The requirement to respect autonomy - The Royal New Zealand ...

viewpointThe impact of many childhood illnesses isreduced with early intervention, using bothprevention and treatment that is available at theprimary care level, with access to primary carebeing pivotal to improving health outcomes. 15,16,17An all-ages analysis of New Zealand hospitaldischarge data from 1989 to 1998 suggested thatone in three hospital admissions was potentiallyavoidable, 18 and a 2010 report from the PublicHealth Advisory Committee recommended implementingfree primary health care at all hoursfor children under six years. 19Despite the overall international evidence supportingthe role of primary care in improvinghealth outcomes 20 there has been little study ofthe effectiveness of current primary care arrangementson child health outcomes in New Zealandapart from the example of immunisation. 21Some information is available from the initialevaluation of the FCHCS conducted for the thenHealth Funding Authority in 1997, one year afterthe scheme’s introduction. 22 Despite the shorttime frame of the study, Sue Dovey and colleagues23 concluded that, after the introductionof the FCHCS, free care was widely available,especially in working hours, and more childrenconsulted with a general practitioner. There waslittle information about which families benefitedmost or any health benefits gained, although theauthors highlighted a reduction in hospital admissionsfor respiratory illnesses. Qualitative analysisof comments made by general practitioners suggesteddoctors were generally supportive, noting‘better follow-up, less pressure to prescribe andthe ability to deal with problems earlier’.Cost as a barrier to care for childrenThere is significant evidence that lower socioeconomicstatus poorly affects health outcomes,including children. 8,24,25 Where cost is a barrier, afamily may delay seeking appropriate and timelycare, thereby potentially letting the child’s illnessworsen. For people with financial difficulties, adelay in seeking care is common. 26 The Ministryof Health identified ‘high fees’ as $15 or more forchildren aged 0–5 years. 7 But even $15 is likelyto represent a barrier for those on the lowestincomes where earnings are insufficient to coverall essentials, and choices must be made betweenpaying for food, clothing, housing, educationalcosts, transport, and so on.According to the Ministry of Social Development,child poverty rates are generally worst foryounger children and remain higher than in the1980s, 27 with 19% of New Zealand children livingin serious hardship in 2008. 28 Previous harsheconomic times have led to increases in povertyand socioeconomic differentials in health. 29 Therecent recessionary environment is likely to be nodifferent. 30,31 Those children living in significantpoverty are three times more likely to be sickthan those from higher income families. 24After-hours—the forgotten careWhile significant attempts have been made bycentral government to reduce fees for primarycare for children during work hours, no suchprogrammes have been funded for after-hourscare. Funding arrangements for after-hours aredelegated to individual District Health Boards(DHBs) who have taken a varying degree of responsibilityfor these. Some initiatives have beenundertaken by individual PHOs.The roughly 75% of each week that is outside thestandard working hours of 8am to 5pm can be animportant time for access to care for children fortwo reasons. Firstly, many childhood illnessestypically deteriorate during the course of anevening. Respiratory diseases such as asthma andcroup, for example, have a natural pattern of deterioratingnocturnal symptoms. Many other illnessesare unpredictable and may not necessarilycause concern only during working hours, or mayarise at the weekend. Secondly, after-hours canrepresent a sole time for access to care for families,especially those living in poverty. Limitedaccess to transport or parental work constraintscan mean that families are not able to seek medicalcare for their children until after-hours.Why is this so hard? The beginningof a debate to find solutionsThe funding of general practice and primary carein New Zealand is complex and opinions are diverseand firmly held as to the merits of different340 VOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE