Auditor-General's overview
Sometimes, an injury or worsening medical condition occurs when our general practitioner's practice is closed. If we, as patients or caregivers, are concerned that the injury or illness cannot wait until our general practitioner (GP) is next available, we need to be able to get to an after-hours primary health care service (after-hours service) regardless of where we live.
The public perspective, particularly from the viewpoint of being service users, is an important consideration and we have, therefore, structured this report around it.
Ensuring that after-hours services are available
The Government has set an expectation that district health boards (DHBs) should ensure that after-hours services are available for 95% of the population in each DHB district within 60 minutes' travel time.
My staff carried out a performance audit to see whether DHB plans (including DHB funding proposals and other documents) met this expectation for geographic availability of after-hours services. To our knowledge, testing whether this expectation has been met has not previously been performed in a comprehensive and systematic manner for all DHBs.
I am pleased to report that all DHBs met the expectation – our audit showed that they had planned for after-hours services to be available as required by government policy. This is pleasing given the challenges of making health care services available in a country such as ours with a small population, and a widely dispersed rural population in particular.
The modelling my staff used showed that, in a typical week and at the time of our audit fieldwork in mid-2009, DHBs had planned for after-hours services to always be available to 99.7% of New Zealand's population within 60 minutes' drive. A small number of people, about 7300, only sometimes had an after-hours services available within 60 minutes' drive. A further 6400 people never had these services available within 60 minutes' drive. These people were generally in rural areas.
We have included a map for each DHB showing the geographic availability of after-hours services in a typical week (see Part 8). The information was accurate at the time that my staff carried out their fieldwork, but might have changed since then.
The modelling my staff used was a new audit technique for my Office. It is an approach that we may use in any future work that involves examining the public's geographic access to publicly funded services.
Are after-hours services accessible?
In practice, a DHB's planning for geographic availability needs to take into account the public's ability to access after-hours services. Accessibility is determined by a range of factors. Before people can get to an after-hours service, they need to know the answers to some important questions:
- Do I need an after-hours service? (see Part 2);
- What after-hours services are available? (see Part 3);
- Can I afford it? (see Part 4);
- Can I get there? (see Part 5); and
- Will I need to go somewhere else as well? (see Part 6).
Delays in getting advice and treatment can be distressing, detrimental to our health, and costly for the public health care system. It is therefore not surprising that, in addition to an expectation about geographic availability, the Government also has expectations about how DHBs will work to ensure that public health care services – including after-hours services – are accessible, which includes being affordable.
My staff noted that, despite a level of geographic availability that met the Government's expectation, most DHBs had not clearly identified and responded to transport and affordability barriers.
My staff also noted that some after-hours services are facing workforce and financial sustainability challenges. If these trends continue, there is a risk that the availability of after-hours services for some areas may reduce.
What do district health boards need to do?
Overall, DHBs need to improve their planning for accessible after-hours services. Specifically, they should do more work to identify affordability and transport barriers, and to consider patient access to pharmacy services.
DHBs have largely been responding to the after-hours challenges of today. This may not be enough to sustain after-hours service coverage in the future. In my view, DHBs need to design their service networks to ensure more sustainable after-hours services. For some, this may mean comprehensively redesigning their existing after-hours service networks.
Delivering services through networks involving public and private providers
Although DHBs have significant influence over after-hours services arrangements in their districts, these arrangements are complex. They involve a range of publicly and privately funded organisations, not totally within a DHB's control, and not all within my audit mandate. The complexity of the arrangements means that planning for and changing the after-hours service arrangements for a given area is not straightforward.
The complexity of planning, funding, and delivering after-hours services is further reflected in numerous reports and ongoing debate in the health sector about aspects of these services. However, public entities should not be deterred from using their influence to make sure the complex arrangements deliver a positive experience and outcome for the users of after-hours services.
I am aware that a number of concerns have been expressed about the quality and effectiveness of after-hours services. My staff did not examine these as part of this audit. I encourage DHBs to further consider these issues as part of their response to this report.
Acknowledgements
I thank the many people working in the after-hours system for the help they have provided to my auditors. I would also like to thank the staff of the DHBs and sector organisations who participated in this audit for their co-operation and assistance.
Lyn Provost
Controller and Auditor-General
27 August 2010