Primary health care service delivery in New Zealand is in an exploratory phase as primary health organizations determine new models of service delivery to reduce the incidence and impact of chronic disease. As organizations have restructured from predominantly primary care providers, the incorporation of a population approach to practice is welcomed but has provided some challenges for providers and funders alike as they reorient and extend practice parameters and determine the most effective methods of service delivery.

To describe and critically examine the underpinning assumptions of a new service delivered through a primary health organization to reduce the impact and burden of chronic disease with a focus on lifestyle risk factors, acting on obesity, nutrition, physical activity and smoking.

‘Heartbeat Tararua’ is a community-based lifestyle change programme focusing on the issues of obesity, nutrition, exercise and smoking and provides both clinical care for high-risk clients as well as operating a community-based prevention programme. The simplistic health education–behaviour change model was identified as problematic in the population approach and the high-risk service alone was unable to address all clients who expressed an interest. A revised population approach was sought that encompassed the existing community capacity and encouraged sustainable change in the community. Drawing from the public health evidence base a revised framework was recommended with a set of strategies based on social–psychological and ecological models with participatory and empowerment approaches. The work demonstrates a skilled practice team well able to reflect on practice, willing to seek advice and work towards establishing new models of primary health care service delivery.