Part 4: Affordability considerations in after-hours plans

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

In this Part, we discuss:

Summary of our findings

Some patients need to pay more for after-hours services than for daytime services. DHBs' after-hours plans showed that co-payments (what a patient pays) for a visit to an after-hours service range from $0 to $95 for New Zealand residents.

Most DHBs' plans identified broad affordability issues and identified actions under way or proposed to address at least one aspect of the affordability of after-hours services. However, in our view, DHBs need to do further work to identify specific affordability issues in their districts, including identifying those population groups most affected by affordability issues.

What district health boards were required to do

In line with the 2009/10 Operational Policy Framework, which was in place when we carried out our audit fieldwork, DHBs are required to work with PHOs to ensure that affordable primary health care services are available. The 2009/10 Service Coverage Schedule holds DHBs accountable for PHOs providing "access to Essential Primary Health Care services at low or reduced cost to their enrolled populations according to fees that they notify to the DHB".13

In our view, it is reasonable to expect that after-hours services may be in a different location with different operating costs from daytime services. However, we expected that DHBs would collect and analyse information to determine whether there were any affordability barriers that would prevent patients from accessing after-hours services. If such barriers existed, we expected the DHBs to have identified actions they would take to reduce or remove those barriers.

We reviewed DHBs' after-hours plans to see whether DHBs had proposed any actions they would take to reduce or remove – or encourage others to reduce or remove – affordability barriers. Some decision-making about the way after-hours services are delivered rests with PHOs,14 and some barriers are beyond the DHBs' ability to address.

Cost of after-hours services

Some patients need to pay more for after-hours services than for daytime services. DHB plans show that co-payments for a visit to an after-hours service ranged from $0 to $95.

Typically, co-payments for after-hours services depend on what service the patient uses, the age of the patient, whether they are enrolled with the PHO, and whether they have a Community Services Card or High Use Health Card. Patients may also need to pay more for pharmaceuticals after hours.

Co-payments for after-hours services for New Zealand residents reported in DHBs' after-hours plans ranged from $0 (for example, at hospital emergency departments15 and – at some general practices – for children under six years of age) to $95 (for visits to some GPs or to some accident and medical centres). The DHB plans showed that temporary visitors to New Zealand and patients requiring home visits could expect to pay considerably more than this for after-hours services in some districts.

Figure 6 shows some examples, from DHBs' after-hours plans, of the higher costs a patient might need to pay for after-hours services.

Figure 6
Examples of higher costs a patient might need to pay for after-hours services

Nelson Marlborough DHB – Funding application to Ministry of Health for urgent after-hours primary health care services (1 May 2009):

… patients accessing PHC [primary health care] services after-hours have higher out-of-pocket expenses which may include higher consultation and prescription costs compared to regular general practice. For example, an enrolled patient paying $27-$30 for a daytime service with their regular General Practitioner (GP) and $3 at the chemist for the prescription, would pay $65-$70 for the GP service and $15 … for the prescription in a similar setting during evening hours. This represents a $50 increase for the service.
Otago DHB – Proposal for after-hours primary health care services (April 2009):

In Otago, an enrolled patient paying $23-$30 for a daytime service with their regular General Practitioner (GP) can pay up to $90 co-payment for an after-hours consultation.

How DHBs reported co-payment information within their after-hours plans varied and was not always clear. This meant that we cannot provide further detail on the variation of co-payments for all DHBs. Further, two DHBs did not include information about after-hours co-payments within their plans, and one included very limited information.

It is useful for DHBs to include information about co-payments for after-hours services within plans because the level of co-payments is an important factor in determining whether patients can afford to access after-hours services.

Identifying and addressing affordability barriers

DHBs should include clearer and more specific information about affordability barriers in their after-hours plans. The plans showed that most DHBs proposed, or were taking, action to address at least one aspect of affordability.

Identifying affordability barriers

Most DHBs assembled some information within their after-hours plans that would help them draw conclusions about the affordability of after-hours services within their district. This included information:

  • about the socio-economic status of communities;
  • from surveys of the health workforce or residents about barriers to accessing after-hours services; and
  • about the costs of after-hours services for patients.

However, few DHBs drew this information together to reach clear conclusions about affordability barriers within their districts. Figure 7 sets out how well DHBs had identified affordability barriers to accessing after-hours services.

Figure 7
How well district health board after-hours plans identified affordability issues

Number of DHBs Level of identification of affordability barriers within DHB after-hours plans
3 Clear information about parts of the population affected by affordability issues, allowing the extent of affordability issues to be gauged.

Two plans identified transport costs as an issue, and two plans identified telephone ownership as a cost issue.
2 Clear information about where there were no affordability barriers.

These plans noted that patient co-payments were affordable, and not a barrier to access. Both plans implied that the cost of transport was a barrier to accessing after-hours services.
13 Broad identification of affordability issues.

These plans stated that there were barriers to affordability for residents in the DHB district, but did not identify which parts of the population were affected by them.

One plan noted briefly, and two plans implied, that there were issues with transport costs.
3 No identification of affordability issues.

Two of these plans included information that implied potential affordability issues – for example, typical income for residents, after-hours co-payments, and uptake of Work and Income New Zealand grants* to pay for health care. However, the plans did not draw any conclusion about whether affordability was a barrier.

* State financial assistance.

Overall, there was room for most DHBs to use clearer and more specific information about whether affordability barriers were preventing or were likely to prevent some patients from accessing after-hours services in their districts. In particular, most plans could be more specific about:

  • which cost factors most affect a patient's ability to afford services – for example, the cost of getting to after-hours services, paying for the service, or paying for pharmaceuticals; and
  • which communities and population groups were most affected by affordability barriers, and where they lived.

Addressing affordability barriers

Most DHBs identified in their plans actions under way, or actions they proposed to carry out, to address at least one aspect of affordability.

Mainly, DHBs proposed to address affordability issues by keeping patient co-payments low, or by introducing patient subsidies either to after-hours services or through vouchers.16 Twelve DHBs proposed, or had in place, such actions.

Four DHBs proposed, or were considering, schemes to assist patients with travel costs. These schemes included travel vouchers, a hardship fund, and taxi money for older people.

Several DHBs stated in their after-hours plans that they did, or should, advise patients about financial assistance available from Work and Income New Zealand to assist with paying for after-hours services.

About half the plans included actions that the DHB implied it could take to address affordability barriers. It was not clear whether the DHBs intended to take those actions.

Recommendation 1
We recommend that district health boards better identify, consider, and respond to affordability barriers when planning, funding, and providing after-hours services.

13: Ministry of Health, 2009/10 Service Coverage Schedule, page 14.

14: For example, when opening times will be and where PHO members decide to locate their businesses.

15: Subject to eligibility requirements.

16: One DHB proposed having a small number of vouchers at the hospital emergency department for patients to use an alternative after-hours service for free or for a reduced cost. Another DHB proposed having vouchers to enable specific high-needs patients to use local after-hours services at a reduced cost.

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