Summary of submissions on the Report of the After Hours Primary Health Care Working Party: Towards Accessible, Effective and Resilient After Hours Primary Health Care.

Summary of submissions on the Report of the After Hours Primary Health Care Working Party: Towards Accessible, Effective and Resilient After Hours Primary Health Care

1. Submissions received

The Ministry received 24 submissions on the Working Party’s report. Of these, 8 were from District Health Boards (DHBs), 1 from a DHB Emergency Department, 4 from PHOs, 2 from national committees, 2 from rural organisations, 6 from professional organisations and 1 from an individual.

2. In summary

The recommendations of the Working Party’s report were broadly supported. Nineteen of 24 submissions received expressed support for DHBs taking the lead in developing and implementing a planning and funding strategy for after hours primary health care, so long as it was in collaboration with PHOs and after hours service providers as the report advised. However, concern was expressed by several responders (3) that the report’s recommendations left the problems of 24/7 to DHBs and PHOs to address largely on their own without a sufficiently developed national policy framework or guidelines. While responders acknowledged that PHOs in practice needed to provide 24/7 coverage to all service users, many (11) pointed out that PHOs are funded for their enrolled population only. Six commented on the need for additional funding for after hours services. More detail on the comments received is provided below.

3. Key themes

(a) DHBs best placed to develop and implement a planning and funding strategy for after hours primary health care – Relates to Recommendation 1 of Working Party’s report

The following advantages in this approach were noted:

DHBs are best placed to have the strategic view of after hours, have responsibility for the health of their population, and can ensure consistency of access for their region (2 respondents)
provides an opportunity for sector working collaboratively together at the local level to find workable and sustainable solutions to after hours issues (4 respondents)
DHBs are best placed to understand the attitudes and expectations of communities and potential for community buy-in (2)
provides opportunities to rationalise/integrate resources (1)

One organisation, while acknowledging that DHBs are “theoretically” well placed to do this, stated that “some DHBs do not have a strong primary care focus”.

Within the context of broad agreement, several responders identified a number of possible risks or provisos with this approach:

it may be perceived to signal a shift of responsibility for after hours problems from PHOs to DHBs and PHOs may expect DHBs to provide additional funding (2 respondents)
it was important that DHBs took a collaborative rather than a “top down” approach to planning (4)
the differences in service delivery across DHBs and urban/rural disparities may be maintained (1)

A related viewpoint, was that the report’s recommendations left the problems of 24/7 to DHBs and PHOs to address largely on their own without a sufficiently developed national policy framework or guidelines (3 respondents)

Suggested ways of mitigating these risks were:

Ministry of Health develop performance measures re after hours and monitor DHB performance in the planning and funding of after hours service provision (2 respondents)
Ministry of Health be involved along with DHBs and PHOs in developing and implementing planning and funding strategy (1)
2-3 of the best performing DHBs be identified to lead by example and support other DHBs (1)

(b) Features DHBs should consider when developing their District After Hours Planning and Funding Strategic Plans (relates to recommendation 2 of Working Party’s report).

Features identified by the Working Party that generated comment were:

co-location models were regarded by one organisation as an “essential part of the solution” and another noted they can assist resilience. Two other organisations were concerned about financial barriers to consumers and warned that consultation was required under the National MECA 2005.
support for developing the role of nurse practitioners in after hours was supported by 3 responders but one organisation was of the view that regarding nurse practitioners as the solution should be approached with caution and raised issues of narrow scope of practice and fragmentation of care.
Regarding the utilisation of Emergency Departments (EDs) by primary care patients, one organisation did not see EDs as the places of appropriate care of primary care patients and another was concerned about the increasing workload arising from it.
Equitably matching assistance to rural areas was linked with the proposed review of the rural premium. The review of rural funding was supported by three submissions.

Additional features that respondents advised should be drawn to DHB’s attention were:

Transport problems impacting on access to after hours services (2 submissions)
Access to pharmaceuticals and dental care after hours (2)
Rural/urban differences and workforce retention and recruitment issues, especially in rural areas (4).

(c) PHOs demonstrate 24/7 arrangements for all service users or enrolled population only?

While responders acknowledged that, in practice, PHOs needed to provide 24/7 coverage to all service users, many (11) pointed out that PHOs are funded for their enrolled population only. Some (2) saw the answer in increased user charges for casual patients. Others (5) considered that resources including additional funding were required to support the additional workload of casuals, particularly in holiday areas. One organisation proposed prospective funding of after hours services for predicted peak workloads.

(d) Sector disposition tool development

The development of a sector disposition tool was supported and a number of organisations advised they were keen to be involved or suggested others be involved such as the College of Nurses Aotearoa, NZ College of Emergency Nurses, Rural Nurses Network, a pharmacy representative, and a consumer.

On the other hand, the intermediate option that the Working Party’s report suggested could be used to distinguish between ED and primary care patients until the sector disposition tool was developed was strongly opposed by 4 organisations who cited patient safety concerns. (The suggested intermediate option involved the health professional posing an additional question “What is the probability of this patient deteriorating with the triage times for triage 4 and 5”).

(e) Recommendation to ACC

Recommendation 15 that ACC should investigate options for payment for primary health care services provided in EDs, given the current limitations imposed by the legislation was supported by 4 submissions.

(f) Funding issues

Six responders commented on the need for additional funding to support after hours services. One organisation commented “the problem is all about adequately funding after hours care” and stated that funding issues need to be addressed at national level. Another claimed that “without additional funding the principles, local solution recommendations simply will not work”. Another organisation raised concerns about DHBs possibly cost shifting from EDs to after hours primary health care. Several responders commented on the need to identify the true cost of providing after hours services and the portion of capitation funding “allocated” to after hours.

Related information

Towards Accessible, Effective and Resilient After Hours Primary Health Care Services - Report of the After Hours Primary Health Care Working Party
Response to Recommendations of After Hours Primary Health Care Working Party