Abstract
A clinic providing primary health care services free-of-charge to all its enrolled patients opened in January 2010 in Dunedin. It was staffed by volunteer clinicians, many of whom were motivated by their Christian faith. Its patients were socially vulnerable, and had complex health needs. This setting provided an opportunity for a ‘natural experiment’, whose aim was to study the delivery, context and effects of free primary health care, and the socio-demographic and clinical characteristics of the target population using such services. The expectation was that the removal of the cost barrier would enable vulnerable patients to better access comprehensive health care.
Since capturing the phenomenon (free primary health care provision) and its context were fundamental to understanding the Free Clinic, the case study methodology was used to examine the application of the phenomenon, as part of developing theory around the place of free general practice care in New Zealand. This case study comprised four component studies. A questionnaire-based study compared the socio-demographic characteristics of patients at the Free Clinic and those at a nearby fee-charging traditional clinic. A nested case study examined the nature of Free Clinic patients' diverse needs, the Free Clinic's model of care, and whether the model was a good match to patients' needs. An audit of electronic records was performed to profile the reasons Free Clinic patients consulted their general practitioner. A controlled before-and-after study of Free Clinic patients matched to other Dunedin residents by propensity scores assessed the effect of the Free Clinic on hospital use by its patients. These studies combined qualitative and quantitative research methods.
Free Clinic patients were on average younger and more likely to be Māori than the wider Dunedin population, and more likely to reside in highly deprived areas, and report high levels of individual-level deprivation. Despite their poorer self-reported health status and greater levels of multimorbidity, Free Clinic patients were likely to report having unmet needs for medical and dental services, and not being able to collect prescription items because of cost. When asked to comment on the Free Clinic’s model of care, patients placed value on the “friendly” and non-judgmental nature of the care they received, and being able to simply drop-in without an appointment to receive support for diverse health and social concerns. Free Clinic patients brought fewer than average ‘reasons-for-visit’, and tended to consult for administrative and repeat prescription requests. Follow-up of Free Clinic patients for five years after the clinic’s opening failed to reveal any significant decrease in their hospital use. Compared with matched controls, Free Clinic patients visited the emergency department more frequently after the clinic opened than before it opened.
Beyond access to health care, patients such as those attending the Free Clinic need access to the social conditions and resources that promote health. Beyond a model of care sympathetic to their needs, a protracted period of making small, incremental efforts is necessary before gains in health may be reaped. Given the limitations of the current primary health care funding and service delivery framework, the establishment of designated ‘fit for purpose’ clinics for vulnerable populations is necessary. Further research is needed to identify primary health care patients with significant unmet health needs, and to find an appropriate measure other than hospital use to evaluate policy interventions aimed at improving primary health care access.