Abstract
The funding and sustainability of primary healthcare are urgent priorities that must be addressed if the recent health reforms are to achieve the goal of equitable access and outcomes for all New Zealanders. This is particularly critical for services where large proportions of the enrolled population have high health needs and/or multiple social disadvantages. Providing adequate services to such groups is recognised as challenging, 1,2 and long-term under-funding of these services is recognised. 3 These populations have higher rates of multi-morbidity, more frequently utilise health and other social services and have higher unmet needs than other groups. 4–7 This results in high concentrations of complexity 6 and the need for evidence-based interprofessional collaborative models of care, 7 including a diverse range of regulated and unregulated workers. 8 However, current data detailing the extent of work and the range of skills and workers needed within practices serving these populations are limited. 9 Within a practice serving a high-needs population , this exploratory study aimed to ascertain the complexity of individuals with type 2 diabetes (T2D) and the volume of work undertaken by members of the practice team providing healthcare to these individuals over 1 year. Context Porirua Union Community and Health Service (PUCHS) operates as a Very Low Cost Access (VLCA) practice and serves a population of 7,189, comprising 48% Pacific Peoples, 21% Māori and 9.2% Refugee (many with English as a second language). Overall, 89% of this population live in the most deprived areas (quintile five) and many have multi-morbidity. Within PUCHS, 9.3% (n=657, including 20 individuals aged 14–29 years) have T2D, compared with 4.7% overall in the primary health organisation (PHO) that PUCHS operates within. Similarly high proportions have pre-diabetes; PUCHS 8.8% (n=627, including 36 aged 14–29 years), PHO overall 4.4%. In return for higher capitation and equity funding than other practices, caps are placed on co-payments charged to individuals attending VLCA practices. 10 PUCHS utilises a wide range of staff to address the enrolled population's needs, including general practitioners (GPs), nurses, health coaches, health-care assistants, and a practice-based prescribing pharmacist, podiatrist, dietitian, counsellor, health improvement practitioner (HIP), cross-cultural worker and community health worker. Many of these staff are culturally matched and live within the local community. Methods Ethical approval was provided by the University of Otago Human Ethics Committee (Health) (HD23/003). To ascertain the practice work, we collected anonymised clinical records and data extracts from the MedTech practice management system for eight individuals with T2D, purposefully selected to include a range of ages, genders and ethnicities. Table 1 describes the data and analysis. Results and discussion A summary of the findings is presented in Table 2. The mean number of recorded long-term conditions (LTC), unique items prescribed and daily record entries per case/year were high, confirming the complexity of these cases. 11 Nevertheless, these numbers alone under-represent complexity. Case 7 had only seven daily record entries; however, this individual was worryingly unengaged in healthcare, difficult to locate and the HIP was actively but unsuccessfully