Viewpoint 193 CSIRO Publishing Journal Compilation © Royal New Zealand College of General Practitioners 2016 Tis is an open access article licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License CORRESPONDENCE TO: Fiona Doolan-Noble Department of General Practice and Rural Health, Dunedin School of Medicine, New Zealand fona.doolan-noble@ otago.ac.nz 1 Department of General Practice and Rural Health, Dunedin School of Medicine, New Zealand J PRIM HEALTH CARE General practice: balancing business and care Fiona Doolan-Noble; 1 Carol Atmore; 1 Richard Greatbanks 2 Are general practices in New Zealand hybrid organisations? If they are examples of hybrid or- ganisations, is ‘hybridisation tension’ increasing? Early in the 1990s, traditional distinctions between public, private and third sector (the collective grouping of voluntary, non-proft and non-government organisations (NGOs)) 1 blurred as increasing levels of state service provision were transferred from public to voluntary and non-proft organisations. Tis resulted in blended or hybridised organisations, structured and operated as non-proft, but expected to behave as more business-like providers of community and social services. 2 Today, hybrid organisations are found at the convergence of public, private and non-proft sectors. Most of these organisations still retain at least some of the inherent tensions born from this blurred state. For instance, there are tensions between volunteer or employee mission-based values and an organisation that must balance its service provision within its funding, creating what is known as ‘hybridisa- tion tension’. 3 Some NGOs such as Māori providers receive Vote:Health funding to provide clinical services, making them clear examples of hybrid organisa- tions. Hybridisation tension can clearly be seen when a Māori organisation is required to report on its activity, based on mainstream concepts. In addition, hybridisation tension can be seen in the area of chronic condition prevention and management. Health funding contracts have focused on reporting and ‘widget’ counting. As a result, the role of practice nurses is frequently modelled to ft funding and contractual agree- ments. Opportunities to use nurses’ extensive clinical skills and knowledge to support patients at risk of, or living with, complex chronic disease is consequently missed. Te main business model of New Zealand gen- eral practices is that of a private business. Tis in- cludes the long dominant owner-operator small business, as well as professional partnerships between small numbers of general practitioners (GPs), and the recently emerging large corporate or social enterprise organisation with GPs as em- ployees. Yet despite this private business model, general practices receive substantial public fund- ing. Historically, such funding has allowed GPs to achieve an appropriate balance between com- munity and patient health-care provision and maintain a viable business. However, increasing Ministry and District Health Board (DHB) stakeholder expectations, including requirements to provide and manage a wider array of primary care-based services, is making this balance look increasingly fragile. Organisational tensions brought about by hybrid- isation pressures in general practice are not new. Te tensions between receiving state funding for patient care and maintaining business viabil- ity go back at least to 1941, when the right was enshrined for GPs to charge patient co-payments while also receiving General Medical Services subsidies. 4 However, these pressures appear to be increasing. Te last 20 years has seen the introduction of budget-holding and the develop- ment of primary care organisations, including the Independent Practitioner Association (IPA) movement. 5 Concern that IPAs lacked account- ability when spending publically funded budget holding savings was a driver behind the Primary Health Care Strategy, leading to the establish- ment of community participation in governance of Primary Health Organisations (PHOs) in the early 2000s. 5,6 Te IPA Council was formed in response to these changes, to represent the interests of organised general practice within the PHO environment. 6 Moves towards more care in the community, 7 while applauded by general practice, is accompanied by ongoing concern that 2 Department of Management, Otago Business School, New Zealand 2016;8(3):193–195. doi:10.1071/HC15912 Published online 27 September 2016