Part 7: Are after-hours services sustainable?

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

In this Part, we discuss:

Summary of our findings

DHB after-hours plans showed that there were after-hours services in most DHB districts that were struggling to recruit and retain the staff they needed, or struggling financially.

DHBs need to design their service networks to ensure sustainable after-hours service networks. For some, this may mean redesigning their existing after-hours networks.

Risks to the sustainability of after-hours services

Workforce, financial viability, and workload are important factors when considering the sustainability of after-hours services.

Do after-hours service providers have enough staff?

Seven of the 21 DHBs had identified in their plans specific after-hours services that had trouble recruiting and retaining enough staff to be sustainable. Most of the services that DHBs had identified as struggling to recruit and retain enough staff were rural. A further five DHBs noted general issues about recruiting and retaining after-hours staff within their district.

An evaluation of part of the implementation of the Primary Health Care Strategy, published in September 2009,20 reported that 24% of surveyed general practices had vacancies for GPs. The mean duration of the vacancy was eight months. Rural practices were more likely to have at least one vacancy, with 38% having a vacancy at the time of the survey (between August 2006 and June 2007).

The GP workforce is also ageing. A survey of GPs21 reported that, between 1998 and 2008, the average age of GPs went up from 42 to 49.

Can service providers afford to keep providing after-hours services?

Our review of DHBs' after-hours plans showed that 11 of the 21 DHBs had identified specific after-hours services that were facing financial difficulties.

Six of the 11 DHBs that identified services facing financial difficulties were giving extra funding to those services. Two of the six DHBs cited high staffing costs for overnight services as the reason for financial difficulties. The services most commonly supported were accident and medical centres. As examples, Whanganui DHB had provided additional funding to an accident and medical centre in its district, and Auckland and Waitemata DHBs have proposed to provide additional funds to accident and medical centres in their districts.

We observed some DHBs arranging for after-hours funding to be used for emergency departments where they had decided to shift after-hours services into the emergency department.

Workloads for after-hours services

The 2009/10 Service Coverage Schedule holds DHBs accountable for sustainable services in rural areas:

A sustainable service needs to be provided in rural areas. This includes services organised so as to ensure that the DHB will work with local PHOs, communities and providers to develop strategies to enable as far as possible that health practitioners have suitable clinical support, and adequate off-duty, holiday and study time.22

A number of service providers, DHBs, and stakeholders expressed concern that the support for isolated health professionals was often insufficient or fragile. This support included paramedic back-up and the ability to hire a locum (for example, a temporary GP) so that isolated health professionals could have a break from being on call.

We were told that a significant proportion of health professionals without adequate support can "burn out", have great difficulty selling their practices, or simply leave a district. In these situations, the community they serve can be left without a replacement GP. This in turn can increase the workloads of nearby health professionals and may, in some instances, result in people having to travel further to services, including after-hours services.

How were district health boards addressing the sustainability of their after-hours services?

DHBs were implementing a variety of measures to address the sustainability of their after-hours services. These included reducing workloads, using telephone advice to reduce face-to-face consultation, and consolidating services.

Reducing workloads

The Ministry of Health (the Ministry) told us that it had funded, through a contract, the recruitment cost of GPs that rural practices could employ as locums for up to two weeks a year. The Ministry also has funding available for rural practices – for example, workforce retention funding to assist with retaining and recruiting primary health professionals in rural communities.

An important factor in the workload for an individual GP or nurse is the frequency with which they are rostered on call to provide after-hours service. Generally, the more health practitioners participating in a roster, the less frequently an individual is required to be on call or to deliver after-hours services.

Most DHB plans stated, or DHBs told us, that there were roster arrangements in place between several general practices to provide after-hours services for particular areas of their districts.

Several DHBs had proposed action to improve the workloads of staff carrying out after-hours work.

For example, West Coast DHB identified that it had a significant and ongoing GP shortage. To increase the number of practitioners available to share after-hours rosters, the DHB proposed to fund advanced training for nurses. Otago DHB proposed to provide a specialist nurse development programme to support nurses participating in after-hours rosters. Nurses were already an established part of after-hours networks in the Southland, Wairarapa, and West Coast DHB districts.

Using telephone advice to reduce face-to-face consultations

Using telephone advice services has the potential to make after-hours workloads more manageable if it results in more patients receiving the right care in the right place at the right time. But telephone advice does not reduce the need for there to be a GP or nurse available for those patients who need to be seen face-to-face after hours.

We note that Healthline, among other things, is required to provide:

… information and advice to help the caller decide on the type of health care they or other person needs and in particular, advice to callers on self-care or advice on where they should go for diagnosis and treatment and the timeframe within which this should occur; [and] information on the availability (including time) and location of health care services, including after-hours primary health care and other services …23

We also note that some GPs have contracted with other providers of after-hours telephone services (see paragraph 1.28).

We consider that telephone advice, including advice about how urgently a person needs care, can make after-hours services more sustainable, but note that it is not the whole solution.

Consolidating services

Fourteen of the 21 DHBs were trying to make their services more sustainable by reducing the number of after-hours services available, which therefore reduces the need for resources. This typically took the form of either drawing several rosters together into a single larger roster or shifting to the "hub and spoke" model.

The hub and spoke model consists of extended hours by general practices, followed by overnight services provided from a central "hub". The hub is usually a hospital's emergency department. Many of the 21 DHBs were using some form of hub and spoke model.

Potentially, this model can involve the DHB having a more sustainable service, but at the cost of longer travel times for patients. Part of the justification for the hub and spoke model is that it reduces the burden on GPs.

There are examples of a hub and spoke model in Thames, Tokoroa, and Taumarunui. GPs in these areas are available until 10pm or 8pm (depending on the local arrangement), and then the rural hospital in each town provides after-hours services overnight.

Consolidation does not remove the need to provide services to isolated regions. DHBs had identified that many isolated services were already struggling. Consolidating services cannot always make geographic coverage more sustainable, because not all services can be consolidated.

Planning for peaks in tourist populations

Several DHBs could do more to take account of high visitor numbers when planning for after-hours services.

In our view, all DHBs need to be aware of the effect casual visitors may have on access to after-hours services within their districts. This is because the increased population can affect the sustainability of after-hours services. DHBs should explicitly take this into account when planning the after-hours capacity of their districts.

In response to the recommendations of the After Hours Primary Health Care Working Party, all DHBs agreed to consider the pressure on after-hours services that is caused in some localities by an influx of casual visitors at certain periods.

Our review of DHB after-hours plans

We used regional tourism data to identify which DHBs would be most affected by influxes of visitors. We then reviewed DHBs' after-hours plans to see whether they had identified and were responding to any potential stresses on their after-hours services.

Of the 10 DHBs we considered to be most affected by casual visitors, eight had identified it as an issue in their plans. Two other DHBs' after-hours plans also mentioned the effect of casual visitors.

However, only two of the 10 that we considered were most affected (Otago DHB and Southland DHB) had planned any initiatives to address the issue.

Figure 10 lists the DHBs we identified as most affected by large numbers of casual visitors and our assessment of how each DHB identified the issue and planned its response.

Figure 10
Our review of district health boards most affected by influxes of casual visitors

DHB Effect of casual visitor numbers Our assessment of how the DHB identified the issue and planned its response
Lakes Significant Issue acknowledged but no action in response.
MidCentral Some Issue not identified.
Nelson Marlborough Significant Issue acknowledged but no action in response.
Northland Some Issue acknowledged but no action in response.
Otago Some Issue well acknowledged and some initiatives in response.
South Canterbury Some Issue not identified.
Southland Significant Issue well acknowledged and some initiatives in response.
Tairawhiti Some Issue acknowledged but no action in response.
Waikato* Some Issue acknowledged within the after-hours plan, but no action specified within the plan. The DHB subsequently told us that it had provided additional funding over the last eight years to PHOs and to Thames Hospital to fund locums to cope with the high number of patients presenting for primary medical services between Christmas and New Year. It has also funded the Order of St John to provide increased weekend paramedic cover.
West Coast Very significant Issue well acknowledged and some action in response. The DHB noted that work in this area will need to be ongoing.

* Although the figures show that, overall, Waikato DHB is not significantly affected by casual visitor numbers, its district includes Coromandel and Ruapehu, which experience very high casual visitor numbers. Taking this into account, we consider Waikato DHB to be somewhat affected by casual visitor numbers.

How district health boards could further mitigate risks to the sustainability of their after-hours services

DHBs need to design their service networks to ensure sustainable and accessible after-hours service networks. For some, this may mean redesigning their existing after-hours networks.

In our view, the DHBs have largely been responding to the current after-hours challenges. We are concerned that this may not be enough to sustain after-hours service coverage in the future. At the time of our audit fieldwork, three of the 21 DHBs were comprehensively reviewing their after-hours arrangements so that they could address the challenges of the future.

The 2005 report of the After Hours Primary Health Care Working Party also recommended that:

DHBs, in collaboration with PHOs and after hours service providers (both PHO member practices and where applicable, Accident and Medical Clinics) and Emergency Departments (EDs) … develop and implement a planning and funding strategy for after hours primary health care for their district, including rural communities, that enables accessible, effective and resilient after hours primary health care services for all service users within current resources …24

During our document review, we noted DHBs making significant efforts and changes to implement this recommendation. However, we consider that DHBs have further work to do in designing services to meet the recommendation's stated aim of enabling accessible, effective, and resilient after-hours services.

Recommendation 3
We recommend that those district health boards not already doing so, comprehensively review and, where necessary, redesign their after-hours service networks to ensure that those networks will be more sustainable in the future.

20: Raymont, A and Cumming, J (2009), Status and Activities of General Medical Practices, Health Services Research Centre, Wellington.

21: The Royal New Zealand College of General Practitioners (November 2009), 2008 RNZCGP Membership Survey: The general practitioner workforce, Current Demographics, Emerging Trends, The Royal New Zealand College of General Practitioners, New Zealand.

22: Ministry of Health, 2009/10 Service Coverage Schedule, page 15.

23: From Schedule E of the Healthline contract between the Ministry of Health and McKesson New Zealand Limited.

24: 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, Executive Summary and Recommendations, pages iv-v.

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