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Objective: To determine how 'population health' has been understood in practice and policy and has influenced health system restructuring in New Zealand since 2000., Methods: Interviews in 2007-2008 with managers, clinicians, government policy advisors and academics were undertaken to explore the relationships between population health, determinants of health, and health system restructuring. This was augmented by a review of major government health policies from 2009 to 2013 to establish which notions of population health were reflected., Results: Population health shifted from a broad notion of health determinants to focus on a small number of quantifiable health targets driven by financial incentives. Meantime, an emphasis on 'quality and safety' impeded population health activities. District Health Board programmes to identify high risk individuals, by disease or hospital service utilisation, diverted attention from broader population health outcomes. District Health Boards were not held accountable for integrating a population health approach in service planning and did not initiate or lead intersectoral work. Community consultation was limited. Primary Health Organisations, although mandated to address population health, typically aligned with the small-business model of general practice making service integration difficult to achieve. In policy, 'population health' dropped from favour in the mid-2000s, although many documents, outside the health sector, carried forward these values., Conclusion: A progressively narrower focus on a small number of health targets and on organisational processes undermined earlier policy intentions and health system restructuring that sought to improve broader population health outcomes.

Background: Primary health care does not adequately respond to populations known to have high needs such as those with compounding jeopardy from chronic conditions, poverty, minority status and age; as such populations report powerlessness., Objective: To explore what poor older adults with chronic conditions who mostly belong to ethnic minority groups say they want from clinicians., Setting and Participants: Participants were older adults whose chronic conditions were severe enough to require hospital admission more than twice in the previous 12 months. All participants lived in poor localities in Auckland, New Zealand's largest city., Methods: Forty-two in-depth interviews were conducted and analysed using qualitative description., Results: An outward acceptance of health care belied an underlying dissatisfaction with low engagement. Participants did not feel heard and wanted information conveyed in a way that indicated clinicians understood them in the context of their lives. Powerlessness, anger, frustration and non-concordance were frequent responses., Discussion and Conclusions: Despite socio-cultural and disease-related complexity, patients pursue the (unrealised) ideal of an engaged therapeutic relationship with an understanding clinician. Powerlessness means that the onus is upon the health system and the clinician to engage. Engagement means building a relationship on the basis of social, cultural and clinical knowledge and demonstrating a shift in the way clinicians choose to think and interact in patient care. Respectful listening and questioning can deepen clinicians' awareness of patients' most important concerns. Enabling patients to direct the consultation is a way to integrate clinician expertise with what patients need and value., (© 2012 John Wiley & Sons Ltd.)