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Primary health care services, free at the point-of-use, are being rolled out nationwide to children under 13 years. Is there also a case for a systematic policy approach to the provision of free primary care access that does not discriminate by age? This is a call-to-action paper by a group of general practitioners, past and present, at free clinics across the country. Free clinics are a rarity in New Zealand and comprise a special subgroup of third sector (non-government, non-profit) clinics. In an email and telephone survey of Primary Health Organisations (PHOs) and primary care governance teams in regions without a PHO, we found 18 primary care clinics currently offering free general practitioner consultations for patients of all ages (Figure 1). We advocate for a more systematic approach to delivering free primary care services for populations with the poorest access to, but the most need for, these services. We are writing to policymakers, clinicians in governance roles, and general practitioners who wish to improve primary care access for vulnerable populations.Figure 1: Locations of free clinics in New Zealand First, we describe the target population of free clinics as those patients most disadvantaged towards health care access and health outcomes in New Zealand. We then give examples of how the collective power of general practitioners greatly influences the effectiveness of primary health care policy targeting vulnerable patients. Finally, we discuss non-profit clinics serving vulnerable patients, the limitations of these clinics, and the role free clinics might play as a special subgroup of third sector clinics.Free clinics serve a particular target populationFifteen percent of adults, and 6 percent of children in the most recent New Zealand Health Survey reported not visiting their general practitioner because of cost in the previous 12 months.1 These figures were higher for Mori adults (25%), Pacific adults (21%), and adults living in neighbourhoods with the most deprived NZDep2006 quintile (22%).1 Groups disadvantaged with respect to primary care access socioeconomically-deprived individuals, and Mori and Pacific people have higher primary care-preventable hospitalisation rates than other demographic groups in New Zealand.2 While patients with the above socioeconomic characteristics are overrepresented at free clinics, these characteristics do not adequately identify the target population of free clinics who in our experience are typically the worst-off of the worst-off . Low-income status is by itself an insufficient descriptor of our target population. Rather than poverty per se, it is the deprivations in living conditions relative to wider society that matter for health and well-being. However, our patients are not just socioeconomically deprived, but also marginalised, vulnerable and high-needs, with whom complex consultations are common, and for whom poorer health outcomes as well as health inequities are the norm. Vulnerability describes the co-occurrence of a persons exposure to risks and adverse events, and their susceptibility to harm arising from a limited capacity to adapt to these challenges.3 Vulnerability is both chronic and cumulative across the life trajectory of individuals. In families, vulnerability traits are transmitted between successive generations. Unstable accommodation, teenage parenthood, a history of childhood trauma, health-damaging risk behaviours, and comorbid mental illness and substance abuse are examples of vulnerability factors prominent in our patient populations.At the surface, our patients have high rates of use and non-use of health services. The labels high-needs patients and high users are often used interchangeably. While the literature does not contain a robust definition for the term, we recognise our patients as high-needs by the complex mixture of ill-health and social problems they struggle to cope with. Consultations with this heterogeneous group of patients are usually complex and challenging. Complexity in the health care context refers to the patient-specific factors that interfere with the delivery of usual care and decision-making for whatever conditions the patient has ,4 a concept having dimensions of depth (severity of need) and breadth (range of needs).5 Complexity predisposes to a mismatch between the patients needs and the capacity of health services to support those needs.6The above factors are associated with a range of negative health outcomes in our target population. Multimorbidity, the coexistence of two or more conditions without a specific disease being the index condition,7 is prevalent among our patients, especially concomitant physical and mental disorders. Multimorbidity also develops at a younger age for our patients. These factors result in our patients bearing a disproportionate share of mortality and health care events compared with patients at other clinics. Because these health inequalities stem from social stratification and health care access barriers that are both avoidable and unfair, they are deemed health inequities.8 In the rest of this paper, we consider how the interactions between government and general practice have contributed to health inequities for our target population, and how this may be redressed.The target populations of free clinics are underserved by the health systemWe believe that the health care needs of the target population of free clinics have been inadequately catered for throughout New Zealands recent history, largely because of the primary care cost barrier. Our main concern is that nationally, general practitioners and government have been unsuccessful in collaborating to remove this barrier for our target population. Our subsidiary concern is that existing mechanisms to reduce the cost barrier - the Community Services Card scheme, Very Low Cost Access funding, and discretionary discounting of general practitioners fees - have been inadequate in securing primary are access for those most likely to experience unmet health care needs.Free competition usually unattainable in the health care market, and the target populations of free clinics do not as a general rule participate effectively in such a market. Income poverty and reduced health literacy prevent such patients from obtaining services commensurate to their health needs in an open market. Discretionary discounting by general practitioners of their fees, while important for offsetting these disadvantages for vulnerable patients, has become less frequent over time,9,10 and is concentrated in paediatric and older persons.11 Discounting operates on an ad hoc basis, and financial and other considerations may prevent this practice from becoming more widespread.The extent of market failure in health is a strong argument for the state playing a leading role in the regulation and provision of health services.12 This applies especially to segments of the population for whom health services are undersupplied privately. Existing policy interventions to redress market failure have been only partially successful. Targeted funding through the Community Services Card (CSC) scheme does not fully compensate for the effect of socioeconomic factors, so low-income status and Mori/Pacific ethnicity are not associated with increased primary care utilisation commensurate to health status.13 Uptake of CSCs is incomplete among the eligible population,14 and even among CSC holders unmet health need is prevalent because of cost.15 The aim of the 2006 Very Low Cost Access (VLCA) scheme was to ensure low patient fees at participating general practices, whose enrolled populations were stipulated to consist of at least fifty percent high needs patients (Mori and Pacific patients, and those living in NZDep quintile 5 areas). However, a large proportion of patients who typically have lesser health needs benefit from capped fees at such clinics, and since the early years many clinics receiving VLCA funding did not have the required proportion of high needs patients.16 Serving patients who by definition have complex clinical needs but limited ability to pay also threatens the financial viability of VLCA clinics, especially since VLCA funding typically does not fully meet operating costs.16Government policy is constrained by political processes,17 since policy is promulgated mindful of the governments popular mandate. Government services cater to the demands of the median voter; poverty is also associated with reduced political participation. So, even in the presence of demand from large minority groups for specific services, there may be little public provision of those services. Government failure thus occurs when demand for particular goods and services is not adequately met by the state or the public sector. The fractious relationship between general practitioners and government has at times in New Zealands history limited the effectiveness of health policy aimed at reducing patient copayments and improving primary care access for socioeconomically deprived patients.In the mid-1930s, only 25% percent of general practitioners18 entered government contracts as part of the First Labour governments proposed national health insurance scheme that would provide general practitioner services free-of-charge to all patients.19 The government was forced to rescind their prohibition of general practitioners charging their patients fees,18 allowing a fee-for-service scheme to operate in parallel with the capitation scheme. In the 1990s, rather than stimulating competition within the primary health care sector, the neoliberal health reforms catalysed the formation of Independent Practitioner Associations as a means of aggregating the negotiating power of general practitioners to secure funding contracts in the new health marketplace. In the implementation of the Primary Health Care Strategy (PHCS) in the 2000s, the government eschewed statutory regulation of fees charged to patients.20 In the post-2008 era, the longstanding distrust between government and general practice21 as well as the mismatch between policy initiatives and the economic realities of operating general practice clinics as private businesses22 prevented the abolition of user fees in primary care and many policy aspirations from being fully realised.The implementation of government primary care policies for children clearly illustrates the power dynamic between general practitioners and government. The government initiative in 1985 to substantially subsidise primary care visits for all children was successfully blocked by the New Zealand Medical Association, who opposed the proposed patient copayment ceiling accompanying the scheme. A decade later, after intense lobbying by general practitioners, the 1996 free child health care scheme did not restrict the fees charged by general practitioners. Although the Zero Fees For Under Sixes package in 2007 did not guarantee universally free primary care for children less than six years during normal working hours, it achieved nearly complete uptake among general practices. Participation by general practitioners was similarly voluntary in the schemes expansion to provide free after-hours primary care services for children under six years in 2011, and free primary care services during normal working hours for children under thirteen years more recently. Whether increased subsidies with these policy initiatives fully cover consultation costs is likely to be a key determinant for general practices committing to providing free services to children.Third sector clinics are not a viable solution for the primary health care needs of vulnerable populationsGiven the combination of market failure and government failure as above, the need for third sector clinics has continuously existed in New Zealand. Crampton defines the third sector as non-government and non-profit.23 He locates third sector agencies within the gap between the state and private sectors, this gap arising because of market failures and deficiencies in existing government-funded services.23 Since unlike for-profit private entities they need not cater to the business interests of their proprietors or shareholders, third sector agencies are better able to provide public goods that benefit populations rather than individuals, and respond to the interests of minority groups.12,24 Unlike government organisations, third sector agencies are able to develop service delivery innovations, unfettered by strict democratic and political accountability structures.12Trade union-sponsored health centres were established in the 1980s, and by Mori, for Mori clinics in the 1990s. Health Care Aotearoa (HCA) formed in 1994, and is a network of third sector clinics sharing as their explicit goals a commitment to the unmet primary care needs of Mori and vulnerable populations.25 Enrolled patients at HCA-affiliated clinics are uncharacteristic of the New Zealand general population in being younger, containing higher proportions of people from ethnic minority groups (36% Mori, 23% Pacific Islander), and being more socioeconomically deprived (55% residing in the most deprived NZDep96 quintile areas).23 Most HCA clinics are located close to their target population, situated either in urban areas with high levels of socioeconomic deprivation, or in medically underserviced, mainly Mori rural areas.23 These clinics offer lower patient fees,24 and are also more likely to provide population-focused preventive care services, as they are capitation funded, which gives financial incentives and the epidemiological tools to deliver these services.26The heavy reliance of third sector clinics on government funding makes the government a key stakeholder for primary care in the third sector.23 Increased accountability to government and pressure to attain those outcomes on which funding is contingent force third sector organisations to reorient their operations towards measurable outcomes and clients for whom funding is available. Where external funding is reduced, services at third sector clinics risk being withdrawn. Also, because funding streams have traditionally been linked to general practitioner services, the loss of general practitioners from third sector clinics is often accompanied by drastic reductions in funding, which may threaten the financial viability of the service. Finally, because on average roughly sixty percent of general practice income is typically drawn from patient copayments,27 third sector clinics that depend mainly on capitation funding may find it insufficient to meet running costs. Serving 1,700 high-needs patients, the Calder Centre is affiliated with the Auckland City Mission and operated at an annual deficit of $300,000 in 2014, preventing them from offering free general practitioner services to their patients (Dimitri Germanov, Calder Centre, personal communication, 18 November 2014).Free clinics are a special subgroup within third sector clinics, and are rare in New Zealand. Of the 1,058 general practice clinics currently in New Zealand (Joyce Brown, RNZCGP, personal communication, 29 October 2014), 296 receive VLCA funding,16 but in our survey only 18 clinics offer general practice services free-of-charge to all age groups. Half of these clinics are located in Special Medical Areas, originally established in 1941 by the government to attract general practitioners to rural and remote geographic areas, under a framework in which the doctors were salaried employees providing services free-of-charge to patients. The resident populations in the Special Medical Areas containing free clinics in our survey Hokianga and Whangaroa in Northland, Opotiki District in the Bay of Plenty, and the East Coast of the North Island are greater than fifty percent Mori, and have high levels of socioeconomic deprivation. Waiheke Islands free clinic and the four free clinics in South Auckland are all located on marae, and the free clinic in Hamilton was formed through merger with a Pacific peoples trust.The future of free clinics in New Zealand is endangered, due to their funding and staffing structures. The free clinics run by Ngti Porou Hauora, an East Coast Mori health provider, have run at a financial deficit since 2011 because capitation funding does not cover operating costs.28 The free clinic in Dunedin is staffed by volunteer clinicians, but likewise operates at a loss.29 Because as discussed above the primary care funding paradigm has consistently been based on patient copayments supplemented by government subsidies, not charging copayments threatens the financial sustainability of clinics whose target populations are vulnerable patients. Clinics providing free services are liable to either close down (Wellington Peoples Centre) or introduce doctors fees for consultations (the Kingdom Clinic in Christchurch).ConclusionAt a national level, the goodwill of local groups makes for a haphazard solution to the unmet primary care needs of vulnerable populations. Across New Zealands history, without sufficiently widespread support from general practitioners, the effectiveness of top-down government initiatives is limited. What is the way forward? In our opinion, the general practitioner community is a major stakeholder in the effort to reduce health inequities. This is because primary care is the linchpin of population health and health systems, and health care itself can, unless it is equitably distributed, contribute to health inequities. We recognise, however, that the prevailing for-profit small business model of general practice in New Zealand is not conducive to removing the primary care cost barrier for vulnerable populations. Our message is therefore targeted at those general practitioners who are interested in expanding primary care for vulnerable groups, and who are willing to adopt new models of funding and delivering primary care services. Collectively, these general practitioners could lead the health systems approach to vulnerable patients, and provide mutual support in what is typically a challenging area to work. It is also this group of general practitioners with whom partnership in policy development is likely to be productive. There is precedent in Scotland, where General Practitioners at the Deep End serving the most severely deprived areas have banded together to achieve shared goals.30 Primary health care access for vulnerable populations should occupy a more central position in health policy development. Whether New Zealand can afford universally free primary health care services is contentious, although we note that one of the reasons for withdrawing hospital user charges in the early 1990s was that administering these charges was costing the government more than simply providing free hospital services.31 Proportional universalism as advocated by the Royal New Zealand College of General Practitioners,32 represents a middle ground between universalism and a fully targeted approach, and involves distributing resources across the whole population progressively according to health need and socioeconomic disadvantage. Low-income households are more likely to require after-hours services than their affluent counterparts,33 but the average cost of an after-hours visit (for example, $44 in 2013 for children over six years)34is prohibitively expensive for the target population of free clinics. Cost barriers outside general practice (such as prescription charges and dental fees) also require attention, and a solution necessarily involves the social welfare and other sectors. New Zealand needs a network of safety-net primary care clinics. The precise policy solutions should be tailored to local circumstances, but will usually involve blending government funding with service delivery by third sector providers. Even where general practitioners are salaried employees, the level of public funding currently available makes the running of third sector clinics financially unsustainable. Regionally, it has been mooted that at least one PHO be given specific mandate for primary care services to high-needs groups, and this function be delegated to District Health Boards where this is not possible.35 Workforce development, such as through the use of nurse practitioners, may enable third sector clinics to better serve vulnerable populations.36 Finally, the shortcomings of safety-net clinics in the United States are instructive in our development of a solution in New Zealand. The majority of such clinics are Community Health Centres, which receive federal government funding, but serve only small numbers of medically uninsured patients, and charge fees on a sliding scale. Free clinics in the United States are fewer in number, and rely on philanthropic funding sources and volunteer clinicians. While United States free clinics see greater proportions of uninsured patients, they tend to be open for limited hours, offer a limited range of services, and their patients are more likely to experience poorer continuity of care. Transferring these lessons to New Zealand, we believe that free clinics make a distinct contribution to that by third sector clinics generally, as free clinics serve vulnerable patients with more extreme levels of need. Even small copayments would result in unmet needs in these groups. Like their American counterparts, free clinics here are under-resourced relative to their task. We assert that funding primary health services for vulnerable populations is a core responsibility of government, and should not be devolved entirely to philanthropic or volunteer-based organisations.

Summary

Abstract

Unmet health care needs and health inequities are prevalent in New Zealand. Throughout New Zealands history, the power dynamic between general practitioners, as a professional group, and the government has contributed to policies directed at primary-care access barriers not being fully realised. This has given third sector (non-government, non-profit) clinics a continuing role in delivering primary care services to vulnerable populations. The viability of free clinics, 18 of which were identified in our survey, is threatened by their funding and staffing structures. We contend that general practitioners have a stake in reducing health inequities and that there is a strong case for a more systematic policy approach to primary health care provision for vulnerable populations in New Zealand.

Aim

Method

Results

Conclusion

Author Information

Lik Wei Loh, PhD Candidate, Department of General Practice and Rural Health, University of Otago, Dunedin; Siobhan Trevallyan, Clinical Director, Waitakere Union Health Centre, Auckland; Stephen J Main, General Practitioner, Hokianga Health, Rawene Hospital, Hokianga; Leo Revell, General Practitioner, Kaute Family Medical Centre, Hamilton; Vivienne Patton, General Practitioner, Kingdom Clinic, Christchurch; Akindele Ojo, Clinical Leader, Ngati Porou Hauora, Te Puia Springs.

Acknowledgements

We are grateful to Prof Sue Dovey, Prof Peter Crampton, and Prof Tony Dowell for their comments during the development of this paper. We wish to acknowledge Mr Bevan Pelvin for his assistance with ArcGIS and the production of the maps in this paper. Any inaccuracies or omissions are the responsibility of the lead author. We also thank Ms Muriel Tunoho (Health Care Aotearoa) for her input into the final draft. We also thank the two peer reviewers who helped us refine the content of this paper.

Correspondence

Lik Loh, Department of General Practice and Rural Health, University of Otago, PO Box 56, Dunedin 9054.

Correspondence Email

lik_wei@mac.com

Competing Interests

Lik Loh received the University of Otago Academic General Practitioner Registrar PhD Scholarship while preparing this paper.

- Ministry of Health. New Zealand Health Survey: Annual update of key findings 2012/13. Wellington: Ministry of Health 2013. Craig E, Anderson P, Jackson G and Jackson C. Measuring potentially avoidable and ambulatory care sensitive hospitalisations in New Zealand children using a newly developed tool. N Z Med J. 2012;125(1366):38-50. Chambers R. Poverty and livelihoods: Whose reality counts? Environ Urban. 1995 Apr;7(1):173-204. Peek CJ, Baird MA and Coleman E. Primary care for patient complexity, not only disease. Fam Syst Health. 2009;27(4):287-302. Rankin J and Regan S. Meeting complex needs in social care. Housing, Care and Support. 2004;7(3):4-9. Grembowski D, Schaefer J, Johnson KE, et al. A conceptual model of the role of complexity in the care of patients with multiple chronic conditions. Med Care. 2014;52(3):S7-S14. Mercer SW, Smith SM, Wyke S, et al. Multimorbidity in primary care: Developing the research agenda. Fam Pract. 2009;26(2):79-80. Kawachi I, Subramanian S and Almeida-Filho N. A glossary for health inequalities. J Epidemiol Community Health. 2002;56(9):647-52. Dovey S and Tilyard M. Fees charged to a consulting population in general practice. N Z Med J. 1991;104(913):222-4. Tilyard M and Dovey S. Changes in payments for general practice consultations 1989-93. N Z Med J. 1996;109(1025):252-4. Tilyard M, Dovey S and Krebs V. General practitioners actual and scheduled charges for consultations with children and the elderly in South Island PHOs. N Z Fam Physician. 2006;33(6):184-7. Crampton P and Starfield B. A case for government ownership of primary care services in New Zealand: Weighing the arguments. Int J Health Serv. 2004;34(4):709-27. Malcolm L. Inequities in access to and utilisation of primary medical care services for Maori and low income New Zealanders. N Z Med J. 1996;109(1030):356-8. Gribben B and Goodyear-Smith F. Can community service card possession be used to measure need? N Z Fam Physician. 2002;29(1):24-9. Barnett R. Coping with the costs of primary care? Household and locational variations in the survival strategies of the urban poor. Health Place. 2001;7(2):141-57. Brown M, Underwood B. Very Low Cost Access practice case studies: Summary report for the PHO Services Agreement Amendment Protocol Group. Wellington: PHO Service Agreement Amendment Protocol (PSAAP) group 2013. Crampton P, Woodward A and Dowel A. The role of the third sector in providing primary care services - Theoretical and policy issues. Social Policy Journal Of New Zealand Te Puna Whakaaro. 2001;December(17):1-21. Hay IM. The caring commodity: The provision of health care in New Zealand. Auckland, NZ: Oxford University Press 1989. Wright-St Clair RE. A history of general practice and of the Royal New Zealand College of General Practitioners. Wellington: RNZCGP 1989. Cumming J and Mays N. New Zealands Primary Health Care Strategy: Early effects of the new financing and payment system for general practice and future challenges. Health Economics, Policy and Law. 2011;6(1):1-21. Cumming J. Integrated care in New Zealand. Int J Integr Care. 2011;11(Special 10th Anniversary Edition):e138. Lovelock K, Martin G, Cumming J and Gauld R. The evaluation of the Better, Sooner, More Convenient business cases in MidCentral and West Coast District Health Boards. Wellington, Dunedin: Centre for Health Systems and Health Services Research Centre December 2014. Crampton P, Dowell A and Woodward A. Third sector primary care for vulnerable populations. Soc Sci Med. 2001;53(11):1491-502. Crampton P. The ownership elephant: Ownership and community-governance in primary care. N Z Med J. 2005 Sep 16;118(1222):U1663. Crampton P, Dowell AC and Bowers S. Third sector primary health care in New Zealand. N Z Med J. 2000;113(1106):92-6. Hider P, Lay-Yee R, Crampton P and Davis P. 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Primary health care services, free at the point-of-use, are being rolled out nationwide to children under 13 years. Is there also a case for a systematic policy approach to the provision of free primary care access that does not discriminate by age? This is a call-to-action paper by a group of general practitioners, past and present, at free clinics across the country. Free clinics are a rarity in New Zealand and comprise a special subgroup of third sector (non-government, non-profit) clinics. In an email and telephone survey of Primary Health Organisations (PHOs) and primary care governance teams in regions without a PHO, we found 18 primary care clinics currently offering free general practitioner consultations for patients of all ages (Figure 1). We advocate for a more systematic approach to delivering free primary care services for populations with the poorest access to, but the most need for, these services. We are writing to policymakers, clinicians in governance roles, and general practitioners who wish to improve primary care access for vulnerable populations.Figure 1: Locations of free clinics in New Zealand First, we describe the target population of free clinics as those patients most disadvantaged towards health care access and health outcomes in New Zealand. We then give examples of how the collective power of general practitioners greatly influences the effectiveness of primary health care policy targeting vulnerable patients. Finally, we discuss non-profit clinics serving vulnerable patients, the limitations of these clinics, and the role free clinics might play as a special subgroup of third sector clinics.Free clinics serve a particular target populationFifteen percent of adults, and 6 percent of children in the most recent New Zealand Health Survey reported not visiting their general practitioner because of cost in the previous 12 months.1 These figures were higher for Mori adults (25%), Pacific adults (21%), and adults living in neighbourhoods with the most deprived NZDep2006 quintile (22%).1 Groups disadvantaged with respect to primary care access socioeconomically-deprived individuals, and Mori and Pacific people have higher primary care-preventable hospitalisation rates than other demographic groups in New Zealand.2 While patients with the above socioeconomic characteristics are overrepresented at free clinics, these characteristics do not adequately identify the target population of free clinics who in our experience are typically the worst-off of the worst-off . Low-income status is by itself an insufficient descriptor of our target population. Rather than poverty per se, it is the deprivations in living conditions relative to wider society that matter for health and well-being. However, our patients are not just socioeconomically deprived, but also marginalised, vulnerable and high-needs, with whom complex consultations are common, and for whom poorer health outcomes as well as health inequities are the norm. Vulnerability describes the co-occurrence of a persons exposure to risks and adverse events, and their susceptibility to harm arising from a limited capacity to adapt to these challenges.3 Vulnerability is both chronic and cumulative across the life trajectory of individuals. In families, vulnerability traits are transmitted between successive generations. Unstable accommodation, teenage parenthood, a history of childhood trauma, health-damaging risk behaviours, and comorbid mental illness and substance abuse are examples of vulnerability factors prominent in our patient populations.At the surface, our patients have high rates of use and non-use of health services. The labels high-needs patients and high users are often used interchangeably. While the literature does not contain a robust definition for the term, we recognise our patients as high-needs by the complex mixture of ill-health and social problems they struggle to cope with. Consultations with this heterogeneous group of patients are usually complex and challenging. Complexity in the health care context refers to the patient-specific factors that interfere with the delivery of usual care and decision-making for whatever conditions the patient has ,4 a concept having dimensions of depth (severity of need) and breadth (range of needs).5 Complexity predisposes to a mismatch between the patients needs and the capacity of health services to support those needs.6The above factors are associated with a range of negative health outcomes in our target population. Multimorbidity, the coexistence of two or more conditions without a specific disease being the index condition,7 is prevalent among our patients, especially concomitant physical and mental disorders. Multimorbidity also develops at a younger age for our patients. These factors result in our patients bearing a disproportionate share of mortality and health care events compared with patients at other clinics. Because these health inequalities stem from social stratification and health care access barriers that are both avoidable and unfair, they are deemed health inequities.8 In the rest of this paper, we consider how the interactions between government and general practice have contributed to health inequities for our target population, and how this may be redressed.The target populations of free clinics are underserved by the health systemWe believe that the health care needs of the target population of free clinics have been inadequately catered for throughout New Zealands recent history, largely because of the primary care cost barrier. Our main concern is that nationally, general practitioners and government have been unsuccessful in collaborating to remove this barrier for our target population. Our subsidiary concern is that existing mechanisms to reduce the cost barrier - the Community Services Card scheme, Very Low Cost Access funding, and discretionary discounting of general practitioners fees - have been inadequate in securing primary are access for those most likely to experience unmet health care needs.Free competition usually unattainable in the health care market, and the target populations of free clinics do not as a general rule participate effectively in such a market. Income poverty and reduced health literacy prevent such patients from obtaining services commensurate to their health needs in an open market. Discretionary discounting by general practitioners of their fees, while important for offsetting these disadvantages for vulnerable patients, has become less frequent over time,9,10 and is concentrated in paediatric and older persons.11 Discounting operates on an ad hoc basis, and financial and other considerations may prevent this practice from becoming more widespread.The extent of market failure in health is a strong argument for the state playing a leading role in the regulation and provision of health services.12 This applies especially to segments of the population for whom health services are undersupplied privately. Existing policy interventions to redress market failure have been only partially successful. Targeted funding through the Community Services Card (CSC) scheme does not fully compensate for the effect of socioeconomic factors, so low-income status and Mori/Pacific ethnicity are not associated with increased primary care utilisation commensurate to health status.13 Uptake of CSCs is incomplete among the eligible population,14 and even among CSC holders unmet health need is prevalent because of cost.15 The aim of the 2006 Very Low Cost Access (VLCA) scheme was to ensure low patient fees at participating general practices, whose enrolled populations were stipulated to consist of at least fifty percent high needs patients (Mori and Pacific patients, and those living in NZDep quintile 5 areas). However, a large proportion of patients who typically have lesser health needs benefit from capped fees at such clinics, and since the early years many clinics receiving VLCA funding did not have the required proportion of high needs patients.16 Serving patients who by definition have complex clinical needs but limited ability to pay also threatens the financial viability of VLCA clinics, especially since VLCA funding typically does not fully meet operating costs.16Government policy is constrained by political processes,17 since policy is promulgated mindful of the governments popular mandate. Government services cater to the demands of the median voter; poverty is also associated with reduced political participation. So, even in the presence of demand from large minority groups for specific services, there may be little public provision of those services. Government failure thus occurs when demand for particular goods and services is not adequately met by the state or the public sector. The fractious relationship between general practitioners and government has at times in New Zealands history limited the effectiveness of health policy aimed at reducing patient copayments and improving primary care access for socioeconomically deprived patients.In the mid-1930s, only 25% percent of general practitioners18 entered government contracts as part of the First Labour governments proposed national health insurance scheme that would provide general practitioner services free-of-charge to all patients.19 The government was forced to rescind their prohibition of general practitioners charging their patients fees,18 allowing a fee-for-service scheme to operate in parallel with the capitation scheme. In the 1990s, rather than stimulating competition within the primary health care sector, the neoliberal health reforms catalysed the formation of Independent Practitioner Associations as a means of aggregating the negotiating power of general practitioners to secure funding contracts in the new health marketplace. In the implementation of the Primary Health Care Strategy (PHCS) in the 2000s, the government eschewed statutory regulation of fees charged to patients.20 In the post-2008 era, the longstanding distrust between government and general practice21 as well as the mismatch between policy initiatives and the economic realities of operating general practice clinics as private businesses22 prevented the abolition of user fees in primary care and many policy aspirations from being fully realised.The implementation of government primary care policies for children clearly illustrates the power dynamic between general practitioners and government. The government initiative in 1985 to substantially subsidise primary care visits for all children was successfully blocked by the New Zealand Medical Association, who opposed the proposed patient copayment ceiling accompanying the scheme. A decade later, after intense lobbying by general practitioners, the 1996 free child health care scheme did not restrict the fees charged by general practitioners. Although the Zero Fees For Under Sixes package in 2007 did not guarantee universally free primary care for children less than six years during normal working hours, it achieved nearly complete uptake among general practices. Participation by general practitioners was similarly voluntary in the schemes expansion to provide free after-hours primary care services for children under six years in 2011, and free primary care services during normal working hours for children under thirteen years more recently. Whether increased subsidies with these policy initiatives fully cover consultation costs is likely to be a key determinant for general practices committing to providing free services to children.Third sector clinics are not a viable solution for the primary health care needs of vulnerable populationsGiven the combination of market failure and government failure as above, the need for third sector clinics has continuously existed in New Zealand. Crampton defines the third sector as non-government and non-profit.23 He locates third sector agencies within the gap between the state and private sectors, this gap arising because of market failures and deficiencies in existing government-funded services.23 Since unlike for-profit private entities they need not cater to the business interests of their proprietors or shareholders, third sector agencies are better able to provide public goods that benefit populations rather than individuals, and respond to the interests of minority groups.12,24 Unlike government organisations, third sector agencies are able to develop service delivery innovations, unfettered by strict democratic and political accountability structures.12Trade union-sponsored health centres were established in the 1980s, and by Mori, for Mori clinics in the 1990s. Health Care Aotearoa (HCA) formed in 1994, and is a network of third sector clinics sharing as their explicit goals a commitment to the unmet primary care needs of Mori and vulnerable populations.25 Enrolled patients at HCA-affiliated clinics are uncharacteristic of the New Zealand general population in being younger, containing higher proportions of people from ethnic minority groups (36% Mori, 23% Pacific Islander), and being more socioeconomically deprived (55% residing in the most deprived NZDep96 quintile areas).23 Most HCA clinics are located close to their target population, situated either in urban areas with high levels of socioeconomic deprivation, or in medically underserviced, mainly Mori rural areas.23 These clinics offer lower patient fees,24 and are also more likely to provide population-focused preventive care services, as they are capitation funded, which gives financial incentives and the epidemiological tools to deliver these services.26The heavy reliance of third sector clinics on government funding makes the government a key stakeholder for primary care in the third sector.23 Increased accountability to government and pressure to attain those outcomes on which funding is contingent force third sector organisations to reorient their operations towards measurable outcomes and clients for whom funding is available. Where external funding is reduced, services at third sector clinics risk being withdrawn. Also, because funding streams have traditionally been linked to general practitioner services, the loss of general practitioners from third sector clinics is often accompanied by drastic reductions in funding, which may threaten the financial viability of the service. Finally, because on average roughly sixty percent of general practice income is typically drawn from patient copayments,27 third sector clinics that depend mainly on capitation funding may find it insufficient to meet running costs. Serving 1,700 high-needs patients, the Calder Centre is affiliated with the Auckland City Mission and operated at an annual deficit of $300,000 in 2014, preventing them from offering free general practitioner services to their patients (Dimitri Germanov, Calder Centre, personal communication, 18 November 2014).Free clinics are a special subgroup within third sector clinics, and are rare in New Zealand. Of the 1,058 general practice clinics currently in New Zealand (Joyce Brown, RNZCGP, personal communication, 29 October 2014), 296 receive VLCA funding,16 but in our survey only 18 clinics offer general practice services free-of-charge to all age groups. Half of these clinics are located in Special Medical Areas, originally established in 1941 by the government to attract general practitioners to rural and remote geographic areas, under a framework in which the doctors were salaried employees providing services free-of-charge to patients. The resident populations in the Special Medical Areas containing free clinics in our survey Hokianga and Whangaroa in Northland, Opotiki District in the Bay of Plenty, and the East Coast of the North Island are greater than fifty percent Mori, and have high levels of socioeconomic deprivation. Waiheke Islands free clinic and the four free clinics in South Auckland are all located on marae, and the free clinic in Hamilton was formed through merger with a Pacific peoples trust.The future of free clinics in New Zealand is endangered, due to their funding and staffing structures. The free clinics run by Ngti Porou Hauora, an East Coast Mori health provider, have run at a financial deficit since 2011 because capitation funding does not cover operating costs.28 The free clinic in Dunedin is staffed by volunteer clinicians, but likewise operates at a loss.29 Because as discussed above the primary care funding paradigm has consistently been based on patient copayments supplemented by government subsidies, not charging copayments threatens the financial sustainability of clinics whose target populations are vulnerable patients. Clinics providing free services are liable to either close down (Wellington Peoples Centre) or introduce doctors fees for consultations (the Kingdom Clinic in Christchurch).ConclusionAt a national level, the goodwill of local groups makes for a haphazard solution to the unmet primary care needs of vulnerable populations. Across New Zealands history, without sufficiently widespread support from general practitioners, the effectiveness of top-down government initiatives is limited. What is the way forward? In our opinion, the general practitioner community is a major stakeholder in the effort to reduce health inequities. This is because primary care is the linchpin of population health and health systems, and health care itself can, unless it is equitably distributed, contribute to health inequities. We recognise, however, that the prevailing for-profit small business model of general practice in New Zealand is not conducive to removing the primary care cost barrier for vulnerable populations. Our message is therefore targeted at those general practitioners who are interested in expanding primary care for vulnerable groups, and who are willing to adopt new models of funding and delivering primary care services. Collectively, these general practitioners could lead the health systems approach to vulnerable patients, and provide mutual support in what is typically a challenging area to work. It is also this group of general practitioners with whom partnership in policy development is likely to be productive. There is precedent in Scotland, where General Practitioners at the Deep End serving the most severely deprived areas have banded together to achieve shared goals.30 Primary health care access for vulnerable populations should occupy a more central position in health policy development. Whether New Zealand can afford universally free primary health care services is contentious, although we note that one of the reasons for withdrawing hospital user charges in the early 1990s was that administering these charges was costing the government more than simply providing free hospital services.31 Proportional universalism as advocated by the Royal New Zealand College of General Practitioners,32 represents a middle ground between universalism and a fully targeted approach, and involves distributing resources across the whole population progressively according to health need and socioeconomic disadvantage. Low-income households are more likely to require after-hours services than their affluent counterparts,33 but the average cost of an after-hours visit (for example, $44 in 2013 for children over six years)34is prohibitively expensive for the target population of free clinics. Cost barriers outside general practice (such as prescription charges and dental fees) also require attention, and a solution necessarily involves the social welfare and other sectors. New Zealand needs a network of safety-net primary care clinics. The precise policy solutions should be tailored to local circumstances, but will usually involve blending government funding with service delivery by third sector providers. Even where general practitioners are salaried employees, the level of public funding currently available makes the running of third sector clinics financially unsustainable. Regionally, it has been mooted that at least one PHO be given specific mandate for primary care services to high-needs groups, and this function be delegated to District Health Boards where this is not possible.35 Workforce development, such as through the use of nurse practitioners, may enable third sector clinics to better serve vulnerable populations.36 Finally, the shortcomings of safety-net clinics in the United States are instructive in our development of a solution in New Zealand. The majority of such clinics are Community Health Centres, which receive federal government funding, but serve only small numbers of medically uninsured patients, and charge fees on a sliding scale. Free clinics in the United States are fewer in number, and rely on philanthropic funding sources and volunteer clinicians. While United States free clinics see greater proportions of uninsured patients, they tend to be open for limited hours, offer a limited range of services, and their patients are more likely to experience poorer continuity of care. Transferring these lessons to New Zealand, we believe that free clinics make a distinct contribution to that by third sector clinics generally, as free clinics serve vulnerable patients with more extreme levels of need. Even small copayments would result in unmet needs in these groups. Like their American counterparts, free clinics here are under-resourced relative to their task. We assert that funding primary health services for vulnerable populations is a core responsibility of government, and should not be devolved entirely to philanthropic or volunteer-based organisations.

Summary

Abstract

Unmet health care needs and health inequities are prevalent in New Zealand. Throughout New Zealands history, the power dynamic between general practitioners, as a professional group, and the government has contributed to policies directed at primary-care access barriers not being fully realised. This has given third sector (non-government, non-profit) clinics a continuing role in delivering primary care services to vulnerable populations. The viability of free clinics, 18 of which were identified in our survey, is threatened by their funding and staffing structures. We contend that general practitioners have a stake in reducing health inequities and that there is a strong case for a more systematic policy approach to primary health care provision for vulnerable populations in New Zealand.

Aim

Method

Results

Conclusion

Author Information

Lik Wei Loh, PhD Candidate, Department of General Practice and Rural Health, University of Otago, Dunedin; Siobhan Trevallyan, Clinical Director, Waitakere Union Health Centre, Auckland; Stephen J Main, General Practitioner, Hokianga Health, Rawene Hospital, Hokianga; Leo Revell, General Practitioner, Kaute Family Medical Centre, Hamilton; Vivienne Patton, General Practitioner, Kingdom Clinic, Christchurch; Akindele Ojo, Clinical Leader, Ngati Porou Hauora, Te Puia Springs.

Acknowledgements

We are grateful to Prof Sue Dovey, Prof Peter Crampton, and Prof Tony Dowell for their comments during the development of this paper. We wish to acknowledge Mr Bevan Pelvin for his assistance with ArcGIS and the production of the maps in this paper. Any inaccuracies or omissions are the responsibility of the lead author. We also thank Ms Muriel Tunoho (Health Care Aotearoa) for her input into the final draft. We also thank the two peer reviewers who helped us refine the content of this paper.

Correspondence

Lik Loh, Department of General Practice and Rural Health, University of Otago, PO Box 56, Dunedin 9054.

Correspondence Email

lik_wei@mac.com

Competing Interests

Lik Loh received the University of Otago Academic General Practitioner Registrar PhD Scholarship while preparing this paper.

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Kawachi I, Subramanian S and Almeida-Filho N. A glossary for health inequalities. J Epidemiol Community Health. 2002;56(9):647-52. Dovey S and Tilyard M. Fees charged to a consulting population in general practice. N Z Med J. 1991;104(913):222-4. Tilyard M and Dovey S. Changes in payments for general practice consultations 1989-93. N Z Med J. 1996;109(1025):252-4. Tilyard M, Dovey S and Krebs V. General practitioners actual and scheduled charges for consultations with children and the elderly in South Island PHOs. N Z Fam Physician. 2006;33(6):184-7. Crampton P and Starfield B. A case for government ownership of primary care services in New Zealand: Weighing the arguments. Int J Health Serv. 2004;34(4):709-27. Malcolm L. Inequities in access to and utilisation of primary medical care services for Maori and low income New Zealanders. N Z Med J. 1996;109(1030):356-8. Gribben B and Goodyear-Smith F. Can community service card possession be used to measure need? N Z Fam Physician. 2002;29(1):24-9. Barnett R. Coping with the costs of primary care? Household and locational variations in the survival strategies of the urban poor. Health Place. 2001;7(2):141-57. Brown M, Underwood B. Very Low Cost Access practice case studies: Summary report for the PHO Services Agreement Amendment Protocol Group. Wellington: PHO Service Agreement Amendment Protocol (PSAAP) group 2013. Crampton P, Woodward A and Dowel A. The role of the third sector in providing primary care services - Theoretical and policy issues. Social Policy Journal Of New Zealand Te Puna Whakaaro. 2001;December(17):1-21. Hay IM. The caring commodity: The provision of health care in New Zealand. Auckland, NZ: Oxford University Press 1989. Wright-St Clair RE. A history of general practice and of the Royal New Zealand College of General Practitioners. Wellington: RNZCGP 1989. Cumming J and Mays N. New Zealands Primary Health Care Strategy: Early effects of the new financing and payment system for general practice and future challenges. Health Economics, Policy and Law. 2011;6(1):1-21. Cumming J. Integrated care in New Zealand. Int J Integr Care. 2011;11(Special 10th Anniversary Edition):e138. Lovelock K, Martin G, Cumming J and Gauld R. The evaluation of the Better, Sooner, More Convenient business cases in MidCentral and West Coast District Health Boards. Wellington, Dunedin: Centre for Health Systems and Health Services Research Centre December 2014. Crampton P, Dowell A and Woodward A. Third sector primary care for vulnerable populations. Soc Sci Med. 2001;53(11):1491-502. Crampton P. The ownership elephant: Ownership and community-governance in primary care. N Z Med J. 2005 Sep 16;118(1222):U1663. Crampton P, Dowell AC and Bowers S. Third sector primary health care in New Zealand. N Z Med J. 2000;113(1106):92-6. Hider P, Lay-Yee R, Crampton P and Davis P. Comparison of services provided by urban commercial, community-governed and traditional primary care practices in New Zealand. J Health Serv Res Policy. 2007 Oct;12(4):215-22. Hefford M, Crampton P and Foley J. Reducing health disparities through primary care reform: The New Zealand experiment. Health Policy. 2005 Apr;72(1):9-23. Moore D, Love T and Ehrenberg N. Review of health services on the East Coast - Public Report. Wellington: Sapere Research Group 2013. Goodwin E. Free GP service making loss. Dunedin: Allied Press Limited; 15/8/13; Available from: http://www.odt.co.nz/news/dunedin/268799/free-gp-service-making-loss. Watt G, Brown G, Budd J, et al. General Practitioners at the Deep End: The experience and views of general practitioners working in the most severely deprived areas of Scotland. Occasional paper (Royal College of General Practitioners). 2012(89):i-40. Gauld R. Revolving doors: New Zealands health reforms, the continuing saga. Wellington: Victoria University of Wellington, Institute of Policy Studies 2009. Royal New Zealand College of General Practitioners. Achieving health equity by eliminating health inequities - Position statements. Wellington: RNZCGP 2013. Jansen T, Zwaanswijk M, Hek K and Bakker Dd. To what extent does sociodemographic composition of the neighbourhood explain regional differences in demand of primary out-of-hours care: A multilevel study. BMC Fam Pract. 2015;16:54. Cheyaanthan Haran CR, Nikki Turner & Innes Asher. The cost of GP visits for 6-17 year olds in New Zealand. Auckland: Child Poverty Action Group Inc. July 2014. Matheson D, Iverson S, Neuwelt P, et al. Towards an equitable primary health care policy for all New Zealanders. 2014. Wilkinson J. Places for nurse practitioners to flourish: Examining third sector primary care. Aust J Adv Nurs. 2012;29(4):36-42.-

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Primary health care services, free at the point-of-use, are being rolled out nationwide to children under 13 years. Is there also a case for a systematic policy approach to the provision of free primary care access that does not discriminate by age? This is a call-to-action paper by a group of general practitioners, past and present, at free clinics across the country. Free clinics are a rarity in New Zealand and comprise a special subgroup of third sector (non-government, non-profit) clinics. In an email and telephone survey of Primary Health Organisations (PHOs) and primary care governance teams in regions without a PHO, we found 18 primary care clinics currently offering free general practitioner consultations for patients of all ages (Figure 1). We advocate for a more systematic approach to delivering free primary care services for populations with the poorest access to, but the most need for, these services. We are writing to policymakers, clinicians in governance roles, and general practitioners who wish to improve primary care access for vulnerable populations.Figure 1: Locations of free clinics in New Zealand First, we describe the target population of free clinics as those patients most disadvantaged towards health care access and health outcomes in New Zealand. We then give examples of how the collective power of general practitioners greatly influences the effectiveness of primary health care policy targeting vulnerable patients. Finally, we discuss non-profit clinics serving vulnerable patients, the limitations of these clinics, and the role free clinics might play as a special subgroup of third sector clinics.Free clinics serve a particular target populationFifteen percent of adults, and 6 percent of children in the most recent New Zealand Health Survey reported not visiting their general practitioner because of cost in the previous 12 months.1 These figures were higher for Mori adults (25%), Pacific adults (21%), and adults living in neighbourhoods with the most deprived NZDep2006 quintile (22%).1 Groups disadvantaged with respect to primary care access socioeconomically-deprived individuals, and Mori and Pacific people have higher primary care-preventable hospitalisation rates than other demographic groups in New Zealand.2 While patients with the above socioeconomic characteristics are overrepresented at free clinics, these characteristics do not adequately identify the target population of free clinics who in our experience are typically the worst-off of the worst-off . Low-income status is by itself an insufficient descriptor of our target population. Rather than poverty per se, it is the deprivations in living conditions relative to wider society that matter for health and well-being. However, our patients are not just socioeconomically deprived, but also marginalised, vulnerable and high-needs, with whom complex consultations are common, and for whom poorer health outcomes as well as health inequities are the norm. Vulnerability describes the co-occurrence of a persons exposure to risks and adverse events, and their susceptibility to harm arising from a limited capacity to adapt to these challenges.3 Vulnerability is both chronic and cumulative across the life trajectory of individuals. In families, vulnerability traits are transmitted between successive generations. Unstable accommodation, teenage parenthood, a history of childhood trauma, health-damaging risk behaviours, and comorbid mental illness and substance abuse are examples of vulnerability factors prominent in our patient populations.At the surface, our patients have high rates of use and non-use of health services. The labels high-needs patients and high users are often used interchangeably. While the literature does not contain a robust definition for the term, we recognise our patients as high-needs by the complex mixture of ill-health and social problems they struggle to cope with. Consultations with this heterogeneous group of patients are usually complex and challenging. Complexity in the health care context refers to the patient-specific factors that interfere with the delivery of usual care and decision-making for whatever conditions the patient has ,4 a concept having dimensions of depth (severity of need) and breadth (range of needs).5 Complexity predisposes to a mismatch between the patients needs and the capacity of health services to support those needs.6The above factors are associated with a range of negative health outcomes in our target population. Multimorbidity, the coexistence of two or more conditions without a specific disease being the index condition,7 is prevalent among our patients, especially concomitant physical and mental disorders. Multimorbidity also develops at a younger age for our patients. These factors result in our patients bearing a disproportionate share of mortality and health care events compared with patients at other clinics. Because these health inequalities stem from social stratification and health care access barriers that are both avoidable and unfair, they are deemed health inequities.8 In the rest of this paper, we consider how the interactions between government and general practice have contributed to health inequities for our target population, and how this may be redressed.The target populations of free clinics are underserved by the health systemWe believe that the health care needs of the target population of free clinics have been inadequately catered for throughout New Zealands recent history, largely because of the primary care cost barrier. Our main concern is that nationally, general practitioners and government have been unsuccessful in collaborating to remove this barrier for our target population. Our subsidiary concern is that existing mechanisms to reduce the cost barrier - the Community Services Card scheme, Very Low Cost Access funding, and discretionary discounting of general practitioners fees - have been inadequate in securing primary are access for those most likely to experience unmet health care needs.Free competition usually unattainable in the health care market, and the target populations of free clinics do not as a general rule participate effectively in such a market. Income poverty and reduced health literacy prevent such patients from obtaining services commensurate to their health needs in an open market. Discretionary discounting by general practitioners of their fees, while important for offsetting these disadvantages for vulnerable patients, has become less frequent over time,9,10 and is concentrated in paediatric and older persons.11 Discounting operates on an ad hoc basis, and financial and other considerations may prevent this practice from becoming more widespread.The extent of market failure in health is a strong argument for the state playing a leading role in the regulation and provision of health services.12 This applies especially to segments of the population for whom health services are undersupplied privately. Existing policy interventions to redress market failure have been only partially successful. Targeted funding through the Community Services Card (CSC) scheme does not fully compensate for the effect of socioeconomic factors, so low-income status and Mori/Pacific ethnicity are not associated with increased primary care utilisation commensurate to health status.13 Uptake of CSCs is incomplete among the eligible population,14 and even among CSC holders unmet health need is prevalent because of cost.15 The aim of the 2006 Very Low Cost Access (VLCA) scheme was to ensure low patient fees at participating general practices, whose enrolled populations were stipulated to consist of at least fifty percent high needs patients (Mori and Pacific patients, and those living in NZDep quintile 5 areas). However, a large proportion of patients who typically have lesser health needs benefit from capped fees at such clinics, and since the early years many clinics receiving VLCA funding did not have the required proportion of high needs patients.16 Serving patients who by definition have complex clinical needs but limited ability to pay also threatens the financial viability of VLCA clinics, especially since VLCA funding typically does not fully meet operating costs.16Government policy is constrained by political processes,17 since policy is promulgated mindful of the governments popular mandate. Government services cater to the demands of the median voter; poverty is also associated with reduced political participation. So, even in the presence of demand from large minority groups for specific services, there may be little public provision of those services. Government failure thus occurs when demand for particular goods and services is not adequately met by the state or the public sector. The fractious relationship between general practitioners and government has at times in New Zealands history limited the effectiveness of health policy aimed at reducing patient copayments and improving primary care access for socioeconomically deprived patients.In the mid-1930s, only 25% percent of general practitioners18 entered government contracts as part of the First Labour governments proposed national health insurance scheme that would provide general practitioner services free-of-charge to all patients.19 The government was forced to rescind their prohibition of general practitioners charging their patients fees,18 allowing a fee-for-service scheme to operate in parallel with the capitation scheme. In the 1990s, rather than stimulating competition within the primary health care sector, the neoliberal health reforms catalysed the formation of Independent Practitioner Associations as a means of aggregating the negotiating power of general practitioners to secure funding contracts in the new health marketplace. In the implementation of the Primary Health Care Strategy (PHCS) in the 2000s, the government eschewed statutory regulation of fees charged to patients.20 In the post-2008 era, the longstanding distrust between government and general practice21 as well as the mismatch between policy initiatives and the economic realities of operating general practice clinics as private businesses22 prevented the abolition of user fees in primary care and many policy aspirations from being fully realised.The implementation of government primary care policies for children clearly illustrates the power dynamic between general practitioners and government. The government initiative in 1985 to substantially subsidise primary care visits for all children was successfully blocked by the New Zealand Medical Association, who opposed the proposed patient copayment ceiling accompanying the scheme. A decade later, after intense lobbying by general practitioners, the 1996 free child health care scheme did not restrict the fees charged by general practitioners. Although the Zero Fees For Under Sixes package in 2007 did not guarantee universally free primary care for children less than six years during normal working hours, it achieved nearly complete uptake among general practices. Participation by general practitioners was similarly voluntary in the schemes expansion to provide free after-hours primary care services for children under six years in 2011, and free primary care services during normal working hours for children under thirteen years more recently. Whether increased subsidies with these policy initiatives fully cover consultation costs is likely to be a key determinant for general practices committing to providing free services to children.Third sector clinics are not a viable solution for the primary health care needs of vulnerable populationsGiven the combination of market failure and government failure as above, the need for third sector clinics has continuously existed in New Zealand. Crampton defines the third sector as non-government and non-profit.23 He locates third sector agencies within the gap between the state and private sectors, this gap arising because of market failures and deficiencies in existing government-funded services.23 Since unlike for-profit private entities they need not cater to the business interests of their proprietors or shareholders, third sector agencies are better able to provide public goods that benefit populations rather than individuals, and respond to the interests of minority groups.12,24 Unlike government organisations, third sector agencies are able to develop service delivery innovations, unfettered by strict democratic and political accountability structures.12Trade union-sponsored health centres were established in the 1980s, and by Mori, for Mori clinics in the 1990s. Health Care Aotearoa (HCA) formed in 1994, and is a network of third sector clinics sharing as their explicit goals a commitment to the unmet primary care needs of Mori and vulnerable populations.25 Enrolled patients at HCA-affiliated clinics are uncharacteristic of the New Zealand general population in being younger, containing higher proportions of people from ethnic minority groups (36% Mori, 23% Pacific Islander), and being more socioeconomically deprived (55% residing in the most deprived NZDep96 quintile areas).23 Most HCA clinics are located close to their target population, situated either in urban areas with high levels of socioeconomic deprivation, or in medically underserviced, mainly Mori rural areas.23 These clinics offer lower patient fees,24 and are also more likely to provide population-focused preventive care services, as they are capitation funded, which gives financial incentives and the epidemiological tools to deliver these services.26The heavy reliance of third sector clinics on government funding makes the government a key stakeholder for primary care in the third sector.23 Increased accountability to government and pressure to attain those outcomes on which funding is contingent force third sector organisations to reorient their operations towards measurable outcomes and clients for whom funding is available. Where external funding is reduced, services at third sector clinics risk being withdrawn. Also, because funding streams have traditionally been linked to general practitioner services, the loss of general practitioners from third sector clinics is often accompanied by drastic reductions in funding, which may threaten the financial viability of the service. Finally, because on average roughly sixty percent of general practice income is typically drawn from patient copayments,27 third sector clinics that depend mainly on capitation funding may find it insufficient to meet running costs. Serving 1,700 high-needs patients, the Calder Centre is affiliated with the Auckland City Mission and operated at an annual deficit of $300,000 in 2014, preventing them from offering free general practitioner services to their patients (Dimitri Germanov, Calder Centre, personal communication, 18 November 2014).Free clinics are a special subgroup within third sector clinics, and are rare in New Zealand. Of the 1,058 general practice clinics currently in New Zealand (Joyce Brown, RNZCGP, personal communication, 29 October 2014), 296 receive VLCA funding,16 but in our survey only 18 clinics offer general practice services free-of-charge to all age groups. Half of these clinics are located in Special Medical Areas, originally established in 1941 by the government to attract general practitioners to rural and remote geographic areas, under a framework in which the doctors were salaried employees providing services free-of-charge to patients. The resident populations in the Special Medical Areas containing free clinics in our survey Hokianga and Whangaroa in Northland, Opotiki District in the Bay of Plenty, and the East Coast of the North Island are greater than fifty percent Mori, and have high levels of socioeconomic deprivation. Waiheke Islands free clinic and the four free clinics in South Auckland are all located on marae, and the free clinic in Hamilton was formed through merger with a Pacific peoples trust.The future of free clinics in New Zealand is endangered, due to their funding and staffing structures. The free clinics run by Ngti Porou Hauora, an East Coast Mori health provider, have run at a financial deficit since 2011 because capitation funding does not cover operating costs.28 The free clinic in Dunedin is staffed by volunteer clinicians, but likewise operates at a loss.29 Because as discussed above the primary care funding paradigm has consistently been based on patient copayments supplemented by government subsidies, not charging copayments threatens the financial sustainability of clinics whose target populations are vulnerable patients. Clinics providing free services are liable to either close down (Wellington Peoples Centre) or introduce doctors fees for consultations (the Kingdom Clinic in Christchurch).ConclusionAt a national level, the goodwill of local groups makes for a haphazard solution to the unmet primary care needs of vulnerable populations. Across New Zealands history, without sufficiently widespread support from general practitioners, the effectiveness of top-down government initiatives is limited. What is the way forward? In our opinion, the general practitioner community is a major stakeholder in the effort to reduce health inequities. This is because primary care is the linchpin of population health and health systems, and health care itself can, unless it is equitably distributed, contribute to health inequities. We recognise, however, that the prevailing for-profit small business model of general practice in New Zealand is not conducive to removing the primary care cost barrier for vulnerable populations. Our message is therefore targeted at those general practitioners who are interested in expanding primary care for vulnerable groups, and who are willing to adopt new models of funding and delivering primary care services. Collectively, these general practitioners could lead the health systems approach to vulnerable patients, and provide mutual support in what is typically a challenging area to work. It is also this group of general practitioners with whom partnership in policy development is likely to be productive. There is precedent in Scotland, where General Practitioners at the Deep End serving the most severely deprived areas have banded together to achieve shared goals.30 Primary health care access for vulnerable populations should occupy a more central position in health policy development. Whether New Zealand can afford universally free primary health care services is contentious, although we note that one of the reasons for withdrawing hospital user charges in the early 1990s was that administering these charges was costing the government more than simply providing free hospital services.31 Proportional universalism as advocated by the Royal New Zealand College of General Practitioners,32 represents a middle ground between universalism and a fully targeted approach, and involves distributing resources across the whole population progressively according to health need and socioeconomic disadvantage. Low-income households are more likely to require after-hours services than their affluent counterparts,33 but the average cost of an after-hours visit (for example, $44 in 2013 for children over six years)34is prohibitively expensive for the target population of free clinics. Cost barriers outside general practice (such as prescription charges and dental fees) also require attention, and a solution necessarily involves the social welfare and other sectors. New Zealand needs a network of safety-net primary care clinics. The precise policy solutions should be tailored to local circumstances, but will usually involve blending government funding with service delivery by third sector providers. Even where general practitioners are salaried employees, the level of public funding currently available makes the running of third sector clinics financially unsustainable. Regionally, it has been mooted that at least one PHO be given specific mandate for primary care services to high-needs groups, and this function be delegated to District Health Boards where this is not possible.35 Workforce development, such as through the use of nurse practitioners, may enable third sector clinics to better serve vulnerable populations.36 Finally, the shortcomings of safety-net clinics in the United States are instructive in our development of a solution in New Zealand. The majority of such clinics are Community Health Centres, which receive federal government funding, but serve only small numbers of medically uninsured patients, and charge fees on a sliding scale. Free clinics in the United States are fewer in number, and rely on philanthropic funding sources and volunteer clinicians. While United States free clinics see greater proportions of uninsured patients, they tend to be open for limited hours, offer a limited range of services, and their patients are more likely to experience poorer continuity of care. Transferring these lessons to New Zealand, we believe that free clinics make a distinct contribution to that by third sector clinics generally, as free clinics serve vulnerable patients with more extreme levels of need. Even small copayments would result in unmet needs in these groups. Like their American counterparts, free clinics here are under-resourced relative to their task. We assert that funding primary health services for vulnerable populations is a core responsibility of government, and should not be devolved entirely to philanthropic or volunteer-based organisations.

Summary

Abstract

Unmet health care needs and health inequities are prevalent in New Zealand. Throughout New Zealands history, the power dynamic between general practitioners, as a professional group, and the government has contributed to policies directed at primary-care access barriers not being fully realised. This has given third sector (non-government, non-profit) clinics a continuing role in delivering primary care services to vulnerable populations. The viability of free clinics, 18 of which were identified in our survey, is threatened by their funding and staffing structures. We contend that general practitioners have a stake in reducing health inequities and that there is a strong case for a more systematic policy approach to primary health care provision for vulnerable populations in New Zealand.

Aim

Method

Results

Conclusion

Author Information

Lik Wei Loh, PhD Candidate, Department of General Practice and Rural Health, University of Otago, Dunedin; Siobhan Trevallyan, Clinical Director, Waitakere Union Health Centre, Auckland; Stephen J Main, General Practitioner, Hokianga Health, Rawene Hospital, Hokianga; Leo Revell, General Practitioner, Kaute Family Medical Centre, Hamilton; Vivienne Patton, General Practitioner, Kingdom Clinic, Christchurch; Akindele Ojo, Clinical Leader, Ngati Porou Hauora, Te Puia Springs.

Acknowledgements

We are grateful to Prof Sue Dovey, Prof Peter Crampton, and Prof Tony Dowell for their comments during the development of this paper. We wish to acknowledge Mr Bevan Pelvin for his assistance with ArcGIS and the production of the maps in this paper. Any inaccuracies or omissions are the responsibility of the lead author. We also thank Ms Muriel Tunoho (Health Care Aotearoa) for her input into the final draft. We also thank the two peer reviewers who helped us refine the content of this paper.

Correspondence

Lik Loh, Department of General Practice and Rural Health, University of Otago, PO Box 56, Dunedin 9054.

Correspondence Email

lik_wei@mac.com

Competing Interests

Lik Loh received the University of Otago Academic General Practitioner Registrar PhD Scholarship while preparing this paper.

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