Part 1: Introduction

District health boards: Availability and accessibility of after-hours services.

1.1
In this Part, we discuss:

The purpose of our audit

1.2
We carried out a performance audit of DHBs' plans for after-hours services, which are funded from the significant public resources allocated to primary healthcare services. We did so to provide Parliament with assurance that DHBs were effectively meeting government expectations about the availability and accessibility of after-hours services and, if necessary, to recommend improvements.

1.3
By "primary health care services", we mean the sort of services people might expect to receive from a doctor (a medical practitioner), usually a general practitioner (GP). Defining "after hours" is more complicated, because times that might be considered "after hours" in some centres are "extended opening hours" in other suburbs, towns, or cities (see paragraphs 1.18-1.22).

The Government's expectations for after-hours services

1.4
The Minister of Health sets out what the country's DHBs1 have to deliver each year through a service coverage schedule and an operational policy framework document. There is a very specific government expectation in the service coverage schedule about the geographic availability of after-hours services – DHBs are expected to ensure that after-hours services are available within 60 minutes' travel time for 95% of a DHB's population.

1.5
We acknowledge that, although DHBs have significant responsibilities and influence over the after-hours service arrangements within their districts, aspects of these arrangements are outside of DHBs' control. This is because a complex mix of publicly and privately funded organisations, including primary health organisations (PHOs), GPs, and accident and medical centres, are also involved in planning and delivering these services.

1.6
The 2006/07 Operational Policy Framework required each DHB to prepare a strategic plan for after-hours services in their district, in collaboration with PHOs.2 Subsequent operational policy frameworks required DHBs to identify how they will work with PHOs to ensure that primary health care services – including services delivered after hours – are accessible, affordable, and within the geographic reach of their populations. In 2008/09, the Ministry of Health (the Ministry) required DHBs to submit proposals outlining how they would make after-hours services more accessible, to receive a share of additional funding.

What we looked at

1.7
We determined whether DHBs had planned for an after-hours service to be available to at least 95% of their population within 60 minutes' drive during a typical week. Our audit looked at DHB plans and then tested those plans by modelling and analysing the availability of after-hours services. We relied on DHBs to verify what services they had available in their districts. We did not audit the actual after-hours services. Generally, we also refer to 60 minutes' "drive" instead of 60 minutes' "travel time" because, although the Government's expectation refers to travel time, it is reasonable to assume that such travel will be on the road network.

1.8
We also looked at the extent to which DHBs had identified any potential barriers, such as transport and affordability, for people who need to access after-hours services.

1.9
Specifically, we:

  • obtained, reviewed, and analysed information from DHBs' strategic plans for after-hours services, funding proposals specific to after-hours services, and other documents to determine what after-hours services were expected to be in place in 2009/10 (we refer to these collectively as DHBs' "after-hours plans");
  • found out where all the after-hours service providers were located, and had the DHBs verify that information;
  • analysed information on the locations of after-hours service providers, average travel speeds across the road network, population and vehicle ownership data from the 2006 Census, roster information for relevant after-hours service providers, emergency department use, numbers of visitors in holiday periods for selected towns, and the medical workforce;
  • collated information from DHBs' after-hours plans about affordability and transport barriers, and any proposed actions within the plans to help remove or reduce those barriers; and
  • met with the Ministry, several different after-hours providers, and spoke with or surveyed a range of interested parties.

1.10
Appendix 1 sets out further information about our audit methodology. Appendix 2 sets out brief information about the funding arrangements for after-hours services.

What we did not look at

1.11
We did not audit:

  • the quality of the DHBs' planning processes and their monitoring of after-hours services;
  • whether the after-hours services were the most appropriate or effective services possible;
  • whether the Government's funding arrangements for after-hours services were adequate or appropriate;
  • DHB planning for emergency services;
  • the Ministry's role in after-hours services;
  • the appropriateness of the expectation that 95% of a DHB's population have after-hours services available within 60 minutes' drive;
  • whether the after-hours services that DHBs had identified in their plans were actually available and accessible; and
  • the performance of non-public entities involved in after-hours service delivery.

Our expectations of the district health boards

1.12
In keeping with the relevant service coverage schedule and the operational policy framework (see paragraph 1.4), we expected DHBs to have planned for after-hours services to be available within 60 minutes' drive for 95% of a DHB's population. In keeping with the service coverage schedule requirements for when a nurse delivers those services, medical back-up (such as a GP) needs to be available, so (where applicable) we expected these arrangements to be in place.

1.13
We also expected that, in leading the planning for after-hours services,3 DHBs would collect and analyse information to determine whether there were any affordability or transport barriers that would prevent people from accessing after-hours services.

Why after-hours services are important

1.14
Without timely access to primary health care, some medical conditions can escalate to the point that more acute forms of care are required.4 The sick or injured person might then require hospital emergency treatment and/or be admitted to hospital.

1.15
Emergency care and hospital admissions are costly to the health sector. Patients can also become more distressed and the outcomes can be worse than if a patient had received care sooner. Having after-hours primary health care services available also provides the public with assurance that help is available when they need it.

Emergency services and after-hours services

1.16
At times, people go to hospital emergency departments even though there are after-hours services, such as general practices, available. At other times, a DHB hospital emergency department may be the only service available to provide after-hours services. Some DHB after-hours plans explicitly included hospital emergency departments as part of their planned after-hours services, especially to provide services when no other after-hours services were available.

1.17
There is much debate about the relationship between access to primary health care, attendance at hospital emergency departments, and emergency department overcrowding. We have not examined this relationship as part of our audit, but we understand that a lack of access to after-hours services can result in additional pressures elsewhere in the health sector.5

How we identified after-hours services

1.18
There is no clear and nationally accepted definition of an after-hours service. Many, but not all, DHBs have adopted a definition used by the After Hours Primary Health Care Working Party:6

After hours primary health care is designed to meet the needs of patients which cannot be safely deferred until regular or local general practice services are next available.7

1.19
In this definition, an after-hours service is a service that is usually provided by a general practice and is needed when "regular" services are not available. However, providers of after-hours services have different operating hours, and different periods that they consider to be either extended opening hours or an after-hours service.

1.20
In the DHBs' after-hours plans, we were not always able to clearly distinguish between extended-hours services and after-hours services.

1.21
Because definitions – and particularly related time periods – vary, for the purposes of this audit we have defined after-hours services as being:

  • services for urgent or acute needs, and services that one might expect to receive from a GP (or from a nurse who has appropriate medical back-up available to them);
  • services available at times when a patient might expect reduced access to their GP, such as when local businesses tend to be closed; and
  • those services contained in DHBs' after-hours plans.

1.22
In this report, we use the term "daytime" services to refer to "regular" primary health care services (that is, the opposite of after-hours services). We acknowledge that some after-hours services would, however, be provided during daytime hours (for example, at weekends).

Providers of after-hours services

1.23
In larger centres, a range of primary health care providers typically provide after-hours services. The range can include general practices and accident and medical centres. Hospital emergency departments either provide back-up or, in some instances, are the sole provider of after-hours services overnight (see paragraph 1.16).

1.24
In smaller centres, a range of general practices typically provide after-hours services, often until 8pm. After 8pm, people are usually expected to access overnight services in the nearest urban centre. Hospital emergency departments usually provide back-up, but in some towns the emergency department is the only after-hours service available.

1.25
In rural areas, a range of general practices typically provide after-hours services. Either a person's own GP, or a GP or rural nurse on a roster for that area, will provide the care that is needed. In remote rural areas, rural nurses might be the only providers of after-hours services.

Telephone advice services

1.26
There is a toll-free national Healthline telephone service (0800 611 116) that operates 24 hours a day, seven days a week. Healthline is staffed by registered nurses with telenursing training, who are expected to provide:

  • an assessment of health problems, advice on the most appropriate level of treatment, and a recommended time frame for receiving that treatment;
  • advice on self-care and symptom management;
  • advice on preventing illnesses;
  • health information (for example, information about diseases);
  • information about the availability and location of health care services; and
  • immediate transfer of the call to emergency services.

1.27
Healthline is delivered by a contracted service provider and funded by the Ministry. It uses a computerised decision support system and has an electronic health topic library for general health information. In the 12 months to 31 March 2010, Healthline received 360,161 calls.

1.28
Some general practices also use the services of a private telephone advice service after hours. These practices can divert their telephones to this service. When a patient phones the practice number, the telephone service will answer the telephone in the name of the practice and provide information that is tailored to the caller's local services and situation.

Other services

1.29
Other services, such as pharmacies, diagnostic facilities, and ambulance services, may also be available after hours.

1: During the course of our work, the Otago and Southland DHBs were amalgamated. There are now 20 rather than 21 DHBs. However, at the time of our audit fieldwork, the planning documents for these DHBs were separate. We therefore treat Otago DHB and Southland DHB as separate entities.

2: Ministry of Health (2006), 2006/07 Operational Policy Framework, Ministry of Health, Wellington, page 120.

3: Many of the providers of after-hours services are private businesses. DHBs cannot control or direct where or how those businesses operate, but they are required to work with PHOs and take a lead role in planning for after-hours services.

4: Conditions that can get much worse if not treated quickly can include asthma, gastroenteritis, diabetes, respiratory infections, and skin infections.

5: Working Group for Achieving Quality in Emergency Departments (2009), Recommendations to Improve Quality and the Measurement of Quality in New Zealand Emergency Departments, Ministry of Health, Wellington.

6: In 2004, the Government set up a working party to look at the provision of after-hours primary health care. The report of the After Hours Primary Health Care Working Party, Towards Accessible, Effective and Resilient After Hours Primary Health Care Services: Report of the After Hours Primary Health Care Working Party, was published in July 2005. It "made fifteen recommendations aimed at ensuring accessible and effective after hours primary health care services and strengthening their resilience" (see www.moh.govt.nz).

7: After Hours Primary Health Care Working Party (July 2005), Towards Accessible, Effective and Resilient After Hours Primary Health Care Services: Report of the After Hours Primary Health Care Working Party, Ministry of Health, Wellington, section 2.2, page 2.

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