Lower cost leads to more children taken to accident and medical clinics

Lowering the cost of going to some Accident and Medical clinics in Auckland on evenings and weekends, appears to have led to an increase in the number of children under six using these clinics, according to research from the University of Auckland.

Lower fees made no difference to the use of Accident and Medical clinics (A&Ms) by other groups including those aged between six and 64 that have high health needs and/or live in the lowest income neighbourhoods in Auckland.

('A&M clinics' refers to those set up for accident and medical care during evening and weekends, located in the community.)

A report written by health service researchers from the School of Population Health, led by Dr Tim Tenbensel, evaluates initiatives designed to reduce barriers to accessing after-hours and urgent medical care in the Auckland region that were introduced in 2011.

These initiatives, sponsored by the Greater Auckland Integrated Health Network and the Auckland Regional After-Hours Network, include the A&M intervention, which introduced subsidised co-payments and increased opening hours to 11 participating A&M clinics across Auckland.

The research was funded by the Health Research Council in partnership with the Ministry of Health. It was commissioned under the government's 'Better, Sooner, More Convenient Primary Health Care initiative', which aims to deliver a more personalised primary health care system that provides services closer to home and makes Kiwis healthier.

For those patients that were eligible for subsidised co-payments, the report's researchers estimated that use of the participating A&M clinics was 13 percent higher than expected, (8600 patients) over the course of the initiative's second year (September 2012- August 2013).

The number of patients aged over 65 using A&M clinics was higher than predicted (although still low). The biggest indication of a positive effect was for children under six years.

"We are confident that increases in the use of A&M clinics, particularly for children under the age of six, can be attributed to the A&M intervention," says Dr Tenbensel. "This is based on economic analysis of the data which shows that reducing co-payments to zero had a strong influence on the use of A&M clinics by under-six-year-olds in low income neighbourhoods."

The report also concluded that there had been little or no effect on adults and older children that lived in low-income neighbourhoods or had high health needs, even though A&M fees for these patients had been reduced by 30-50 percent. This was because these patients were not aware of the lower fees and because reduced fees remained a significant barrier for them.

The researchers also estimated that 10 percent fewer eligible patients than expected (7000 patients) presented to hospital emergency departments in 2012-13, but Dr Tenbensel emphasised that this decrease may not be attributable to the A&M intervention, because of other confounding factors.

The report also evaluated two other initiatives: an after-hours telephone triage service offered by HomeCare Medical Limited (HML), (where patients can call their GP after hours), and the St John Transport (SJT) Initiative, which aims to reduce the number of patients St John Ambulance services transports to emergency departments who can be safely managed in the community.

Awareness of the HML service was found to be low, with only 10 per cent of surveyed patients aware that their family doctor provided an after-hours telephone service.

Over the first 24 months of the SJT Initiative (December 2011 to November 2013), 2967 patients were diverted by ambulance to an Auckland A&M clinic. In 88 per cent of these transfers, patients were successfully managed in primary care, while 10 per cent were referred on to hospital.

The report concluded that the SJT Initiative had made a "small difference" to patients' use of A&M clinics and hospital emergency departments. Surveys of ambulance patients showed that those who were transferred to A&M clinics were satisfied with their care as long as they were seen by a doctor or nurse on arrival.

"While it is too early to expect these initiatives to show positive results, the report does indicate the key issues to address if these services are to play a positive role," says Dr Tenbensel.

"The value in all the initiatives lies more in the processes by which they came about – as a consequence of constructive engagement between Auckland region health organisations – and less in the capacity of these instruments to quickly solve endemic, structural health system problems," he says.