OPINION: Cutting funding to Newtown Union Health Service is false economy, because it will increase secondary care costs elsewhere, argues Ben Gray.
The Capital & Coast District Health Board has cut funding to Newtown Union Health Service by $275,000. That is 7.8 per cent of its budget. The move comes as the board cuts its budget by $20 million - 2.3 per cent - over the next two years.
The Newtown service cannot absorb a reduction in its budget by that amount without a significant impact on services.
It is galling for the board to announce that it has achieved its budget cut "without sacrifices". This decision will impact on the care received by a very vulnerable group of patients.
The board says that a large portion of the money it has available to support primary-care services goes to the Newtown service. This is a result of the Newtown service taking on work that was not being done in other practices.
The Newtown service is a very unusual practice. It manages as many people with serious ongoing mental- health problems as the secondary care South Community Mental Health Team.
For years, nearly all newly arrived refugees who have settled in the east of the city have come to the Newtown service. Twenty-four per cent of its population is from the Middle East and Africa, compared with just 1 per cent for the whole population. Many of these people have limited English proficiency.
In Auckland, interpreters for primary care patients are funded by the district health boards (DHBs). In Wellington, there is no such funding in primary care, so the Newtown service relies on the top-up from the Capital & Coast DHB to be able to care for these people.
To cope with these more complex patients in primary care, the Newtown service has been a leader in developing new models of care.
The Newtown service is one of only two practices that has a midwifery team as part of the practice. They are funded from central government on the same basis as other midwives. The additional DHB funding enables them to look after many women with limited English proficiency, or women with mental-health problems all superimposed on low incomes and poor living circumstances.
These women cannot be effectively cared for by the secondary services, because this can only be done by being integrated into the communities from which the women come, and the DHB is critically short of midwives in the secondary service.
The quality of that integration at the Newtown service is reflected in having the best childhood immunisation statistics in the country.
The Newtown service has developed a different model of specialist input into care, which the DHB is now rolling out to other practices. Instead of referring patients to outpatients, the Newtown service runs joint clinics with the specialists at the practice. The Newtown service has been doing this in psychiatry and diabetes for years.
The specialists will see some patients, but in many instances are able to resolve the questions the GP or nurse has with discussion only. As a result of this relationship, the primary-care clinicians have increased skill in managing these conditions. This has led to more patients benefiting from specialist input and fewer being referred to secondary care.
The problem is that there has been a transfer of work from outpatients to the practice and the extra money from the DHB does not make up the shortfall. For example, there are 35 patients with both ongoing mental health and diabetes problems. On average, those patients were seen 20 times a year.
There is no funding to acknowledge the extra costs of people with this sort of co-morbidity. The DHB has put a lot of effort into trying to work out how to integrate care.
The Newtown service has developed a working model that involves more care being provided in primary care. This cannot keep on working without funding.
Services cut at the Newtown service will lead to greater secondary care costs. Many of the migrant populations come from countries where people go to hospital for care. The Newtown service has been able to alter that by providing high- quality primary care with interpreters, and opens the clinic seven days a week.
The emergency department is rarely able to access interpreters and does not have the background information that the Newtown service has, so care is difficult. A common response to poor communication with the patient is to over- investigate, with a consequent increase in costs.
The clinical leader of obstetrics has reported that the DHB could not sustain the closing of the the Newtown service midwifery service. The Newtown service will need to consider reducing the depth of care provided, such as referring all the patients needing to start insulin to the diabetes clinic - a particularly time- intensive task.
This will increase the board's costs, as well as reduce the accessibility of this service to the community.
The most important issue is that a service providing care for the most disadvantaged is being asked to cut services. Primary care is the most cost- effective place to spend money. The Newtown service spends the money it gets very effectively. Maybe the DHB should find more money by cutting hospital services by 7.8 per cent to put into other primary-care services to redress the unfairness, rather than penalising the patients at the Newtown service.
Dr Ben Gray is a senior lecturer at the University of Otago Wellington Department of General Practice and Primary Health Care. He worked for 19 years at the Newtown service, until January this year.
- © Fairfax NZ News
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