Part 5: Transport considerations in after-hours plans

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

In this Part, we discuss:

Summary of our findings

Transport barriers are another access issue that we expected DHBs to consider in their after-hours plans. People's access to after-hours services can be affected by the transport options in their particular location, including their access to motor vehicles or to public transport. Older people, in particular, can have difficulty accessing after-hours services because of transport barriers.

Most DHB after-hours plans identified transport barriers and actions to address those barriers, but the plans varied widely in how extensively they addressed these. In our view, if DHBs' after-hours plans were more specific about the types of transport barriers and who they affect, DHBs and after-hours service providers could better identify where and how they could help patients to access services.

DHBs, where within their influence, need to better identify, consider, and respond to access barriers other than affordability – such as transport barriers – when planning, funding, and providing after-hours services.

What district health boards were required to do

The 2009/10 Operational Policy Framework states that:

DHBs are required to work with PHOs to: …
Ensure their population can access First Level Primary Care Services 24-hours a day, 7 days a week.17

We expected that DHBs, in leading the planning for after-hours services, would collect and analyse information to determine whether there were any transport barriers that would prevent patients from accessing after-hours services. We looked in DHBs' after-hours plans for this information.

We also reviewed DHBs' after-hours plans to see whether DHBs proposed any action to address transport barriers. However, we did not expect that they would always be able to do so, because some decision-making about the way after-hours services are delivered rests with PHOs, and because some barriers – for example, the extent of the roading network – are beyond the DHBs' ability to address.

Identifying and addressing transport barriers

Most DHBs could improve how they identify barriers that could stop patients from getting to after-hours services. They could include clearer and more specific information about any actions that they or others intended to take to address these barriers.

Identifying barriers

Most DHBs identified transport barriers to some extent. Those DHBs with more advanced identification of transport barriers had identified particular communities most likely to be affected by the barriers. The findings and examples in this Part are intended to assist DHBs in further considering transport barriers and including more specific information about them in their after-hours plans.

The extent to which DHBs identified transport barriers in their after-hours plans varied widely. In summary:

  • 12 DHBs provided some information about the nature of transport barriers in their district;
  • one DHB identified "transport" as an issue, but did not provide any details about the nature of the problem;
  • two DHBs provided vague information that implied transport problems, but stopped short of stating whether there were problems or not; and
  • six DHBs did not identify any transport problems.

For the 12 DHBs that provided some information about the nature of transport barriers, the most common barrier identified was travel distance/time.

For example, Northland DHB discussed after-hours issues on a geographic basis, by PHO. As part of this work, the DHB commented briefly on transport arrangements in place and geographic constraints, including the amount of travel time required for some patients from specific areas.

Three DHBs' plans specified which communities were most affected by transport barriers. For example, Lakes DHB identified a particular township, Turangi, where residents usually have to travel 45 minutes to reach after-hours services in Taupo. The DHB noted that travel to and from Taupo was a problem for some Turangi patients, and its proposal indicated that the problem related to travel cost. We considered this information useful because it set out which community was affected and the reasons why.

Four DHBs' plans identified that the availability of motor vehicles could be a barrier to accessing after-hours services. Another DHB identified a high percentage of households in the district without access to a motor vehicle. We looked at whether there were any particular areas affected by motor vehicle access. Figure 8 sets out our results. Our analysis showed that only a very small number of people were living in areas where a relatively high proportion of households did not have access to a motor vehicle and were some distance from after-hours services.

Figure 8
Analysis of whether there are particular areas within districts with low motor vehicle ownership

We carried out our own analysis to see whether there were areas where a relatively high proportion of households did not have access to a motor vehicle and were some distance from after-hours services. We looked for extreme examples.

We used 2006 Census information by meshblock for each district to see if there were any meshblocks where at least half the households did not have access to a motor vehicle. A meshblock is the smallest geographic unit that Statistics New Zealand uses for recording census information.*

We did this to assess where people in particular areas might have the most difficulty getting to after-hours services. We acknowledge that there will be people without access to a vehicle in meshblocks with relatively high levels of car ownership.

Twenty of the 21 DHB districts had at least one meshblock where at least half the households did not have access to a motor vehicle. Almost all these meshblocks were within, or close to, urban centres or townships, and most of them were in Auckland, Wellington, and Christchurch. The residents in these areas did not usually have far to travel to the nearest service, although in most cases it is likely that they would need some form of transport to get there.

There were few meshblocks in rural areas where at least half the households did not have access to a motor vehicle. They were all in the North Island. There were:
  • two small rural areas in different districts some distance (roughly 15km and 30km) from after-hours services where at least half the households did not have access to a motor vehicle; and
  • two small rural areas in another district where at least half the households did not have access to a motor vehicle. After-hours services were located in, or very close to, one of these areas. The other area was about 25km away from the nearest after-hours service.

* Statistics New Zealand's website ( stated: "The size of a meshblock depends primarily on the number of people and type of area covered. Generally, meshblocks in rural areas have a population of around 60 people, while in urban areas meshblocks are roughly the size of city blocks and contain approximately 110 people. The meshblock pattern changes slightly every year, but for most statistical purposes a five-year update to coincide with each census is sufficient. At the time of the 2006 Census of Population and Dwellings there were 41,376 meshblocks ...".

A few plans stated or implied that transport costs could be a barrier for patients accessing after-hours services. This is not unexpected because there are fewer after-hours services than daytime services. The after-hours services may be further away and more expensive to travel to.

Public or other transport may not be as available after hours as during daytime hours, which means more expensive forms of transport may be used – for example, a taxi or ambulance instead of a bus or private car. Using an ambulance may have cost implications for the individual in some areas, and may result in the patient being unable to easily return home.

Addressing transport barriers

Most DHBs' plans had identified actions that the DHB or others intended to take to help patients with transport issues. In many cases, DHBs' after-hours plans could be clearer about what action was to be taken.

Seven of the DHBs identified clear actions that would go at least some way to addressing the transport barriers identified within their after-hours plans. Nine DHBs' plans included actions that the DHB implied that it or others might take to address any transport barriers.

Initiatives to address transport barriers that DHBs had implemented or proposed included:

  • planning the location of after-hours services to minimise travel distances for residents;
  • providing transport subsidies for patients to travel to after-hours services (several DHBs proposed to explore this) or for home visits;
  • formal home visiting services; and
  • discussing transport issues with ambulance providers.

Several DHBs stated in their plans that the use of telephone advice services will allow some patients to access after-hours services without the need for travel.

Nine DHBs had limited or no identification of transport barriers in their after-hours plans. Half of these plans included vague descriptions of actions that DHBs or other parties might take to help patients with transport issues. It was not clear from the plans whether the DHBs or other parties intended to take any action.

Services for people unable to travel to after-hours services

DHBs need to provide clearer information in their plans about issues and services for patients unable to travel to after-hours services.

In addition to mobile patients without access to transport, older people may not be able to travel to after-hours services because of immobility or general frailty.

Eleven DHBs referred to travel barriers for older patients in their after-hours plans. This information was usually brief. There was seldom clear information about the location and number of people who could be affected by such barriers.

The clearest information we saw about barriers for patients unable to travel to after-hours services included brief information about the needs of older people and/or contextual information about gaps in the current service. For example, Capital and Coast DHB provided information about variability in care arrangements at rest homes and it had actions planned to address this.

One DHB, which had reviewed its house-call services in 2009, told us that this is a difficult matter to address because the cost of providing after-hours services for those not able to travel is high, and only a very small group of patients need the service.

It is important that DHBs have a good idea of the general location and number of patients unable to travel to after-hours services, including the reasons why they are unable to travel. DHBs need this information to identify whether they have enough services in place, and whether any changes to services would have adverse effects on these patients.

Home visiting services

It was often not clear whether home visiting services were available as part of after-hours services. Five DHBs stated in their plans that after-hours care arrangements included an option for home visits by GPs. Another DHB identified provision for home visits by a district nurse. Another DHB proposed arrangements for a mobile after-hours service for rest homes.

Several other DHBs had unclear or ambiguous information in their after-hours plans about whether formal home visiting services were available. Many plans included some information about co-payments for house calls, but there was not always enough information to determine the extent of home visiting services in a district.

Older people

Older people, including those living in rest homes, may not be able to travel to after-hours services because of general frailty or mobility difficulties. It may be difficult for older people, especially those living alone, to travel to services during the night, even where transport is available.

It is important that DHBs record information in their after-hours plans about issues that older people are likely to encounter in getting to, or otherwise accessing, after-hours services. This information will help to identify whether there are fundamental problems for this group of people in accessing services and where the effectiveness of services can be improved. It is also important information for decision-makers to consider if they are changing the way that after-hours services are arranged.

Overall, DHBs' after-hours plans needed to consider transport barriers for older people more. Only a few plans considered difficulties that older people may have accessing after-hours care.

In summary:

  • four DHBs' after-hours plans discussed transport issues for older people and/or issues for older people accessing home-based services after hours;
  • seven DHBs broadly identified in their after-hours plans that older people can have difficulty accessing after-hours services, but provided little further detail;
  • one plan proposed work to identify barriers for older people accessing after-hours care;
  • one plan proposed a separate project to prepare a comprehensive management plan for providing after-hours care within rest homes; and
  • eight DHBs' after-hours plans did not identify issues for older people. However, some of these plans identified services in place – for example, home visiting services.

Several DHBs that identified broad or specific issues for older people proposed some actions to address the issues. These included:

  • providing subsidies for home visits;
  • review of care planning within rest homes – for example, whether well-qualified staff are always available; and
  • a taxi fund for patients who would otherwise require a home visit.
Recommendation 2
We recommend that district health boards, where it is within their influence, better identify, consider, and respond to access barriers other than affordability – such as transport barriers – when planning, funding, and providing after-hours services.

17: Ministry of Health (September 2009), 2009/10 Operational Policy Framework, Ministry of Health, Wellington, page 42.

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