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Health Feature_Title copyIMG_1648 copyWhen Debbie Ley­land goes to see her GP in New­town, it can be a stress­ful busi­ness, and she doesn’t always feel able to pick up her pre­scrip­tion straight away. So she gets the GP to fax it to the phar­macy. For that, they charge her $5. Then, when she goes to pick up the pre­scrip­tion, the phar­macist charges her anoth­er $5 for receiv­ing the fax. In short, she has to pay $10 a pop for two parts of the health ser­vice to use the most anti­quated form of com­mu­nic­a­tion still in semi-reg­u­lar use; $10 that, as a sick­ness bene­fi­ciary, she can ill afford; $10 that needed to be spent on food, or heat­ing, or transport.

This story is just one among thou­sands that sug­gest all is not well with Wellington’s health­care sys­tem. Offi­cial fig­ures show that a third of res­id­ents — more than 80,000 people — are unable to get the health­care they need. That’s the worst record of any of New Zealand’s major centres. Many people either can’t afford the cost of a vis­it to a health clin­ic or simply can’t get in front of a doc­tor. And the health centres serving the poorest areas are either strug­gling to main­tain ser­vices in the face of severe fund­ing cuts or rais­ing vis­it fees. Unsur­pris­ingly, the num­ber of people unne­ces­sar­ily turn­ing up to hos­pit­al A&E depart­ments is rising. How, some are ask­ing, has this happened, and why isn’t more being done about it?

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One of those sound­ing the alarm the loudest is Don Math­eson, a pro­fess­or of pub­lic health at Mas­sey Uni­ver­sity. Many of Wellington’s health prob­lems, he argues, stem from offi­cials not get­ting the bal­ance right between the dif­fer­ent parts of the sec­tor. In health, an import­ant dis­tinc­tion is drawn between primary care, which includes things like health centres and GP clin­ics, and sec­ond­ary care, which involves the com­plex oper­a­tions that take place in major hos­pit­als. While both kinds of care mat­ter, experts like Math­eson argue for a great­er stress on primary care, for two reasons.

The first is about equity: primary care makes the biggest dif­fer­ence to the region’s most deprived com­munit­ies — which tend to be found in places like New­town, parts of Lower Hutt and east­ern Pori­rua — because the dis­eases of poverty are very often best treated by GPs. The second reas­on is about effi­ciency: primary care is often the most effi­cient way to treat patients, giv­en that it is far cheap­er to provide a GP appoint­ment than to have someone turn­ing up in A&E.

Mak­ing sure every­one can see a GP when they need to is a struggle for any health sys­tem, Math­eson says, point­ing to what he calls New Zealand’s “deeply embed­ded” health inequal­it­ies. Māori and Pacific com­munit­ies and women have always been par­tic­u­larly dis­ad­vant­aged. But, he says, the situ­ation is worsen­ing. His con­cerns are sum­mar­ised in the title of a report he wrote last year, ‘From great to good: how a lead­ing New Zea­l­and dis­trict health board lost its abil­ity to focus on equity dur­ing a peri­od of eco­nom­ic con­straint’. Up until 2008, which brought both a glob­al fin­an­cial crisis and a change of gov­ern­ment, the Cap­it­al and Coast Dis­trict Health Board (CCDHB) had been lead­ing New Zea­l­and when it came to improv­ing health­care for those who most need it, he argues.

But in response to cent­ral gov­ern­ment tar­gets and tight­er fund­ing, the board, which serves 250,000 people in Wel­ling­ton city, Pori­rua and the Kapiti coast, switched its focus to hos­pit­al ser­vices at the expense of GP clin­ics. “Over the pre­vi­ous [pre-2008] peri­od, the board had tried to invest in redu­cing bar­ri­ers and improv­ing access for high-needs com­munit­ies, but this was a board ini­ti­at­ive, not cent­ral gov­ern­ment,” Math­eson says. “So then the pres­sure came on, and they began to dis­in­vest in any­thing the Nation­al gov­ern­ment wasn’t inter­ested in.”

Indeed, Matheson’s cal­cu­la­tions in ‘From great to good’ showed the pro­por­tion of CCDHB fund­ing going to primary health­care stuck at a “very low” 6 per­cent dur­ing the past five years, des­pite the clear need for great­er invest­ment, while hos­pit­al ser­vices took an increas­ingly large slice of the budget. Partly to blame, Math­eson argues, are the government’s health tar­gets, which stress either hos­pit­al ser­vices — such as more hip oper­a­tions — or GP ser­vices that are rel­at­ively easy to meas­ure, such as the num­ber of people who have been giv­en advice on quit­ting smoking. Not tar­geted are things like ambu­lat­ory sens­it­ive hos­pit­al­isa­tion (ASH) rates — in essence, the num­ber of hos­pit­al admis­sions that could have been avoided with bet­ter treat­ment else­where in the sys­tem — or “unmet health need”, which meas­ures the extent to which people are miss­ing out on health­care. As a res­ult of this shift in focus, Math­eson argued in ‘From great to good’, “hos­pit­al sec­tor expendit­ure grew rel­at­ive to the primary health care sec­tor… the his­tor­ic­al pat­tern of inequit­able access to primary care per­sisted, and unplanned admis­sions to hos­pit­al grew, sug­gest­ing increased inef­fi­ciency in the board’s operations.

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CCDHB’s dir­ec­tion dur­ing this peri­od… became increas­ingly focused on the Min­is­ter of Health’s tar­gets. This nar­row­ing of focus crowded out the pre­vi­ous focus the board had on equity for the pop­u­la­tion that it serves. While pre­vi­ously it had led per­form­ance in address­ing equity, it is now act­ively dis­in­vest­ing in the pro­viders that helped secure that lead­er­ship pos­i­tion.” One effect of that “dis­in­vest­ment” — in which $10 mil­lion was cut from primary care ser­vices in 2010 — was a sub­stan­tial reduc­tion in fund­ing to the New­town Uni­on health centre, which works with low-income, high-needs pop­u­la­tions. The effects of those cuts, Math­eson says, have been “quite disturbing”.

Over at CCDHB, Dr Ash­ley Bloom­field, who works on primary health ser­vices across Wel­ling­ton, the Hutt Val­ley and Wair­ar­apa, dis­agrees with many of Matheson’s argu­ments, espe­cially around tar­gets. “Tar­gets do have their dis­ad­vant­ages,” he says — they can “pre­clude a focus on invest­ments that might be import­ant to cer­tain pop­u­la­tions”. But they have “really helped primary care focus on some of the key out­comes.” He points to “start­ling” improve­ments in immun­isa­tion rates and steady increases in the num­ber of heart dis­ease and dia­betes checks being car­ried out.

Although primary care fund­ing hasn’t increased as a pro­por­tion of total spend­ing, the actu­al dol­lar amount going to those ser­vices has increased con­sist­ently over the last five years, Bloom­field says — and this des­pite the DHB slash­ing its long-stand­ing and large fin­an­cial defi­cit. It has also intro­duced a reg­u­lar report on health res­ults for its poorest com­munit­ies, and plans to get hos­pit­al and health centre ser­vices work­ing more closely togeth­er through a new “alli­an­cing” scheme.

Bloom­field insists that the very high num­bers of people either strug­gling to see a GP or turn­ing up unne­ces­sar­ily at the hos­pit­al “are abso­lutely of con­cern. In fact, it’s a focus for us, and we want to address it. We spend two-thirds to three-quar­ters of our time focused on the very issues that will affect [those] rates.” But Math­eson argues that the DHB’s fund­ing decisions tend to under­mine its stated aims. Too often, he says, “the board’s stra­tegic dir­ec­tion would be ful­some in its com­mit­ment to equity and issues such as the obesity epi­dem­ic, then fol­low with budget­ary decisions to reduce fund­ing for ser­vices provid­ing care to low-income people, and cut the money going into health pro­mo­tion for improved nutrition.”

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There are sev­er­al places that prob­lems with primary health­care can show up, and the first of them is in the health centres that need the fund­ing most. Two years ago, a storm of protest was gen­er­ated when the DHB cut $275,000 (or about 8 per­cent) from the budget of New­town Uni­on, which serves a pre­dom­in­antly poor, eth­nic minor­ity and refugee pop­u­la­tion. (Even big­ger cuts have hit health centres in Lower Hutt: see the box-out, ‘Tough times out­side the mainstream’.)

In response, Debbie Ley­land set up the United Com­munity Action Net­work (UCAN). Des­pite all her cam­paign­ing in the last two years, she remains con­cerned about the health centre’s future. One of New­town Union’s strengths is that it goes well bey­ond being a GP clin­ic: spe­cial­ists from Wel­ling­ton Hos­pit­al spend part of their week there, allow­ing health prob­lems to be dealt with faster and more hol­ist­ic­ally. But since the cuts, the centre has had to scale back on its much-lauded mid­wifery ser­vice, which reaches out to refugee women who would oth­er­wise struggle to get the care they need. New­town Uni­on has also reduced its week­end appoint­ments and scaled back on advocacy work that helps low-income patients deal with an often con­fus­ing and com­plex health sys­tem. Its charge for a doctor’s vis­it, mean­while, has been increased to $15 — an amount many struggle to afford.

The res­ult, Ley­land says, is that New­town “is becom­ing a really unhealthy area, because people can’t afford to get to the doc­tor. It’s hor­rible.” Then there are issues like the fax charges, which she says star­ted about six months ago, though she’s not sure why. “It’s wrong, eh? I’m on a bene­fit… if you fig­ure out the amount it costs for food, for power… for some people, it’s either a loaf of bread and mak­ing sure there is some­thing to eat for the next day — or get­ting their medi­cine. So what are you going to do?”

Eileen Brown, the chair of New­town Uni­on, says the ser­vice does “a bloody good job” on lim­ited fund­ing. The core funds for health prac­tices come from a per-patient pay­ment, based on the amount of health ser­vices used by the aver­age per­son — but Newtown’s pop­u­la­tion is far from aver­age. “We have to do the same things that [centres in] Khan­dal­lah do,” Brown says, “but it’s a far more chal­len­ging pop­u­la­tion we are deal­ing with.” While places like New­town Uni­on get extra funds through the Very Low Cost Access policy and schemes like Ser­vices to Improve Access, the money is “nowhere near the level needed”; inter­na­tion­al research sug­gests they need at least three times as much fund­ing as oth­er health centres.

Recent tar­geted announce­ments from cent­ral gov­ern­ment haven’t amoun­ted to more than about $5 a patient, and over­all in the last few years, Brown says, “we have had no increase in our fund­ing, but of course our costs have increased”. As a res­ult, the centre’s doc­tors and nurses have to take on an increas­ing work­load, risk­ing burn-out and mak­ing it harder to attract staff. Even after cut­ting back on ser­vices, the centre has little room to man­oeuvre. “We are viable,” she says, “but it’s tight.”


Wellington’s primary health­care prob­lems are also starkly exposed in the stat­ist­ics. On the more eas­ily con­trolled meas­ures, such as immun­isa­tion, there has been pro­gress, espe­cially the remark­able feat of clos­ing the gap in immun­isa­tion rates between Māori and Pacific people and the wider population.

The big­ger pic­ture, how­ever, is con­cern­ing. Take the ASH rates, for example, which Bloom­field acknow­ledges are “a key out­come”, since they sig­nal how well the primary health­care sys­tem is work­ing to keep people out of hos­pit­al. While these rates are below the nation­al aver­age, as he points out, they have been get­ting worse since 2008: hav­ing been nearly 20 per­cent bet­ter than the nation­al aver­age, they are now only about 10 per­cent bet­ter. Unplanned hos­pit­al admis­sions, anoth­er indic­at­or of health prob­lems not being effect­ively dealt with in primary care, have also ris­en sig­ni­fic­antly in recent years, from under 22,000 a year to over 25,000 a year. Those extra admis­sions will have cost the DHB around $15 mil­lion, Math­eson calculates.

Finally, there are the region’s troub­ling levels of unmet health need, which at one-third of the pop­u­la­tion — against a nation­al aver­age of just over a quarter — are not only high but show­ing no signs of fall­ing. CCDHB board mem­ber Dav­id Cho­at, a Labour Party mem­ber, says there needs to be “some ser­i­ous work done so that we can under­stand the prob­lem and address it”. But he sees signs of pro­gress, includ­ing a recent com­mit­ment by the board to tackle the issue more vig­or­ously. “I’m really hop­ing that will give us the where­with­al to go for­ward,” he says, “and fig­ure out what is going wrong in our district.”


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