Seen and unseen work: the intensity of service provision for individuals with type 2 diabetes in a high-needs population

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 complexity⁶ 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 prediabetes; 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, healthcare 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.

View Tables 1–2.

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 trying to engage them. This highlights the hidden complexity of work when care is recognised as not optimal but remains invisible if relying solely on services provided as an assessment of future service requirements.

Outbox and inbox interactions predominantly undertaken by GPs contributed a large work volume and require timely attention to ensure safety and quality are maintained. Given the number of LTC, coordinating referrals and responding to incoming results and communications is likely more complex than other population groups.

The range of workers contributing to service provision is notable. While GP and nurse work are expected, the practice-based prescribing pharmacist role in primary care is relatively new¹² and well utilised, as were the growing use of the newer HIP and health coach roles. Both HIP and health coach roles are funded centrally through the PHO; however, HIP services are shared between practices. Given the nature of diabetes and the socio-economic status of the population, there are likely to be opportunities for more intense work by dietitians and there was no involvement from a social worker; these workers’ input is limited by funding.

Work completed by nurses, HIPs, health coaches and community health workers is not charged to the individual and is therefore financially invisible and only seen if documented in the daily records. The low value of invoices compared with the high volume of work represented in the daily records by GPs and the pharmacist and podiatrist whose work was directly invoiced to the individual is particularly striking. Total daily record entries from these providers (n=118) divided by the total directly invoiced to all individuals ($612) gives an average of $5.19 per daily record entry for these workers alone. This does not include non-contact time for outbox and inbox transactions, following up on referrals or trying to contact patients. GPs are allocated 15-minute appointments; however, the complexity of care required in this population frequently requires longer consultations,² which could not be accounted for in this analysis.

Conclusion

This study demonstrates the amount of work staff in a VLCA practice provided over 1 year to a purposefully selected sample of individuals with T2D, and highlights the complexity of these cases with multiple LTCs and high medication use. It reveals the range of workers and the work volume involved in caring for this population with complex needs. Lack of invoicing aside, work may be under-represented and under-valued if entries by workers are missing from daily records, and it was impossible to quantity the time taken for work completed and the real cost of each health transaction. Time required for care delivery is particularly pertinent in populations where social disadvantage impacts engagement in healthcare. The extremely low fee-for-service invoiced to individuals for care compared to current VLCA practice funding¹⁰ highlights problems with funding models and service sustainability. Together these data highlight factors that require consideration in future funding and resourcing arrangements. Further research is required to holistically examine the nature and intensity of this type of interprofessional work in culturally diverse high needs and other practices, the current funding received, the financial and workforce resourcing requirements and the health outcomes achieved.