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

viewpointfunding options. However, significant progresshas been made; the various funding packages supportmany thousands of New Zealand families,and practitioners and practices involved seemsatisfied with the arrangements.Some, though limited, progress has been madewith after-hours care. For example, an AucklandPHO in 2004 created free access at all hours forchildren under six. 32 A Whangarei PHO droppedafter-hours fees to $5 in 2009. 33 These examplesdemonstrate that further change is possible andwe suggest that universal zero fees for undersixes24 hours a day seven days a week is an idealthat should be debated. However, it is importantthat this discussion is not confused with the meritsor otherwise of the general debate regardingco-payment as a means of maintaining previousand current agreements between the governmentand professions over primary care funding. Wesuggest that the needs of children under six, asa vulnerable group with no active voice of theirown, are best served by a system that effectivelyremoves financial barriers to access.How might a zero/very low cost–feesystem work?Firstly, funding solutions need to be universallyapplicable so that potential tensions do not arise betweendifferent practices and between regular daywork and after-hours. Previously suggested solutionshave foundered because they do not take intoaccount the economic reality of practice funding.Given the uptake of the various under-sixesfunding arrangements, it is clear that practicesin high income areas and in comparable parts ofthe same city are able to participate in the schemewithout apparent financial penalty. It is importantthat both those who are participating andthose who are not debate the rationale for theirdecision and include both financial and ethicaldimensions to their views.Finding a solution is particularly important withafter-hours funding. Some after-hours servicesare running with minimal, if any, financialviability while others may be able to make asignificant income. Experiences such as thoseat the Whangarei and Auckland PHOs showthat solutions are possible, and it is importantthat these experiences are shared and developed.Additional funding will be necessary to securefree out-of-hours services and DHBs and PHOsshould all work to identify the sums of moneyrequired. The costs may not be as significant asfeared: for example, an estimate from a mediumsized North Island DHB indicates nearly$100,000 would be required per annum to secureGP-led after-hours provision for a population ofaround 13 000 children (personal communication).However, in other areas, particularly thosewith low throughput, the financial viability ofGP-based after-hours, especially overnight, islikely to be unrealistic. These areas may requiredifferent creative solutions, such as working moreclosely with emergency departments or transportoptions to bigger hubs.Contracting arrangements will need to be trustworthyand realistic, which has not always beenthe case in primary care funding. In this area theequivalent of a higher salaries commission mightdevelop an agreed formula for after-hours funding.It is also important that appropriate local arrangementsare developed with emergency departments.Despite indications of pressure on thesedepartments, there is a dearth of informationabout the proportion of current presentations thatmight appropriately be managed in primary careinstead. There is also a need for constructive jointprogrammes to both educate the public and agreeon referral patterns between emergency departmentsand after-hours providers. We suggestfurther modelling of different funding and workloadpatterns at different geographically-basedsites to explore this.ConclusionsNew Zealand has a long-established movementtowards providing free health care to the undersixes.Yet complete implementation of this goalremains elusive. Further information must besought alongside any changes in access arrangements.Continuing evaluation of the aim of fundingarrangements should be incorporated in theconsensus about the role of general practice andprimary care in child health. It is important thatrealistic expectations are debated around healthVOLUME 2 • NUMBER 4 • DECEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 341