Rural Ranking Score: The case for change. Rural sector and rural health care are important

Transcription

1 Rural Ranking Score: The case for change Rural sector and rural health care are important The rural sector is critical to the New Zealand economy. Primary rural industries such as agriculture, forestry, fishing and mining are responsible for generating two thirds of New Zealand s export wealth 1. Approximately 576,000 2 people live in rural areas. These people depend on a small number of health service providers along with reduced access to alternatives due to isolation. Many rural areas have high needs, with low socio-economic status and a high proportion of Māori. In addition, it should be noted that people from urban communities expect a certain level of services to be available to them when they are in rural areas for recreation purposes. Rural general practice is the mainstay of primary health care in rural communities. However, in general, rural practitioners: work in considerable isolation from hospital emergency departments, laboratory services and other hospital services; are required to have a wider range of medical and nursing skills than their urban colleagues, particularly for urgent and emergency care; travel further to emergency callouts and home visits and to meet their continuing education requirements; and work longer hours than their urban colleagues and have considerably more onerous after-hours cover commitments. The more responsibilities practices have and the further away from support they are, the more difficulties they face in attracting and retaining staff. The RRS The Rural Ranking Score (RRS) 3 was initially developed in 1995 by the New Zealand Rural General Practice Network (NZRGPN), the Funder/s and the Ministry of Health (Ministry) as an objective measure of rurality which could be used to allocate funds on a nationally consistent basis to where they were most needed. The RRS applies solely to individual GPs and is based on a range of factors for which points are claimed.these include: travelling time from the surgery to the nearest major hospital; on call roster obligations; responsibility for major trauma; travel time to nearest GP colleague; travel time to most distant practice boundary; and whether the GP holds regular peripheral (off-site) clinics. 1 Rural population in New Zealand The RRS is a scale used to determine the eligibility for additional funding to rural General Practitioners (GPs) to improve recruitment and retention of the rural general practice workforce. 1

2 The case for change The environment for providers in rural areas has changed significantly since the RRS was developed and introduced. For example: the unit of service provision has become a practice team instead of the doctor; nurses as well as doctors now provide after-hours cover; the practice scope between urban general practice and rural general practice has widened. For example, urban areas are often supported by Accident & Medical Centres and, as a result, often have easier access to a range of services; there is an increasing emphasis on keeping people out of acute hospital beds which requires a higher level of diagnostic skill and a higher level of local intervention; and in 1995 there were 4 RHAs, the Ministryand the Public Health Unit, whereas there are now 20 District Health Boards(DHBs), 31 Primary Health Organisations (PHOs)and the National Health Board (NHB). The main problems with the current funding model are as follows. Workforce There continues to be significant recruitment and retention issues in some rural areas. There is debate about how effective the rural incentive funding is in creating sustainable change in the rural general practice workforce. As at the end of September 2012, NZRGPN had a total of 50 permanent vacancies listed across 47 rural practices (3 practices have 2 vacancies). This trend is increasing with the main reasons being given as retirement or rural GPs relocating to Australia. Lack of clarity around definitions The current RRS lacks clear and objective definitions to ensure that it is applied consistently and equitably across DHBs, PHOs and general practice. Examples of obscure and imprecise definitions are associated with the terms on call duty and peripheral clinics, that is: On Call: no clear definition of what constitutes on call services and how and when they are provided. Peripheral clinics: no clear definition of what constitutes a peripheral clinic. Points have been awarded for a variety of different types of peripheral clinics, for example: a GP offering a morning clinic once a fortnight from their home; a GP offering an off-site clinic once every two months; a sexual health clinic held at a local high school; and a husband and wife GP team offering a clinic at a holiday location they frequent at Christmas time. The Ministry conducted a survey in early October 2012 and identified two practices that were awarded zero points despite reporting having three and four peripheral clinics respectively. In addition, one practice was awarded five points despite reporting no peripheral clinic. 2

3 Use of discretionary points DHBs have been awarding discretionary points to some practicesunder the current RRS to enable local flexibility that address issues outside of the indicated parameters for the RRS. There is significant variation in the awarding of discretionary points by DHBs and between practices.many of these variations appear to have been based on historical arrangements rather than to meet the needs of rural general practice. It would also appear that once discretionary points are awarded, DHBs are reluctant to withdraw them. Several DHBs have decided not to withdraw them in order to preserve relationships and maintain these services which often involve ensuring care for disadvantaged communities in a semi-rural area. In some cases DHBs have awarded additional points so a practice/community can provide Emergency Services Rescue for patients with medical conditions (heart attacks, stroke, etc) which also provides access to an Accident Compensation Corporation PRIME contract. The impact of these additional points can lead to the practice gaining access to the Rural Bonus funding by tipping a practice over the 35 point threshold. A recent survey of 13 DHBs involving 40 practices found that the allocation of discretionary points ranged from 5 to 35 points per practice. The survey showed that 43 percent of practices were awarded discretionary points. However, it should be noted that some DHBs developed a different approach to awarding discretionary points which confuses the picture. Variation in interpretation and application of the current model There is considerable variation between funding to practices with similar sized populations and the same RRS score. Examples of this variation are illustrated in the table attached as Appendix 1. Perverse incentives (oncall duty) The current model does not incentivise collaboration and sharing of rosters. After-hours issues To get after-hours funding (held by the Ministry) a practice must contribute to urgent care 24 hours a day for 7 days a week. There are currently some practices receiving a share of the after-hours funding that no longer provide the specified services.the rationale to support some of the alternative after-hours arrangements is debatable and needs clarification. One of the criteria for additional after-hours funding is based on scores.this has not been revised. 3

4 Scoring reflects the number of GPs in a practice rather than the workload The RRS Governance Group has identified a number of examples of inequity of payment for services undertaken. For example: Practice A has one GP claiming a RRS of 40. The practice covers a 1:2 roster and is awarded $5,000 Rural Bonus. Practice B is a neighbouring practice which has 4 GPs claiming a rural score of 40. They receive $20,000 Rural Bonus (4x $5,000) but effectively share in 1:4 roster. This is perceived as an unfair situation by Practice A. Limited transparency of funding flows There is limited transparency as to how the Rural Premium funding flows from DHBs to PHOs to practices. PHOs have the ability to use some of the Rural Premium funds. Some PHOs are perceived to invest this fund well supporting their practices and others are not. No monitoring of outcomes The RRS has no review mechanisms or assurance checks to ensure that the outcomes being sought are being delivered, that is, improved recruitment and retention. DHBs and PHOs do not appear to have consistent and robust mechanisms to monitor performance. The RRS is a self-administered questionnaire, requiring a high level of trust creating a lack of transparency. Changes in rurality With increasing urban spread the access to clinical support for GPs close to urban centres has improved since the current RRS was developed. Travel into neighbouring towns has become easier with improved roading and outreach services. There has also been improved access to ambulance support in many of these communities. RRS Governance Group Over the past two years the Ministry, DHBs and the NZRGPN have been working together to develop a revised RRS. The RRS Governance Group has been established to review and implement the scoring tool to better reflect today s rural health care. A revised, fit-for-purpose, tool is needed to support and sustain an appropriate level of primary health care for rural communities. A range of names has been considered and the RRS Governance Group has settled on the Revised Rural Ranking Score. The complexity of the issues that have arisen as the RRS Governance Group has modelled different scenarios has illustrated how difficult it is to separate out rural funding issues from wider primary care services within a constrained funding environment. Consequently, the RRS Governance Group has recommended that it is 4

5 unwise to embark on large scale change at this point in time. Full details of the changes that have been agreed, along with transitional funding arrangements for impacted practices, will be released to the sector in the New Year. In summary, the changes involve the introduction of an In/Out rule, tighter definitions around on-call, the removal of discretionary points and peripheral clinics, and inclusion of points for teaching activities. Dr Sharon Kletchko Chair RRS Governance Group Dr Jo Scott-Jones Chair NZRGPN

6 Appendix 1 DHB Current RRS score of example practices Enrolled population Current funding per DHB (12-13) Comparison of services provision/comments DHB $113,167 Practice provides 24/7 after hours through 1:6 roster with other local practices DHB $126,780 Practice provides 24/7 after hours through 1:5 roster with other local practice DHB $63,682 Practice provides 24/7 after hours through 1:6 roster with other local practices DHB $323,250 Practice do not provides cover for local ambulance as Level 2 hospital in same town. Practice provides all other rural services. DHB $285,424 Practice provides full range of services. 24/7 after hours covered by practice GPs working a 1:6 roster DHB $502,000 Practice provides 24/7 after hours (except maternity support) through 1:6 roster. DHB $327,200 Practice provides full range of services. 24/7 after hours covered by practice GPs working a 1:7 roster DHB $153,949 Practice provides 24/7 after hours (except maternity support) through 1:3 roster. DHB $113,191 Practice on 1:3 on call roster providing 24/7 after hours. Provide provides full range of rural services except local ambulance cover. DHB $127,144 Practice on 1:2 on call roster providing 24/7 after hours. Practice provides full range of rural services except weekend clinics. DHB $151,416 Practice on 1:2 roster weekdays (and 1:4 at weekends), providing 24/7 after hours cover. Practice provides full range of rural services except weekend clinics. DHB $144,424 Practice on 1:4 roster providing 24/7 after hours cover. Practice does not provide weekend clinics, support to local midwives or teaching. 6