Round the clock service going in circles
In his latest New Zealand Doctor column, entitled: “ROUND THE CLOCK SERVICE GOING IN CIRCLES”, Victor Klap said:
"Anyone with a family knows what it’s like. A child wakes up screaming in the middle of the night, burning with fever, throwing up, totally wretched.
As a parent you want medical reassurance there is nothing seriously wrong, and you want it now. At 3am. you don’t want to wait until morning. In a civilised society, you shouldn’t have to.
But in some areas around New Zealand, patients are finding their after hours accident and medical clinics with the lights out and no-one home.
The delivery of 24-hour care is failing in different ways across New Zealand. The consequences of this failure are already evident with increased costs of access for patients after hours and the closure of after hours facilities in many areas in NZ. This leads inevitably to an increased load on emergency departments after-all, it’s “free”.
IPAC is actively lobbying at all levels to ensure that this issue is dealt with as a priority. In early October we will be debating the issue with the Ministry and DHBs at the national PHO contract negotiations. And while we don’t expect to resolve this complex issue in one go we are seeking some support for important principles that will provide a framework within which solutions can be developed. .
The After-Hours care saga has been exacerbated in the PHO environment by a combination of contractual expectations, changes in funding mechanisms and the perverse impact of the ‘clawback’.
Essentially the contract between PHOs and DHBs requires the PHO to provide first level services on a 24-hours a day, seven days a week basis for 52 weeks of the year for all service users.
PHOs are being held accountable for the delivery of 24 hour cover. This accountability is in a context where PHOs have limited financial resources to meet the cost of 24-hour cover and limited control over those resources due to the claw back mechanism.
It has to be recognised that the advent of PHOs, capitation and casual claw back is undermining a situation that was already fragile.
Unfortunately, the issue does not have a readily identifiable contractual solution. What we need to do is establish an agreement on core principles and then work to resolve the problem.
We all recognise that after hours care in New Zealand is a complex issue with different sets of drivers in large urban, small urban and rural environments. There is no one size fits all solution that will meet the needs of all populations.
Ensuring a cost effective service that is reasonably accessible to patients is a constant balancing act between clinical workforce requirements and the basic dollars and cents.
For more than a decade general practice funding has not recognised the additional cost of delivering care after hours. The cost of providing medical assistance to a child at 3am bears no relation to the cost of a normal clinic visit. This needs to be addressed.
Interestingly our trans Tasman politicians are in the midst of a bidding war with both major political parties committing substantial additional funding to after hours care. The Howard Government has promised a $400 million top up which equates to $20 per person.
Unfortunately, PHOs in New Zealand are relatively powerless to resolve the after hours problem as they have insufficient funding and no control over who provides after hours care to their population. This means they cannot control the leakage of funding to other providers that directly competes with their own members for the easier-to-deliver evening and daytime care.
Philosophically, if the PHO has the obligation and if continuity of care is a foundation principle then the PHO should retain control over after hours provision and not have its resources captured by providers with which it does not have a relationship.
In summary the over-arching principles that we are seeking Ministry of Health and DHB support for are:
- PHOs should have control over how their capitation funding flows for the provision of after hours care.
- There should be nationally agreed minimum standards of after hours care provision
- After hours care should be funded in a way that recognises the additional cost of maintaining the capacity to deliver the service.
Nobody wants to wake up with a sick child in the middle of the night and think there is nowhere to go for help. That is not acceptable for any of us. A solution must be found."
Victor Klap, Chief Executive
Publish Date : 6/10/2004
Author : Victor Klap