Malcolm L, Barnett P
Department of Public Health, Wellington School of Medicine, Wellington South, New Zealand.
Health Policy. 1994 Jul-Aug;29(1-2):85-100. doi: 10.1016/0168-8510(94)90008-6.
Services have almost completely replaced hospitals as the organisational units in the reformed New Zealand health care system. Within the secondary service provider sector service management, the decentralisation of general management to budget-holding clinical groupings has been an important factor in achieving a population focus, cost containment, accountability and integration. It is being further developed within the 23 newly formed Crown health enterprises (CHEs), the main providers of secondary, hospital and related services. The CHEs are evolving roles beyond a narrow definition of 'providers', taking initiatives to collaborate with other providers, or rejecting those elements of competition that might interfere with effective local co-ordination of services. Service management is also being extended to the demand-driven, fee-for-service primary care sector, where inflation-adjusted expenditure over the last decade has grown at more than 6%, compared with zero growth in the capitation-financed secondary sector. This is being achieved in both general practice and community budget-holder groupings through what might be called managed primary health care. The current health reform process has also created four regional health authorities (RHAs), responsible, within capped and capitated budgets, for the fully integrated purchasing of services from both primary and secondary providers. The success of these innovative arrangements, which could be of international significance, will depend upon the quality of the developing relationships between providers and their purchasing RHAs.
在经过改革的新西兰医疗体系中，服务机构几乎已完全取代医院成为组织单位。在二级服务提供商部门的服务管理中，将一般管理权力下放至持有预算的临床分组，这在实现以人群为重点、成本控制、问责制和整合方面发挥了重要作用。这一做法在23家新成立的皇家健康企业（CHEs）中得到进一步发展，这些企业是二级、医院及相关服务的主要提供商。CHEs的角色正在超越狭义的“提供商”定义，主动与其他提供商合作，或摒弃那些可能干扰当地有效服务协调的竞争因素。服务管理也正在扩展至需求驱动、按服务收费的初级保健部门，在过去十年中，经通胀调整后的该部门支出增长超过6%，而按人头付费的二级部门则零增长。这是通过所谓的管理型初级卫生保健在全科医疗和社区预算持有分组中实现的。当前的医疗改革进程还设立了四个地区卫生当局（RHAs），它们在预算上限和按人头付费的预算范围内，负责从初级和二级提供商全面整合采购服务。这些具有国际意义的创新安排能否成功，将取决于提供商与其采购RHA之间不断发展的关系质量。
