co.nz NZ Rural GP Network (covers Warkworth south) P O Box 547 Wellington Tel: +64-4-472 3901 Fax: +64-4-472 0904 Email: [email protected] Website: www.nzlocums.com.nz There are a large number of non-government recruitment agencies; a few of these are listed below: Auckland Medical Bureau P O Box 37-753 Parnell Auckland 11 Tel: +64-9-377 5903 Fax: +64-9-377 5902 Email: [email protected] Website: www.doctorjobs.co.nz Geneva Health International Level 2 137 Quay Street P O Box 106339 Auckland Tel: +64-9-916 0200 Fax: +64-9-916 0201 Email: [email protected] Website: www.genevahealth.com Gold Standard Locums P O Box 487 Cambridge Tel: +64-7-823 4607 Fax: +64-7-823 4608 Email: [email protected] Website: www.locums.co.nz KIWIS Stat Unit 1, 88 Hayton Road Christchurch Tel: +64-3-339 0335 Fax: +64-3-339 0598 Email: [email protected] 12 The Canterbury Medical Locums Association Medlab South Christchurch Tel: +64-3-363 0824 Fax: +64-3-363 0803 Locum List Practice Manager, Dunedin Urgent Doctors and Accident Centre Tel: +64-3-479 2900 Fax: +64-3-477 0194 Email: [email protected] Section 88 General practitioners working outside the Primary Health Organisations (see page 36) are required to hold a Section 88 notice to qualify for subsidies. These are generally geographically restricted and new section 88s are only allocated in areas where there is an undersupply of doctors. The section 88s are being rapidly phased out however as the overwhelming majority of patients will be treated in PHOs where there is capitation paid quarterly for the patient population enrolled with that PHO. 13 SECTION 2 General practice overview What services do GPs provide? In New Zealand general practitioners provide primary, communitybased, comprehensive and continuing patient-centred care to individuals, families or whanau and their community, hapu and iwi. Functions of general practice include: first contact, diagnosis, management, continuity of care, health promotion, prevention and screening. GPs act as gatekeepers, as access to public secondary and tertiary services requires referral by a GP Many private specialists also . only see patients referred by a GP . General practices are normally involved in the provision of 24-hour cover for their population. Provision for after hours cover is provided in a variety of ways. For example, some practices run their own after hours care, while others are members of an after hours centre or roster after hour care with other practices. What is the work environment? Many general practices run as private businesses but organisations such as community trusts, accident and emergency services, or Maori health providers employ GPs. 14 In New Zealand, general practices function as teams. Most general practices employ practice nurses and reception staff and a growing number employ practice managers. Practice nurses play an important role, providing health advice and services such as immunisation, screening, diet, diabetes and asthma care. Other staff such as psychologists, social workers, physiotherapists may work in, or be associated with, practices. Who pays for general practice visits? Most practices are in Primary Health Organisations (PHOs, see page 36) and receive funding based on their enrolled population. Those practices who provide care for populations with a high percentage of Maori, Pacific and lower socio-economic groups receive increased funding and are able to provide consultations at a lower cost to all their patients. This provision also applies to 65-year-olds and older, to under six-year-olds, and is being extended to other age groups by 2007. Almost 95 per cent of the population were enrolled in 79 PHOs by 2005. A few practices continue to be funded on a fee-for-service basis, where patients are charged a fee for each consultation, reduced if applicable by a subsidy from the government (see Appendix 1). In addition, some patients carry health insurance, which may include a refund for GP visits, but the majority have cover only for specialist or surgical services. Where the insurance covers GP visits, the full fee is charged and the patient makes a claim to their insurer. Self-employed GPs set their own fees for consultations and other services, although under new funding arrangements there may be a cap to the amount charged. Practitioners’ fees vary depending on the way 15 they are funded, their population, the cost of operating the practice (rents etc.), factors relating to the consultation such as the time and complexity of the consultation and the circumstances of the patient. It is best to check with the practice where you will be working. Referred services Most laboratory tests and x-rays are free to the patient, but may be associated with a budget held by the practice; check with your practice for details. Private radiology clinics charge for all tests undertaken, unless they have been contracted to provide them by a local District Health Board. Medicines Some medicines are subsidised in New Zealand. PHARMAC (www.pharmac.co.nz), a government organisation, specifies which medicines will be subsidised; these are listed in the pharmaceutical schedule. Where there is more than one medicine with similar effects, the Government may subsidise only one brand (for more detailed information see Appendix 1). Computerisation Almost all practices in New Zealand are computerised to some extent. Some have only reception activities such as an age/sex register, daily log, and accounts on a computer, but increasingly practices have fully integrated clinical notes, integrated lab results and clinic letters, and email and internet access. There are a number of patient management systems (PMS) in use for example MedTech, Houston and Profile. 16 General practice workforce As of March 2003, 2324 doctors reported their main work place as general practice, this is 37 per cent of the medical workforce.2 A considerable proportion of the New Zealand general practice workforce was trained overseas; The Medical Council vocational register at March 2003 showed that of a total of 13,094 medical practitioners in all vocations 5270, or 40 per cent obtained their primary medical qualification overseas. New Zealand has an average of 1150 patients per doctor. However there is considerable variation between rural (1488 per doctor) and urban regions (1093 per doctor).2 As these figures suggest, New Zealand has a shortage of GPs in rural areas and also in the more deprived urban areas. The Medical Council workforce report can be found on its website: www.mcnz.org.nz. The Health Workforce Advisory committee provides information to the Minister of Health on workforce issues. Its website provides some informative reports: www.hwac.govt.nz. Medico legal environment The Accident Compensation Corporation (ACC) (www.acc.co.nz) provides compensation for personal injuries to all people in New Zealand and removes the right to sue for personal injury (other than for exemplary damages); this includes treatment injury. This system is reflected in the cost of medical indemnity premiums in New Zealand, which are considerably lower than in other countries such as Australia. Medical indemnity insurance, or malpractice insurance, is not compulsory for the self-employed, but it is strongly recommended. 17 Medical indemnity insurance is provided by: The Medical Protection Society Website: www.mps.org.uk Tel: 0800 225 5677 Despite this protection from being sued, there are still a number of investigations to which a GP can be subject, such as from the Health and Disability Commissioner, or a coroner. For further information contact the RNZCGP or the Medical Protection Society on the 0800 number above. 18 Professional development The legal framework for general practitioners is the Health Practitioners Competence Assurance Act, whose primary purpose is to ensure that all medical practitioners are competent to practise medicine. The Medical Council has set up a number of processes to implement this provision. All doctors throughout their career must be involved in continuing education, quality improvement activities and audit. See the Medical Council website (www.mcnz.org.nz) for more information on requirements. Contact the College or your local independent practitioners’ association to find out about CME programmes and what is available in your area. The Royal New Zealand College of General Practitioners The College (www.rnzcgp.org.nz) is a membership-based organisation; its current membership is around 3500, covering about 95% of New Zealand’s GPs. We provide advocacy and support for general practice and practitioners, delivering postgraduate education, professional development and quality tools – all aimed at supporting and strengthening general practice. The College provides educational programmes that focus on rural general practice for undergraduates, and a two-stage General Prac- 19 tice Education Programme (GPEP). The Stage One programme includes both a 40-week course for registrars and a seminar programme, each aimed at preparing candidates for the College’s Primary Membership Examination (Primex). The exam has both written and practical components, and once passed candidates have achieved Membership of the College. The Stage Two Advanced Vocational Education (AVE) programme leads to Fellowship of the College and enables the GP to apply to the Medical Council for registration within the vocational scope of general practice. This entitles doctors to practise in general practice without supervision. Currently this pathway for general practice registration is the only pathway recognised by the Medical Council. The diagram below describes the preferred pathway to Fellowship. A number of other options are also available. Educational Pathway to Fellowship and Vocational Registration Postgraduate years Hospital based training General Practice Education Programme (GPEP) Maintainance of Professional Standards (MOPS) Rural general practice rotation option STAGE I Practice Education Programme and Seminar Programme Option PRIMEX Examination STAGE II Advanced Assessment Visit General Vocational MRNZCGP FRNZCGP Education 3 year cycle Registration within the Vocational Scope of General Practice 20 Doctors who are registered within the vocational scope of general practice are required by the Medical Council to undertake a Maintenance of Professional Standards Programme (MOPS); the College provides a MOPS programme for its members, currently the only programme for GPs which is recognised by the Medical Council. The College maintains a national network of continuing medical education providers. These organisations have agreed to run GP focused education that meets the criteria for high quality. Practice accreditation The College has a practice accreditation programme, Cornerstone, whereby practice teams assess themselves against general practice standards set out in the College publication Aiming for Excellence. Teams of trained independent assessors – GPs, nurses and practice managers – check the assessment findings, aiming at achieving the optimum patient care in every practice. GPs also earn MOPS credits going through the process. Full details are available from the College. Independent Practitioner Associations Since 1993 the majority of general practitioners have organised themselves into groups called Independent Practitioner Associations (IPAs). IPAs provide a range of management and support services for their members such as continuing medical education, quality improvement activities and information technology support. Some are also linked to Primary Health Organisations. New Zealand Guidelines Group (NZGG) The New Zealand Guidelines Group provides training on developing guidelines and manages the production of many NZ clinical 21 guidelines. Clinical guidelines are produced to help doctors and patients make decisions about health care in specific clinical circumstances. The NZGG also maintains a website containing its own and other New Zealand guidelines, and provides links to overseas sites: www.nzgg.org.nz Medical Journals The key publications for GPs in NZ are: New Zealand Family Physician: journal of the Royal New Zealand College of General Practitioners, tel: +64-4-496 5972. GP Pulse: current affairs magazine of RNZCGP tel: +64-4-496 5962 , New Zealand Medical Journal: journal of the New Zealand Medical Association, tel: +64-4-472 4741. New Zealand Doctor: fortnightly newspaper produced by CMPMedica, tel: +64-9-488 4279. 22 Doctor/patient relationship Patient-centred care Good general practice in New Zealand is based on patient-centred practice. In using patient-centred approaches the doctor moves beyond the pathophysiology of disease and explores the biological, psychological and social components of their patients’ illnesses. Patient-centredness does not diminish the importance of biomedicine, but assumes biomedical expertise and builds from it. The patient-centred method consists of six interactive components:3 1. Exploring both the disease and the illness experience: this involves the GP understanding two conceptualisations of ill health: disease and illness.* 2. Understanding the whole person: over time accumulating an understanding of the whole person to enable the un* ‘Disease’ which relies on signs and symptoms to detect abnormalities of structure or function and to make a diagnosis. ‘Illness’ which is the patient’s individual experience of ill health. It focuses on their feelings about being ill, ideas about what is wrong, the effect of their problems on their function and their expectations of what should be done. Effective patient-centred care requires attending as much to the patient’s personal experiences of illness as their disease. 23 derstanding of illness in terms of their life setting and stage of development. 3. Finding common ground: requires working with the patient to develop an effective management plan by reaching agreement about the nature of the problem and priorities, the goals of treatment and the roles of the patient and doctor. 4. Incorporating prevention and health promotion: working together to identify areas of lifestyle etc. that need strengthening in the interests of long-term physical and mental health. Also monitoring recognised problems and screening for unrecognised disease. 5. Enhancing the patient-doctor relationship: building effective relationships which encourage working together and can assist in healing. 6. Being realistic: learning to manage time and energy efficiently for the maximum benefit of patients. FIFE The acronym FIFE4 provides a guide to undertaking a patient-centred assessment. F: Feelings “Do you have any fears and concerns I should know about?” I: Ideas “What do you think this pain means?” F: Function “How does this illness affect your daily activities?” E: Expectations “What is your expectation of this consultation?” The New Zealand Medical Association Code of Ethics These principles of ethical behaviour are applicable to all doctors, including those who may not be engaged directly in clinical practice. 24 1. 2. 3. 4. 5. Consider the health and well-being of your patient to be your first priority. Respect the rights of the patient. Respect the patient’s autonomy and freedom of choice. Avoid exploiting the patient in any manner. Protect the patient’s private information throughout his/her lifetime and following death, unless there are overriding public interest considerations at stake, or a patient’s own safety requires a breach of confidentiality. 6. 7. 8. 9. Strive to improve your knowledge and skill so that the best possible advice and treatment can be afforded to your patient. Adhere to the scientific basis for medical practice while acknowledging the limits of current knowledge. Honour your profession and its traditions in the ways that best serve the interests of the patient. Recognise your own limitations and the special skills of others in the prevention and treatment of disease. 10. Accept a responsibility for assisting in the allocation of limited resources to maximise medical benefit across the community. 11. Accept a responsibility for advocating for adequate resourcing of medical services. www.nzma.org.nz/about/ethics.html Boundary issues Boundary issues are very important in general practice, in particular in rural communities where many patients will be your friends or acquaintances. There is a need to set clear boundaries clarifying what is acceptable to you and your profession. How you manage 25 boundaries will depend on the situation, the people involved and your own style. Some ways of maintaining boundaries include:5 • • • • • • • Asking only relevant personal details when taking a medical history. Explaining sensitive examinations or treatment before carrying them out. Keeping discussions and records confidential. Providing privacy with screens for undressing, draping or dressing. Checking if the patient wants a chaperone or support person present. Avoiding words, actions or jokes that are sexual put downs or are embarrassing. The doctor keeping own personal problems private. The Medical Council provides clear guidance on sexual relationships between a doctor and patient. Medical Council statement on sexual abuse in the doctor/patient relationship Sexual behaviour in a professional context is abusive. Sexual behaviour comprises any words or actions designed or intended to arouse or gratify sexual desires. The doctor must ensure that every interaction with a patient is conducted in a sensitive and appropriate manner, with full information and consent. The Council condemns all forms of sexual abuse in the doctor/patient relationship for the following reasons: • The ethical doctor/patient relationship depends upon the doctor creating an environment of mutual respect and trust in which the patient can have confidence and safety. 26 • The onus is on the doctor to behave in a professional manner. Total integrity of doctors is the proper expectation of the community and of the profession. • The community must be confident that personal boundaries will be maintained and that as patients they will not be at risk. It is not acceptable to blame the patient for the sexual misconduct. • The doctor is in a privileged position, which requires physical and emotional proximity to the patient. This may increase the risk of boundaries being broken. • • Sexual misconduct by a doctor risks causing psychological damage to the patient. The doctor/patient relationship is not equal. In seeking assistance, guidance and treatment, the patient is vulnerable. Exploitation of the patient is therefore an abuse of power and patient consent cannot be a defence in disciplinary hearings of sexual abuse. • Sexual involvement with a patient impairs clinical judgment in the medical management of that patient. The Council will not tolerate sexual activity with a current patient by a doctor. See Medical Council website for further guidance: www.mcnz.org.nz/standards/guidanceresources/#sexualabuse 27 SECTION 3 Health of New Zealanders Cultural diversity The main cultural groups in New Zealand are 80% European, 14.7% Maori, 6.5% Pacific peoples, 2.9 % Chinese and 1.7% Indian. These figures are from the 2001 census taken from the Statistics New Zealand website. Respondents may claim more than one ethnicity. Each of these groups has a different place in the history of New Zealand. Maori are the indigenous people of New Zealand arriving here from around the 10th century A.D. Estimates of the size of the Maori population at the time of European contact at the beginning of the nineteenth century range from 100 000 to 500 000.6 In the years following contact with Europeans, numbers decreased dramatically to a lowest point of 42 000 in 1896.6 From this time there has been a recovery in Maori population. European settlement in New Zealand started around 1840, predominantly with settlers from the British Isles but later also included people from the Netherlands, Yugoslavia, Germany and other nations. Since 1960 people from the Pacific Islands have added to the cultural diversity of New Zealand. The population from Pacific Islands ethnic groups has grown sharply from 100 000 in 1981 to 262 000 in 2001. 28 New Zealand has received refugees from different areas of the world since the 1930s. These include Indo-China (largest group), Poland, Chile, Russia, East Europe, Assyria, Ethiopia, Bosnia and Somalia.6 See the Statistics New Zealand website for further information: www.stats.govt.nz Health status (MSD 2004 social report, MoH 2004 Pacific Health Chart book) Overall mortality rates in New Zealand have declined dramatically over the last 50 years. In the period 2000–2002, life expectancy at birth is 81.1 years for women and 76.3 years for men. Since the mid 1980s, gains in longevity have been greater for males than for females. With the decline in the infant mortality rate (from 11.2 deaths per 1000 live births in 1986 to 4.9 per 1000 in 2003), the impact of infant death on life expectancy has fallen. The gains in life expectancy since the mid 1980s can be attributed mainly to reduced mortality in middle-aged and old age groups (45–84 years). There are marked ethnic differences in life expectancy. In 2000–2002, female life expectancy at birth was 81.9 for non-Maori, 76.7 for Pacific people, and 73.2 years for Maori; male life expectancy at birth 77.2 for non-Maori, 71.5 for Pacific people and 69 years for Maori. Common diagnoses (Portrait of Health Key results of the 2002/3 NZ health survey) One in five adults aged 15–44 years have been diagnosed with asthma. There was no significant difference between women and men aged 15–44 years. In both females and males the prevalence of asthma was significantly higher (about four times) in Maori and European/Other groups, then Pacific people and Asian ethnic groups. 29 One in 10 adults have been diagnosed with heart disease. There was no significant difference between women and men nor in ethnic groups. One in 20 adults have been diagnosed with cancer. Females are significantly more likely than males to be diagnosed with cancer. One in 23 adults have been diagnosed with diabeters and its prevalence was higher in Maori and Pacific people than in the European/ Other ethnic group. Maori also have higher death rates from sudden infant death syndrome (SIDS), youth suicide, violence and motor vehicle crashes. Maori infant mortality is significantly higher, 11.6 per 1000 compared with 5.3 per 1000. Maori and non-Maori differences in health are present in almost every disease category as well as admission rates to hospital.9 Pacific people Pacific people also have poorer health outcomes than the nation as a whole. Life expectancy for Pacific women is 76.2 years, and for Pacific males 68.8 years, around six years less than European New Zealanders.8 Pacific people have the highest rates of meningococcal disease, rheumatic heart disease and obesity of all people living in New Zealand. There is an increasing rate of SIDS, low immunisation rates, high hospitalisation rates in children, particularly for pneumonia, asthma and middle ear infections and high rates of diabetes, tuberculosis and liver cancer in adults.8 Reducing health inequalities The government has made reducing health inequalities a key priority for all disadvantaged groups, particularly for Maori. This has involved addressing issues of access to, and effectiveness of, health 30 services and also tackling the underlying social and economic conditions that impact on people’s health. Directions to improve health of Maori have involved:6 • • • • Greater Maori participation at all levels of the health sector Development of Maori health organisations ‘by Maori for Maori’ Resource allocations that take into account Maori health needs and perspectives Development of culturally appropriate practices and procedures by all health providers. Maori health To understand the reasons for Maori health disparities it is important to understand the history of NZ and the current patterns and social relationships. The Treaty of Waitangi The Treaty of Waitangi defines the relationship between Maori and the Crown; it is recognised as the founding document of our nation. The Treaty of Waitangi was signed in 1840 by Maori chiefs and by Captain William Hobson on behalf of the Crown. The Treaty was written in both the Maori and English languages but one is not an exact translation of the other, so this has created different expectations. Maori believed that greater recognition of Maori authority was promised, whereas the government insisted that there had been a full and complete transfer of sovereignty.6 In practice, power passed very quickly from Maori to non-Maori. Grievances from the past continue today around land, language, authority and self-determination. Today the Treaty is used as the document that underpins the Government’s relationship with Maori; it is reflected in all government strat- 31 egies. Some compromise has been reached around the differing interpretations by defining principles inherent in the Treaty. The principles most often applied to health are:6 • Partnership – working together with iwi, hapu, whanau and Maori communities to develop strategies for improving the health status of Maori. • • Participation – involving Maori at all levels of the sector in planning, development and delivery of health and disability services. Protection – ensuring Maori rates of illness are improved to at least the same level as non-Maori, and safeguarding Maori cultural concepts, values and practices. More information on the Treaty can be found at www.govt.nz/ aboutnz/treaty. A glossary of Maori words used in this document can be found on page 71. Maori view of health Maori have an holistic view of health. The whare tapa wha (foursided house) model is one model used to describe the Maori health perspective.6 The whare tapa wha model compares health to the four walls of the house, all four being necessary to ensure strength and symmetry, though each representing a different dimension: taha wairua (the spiritual side), taha hinengaro (thoughts and feelings), taha tinana (the physical side), taha whanau (family). It is similar to the familiar ‘physical, psychological, social and spiritual’ dimensions of diagnosis promoted in British general practice for many years. 32 The characteristics of whare tapa wha are:6 Focus Taha Wairua Taha Hinengaro Taha Tinana Taha Whanau (Spiritual) Key aspects The capacity for faith and wider communion Health is related to unseen and unspoken energies (Mental) The capacity to communicate, to think, and to feel Mind and body are inseparable (Physical) The capacity for physical growth and development Good physical health is necessary for optimal development (Extended family) The capacity to belong, to care, and to share Individuals are part of wider social systems Themes The Maori health website (www.maorihealth.govt.nz) provides further information on Maori health. 33 Health care sector overview Minister of Health The Minister of Health has overall responsibility for the health system. The Minister determines the health and disability strategies, powers with respect to District Health Boards (DHBs), making appointments to ministerial committees and professional regulatory boards, and agrees how much public money will be spent on the public health system. Ministry of Health The Ministry of Health has a number of key functions including providing policy advice to the Minister of Health on all aspects of the health and disability sector, acting as the Minister’s agent and providing a link between the Minister of Health and DHBs. In addition, the Ministry of Health provides public health surveillance and information services and implements and administers and enforces relevant legislation and regulations. The Ministry of Health has responsibility for funding some services such as public health and disability support services. Over time the majority of funding for health and disability support services is likely to be transferred to District Health Boards. District Health Boards District Health Boards are responsible for the provision of health care services in their area, including both primary care and hospital 34 services. There are currently 21 DHBs. The boards are made up of a majority of members elected by the community and a minority appointed by the Minister of Health. Central Government provides broad guidelines on what services the DHBs must provide and national priorities have been identified in the New Zealand Health Strategy. Services can be purchased from a range of providers including general practitioners, public hospitals, non-profit health agencies, iwi groups or private organisations. Funding is allocated to DHBs using a weighted population-based funding formula. The New Zealand Health Strategy The New Zealand Health Strategy 2000 identifies seven fundamental principles for the health and disability sector: 1. 2. 3. 4. 5. Acknowledging the special relationship between Maori and the Crown under the Treaty of Waitangi Good health and well-being for all New Zealanders throughout their lives An improvement in health status of those currently disadvantaged Collaborative health promotion and disease and injury prevention by all sectors Timely and equitable access for all New Zealanders to a comprehensive range of health and disability services, regardless of ability to pay 6. 7. A high-performing system in which people have confidence Active involvement of consumers and communities at all levels. It also highlights 13 population health objectives: 1. 2. 3. Reduce smoking Improve nutrition Reduce obesity 35 4. 5. 6. 7. 8. 9. Increase the level of physical activity Reduce the rate of suicides and suicide attempts Minimise harm caused by alcohol and illicit and other drug use to both individuals and the community Reduce the incidence and impact of cancer Reduce the incidence and impact of cardiovascular disease Reduce the incidence and impact of diabetes 10. Improve oral health 11. Reduce violence in interpersonal relationships, families, schools, and communities 12. Improve the health status of people with severe mental illness 13. Ensure access to appropriate child health care services including well child and family health care and immunisation. The Primary Health Care Strategy 2001 This strategy follows on from the New Zealand Health Strategy. It sets a direction for primary care placing emphasis on population health and the role of the community, health promotion and preventive care. Primary Health Organisations (PHOs) have been set up to provide essential primary health care services to a defined group of people who are enrolled with them. People join a Primary Health Organisation by enrolling through a provider of primary health care services such as a general practice. In March 2005 about 95% of the whole population was enrolled in a Primary Health Organisation. PHOs are not-for-profit bodies funded by District Health Boards. PHOs are expected to involve their communities and all providers and practitioners in their governing processes. 36 The new direction brings extra funding to primary health care, aiming to provide lower cost primary health care to all New Zealanders. It is being introduced gradually, originally over 10 years, but is now scheduled to be complete in 2007, targeting those most in need; those in low income groups, Maori and Pacific people, over 64s, and under 25s. All age groups will have full capitation by July 2007. PHOs are taking different forms and have different funding arrangements depending on the needs of their population. Some general practice organisations (Independent Practitioner Associations) – see page 21 – are joining or forming PHOs. Further information on the health and disability sector can be obtained from a number of websites including: Ministry of Health: www.moh.govt.nz/publications An overview of the Health and Disability Sector in New Zealand European Observatory of Health Care Systems: www.observatory.dk This site provides two reports describing the NZ health system: a comprehensive profile of the New Zealand health care system, and a comparison between health care systems in eight countries, one of which is New Zealand. 37 Regulatory requirements There is a range of regulatory requirements that GPs need to be aware of in their numerous roles, as a medical practitioner, an employer, a professional delivering services to ‘customers’ and a business person. Described in brief below are some of the most important Acts and Codes you need to know about as a medical practitioner. References are also provided for important Medical Council statements that provide more specific guidance on the various aspects of medicine. Health Practitioners Competence Assurance Act 2003 The principle purpose of this Act is to ensure that all registered health practitioners are competent to practice. Risk to the public is a key concept. The Act provides for registration authorities (the Medical Council for medical practitioners) and also disciplinary providers and institutions. Decisions on scopes of practice, vocational registration, maintenance of competence and the effects of disciplinary processes are all taken by the Medical Council. Health and Disability Commissioner Act This Act created the Office of the Health and Disability Commissioner, the Code of Health and Disability Services Consumers’ Rights, the Director of Advocacy and the Director of Proceedings. The Office aims to promote and protect patient rights, resolve complaints relating to those rights, and ongoing education of providers and consumers. It is a key element in the new environment of consumerfocused and consumer-accountable health and disability services. 38 For further information see www.hdc.org.nz. The Code of Health and Disability Services Consumers’ Rights 1996 The Code of Consumers’ Rights (the Code) details the 10 rights of consumers and the duties of providers: 1. 2. The right to be treated with respect The right to freedom from discrimination, coercion, harassment, and exploitation 3. 4. 5. 6. 7. 8. 9. The right to dignity and independence The right to services of an appropriate standard The right to effective communication The right to be fully informed The right to make an informed choice and give informed consent The right to support Rights in respect of teaching or research 10. The right to complain. Information and consent Rights 5, 6 and 7 of the Code require doctors to obtain informed consent. It is an interactive process between a doctor and patient where the patient gains an understanding of what is involved in receiving a proposed procedure or treatment and, free from coercion, gives agreement. The Medical Council provides the following relevant statements on informed consent: • Information and consent www.mcnz.org.nz/about/forms/ConsentApr02.PDF 39 • Legislative requirements about patient rights and consent (outlines the statutory provisions that allow a doctor to proceed without obtaining informed consent). www.mcnz.org.nz/about/forms/legislativereqpatientrights.PDF Privacy Act 1993 The Act created the Office of the Privacy Commissioner and enabled the Health Information Privacy Code to be issued. It applies to every person or organisation in New Zealand in respect of personal information held in any capacity other than for the purposes of their personal, family or household affairs. The Act empowers the Privacy Commissioner to investigate complaints of interferences with privacy, places some controls on the administration of public registers and authorises some government agencies to undertake information-matching programmes. Health Information Privacy Code 1994 This Code deals with health information collected, used, held and disclosed by ‘health agencies’ and is a substitute for the information privacy principles in the Privacy Act. It applies to health information relating to identifiable individuals; the code does not apply to anonymous or aggregated statistical information where the individuals cannot be identified. For further information see: www.privacy.org.nz Guidelines for the maintenance and retention of patient records The Medical Council provides specific information on this topic. They cover: maintaining patient records, practice systems, fees and pa- 40 tient records, transferring patient records, retaining patient records, storage requirements, destruction of patient records. For further information see: www.mcnz.org.nz/about/forms/recordsguide.PDF Statement on confidentiality and public safety The Medical Council provides guidance for doctors balancing the need for confidentiality and disclosure of patient information in the interests of public safety. For further information see: www.mcnz.org.nz/about/forms/confidentialityandpublic safety.PDF Medicines Act 1981 and the Misuse of Drugs Act 1975 These Acts and regulations govern legal and illegal use of all drugs and prescribing. Medsafe (a business unit of the Ministry of Health) administers them. The Medicines Act and regulations control which products may legally be distributed, the places where medicines may be manufactured (through a licensing system), the importation and distribution of medicines, as well as quality standards for medicines and for packaging. It outlines the circumstances under which a person may legally sell or distribute a new medicine. The general rule is that it is an offence to distribute a medicine that has not received Ministerial consent as notified in the New Zealand Gazette. The Misuse of Drugs Act and regulations regulate controlled drugs and outlines who may supply, possess and deal with them and how they are to be stored. 41 Mental Health (Compulsory Assessment and Treatment) Act 1992 This Act provides for the compulsory assessment and treatment of people who are mentally disordered, as defined by the Act. Mental disorder in relation to any person means an abnormal state of mind (whether of a continuous or intermittent nature), characterised by delusions, or by disorders of mood perception or volition or cognition, of such a degree that it: • • Poses a serious danger to the health or safety of others, or Seriously diminishes the capacity of that person to take care of himself or herself, and ‘mentally disordered’ in relation to any such person has a corresponding meaning. A duly authorised officer should be contacted immediately for guidance. The Act allows for medical practitioners to administer sedation and/or call for police assistance in emergencies. A doctor’s duty to help in an emergency If a doctor is asked to attend a medical emergency as defined in this statement, they must respond. It is both an ethical and legal obligation. Rarely will there be times when attending a medical emergency is impossible or unsafe for the doctor or patient. If a doctor chooses not to attend, he or she may be required to defend that decision in the event of a charge of professional misconduct or criminal prosecution. For a full copy of the statement see: www.mcnz.org.nz/about/ forms/obligation%20to%20render%20assistance.pdf 42 Guidelines on transmissible major viral infections The Medical Council encourages the testing of health care workers and patients exposed to Hepatitis B, C and HIV. It also provides guidance to health care workers infected with these viruses. For a full copy of the statement see: www.mcnz.org.nz/about/ forms/policy%20transmissible%20viral%20infection.pdf 43 Orientation to general practice This section provides practical information for getting started in New Zealand general practice. It provides information on medical records, prescribing, forms, making referrals and the recommended contents of a doctor’s bag. Content of medical records The following are the recommendations for medical records in NZ: Demographic data • • • • • • • • • Name of patient NHI number Gender Address Date of birth Ethnicity Registration status Registered/casual Principal care giver/next of kin 44 • • • • Significant relationships Contact phone number Community Services Card Occupation Consultation records • • • The entry is dated Person making entry is identifiable The entry is legible Recent consultations recorded • • • • • • Reason for encounter History Examination findings Assessment Investigations ordered Management plan including medication change, additions, follow up arrangements • Medicines are clearly identifiable: drug name/dose/frequency/time. Medical records show • Clinically important drug reactions and other allergies are easily identified • • • • Awareness alert for specific disability etc. Problem lists are easily identifiable Preventive care Current medicine list 45 • Risk factors are identified and markers used – Family history – Smoking – Alcohol, drug – Blood pressure – Weight/height/BMI • Immunisations – Last tetanus booster recorded – Childhood immunisations – Flu shots if indicated • Referrals and responses are easily accessible in clinical records – Laboratory – X-ray – Other tests – Other health information • Screening – Cervical smears – Mammograms – Other screening according to national or local policies. Prescribing The MIMS New Ethicals Catalogue (equivalent of the British MIMS) is published twice a year and carries the details of all agents which may be prescribed, in addition to lists of agents available ‘over the counter’ (OTC), i.e. directly from pharmacists without a prescription, and The Medical Practitioner Supply Order List (see below). There are also a variety of tables at the back with information such as 46 height/weight charts, management of common poisonings, tropical diseases, etc. Available in book form, on compact disk and through some practice management computer systems. The Pharmaceutical Schedule lists the prescription medicines and related products that are subsidised by the government. PHARMAC publishes the schedule three times a year and provides monthly updates. It is distributed free to GPs and can also be accessed electronically via the PHARMAC website (www.pharmac.co.nz) or on some patient management systems (PMS). The medicines The most commonly used agents tend to have one version, which is fully funded. Either prescribe generically or choose Fully funded agents marked with an S in the New Ethicals and a tick (✓) in the Pharmaceutical Schedule. If there is a part charge to the patient on an agent it is marked SP. If the agent carries no subsidy (e.g. Viagra) it is marked NS. Some expensive or sophisticated agents (e.g. cytotoxics) can only be prescribed on the recommendation of an appropriate specialist. These are marked ‘retail phcy, spec.’ or ‘hosp. phcy, spec.’ in MIMS New Ethicals. When prescribing these, the script has to be endorsed ‘Recommended by (insert the specialist’s name) and then the date of recommendation’ e.g. ‘Recommended by Dr Grieg 20.02.2002’. The recommendation is valid for two years. Some agents, usually expensive ones like ‘statins’, the newer antidepressants or long acting beta-agonists or recently released ones like angiotensin II inhibitors, are only subsidised if certain patient criteria are met. These require ‘Special Authority’ (marked SA in the book), and require submission of an application form and approval. 47 Medical Practitioners Supply Orders (MPSO) There is a list of agents in the front of MIMS New Ethicals, which can be obtained by medical practitioners on a special order form for personal administration to patients in emergencies or to initiate treatment. Rural practitioners may select agents from the main body of the book but beware that you will be liable for any part-charges relating to the agents and will have to consider passing that charge on to the patient. There is a special green form with which to put in your requests. There is a separate MPSO form for controlled drugs. Ask another GP in the practice. Writing the prescription There are a number of legal requirements, including: • • • • • You will need a prescription pad with your name and Medical Council number on it Always keep your prescription pad secure Prescription of controlled drugs is written on a special pad of triplicate forms obtained from the Ministry of Health You have a responsibility to write prescriptions clearly and legibly All prescriptions must be dated. For further information please refer to: Medsafe www.medsafe.govt.nz Ordering lab tests and x-rays Most laboratory tests and x-rays are free. Private radiology clinics charge for all tests undertaken, unless they have been contracted to provide them by a local District Health Board. Talk to the practice staff for information on where the closest services are. 48 Medical certification As a GP you will be required to sign a range of medical certificates such as sickness and death certificates. The Medical Council provides guidelines on the requirements and your obligations when completing these forms: Guidelines for Medical Certification. www.mcnz.org.nz/standards/guidanceresources/default.asp Patient admission to hospital or specialist referral There are two systems available: • • Government-funded health care Private health care. Government-funded health care Secondary and tertiary care is provided entirely free through public hospitals. They treat the majority of acute medical and surgical conditions. A drawback is the waiting times for non-acute conditions. However, there may be ways to expedite appointments for clinics or surgery if a patient’s condition deteriorates. Phone contact with relevant departments or specialists is usually necessary to make any progress, and they will ask you to write another letter explaining the need for greater urgency. National and local guidelines on referral and assessment for publicly funded secondary services are available from www.nzggcareplans.org.nz. Chasing consultants at the hospital can be a variable experience. Some respond within a minute of being paged, others don’t carry pagers and can be difficult to contact. In general, when you want 49 advice, seek a consultant. To arrange admission, ask for the registrar or house surgeon. When seeking advice it is good to keep the patient beside you because inevitably you’ll be asked about something you haven’t thought to check on. It also helps the patient to have the situation clarified for them by listening to the call, though your technical conversation may need translating afterwards for them. Private health care This is based on private specialist clinics and private hospitals. Private care tends to be much quicker for non-emergencies; you choose your consultant and the accommodation tends to be plusher. There is a small General Specialist Subsidy but otherwise the patient pays for everything. This includes specialist fees, surgical fees, theatre fees, hospital accommodation, disposable supplies and materials. Pharmaceuticals are funded in the same way as for primary care. Insurance companies will pay variable amounts towards costs, typically 80% of an agreed schedule. ACC will pay up to 100% of costs depending on circumstances for accident-related conditions. Access to specialists in their private practices is generally very good. Talk to your practice about specialists available in your area. Forms This section includes a variety of the forms you will meet in your first few days. 50 Practitioner Supply Order Form (F270) This one is useful. You can use it to stock your medical bag from a pharmacy. If you are a rural GP you are not restricted to the Practitioner Supply Order in the front of MIMS New Ethicals but you need to pay any charges. ACC forms ACC 45 – a form for registering the first consultation associated with an accident. It can also be used at this time for referral for investigations, therapy or specialist opinions. It is a quadruplicate form with copies to: 1. 2. 3. 4. ACC head office the GP (keep in notes) the patient (takes away), and the one for referrals (give to patient or keep in notes if not immediately needed). ACC 18 – for subsequent consultations requiring time off work. Also in quadruplicate, keep the second layer for the notes, the other three go with the patient. (Re-visits for clinical reasons but not requiring work certificates require no forms.) ACC 41/ M 41 – for later referral for investigation etc. Triplicate form; keep one for notes, give two to patient for the therapist to process. ACC 2152 – for claims for injury caused by medical treatment. Many practices now have these forms available on computer. Sickness Benefits The main form is called Community Wage – Medical Certificate. Put out by the Ministry of Social Development. 51 Practices will have their own ‘sick notes’ for employers. Disability Allowance Application Also available from the Ministry of Social Development, these are for people with a long-term disability (i.e. expected to last for at least six months or during terminal illness) to cover such things as: • • • • • • • • • Medical fees Prescription fees Transport to clinics Gardening Personal medical alarms Phone Heating Special foods Access to private counselling or physical treatments. There is a section for GPs to fill in and they need to be renewed regularly. Pharmaceutical ‘Special Authority Application Form’ This form is for obtaining a waiver on patient part-charges for certain expensive but important items. A variety of forms exist such as for lipid lowering agents (Statins), Long Acting Beta Agonists, Angiotensin II inhibitors and you will find these both as generic forms from PHARMAC and pre-printed forms from the drug companies promoting their products. Medical Certificate for Driver Licence The extent of the examination depends on the type of licence required (e.g. commercial or driving heavy goods) and on the patient’s state of 52 health. See the booklet Medical Aspects of Fitness to Drive put out by the Land Transport Safety Authority for further guidance. Aviation medicals, racing drivers, jet-boat medicals, diving medicals etc. all have their own forms (and in some cases designated medical examiners – i.e. you can’t do them.) Contents of a doctor’s bag The content of a GP’s bag should enable the treatment of emergencies, as well as other problems encountered on house calls. The contents required will depend on the style and location of your practice, for example if you work in a rural area you may require more emergency drugs. The bag should be large enough to carry everything you need and be well organised to enable items to be easily located. The bag should always be kept in a secure location when not in your possession; prescription pads should be kept to a minimum. Controlled drugs can only be in the doctor’s bag if they are there for immediate use (with the exception of diazepam). If controlled drugs are stored in the doctor’s bag in case of an emergency use, there is a requirement for the bag to be in a locked container bolted to the floor of the boot of the car. The content of the bag needs to be reviewed regularly and a system established to replace items when used or outdated. The following are suggested minimum contents:11 • • • • • Airway Gloves Stethoscope Auriscope Opthalmoscope 53 • • • • • • • • • • • • • Sphygmomanometer Thermometer Tourniquet Lubricating jelly Spatula Alcohol wipes Range of needles and syringes Dressings Scissors Torch BM stix Protective device for mouth-to-mouth resuscitation Stationery: – Prescription pads – Letter writing paper – Pen – ACC forms • Drugs for medical emergencies, minimum oral and injectable: – – – – – – – – Adrenalin 1/1000 or 1/10,000 inj. Aspirin tabs Atropine inj. Diazepam inj./rectal Ergometrine 50% Glucose/glucagon inj. Antihistamine inj. Local anaesthetic inj. 54 – – – • • Penicillin inj. Corticosteroid inj. Naloxone inj. Optional depending on the circumstances: Blood tubes: – – red top purple top • • • Urine pots Laboratory swab Urine dipstix. General practice systems Providing good general practice care means working as part of a well functioning team. Good quality care systems need to be in place, for example, recall, managing patient test results and infection control. The College, in collaboration with practice nurses, practice managers, consumers and many other organisations has developed a set of indicators for general practice premises and systems in NZ. These are described in Aiming for excellence: an assessment tool for general practice. It does not cover clinical competence, but covers: • • • • • Factors affecting the patients Physical factors affecting the practice Practice systems Practice and patient information management Quality improvement and professional development. 55 Indicators are divided into those that are required by legislation, those that are considered essential by the RNZCGP and those desirable to provide high quality care. To obtain a copy contact the College. 56 Practice orientation This template provides prompts for information considered important for the orientation of new doctors to a practice; it may be altered to suit the needs of your practice. It will take around 30 minutes to complete initially but far less time to keep updated. An electronic copy of this template can be downloaded from the College website: www.rnzcgp.org.nz Aim to have this information ready on the day you start work, or ideally, a few days earlier. Practice profile The philosophy of our practice is… Funding method (fund holding, capitation etc.) The demographic mix of the practice’s patients is… The socio-economic mix is… Specific regional problems (e.g. freezing work accidents, leptospirosis) The specialist areas of this practice are (e.g. acupuncture, maternity)… The hours of consultation are… Length of an average consultation is… The number of patients we see a day is… 57 Practice staff Practice partners Practice manager Practice nurse/s Receptionist/s Others who also work from the practice premises (e.g. physio) The nurse’s duties include (smears, taking bloods)… Where rosters are kept Physical environment A map of the area is found… Layout of the practice and where to find dressings, emergency equipment etc. The layout of the room: smear equipment, forms etc. Day-to-day routines The patients are greeted… The patients get from receptionist to doctor… The patients information/fee is communicated to the receptionist… The bloods/specimens are collected at… Procedure for turning alarm on is… Procedure for turning alarm off is… Practice processes Our protocol manual is kept… The telephone consultation protocol for this practice is… Prescription procedure is… 58 Repeat pharmaceutical prescribing policy is… Patient test results protocol is… Procedure for referring patients to hospital (i.e. outpatients)… Procedure for admitting patients to hospital… Protocol for dealing with non-registered patients i.e. visitors, tourists is… Instructions for all electronic equipment is kept… Privacy officer Infectious control officer Code of dress Fees (This is confidential information, please keep it in the confines of the practice.) Our fee schedule is… Minimum fees How much discretion does locum have with fees? Emergencies The emergency equipment is kept… The emergency procedure is… The panic button is found… Police number COOP protocol (in event of armed confrontation) Fire control officer Evacuation drill The acute mental health services contact phone number is… 59 After hours arrangements On call Always ensure that someone knows where you are at all times A second GP to cover you on call outs is… House calls House calls are/are not part of the service offered to the patients of this practice Any limitations e.g. only during the day Time set aside for house calls Patients we see on house calls List of the special needs patients Protocol for night visits (Some after hours clinics send their doctor in a taxi – so they get there, and they have a chaperone if needed. They also carry a cell phone which has a quick dial to the clinic, the ambulance and the hospital.) Notes Computerised practices Patient management system used Computer password The information held on computer in this practice is… The information you will be expected to put on computer is… The key person to help you with accessing the computer information is… Manuals are kept… 60 Manual practices This is an example of how the patient notes are written (i.e. problem list, progress notes)… Recalls are written… Follow-ups are written… Results are written… This is how the notes are organised… Practice contacts Name and phone number of : Hospital Physiotherapist District nurse Mental Health Services Most frequently used specialists Pharmacy Investigations clinic (i.e. x-rays) Laboratories used Abuse contacts (e.g. women’s refuge, female solicitor, Children and Young Persons Service, Doctors for Sexual Abuse Care, etc.) Local self-help groups Consumer advocate Kaumatua Iwi providers 61 Forms Include forms most often used; examples of completed forms can be useful. Forms ACC Death certificate Specimens blood Referral Laboratory tests GMS MOT Sickness Other Refills kept When processed Delivery pick-up Additional information for rural GPs The local hospital is: Hospital facilities (i.e. obstetrics, A&E, surgery) The staff at the local hospital are… The phone number is… It is …kms from the practice It takes …(time) to get to and from the practice The base hospital is: It is …kms from the practice It takes …(time) to get to and from the practice Ambulance How to access ambulance It takes …(time) to get an ambulance to the practice 62 Ambulance officers – level of training You will/will not be required to go to each ambulance call out Other phone numbers you will need The nearest GP support person is… The emergency procedure is… Emergency equipment At practice: • • What is available Where kept At home: • • What is available Where kept At the local hospital: • • What is available Where kept Essential information about the accommodation The accommodation is… The key and the spare is… Water Gas Electricity Rubbish Milk Other Groceries 63 Leisure activities available Local takeaways/restaurant The duties that go with the accommodation are: Pets Garden If you have any problems call… Tradespeople/neighbours to call if you have problems with power, water etc… Insurance company Please leave the house, car and the practice in a clean and tidy condition. 64 APPENDICES Appendix 1 Subsidies General medical subsidy (GMS) Entitlement to this patient subsidy depends on qualifying for a Community Services Card (CSC) – except for children under six years. There is a scale of subsidies according to age and CSC status. A3 (Adult, no CSC) A1 (Adult with CSC) J3 (Juvenile six years and over, no CSC) J1 (Juvenile six years and over, with CSC) Y3 & Y1 (ALL children under six years) Nil $15 $15 $20 $35 High user health card (HUHC) This may be obtained by those who are not entitled to a CSC but have required 12 consultations over the preceding 12 month period. The subsidies are the same as for CSCs. See Health PAC for further information www.hbl.co.nz. Medicines From 1 July 2005 persons over 64, or under 25, or enrolled in an Access PHO will pay at most $3 per prescription. Persons holding a HUHC, CSC or Prescription Subsidy Card may get extra benefits. 65 Accident Compensation Corporation (ACC) payments Treatment for accident-related injuries is subsidised by Accident Compensation Corporation (ACC). For consultations relating to accidents (defined as injury resulting from an external force or from occupational overuse – as well as sensitive claims relating to sexual abuse and its consequences), GMS is not claimed. Most practices add a patient surcharge to make up the usual fee. If a consultation includes both an accident-related and non-accident issue you may claim both a GMS subsidy and an ACC payment. ACC makes further payments for various procedures (e.g. suturing, splinting, aspirating) according to a schedule. Maternity benefits All maternity consultations in primary care are free to the patient by legislation and funded according to a schedule of fees. A Lead Maternity Carer (LMC), e.g. GP midwife or specialist, holds fixed fund, ing for each pregnancy. The involvement of anyone else in the shared care of a pregnancy involves the billing of, and transfer of, funds from the LMC who holds the budget. Practice Nurse consultations Each practice has its own philosophy on nurse-only consultations. Legislation requires that a doctor must see a patient (and record this with a clinical note) for GMS to be claimed. Some practices charge patients for nurse consultations. Immunisation subsidies There is an immunisation subsidy available for immunisations. 66 Capitation subsidies Most practices are subsidised on the basis of a profile of their patients as defined by an ‘Age/Sex Register’ which is analysed quarterly by the Ministry of Health. These practices receive a monthly income based on a capitation formula which may take into account not only the age and sex of the patient, but also their community service and high user health card status, deprivation index and ethnicity. Rural bonus There are a variety of additional funds that rural practices may receive depending upon their isolation. The Rural Ranking Scale defines the degree of isolation of the practice, taking into account issues such as distance to nearest base hospital, ambulance support services, on call poster etc. Bonuses usually take the form of an annual or quarterly payment to the practice. Various other sources of income include Payments from insurance companies for medical examinations, social welfare payments (social welfare is administered by the Ministry of Social Development and other private arrangements. 67 Appendix 2 Glossary of frequently used abbreviations ACC AVE AMPA CAC CMC CME CRC CTA DHB FRNZCGP Accident Compensation Commission Advanced Vocational Education Accident and Medical Practitioners’ Association Complaints Assessment Committees Council of Medical Colleges Continuing Medical Education Competence Review Committee Clinical Training Agency District Health Boards Fellow of the Royal New Zealand College of General Practitioners H&DC HUHC HWAC Health and Disability Commission High User Health Card Health Workforce Advisory Committee 68 GMS ICTP IPA IPAC MCNZ MOH MOPS MPDT MRNZCGP General Medical Services Intensive Clinical Training Programme Independent Practitioners’ Association Independent Practitioners’ Association Council Medical Council of New Zealand Ministry of Health Maintenance of Professional Standards Medical Practitioners’ Disciplinary Tribunal Member of the Royal New Zealand College of General Practitioners MSD NZFP Ministry of Social Development New Zealand Family Physician – College journal that focuses on general practice academic papers NZMA NZMJ NZNO Pharmac PHC PHO Primex CQI Registrar New Zealand Medical Association New Zealand Medical Journal New Zealand Nurses’ Organisation Pharmaceutical Management Agency Primary Health Care Primary Health Organisation Primary Membership Examination (of the College) Continuous Quality Improvement Years 7,8,9 of the hospital run 69 RNZCGP Royal New Zealand College of General Practitioners WONCA 1/10th... World Organisation of Family Doctors % of weekly hours e.g. 2/10th =1 day Maori words used in this document Whanau Hapu Iwi Kaumatua Family Section of a tribe Tribe Male tribal elder Whare tapa wha Maori model of health Taha wairua Taha hinegaro Taha tinana Taha whanau Spiritual health Mental health Physical health Extended family 70 References 1. The Royal New Zealand of General Practitioners. Aiming for excellence: The RNZCGP practice standards validation field trial final report. Wellington: RNZCGP; 2001. 2. Medical Council of New Zealand. The New Zealand medical workforce in 2000. Wellington: Medical Council of New Zealand; 2000. 3. Stewart M, Brown J, Weston W, McWhinney I, Mc William C and Freeman T. Patient-centered medicne: Transforming the clinical method. Thousand Oaks, CA: Sage Publications; 1995. 4. Gray R and Gray D Teaching. Patient-centered care family medicine 2002; 34(9): 644–645. 5. Corkill, C. The doctor-patient relationship. In Coles Medical practice in New Zealand Medical Council; 1999. 6. Durie, M. Whaiora: Maori health development. Auckland: Oxford University Press, Second edition; 1998. 7. Statistics New Zealand. Age, sex and ethnic diversity-family. www.stats.govt.nz/domain accessed 20.08.02. 8. Health Funding Authority. Striking a better balance: A health funding response to reducing inequalities in health. Dunedin: Health Funding Authority; 2000. 9. Ministry of Health. The health and independence report: Director Generals Annual Report on the state of public health. Wellington: Ministry of Health; 2001. 71 72