Towards Accessible, Effective and Resilient After Hours Primary Health Care Services: Report
Towards Accessible, Effective and Resilient After Hours Primary Health Care Services
Report of the After Hours Primary
Health Care Working Party
The After Hours Primary Health Care Working Party
Co-chairs
Dr Sharon KletchkoDr Jim Primrose
Members
Dr Tom BrackenMr John Macaskill-Smith
Dr Ben GrayDr Tim Malloy
Ms Linda DubbeldamMs Cathy O’Malley (from March 2005)
Dr Peter FoleyMs Georgina Paerata
Ms Carolyn GulleryDr Alistair Sullivan
Ms Julene HopeDr Richard Tyler (November 2004 – February 2005)
Dr Robert KofoedDr Jim Vause
Dr Maree Leonard
Project Manager
Ms Floss Caughey
Citation: After Hours Primary Health Care Working Party. 2005. Towards Accessible, Effective and Resilient After Hours Primary Health Care Services: Report of the After Hours Primary Health Care Working Party.
Wellington: Ministry of Health.
Published in July 2005 by the
Ministry of Health
PO Box 5013, Wellington, New Zealand
ISBN 0-478-29659-2 (Book)
ISBN 0-478-29662-2 (Web)
HP 4168
This document is available on the Ministry of Health’s website:
Contents
Executive Summary and Recommendations
1Introduction to After Hours Primary Health Care
1.1New Zealand context
2.2Definition
2.3Guiding principles
2.4The challenge
3Ensuring Access to After Hours Primary Health Care Services
3.1Current access issues
3.2Proposed solutions to ensure access
4Clarifying Roles and Responsibilities for Service Planning and Delivery
4.1Current issues
4.2Proposed actions to clarify roles and responsibilities for effective service planning and delivery
5.Strengthening Resilience
5.1Current issues impacting on resilience
5.2Proposed actions to strengthen resilience
Appendices
Appendix 1: Terms of Reference: After Hours Primary Health Care Working Party
Appendix 2: He Korowai Oranga: Setting a New Direction for Mäori Health
Appendix 3: Principles Based Planning Framework for After Hours Primary Health Care
Appendix 4: Models of After Hours Primary Health Care: What Works and Where?
Appendix 5: Special Needs Grants
Appendix 6: Information on Fee for Service Deductions for Casual Visits
Executive Summary and Recommendations
The After Hours Primary Health Care Working Party (the Working Party) has made 15recommendations aimed at ensuring accessible and effective after hours primary health care services and strengthening their resilience to meet people’s urgent need for care.
The Working Party believes these recommendations, if implemented, will meet the project objectives stated in its Terms of Reference (refer Appendix 1). These are to:
‘develop and recommend a national policy framework as it relates to after hours primary health care that:
- provides clarity to practitioners, after hours service providers, Primary Health Organisations (PHOs), District Health Boards (DHBs) and the Ministry of Health about their respective responsibilities for the provision of after hours primary health care; and
- creates an environment that promotes locally developed solutions to the provision of services, particularly over night’.
The Working Party considers that DHBs, in collaboration with PHOs and after hours service providers, must take a lead role in the planning of after hours service development for their districts. This will require exploration of different funding approaches to ensure resilience of these services so that their communities can have confidence that after hours primary health care services will be available to them when they need them.
Responsibility for delivering primary health care services that are accessible 24 hours, seven days a week (24/7) should remain with PHOs. PHOs will need to demonstrate to the DHB that they have 24/7 arrangements in place. This can be achieved either by subcontracting with their member practices or by contracting other after hours service providers.
It is important that people appreciate that 24/7 primary health care does not mean 24/7 access to routine non-urgent care. After hours primary health care is designed to meet the needs of patients that cannot be safely deferred until regular general practice services are next available.
As accessible, effective and resilient after hours services have continued to be an issue for primary health care, DHBs, along with their respective PHOs and after hours service providers, are urged to start planning now.
Recommendations to DHBs
1.DHBs, in collaboration with PHOs and after hours service providers (both PHO member practices and, where applicable, Accident and Medical Clinics) and Emergency Departments (EDs):
(a)identify current after hours services and current resources (medical and nursing workforce and funding from the full range of funding streams as listed in section5.1)
(b)analyse the service and resource needs, the gap (if any) between these needs and the current services and resources, and any opportunity costs arising
(c)develop and implement a planning and funding strategy[1] for after hours primary health care for their district, including rural communities, that enables accessible, effective and resilient after hours primary health care services for all service users within current resources
(d)facilitate effective relationships between PHOs and after hours service providers, when requested, as part of the change management process required to achieve sustainable after hours primary health care services.
2.The District After Hours Services Plans should follow as a guide the Principles Based Planning Framework for After Hours Primary Health Care (Appendix 3); and the information on models of after hours primary health care (Appendix 4), and should:
(a)support service models that fully utilise the competencies of the primary care team and consider the impact of the Health Practitioners Competence Assurance Act 2003 and the concept of scopes of practice
(b)encourage the rationalisation of after hours services in urban areas to provide adequate geographical access, including to services overnight
(c)explore co-location models as an option
(d)build professional development into service planning, especially where health professionals are expected to take on different roles
(e)consider the potential for nurses, including nurse practitioners, to strengthen the workforce capacity for after hours services
(f)in relation to the current utilisation of EDs by primary care patients, consider the opportunity costs to DHBs, equity of access issues and the possible impact on health outcomes in terms of unacceptable delays in accessing services
(g)ensure that any additional assistance for urban after hours services is equitably matched for after hours services in rural areas too distant to participate in or access the urban-based models
(h)collaborate to ensure seamless after hours primary health care across DHB boundaries.
3.As after hours services are an emergent priority, DHBs are urged to commence their after hours service planning immediately without waiting for the planning requirement to be incorporated into the District Annual Planning (DAP) process for the 2006/07 financial year.
4.DHBs should ensure that Accident and Medical Clinics that are not open 24/7 have an on call service or formal arrangements in place with other providers to meet their section 88[2] obligations.
Recommendations to PHOs
5.PHOs should work collaboratively with their respective DHB to assist with defining the after hours service needs of their service users and developing a planning and funding strategy that adequately addresses those needs, guided by the Principles Based Planning Framework for After Hours Primary Health Care (Appendix 3).
6.Accountability for 24/7 primary health care service delivery should remain with PHOs. PHOs must demonstrate to the DHB that they have 24/7 arrangements in place for all service users:
(a)by establishing subcontractual arrangements with their member practices that make their after hours obligations clear and/or
(b)by contracting with another provider to provide after hours services.
7.The PHOs’ contracts or subcontracts for after hours service provision should:
(a)detail the principle of funding following the patient so that as the increased first contact primary health care strategy funding becomes available, this can be used to improve access to after hours services for their enrolled patients
(b)ensure that eligible enrolled people get access to low cost pharmaceuticals.
Recommendations to the Ministry of Health
8.The Ministry of Health should arrange for the preparation of an after hours primary health care planning and funding strategy, as outlined in Recommendations 1 and 2, to be included as a DAP requirement for DHBs.
9.Once adequate utilisation data is available, the Ministry should review the first contact capitation formula in collaboration with key stakeholders.
10.The Ministry should review and clarify the policy regarding the use of Services to Improve Access (SIA) funding to support improved access for high needs populations to after hours primary health care.
11.The Ministry, in collaboration with key stakeholders, should review the existing rural premium funding (workforce retention funding and reasonable roster funding). Consideration should be given to the impact of changes in after hours service delivery and to compensating those rural providers for whom after hours, particularly overnight services, continue to be an onerous responsibility.
12.The Ministry should give priority to the establishment of an expert sector group to develop a face to face sector disposition tool. The sector disposition tool would be designed to assist the after hours health professional determine which service – the primary health care service or the ED – patients should most appropriately attend for treatment. The expert sector group should be drawn from the following organisations: New Zealand Faculty Australasian College for Emergency Medicine (ACEM); College of Emergency Nurses of New Zealand (ENNZ); New Zealand College of Practice Nurses (NZNO); Royal New Zealand College of General Practitioners (RNZCGP); Accident and Medical Practitioners’ Association (AMPA); New Zealand Rural General Practice Network (RGPN); telephone health advice service; and the ambulance sector.
13.The Ministry, in collaboration with DHBs, should explore the feasibility of integrating telephone health advice with after hours primary health care services.
Recommendation to the Ministry of Health and Accident Compensation Corporation
14.The Ministry of Health and Accident Compensation Corporation (ACC), in consultation with key stakeholders, should complete the review of Primary Response in Medical Emergencies (PRIME) as a matter of urgency.
Recommendation to Accident Compensation Corporation
15.ACC should investigate options for payment for primary health care services provided in EDs, given the current limitations imposed by the legislation.
Towards Accessible, Effective and Resilient After Hours Primary Health Care Services1
1Introduction to After Hours Primary Health Care
1.1New Zealand context
New Zealanders report having comparatively good access to primary care when they need it, whether during regular hours or after hours. A recent survey of five countries[3] (Australia, Canada, New Zealand, United Kingdom and United States) showed that:
- fewer people in New Zealand (33 percent) reported difficulty getting care on nights, weekends and holidays without going to the ‘ER’ (in New Zealand, Emergency Department or ED)
- more people in New Zealand (60 percent) reported being able to get a same day appointment when sick or in need of medical attention.
Figure 1:Difficulty getting care on nights, weekends, holidays without going to the ER
Source: 2004 Commonwealth Fund International Health Policy
While after hours primary health care services in New Zealand are generally considered to be accessible and effective, concerns have been raised about their resilience. The recommendations in this report are aimed at ensuring the accessibility and effectiveness of after hours primary health care services, and strengthening their resilience.
2.2Definition
The After Hours Primary Health Care Working Party (the Working Party) has agreed on the following definition of after hours primary health care:
After hours primary health care is designed to meet the needs of patients[4] which cannot be safely deferred until regular or local general practice[5] services are next available.
Figure 2:After hours primary health care[6]
2.3Guiding principles
The Working Party believes that future planning of after hours primary health care should be guided by three key principles. These are:
1.accessible to patients and their families/whänau
2.effective service delivery
3.resilient with sufficient resources to provide the service so that the community can have confidence in ongoing service coverage.
The diagram below outlines dimensions for each key principle.
Figure 3:After hours primary health care framework
Each of these principles presents a challenge for the planning, funding and delivery of after hours primary health care.
Accessible after hours services:
- are open or on call 24 hours, seven days a week (24/7) within reasonable travel times
- are affordable to the communities they serve and do not have significant cost barriers
- are acceptable and informative to patients so they know where to go and what copayments they can expect to pay.
Effectiveafter hours services demonstrate:
- continuity of care – in most models of after hours service delivery it is common for the patient to see a general practitioner (GP) or nurse who is not their regular health professional, which places greater importance on the efficient transfer of information between providers and on management systems that support this transfer
- co-ordinated care that is well linked in with other key services such as ambulances, the ED, social support, laboratory services, imaging/radiology and pharmacy services
- teamwork so that the competencies of the primary health care team are well utilised
- safety for both patients and providers.
Resilient after hours services:
- are sustainable over the long term, and able to recruit and retain a sufficient, competent workforce
- are funded at a level from all sources, including patient co-payments, to maintain the service
- are capable (right competence, right time, right place)
- make efficient use of resources to achieve the best outcomes for least cost.
Planning for accessible, effective and resilient after hours primary health care should also be congruent with the key directions of the Primary Health Care Strategy[7] and with He Korowai Oranga: Mäori Health Strategy[8] which sets a new direction for Mäori health development, building on the gains made over the past decade (refer Appendix 2).
2.4The challenge
How can New Zealand ensure accessible and effective after hours primary health care services, and strengthen their resilience within available resources – funding, facility and workforce?
This challenge has a number of key features.
- In rural areas, the smaller workforce teams available to share after hours responsibilities mean these responsibilities are more onerous to the point where they impact on workforce recruitment and retention.
- During the overnight period, workforce issues generally become more severe. This is because GPs and nurses working during the day are increasingly reluctant to be on call overnight as well and salaried staff expect higher remuneration. (Weekends can pose similar workforce problems for after hours service provision.)
- Low patient numbers presenting after hours in rural areas and overnight in urban areas can mean the service is not financially sustainable within current contracting approaches.
- Higher patient co-payments create access barriers for patients.
An unplanned ‘market’ response to these issues can lead to:
- a mismatch between public and provider expectations in relation to after hours service delivery
- the expectation that rural people must travel long distances to after hours services
- adverse effects on rural workforce recruitment and retention that impact on the availability of regular daytime primary health care services
- closure of overnight services in urban areas
- growing inequities for both users and providers of after hours services
- increased attendance of primary care patients after hours at hospital-based EDs, incurring opportunity costs for District Health Boards (DHBs).
3Ensuring Access to After Hours Primary Health Care Services
3.1Current access issues
Growing gap between public and provider expectations –Some people expect primary health care services for routine non-urgent care to be available 24/7. While, through Healthline and other telephone advice services, professional advice is readily accessible 24/7, the available primary health care workforce is stretched to provide after hours primary health care designed to meet the needs of patients whose care cannot be safely deferred until regular general practice services are next available.
Risk of service coverage gaps – While rural communities have been most affected by problems in after hours service delivery, some urban areas have been faced with sudden closure of overnight facilities. While the DHBs have seen to it that alternative arrangements have been put in place, the options are often limited by the need to take action immediately.
Cost barriers – Fees for after hours primary health care services are often higher than daytime services to reflect the higher cost of service delivery. High fees for after hours services create access barriers for patients, who may delay seeking the urgent primary health care treatment they require.
Even when the fees charged are not significantly greater than daytime services, some people on low incomes (such as beneficiaries) may have difficulty meeting an unforeseen expense or are reluctant to attend because of prior bad debts with the after hours service provider.
Travel distance and cost – Changes to after hours service delivery that result in communities travelling further to services can be a problem for people without ready access to private transport. This is particularly a problem in areas of high deprivation. (Refer to sections 4.1 and 4.2 for comment on the travel time specified in the PHO Service Agreement.)
Access to reduced pharmaceutical co-payments–When Primary Health Organisation (PHO)enrolees access after hours primary health care services that are not part of, or contracted to, their PHO, they do not get reduced pharmaceutical co-payments. Even when the after hours service provider is part of, or contracted to, their PHO, the PHO enrolees may still not get reduced pharmaceutical co-payments because the after hours provider is unable to identify eligible PHO enrolees.