Reflecting on my time in New Zealand I am struck by the focus on young people as a flavour to the public provision of healthcare. Originally, New Zealand’s subsidised access to care began with the over 65’s, but even they had to pay a co-payment. The next group to gain access to a subsidy were kids under six. When this was introduced in the mid-2000’s, practices were given additional capitation funding so that the cost of provision to children was free at point of delivery. From the first of July, the government will extend this open access to care to include children up to the age of 13. This is a very significant move for a government which has been committed to co-payments from the inception of funding for primary care.
Similar to Australia, screening is provided to children entering school to diagnose children with developmental issues likely to impact on their success at school. In addition, funding for Youth Health Centres is provided. This funding source allows local groups, including schools and community organisations, to support primary care options targeted at the needs of youth. This has led to care being offered in places young people are more likely to feel comfortable.
This approach is backed up with funding for “Primary Solutions” a program for 10-24 year olds. The idea behind Primary Solutions is to ensure that every younger community member has support for the inevitable crises of confidence and conflicts which accompany moves into adulthood. Funds are provided so that the youth can choose to see a counsellor in general practice, or spend one hour with a trained nurse or their general practitioner each year. The young person determines who they feel most comfortable with and the funding follows this choice. All of the providers use a similar approach to offer support and screen for more serious presentations. If these are found, the young person is then booked in with a mental health provider for a longer term service. Interestingly, reviews of referrals to mental health services have found that too much time was spent processing referrals. Consequently, at least one of the Primary Healthcare Organisations now allows primary care providers access to its booking engine for psychology and mental health. This means patients are directly booked with providers. Very clear referral guidelines means that this system works and they have no plans to go back to the historic referral model.
Given many boys and male adolescents do not attend the primary care practice they are registered with, some practices have re-directed their capitation funds for the above services into a program called “HEADS”. This is a program from the United States which is well validated and is seeing improved engagement with young males and their health. The overall objective is to produce confident young men engaging in fewer self-destructive behaviours, including suicide.
Another element of the healthcare system which demonstrates how much youth do matter is the sexual health funding stream. Youth under the age of 24 can access free medical care for sexual health matters ranging from contraception to fertility advice, sexually transmitted infections, sexuality and pap smears. After the age of 24, a co-payment applies to episodes of care in these areas. Services can be provided by doctors or nurses for any of these deliveries, reinforcing both patient choice and best use of limited clinical expertise within primary care. It is rare in New Zealand for a general practitioner to collect a smear or be the first line of reference for matters related to contraception!
Finally, the government recognises that different groups have varying use of the healthcare system and different capacity to pay. Depending upon the demographic profile of a general practice more or less funding is provided in the form of General Medical Services Grants. These are used to offer lower co-payments to social welfare recipients. Age related bands are also used to determine co-payments. People less than 24 pay smaller co-payments than those over 24, those over 35 and those over 45. This incremental funding approach reflects the various costs and income earning power of the population…so youth really does matter in New Zealand
Tracey Johnson, General Manager and Churchill Fellow 2014