I
Strong Links
Building better services to meet the health and disability support service needs of people in Porirua
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The report of the Central Regional Health Authority s Porirua Needs Assessment Project September 1994 - ISBN -0-478-04767-3 - Contents
Contents
List of tables iv
List of figures v
Executive summary vi
1. Introduction 1
1.1 The goal of the Porirua project...... 1 1.2 Needs assessment in the Central region...... 1 1.3 Why Porirua?...... 2 1.4 The "core" area of southern Porirua ...... 2 1.5 Community consultation and links with local agencies...... 4 1.6 Personnel and methods...... 4
2. Socio-demographic profile of Porirua City 5
2.1 introduction...... 6
2.2 General description of the geography of the Porirua City area...... 6 2.3 Population overview...... 7 2.4 Ethnic group populations ...... 8 2.5 Age and sex composition...... 10 2.6 income profile ...... 12
2. 7 income support...... 13
2.8 Educational profile:...... 15
2.9 Occupation...... 16 2.10 Employment status...... 17 2.]] Household composition...... 18 2.12 Residential mobility...... 19 2.13 Access to transport...... 20 2.14 Discussion...... 22
3. Disability status in southern Porirua 23 3.1 introduction...... 24 3.2 Prevalence of disability and support needs ...... 24 3.3 Comment...... 27
1 •1
4. Health status in southern Porirua 28 4.1 Introduction ...... 30 4.2 Morbidity...... 30 4.3 Mortality...... 35 4.4 Discussion of selected conditions...... 39
5. Services and their utilisation in southern Porirua 53 5.1 Primary health care services ...... 54 5.2 Public health services...... 63 5.3 Secondary health services...... 64 5.4 Mental health services...... 66 5.5 Disability support services ...... 68
6. Consumer views 73 6.1 Introduction ...... 4 6.2 What consumers said...... 74
7. Consultation and the views of community groups 79 7.1 Introduction ...... 80 7.2 Consultation with Maori...... 8] 7.3 Consultation with Pacific Island people...... 82 7.4 What the submissions said...... 83
8. Provider views 90 8.1 Introduction...... 9] 8.2 What providers said...... 9]
9. Conclusion and recommendations 105 9.1 Key population and access features...... 105 9.2 Key health issues...... 106 9.3 Service provision - health: the current situation ...... 108 9.4 A strategy for improving health status...... 1]] 9.5 Timetable and resources - health services...... 122 9.6 Key disability service provision issues...... 125 9. 7 A strategy for improving disability support...... 127 9.8 Disability action summary...... 129
ii
9.9 Timetable and resources: disability support services 131
10. References 134
APPENDICES 137
Acknowledgments 137
Porirua City, population by age, sex and ethnic group, 1991 138
Comparative profile, Porirua City by ward, 1991 139
Comparative profile, Porirua City by ward: ratio to the Central region, 1991 140
List of submissions received from community groups 141
ii List of tables
Table 1: Porirua City, usually resident population by ward ...... 7 Table 2: Porirua City, population by ethnic group and ward, 199]...... 8 Table 3: Porirua City, population by specific Pacific Island ethnic groups and ward, 1991...... 9 Table 4: Porirua City, population by Iwi and ward, 199]...... 9 Table 5: Porirua City, population by age and sex, 1991...... 1] Table 6: Porirua City, population by 5 year age group and ward, 199] ...... 11 Table 7: Porirua City, household income distribution (%) by ward, 1991 ...... 13 Table 8: Porirua City, income support (%) by ward, 1991 ...... 14 Table 9: Porirua City, occupations of residents (%) by ward, 199]...... 17 Table 10: Porirua City, occupation by ethnic group, 199] ...... 17 Table 11: Porirua City, work status by ward (%), 199]...... 18 Table 12: Porirua City, full-time unemployment rate (%) by age and ethnic group, 1991...... 18 Table 13: Porirua City, family type by ward, 1991 ...... 19 Table 14: Porirua City, private motor vehicles available per dwelling by ward, 1991 ...... 21 Table 15: Assistance used in the previous 4 weeks by households in which there was aperson witha disability ...... 25 Table 16: Comparison of self-assessed health status by area and ethnic group (percentages) ...... 30 Table 17: Hospitalisations involving people from southern Porirua. for 199]...... 31 Table 18: Comparison of southern Porirua age standardised rates of hospitalisation .for 1991, with northern Porirua and with the rest of Wellington/Wairarapa ...... 33 Table 19: Hospital admissions of southern Porirua people by ethnic group, for 1991 ...... 34 Table 20: Summary of selected services provided by Kenepuru Hospital...... 65 Table 21: Percentage ofpeopie who have used a service in the last two years who said itwas too expensive...... 75 Table 22: Percentage ofpeople who have used the service in the last two years, who thought it took too long to get an appointment...... 76
i), 1 List of figures
Figure 1: Map of the Porirua City area showing ward boundaries...... 3 Figure 2: Comparison of Porirua City and Central region populations...... 10 Figure 3: Porirua City, population proportion by age and ethnic group, 1991 ...... 12 Figure 4: Porirua City, household income by indicative ward, 199]...... 13 Figure 5: Porirua City, family type by ward, 199]...... 19 Figure 6: Porirua City, years at usual residence by ward, 1991 ...... 20 Figure 7: Leading causes of hospitalisation ofpeople from southern Porirua, 199]...... 32 Figure 8: Hospital admissions rates fior people firom southern Porirua, by age and sex, for 199].... 34 Figure 9: Comparison of trends in death rates in selected districts...... 35 Figure 10: Most common causes of death in southern Porirua, 1987-1990 ...... 36 Figure 11: Leading causes ofpremature death in southern Porirua, 1987-1990...... 36 Figure 12: Numbers of deaths by age and sex for southern Porirua, 1987-1990...... 37 Figure 13: Location of health and disability support services based in southern Porirua ...... 57
V :1 Executive summary
This report takes its name from the over-arching finding of the research and consultation carried out: that a good foundation exists for providing quality health and disability support services in Porirua, but that strpngTiniks —need Tbe madbfween ser jiovidë?s and mortiUiii1between servibe —providers and consumers.,
The project focussed on the southern three wards of Porirua City, which encompass a population of just over 30,000. This community was selected because of its low socio- economic status and high perceived need for services. The population is culturally very mixed, with large numbers of Maori, Pacific Island, European and people from other ethnic groups. Mean incomes are low, unemployment is high. Educational levels are low. There is a high proportion of single parent families. The population is very young, and households are large. Ownership of private transport and telephones is lower than elsewhere.
Although a simple self-assessment of health status by Porirua people did not differ markedly from national findings, hospital morbidity and mortality data, supplemented by other research, indicated a worse status than elsewhere for a broad range of conditions. Age standardised hospitalisation rates overall are higher than the regional mean. Rates for pregnancy and childbirth, vaccine-preventable disease, diabetes, alcohol-related and a range of other conditions are all higher than elsewhere in WellingtonlWairarapa. Close contact communicable diseases, asthma and non-motor-vehicle accidental injury were common specific causes of hospital admission. Leading causes of mental health admissions were schizophrenic psychoses, affective psychoses and alcohol-related conditions. Trends in death rates have been worse than in other parts of WellingtonlWairarapa, both overall and for specific causes such as asthma and ischaemic heart disease. In common with trends elsewhere, cot deaths (formerly high) have declined in recent years. Implicated in the more negative trends are factors which include a high incidence of smoking, sometimes poor knowledge and access to information about nutrition and healthy lifestyle, poor access to or use of primary services and a number of socio-economic factors.
The scarcity of data on disability made describing the disability status of the population very difficult. Approximately 40% of households approached in a survey indicated that one or more members had a disability of some sort. Visual (23%), hearing (17%) and physical (13%) disabilities were reported. Poorer households in the sample were less likely than others to use disability related assistance. Survey data on intellectual and psychiatric disabilities were insufficiently robust to be meaningful, but the presence of a major psychiatric hospital means that mental health issues, and in particular community care of former patients, have a high profile in the area.
Although the range of health and disability support services in Porirua is similar to that found in other communities, access, as indicated by uptake of benefits and subsidies, is worse. Expenditure levels for immunisation, maternity care, pharmaceuticals, dental care and practice nurse subsidies were all lower than the regional mean. There are limited services provided specifically by and/or for Maori through a Maori mental health unit, a marae-based primary health service in Takapuwahia, the Public Health Service and some voluntary health and disability support groups. To date, there has been a negligible amount of dedicated service provision by and/or for Pacific Island people. vi I 4 Input from consumers and community groups repeatedly identified costs, transport and access to information and advice as among the barriers to service use. Issues of cultural appropriateness, communication problems, access to after hours accident and emergency and a range of other specialist services, support for people with psychiatric disabilities, and the pressure placed on voluntary groups were also frequently commented on. While the public appreciated many of the services available and the work of providers, they also felt strongly about gaps and inadequacies.
Providers in Porirua in general clearly identified the major health and disability problems in their community, and the barriers to providing better coverage. Diabetes, asthma, immunisation, the needs of people with psychiatric disabilities in the community, alcohol, diet and lifestyle related issues, and access to ENT and other specialist services were among the issues identified. Although some providers saw transport and physical access as less of a barrier than their clients did, they readily identified cost, cultural and language factors, knowledge, and the compound effects of a range of socio-economic factors as affecting service use and health status. While they often desired to overcome these obstacles, they also often lacked the necessary time, resources, skills, knowledge and/or cultural characteristics required to do so.
The report concludes that the level and character of health and disability services purchased in Porirua needs to be adjusted to better mesh with the population characteristics and needs of the community. Recommendations include measures directed to achieving:
• enhanced primary health services for Maori, particularly in east Poriruã • enhanced primary health services for Pacific Island people • an improved response to the health and disability needs of the refugee New Settler population here and elsewhere in the Wellington region • a more coordinated and systematic response by general practitioners to immunisation, diabetes and smoking-related problems • increased provision of asthma education • improved community-based diabetes education and detection • coordination and promotion of community-based responses to smoking issues • additional ENT services • purchasing of more targetted youth health and disability support services • implementation of recommendations from a recent review of regional mental health services, tailored to the particular characteristics of Porirua, including the needs of Maori and Pacific Island people • purchasing of culturally appropriate assessment and coordination, and home support services.
Full details of the strategy, individual recommendations and a three year implementation plan are set out at the rear of this report.
The community will be invited to respond to the overall strategy and the particular recommendations before final decisions are made.
vu i\ I 1. Introduction
1.1 The goal of the Porirua project
The overall goal of the project has been to develop a purchasing strategy for health and disability support services that will improve access, based on information about the existing health and disability status of the population, what is working well now, unmet needs, and any barriers to access. Work was carried out in late 1993 and early 1994, so that recommendations could be developed for implementation in the Central RHA s 1994/95 purchasing plan.
1.2 Needs assessment in the Central region
The Porirua project is part of a programme of needs assessments being carried out by Central RHA. This comprises projects focusing on region-wide health and disability issues, as well as issues within particular communities. The purpose of the programme is to provide Central RHA with information so it can improve service purchasing. A central feature of all the needs assessment projects is a strong emphasis on practical outcomes. Regional issues on which projects have been initiated in 1993/94 include:
• immunisation • hearing loss in children • needs of people who have head injuries • alcohol and drug services • Maori mental health • services for people with coronary heart disease • access to surgical services • youth service needs.
The project has also been conducted concurrently with a Greater Wellington Mental Health Services Review. Reference to this and other projects with a bearing on services in Porirua can be found in chapter 9 of this report. Community-focussed projects initiated in 1993/94 include this study; a study of Wairoa (completed in January 1994);2 and a project to be undertaken shortly in part of Wanganui. These communities were targeted as having low health status and high service need based on "health and equity" scores derived from socio-demographic factors associated with low health status and high need. The proportion of the population that was Maori, the percentage aged
The Central region is the area for which Central RI-IA is responsible for purchasing health and disability support services. It ranges from Ruapehu and Wairoa in the north to Nelson and Marlborough in the south. 2 A Healthy Future for Wairoa. Central Regional Health Authority, Wellington. I under 15 years, and the proportion of the population which was Pacific Island were also independently taken into account when selecting communities for attention.
1.3 Why Porirua?
Porirua emerged as one of the areas in the Central region with particularly strong indications of low health status, both in terms of socio-demographic indicators (Chapter 2) and in terms of more direct measures provided by morbidity and mortality data (Chapter 4). Health problems in Porirua have also been pin-pointed in a number of other health-related studies , starting with a landmark survey by Salmond and others in the 1970s 2 . Collectively, they demonstrate that southern Porirua, in particular, has suffered disproportionately from low , immunisation, high levels of communicable disease, asthma, diabetes, mental health problems, child hearing loss and a range of other problems. At the same time there have been significant access and utilisation issues, relating to factors such as the mode of service provision, income and costs, cultural barriers, transport problems and health education. These problems, which are well known to community leaders, consumers and health workers in Porirua, have been present for a long time. Central RHA s project has complemented this existing data and knowledge to bring together a comprehensive, well researched picture of Porirua s people and their health and disability support needs. This provides a foundation for identifying and implementing strategies for change.
1.4 The "core" area of southern Porirua
It is not widely appreciated outside Porirua that its city boundaries encompass both very low and very high socio-economic areas. Chapter 2 provides information on these differences. This project has focussed on the lower socio-economic area encompassed by the three southern wards of Titahi Bay, Cannons Creek and Tairangi. Together, these wards cover Titahi Bay, Elsdon-Takapuwahia, central Porirua, Ranui Heights, Cannons Creek, Waitangirua, Ascot Park and Papakowhai. (See Figure 1 on the following page.) These wards contain approximately 61% of households in Porirua City and form a fairly coherent physical community, although containing distinct social communities layered and clustered within it. In this report, our analysis focuses on these three wards (which we refer to as the "southern wards" or "southern Porirua") but with references where appropriate to other wards, the whole city area and the Central region.
The main findings of these studies are referred to at appropriate points in the report. 2 Salmond G (1975) Maternal and Infant Care in Wellington - a health care consumer study, Special Report No. 45, Management Services and Research Unit, Department of Health. Wellington.
2 I Figure 1: Map of Porirua City showing the ward boundaries
j Wellington
[1 1.5 Community consultation and links with local agencies
In undertaking this type of project, we have recognised that the community must be involved and that we should seek to work with community-based organisations and groups to identify and achieve desired change. At the outset, the Porirua Community Health Group was consulted about the project. Their comments and advice were helpful and appreciated, as were the views of public health nurses and workers in the area, who the team met with in the initial phase of the work. Central RHA staff met members of the Maori community at a hui at Maraeroa Marae in early November, to talk about the project. They undertook to report back to the community at a subsequent hui to be held in 1994. Meetings were also held with officials of the Ministry of Pacific Island Affairs and Pacifica, and progress was reported at a fono held in Porirua in early 1994. A constructive relationship was established between staff of Central R}TA and of the Porirua City Council. The Council had independently planned to carry out a study of health status and issues to inform its development of health-related policies and programmes, which include a Healthy Cities programme and community development activities. Staff of the two agencies have liaised and cooperated on a number of aspects of their respective projects.
1.6 Personnel and methods
The project has been carried out by a team of Central RHA staff assisted by external researchers contracted for particular tasks. It has involved: • a review of existing reports and data on Porirua • analysis of population data to health and disability implications (chapter 2) • analysis of available disability data (chapter 3) • analysis of recent hospital morbidity, mortality and other health status data (chapter 4) •. a general inventory of services available in Porirua and service utilisation data (chapter 5) • interviews with consumers about health and disability issues, and their use of and views about specific types of services (chapter 6) • consultation with community-based health and disability interest groups (chapter 7) • interviews with service providers in Porirua (chapter 8) • synthesis of this material to generate a conclusion and recommendations (chapter 9)
Further details of the approaches used are given in the relevant chapters of the report. In addition a household survey was conducted in conjunction with the Porirua City Council. It was intended to measure health and disability support service needs, usage and perceptions of a random cross-section of Porirua households. A total of 473 primary caregivers were interviewed in southern Porirua, with a similar number interviewed throughout Porirua City. Information from the household survey is interspersed throughout the report. On the basis of the information obtained, and within the bounds of what is feasible and appropriate, the project team has developed recommendations on the need for different or additional services in Porirua City, and ways that existing services can better meet community needs.
4 I 2. Socio-demographic profile of Porirua City
Highlights
The population of PorE rua City was 46,440 at the time of the 1991 Census. The socio-demographic profile of Porirua City differs from that of the Central region as a whole in many ways. The proportions of the following groups are substantially higher in Porirua City than in the Central region: • Maori (51% higher) • Pacific Island people (610% higher) . young people aged 14 or less (25% higher) • people aged 15 and over who are unemployed (19% higher) • households with children under 5 years of age (56% higher) • households with at least one single parent .family (61% higher)
The proportions of the following groups are substantially lower in Porirua City than in the Central region: • people aged 65 and over (49% lower) • one person households (43% lower) • houses owned with no mortgage (45% lower)
Within Porirua City there are marked differences in socio-demo graphic characteristics between areas (suburbs), and between ethnic groups. These differences tend to be greater than those between the City as a whole and the Central region. • Pacific Island people comprise 41% of the population of Tairangi and Cannons Creek wards; compared to 10% in Titahi Bay ward, and 1% each in Plimmerion and Horokiri wards. • Around 32% of households in Tairangi/Cannons Creek have single parent families, compared to 6% for Plimmerton/Horokiri. • Residents in 27% of the dwellings in the three southern wards do not have motor vehicles available for private use. Many therefore depend on public transport to access services provided in Porirua, Wellington and Lower Hutt. • The above-average income recorded for Porirua City as a whole is inflated by Plimmerton and Horokiri wards, which have significantly higher income levels than the Regional average. Tairangi and Cannons Creek have much lower income levels. Titahi Bay ward tends toward the average for Porirua City, in this and many of the other variables considered. • Consistent with this pattern, the 1991 unemployment rate ranged from around 5% in Plimmerlon/Horokiri, to 20% in Cannons Creek.
Information about people with disabilities was not readily available. This information gap will need to be addressed in order to take a systematic approach to the purchase of disability support services.
5 11 2.1 Introduction
2.1.1 AREA COVERED This chapter focuses on the southern wards of Titahi Bay, Cannons Creek, and Tairangi. As noted in the introduction, this is because they score relatively highly on various indicators of health need. The two "northern" wards Plimmerton and Horokiri (mainly Whitby), are included to give a complete picture of Porirua City. The considerable variability (for example, pockets of very high and very low income) within particular wards should be noted.
2.1.2 SELECTION OF VARIABLES FOR ANALYSIS A recent review of the impact of economic and social factors on health identifies the following as important variables: income, education, social class, unemployment, sex, family structure, area, transport, housing, and ethnic group. These factors have been used to guide the selection and analysis of variables. To the extent that they also affect access to health services, and probably disability support services too, these factors have particular implications for Central RHA s purchasing directions.
2.1.3 PRESENTATION The three southern wards are shaded in the tables throughout this chapter. For each substantive section, main findings are described and illustrated, with significant comparisons noted: both between Porirua and the Central region as a whole, and between sub-areas within the city. Likely confounding factors, which may influence patterns superficially apparent from the data, are noted. Technical caveats relating to data limitations are foot-noted. Implications for health and disability support service purchasing are noted in the conclusion.
2.1.4 ETHNIC GROUP CLASSIFICATION Statistics New Zealand s ethnic group classification "level one" is used in this report. The term "Maori" includes people who identified themselves as "New Zealand Maori" as either their sole ethnic group, or as one of several ethnic group S.4 "Pacific Island people" include those who identified as of specific Pacific Island ethnic groups, including in combination with any other group, but excluding those who also specified Maori as one of their ethnic groups.
2.2 General description of the geography of the Porirua City area
The main Porirua shopping centre is located at the heart of the Porirua area, and is immediately surrounded by light industrial areas. Some facilities, such as the train and bus stations, some schools, and the Recreation Centre are located close to the shopping centre.
IQ This chapter does not examine differences within wards. 2 Barwick H (1991) The Impact of Economic and Social Factors on Health, report prepared for the Department of Health by the Public Health Association of New Zealand. Statistics New Zealand (1993) New Zealand Standard Classification of Ethnicity, Statistics New Zealand. Wellington (see page 26) Except for data on Iwi affiliation, which is based on the "any Maori ancestry" Census question. Except for the data presented on specific Pacific Island ethnic groups.
The residential areas of the city are separated from the central business district by tracts of undeveloped land, farmland, State Highway I and the main trunk railway line (which pass through the middle of the area), and Porirua harbour and Pauatahanui inlet among other features. Some parts of Titahi Bay, Elsdon and Porirua East include large numbers of state houses, accommodating families on relatively low incomes. There are also areas of pensioner housing, such as in central Titahi Bay, that have a, significant impact on the profile of the local population. Residential areas are well removed from the main shopping area. Most residents need to use some form of powered transport to get to the main shopping area. Residents need to travel to Wellington for some services, such as hospital based after-hours accident and emergency services.
2.3 Population overview
The total usually resident population of Porirua City was reported as 46,440 in the 1991 Census of Population and Dwellings. In respect of population size it is a relatively large TLA, 2 comprising 5.4% of the Central region s total population (856,629).
Table 1: Porirua City, usually resident The population is distributed across the population by ward five wards of Porirua City, as shown in Ward 1981 1986 1991 Table 1. Cannons Creek is the largest ward in population terms, with 28% of 10605 99 74.46 7,821 L7,608 Porirua s residents, followed by Titahi Bay k 12516 1158 with 23 percent. The three southern Plimmerton 6,642 7,242 7,263 wards comprise 67% of the Porirua City Horokiri 5,232 6,588 7,950 population; and the two northern wards,
Porirua City 42,444 45,729 46,440 33 percent.
Since 1986, the population in the three southern wards has declined very slightly. By contrast, Horokiri ward has shown the greatest growth: by 52% from 1981 to 1991, and by 21% from 1986 to 1991. Porirua s population increased by 9% over the previous ten years; and an increase of 2% over the previous five years. From a base population of 46,542 in 1991,4 the usually resident population of Porirua City is projected to grow over the five years to 1996, by between 1.6% 6). (low projection) and 7.2% (high projection Over the ten years from 1991-2001, Porirua City s population is projected to increase by between 4.4% and 16.0%.
Numbers of people with disabilities is discussed in the following chapter. 2 TLA = Territorial Local Authority. - Generated with Supermap2 from 1991 Census data, Department of Statistics. The given 1991 (Census) base population is not necessarily identical to that derived from Supermap 2, as it has been adjusted to include persons whose residence was not specified. Assuming low fertility, high mortality, and low migration.. 6 Assuming high fertility, low mortality, and high migration. Source: Porirua City Council Demographic Profile. 1993/94 Series. Statistics New Zealand. Projections are not available from this source for particular ethnic groups, or sub-areas within the City.
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Porirua City had 13,458 permanent private dwellings, as at the 1991 Census. This was an increase of 18% over the previous ten years; and 8% over the previous 5 years. The average number of residents per dwelling declined from 3.71 in 1981, to 3.45 in 1991.
2.4 Ethnic Group Populations
2.4.1 OVERVIEW The population of Porirua City in 1991 was 56% European, 21% Pacific Island people and 19% Maori. Four percent were from other ethnic groups (or did not specify what ethnic group they belonged to). This pattern is markedly different from that of the Central region population as a whole, which was 80% European, 3% Pacific Island people, and 13% Maori. Of Porirua City s "Other" group (excluding "not specified"), 25% were Indian, 16% Chinese and 59% from ethnic groups not separately listed. It is likely that this largely includes people of south-east Asian origin. The ethnic distribution also varies markedly within Porirua City, as shown in Table 2. European people comprise 92% of residents in the two northern wards, and 61% in Titahi Bay. Pacific Island people comprise 41% of the population of Tairangi and Cannons Creek wards combined. Eighty eight percent of Porirua City s Pacific Island people live in Tairangi or Cannons Creek wards, and 92% of Maori live in the three southern wards. Of the "other" ethnic groups not separately listed, almost half (47 percent) are in Cannons Creek Ward.
Table 2: Porirua City, population by ethnic group and ward, 19911 Ethnic Titahi Bay TairangiOar Plimmerton Horokiri Porirua City
European 8492 2,298 6,660 7,341 26,268
Maori 2817 1,881 372 321 8,793
Pacific Is. 1,095 3,153 72 102 9,738
Chinese 66 21 42 39 195
Indian 63 57 30 30 300
Other 102 114 54 96 699
Not specified 93 78 36 24 447
Total 10,725 7,608 121 7,260 7,953 46,440
2.4.2 PACIFIC ISLAND ETHNIC GROUPS Sixty percent of Porirua s Pacific Island people are Samoan, 22% Cook Island Maori, 13% Tokelauan, 3% Niuean, 2% Tongan and 1% Fijian 2. This is similar to the Pacific Island ethnic group composition of the Central region as a whole. The distribution of Pacific Island ethnic groups with Porirua City is shown in Table 3 below.
Generated with Supermap2 from 1991 Census data, Department of Statistics. 2 Note that the total for the table giving population of specific Pacific Island ethnic groups is not equal to that for Pacific Island people in Table 2 above. This is because the summary ethnic group Table is based on a definition of Pacific Island ethnic group which excludes persons identifying as both Maori and Pacific Island ethnic group.
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Table 3: Porirua City, population by specific Pacific Island ethnic groups and ward, 1991 Ward Samoan Cook Is. Niuean Tongan Tokelau Fijian - 822 279 54 30 87 6 1,935 822 72 42 582 15 Cannons Cr 3,609 1,239 177 93 720 33 Plimmerton 39 30 3 3 6 6 Horokiri - 51 45 6 3 9 3 Porirua City 6,459 2,418 312 171 1,404 63
2.4.3 1w! AFFILIATIoN Of Porirua residents with Maori ancestry, the most common Iwi affiliations are Ngati Porou (20%), Ngapuhi (12%), Ngati Kahungunu (11%) and Ngati Toa (9%). Twenty percent of those with Maori ancestry in Porirua City stated that they did not know what Iwi they belonged to, or that they did not belong to any Iwi. This proportion is less than for Maori in the Central region as a whole, of whom 26% stated no Iwi affiliation. The distribution of Iwi with more than 200 members within Porirua City is shown in Table 4 below. The pattern is consistent with the general distribution of Maori throughout Porirua; except for Ngati Toa. Sixty-seven percent of Porirua s Ngati Toa live in Titahi Bay, and are concentrated in the Elsdon—Takapuwahia area. However, more than 80% of Maori in Titahi Bay wards are not of Ngati Toa Iwi.
Table 4: Porirua City, population by Iwi and Ward, 19911
lwi2 ii Bay Tarangi Cannons C. Plimmerton Horokiri Porirua City
Ngati Porou 573 420 741 48 81 1,863 Ngapuhi 96 198 435 48 45 1,125 Ngati Kahungunu 96 207 321 42 63 1,029 Ngati Toa 540 75 99 78 9 801 Tai flu (3) 56 168 249 27 42 645 Tuwharetoa 23 141 240 27 18 552 Ngati Raukawa 74 90 168 48 39 519 Tuhoe 114 126 249 12 6 513 Tainui-Ngati Maniapoto 108 120 135 21 30 411 Te Atiawa 35 67 117 42 15 399 Te Arawa(4) 23 68 168 12 6 375 Ngai Tahu 78 36 60 30 48 249 Te Whanau-A-Apanui 39 60 06 12 0 213 Don t know/belong 503 339 588 162 192 1,881 Total Maori ancestry(5) )09 1,827 3,237 567 537 9,192
Generated with Supermap2 form 1991 Census data, Department of Statistics. 2 Includes all Iwi in Porirua City with more than 200 members recorded. Excludes Ngati Haua. Hauraki and Ngati Raukawa. Excluding Waitaha-Bay of Plenty. Total Maori ancestry is greater than the number recorded for the New Zealand Maori ethnic group due to different definitions used. I 2.5 Age and sex composition
Porirua City has a relatively young population. The median age is 27 years, compared to around 32 years for the Central region as a whole.
As shown in Figure 2 below, 29% of Porirua City residents are under 15 years of age, compared to 23% for the Central region. Conversely, only 6% of Porirua residents are 65 or over, compared to 11% for the Central region.
Figure 2: Comparison of Porirua City and Central region populations
35 0 • Porirua City • 30 Central Health Region 0. 0 0. 25 .3 20 C) > 4S C.) C) 0. U) 0
Under 15 15 to 24 25 to 44 45 to 64 65 & over Age group (years)
The numbers of residents for each of Porirua s five year age and sex groups are given in Table 5. The age-specific sex ratio pattern for Porirua is broadly consistent with that of the Central region. Males outnumber females up to 15 years of age. After 60, females increasingly outnumber males, and above 84 years there are only 38 males per 100 females.
It is not possible to extract median values for the Central region from Supermap2. The figure of 32 years was estimated by calculating the mean of the given median .ages for the four relevant former area health boards.
10 I
Table 5: Porirua City, population by For Porirua City, the deficit of males is age and sex, 19911 relatively pronounced between the ages of 25 Age (yrs) Male Female Total and 34 years (around 89 males per 100 females, compared to 96 per 100 for the Central region). 0-4 2,637 2,457 5,094 5-9 2,226 2,082 4,308 In this age band, there are 450 more females 10-14 2,049 1,968 4,017 than males in Porirua City. 15-19 2,235 2,253 4,488 The age composition of the local population 20-24 1,875 1,989 3,864 25-29 1,782 2,022 3,804 varies considerably within Porirua City. 30-34 1,842 2,052 3,894 Numbers in each age group, for respective 35-39 1,707 1,803 3,510 wards, are given in Table 6. The median age 40-44 1,614 1,644 3,258 ranges from around 22 years in Tairangi and 45-49 1,251 1,260 2,511 Cannons Creek, to 34 years in Plimmerton. The 50-54 1,053 1,011 2,064 median ages for Titahi Bay and Horokiri wards 55-59 819 738 1,557 are intermediate, at around 30 years. 60-64 705 687 1,392 65-69 534 540 1,074 Tairangi and Cannons Creek wards have very 70-74 297 402 699 young populations, with 34% of residents under 7579 165 243 408 the age of 15, but only 3% above 64 years. 80-84 81 201 282 Titahi Bay and Plimmerton wards have the 85+ 60 156 216 highest proportion of residents who are aged Age total 22,929 23,514 46,443 over 64 years (10 and 8% respectively). Plimmerton and Horokiri wards have a relatively large proportion of their population in the 25-44 age group, at around 36 percent. This compares with around 28% for the three southern wards. Table 6: Porirua City, population by 5 year age group and ward, 19911
Age (yrs) Titahi Bay TauiangI Cannons Cr Plimmerton Horoki ri Porirua Under 5 1,044 964 1,746 558 756 5,094 5 to 9 B5 934 1,553 540 702 4,311 10 to 14 798 789 1 206 570 654 4,017 15 to 17 567 54 780 342 459 2,700 18 to 19 381 363 594 204 249 1,791 20 to 24 738 1,323 465 417 3,861 25 to 29 966 645 1,119 492 567 3,801 30 to 34 567 666 828 3,891 35 to 39 723 507 777 687 810 3,507 40 to 44 672 750 3,258 45 to 49 474 609 2,508 50 to 54 411 387 2,061 55 to 59 330 246 1,554 60 to 64 453 306 192 1,395 65 to 69 414 201 126 1,071 70 to 74 279 162 69 702 75 to 79 90 39 408 80 to 84 54 42 285 85 and over 42 48 219 Total 7,263 7,950 46,440
Generated with Supennap2 from 1991 Census data, Department of Statistics
11 2.5.1 AGE PROFILES OF THE DIFFERENT ETHNIC GROUPS The age compositions of the main ethnic groups in Porirua City also differ markedly, as shown in Figure 3. Half of the Maori and Pacific Island population in Porirua is under 20 years of age, but only 31% of Europeans are.
Of the European population, 12% are 60 or over, compared with 2% for Maori, and 5% for Pacific Island people.
A detailed breakdown of Porirua City s population by age group, by ethnic group and sex is given in the appendices.
Figure 3: Porirua City, population proportion by age and ethnic group, 1991
45 40 LII European 35 a) > I Maori a) Pacific Is. "-0- . 20 rL 15 a) 0 a. 5: 0 A A
0-14 15-24 Ii25-44 45-64 65+ Age group (years)
2.6 Income profile
2.6.1 OvERvIEw Both the median personal income for Porirua City ($14,913), and median household income ($39,690), are higher than for the Central region as a whole ($14,237, and $30,155).
Whereas Porirua City as a whole shows above average income patterns, two strikingly divergent patterns are visible within the city, as detailed in Table 7. For the three southern wards, the median household income is around $30,000. For the two northern wards, median household income is around $55,000. The contrasting pattern is illustrated for Cannons Creek and Horokiri wards, in Figure 4.
Median age is not available by ethnic group from Supermap2. Nor are age breakdowns by 5 year age groups by ethnic groups. 2 Income figures refer to total income received in the twelve months prior to the 1991 Census, by residents aged over fourteen years. Estimate for Central region derived as for median age - see earlier footnote. 12 I
Table 7: Porirua City, household income distribution (%) by ward, 19911 Total income I T6hi lairangi Cannons Plimmerton Horokiri I Porirua Central I... say Creek City region
Nil or Loss 0 0 0 0 $5,000 or less 0 0
$5,001 - 10,000 2 5 6
$10001- 15,000 5 2 9 10
$15,001-20,000 5 3 6 9
$20,001-25,000 5 3 6 8
$25,001-30,000 4 3 5 7
$30,001-35,000 11 9 11 13
$40,001-45,000 11 9 10 10
$50,001-55,000 20 23 15 12
$70,001 or more 10 25 34 16 12
Not available 6 7 8 7 6 I Not specified 8 5 6 10 7
Total cIo 100 100 100 100
2.6.2 ETHNIC GROUP DIFFERENCES Figure 4: Porirua City, household income Distinct income patterns are also by indicative ward, 1991 associated with the different ethnic groups of Porirua. $70001+ Over half of Maori (57 percent) and $50001- Pacific Island people (59 percent) $40001- received less than $15,000 personal $30001- income in 1991. This compares with E 41% of European people.2 $25001- C $20001- • Horokjh Fifteen percent of Europeans received over $40,000, compared to 3% for $15001- Cannons C. 0 Maori and none for Pacific Island x people. $5001-
<$5001 Nil or Loss 2.7 Income support 0 10 20 30 40 2.7.1 OVERVIEW Percent of ward households Fifty-three percent of Porirua City s residents aged over 14 years received some kind, or combination, of income support in the 12 months preceding the 1991 census. This is similar to the proportion for the Central region, at 55 percent.
Generated with Supermap2 form 1991 Census data, Department of Statistics. 2 Median income is not available, by ethnic group, from Supennap2.
13 Ll Types of benefits received were Family Benefit (alone or in combination with other type/s): 20 percent; National SuperannuationlGRl: 10 percent; Unemployment Benefit: 8 percent; Domestic Purposes Benefit (alone or in combination): 5 percent; Sickness/Invalids Benefit: 3 percent; and Youth/Student Allowance: 2 percent. The proportion of Porirua residents receiving National SuperannuationlGRl is considerably lower than for the Central region as a whole. This reflects Porirua s relatively young population. Receipt of Family Benefit/Support is correspondingly higher for Porirua. Within Porirua City, the pattern of income support is divergent (see Table 8). In the two northern wards, over half received no income support payments. Of those who received income support, this was typically either the (non-means tested) Family Benefit alone; or National SuperannuationlGRl. In the three southern wards, two or more -types of income support were received by 11 to 16 percent. For Tairangi and Cannons Creek wards, the major types were Family Benefit (alone 2), or in combination Unemployment Benefit, and Domestic Purposes Benefit (alone or in combination). For Titahi Bay ward, major types were Family Benefit (alone or in combination), National SuperannuationlGRl, Sickness/Invalids Benefit, and Unemployment Benefit.
Table 8: Porirua City, income support (%) by ward, 1991
Income support type Plimmer- Horokiri Porirua Central ton City region
National Super/GRI 15 4 7 14 8 10 18 Family Benefit 12 14 10 17 23 15 12
Unemployment Benefit 7 12 14 3 2 8 7
Youth/Student Allowance 2 2 2 2 2 2 2 Sickness/Invalids Benefit 8 2 2 0 3 2
Domestic Purposes Benefit 1 3 0 0 2
Other Single Payments 3 3 3 2 2 2 3
Total, One Payment Only 48 39 42 39 38 42 44 Family Benefit/Support 2 3 3 2 3 Family Benefit/Support/DPB 3 4 6 0 3 2
Other Combinations 8 8 3 2 6 6
Total, Two or More ii l lb 5 3 11 11
No Payments Received 37 42 36 54 57 44 42 4 4 6 3 2 4 3
Total 100 100 100 100 100 100 100
It is not possible to tell, from Supermap2, the total number or proportion of people receiving all respective single types of income support. The given categories are as presented in the table below. For example, we can tell how many people received Unemployment Benefit only, but not how many received this Benefit plus any other. 2 Note the difference in uptake of Family Benefit alone (which was non-means tested) and Family Benefit plus Family Support (income related) between wards. Generated with Supermap2 from 1991 Census data, Department of Statistics.
14 I/A 2.7.2 INCOME SUPPORT RECEIVED BY DIFFERENT ETHNIC GROUPS
Income support (one or more types) was received by 49% of Porirua City s European residents aged over 14 years, 60% of Maori and 56% of Pacific Island people. While 7% of European people received two or more types , for Maori this proportion was 19 percent, and for Pacific Island people, 15 percent. The pattern of income support type among Porirua s ethnic groups, and sub-areas, reflects their different demographic composition. For the European group, Family Benefit (mostly alone) was received by 20 percent; and National SuperannuationlGRl by 14 percent. For Maori and Pacific Island people, major types received were Family Benefit alone or in combination (21% for Maori, and 19% Pacific Island); Unemployment benefit (14 and 17 percent); Domestic Purposes Benefit, alone or in combination (10 and 6% respectively).
2.7.3 INCOME SUPPORT RECEIVED BY PEOPLE WiTH DISABILITIES While many people on the invalids/sickness benefit will have disabilities, it is not clear what proportion of recipients of other benefits do. One would expect that they are highly represented among those receiving the unemployment benefit due to the difficulty many (who are able to work) face in gaining paid work.
2.7.4 THE COMMUNITY SERVICES CARD, HIGH USE HEALTH CARD AND PRESCRIPTION STOP-LOSS Ten percent of southern Porirua respondents in the household survey reported having a high use health card, and slightly more than one in three reported having a group 1 Community Services Card. It is likely that not all who are eligible are claiming these benefits. In the consumer consultation outlined in Chapter 6, participants reported feeling confused about eligibility. Data is not available on the extent of uptake among eligible people or any systematic population differences in uptake. More than a quarter of the households in southern Porirua reached the twenty item pharmaceutical stop-loss last year. It seems likely that some people will be confused about the stop-loss regime, or be unable or unwilling to incur the costs of pharmaceuticals prior to reaching the stop-loss. Again, there is no data available on this.
2.8 Educational profile
One third (33 %) of Porirua City residents, aged over 14 years, specified in the 1991 Census that they had tertiary educational qualifications. This is less than for the Central region as a whole, at 37 percent. A further third (33 percent) had no qualifications, compared to 29% for the Central region. The educational profile varies markedly within Porirua City. Though half the residents of the two northern wards have tertiary qualifications, less than one third of residents in the southern wards do. Almost half of Tairangi and Cannons Creek residents (45 and 46% respectively) specified that they had no qualifications, compared with around 14% for the northern wards.
Note that receipt of multiple payment types does not necessarily imply that they were received simultaneously. It could be, for example, that unemployment benefit only is being received, then, upon change of situation, DPB is received.
15 2.8.1 QUALIFICATIONS OF PEOPLE FROM DIFFERENT ETHNIC GROUPS Forty-one percent of European residents in Porirua City, aged over 14 years, have tertiary qualifications. This compares with 21% for Maori and 17% for Pacific Island people. For European people, 26% have no qualifications compared to 48% for Maori and 44% for Pacific Island people.
It is likely that the difference in educational levels between ethnic groups would be less marked if Plimmerton and Horokiri were not included. However, data to quantify this pattern are not available at ward level from Supermap2.
2.8.2 QUALIFICATIONS OF PEOPLE WITH DISABILITIES No local data is available for this group.
2.9 Occupation
2.9.1 OVERVIEW Porirua City s occupational distribution is similar to that of Central region as a whole, except in two respects. One fifth (20 %) of workers living in Porirua are clerks, compared to 15% for Central region. Only 1% are agricultural, fisheries and similar manual workers, compared with 10% for the Central region. Clerks, with administrators/managers, professionals, technicians, and service/sales workers, make up 70% of the occupations in which workers living in Porirua are employed.
Distinct occupational patterns within Porirua are illustrated by a comparison of Horokiri and Cannons Creek wards. In Horokiri, 53% of the work force are administrators/managers, professionals, or technicians; and 13% work in trade, machine operator, or elementary occupations3 . By contrast, in Cannons Creek 19% are administrators/managers, professionals, or technicians; with 42% working in trades, as machine operators, or in elementary occupations.
l Full-time and part-time workforce aged 15 years and over. 2 Where people work has service implications, in that people will often seek services close to their place of employment. However, information about where people work was not available for inclusion in this report. Includes general labourer and associated occupations.
16
Table 9: Porirua City, occupations of residents (%) by ward, 19911
Occupation group Titahi Tairangi Cannons Plimmer- Horokiri Porirua Central Bay Creek ton City region Ad mini strata rs/M an a g ers 9 6 5 17 22 12 12 Professionals 11 7 7 19 16 13 13 Technicians 11 8 7 17 15 12 12 Clerks 21 20 20 19 20 15 Service/Sales Workers 15 14 14 11 12 13 12 Ag/Fish Workers 1 1 1 1 2 1 9 Trades Workers 13 12 11 8 8 10 10 Machine Operators 9 15 16 2 3 8 8 Elementary Occupations 8 14 15 3 2 8 7 Armed Forces 0 0 0 0 0 0 Not Specified 2 2 3 1 1 2 Total 100 100 100 100 100 100 100
2.9.2 ETHNIC GROUP COMPARISON
Forty-eight percent of European workers living in Table 10: Porirua City, occupation by Porirua are administrators/ ethnic group, 19911 managers, professionals, or technicians. This compares to Occupation group lEuropean Maori Pacific Is.
Administrators/Managers 18 6 2 24% for Maori and 16% for Professionals 15 8 5 Pacific Island people. Technicians 15 10 7
Clerks 19 20 21
Ten percent of Europeans are Service/Sales Workers 9 11 13 machine operators or in Ag/Fish Workers
elementary occupations, Trades Workers 12 12 11
Machine Operators 6 16 21 compared with 28% for Maori Elementary Occupations 4 14 16 and 31% for Pacific Island Armed Forces 0 0 0 people. Not Specified 3 3
Total 100 it.I. III.] However, for each ethnic group, the major occupational category is clerical, around one fifth of each group being in this category.
2.10 Employment status
2.10.1 OvERvIEw In 1991, 47% of Porirua City s residents aged over 14 years were wage or salary earners. Seven percent were unemployed and 39% were not in the labour force. This pattern is broadly consistent with that of the Central region as a whole, as detailed in Table 11.
Generated with Supermap2 from 1991 Census data. Department of Statistics. I 17
However, unemployment rates were higher than this in the three southern wards, being up to 10% in Cannons Creek and Tairangi.
Table 11: Porirua City, work status by ward (%), 19911
Work status litahi Tairangi cannons Plimmer- Horokiri Porirua Central Bay Creek ton City region Wages or Salary 43 45 38 56 60 47 45 Self Employed 3 2 2 6 6 4 5 Employer of Others 2 1 1 4 5 2 4 Unpaid/Family Business 0 0 0 0 0 0 Not Specified 1 1 1 1 1 Unemployed 7 10 10 4 4 7 6 Non Labour Force 44 41 48 28 24 39 39 Total 100 100 100 100 100 100 100
2.10.2 PEOPLE WITH DISABILITIES People with disabilities experience high levels of unemployment, with estimates ranging from 30% up. In Porirua, where general unemployment levels are high, levels of unemployment among people with disabilities is also likely to be high.
2.10.3 ETHNIC GROUP COMPARISON Table 12: Porirua City, full-time Unemployment rates vary markedly by ethnic unemployment rate (%) by age and group in Porirua, as elsewhere. The full-time ethnic group, 19912 unemployment rates for Maori and Pacific Age (yrs) European Maori Pacific Is. Island people are three times those of Europeans. 15-19 20 41 46 20-24 12 27 30 25-34 7 22 19 Table 12 also shows that unemployment is 35-44 4 11 14 particularly high among younger people. 45-59 4 9 13 15-59 7 21 21
2.11 Household composition
Twenty-seven percent of families in Porirua City are one-parent families. This is a considerably larger proportion than for the Central region as a whole (17 percent).
One parent families comprise over a third of all families in Cannons Creek and Tairangi wards. As seen in Table 13, and Figure 5, this contrasts strongly with the two northern wards, in which around 7% are one parent families.
Generated with Supermap2 from 1991 Census data, Department of Statistics. 2 Generated with Supermap2 from 1991 Census data, Department of Statistics. The "full-time unemployment rate" figures given here are not entirely consistent with those given above in the employment status section, due to data being based on differing definitions.
18 11
In the Maori ethnic group, 38% of families are one-parent families. For Pacific Island people the proportion is 28 percent and for European, 14 percent.
Table 13: Porirua City, family type by ward, 19912 Family type Plimmer- Horokiri Porirua Central ton City region One Parent Family 165 147 2,763 37,416 Two Parent Family 1,104 1,398 6,324 107,253 Couples only 783 669 2,808 78,930 Total 2,052 2,214 11,898 223,608
Figure 5: Pori.rua City, family type by ward, 1991
100%
80%
60% E 4! 40%
20%
0% Titahi Bay Tairangi Cannons C. Plimmerton Horokiri
• One Parent Family El Two Parent Family 0 Couples only
2.12 Residential mobility
Fifty-six percent of Porirua City s residents had lived at their current residence for five years or more prior to the 1991 Census. This shows a similar level of residential stability to the Central region as a whole, at 53 percent.
Within Porirua, Tairangi and Cannons Creek wards show the highest level of stability, 60% having lived at their current residence for five years or more. For Horokiri ward, only 43% had lived at their current residence for this long. In Horokiri, 16% had lived at their current residence for less than one year: compared with Tairangi, where 11% had been for less than one year . See Figure 6 below.
This relates to families where the female partner is of the respective ethnic group. 2 Generated with Supermap2 from 1991 Census data, Department of Statistics It should be noted that for Cannons Creek, there is a high level of "not specified" responses on this item (11 percent). This alone could account for some of the observed differences between wards, or clusters of wards.
19 I Titahi Bay had the highest proportion of residents who had been at their current residence for thirty years or more: 6 percent.
Caution is needed in interpreting data on residential stability. High levels of mobility could reflect economic or other inability to retain satisfactory accommodation. On the other hand, low level of mobility may reflect economic or other inability to move to alternative, preferred locations.
Figure 6: Porirua City, years at usual residence by ward, 1991
25
20
15
10
U 0 U 0
0 <1 1 2 3 4 5-9 10-14 15-19 20-29 30+ Years at usual residence
Titahi Bay Tairangi - - - - Cannons C. -°-- Plimmerton -0---- Horokiri
2.13 Access to transport
2.13.1 PRIVATE TRANSPORT Residents in 18% of Porirua City s dwellings do not have motor vehicles available for private use. This is a higher proportion than for the Central region as a whole, at 13 percent.
Motor vehicle availability varies markedly within Porirua. Whereas in Cannons Creek, motor vehicles are unavailable in 33% of dwellings, this is so for only 1% of Horokiri Ward dwellings.
Numbers of dwellings with respective numbers of available vehicles are shown in Table 14
20 I
Table 14: Porirua City, private motor vehicles available per dwelling by ward, 19911
Number of motor annons Plimmer- Horokiri Porirua Central vehicles Creek ton City region
0 714 465 159 33 2,460 39,588
,$63 948 1,095 849 5,979 142,704
2 954 1,212 3,663 88,176
3 204 267 822 19,707
4 54 69 189 4,608
5+ 18 21 60 1,830
Not Specified 51 18 303 6,135
Total 2,532 2,466 13,476 302,745
Even if a household does have a car, it does not follow that it is always available for use. For example, the household survey found that during the day, less than half of the caregivers interviewed had access to a car and were dependent on either friends or public transport if they could not walk to where they needed to go.
2.13.2 PUBLIC TRANSPORT Many Porirua residents lack private transport, and therefore need to use public transport to gain access to many services. For example, Kenepuru hospital is not within easy walking distance of any residential area. From Porirua East or Titahi Bay, two bus trips will be required; from Plimmerton a train and bus trip; and from Whitby two bus trips and a train trip.
Travel outside the area is complex, requiring a number of transfers. This can be time consuming, expensive and, for many, fatiguing. For example, a trip to Wellington Hospital, for residents of Titahi Bay, Elsdon, and Porirua East requires a bus to Porirua Station, a train to Wellington Station, and a bus from there to Newtown. If minimal delays are incurred making connections the trip will take around one and a half hours each way. Such a trip costs an adult travelling at full fare in the region of $14 (return). Many people will need to take children and/or other family members with them, further adding to the cost.
A trip from Porirua to Lower Hutt is more difficult, as there is no direct connection, and travellers must go via Wellington. This adds a further train trip and extra time and costs to the journey.
Outside normal working hours, public transport is less frequent, and people travelling at this time may fear for their personal safety. After-hours hospital based accident and emergency services are only available at Wellington Hospital, necessitating such a trip for those without access to private transport.
Public transport difficulties present an additional access barrier to many people with disabilities, and others who are frail, injured or unwell. These people have a high level of need, may have more limited mobility options (for example, they cannot elect to walk or ride a
Generated with Supermap2 from 1991 Census data. Department of Statistics
21 bicycle, and may not even be able to get to or board a bus), and face high costs in using transport services.
2.14 Discussion
Divergent socio-economic patterns are found within Porirua City. These relate both to sub-areas within the City, and ethnic groups
The population of Porirua City, particularly the three southern wards, appears relatively stable. This suggests that population change will not create pressure for the development of new health and disability support services. However, this does not tell us about existing levels of unmet need, or about emerging health issues within the existing population. These are discussed in the following chapters of the report.
The high population of Pacific Island and Maori people in Porirua presents a challenge to health and disability support services, not only to address special health issues experienced by these communities, such as diabetes, asthma, and glue ear, but also to ensure that services are provided in ways that are culturally appropriate and acceptable. Special requirements of distinct groups within these communities (for example, non-Iwi-affiliated Maori) will also need to be recognised.
The high proportion of children in Porirua suggests that child health is a significant area of service need in Porirua, particularly for Maori and Pacific Island communities. The high level of single parenthood also suggests the need for special attention in this area.
The apparent relative stability of the population as a whole can hide quite wide sub-group fluctuations. For example, while the number of children under five years in Porirua City increased by 9% between 1986 and 1991, this was offset by a decrease of 13% among five to fourteen year olds.
With low average income levels in the three southern wards, the cost aspect of service accessibility will need continuing attention. Other aspects of socio-economic deprivation - relatively low education levels, concentration in manual occupations, and high unemployment - tend to re-reinforce both this issue and health education needs.
A further issue directly affecting access to services is the availability of transport. Motor vehicles are unavailable in over a quarter of all dwellings in the three southern wards. This indicates a need for location of service provision within the local community. Where this is not possible, adequate transport arrangements will be required to ensure service accessibility. This particularly applies to times when public transport is unavailable.
22 I 3. Disability status in southern Porirua
Highlights • There is a great scarcity of reliable information on disability status. Accordingly, data in this chapter are drawn largely from the household survey conducted as part of the project.
• Forty-one percent of households in southern Porirua reported having at least one person with a disability living in them (Ye, in the terms used in the survey, have been told they have a disability by a health worker or doctor, or who classify themselves as disabled, regardless of cause, accident at birth or aging).
• In about a third of households where there are people with disabilities, some disability related assistance was received. This was most common in European households, especially in the case of using equipment or adapted transport.
• Households in the lowest income groups were much less likely than others to use disability related assistance.
• Visual disability was the most common type of disability reported in the household survey, occurring in 23% of all households.
• Hearing disabilities were also relatively common, with 17% of households recorded as including at least one person with a hearing disability.
• Thirteen percent of the households in southern .Porirua are reported to include someone with a physical disability.
• The household survey identified 3% of households as including someone who has a intellectual disability. This compares with an assumed prevalence rate of around 0.33% in the population generally. The lack of comparability between the measures, and the possible sampling error in the survey mean that no firm conclusions can be drawn from this data.
• The household survey also identified 3% of households as including someone who has a psychiatric disability. Again, reasons relating to comparability of the measures used, the size of the possible sampling error, and factors relating to people s willingness or unwillingness to reveal information about psychiatric illness or disability in a survey of this kind, mean that this figure has to be treated with caution.
• The presence of a major psychiatric hospital in the city is certain to lead to higher numbers ofpeople with psychiatric disabilities in the area than elsewhere.
• Ethnic group differences were observed, and probably reflect cultural bias in recognising people as having a disability, and/or a bias in the numbers of people in these populations who have been .formally diagnosed as having a disability. Further research would be necessary to state confidently what ethnic group differences exist.
23 1 3.1 Introduction
The socio-demographic and other factors used to select Porirua and other communities for attention in our needs assessment programme were health-focussed. These factors are not necessarily also good predictors of the disability status of a community. An emphasis on populations with a high proportion of children, for example, biases the choice of community away from areas in which there is likely to be a high level of age-related disability. Balanced against this, however, is the fact that stresses associated with life in low-socio-economic communities tend to be associated with a range of mental health problems. It has not been possible to present comprehensive or reliable data on the prevalence of disability in Porirua City. The scarcity of reliable data arises from difficulties inherent in defining disability and practical problems related to gathering information from an appropriate sample. There have been two main definitional problems: length of time before an injury or illness (eg psychiatric) becomes a disability, and the boundary between disability, injury, and illness (eg is chronic asthma an illness or a disability?). Furthermore, not all people with disabilities identify themselves as such for a variety of reasons. There has never been a national census of people with disabilities in New Zealand. Work to date has largely applied overseas estimates to the New Zealand population. The margin of error in such estimates is likely to be enormous, especially when looking at specific populations within New Zealand, such as southern Porirua. southern Porirua for example, has a major psychiatric hospital in its centre, which will influence the number of people with psychiatric disabilities who live in the area - it is likely that a disproportionate number of people who have acute and chronic mental illness live in the area. While many previous residents of the hospital have left the area, many have taken up residence in Porirua s cheaper housing areas. Data in this section is drawn from the household survey that was conducted in southern Porirua for the purposes of this project. Disability information was but one part of a much wider range of information sought, thereby preventing detailed disability information being gathered.
3.2 Prevalence of disability and support needs
People with disabilities have conventionally been categorised into five groups, determined by the kind of disability. These are physical, sensory, psychiatric, intellectual, and age-related disabilities . 2 This section presents data for southern Porirua, based on these definitions, from the household survey conducted as part of the Porirua needs assessment project.
The Ministry of Health is currently developing a definition of disability that will clarify these issues. 2 These groupings fail to capture the diversity of disabilities that people experience. In particular they do not adequately recognise those with head injury, communications disorders, or those with multiple disabilities. The household survey of Porirua residents was conducted by the National Research Bureau for the Porirua City Council and the Central Regional Health Authority. As the sample was relatively small it was not possible to look at age, sex or ethnic group breakdowns. 24 I I
3.2.1 OVERVIEW Forty-one percent of households in southern Porirua were recorded as having at least one person with a disability living in them. Just under a third of these (13%) reported having more than one person with a disability. This proportion may sound high, but is not inconsistent with the general rule of thumb that one in ten people has a disability of some sort.
Table 15 below presents a summary of the kinds of assistance received by people with 4 disabilities in southern Porirua.
Table 15: Assistance used in the previous 4 weeks by households in which there was a person with a disability
In about a third of households where there are people with disabilities, some assistance was received. This is most common in European households, especially where equipment or adapted transport is used. Households in the lowest income groups were much less likely than others to use assistance.
There are several possible explanations for these differences. One may be the somewhat higher prevalence of people with physical disabilities in European and Other households, which in turn may be linked to the older age structure of this group. Another is that these things often cost money to obtain and/or maintain. Government assistance with costs is more readily available to enable someone to participate or continue to participate in the paid workforce, which again introduces an ethnic group bias (since Maori and Pacific Island people are less likely to be in paid employment). Yet another possibility is that Europeans are generally more adept at accessing services.
3.2.2 PHYSICAL DISABILITY This group includes people who have reduced physical capacity. This may result from any number of causes such as cerebral palsy, or spinal cord injury. Thirteen percent of the households in southern Porirua are reported to include someone with a physical disability. Prevalence was highest among European households (18%), followed by Maori (12%) and Pacific Island households (7%).
3.2.3 SENSORY DISABILITY This group generally includes those who are deaf, have partial loss of hearing or some hearing defect, and those who are blind, have partial loss of vision, or some defect of vision.
25 Visual disability was the most common type reported in the household survey, occurring in 23% of all households. Visual disabilities were reported most frequently in Maori households (29%), followed by European (23%) and Pacific Island (17%). The survey was designed to exclude people who had long or short vision that was corrected with glasses. The extent to which it was effective in doing so it not certain. Hearing disabilities were also relatively common, with 17% of households recorded as including at least one person with a hearing disability. Hearing were reported most frequently in European households (22%), followed by Maori (15%) then Pacific Island (11%). From comments made by respondents, it appears that some of those included will be children who have had glue ear but are likely to recover full hearing.
3.2.4 PSYCHIATRIC DISABILITY As mentioned above, the presence of a major psychiatric hospital in the city is certain to lead to higher numbers of people with psychiatric disabilities in the area. There will be significant numbers of people living in the institution as well as in close proximity following deinstitutionalisation. Many of these people will not have been picked up in the household survey because they were not living in the houses surveyed. A number may also have declined to participate in the survey. It is also possible that some people may be inhibited about declaring that they have, or are living with someone who has, a psychiatric disability. People are usually considered to have a psychiatric disability where they have a psychiatric condition that is expected to endure, continuously or intermittently, for more than six months. An acute psychiatric episode does not constitute a permanent disability. Psychiatric disability includes chronic depression and schizophrenia among other conditions. The household survey identified 3% of households as including someone with a psychiatric disability. Because the basis of measurement was households rather than individuals, the data is not comparable with other prevalence statistics, and no firm conclusions can be drawn. Numbers are also too small to report any ethnic group differences.
3.2.5 INTELLECTUAL DISABILITY People with intellectual disabilities have a permanently impaired ability to learn. This is caused by damage to the brain which may result from illness or injury, but is most commonly present at birth. People with severe intellectual disabilities are likely to be multiply disabled as a result of a syndrome or severe brain damage. For example, some people with cerebral palsy, but by no means all, are intellectually disabled, and people with Down s Syndrome often have vision and heart problems as well. The household survey identified 3% of households as including someone who has a intellectual disability. Numbers are too small to draw any strong conclusions, or to report any ethnic group or other differences.
A review of prevalence rates for moderate or severe intellectual disability suggests a rate of approximately 0.33% in the population generally. As with the data on psychiatric disabilities, given the margin of error involved in a sample survey of this type, and the basis for measurement (household rather than individual), no firm conclusions can be drawn from this finding.
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3.2.6 AGE-RELATED DISABILITY These are relatively common disabilities such as hearing and vision loss, and loss of mobility that tend to occur in older people as part of the natural ageing process. Often they are related to conditions such as stroke and arthritis that are more common among older people. Data is not available on the numbers of people with age related disabilities. However it is safe to assume that a significant proportion of the older age group will eventually experience one or more age related disabilities, based on New Zealand and overseas studies. Data on the disabilities of older people was not collected in the household survey.
3.3 Comment Ethnic group differences reported above may reflect cultural bias in recognising people as having a disability, and/or a bias in the numbers of people in these populations who have been formally diagnosed as having a disability. Further research would be necessary to state confidently what ethnic group differences exist. The value of count information (such as that presented above) is debatable. This is because the needs of people with disabilities cannot be inferred from this kind of labelling approach. People s experience of disability-related need varies from person to person, and may be determined by factors other than the kind of disability they have been diagnosed as having. Among those with disabilities are people who have: • been disabled since birth and some who became disabled suddenly, or gradually • severe disabilities and others who have moderate or mild disabilities • multiple disabilities • permanent functional loss and others who have temporary functional loss • fluctuating levels of functional loss/need • friends and family to support or care for them, and others who are alone • different needs related to their life-cycle stage • progressive disabilities.
All of these factors interact and affect the kinds and levels of support and/or services an individual may require to have a reasonable quality of life. Important elements in planning services for people with disabilities are not what kind of disabilities a person has, but: • the kinds of activities that they wish to engage in • the kinds of disability related barriers they face in achieving these objectives • what resources and abilities the individual has to draw on.
It is expected that the introduction of comprehensive needs assessment processes, and the related standards, will provide high quality information on which to base the purchasing of disability support services. In the meantime Central RHA will rely On information of a more qualitative nature, derived from consultation processes such as those outlined in chapters 6, 7 and 8 of this report. Service providers and people with disabilities themselves have offered clear guidance on initiatives they believe Central RHA could take to improve the delivery of disability support services to people with disabilities in southern Porirua.
27 4. Health Status in southern Porirua
Highlights
Self-assessed health status • Eighty-six percent of people surveyed in southern Porirua assessed their own health as excellent, very good or good, a figure similar to that found in a national survey (91%). Comparing results at the two levels by ethnic group, Maori were the same, Pacific Island slightly higher, and European/Other slightly lower in southern Porirua than nationally. Hospital admissions Hospital data provide a direct measure of service utilisation and an indirect measure of health status. Total hospital/sat/on rates in southern Porirua are higher than rates for the region as a whole. Within Porirua, 1991 rates were 22% higher among Europeans/Others than for Maori and 34% higher than for Pacific Island people. This was counter to national \ \ data showing a general trend for Maori and Pacific Island people to have higher rates of admission. • The most .frequent general causes of hospitalisation in 1991 were pregnancy and \\ childbirth, non-specific symptoms and signs, followed by respiratory disorders. • The age standardised hospitalisation rate for pregnancy and childbirth was four times that of the rest of Well/n gton/Wairarapa and twice that of northern Porirua. • The most common specific causes of hospilalisation were close contact communicable diseases, asthma, and non-motor vehicle accidental injury. • The age standardised hospitalisation rates for vaccine preventable communicable diseases were more than twice as high as for the rest of Wellington/Wairarapa, and four times higher than for northern Porirua. • Despite the high prevalence of ear problems among children in sothern Porirua, public hospital operation rates for otitis media with effusion ("glue ear") did not differ from the rest of Weilington/Wairarapa. Waiting times were high. • Maori and Pacific Island infants had higher hospitalisation rates for close-contact communicable diseases such as whooping cough and measles when compared with others, although between the ages of] and 14 the rate for European/Others was significantly higher than for Maori. • The age standardised hospitalisation rates for diabetes among residents of southern Porirua were two and a half times greater than for the rest of Wellington/Wairarapa, and more than three times greater than for northern Porirua. • Mental health conditions accounted for the highest proportion (44%) of all bed occupancy days - well ahead of circulatory disease and pregnancy related causes at 11% and 8% respectively. • The leading cause of mental health admissions was schizophrenic psychoses, followed by affective psychoses, then problems with alcohol dependence or abuse.
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• Overall, the rate of menial health admissions for Europeans/Others was 41% higher than for Maori, and 3 times higher than for Pacific Island people. • Age standardised hospitalisation rates for alcohol related conditions were two and a half times greater among southern Porirua residents than for the rest of Wellington/Wairarapa, and three and a half times greater than for northern Port rua. • Maori had significantly higher admission rates for stroke, chronic obstructive respiratory disease, and other cardiovascular diseases. All admissions for tuberculosis and stomach cancer were for Pacific Island people. • Europeans/Others had significantly higher, admission rates in 1 99/han others for bowel cancer, malignant melanoma, peripheral vascular disease, diabetes, hearing, other smoking related disorders, non-motor vehicle unintentional injury, injury from causes unknown, perinatal conditions, and non-neural tube congenital abnormalities. • There were no specific causes of admissions to hospital for which southern Porirua s rates were significantly lower than those for northern Porirua or the rest of We//in gton/Wairarapa. Health Risk Factors • Smoking is an important factor in poor health status in southern Porirua. The household survey found that 51% of southern Porirua households contained smokers. Smoking was most common in Maori households, followed by Pacific Isleind households, then European/Other households. Deaths • southern Porirua generally has a higher death rate than other districts in the Wairarapa/Wellington region. Furthermore, while deaths rates have recently been dropping in most other areas, they have increased in Port rua. • The most .frequent causes of death are ischaemic heart disease (conditions such as heart attack), followed by chronic obstructive respiratory disease, then stroke. • Sudden Infant Death Syndrome (SIDS) was the leading cause of infant mortalii y between 1987 and 1990, but has declined by up to two thirds since then. • There were 30 suicides recorded in southern Porirua between 1987 and 1990, with a firther 4 recorded as probable suicide. Southern Porirua s suicide rates were significantly higher than those for the rest of Wellington/Wairarapa. • In southern Porirua there were 17 deaths due to asthma between 1987 and 1990. Over this same period there were no deaths in northern Porirua. • While nationally death rates for ischaemic heart disease have decreased this is not evident in southern Port rua. • National improvements in the numbers of deaths due to unintentional injury are not apparent in southern Porirua.
29 a 4.1 Introduction
This chapter looks at health status data for Porirua 1 . It focuses on the core area comprising the southern wards of Cannons Creek, Tairangi and Titahi Bay, referred to here as southern Porirua. The commentary is based primarily on hospital morbidity data and mortality statistics, as relatively comprehensive data sources are available for these events. However, much illness, injury and disease does not result in hospital admissions or death. Most health care is provided by primary care services such as general practitioners and other private and voluntary sector agencies and individuals. Even where hospitalisation or death occurs there is often a period when care is provided in the community, both before and after hospitalisation. Data from these sources are not readily available, however. Caution should therefore be exercised in drawing conclusions about prevalence or need. Use of health services is not solely dependent on need, but is also influenced by knowledge, attitudes and beliefs and perceived or real barriers to access. Hospital and mortality data are complemented by data drawn from a household survey carried out for Central RHA and Porirua City Council in early 1994.2
4.2 Morbidity
4.2.1 SELF-ASSESSED HEALTH STATUS One means of measuring health status is to ask people directly for a subjective assessment their current state of health. The table below presents a comparison of the self-assessed health status of people from southern Porirua and all of New Zealand. The ratings for southern Porirua were obtained from the household survey conducted in the area as part of this project. The national figures are derived from the Household Health Survey conducted by the Ministry of Health and Statistics New Zealand during 1992/1993.
Table 16: Comparison of self-assessed health status by area and ethnic group (percentages)
Morbidity and mortality data and analysis in this chapter are drawn largely from a report prepared by Scott Metcalfe, Mutt Valley Health, Public Health Service, and from work carried out by the Research Unit of the Central RI-IA. 2 National Research Bureau (1994) Assessment of health and disability needs in the southern Porirua area, report prepared for the Central RHA, Wellington. Statistics New Zealand and the Ministry of Health (1993) A Picture of Health, Wellington. 4
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Nationally, a larger proportion of Europeans report good to excellent health than Maori and Pacific Island people. However, in southern Porirua the self assessed health status of Europeans/Others was more similar to that of Maori and Pacific Island people. This is in keeping with the morbidity and mortality data presented below, which indicates that Europeans/Others in southern Porirua have poorer health status than in the wider Central region.
4.2.2 OVERVIEW AND BROAD CAUSES OF HOSPITALISATION The hospitalisation data in this section covers all public hospital separations recorded during 1991, including where the patient died, and events recorded in the Ministry of Health s Mental Health Register. An inclusive definition of the Maori population is used to calculate rates.2
During 1991 there were a total of 5,365 hospital discharges involving people from southern Porirua. They spent a total of 49,627 days in hospital, as shown in Table 17. Table 17: Hospitalisations involving people from southern Porirua, for 1991
Number Percentae Bed Percentage Reason for admIssion admissions o{ all occupancy of all bed adrmssons days days pregnancy/childbirth/puerperium 1,093 20 3,906 8 supplementary codes 857 16 3,131 6 respiratory 596 11 2,521 5 injury & poisoning 480 9 2,588 5 circulatory disease 304 6 5,422 11 genito-urinary 270 5 757 2 symptoms, signs - ill-defined (no diagnosis) - 251 5 797 2 gastrointestinal (digestive) 224 4 1,256 3 neoplasms (cancers) 211 4 1,351 3 mental disorders 188 4 22,018 44 nervous system/sensory organs 185 3 2,133 4 musculo-skeletal/connective tissue 179 3 985 2 infectious/parasitic diseases 135 3 575 1 skin/subcutaneous tissue 104 2 489 1 perinatal (just before and/or after birth) 95 2 605 1 endocrine/nutritional/metabolic 88 2 489 1 congenital anomalies 79 1 484 1 diseases of the blood/blood-forming organs 26 0 123 0 Total admissions 5,365 100 49,630 100
"Separations" include discharges, deaths in hospital and transfers to other hospitals. 2 Refer to Chapter 2 for a discussion of inclusive and exclusive ethnic group definitions. There is debate about the appropriateness of using the former definition in deriving a population denominator for Maori morbidity data. Nevertheless it has been used by the Ministry of Health and Te Puni Kokiri in recent analyses. Use of an exclusive (sole Maori ethnic group) definition would yield higher Maori rates than are shown in the analysis on which discussion in this chapter has drawn. Based on broad ICD9 chapter headings.
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Expressed as an age-standardised rate, overall hospital discharges for southern Porirua in 1991 amounted to 1,800 per 10,000 population. If typical, this is a significantly higher rate than for the Porirua-Kapiti Coast area and the Central region as a whole.
The most frequent causes of hospitalisation were pregnancy and childbirth, non-specific symptoms and signs, followed by respiratory disorders. Mental health conditions accounted for the highest proportion (44%) of all bed days.
4.2.3 SELECTED CAUSES OF HOSPITALISATION Excluding pregnancy and other general causes of hospitalisation, relatively few conditions account for a large proportion of all hospitalisation and bed days. Figure 7 shows the most common specific causes of hospitalisation in 1991. Together they accounted for 40% (2,161) of all hospital admissions, and 62% (30,570) of all bed days.
Figure 7: Leading causes of hospitalisation among people from southern Porirua, 1991
vaccine-preventible cerebrovascular disease (stroke) alcohol-related (non-injury) alcohol/other related iatrogenc diabetes Teflitus other cancers XD (chronic obstr resp dis) other congenitalanorrties other sex-associated other nutrition-related ischenic heart disease perinatal (non-congenital) other cardiovascular dis- Injury, cause not specified mental health non- MVC unintentional Injury asthma other close-contact conrndis 310
0 25 50 75 100 125 150 175 200 225 250 275 300 number of hospital admissions
The most common leading causes were close contact communicable diseases (e.g. acute bronchitis, influenza, gastro-enteritis), asthma, and non-motor vehicle accidental injury, accounting for 1742, 892, and 1309 bed days respectively. Although strokes only accounted for 32 admissions, they accounted for 3498 bed days. Similarly, alcohol related non-injury causes accounted for only 33 hospital admissions, but 3130 bed days.
Age standardised rates for mean annual discharges during 1988-92 were 1,282 per 10,000 population in the wider Porirua-Kapiti Coast area, and 1,324 per 10,000 in the Central region as a whole.
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4.2.4 SOUTHERN COMPARED WiTH NORTHERN PORIRUA AND WELLINGTON!WAIRARAPA There are several conspicuous differences in the leading causes of hospital admission between southern Porirua and the rest of WellingtonfWairarapa. In the rest of Wellington!Wairarapa unintentional injury (excluding motor vehicle accidents) was the most common cause. On the other hand, asthma ranked as only the 7th most common cause of hospitalisation for the rest of Wellington/Wairarapa, compared with second place for southern Porirua.
For a number of specific causes of hospitalisation, the age-standardised rates for southern Porirua are significantly higher than for northern Porirua and for the rest of WellingtonlWairarapa, as shown in Table 18 below.
Table 18: Comparison of southern Porirua age standardised rates of hospitalisation for 1991, with northern Porirua and with the rest of Wellington/Wairarapa
Southern northern RSt of Porirua Porirua WeUinton[ ______Watrarp Reason for admission number of rate of extent to which extent to which dmis51ons admission per the southern the southern 1000 populatiqn. Ponrua rate is Porirua rate is higher higher asthma 263 8.8 2.8 2.1 Mental Health register2 178 5.8 5.1 1.3 other close-contact comm disease 310 10.2 1.9 1.3 other cardiovascular disease 94 3.6 2.5 1.6 CORD (chronic obstr resp disease) 62 2.4 4.7 2.2 diabetes mellitus 45 1.7 3.3 2.5 alcohol-related (non-injury) 33 1.2 3.5 2.5 vaccine-preventible 32 1.0 3.9 2.3 other sex-associated 3 78 2.3 1.9 1.3 other nutrition-related 78 2.9 2.0 1.3 lung cancer 26 1.0 1.3 1.9 cervical cancer 18 0.6 2.8 1.7 hypertension 11 0.4 - 2.6 pregnancy, childbirth and post-natal 1093 32.0 2.0 4.2
There were no specific causes of admissions to hospital for which southern Porirua s rates were significantly lower than those for northern Porirua or the rest of Wellington/Wairarapa.
4.2.5 ETHNIC GROUP DIFFERENCES During 1991, people in the Europeans/Others group had higher rates 4 of hospitalisation than Maori or Pacific Island people, according to the data in Table 19. The rates were 22% higher
The WellingtonlWairarapa area used here excludes southern Porirua, but includes the Kapiti Coast except for Otaki and environs. It does not necessarily correspond to the boundaries used in other studies, so caution should be exercised in comparing data from this report with data from others. 2 Crude admission rate per 1000 population. Includes sexually transmitted diseases, pelvic inflammatory disease, and induced abortions. Age standardised rates per 1000 population.
PUBLIC HEALTH 33 COMMISSION LIBRARY than for Maori and 34% higher than for Pacific Island people. This contrasts with what we know of the health status of the groups generally. Although their relatively poor socio- economic status may mean the health status of southern Porirua Europeans/Others is lower than elsewhere, other factors are likely to be involved. It may be that Europeans more readily seek and obtain help with health problems. It may also be that the health status of the South East Asian refugee community included in the category is sufficiently poor to affect the overall level of admissions of the group. Finally, possible systematic misrecording of Maori (and Pacific Island) ethnicity needs to be considered. Misrecording is known to be a problem in mortality records, where a similar ethnic group trend is observed. (see section 4.3.4)
Table 19: Hospital admissions of southern Porirua people by ethnic group for 1991
When age and sex group comparisons are made, other ethnic group differences become apparent, as shown in Figure 7 below.
Figure 8: Hospital admissions rates for people from southern Porirua, by age and sex, for 1991
1400 1357
• Maori 1200 EI Other C 0 i 1000 Pacific Island
CL 0 C. cc 800 0 I.. 600
400 310 310 281 261 1 28 200 092 129 10^2A 104 93 63 56 ^ 232 54 A 72I 55 [] 1-4yrs 5-14 15-24F 15-24M 25-44F 25-44M age and gender group (in years, FfemaIe, MmaIe)
Hospitalisation rates were significantly higher for infants, children, and 15 to 24 year old males, for Europeans/Others. Maori had the highest hospital admission rate for females aged between 15 and 24. Maori and Pacific Island women between the ages of 25 and 44 years had
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slightly higher admission rates than other women. There were no statistically significant differences among any other age and sex groups. With respect to specific causes of hospitalisation, Maori had significantly higher admission rates than other groups for stroke, chronic obstructive respiratory disease, and other cardiovascular disease. All admissions for tuberculosis and stomach cancer were for Pacific Island people. However they had fewer mental health related admissions. Maori and Pacific Island admission rates for asthma were higher than for "Other", but the differences were not statistically significant. All admissions for bowel cancer, malignant melanoma, and peripheral vascular disease in 1991 were for people from the "Other" ethnic group. They also had significantly higher admission rates for diabetes, hearing, other smoking related disorders, non-motor vehicle unintentional injury, injury from causes unknown, perinatal conditions, and other congenital abnormalities.
4.3 Mortality
4.3.1 OVERVIEW Porirua generally has had a higher death rate than other districts in the Wairarapa!Wellington region. Furthermore, while deaths rates declined in most other areas in the late 1980s, they increased in Porirua. Figure 9 below provides a comparison of age/sex-standardised death rates over the period 1987-1990.
Figure 9: Comparison of trends in death rates in selected districts
o 800
750 Frirua CL —0---- o 700 0. —h---- Kapiti C 650 CD —0---- L Huff 0 6 600 —x— U Huff 0 55 0 Wellington N cL 500 z cc 400 1987 1988 1989 1990
The remainder of this section is based mainly on mortality data for the four years from 1987 to 1990, complemented by more recent data where available. Over this period there was a otal of 943 deaths. The average annual death rate was 780 per 100,000 population. The average number of potential years of life lost before the age of 70 was 3,161 per year2.
An exclusive definition of Maori is used for this section, comprising only those who identified their ethnic group as solely Maori in the 1991 Census. The Pacific Island group includes those who identified as belonging to one or more Pacific Island ethnic groups but not to any other ethnic group. These definitions provide a better match with official mortality data. 2 Potential years of life lost before the age of 70 (PYLL70) is a measure that takes into account the age at death. It is used to gauge the extent of premature death in a population.
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4.3.2 MAIN CAUSES OF DEATH The most frequent causes of death in southern Porirua were ischaemic heart disease (conditions such as heart attack), followed by chronic obstructive respiratory disease, and stroke, as shown in Figure 10 below. These 20 causes account for 90% of all deaths in southern Porirua, but are strongly influenced by deaths of older people. Figure 10: Most common causes of death in southern Porirua, 1987-1990
stomach cancer other congenital anomalies breast cancer retcubendothelial cancer alcohol related, non-injury peropheral vascular disease asthma large bowel cancer SIDS (cot death) non . rrtor vehicle injury motor vehicle traffic accident mental heath, incl. suicide other cancers lung cancer other communicable- disease other cardiovascular disease other, miscellaneous causes stroke chronic obstructive resp.- db. ischaerric heart div. (heart attack 200
0 20 40 60 80 100 120 140 160 180 200 number of deaths
Figure 11: Leading causes of premature death in southern Porirua, 1987-1990
alcohol related, non-injury breast cancer large bowel cancer other cancers lung cancer chronic obstructrve resp. div. stroke asthma ret,cuendotheIiaI cancer neural tube defect (spina btida) pen-natal, non-congenital other, miscellaneous causes other cardiovascular disease other corrrrunable disease non-rrtor vehicle injury other congenital anomalies mental health, incl. suicide ischaerric heart div. (heart attack motor vehicle traffic accident SIDS (cot death)
0 200 400 600 800 1000 1200 1400 1600 1800 potential years of life lost before age 70
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) < ) 2 CD 0 C) 0m number of deaths CD ' 0- 0 CJQ (4 000_S CD (a cr . JQ fJ . 0) 00 0 I ) . 0) 00 0 CD . 0 0 0 0 0 0 0 0 0 0 0 0 C) 0 0 CD ) - —.o - ---EL n - (D0<(D CD <1 Fs3 < — CDIh. CD-1 CD CD CD (D 0 U) Ca. CDCD ) CD CD CD -t CD CD w _1U) (D< C) U) (1)0 CD CD C) U) 1-4 0 0)< U) 0 CD 0- CD 0- (4 = 0 U) 0- C) ,- CD CL CD OD 0 5-14 _ a 0 = — CD CD CD ri CD • (D — 0 CD CD 0 C) CD 15-24F U) CDQ CD CD CD C) CD CD CD CD -I CD CD _U) CD CD CD 15-24M CO) CD CD CD< CD p 0 (ID 0 CD 0 CD 4) . 0 U) 0-+ C) CD,- cn = 0 . 25-44F 0- P C) U) -iCD 1(D b-, 0 2Do. UQ CD CL CD CD - CD U) ) 0 0 — to -1CD 0- - CD Ln U) 25-44M 0 CD CL CL 0 (D CD 0 Q-tU) L CD CD 0 45-64F (ID—f (D0 CD C) — c 1 UQ CD -a )C) CD _•CD U) —f (D, CD -t 45-64M ID U) 0- CD r+ r+ CD Q - CL . 0 J CD • - 1 r+ CD CD CD CD CD CD 0--f U) I OU = . 0- 65-74F CD • CD CD -. — CD C) CDCD J 0- 0- — — -I a CD 0- CD -f h 0 CD _. U) CDCD CD U 65-74M CD 1 CD - - 00- CD - 0 (D -, — CD -t UQ Q -t 0 • —f-I 0 -s- CD jq 75+ F U) CD 0- CD = C) 0- -I- 0- 0 ci 0 - -I C) p 00 CD 75+ M (D CD ) - CD CD — C) OCD 0, 1 00 U) 0-U)cj CD -t t U) I
School children There were only 6 deaths in this age group, and no particular cause predominated.
Late adolescent/young adult females Road traffic-related incidents were the leading cause of death in females aged 15-24 years. There were 7 deaths between 1987 and 1990, and the rate was three times that of the rest of the rest of WellingtonlWairarapa. However, as the numbers are very small the rate is not likely to be reliable for comparative purposes. The next most common cause of death was suicide, which accounted for 3 deaths.
Late adolescent/young adult males The most frequent causes of death among this 15-24 year old males were suicide (5) and motor vehicle accidents (4). No causes of death had significantly higher death rates than the rest of Wellington/Wairarapa for this group.
Young adult females Breast cancer caused the most deaths in women aged 25-44 years (4), followed by motor vehicle accidents (3).
Young adult males Nine men, aged 2 5-44, died of motor vehicle crashes, and eight committed suicide. The rates for both these causes were significantly higher than the rest of Wellington!Wairarapa. Other cardio-vascular disease (5), and heart attacks (4) were the next most common causes of death.
Middle age females Heart attacks were the most common cause of death for women aged 45-64 years (12). Cancer of the lung (8), other cardio-vascular disease (6), breast cancer (5) and stroke (5) are other frequent causes of death in this group.
Middle age males Heart attacks account for a third of all deaths among 45-64 year old males (50). The age/sex standardised death rate is 65% higher than for the rest of the WellingtonlWairarapa region. The next most common causes of death are cancer of the large bowel (9), and then cardio- vascular disease (9).
Older females Heart attacks are again the major cause of death for females aged between 65-74 years. They accounted for 24 deaths - more than a quarter of the total deaths in this group. The next most common cause was chronic obstructive respiratory disease, resulting in a total of 9 deaths.
Older males Males aged 65-74 most commonly died of heart attacks, a total of 35 deaths, accounting for a quarter of all the deaths in the group. Chronic obstructive respiratory disease was next, followed by stroke, accounting for 24 and 15 deaths respectively.
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Elderly females While heart attacks are again the most common cause of death (44) among women in the 75 plus age group, stroke is the next most common (31), followed by other cardio-vascular disease (25). These three causes accounted for just over half of the deaths in the group.
Elderly males Heart attacks predominate as the main cause of death among males aged 75 and over too. Chronic obstructive respiratory disease is next (21), followed by stroke (14). Together these three causes account for just over half the deaths in this group.
4.3.4 ETHNIC GROUP DIFFERENCES Between 1987 and 1990, 74 Maori from southern Porirua were recorded as dying, with 140 Pacific Island people and 729. Europeans/Others. However, experience from Auckland and elsewhere strongly suggests that Maori are systematically under-reported in mortality statistics, often recorded as Other. If under-counting was as marked in southern Porirua as it was in Auckland during the mid-1980s, then the true number of Maori deaths would have been closer to 135, with a corresponding decrease in deaths in the Europeans/Others group to around 670.2 This would place age-standardised death rates as slightly higher for Maori than for Europeans/Others. Although undocumented, it is possible that under-reporting through misclassification also Occurs for the Pacific Island population. Rates of death from different causes have not been compared between ethnic groups as the low numbers involved make the margin of error in calculating rates too high, and this could lead to spurious conclusions.
4.4 Discussion of selected conditions
4.4.1 SUDDEN INFANT DEATH SYNDROME (SIDS)
Deaths southern Porirua s death rate for SIDS was double that of the rest of WellingtonlWairarapa in the period up to 1990. The high death rate affected families in the Europeans/Others group as much as others, thus differing from the national pattern, where Maori rates have been much higher. However, in keeping with trends elsewhere numbers and rates have declined significantly.
Graham P. Jackson R, Beaglehole R (1989) The validity of Maori mortality statistics. New Zealand Medical Journal, 102:124-6. 2 Calculated as: reported number x 801(80-36). This is based on data from the ARCOS study during the 1980s in Auckland. 36 out of 80 self-identified Maori on the ARCOS register who died of myocardial infarction were misclassified as Other" on their death certificates Public Health Commission (1993) Our health, our future: the state of the public health in New Zealand, Wellingtoi1. Ibid.
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Comment With numbers of deaths declining from 8 in 1990 to 2 in 1991, 2 in 1992, and 3 in 1993, significant in-roads have been made into this problem in Porirua. However, ongoing attention needs to be given to health education regarding the recognised risk factors of prone sleeping position, lack of breast feeding and passive smoking.
4.4.2 MENTAL HEALTH Deaths There were 30 suicides recorded in southern Porirua between 1987 and 1990, with a further 4 recorded as probable suicide. southern Porirua s suicide rates were significantly higher than those for the rest of Wellington!Wairarapa. and for the Central region as a whole. Five suicide victims were diagnosed as having a psychosis or personality disorder. Eight suicides involved males ages between 25 and 44 years. However, suicide rates were higher among males in the younger age groups (under 25) and among females aged 75 and over.
Admissions Mental health was the most common cause of bed day use. The leading cause of mental health admissions were schizophrenic psychoses; 58 episodes accounting for 32% of all mental health admissions. Half of these were for 25-44 year old males, with 15-24 year old males and 25-44 year old females each accounting for 17%. The second most common cause for admissions were affective psychoses; 27 episodes accounting for 15% of all mental health related admissions. Problems with alcohol dependence and/or abuse were the next most common cause for admission: 16 episodes accounting for 9% of all mental health related admissions. More than half (9) of these were for males aged between 25 and 44 years. Overall, the rate of mental health admissions for Europeans/Others was 41% higher than for Maori, 2 and 3 times higher than for Pacific Island people. However, Maori admission rates for schizophrenia were 25% higher than for European and Other.
Comment An important factor that affects the mental health data is the presence within Porirua of New Zealand s largest psychiatric hospital. Higher rates of suicide may reflect the presence of patients with chronic schizophrenia or similar conditions living in Porirua Hospital or in the community nearby. They may however be due to unrecognised depression and other conditions in people without formal contact with psychiatric services. 3 Further investigation would be required to clarify this.
Central RHA (1994) Morbidity and mortality profile of the Central region, Wellington. 2 Again, this differs from both national and Central region data, which show Maori admission rates as higher than for non-Maori over the same period. Te Puni Kokiri (1993) Nga Ia o te oranga hinengaro Maori. Wellington.
Joyce P (1991) The non-recognition of depressive disorders: a continuing public health concern! New Zealand Medical Journal: 104: 7-8.
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High rates of mental health hospitalisations again could reflect the needs of tertiary patients in the community. Barriers to accessing appropriate services, and levels of unmet need for mental health services should be investigated further.
4.4.3 ASTHMA Deaths In southern Porirua there were 17 deaths due to asthma between 1987 and 1990. Over this same period there were no asthma-related deaths in northern Porirua.
Admissions For southern Porirua there were 236asthma admissions in 1991, accounting for 892 bed days. southern Porirua s age standardised admission rate was twice that of the rest of Wellington/Wairarapa excluding Porirua City. Over half of the hospitalisations were of children from 0-4 years. Children between 5 and 14 accounted for 16% and women between 25 and 44 accounted for 11%. Rates for all these groups, and 45-64 year olds were significantly higher than for northern Porirua, and Porirua City s rates in turn were higher than those for the rest of Wellington/Wairarapa for these ages.
Comment The household survey of southern Porirua estimated that around 40% of households in southern Porirua include one or more people with "asthma or wheeziness in their breathing". In the survey sample of 473 households, 278 people with these symptoms were reported, spread across 189 households. They were distributed fairly evenly across the age groups. Maori caregivers were one and a half times more likely than others to report that their household contained people with asthma or wheeziness. There was no difference in the proportion of Pacific Island and European/Other caregivers giving a positive answer. Examination of hospitalisation data to 1992 shows that although Porirua rates for asthma have remained higher than for the rest of WellingtonlWairarapa, and although Wellington!Wairarapa admission rates were themselves significantly higher than for the rest of New Zealand 2, both Porirua and the wider region have shown a gradual reduction in rates since the late 1980s. 3 Throughout, Maori and Pacific Island age-standardised admission rates have been higher than for others.
National Research Bureau (NRB Ltd), 1994, Assessment of Health and Disability Needs in the southern Porirua area, a report prepared for the Central Regional Health Authority. 2 Metcalfe S. Roseveare C (1993) "Overs and Unders ". a comparison of Health Goal indicators, Wellington Area Health Board vs the rest of New Zealand Regional Public Health Service, Wellington Area Health Board. Central Regional Health Authority (1994) Morbidity and mortality profile of the Central region, Wellington.
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One study has found that although the number of hospitalisations may be higher, the prevalence of asthma (at least for symptoms in adolescence) is no higher in southern Porirua than in Wellington and Lower Hutt. The high number of deaths from asthma in southern Porirua could reflect a higher number of people with asthma in the community (despite Robson et al s findings), and/or signal high case fatalities, where people die in the community without reaching hospital. Poor access to primary health care could also contribute to these deaths. Death rates from asthma generally have declined in recent years, although the data available here do not reveal whether southern Porirua has shared in this trend. Good primary health care includes access to early general practitioner consultations, ongoing education and help (eg by practice nurses), clear management plans accepted by patients, prescription and dispensing of suitable prophylactic medication. A 1990 report suggested that southern Porirua people may sometimes lack knowledge and skills to confidently manage their asthma, that co-ordination between services is poor, that much education is inadequate or contradictory, and that services for Pacific Island people and many Maori do not meet their needs.2 Practice nurse use appears much lower for Porirua City, as are pharmaceutical subsidies; non-filling of scripts for preventative medication might for instance be important, due to patients not understanding properly and/or being unable to pay prescription part- charges. In the southern Porirua household survey, only 16% of households containing people with asthma mentioned problems getting or using treatment. The main barrier mentioned was cost. Although half these homes have a peak flow meter, it is not used in, 50% of them. Approximately 20% had a written plan, but again about half did not use it. 3 In some cases non-use was associated with the fact that did not have serious attacks. Conversely, in some households where there was use of a peak flow meter and a written plan, the person s asthma was still reported to be not under good control, suggesting that further assistance or other measures may be needed for these people. Passive smoking, allergens and viral respiratory tract infections could also be factors. The household survey found that 58% of households with someone who had asthma or wheeziness contained at least one smoker.
4.4.4 !SCHAEMIC HEART DISEASE Deaths There were 200 deaths due to ischaemic heart disease in southern Porirua between 1987 and 1990. Acute myocardial infarction was the recorded cause for 114 (57%) of these deaths. The age standardised rate of premature death was 86% higher than for the rest of WellingtonlWairarapa excluding Porirua City, but not significantly higher than that for
Robson B, Burgess C, Pearce N, et al (1993) Prevalence of asthma symptoms among adolescents in the Wellington region by area and ethnicity New Zealand Medical Journal, 106:239-41. 2 Grainger J (1990) Asthma services in the West Coast district of the Wellington Area Health Board. Wellington Area Health Board. A more coordinated approach by general practitioners and hospital staff appears to have been effective in reducing admissions. Pacific Island households were less likely than others to have either a peak flow meter or a written plan. They were also less likely to say they knew what triggered their asthma.
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northern Porirua. Women aged between 25 and 44 had death rates nearly 9 times higher than their peers in the rest of Wellington!Wairarapa excluding Porirua City. Admissions There were 80 hospital admissions for residents of southern Porirua during 1991, accounting for 624 bed days. 45 of these were for myocardial infarction, 9 for unstable angina, and 3 for nocturnal angina. Thirty-one were recorded as unspecified chronic ischaemic heart disease. Age standardised hospitalisation rates did not differ significantly from the rest of WellingtonlWairarapa or northern Porirua. Analysis of morbidity data for 1988-1992 shows that the age standardised rate for Porirua City is similar to that of the Hutt Valley and Wellington City. Comment High premature death rates for ischaemic heart disease were not reflected in public hospital use. This might be due to high case fatalities (eg sudden death), which in itself would be a major problem. It could also mean that ischaemic heart disease is more prevalent but that there are barriers to accessing appropriate care. Further investigation is required to explain the reasons for the high death rates. Smoking and other lifestyle factors are probably very important, particularly since stroke deaths and peripheral vascular disease hospitalisations were also high. The southern Porirua household survey2 suggests that southern Porirua residents knowledge about good nutrition was limited, with only a third or less being able to identify foods that should be avoided for a healthy heart. For example, only 17% of respondents identified fried foods/junk foods/takeaways as one such food category. Community groups in Porirua have identified health education/information as a key area for improvement. (see chapter 7) Though nationally death rates for ischaemic heart disease have decreased 3, this is not evident in southern Porirua. Further research is required to explain this.
4.4.5 CEREBROVASCULAR DISEASE Deaths Between 1987 and 1991, there were 81 deaths among people from southern Porirua. Eight of these were from the late effects of stroke. Admissions There were 32 hospitalisations of southern Porirua people using 3498 bed days during 1991. Three were for late effects. There were 84 hospitalisations for Others and four each for Maori and Pacific Island people.
Morbidity and mortality profile of the Central region (1994), Central Regional Health Authority. 2 National Research Bureau (1994) Assessment of Health and Disability Needs in the southern Porirua area, Report of a household survey, prepared for the Central RI-IA, Wellington. Public Health Commission (1993) Our health, our future: the state of the public health in New Zealand, Wellington.
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Comment As with ischaemic heart disease, the death rate from strokes was very high but was not reflected in hospital use. This again might be due to high case-fatality rates, or problems accessing hospital care - particularly referrals and services for stroke care and rehabilitation. Difficulties with preventing and treating hypertension (high blood pressure) may be important, especially since admission rates for hypertension were much higher than expected for southern Porirua. Again this could reflect barriers to accessing primary health care and/or prescription costs. Smoking and lifestyle factors are probably important as well.
4.4.6 OTHER CARDIOVASCULAR DISEASE Deaths There were 66 deaths among southern Porirua residents from 1987 to 1990. These included: chronic rheumatic heart disease 18 diseases of the pericardiumlendocardium 22 non-alcoholic cardiomyopathy 4 subarachnoid haemorrhage 5
The age-standardised death rate for southern Porirua was twice that of the rest of Wellington/Wairarapa, excluding Porirua City.
Admissions In 1991, residents of southern Porirua were admitted to hospital 94 times for other cardiovascular disease problems, accounting for a total of 842 bed days. These included: congestive heart failure 43 arrythmias 32 diseases of the pericardiumlendocardium 6 non-alcoholic cardiomyopathy 6 chronic rheumatic heart disease 3 subarachnoid haemorrhage 3
The-age standardised hospitalisation rate for southern Porirua was 59% higher than that for the rest of WellingtonlWairarapa excluding Porirua City, and two and a half times that of northern Porirua. Rheumatic fever, which can lead to rheumatic heart disease, is a notifiable disease. There have been 6 notifications for the Porirua area since July 1993, and none for other areas in greater Wellington.
Comment Smoking, diet, alcohol and high blood pressure are all factors affecting most of the above conditions.
During 1988-92 there was an average of 2 hospitalisations of residents of Porirua City per year for chronic rheumatic heart disease. There were four for the whole of greater Wellington.
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Rheumatic fever is linked to overcrowding and low socio-economic status. Secondary prevention can be achieved through regular medication (with antibiotics). Effective primary prevention strategies may require more investigation.
4.4.7 PREGNANCY AND CHILDBIRTH Admissions Pregnancy and childbirth were the leading cause of hospitalisations among southern Porirua residents during 1991, accounting for 1093 admissions and 3096 bed days. The primary diagnoses for these admissions included:
unviable early pregnancy 52 therapeutic/illegal abortions 61 complications during pregnancy 236 conditions requiring special care during labour and delivery 1822 normal deliveries including minor tears 400 complications of labour and delivery 159 postnatal complications 1093
The age standardised admission rate was four times higher than for the rest of WellingtonlWairarapa and twice that of northern Porirua. This contrasts with low maternity benefit expenditure for the area. (see chapter 5) Comment High hospital use for pregnancy/childbirth etc is probably associated with high fertility expected in a younger population with high proportions of Pacific Island people and Maori. Despite southern Porirua hospitalisations being four times higher than the rest of the region, maternity benefit claims for Porirua City were considerably lower (one third less). Cultural barriers, a greater use of hospital-based maternity services than elsewhere, lack of transport, and lack of childcare may contribute to these benefit claim patterns.
4.4.8 UNINTENTIONAL INJURY This category includes unintentional injuries including motor vehicle crashes and traffic related injuries (referred to as motor vehicle injuries) and non-motor vehicle injuries. Deaths During 1987-1990, twenty-nine southern Porirua lives were lost from motor vehicle injuries. These included 15 car drivers or passengers, 5 motorcycle drivers or passengers, and 6 pedestrians. There were a further 26 from non-motor vehicle injuries. These included 7 falls, 5 drownings, 3 burns, and poisonings, suffocations and railway accidents. Sixteen percent (4) of these deaths were among preschoolers (less than five years of age).
Including, in 37 cases, women admitted with nutritional deficiencies. 2 Feotal distress for example. If data for southern Porirua alone was available, this discrepancy would probably be even more marked.
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Admissions Motor vehicle events led to 58 admissions and accounted for 464 bed days among southern Porirua residents in 1991 . Non-motor vehicle injuries resulted in 208 hospital admissions, taking up 1309 bed days in 1991. The cause was not specified for a further 148 admissions taking up 767 bed days. Where cause was specified the number of admissions included: falls 127 late effects of previous accidents 32 struck by objects 15
Those accidents where cause was not recorded included: head injury 51 burns 12 miscellaneous 76
Regardless of cause, head injury hospitalisations in 1991 totalled 94 and used 335 bed days. An analysis for a more extended period (1988-1992) for Porirua City found an average of 92 admissions per year. Admissions for head injury were twice as common among males than females, and more common among Maori than Pacific Island people or Others. The age standardised rates for Porirua City, the Hutt Valley and Wellington City are similar, ranging around 18 to 21 per 10,000.2 Differences by sex and ethnicity are also consistent. Fractures of the neck of femur caused 26 hospitalisations and took up 499 bed days in 1991. These hip fractures mostly involved falls among elderly women, and the rate was twice that for the rest of Wellington!Wairarapa excluding Porirua City.
Comment Unintentional injury hospitalisation data are difficult to interpret, since cause of injury is not coded in many cases. Lack of improvement in the numbers of deaths, against the national trend, could signal entrenched problems, with improvements occurring elsewhere not happening in southern Porirua.
4.4.9 VACCINE PREVENTABLE COMMUNICABLE DISEASES Admissions In 1991 there were 32 hospitalisations among southern Porirua residents, accounting for 90 bed days. These included 20 admissions for measles and 12 for whooping cough. Twelve
Due to the classification system used, these admissions in many instances appear under other causes, and hence are not shown as a specific group in Figure 7 or Table 18. 2 Morbidity and ,nortalitv profile of the Central region 1994, Central Regional Health Authority, Wellington. ibid.
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admissions were for infants, a further twelve for preschoolers aged between I and 4 years, six for 5-14 year olds and two for adults. The age-standardised hospitalisation rates were more than twice as high as for the rest of WellingtonlWairarapa excluding Porirua City, and four times higher than for northern Porirua.
Comment Hospitalisations for vaccine-preventable communicable diseases occurred during the pertussis and measles epidemics experienced in 1991 through New Zealand. In the Wellington region, measles notifications were highest in Porirua!Kapiti (predominantly Porirua), and were particularly high among Pacific Island and Maori preschool children. Pertussis notifications from PorirualKapiti were about three times higher than other districts. The southern Porirua household survey indicated that the vast majority of southern Porirua mothers are aware of the benefits of immunisation and say that their youngest child has been immunised. However, one in ten respondents said that they did not see the need for immunisation or believed that it could be harmful to some extent.3 Improved immunisation coverage through better access to primary health care, improved care coordination and patient tracking, and culturally appropriate delivery systems able to meet the needs of parents/whanau could reduce rates of these diseases.
4.4.10 OTHER CLOSE-CONTACT COMMUNICABLE DISEASES Deaths Between 1987 and 1990 there were 48 deaths from other close contact communicable diseases. Causes included: acute bronchitis/bronchiolitis 5 meningococcal disease meningitis 1 pneumonia/lower respiratory tract infections 41
Thirty eight deaths occurred among Europeans/Others, 2 among Maori, and 8 among Pacific Island people.
Admissions There were 310 hospitalisations of southern Porirua residents during 1991, accounting for 1340 bed days. These were for: pneumonia/lower respiratory tract infection 91 acute upper respiratory tract infection 54 acute bronchitis/bronchiolitis 44
Roberts A (1992) A study of the 1991 measles epidemic in the Wellington Area Health Board region: costs, complications and problems Regional Public Health Sen ice, Wellington Area Health Board. 2 Mansoor 0 (1991) Does control ofpertussis need rethinking? CDNZ, 91:43-8. National Research Bureau (1994) Assessment of Health and Disability Needs in the southern Porirua area, a report of a household survey, prepared for the Central Regional Health Authority, Wellington. (unpublished)
47 gastroenteritis 52 acute otitis media 17 quinsy 8 meningitis 5 acute post-streptococcal glomerulonephritis 2
Thirty six admissions were for infants, 127 for preschoolers, and 47 for 5-14 year olds. These age groups accounted for 68% of all admissions. Age-standardised hospitalisation rates were 35% higher in southern Porirua than in the rest of Wellington!Wairarapa, and 85% higher than in northern Porirua. Maori and Pacific island infants had higher hospitalisation rates when compared with others, although between the ages of 1 and 14 the rate for Europeans/Others was significantly higher than for Maori.
Comment As for asthma, access to primary health care, passive and active smoking, non-uplifting of prescriptions/ difficulty with costs could all contribute to the high rates and possible higher case-fatalities. Low incomes, with overcrowding, iron deficiency and poor nutrition could also be contributing factors, lowering resistance and affecting the spread of viruses. Iron deficiency anaemia is high in southern Porirua infants.
4.4.11 LUNG CANCER, CHRONIC OBSTRUCTIVE RESPIRATORY DISEASE, AND OTHER SMOKING RELATED DISEASE Deaths There were 133 deaths among residents of southern Porirua due to these causes between 1987 and 1990. The causes include: chronic obstructive respiratory disease 90 lung cancer 34 cor pulmonale 2 miscellaneous related cancers 7
Lung cancer deaths tended to occur in a younger age group than the other causes.
Admissions These smoking related diseases accounted for 108 hospital admissions in 1991. Specific causes were: chronic obstructive respiratory disease 62 lung cancer 26 cor pulmonale 3 miscellaneous related cancers 14 intrauterine growth retardation 3
Crampton P (1992) Iron deficiency anaemia in infants - Porirua Study (This study found iron deficiency anaemia in 10 of a sample of 43 infants). Also Farrell, A. (personal communication).
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Southern Porirua s age standardised hospitalisation rates for these causes were two and a quarter times as high as those for the rest of Wellington/Wairarapa excluding Porirua City, and four and a half times higher than northern Porirua s rates. Age standardised hospitalisation rates for southern Porirua Maori were 5 times higher than for Other for lung cancer, and two and a quarter times higher for chronic obstructive respiratory disease (CORD). There were no admissions for lung cancer among Pacific Island people.
Comment The data reflects past smoking behaviour, since there is considerable lag time between exposure (prolonged tobacco smoking) and developing lung cancer and chronic obstructive respiratory disease in particular. The data is consistent with higher rates of ischaemic heart disease and stroke, where smoking is a significant factor causing development of arteriosclerosis. This suggests that smoking may be an important factor in southern Porirua s poorer health status. Further evidence is available in that high rates were also observed for conditions associated with past active and/or passive smoking: CORD, lung cancer, ischaemic heart disease and stroke and peripheral vascular disease, and "other" smoking-related illnesses. High rates are also found for childhood conditions associated with present passive and/or active smoking: SIDS, respiratory communicable diseases, asthma, and otitis media with effusion ("glue ear"). The southern Porirua household survey found that 51% of the households surveyed contained smokers. Smoking was most common in Maori households (66%), followed by Pacific Island households (54%), then European/Other households (43%).
4.4.12 HEARING Admissions In total, 49 operations took place in 1991 for middle ear disorders in southern Porirua residents. "Glue ear" operations (myringotomy and/or grommet tube insertion and/or adenoidectomy etc) numbered 29. This included 11 preschoolers, 15 children aged 5-9 years, and 2 aged between 10 and 14 years. A further 15 middle ear reconstruction operations 2 were carried out. The age standardised rate for middle ear reconstructions among southern Porirua residents was two and a half times that of the rest of Wellington!Wairarapa excluding Porirua City. Rates were especially high for 15 to 24 year olds and 45 to 64 year olds; 8 and 4.7 times higher respectively.
Comment During 1991, failure rates reported for new entrant hearing screening were at least two and a half times higher in southern Ponrua than in the Huff Valley or Wellington. More than 25% failure rates were reported among Porirua s Maori and Pacific Island new entrants.3
National Research Bureau (1994) Assessment of Health and Disability Needs in the southern Porirua area. a report of a household survey, prepared for the Central Regional Health Authority, Wellington. 2 Usually needed because of untreated chronic suppurative middle ear disease Metcalfe S. Ratcliff B. Nye J (1992) Analysis of new entrant and pre-school hearing testing data Public Health Service, Wellington Area Health Board.
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The southern Porirua household survey found that of households with children under the age of 5 years (37% of the sample) just over half had a child with an ear infection in the past 12 months, and 40% had experienced a serious ear infection lasting a week or more. In one in ten households where there was a preschooler, there was a child with grommets. Despite the apparently high prevalence of ear problems among children in southern Porirua, public hospital operation rates for otitis media with effusion ("glue ear") did not differ from the rest of Wellington!Wairarapa. This suggests lack of services or barriers to access available at that time. Access problems do not appear to have improved in southern Porirua, despite increases in the numbers of ear nose and throat (ENT) surgeons in public hospitals in the region. The household survey found that children in five percent of households containing a preschool aged child were waiting for grommet operations. Waiting times of up to two years have been involved.2 The effects of passive smoking upon eustachian tube function and on viral upper respiratory tract infections are important in the development of otitis media with effusion.
4.4.13 NEURAL TUBE DEFECTS AND OTHER CONGENITAL ANOMALIES Neural tube defects are congenital malformations involving the neural tube. Problems in the way the neural tube develops during pregnancy go on to cause abnormalities of brain and spinal cord in babies. Abnormalities include anencephaly, hydrocephalus and spina bifida.
Deaths There were seven deaths resulting from neural tube defects among southern Porirua residents between 1987 and 1990, with a further 13 people dying as a result of other congenital abnormalities. Six neural tube defect deaths were in infants and one was a child aged between 5 and 14 years. Southern Porirua s infant neural tube defect death rate was nearly four times that of the rest of WellingtonlWairarapa excluding Porirua City.
Admissions During 1991 there were 9 hospitalisations recorded specifically for neural tube defects using 259 bed-days, and 70 for other congenital abnormalities (225 bed-days).
Comment Deaths from neural tube defects may reflect underlying poor nutrition in southern Porirua women of child-bearing age. Measures to improve nutrition, and the intake of folic acid in particular, could reduce the incidence of neural tube defects.
National Research Bureau (1994) Assessment of Health and Disability Needs in the southern Porirua area, a report of a household survey, prepared for the Central Regional Health Authorit y, Wellington. 2 This issue is being addressed through a current Central RHA "blitz" on waiting lists for grommets. Elwood, M (1993) Prevention of neural tube defects; clinical and public health policy New Zealand Medical Journal, 106: 517-518.
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4.4.14 DIABETES This section reports data where diabetes was recorded as the primary diagnosis. Diabetes can also underlie other conditions. For example, diabetes can lead to ischaemic heart disease.
Deaths There were 11 deaths resulting from diabetes mellitus between 1987 and 1990. Eight of these deaths were among people 65 years of age and older. Nine deaths were reported for Europeans/Others, 2 for Maori and none for Pacific Island people.
Admissions There were 45 diabetes related hospitalisations of southern Porirua residents during 1991, using 230 bed days. Eighteen of those admitted were men aged between 45 and 64 years, accounting for 40% of all admissions. The age standardised hospitalisation rates for southern Porirua were two and a half times greater than those for the rest of Wellington!Wairarapa. This disparity is confirmed by an analysis of a data over a longer time frame (1988-1992), during which age-standardised rates for Porirua City were one-and-a-half to two-and-a-half times those of other parts of greater Wellington. Within Porirua City there are also major variations. Southern Porirua had age standardised rates more than three times greater than those for northern Porirua in 1991. Although in 1991 admissions of Europeans/Others from southern Porirua were much higher (33) than for other groups (9 Pacific Island people and 3 Maori), an analysis of hospital separation data over a longer time frame (1988-1992) for the whole of Porirua City found that age standardised rates for Maori and Pacific Island people were higher than for other ethnic groups. This pattern was found in all parts of the Central region and is consistent with national trends.
Comment Data for diabetes mellitus do not reflect its true impact since they do not measure its contribution to other causes of hospitalisation or death. Indications of high hospitalisations in Europeans/Others in southern Porirua for diabetes mellitus is surprising, given the pattern regionally and nationally for Non Insulin Dependent Diabetes Mellitus (NIDDM, the predominant type of diabetes) to affect Maori and Pacific Island people more and result in the development of renal and other microvascular 3 complications at younger ages.2 The southern Porirua household survey 4 found that 30 (6%) of the households surveyed contained someone with diabetes, but that the proportion of Maori households was double this (12%), a finding more in keeping with wider trends. Further research is required to explain these apparent discrepancies. The survey also showed that only
Morbidity and mortality profile of the Central region (1994), Central RHA, Wellington. 2 Public Health Commission (1993) Our health, our future: the state of the public health in New Zealand, Wellington. Isaacs RD, Scott DJ (1987) Diabetic discharges ftoin Middlemnore Hospital in 1983 New Zealand Medical Journal; 100:629-31. National Research Bureau (1994),4 ssessment of Health and Disability Needs in the southern Porirua area, a report of a household survey, prepared for the Central Regional Health Authority, Wellington.
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4% of Pacific Island caregivers reported that their household contained someone with diabetes. Although the very small numbers involved mean that this finding should be interpreted with caution, it may suggest there is a level of undetected and untreated diabetes in the Pacific Island community in Porirua. NIDDM is often under-recognised in primary health settings and may benefit from greater screening, education and support in primary health settings. Like hypertension, NIDDM can be prevented or helped in the first instance through changes in diet.
4.4.15 ALCOHOL RELATED CONDITIONS This section excludes alcohol related injuries resulting in either death or hospitalisation. Deaths Between 1987 and 1990 there were 15 alcohol related deaths. Seven of these were due to alcoholic cardiomyopathy, another seven from alcoholic liver disease, and one from accidental alcohol poisoning. This excludes injury-related death and suicides in which alcohol may have been a factor. There were 12 deaths among people from the European and Other ethnic group, two among Maori, and one among Pacific Island people. Admissions In 1991 there were 33 hospitalisations among southern Porirua residents, accounting for 1,724 bed days. Thirty-nine percent of these were for men aged between 25 and 44. Only a third of all alcohol related admissions were for females. Age standardised admission rates for residents of southern Porirua were two and a half times greater than those of the rest of WellingtonlWairarapa, and three and a half times greater than those of northern Porirua. Comment As with diabetes, the numbers of deaths or admissions do not give a true picture of the impact of alcohol use on the health of the population. Excessive alcohol use has very widespread effects on social and mental health, including mood changes, reckless behaviour, intentional and unintentional injury, as well as physical disease.
Brown C R S, Ruder P N, Scott R S, Maipress W A, Beaven D W (1984) Diabetes Mellitus in a Christchurch working population New Zealand Medical Journal, 97 487-9 Scragg R, Baker J, Metcalf P (1990) Factors associated with the development of diabetes mellitus: results froin a cross-sectional survey in Kawerau New Zealand Medical Journal, 103: 575-7 Strack M F, Wells J E, Joyce P R, Hornblow A R, Oakley-Browne M A, Bushnell J A (1989) Factors affecting the use of mental health services in people with alcohol disorders New Zealand Medical Journal, 102: 601-3
52 5. Services and their utilisation in southern Porirua
Highlights • A similar range of health and disability services are provided in Porirua, as are found in most large urban areas. However, utilisation indicators suggest that people in southern Porirua do not enjoy the same level of access as people elsewhere. • There are 20 general practitioners, equivalent to 16 full-time general practitioners, practising in southern Porirua, four of whom are women. • There is one full-time general practitionerfor every 1949 people in southern Porirua, 1818 people in the Wellington. region, and 1711 people in New Zealand. • GMS expenditure per head in southern Porirua was 10% higher than the rest of Central region, but 21% lower than the national average. • Practice nurse subsidy spending per head was 21% lower than the rest of the Central region, and 40% lower than the national fi gure. • Immunisation benefits expenditure in southern Porirua came to $7.73 per child under 5 years 11% lower than for the rest of the Central region, and 38% lower than national expenditure. • Per capita spending on pharmaceutical subsidies in Porirua City was 31% lower than .for the whole of the Central region. • Maternity Benefit subsidies in southern Porirua, at $1184 per live birth, were 8% lower that for the rest of the Central region. • Plunket maintains contact with approximately 90% babies born in the area for the first six attendances, but then the proportion declines. • While nearly all children receive dental services up to form II, the utilisation rate falls off after this- especially for Moon and Pacific Island teenagers. In 1992193, general dental benefit expenditure for children aged 13-17 living in Porirua City was, on a per capita basis, 11% lower than for the Central region as a whole. • Ora Toa Health Centre is the main provider of services for Maori. It provides effective health education, appropriate programmes and practices to promote health and wellness among Ngati Toa and the wider community. • Children and younger teenagers with disabilities may receive long-term care at Puketiro, and short-term residential care in the children s ward at Kenepuru although access is limited by available resources. • The attendant care service covers Wellington, the Hutt Valley and Porirua. Demand for this service by eligible consumers grossly exceeds the capacity of the service, which is limited by the extent of government funding available. • A wide range of other services are provided in Porirua, but utilisation data is not available for them, suggesting an opportunity to improve data capture.
53 This section describes a range of health and disability support services provided in southern Porirua. Service providers were identified through a number of sources and most were visited in the course of the study. The many voluntary organisations providing community-based services, and traditional healers such as those practising rongoa Maori, or Pacific Island traditional healing or alternative therapists are not covered in this section. We acknowledge the important contribution of these groups and individuals to service provision in the Porirua area.
5.1 Primary healthcare services
Primary health care services are those to which users have direct access without the need of referral. Access to secondary and specialist services is usually by way of referral from primary health care providers. There are several key areas of primary care. They are general practice, community pharmacy, pregnancy and childbirth services, well child services, family planning, dental services, diagnostic imaging services, ambulance services, and services for Maori.
5.1.1 GENERAL PRACTICE General practices provide comprehensive assessment, diagnosis, treatment and referral services. When practice nurses are employed, they may operate patient recall systems, and provide immunisations, cervical screening and patient education, among other tasks.
Number of services There are 20 general practitioners, equivalent to 16 full-time GPs, practising in southern Porirua. There are four women GPs in southern Porirua. Practitioner numbers range from one to four GPs in each practice. In southern Porirua there is one full-time GP for every 1949 people. For the Wellington region the ratio is 1818 per GP and for New Zealand, 1711 per full-time GP. There is insufficient comparative data to determine whether southern Porirua is underserviced.
Location of services Practices are located throughout southern Porirua, with most located in or adjacent to shopping centres (see the map on page 57). There are three large health and medical centres in southern Porirua: • Titahi Bay Medical Centre has four GPs, three part time practice nurses and an independent physiotherapist sharing the premises. • The Porirua Union & Community Health Service, located in Cannons Creek, provides primary health care services to union members, beneficiaries and their families at a reduced cost. There are three GPs and two practice nurses in the centre. • Waitangirua Health Centre has four GPs and two part-time practice nurses. This is a CHE- owned facility that provides a base for other community based professionals such as a dietitian, social worker and physiotherapist.
Malcolm L (1993) Trends in primary medical care related services and expenditure in New Zealand 1983-93 New Zealand Medical Journal, 106:470-4 Wellington and New Zealand figures include the population of southern Porirua.
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There does not appear to be any particular need for Porirua residents to travel outside the area for GP services. It is likely, however, that a certain proportion do so for reasons such as proximity to work, preference for the style of a particular practitioner or other such reasons.
Services provided The nature of the services provided varies from practice to practice according to the needs of the practice population and the special interests of practitioners. In addition to "core" general practitioner services, GPs provide pregnancy and childbirth services, care for residents of nearby rest homes or supported houses, and they support Iwi programmes. Female GPs are preferred by some patients, who will travel a considerable distance to see a female doctor. As well as providing services during normal working hours and some evening and weekend sessions to accommodate working patients, GPs in the area participate in three local rosters for after-hours emergency services. They are now moving to establish a single after-hours emergency service that will cater for the whole of Porirua City.
User charges Government funding to most GPs is by way of General Medical Services (GMS) benefits. The level of these varies according to the Community Services Card status and age of the individual patient. General practitioners can also claim an Immunisation Benefit of $7.65 for childhood immunisations and practice nurse salary subsidies of $11 per hour for up to 30 hours per week. There are ten practices claiming practice nurse subsidy in Porirua City. The Porirua Union Health Centre is one of the few in the region funded on a different basis. The centre is paid a capitation fee for each person registered with the centre instead of GMS, immunisation and practice nurse subsidies. The fees of most GPs appear to fall in the range of $20-$30. This is offset by the appropriate GMS subsidy. In addition, many GPs reduce or waive fees to patients who cannot afford to pay for essential treatment. Fees for practice nurse services are generally lower than those for GP consultations (and sometimes may be free).
Utilisation There is little data on who uses general practice services. Expenditure on government subsidies (presented below) gives one indication of service utilisation. Claims are recorded by the address of the provider rather than where people using the service come from. Therefore caution needs to be exercised in interpreting this data. A total of $1,385,900 was spent on GMS subsidies in southern Porirua from March 1992 to February 1993. This equates to an average of $44.45 per person. GMS expenditure per head in southern Porirua was 10% higher than the rest of Central region, but 21% lower than the national average. This may reflect the low incomes of many people in southern Porirua, and the resulting higher average value of GMS claims, rather than a higher number of claims per head. A total of $168,032 was spent on practice nurse subsidies in southern Porirua. This amounts to $5.39 per person. Practice nurse subsidy spending per head was 21% lower than the rest of
Fees and total GMS expenditure are discussed below.
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the Central region, and 40% lower than the national figure. This may be attributable to the lower number of full time equivalent general practitioners working in southern Porirua, but may also reflect relatively low utilisation of practice nurses in this area because practices in poor areas may not be able to afford them. Immunisation benefits expenditure in southern Porirua was $29,174, which amounts to $7.73 per child under 5 years. This expenditure is 11% lower than for the rest of the Central region, and 38% lower than national expenditure.
56 MAP 2 PORIRUA CITY CENTRE Legend of service units + Hospitals \I Ambulance station VHR Medical centre 0 41.1 i c1AFPA DIP GP practices/surgeries \: . HipR1 + Pharmacies — ç AWCS — D Dental surgeries/clinics Laboratory collection sites T P NZ Plunket Society clinics 4PORIRUA\ r\ x ,— Physiotherapists \\ A FPA NZ Family Planning Association PuKETIRo•J1, AOTH Ora Toa Health Centre L\% Mental Health Resource Centre • "•-f," 1 Whitiora Halfway House KENEPURU\ A RKH Russell Kemp Home & Hospital AB Public Health Service West Coast base V A A PR Ponrua Radiology M arae -
J / tarerta ___) \.. — ARKH kj - •- r;
Titahi 8ay(j; \\
Takapuwahia L A. tNRANGIWA 7TM MY WARD I i - - - PORIRUA Tast
/ - cj hills-
j/ c I: -_ /
CROWN COPYRIGHT RESERVED P HEALTH AND DISABILITY SUPPORT SERVICES BASED IN SOUTHERN PORIRUA 5.1.2 COMMUNITY PHARMACY Community pharmacists provide general health advice and information in addition to dispensing prescribed medicines and selling "over the counter" or pharmacy only medicines. Community pharmacists may well be the first source of advice for people contemplating whether they need to go to a GP. There are nine community pharmacies located in southern Porirua - four in Porirua East, three in the central Porirua shopping centre, and two in Titahi Bay. Services are generally sited close to GP surgeries. Restricted medicines and special authority medicines are dispensed by the Kenepuru Hospital Pharmacy. All members of the community are potential users of the service. Those with chronic or ongoing health problems are likely to be higher users of the service. Pharmacies are open during normal business hours. Out of hours services are provided by the Urgent Pharmacy (cooperatively run by a number of the local pharmacists) and one seven day pharmacy. The cost of prescription medicines, other than user part charges and premiums on some items, is met through the pharhiaceutical benefit scheme. The level of user charges depends on Community Services Card status, and whether or not the individual has a High Use Health Card . Stoploss limits also apply. In addition, premiums or part charges apply to some prescription items where less expensivealternatives are available. Utilisation Spending on pharmaceutical subsidies in Porirua City was $4,395,037 between January 1992 and February 1993. This amounted to $94.60 per head, which is 31% lower than per capita expenditure for the whole of the Central region at $136.55. This could be due to under-utilisation of GP services, so that people are not getting prescriptions in the first place, or to prescriptions not being filled because of the disincentive/barrier created by user part charges. Further work is required to understand the reason for low expenditure on pharmaceutical benefits.
5.1.3 PREGNANCY AND CHILDBIRTH SERVICES Pregnancy and childbirth services aim to ensure a healthy outcome for pregnancy through care of the mother in the antenatal period, supervision or management of labour and delivery, usually on an inpatient basis, and care of the mother and baby in the postnatal period. Women choose between private general practitioner and/or midwife care, or public care during the antenatal and postnatal period. They may also choose delivery, if the pregnancy is normal, at Kenepuru or Wellington Women s Hospitals. Generally antenatal and postnatal services are provided during normal working hours, although most practitioners make provision for urgent after-hours services. Location of services Antenatal, delivery and postnatal services for Porirua women are provided by general practitioners, obstetrics specialists, independent midwives, Kenepuru Hospital and Wellington
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Women s Hospital. There are nine GPs and three midwives claiming maternity benefits in southern Porirua. Medical practitioners and midwives are located throughout the district. CHE based antenatal services and delivery services for normal deliveries are provided at Kenepuru Hospital. Midwives travel to provide domiciliary antenatal and postnatal services. Most women in Porirua choose to have their babies at Kenepuru. An estimated third however, are likely to be transferred to Wellington Women s because of risk factors. Some others may also give birth elsewhere, for example in the Hutt hospital. The household survey indicated that half of the women in southern Porirua, who were living there at the time, had their last baby out of the area. Funding base Most private medical practitioners and midwives are remunerated through the Maternity Benefit on a fee-for-service basis. (The exception to this is the Porirua Union Health Centre, which receives global fees.) Hospital maternity services are purchased through block contracts. Most maternity services are provided without charge to users. Utilisation In southern Porirua $1,023,403 was spent on Maternity Benefits, amounting to $1184 per live birth. Maternity Benefit subsidies per live birth in southern Porirua were 8% lower that for the rest of the Central region. 5.1.4 WELL CHILD SERVICES Well child services aim to promote healthy child development and prevent disease. They cover new born screening, monitoring of early child development, health surveillance and screening during childhood, immunisation, parent education, hearing and vision testing and support for children with special needs. The main provider of well child services in southern Porirua is the Plunket Society. General practitioners, practice nurses, and public health nurses also provide some child health services. Plunket services Plunket services are purchased by Central RHA through a block contract. The service is intended to reach all young children and their carers, with special emphasis on new born babies. They attempt to give special assistance to young mothers and mothers who have little support. The Karitane Family Centre provides more intensive one-to-one care for parents who are identified as needing extra help in any aspect of child health or parenting skills. There are six Plunket Clinics located throughout southern Porirua. The initial contacts are usually at home. From 2 - 4 years old, contacts are carried out in a pre-school setting, or at a Plunket Clinic. Southern Porirua is served by a number of mainly part time Plunket Nurses, Karitane Nurses and Maori and Pacific Island health workers. The staffing of seven full time equivalents reflects a nationally determined formula. Plunket clinics are staffed on a part-time basis. The Karitane Centre operates from 8:30am to 4:30pm Monday to Friday. It is up to individual Plunket nurses to decide whether they will give their after-hours numbers to clients. The Plunket Society has just established an 0800 number service for after-hours enquiries.
We Plunket services are provided at no charge to the user. Usual general practice fees would apply to parents seeking well child services from GPs or their practice nurses. Nearly all babies are enrolled with Plunket at or before discharge from maternity services. Plunket maintains contact with approximately 90% for the first six attendances, but then the proportion declines. In the period June to December 1993, 382 new babies were enrolled with Plunket services in south Porirua. In the same period, nurses had contact with 274 older (six to nine months) babies. 1256 appointments were not kept.
5.1.5 SEXUAL HEALTH SERVICES
Family planning services Family planning services cover issues related to sexual and reproductive health, including contraception, pregnancy tests, cervical smears, and menopause services, as well as advice and counselling services. The New Zealand Family Planning Association (NZFPA) has been the main specialist provider of most of these services in Porirua, although most general practices also provide some of these services as part of comprehensive family care. Family Planning has traditionally been available to all teenagers and adults. There is an emphasis, however, on those who may not be using other services, such as young teenagers and Pacific Island women. The NZFPA clinic is based in the city centre and is open between Monday and Friday, offering sessions at different times of the day. It is staffed on a part time basis. The nurses divide their time between the Porirua and Wellington clinics. Outside the Family Planning clinic operating hours in Porirua an on-call doctor is available, otherwise the Wellington clinic, which is open on Saturday, covers the service. A teen clinic which uses teenage/peer counsellors operates once a week. An on-site service is to be established at Aotea College following an introductory education programme. NZFPA is funded through a contract with Central RHA and through user charges. Consultation fees range from $15 for the waged to $5 for young people. Higher fees apply for special procedures such as vasectomies. The NZFPA provided 2111 consultations in Porirua in 1992/93. Maori and Pacific Island people comprised 21% and 10% of users respectively. Seventeen percent of users were students.
Sexual health (sexually transmitted diseases) Treatment services have hitherto been based in Wellington, with health education outreach services in Porirua. As of May 1994, Capital Coast Health has provided a treatment service in Porirua.
5.1.6 DENTAL SERVICES The purpose of dental services is to maintain people s teeth and gums in good condition. The services are provided by school dental services, under the dental benefits scheme, through contracts with dentists and dental specialists, and by hospital dental departments. Nine school dental therapists cover the 18 school dental clinics in southern Porirua and Plimmerton. I
The School Dental Service The School Dental Service provides preventive, educative and restorative dental services for pre-schoolers, primary and intermediate school children (2.5 years old to Form II). Services are provided by school dental nurses/therapists in clinics located at or close to primary schools, and the overall service is managed by Hutt Valley Health. The service is purchased by Central RHA, and there are no user charges.
The Dental Benefits Scheme This scheme applies to young people from Form III for the remainder of their secondary schooling. The children can enrol with contracting private dentists to receive routine dental care, but it is up to them to take the initiative in obtaining dental care. Dental benefit fees are paid to contracting dentists in full settlement by Central RHA. Four private contracting dentists provide services to teenagers as well as adults. While nearly all children receive dental services up to form II, the utilisation rate falls off after this - especially for Maori and Pacific Island teenagers. Dental benefit enrolment patterns in Porirua City for 1991 showed that only 27% of non-European teenagers (Maori, Pacific Island and other ethnic groups) enrolled, compared to 63% of European children. In 1992/93, general dental benefit expenditure for children aged 13-17 living in Porirua City was $187,657. On a per-capita basis this was $43.68 per head, 11% lower than for the Central region as a whole ($48.65 per head).
Contracts with dentists and dental specialists Dental services for pre-schoolers, primary and intermediate school children that are beyond the scope of dental therapists are provided by contracting dentists, oral surgeons, or dentists at the public hospital.
Hospital dental department Adults aged 18 years and older pay for their own dental care. The New Zealand Income Support Service provides a special needs grant (maximum $200 per year) for low income adults needing dental care. The hospital dental service also meets the needs of some people with low incomes. Hospital dental departments provide dental services that are an essential part of a person s hospital treatment or emergency treatment. Porirua Hospital also provides inpatient care and outpatient basic oral care to low income adults (Community Service card holders). The hospital dental department charges outpatients at a cost similar to the dental benefit fees. Hospital inpatient dental services that are purchased by Central RI-IA are provided at no charge to those who are eligible.
5.1.7 DIAGNOSTIC IMAGING AND LABORATORY SERVICES
Diagnostic imaging Diagnostic imaging services provide GPs with information they need to make diagnoses and manage conditions. This includes X-rays (radiology), ultrasound, and other imaging procedures.
61 Porirua Radiology at Hartham Place is the only private provider of diagnostic imaging services in southern Porirua. Kenepuru Hospital undertakes some GP-referred imaging for GPs who are prepared to read their own film. Outpatient fees apply to any services provided by CHEs to patients without Community Services Cards. A few private radiology services attract a patient subsidy. ACC payments also apply to accident related cases. Other fees are met by patients (or private insurance schemes, where applicable). Services provided in Porirua are largely "plain film" X-rays. Patients need to travel outside Porirua if referred for mammography, ultrasound, or other more specialised diagnostic imaging procedures.
Laboratory Services Diagnostic laboratories provide GPs with the laboratory diagnostic testing to assist with diagnosis and management. This includes the collection of specimens (including bleeding as required), transportation of samples, analysis and reporting to the requesting GP. Most services are provided through the Wellington based Medical Laboratory which maintains specimen collection in Porirua City and Waitangirua Health Centre (for collection of blood and urine samples for example), and operates a courier service to local practices. Kenepuru hospital also operates a laboratory testing service, but does not generally undertake Schedule work for GP-referred patients. Community laboratory services are purchased on a fee for service basis. Schedule tests do not attract user part charges. (Blood sugar tests, which are not on the schedule, are provided without charge by the laboratory.) Patients are not required to travel outside the district. Where complex or unusual tests are required, referral of specimens is made by the local laboratory.
5.1.8 AMBULANCE SERVICES Ambulance services respond to accidents and medical emergencies and major incidents. They provide an emergency treatment and transport service. The Wellington Free Ambulance service covers the Wellington, Porirua, Hutt and Kapiti Coast areas around the clock. It has six centres (stations), one of them located at Mungavin Avenue in Porirua East. Emergency transport and emergency medical treatment are provided in response to 111 calls where it is believed that a person needs pre-hospital emergency care, assessment and treatment. The Wellington Free Ambulance is funded mainly by government (50%) and ACC (30%). The remaining 20% comes from public donations, Wellington City Council and Wellington Free Ambulance Trust. As the name suggests, all services are free to the user. For the Wellington region in 1993/94, there were 4933 accident patients and 8945 medical patients transported by the emergency ambulance services. It is estimated that emergency transfers of patients to Wellington hospital number about three to four from 8am to 4pm, and about five patients from 4pm to 8am Monday to Friday, with
Anonymous. Wellington Free Ambulance, p20 The Dominion 24 February 1994.
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slightly more use at weekends because of traffic and sporting accidents (le approximately 10 per 24 hours, or 300 per month).
5.1.9 PRIMARY CARE SERVICES FOR MAORI Several services in southern Porirua focus on improving the health and well-being of Maori.
Ora Toa Health Centre is the main provider of these services. In 1990, Te Runanga o Toa Rangitira established Ora Toa to provide effective health education, appropriate programmes and practices to promote health and wellness among Ngati Toa and the wider community. It is currently funded through contracts with Capital Coast Health, Te Puni Kokiri, and ALAC to provide and coordinate these services. Ora ba is essentially a primary health service, and currently runs programmes as listed below: • asthma education and support • whanau outreach • mokopuna health • adolescent health • young mothers • kaumatua wellness • cervical cancer education and screening • diabetes education and support • exercise and nutrition • drug and alcohol information, education and counselling • anger management • fertility management and sexual health • special clinics in podiatry, influenza and hearing testing and support.
Ora Toa provides health promotion and education programmes targeted to Maori and their whanau. The service is primarily intended for use by Ngati Toa, but is available to any person who wishes to use it. The Ora Toa centre is located in Takapuwahia and some of the health promotion programmes are run from the local Marae. The unit is open during normal business hours, but services are on call 24 hours a day. Other Maori health service providers in the area are Te Whare Marie (the Maori Mental Health Service) and the Maori Health Unit of the Public Health Service. These are discussed later in this chapter.
5.2 Public health services
The Hutt Valley CHE, Hutt Valley Health, provides public health services to southern Porirua. These are managed by its regional office in Lower Hutt, but it also has an office in Porirua. Public health services are purchased by the Public Health Commission, with Central RHA acting as its purchasing agent.
Verbal estimate provided by Wellington Free Ambulance staff.
63 Services provided cover investigation, monitoring and action in the following areas: • environmental health such as water quality, sewage disposal, environmental noise, liquor licensing, hazardous substances, smoke-free environments • food standards, good nutrition and exercise • the spread of communicable diseases such as vaccine preventable diseases, sexually transmitted diseases, AIDS and imported diseases • major public health concerns such as hearing loss in children, cot death or SIDs, tobacco smoking in pregnancy, motor vehicle crashes, melanoma, cervical screening, Maori health and adolescent health.
The Porirua office of the Public Health Service has a large staff, which includes public health nurses, vision hearing testers, an ear nurse specialist, health protection officer, Maori health workers, medical officers, community health workers, a nutrition advisor, a smokefree advisor and a communicable disease team. Regional Maori coordinators and Pacific Island educators oversee the delivery of services to Maori and Pacific Island people in Porirua. Clinics for Pacific Island people are organised when needed and held at the Whitireia Community Polytechnic. The Maori programme is delivered through Ora Toa. The unit s Healthy Schools and Communities Programme covers the 25 schools and colleges in the area. Numbers of visits vary according to need - those in greatest need are visited weekly. Activities include: • new entrant review and assessments as required • assessment and monitoring of children as required, and referral to other professionals where needed • support for schools in the development of a school health plan, curriculum development, and information about topical health issues • self-referral wellness clinics in the intermediates and at Porirua College • visions and hearing testing.
The unit also operates the community sponsored ear van . This service follows up on children who fail hearing tests. Assessments are undertaken, basic treatment provided if possible, and referrals to specialists are made where appropriate.
5.3 Secondary, health services
5.3.1 SPECIALIST AND HOSPITAL SERVICES These comprise specialist medical and surgical services to which an individual usually has access via a general medical practitioner. Accident and emergency services are an exception to this referral requirement, although .they are provided in a hospital setting. Specialist services may be provided on an inpatient, outpatient and daypatient basis and publicly provided services tend to be grouped around a hospital campus. Other support services are provided on or from the same site - diagnostic support services such as pharmacy, laboratory and diagnostic imaging, and domiciliary services such as domiciliary/district nursing, meals on wheels and home help.
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Hospital-based services Services for Porirua and the Kapiti Coast are centred at Kenepuru Hospital, which is operated by Capital Coast Health. It is located 2km from Porirua city centre and next to Porirua Hospital. (There are a number of private specialists practising in the broader Porirua area but none in southern Porirua.) Kenepuru Hospital provides: • maternity care for normal deliveries (including antenatal and postnatal care) • medical outpatient clinics and inpatient services • paediatrics; inpatient, outpatient and daypatient services • elective surgery; general and orthopaedics • outpatient clinics for surgical assessment. Table 20 below provides additional information on the provision of these services.
Table 20: Summary of selected services provided by Kenepuru Hospital
rv1cs eflJees prations seryj. otolaryngology yes general surgery yes yes yes yes gynaecology yes ophthalmology yes (includes optometry) orthopaedic yes yes yes yes paediatric surgery yes cardiology yes gastroenterology yes secondary general medicine yes oncology/radiotherapy yes respiratory medicine yes
pregnancy & childbirth yes yes
paediatric medicine yes yes yes
In addition Kenepuru also provides: • inpatient care for the young physically disabled • age related intermittent care • assessment and rehabilitation for the elderly • community health services, including physiotherapy, dietetics, social work and occupational therapy • detoxification services.
Some outpatient services are provided off-campus. For example, some paediatric clinics are held at Waitangirua Health Centre. Hospital-based services are supported by some outreach services (in addition to those provided through Community Health Services). These include a paediatric domiciliary nurse and a diabetic educator. Kenepuru has 154 beds in use, and one operating theatre in use four days a week. Acute admissions (eg medical and paediatric admissions) are accepted at all hours. Emergency services are available during normal working hours. However, just over 50% of southern Porirua respondents (primary caregivers) in the household survey were not aware that Kenepuru did not provide accident and emergency care outside normal working hours. These services are purchased through a contract with Central RHA. Outpatient fees are determined by Community Services Card status.
Community-based services A range of community health and domiciliary services that support people living in their own homes and provide health promotion/education and support to non-hospital based services, are provided from Kenepuru. These include: • general and specialist district nursing (oncology, diabetes, and stomal) • occupational therapy and physiotherapy • social work • health promotion and education (in areas such as asthma and diabetes prevention and men for non-violence) • home support (meals on wheels, laundry services for families with disabled children) • provision of equipment for home use (such as ventilators).
These services are provided in a range of settings from people s homes, the hospital, and the Waitangirua Health Centre. Outpatient charges are made for services provided on CI-IE premises, but services provided in people s homes are free. People need to travel out of the area for out of hours accident and emergency services, and highly specialised services such as intensive care and cancer treatment. They also need to travel for surgery other than general and orthopaedic surgery, such as gynaecology.
5.4 Mental health services
Mental health services consist of four main groups of services: • adult mental health and psychiatric disability support services • child, adolescent and family mental health services • forensic psychiatric services • alcohol and drug services.
Adult mental health and psychiatric disability services include primary health services; health promotion and education, community based assessment, treatment, rehabilitation and follow- up services, crises intervention and after hour services; day hospital treatment services;
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inpatient acute and intensive mental health care; inpatient medium term care; long stay hospital care; respite care; supported accommodation; day services; carer support and self-help groups. Child, adolescent and family mental health services include education and consultation services with related community and statutory agencies; home-based or clinic based assessment, treatment and therapeutic services. Forensic psychiatric services include liaison, consultation and assessment with referrals from Courts, Prisons and related community organisations; preparation of assessment reports for the Courts; community assessment and follow-up services; inpatient assessment, treatment and rehabilitation in facilities with varying degrees of secure care. Alcohol and drug services include health education and promotion programmes; screening, referral and early intervention services; outpatient assessment, treatment and counselling services; specific day treatment , programmes; residential assessment and treatment programmes; rehabilitation and continuing care services; detoxification and special treatment programmes such as methadone programmes. There are also public health promotion and protection programmes such as needle exchange and HIV education services purchased through the Public Health Commission. While mental health services have traditionally been provided from the Porirua and Kenepuru hospital campus, increasing emphasis is placed on decentralising the services closer to the communities where people live. Most of the mental health services provided from Porirua and Kenepuru are considered secondary and tertiary services, catering for people referred from Wellington, the Hutt Valley, the Kapiti Coast and Wairarapa.
Adult mental health and psychiatric disability support services: Services provided in Porirua include: • inpatient acute care and intensive mental health care in Porirua Hospital • inpatient rehabilitation and long-term mental health care in Porirua Hospital • Maori mental health services from Te Whare Marie based at Porirua Hospital: day treatment and rehabilitation programmes, Maori outreach and liaison services and follow- up services • a network of community houses, hostels and day activity centre located in Titahi Bay and Porirua. There are currently 66 (known) beds in supported housing arrangements in the Porirua area. While the rate of beds per head is higher than elsewhere, this probably reflects the higher concentrations of people with psychiatric disabilities who live in relatively close proximity to Porirua Hospital. Attendances at day services are higher than elsewhere in the region for the same reason. There are only three different providers of day services though, while in Wellington there are 11 • crisis and after hours services delivered from Porirua Hospital • community mental health teams and outpatient services • psychiatric survivors network for Maori (Te Ropu Pokai Taniwhaniwha, at Mokai Kainga Marae and Takapuwahia Marae).
67 Child, adolescent and family mental health services: Assessment and therapeutic programmes are delivered by Capital Coast Health from the Puketiro Centre at the PorirualKenepuru campus. Services are primarily delivered through the clinic or community visits to the family s home or place of care. In the area of child abuse assessment, the service has a close cross referral relationships with the Children and Young Persons Services of the Department of Social Welfare and community organisations in the Porirua area. It has a similar relationship with Special Education Services, and other family services organisations in the region with regard to developmental and psycho-social problems.
Forensic Psychiatric Services: Both community-based and inpatient services are provided. These include: • regional forensic service teams based at Porirua Hospital and covering referrals from the wider Wellington region • assessment, consultation, liaison and follow-up services from the regional team • inpatient medium secure treatment and rehabilitation services at Purehurehu and minimum secure services at Porirua Hospital.
Alcohol and drug services: Residents in the Porirua area have access to a range of outpatient assessment and treatment, residential programmes, a methadone programme and health promotion and protection programmes provided in the Wellington region. Services located in the Porirua area include: • the alcohol and drug counselling service in Porirua by the Capital Coast Health Alcohol and Drug Services • the Medical Detoxification unit at Kenepuru Hospital • the NSAD head office at Porirua and the NSAD Kapiti Field Centre • the Puangi Hau alcohol and drug programme for Maori clients located in Porirua • the Serenity Foundation Trust on the Kapiti Coast.
A number of new groups including a Pacific Island alcohol and drug counselling service were being established in the Porirua area in late 1993.
5.5 Disability support services
5.5.1 ASSESSMENT From July 1994 assessment protocols for people with other than age related disabilities will be introduced. Access to disability support services will increasingly be through an individual needs assessment process, such as is already in use for older people with disabilities.
Services for people with psychiatric disabilities are not covered here as they are addressed elsewhere in this chapter.
68 5.5.2 NON-RESIDENTIAL SERVICES FOR CHILDREN AND YOUNG PEOPLE WITH DISABILITIES Services for young people with disabilities primarily assist young individuals and their families so the young person can develop to their full potential. This includes creating a safe and stimulating environment, and identifying realistic goals. Often the focus is on developing teaching/] earning skills and ways of managing better. The main service providers in Porirua City are the Puketiro Centre and CCS, although IHC also provides some services for children and their care givers. Puketiro Centre Puketiro is located adjacent to Porirua (psychiatric) Hospital, approximately one kilometre from the main Porirua shopping centre. It provides a special purpose unit for children with developmental delay, intellectual and physical disability. Its services are divided into family health and disability services. There are beds available for intermittent and continuing care. It shares the same site as Kenepuru and Porirua hospitals. Child and family counselling is also provided, focusing on personal and relationship skills, social and community skills and crisis intervention. Puketiro services are purchased by Central RHA through its contract with Capital Coast Health. Wellington CCS CCS has itinerant early childhood workers who work with children with disabilities in most kindergartens in Porirua, and a field officer who works with children with disabilities and their families. CCS Wellington (based in Johnsonville) provides support services and advice to families with disabled children to enable them to participate in most kindergartens and primary schools. It has three itinerant early childhood workers and one field worker. The field worker provides a range of services, including assessing the needs of the family in terms of benefits, transport, accommodation, attendant care, home help and education for the child. They also liaise with other service providers. CCS gets a relatively small proportion of its funding from the CFA. Its field worker contracts are due to transfer to Central RHA in July 1994.
IHC IHC runs a support centre for children with intellectual disabilities at Grays Road, Plimmerton, which is slightly outside the main geographical focus areas of this report, but is used by parents of children with intellectual disabilities in southern Porirua. IHC also organises carer support groups and links up with education. It gets government funding through the Residential Care Support Subsidy for people with Intellectual Disabilities which has administered by the Community Funding Agency (CFA) on behalf of Central RHA during 1993/94. The IHC will contract directly from the RHA from July 1994. Puketiro is specifically for young people, although residents of Kowhai villa are an ageing population. It covers both local residents and people from outside the immediate area.
5.5.3 RESIDENTIAL CARE FOR OLDER PEOPLE Although older people have a strongly expressed preference for receiving services in their own home wherever possible, a small number of people in this age group need a higher level of assistance with personal care, domestic tasks and clinical support than is currently able to be provided at home. For this group, two levels of residential care are rest homes and continuing hospital care. Q
Rest home services provide 24 hour access to hotel and personal care, while continuing hospital care services also provide 24 hour management of care by registered nurses. Access to services for older people is through a formal needs assessment process. Needs assessment is contracted through Capital Coast Health in accordance with the Support Needs Assessment Protocol (SNAP), a national standard protocol for assessment for older people. The level of support required is assessed, people are advised of the appropriate options and referral to service providers is made. This assessment is a pre-requisite for access to disability support services for older people such as rest home, continuing hospital care or home support services. In the Porirua area, there are two rest homes, Russell Kemp and Glenbrook House. In addition, Russell Kemp Home provides continuing hospital care. These facilities also provide intermittent or respite care. Respite services are also provided at Ward 6 of Kenepuru Hospital. Financial assistance is available for both rest home and continuing hospital care. Financial assessments performed by NZ Income Support Service determine the level of user contribution. Most residents of rest homes and hospitals in the Porirua area are European. Under- representation of Maori and Pacific Island people is believed to reflect a cultural preference for the elderly to be cared for by their own family and the lack of acceptability of existing residential services where home care is not the preferred choice.
5.5.4 RESIDENTIAL CARE FOR YOUNGER PEOPLE WITH DISABILITIES Kenepuru Hospital has a ward for long stay people with physical disabilities, called Whitirea. It also provides some intermittent care for people with physical disabilities. It provides for people from around 15 to 64 years of age. Whitirea, aims to operate as flexibly as possible, especially with respite care, so that people with disabilities maintain a lifestyle that maximises their living in the community. It is nevertheless seen as less suitable for younger people with disabilities. Children and younger teenagers may receive long-term care at Puketiro, and short-term residential care in the children s ward at Kenepuru, although access is limited by available resources. IHC coordinates respite, intermittent and shared care for people with intellectual disabilities. They also have a number of community homes in which young adults live.
5.5.5 HOME SUPPORT AND ATTENDANT CARE Home support services are available to people with disabilities, including older people. The services include household management, limited personal care, meals on wheels, carer support and professional community services such as domiciliary nursing, social work and physiotherapy services. Access to home support services for people over 65 years is through the needs assessment process conducted by the assessment and service coordination team based at Kenepuru Hospital using the support needs assessment protocol. For people under the age of 65, access to home support services is through assessment by the specialist assessment team based at Capital Coast Health or a GP.
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Personal care includes assistance with activities such as bathing, personal grooming and dressing. Personal care for people with disabilities under 65 is provided through the attendant care scheme. There is one attendant care service for Wellington, Hutt Valley and Porirua, which is in high demand. Professional community services and meals on wheels are provided through the Crown Health Enterprise. There is a small user charge for meals on wheels. Russell Kemp Home also has a service offering low-cost meals delivered to homes. Household management services help people maintain, organise and control their home environment, including assistance with laundry, cleaning and preparation of food. These services are provided privately through individuals and agencies. Household management for both older people and people under 65, and personal care for people over 65, are means tested by NZ Income Support Service to determine the amount of user contribution.
5.5.6 EQUIPMENT SERVICES Equipment services for people with disabilities help them maximise their abilities to participate and to function independently. They include aids to daily living (such as built-up taps), mobility (wheelchairs and walking frames), and communication (such as scanners, hearing aids, and speech synthesisers). Assessment and provision of hearing aids is through the audiology clinic at the Puketiro Centre. There is an $89 subsidy for hearing aids paid through the CI-IE. The residual cost may be met by the user, or be paid in full by government if the person is eligible under the DPCW Act. Assessment and provision of most equipment is undertaken by personnel at Kenepuru Hospital. Wheelchairs services are provided through the regional wheelchair service at Wellington Hospital. Funding of equipment is complex. The provision of some types of equipment are purchased by Central RHA through the CHE. Some equipment is funded under the DPCW Act (1975), which is currently administered by the New Zealand Income Support Service. Access to this funding is governed by the terms of the Act and is based on a professional assessment by an appropriate accredited equipment assessor. User contributions may be required for some equipment available from CI-]IEs. Aids for vision available through low-vision clinics are hired or purchased by the user.
5.5.7 MOBILITY SERVICES There are two main mobility services in the area. The Total Mobility scheme provides vouchers for subsidy of travel costs (taxis) and is funded by Transit New Zealand. The scheme is administered by CCS. Porirua Taxis operate accessible vans that can be used by people with disabilities. Operation Mobility is a preferential parking scheme, also administered by CCS. It controls the issue of parking stickers that identify cars as eligible to occupy car parks designated for use by people with disabilities.
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5.5.8 SERVICES OR PEOPLE WITH HEARING DISABILITIES In addition to hearing testing at the audiology clinic, mentioned above, the Hearing Association provides basic hearing tests, speech reading classes, support group, counselling, information about hearing aids, and community visiting. The Wellington Branch of the Hearing Association runs weekly day-long sessions in Porirua, and fortnightly sessions at Takapuwahia Marae. The Hearing Association is funded through a mixture of Ministry of Education, Community Funding Agency and private/voluntary funding.
5.5.9 SERVICES FOR PEOPLE WITH VISUAL DISABILITIES The main provider of these services is the Royal New Zealand Foundation for the Blind. From its base in Wellington, it provides the following services: • rehabilitation services, including equipment, orientation and mobility • education services, including preschool and adult • braille services and library services • guide dog services • Maori services • vocational services.
The Foundation s services are used by people with visual impairment or vision loss who have been assessed by an ophthalmologist, and are members of the RNZFB.
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6. Consumer views
Highlights • The affordability of services was seen by those surveyed as a barrier to access. This can relate to either the cost of the services, or the costs of accessing the service (such as transport and child care).
• Transport was another key barrier to accessing services. More home visits and extended services at Kenepuru Hospital were identified as possible solutions to some of the transport problems.
• People are uncertain about the services available in the area, and processes for accessing these services. Better information for consumers is seen as important.
• In both the household survey and the focus groups, waiting times were identified as a malor issue. This applied both to waiting times to get an appointment and delays in being seen when keeping an appointment. Preferred waiting times have been proposed.
• There was a general belief that the present system is oriented toward those who enquire, claim and negotiate access to services. This suggests that some people will have difficulty getting .fair access to services. Use of assistance with cross-cultural communication and psychiatric survivors as advocates for others were strongly recommended.
• Access to accident and emergency services is seen as poor in southern Porirua. People want services that will ensure that they canget direct access to emergency care 24 hours a day, 7 days a week, in their area.
• Round the clock crisis support, and day services for people with psychiatric disabilities, 7 days a week, are seen as necessary service developments.
• There was support from Maori for more services to be provided by Maori. Priority areas were identified.
• A number of criteria for providing a satisfactory service were identified. These centred on the user feeling understood and the service being well organised.
73 L 6.1 Introduction
Central RHA wanted to hear consumers views about the health and disability services provided in Porirua, and their suggestions for how services could be improved. Two approaches were used to gather this information: a series of focus group meetings and the household survey that has been referred to earlier in the report. Again the focus was on southern Porirua, with consumers from Titahi Bay, through Cannons Creek to Ascot Park being consulted. This chapter reports the consumer views that were made known through these processes.
6.1.1 Focus GROUP MEETINGS Central RHA contracted with Whitireia Polytechnic to coordinate 10 focus group meetings, where consumers of particular services would discuss the issues of concern to them. While seven to ten people was the ideal number for these groups, some were only half that size. The meetings were focused around the following groups of consumers: • mothers using child health services • users of mental health services (individuals and carers) • Pacific Island people • new settlers • older adults • women • young adults • Ngati Toa • other Maori • people with disabilities.
6.1.2 THE HOUSEHOLD SURVEY The household survey was a joint initiative between the Porirua City Council and Central RHA, and was carried out by the National Research Bureau (NRB). A total of 473 primary caregivers were interviewed face to face in southern Porirua, and were representative of the local population in age and ethnic group mix. Their experience and views of about local health and disability services are reported here. Other findings from the household survey are interspersed throughout the appropriate chapters of the report.
6.2 What consumers said
Several consistent themes emerged from the focus group meetings and survey. These are listed below.
6.2.1 AFFORDABILITY OF SERVICES In all focus groups the cost of consulting a GP and obtaining prescriptions were identified as significant barriers to accessing primary health care services. Ongoing dental services were also identified as being out of the reach of many people on low incomes. Ways of making services more affordable, such as placing payment on a Koha basis or making small regular payments (as the Union Health Service uses) were seen as necessary.
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Participants reported avoiding incurring these costs by arranging for several family members to share a consultation, only seeking help for children s needs, or consulting a pharmacist or nurse.
Fifty-seven percent of survey respondents identified cost as a major barrier. The services most frequently remarked on in this respect are listed in Table 21 below.
Table 21: Percentage of people who had used a service in the last two years who said it was too expensive
As some of the services identified were free, people may have been thinking of the transport or other costs involved in accessing those services. There is also a possibility they do not realise that the services are free. This may mean that people are avoiding services unnecessarily for fear of incurring costs.
The household survey identified that just over a quarter of the households had private health insurance, particularly where they were on relatively high incomes. Ten percent of households had a High Use Health Card, and a third had a Group One Community Services Card. In more than a quarter of the households, the 20 item limit on prescription user charges had been reached last year.
There was a mixed reaction among participants in the focus groups to the use of High Use. Health Cards and the Community Services Card. Some had been impressed with the discounts available to them as card users, but others were confused about their eligibility and found changing criteria difficult to follow.
6.2.2 TRANSPORT Transport was raised as a problem for many people in Porirua, especially for: • carers of people with psychiatric disabilities • people with disabilities • Pacific Island people • older people • children needing to use accident and emergency services • people requiring ongoing specialist care.
As the sample size was relatively small, this item was based on the report of only two consumers.
75 For people with disabilities and older people home visits were seen as one way of addressing transport and other disability issues.
The location of more services at Kenepuru Hospital (such as 24 hour accident and emergency and a wider range of specialists) was also raised as a measure that would reduce the need for people to travel out of the area for services.
6.2.3 INFORMATION ABOUT SERVICES Better information about the range of services available and how to access them arises as a priority need. Consumers expressed confusion about the availability and cost of services. Some were not aware of the opening hours of the Accident and Emergency Service at Kenepuru for example. Others could not understand apparent inequities in the costs of similar services, and couldn t predict the amount they would have to pay.
A number of services were well known, such as the Hearing Van, while others had a very low profile, such as the Puketiro Child and Family Service.
6.2.4 WAITING TIMES Another key area concerned waiting times. In both the household survey and the focus groups, waiting times were identified as a major issue.
Nearly half the respondents in the household survey said it took too long to get appointments with some services. The services most commonly mentioned are listed in Table 22 below. More than 50% of Maori and Pacific Island people were dissatisfied with waiting times compared with 40% of Europeans.
Table 22: Percentage of people who have used the service in the last two years, who thought it took too long to get an appointment
It was also noted, in both the household survey and the focus group meetings, that people often had to wait for more than an hour in the service s waiting room. This was not considered acceptable on a number of grounds. For example, some may have other responsibilities to which they need to return promptly (such as paid work or child care), and others may find waiting difficult for reasons such as personal discomfort or the need to keep children under control.
More than half the people in the household survey complained of "having to wait a very long time before you see anyone" after arrival for an appointment. Maori reported this most often
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(60%), followed by Pacific Island care givers (56%) and Europeans (47%). The services that the largest proportion of people who had used them in the last two years mentioned in this respect were GPs (4 1%), hospital outpatient services (19%), the Union Health Service (16%), and accident and emergency services (15%).
6.2.5 SKILLS NEEDED TO ACCESS SERVICES There was a general belief that the present system is oriented toward those who enquire, claim and negotiate access to services. Standards of service seemed to improve once people established their credibility with key staff, acquired a working knowledge of key services, and became familiar with the early signs of approaching crisis.
This suggests that some people will have difficulty getting fair access to services where they lack knowledge or skills, or where self advocacy is not possible for them because of lack of confidence or cultural barriers.
In particular, the use of translators and other assistance with cross-cultural communication should be increased in existing services. Pacific Island health educators who could be available in emergencies were suggested.
The increased use of psychiatric survivors as advocates for people with psychiatric disabilities was also strongly recommended.
6.2.6 ACCIDENT AND EMERGENCY SERVICES People wanted better access to accident and emergency services. Several focus group participants reported having to make a number of phone calls to locate someone to provide emergency care, then having to travel to another suburb or to Wellington Hospital to obtain it.
Twenty-four percent of respondents to the household survey, who had used the service in the last two years, said that when you want to use a GP in the weekend "it is really hard to get them to do anything", and 13% said this of accident and emergency services.
6.2.7 PSYCHIATRIC SUPPORT SERVICES Although services had a policy of 24 hour cover, consumers felt this was not always available in practice. As a result, carers have been placed in danger and inappropriate referrals have been made to the police.
More day services for people with psychiatric disabilities were seen as desirable, together with more support staff to carry out ongoing follow-up, more counsellors, more services based in the community rather than at Porirua Hospital, access to psychiatrists with appropriate cultural backgrounds, easier readmission to psychiatric hospitals, and more general practices with doctors who have specialist mental health knowledge.
6.2.8 SERVICES FOR MAORI Maori wanted more services provided by Maori, particularly in the areas of sexual abuse counselling, mental health treatment, and education on alcohol and drugs, family planning, and parenting. They also called for additional detoxification and treatment programmes, and antenatal and postnatal services.
77 6.2.9 INDICATORS OF GOOD SERVICE PROVISION A number of criteria for providing a satisfactory service were identified. These centred around the user feeling understood and the service being well organised. As health system users, people wanted: • staff taking time to talk with them. In the household survey people reported feeling most comfortable talking to their GP (66%), followed by their midwife (47%), Plunket nurse (39%), Union Health Service (33%), and doctor s practice nurse (28%). • to be involved in their own care • workers being of an appropriate sex and culture who would "make them confident to go along" • support for the user s independence • having an educational/preventive component to the service • continuity (except where the person was not happy with the staff or wanted to be helped by a different service such as on leaving Porirua Hospital when a community-based service seemed more appropriate). In the household survey, people were most critical of the Union Health Service in this respect, with 19% of people who had used the service in the last two years saying that "they had a different person to deal with nearly every time they went there." • advice made specific and written down during the consultation • clear and accurate explanations given • regular contact from some services (such as the Plunket Nurse) • information being available on a relevant range of support services • follow-up, such as phone calls to ensure the treatment has been effective or to report test results • reminders when routine procedures are due. Respondents to the household survey identified GPs (18%), Plunket nurses (11%), the Union Health Service (9%) and the doctor s practice nurse (9%) as service providers who could "try harder to keep people informed of when to come in for checks or treatment." • confidentiality respected, especially in the reception area and in sharing information among agencies • adequate numbers of staff. Nearly 40% of respondents in the household survey said that services they used were understaffed. The services most commonly cited in this respect, by people who had used them in the last two years were GPs (17%), hospital outpatient services (16%), and accident and emergency services (13%). • the environment being comfortable for people from different ethnic groups
It was felt that all services should try to meet these criteria. According to the household survey, perceptions of the cultural sensitivity of southern Porirua s health and disability support services was mixed. Nearly half thought they were excellent or mostly good ; a third rated them as sometimes good and sometimes not , but only 11% rated them as poor. This was not because the majority of respondents were Pakeha, as there was little difference in the ratings made between people from different ethnic groups. The findings suggest that there is considerable room for improvement.
Maori expressed a preference for increased home visits in order to receive their service in an environment in which they felt at ease.
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7. Consultation and the views of community groups
Highlights • The submissions analysed below came from a diverse range of community groups concerned with health and disability support services in Porirua. They were representative of a wide cross section of interests.
• Services provided by professional medical and community organisations were widely acknowledged. However, they were often said to be under-resourced and, for a variety of reasons, not accessible to, not reaching, or not used by many people in need of treatment and help. There were also gaps in the services available.
• There was frequent comment in the submissions about the number of people on low incomes and the number of beneficiaries, who have great difficulty meeting the cost of available services. Affordability was regarded as the major obstacle to accessing services.
• The next most significant barrier was said to be lack of transport and the cost of transport.
• A range ofprovzders and community organisations offered assistance, in a number of ways, to people with limited means but they also had limited resources.
• The help available from community-based and home-based services was also widely recognised. They were said to be unable to cope with the demand. Needs commonly identified were:
- community care and support .for discharged psychiatric patients - home care and voluntary help for the elderly - respite and attendant care, and home help for people with disabilities - counselling and assistance for people under stress. • The health services available at Kenepuru Hospital were appreciated, in part, because they are local services. There was a clear call for enhanced hospital based services at Kenepuru so it could cater more comprehensively for Porirua s health service requirements. People wanted shorter waiting lists, more, and quicker access to specialist services, extended hours for accidents and emergencies and increased availability of domiciliary health professionals.
• People wanted better access to readily understandable advice and information about how to slay healthy, common illnesses and conditions and where to go for treatment and assistance.
• Maori saw a need for health services that respected their cultural identity, and on- going community education. Some of this could take place on a marae. Among the issues which should be targeted were alcohol and substance abuse and smoking.
79 • Pacific island groups were also concerned about the need for cultural safely in the provision of health and disability services. The language barrier, especially for recent immigrants, and the costs involved inhibited Pacific island people from using health services.
• More interpreters were needed to assist Pacific island people and new settlers with language difficulties. Printed information should also be made available in different languages.
• Other priority issues mentioned were care and support for psychiatric patients in the community and health education. A number of priorities for health and disability services relating to differing age groups were identified.
• Some groups were concerned to state the issues relating directly to their particular area of interest. In general terms: though, they shared the concerns of the other community groups. Many groups sought greater assistance and funding from the health and disability services to strengthen the support available from their groups and the community for their people and/or members.
• One group summarised a common thread running through the submissions, saying that more should be done to make the health structure fit the people, rather than making people fit the structure.
7.1 Introduction
Central RHA has a commitment to community consultation as an important element in developing its purchasing strategies. Views of community groups on health and disability issues in Porirua were obtained by a variety of means, including direct discussion with particular groups, hui, fono and more structured submissions.
7.1.1 INVOLVEMENT OF THE PORIRUA COMMUNITY HEALTH GROUP The Porirua Community Health Group, whose role is to provide a link between Central RI-IA and the community, was contacted at the planning stage of the project for their advice on its development. The Group gave advice and input at several points during the project, and endorsed the emphasis on seeking improvements in access to primary health and disability support services. The Group advised that: • the cultural diversity and other features of the community required services to be geared to the family/whanau • health workers need to have acceptance in the community and a commitment to coordination of services • services should be provided continuously, so that patterns of use become well-established and reliable information is at hand • income levels are such that even small costs can form a significant barrier to access. The level of fees and charges, the cost/availability of travel and the availability of telephones were seen as key related factors.
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The Group highlighted a number of concerns, such as child health, Maori health, Pacific Island health, mental health, transport, and maternity services, as key priorities for action. In addition to its advisory role, the Group also made a submission as part of the formal consultation with groups, reported later in this chapter. At the time of writing, it was helping provide community feedback to Central RHA s Purchasing Directions; a region-wide consultation document circulated in February 1994. This feedback is referred to in the concluding chapter of this report.
7.2 Consultation with Maori
A hui at Maraeroa Marae, one of a round of consultations with Maori in the region, provided an early opportunity for an exchange of views about issues in Porirua and the function of the needs assessment project. Those present emphasised the need to recognise and value the contribution of Maori who are making a voluntary input into, or directly providing services. The stress experienced also needed recognition. The role and value of Rongoa Maori (traditional healing including the use of herbal remedies, physical treatments and spiritual healing) was particularly emphasised. Central RHA staff acknowledged the value of Rongoa to Maori and the desirability of it being available as an integrated part of Maori health services. Though it is not appropriate for the person receiving services from a Rongoa healer to pay a fee for the service, some means of providing the healer with a reasonable income needs to be found. It was suggested that Maori themselves need to advise on how best that can be achieved. There was discussion about possible adoption of a proposal for a health service based at Maraeroa. The process through which proposals could be developed and presented was discussed. 2 Strengthening and better integration of some existing services was called for, with particular reference being made to the relationship between services or programmes addressing mental health and substance abuse problems. Needs assessment was discussed at some length. The importance of Maori conducting their own research was emphasised by participants. There was agreement that both parties would share the results of relevant needs assessment work and that Central RHA would meet further with those developing the marae- based health service proposals and with any other groups seeking to develop proposals for health services incorporating Rongoa. A second opportunity to discuss Maori health issues was through the consultation with various groups or organisations providing a health service to Maori by Maori. 3 Key barriers identified were: • the cost of services • lack of - or inconsistent - information about health services • availability of transport to attend the services
Report on the Maori Consultation Hui at Maraeroa Marae, Porirua, November 1993 Central Regional Health Authority, Wellington. 2 There has been subsequent discussion between the Marae Committee and Central RHA regarding this proposal. (See also Chapter 6). Iwi provider interviews are discussed more specifically in the previous chapter.
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• people fearing the services, or the service providers, and in some cases the location of services.
There is consensus among Maori that the key health concerns are child health (particularly hearing problems), mental health, and the care of kaumatua. It is also widely believed that in order to improve the health status of Maori, services need to be provided by Maori for Maori.
7.3 Consultation with Pacific Island people
Some face to face discussions with Pacific Island people occurred at other points in the project, and the goals and methods of the project were discussed with Ministry of Pacific Island Affairs officials at an early point. However, the most significant forum for direct discussion of the views and needs of Pacific Island communities in Porirua was at a fono organised by Central RHA in cooperation with Whitireia Polytechnic in early March 1994. Samoan, Tokelauan, Cook Island and Nuiean communities were represented. As with the consultation with Maori, recognition and support of traditional healing arose as an important issue, as did a desire for Pacific Island people to provide services to their own communities. This linked with discussion about a need for training of more Pacific Island health workers to meet the significant lack of qualified personnel that exists at present. Resourcing, in the sense of finding and buildings, was also a common topic of questioning and discussion. There was considerable support for the creation of a Pacific Island health centre in Porirua. It was pointed out by Central RHA staff that they purchased services, and that premises were a matter for providers and their communities to supply. This did not necessarily mean that new buildings needed to be erected. Existing church and community buildings should be considered as potential venues for services to operate from. Recognising that groups did not necessarily have experience in developing proposals, Central RHA offered to look at organising workshops at which the practicalities of service proposal planning and development could be worked through. In response to a set of discussion points, a wide range of priority issues affecting the health of different age groups were identified. In the area of child health, immunisation, asthma, glue ear and hearing problems, dental and nutritional issues were identified. For adolescents, it was mental health and self esteem, alcohol and drugs, smoking, suicide, and family planning. In the area of women s health, ante- and post-natal care, cervical and breast cancer, and a range of issues surrounding childbirth (for example, length of hospital stay, knowledge of the options, including midwifery services, and recognition of traditional skills in childbirth) were commonly identified. Care and services for the elderly were also touched on. In all areas, cost and knowledge about services were commonly mentioned as limiting access or utilisation. Language issues, and a need for assistance from interpreters also arose as factors relevant to service use.
1 Workshops of this kind have successfully been organised for Maori groups, in cooperation with the Business Studies Department of Massey University.
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7.4 What the submissions said
In addition to the consultations outlined above, and as a further systematic means of informing community groups about the project and obtaining their involvement and views, the team wrote to all known community-based bodies with an involvement in or a perspective on health and disability issues in Porirua. This included groups identified with a specific type of issue, such as asthma, multiple sclerosis or intellectual disability, and groups with more general service or welfare concerns. Groups representing particular cultural communities were also contacted. Schools were approached for comment on health and disability issue and needs as they saw them. Groups were supplied with an outline of the project and its objectives and were asked to provide feedback identifying: • the part(s) of the community they represented • the most important health and disability issues they faced • positive features of the services they used • aspects of services that are not meeting people s needs • suggestions about ways in which these services could be improved • the priority areas for improvement.
They were also invited to comment on other health and disability support services they considered important. A total of 46 submissions were received (see the appendices for a list of contributors). These were widely representative of the groups involved in Porirua s health and disability services. Some groups also made oral submissions to Central RHA. The submissions can be divided into four broad groups. Most were from general community groups (22 submissions). There were 10 from specialist health and disability groups and the others came from schools and Maori and Pacific Island groups. They expressed a wide range of common and different perspectives on Poriruas health and disability services. The following sections review points made in the submissions under the groupings outlined above.
7.4.1 THE MOST IMPORTANT HEALTH AND DISABILITY ISSUES FACED Cost The inability of people to pay for services such as GPs (when services were unavailable at hospital), prescription charges, the fees to belong to support groups, X-ray charges, hearing aids and dentistry were raised. Difficulties faced in replacing teeth, glasses and hearing aids were also mentioned.
Transport Transport difficulties were common concerns. These ranged from the cost of transport, its availability and a lack of transport for those unable to use public transport because of disabilities.
Transport difficulties are seen as particularly pronounced for:
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• those needing to use services outside Porirua. A proposal was made that people in this category should qualify for some assistance towards transport costs • those needing to use transport at night or in an emergency • those with both physical and emotional disabilities.
Though some voluntary organisations provided assistance with transport, they were unable to cope with demand because of limited resources.
Home-based and community-based support services Both home-based and community-based support services were said to be stretched in the assistance they were able to give people over a wide range of health and disability support needs.
Areas of need identified were home-based support services for: • people looking after aged parents and those requiring on-going care • activities designed to maintain fitness and independence for older people • people unable to work because of illness and associated problems • people suffering from social isolation.
Also identified were community-based support services for: • mothers requiring help after discharge from maternity hospital to ensure successful breastfeeding and follow up services (mothers were said to be sent home too early and there was inadequate coordination between hospitals, midwives and Plunket) • access to general and specific health care for women • a shortage of counsellors in many health areas • lack of child care while mothers were at counselling • problems with difficult children, aggression and domestic violence • counselling for sexual abuse, assault and accident victims (there was said to be a severe shortage of counsellors for these people) • families, in particular single parents, unable to meet costs of food, household expenses and school costs • public education programmes on health promotion and prevention.
Specific medical problems The submissions from schools generally identified a common range of ailments among their pupils. Those most frequently mentioned (in four of the six submissions) were skin complaints (impetigo, school sores, scabies), and ear and eye infections. It was said there was a long waiting list for ear problems. Children could wait up to two years for ear operations and all this time their school work suffered.
Maori concerns The concerns noted in submissions representing a Maori perspective were, for children and young people: • availability of immunisations • nutrition
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• dental care • vision and hearing problems • family planning and education, • cervical and breast screening • substance abuse. For kaumatua, the concerns noted were nutrition education, cancer, cervical screening and breast examination. Diabetes, arthritis, asthma, dental care, heart conditions, hearing and vision problems were also mentioned. It was also noted that there was a need for on-going education to help those in need to cope with diet requirements and breathing and other exercises. Psychiatric services were not meeting the needs of Maori whanau. There was a lack of understanding of how psychiatric illness affected not only Turoro (patients), but also the extended family and their role in care and rehabilitation. Another concern was that there was no patient advocate in the mental health system who Turoro and their family could approach about their concerns.
Pacific Island concerns The need for recognition of cultural safety in the provision and delivery of health services was identified. One group was concerned about "identity diffusion" which caused psychological, economic and other problems for Pacific Island people.
New settler concerns Health problems deemed of particular concern to new settlers who had come to New Zealand as refugees included: • chest problems, for example, TB • dental problems, especially for children • gastro-intestinal conditions • general medical complaints • mental disorders, caused by past experiences • stomach ulcers, caused by stress.
7.4.2 PosiTivE ASPECTS OF SERVICES USED Many submissions made positive comment about Kenepuru Hospital. The fact that it was local and more easily accessible (during normal hours) than hospitals outside Porirua was mentioned. Another advantage noted was that Kenepuru had specialist services located under the one roof The accessibility of orthopaedic services, and prompt attention from domiciliary physiotherapy and occupational therapy services were also noted. Community health centres, especially the Union Health Centre, were said to be relatively cheap and readily accessible. Submissions from schools often praised public health nurses for their regular visits, for prompt referrals to other health professionals, for follow-up visits made to families, and for keeping school staff informed.
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Diabetes education was appreciated for being on a one-to-one basis, and for providing follow-up education. The availability of home visits was also thought to be valuable. The regular training and availability of Asthma Society field officers was felt to be valuable, as was the Society s newsletter.
Location of services A number of submissions called for services to be located in the town shopping centre for improved accessibility, and for better coordination of services. It was felt some specialists could meet people at such centres rather than in hospital settings.
Services for people with disabilities The low cost of many services used by severely disabled people was commended as enhancing access, and noted as particularly important in a low-income area such as Porirua.
Services for Maori Submissions representing a Maori perspective praised Rongoa healers who offered services at no charge. Some Maori were also reported as preferring to use medical practitioners who also supported traditional healing methods. As there were now more Maori services available, and more Maori people involved in planning and providing services, consumers felt happier about using the services. They felt they had a choice. A number of other services also received favourable comment, although not as widespread as the above.
Services for Pacific Island people One group said they preferred to use Fofo healers rather than GPs or hospitals, because of easier cultural acceptance and accessibility of the healers.
7.4.3 ASPECTS OF SERVICES THAT ARE NOT MEETING PEOPLE S NEEDS Hospital services were criticised for: • the difficulties arising from the lack of after-hours A & E services at Kenepuru • the length of waiting lists to see hospital specialists and the need for more specialists • early discharge of mothers from maternity hospital • the lack of continuity and liaison between the range of health providers a patient may require • the lack of a rheumatology clinic • the need to go to hospitals outside the area for some service (admission for arthritis for example) • pregnant women often having to attend Wellington Hospital in the absence of a high risk clinic at Kenepuru • failing to use the new settler interpreters available from the Wellington Community Interpreting Service.
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Community Based Services The need for more counsellors was frequently mentioned. Sexual abuse and assault victims were specifically mentioned in several submissions. Domestic violence, in particular the need for help and counselling for parents unable to control teenage violence and aggression in the home, was also cited. It was also said that there was often a part charge for counselling services which many people could not afford. Several submissions reported concern among some of their people about the adequacy of- and access to - care and support services when people were moved from hospital to the community. Puketiro Centre was criticised for poor liaison and sharing of understanding of children s problems with the schools attended by children using the Centre s programme. The need for comprehensive protocols for the treatment and management of diabetes was identified.
Services for people with disabilities The limit on hours available for attendant care, problems with obtaining finds for attending out-of-town facilities such as the Rotorua Cerebral Palsy Unit, and rigid criteria for access to paid alternative care, were also criticised. The abolition of the free nappy service to families of children with physical disabilities and the reduction of the number of catheters and incontinence pads supplied were seen as retrograde steps in the provision of disability support services. Limits on new intakes to residential services for young people were also seen as placing stress on families.
Pacific Island perspective One group said that Pacific Island people would usually see a general practitioner only at the last possible moment. This was due to financial and social reasons, including language difficulties, "fakama" or passive unassertiveness, and their stoic disposition. Access to hospitals was limited for Pacific Island people due to the costs involved and the language barrier. Inpatient psychiatric services were criticised for paying lip-service to cultural safety and the "community care" philosophy. Inpatients experienced a lack of trained interpreters and medical staff. Patients were discharged without adequate follow up and family support. There was a scarcity of mental health education workshops in the community.
7.4.4 SUGGESTED IMPROVEMENTS Extension of public hospital services There was significant support for the strengthening and extension of the specialist services available in Porirua and at Kenepuru Hospital.
Public education Many submissions referred to the need for increased education regarding public health issues. Action was strongly urged on education about the dangers of smoking and substance abuse.
87 The information should be presented in culturally acceptable ways. For example, one submission suggested training should be offered for Samoan nurse educators. The venues suggested for public health education included schools and pre-school centres, marae, Plunket and parenting groups. Public health nurses and health professionals should be involved. Programmes could include education in motherhood and parenting, breast feeding, child health, diet, hygiene, common ailments (contagious skin diseases, ear infections and sight problems, hepatitis and inoculations). One submission suggested that training courses for health and disability support service staff, on different types of disability could be organised by health agencies. information Comprehensive information on the services available in the community was requested by several groups. It was suggested that multi-lingual leaflets could be available at hospitals and community or health centres.
Communication The use of interpreters at Kenepuru Hospital to assist those who did not understand English well was suggested in a number of submissions. This was needed for Pacific Island people, refugees and new immigrants from Asian countries. It was suggested that a list of professional translators be available to hospital staff and that the hospital should pay for this service. As with people who do not understand English, interpreter services for people with disabilities was also seen as important, not just for people with hearing disabilities, but also for people who cannot express themselves clearly such as those with cerebral palsy, motor neurone disease and those who have had strokes.
Free health checks Two groups proposed that regular health checks be available, free of charge, for vulnerable people in the community.
Psychiatric services One health need which attracted widespread comment and concern was what was often said to be the inadequate follow-up and community support available for psychiatric patients after their discharge from hospital. Many of these people were not able to cope without that support. The strengthening of these services was widely regarded as a high priority. A better selection method for deciding who should be discharged into the community was also considered necessary. •Turoro (patients), prior to discharge, should be better prepared with life skills education.
Services for people with disabilities Improved availability of well supervised but small scale residential care was recommended. Stimulating day services for profoundly disabled adults were believed to be needed.
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Meeting the needs of Maori and Pacific Island people More health personnel with an understanding of Maori protocol to ensure that needs are adequately met, were recommended. A similar call was made on behalf of Pacific Island people.
Support for community-based groups One submission urged greater emphasis on "empowering people to look after themselves and operating within their own community-based groups, with proper consultation and support at all levels. Need for support, both technical and financial, for community based groups endeavouring to care for their own people was highlighted.
Other areas identified While there were are great number of suggestions made, the following were made in a substantial number of submissions: • increased funding and support of mental health services • transport services to health services should be improved, and should be cheaper or free • funding for home-based support services in general should be increased • hospital services and especially the availability of specialists, should be increased • the number of counsellors/social workers should be increased.
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8. Provider views
Highlights
• The cost of health services in general was seen by some providers as a key issue. Poverty, unemployment and socioeconomic conditions were described by some as underpinning all health problems, and some argued that if the health status of the Port rua population is to improve it first needs to improve its socioeconomic status. • New immigrants, particularly if they are not entitled to or do not receive social services and benefits, are seen to be a group at risk of not receiving care. • All the pharmacists and two thirds of the GPs interviewed commented that clients have problems paying.for pharmaceuticals and general practice visits. • Transport was seen as an issue for access to services by more than half of the providers.. The most significant concern was the cost of transport to Wellington and the Hutt Valley for specialist treatment not available in the Port rua area. • Waiting times for ear, nose and throat (ENT) services were mentioned by many providers as being unacceptable, with an up to two year waiting list being seen as totally inadequate. Other outpatient services criticised for long waiting lists were orthopaedics, eyes, rheumatology, joint replacement surgery and dentistry. • The biggest service gap identified was lack of information about services that are available. • The most common cultural barrier mentioned by providers was consumer distrust or inappropriateness of Pakeha services. The cultural identity of the provider was the second most common focus of comment. Many felt that there were not enough health professionals of the same culture as the clients, although others pointed out that some people don t want aprovider from their own culture for reasons ofprivacy. • Staff interviewed at Kenepuru felt that language ,formed a definite barrier for those whose first language was not English. Interpreter or translation services at the hospital was seen as an area needing to be addressed. • Other cultural barriers were seen to be consumer s low expectations of services, lack of confidence to approach providers, general negative perceptions of the system , and lack of culturally appropriate information concerning services. • Maori providers emphasised the importance of their ability to of a service to Maori by Maori, and working with a Maori kaupapa. • Access to respite care and support for families with a disabled person were seen to be restricted in southern .Porirua. • Several providers considered that people with psychiatric disabilities are often discharged into the community with no backup. • Adolescents and young people are seen by many providers as a group at risk of not receiving adequate/appropriate care. The lack of clinical services for young people in Porirua, in areas such as sexual health and education were identified.
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• Asthma, respiratory diseases, chest infections and smoking were seen as the biggest key group of health issues, identified by most of the GPs. all of the pharmacists and CHE groups interviewed. • Other specific heath concerns mentioned included alcohol related diseases, hypertension, cancer, contact and non-contact skin diseases such as scabies and head lice, rheumatic fever, back problems and accidents.
8.1 Introduction
This chapter outlines the results of consultation with providers of primary health and disability support services in the Porirua area.
8.1.1 APPROACH The provider groups contacted included GPs and medical centres; dental health groups; private rest home and hospitals; maternity services; pharmacists; physiotherapists; family planning and well child care services; support services for people with physical, sensory, intellectual and psychiatric disabilities; community services; Maori health service providers; and Crown Health Enterprise units.
Major providers were interviewed face-to-face. Due to time constraints, others were contacted by phone or invited to give a written response to the interview topics. Over 30 interviews were held. The views of groups whose primary function is consumer representation were presented in the previous chapter.
Topics covered in the consultation were:
• characteristics of the service (who provides it, client base, hours available etc) 2 • relationships with other services • areas of strength and scope for improvement • perceived barriers to accessing services • key health and disability issues for clients • priorities for health and disability service provision • general comments and recommendations.
8.2 What providers said
8.2.1 AFFORDABILITY The cost of health services in general was suggested by some providers as a key issue. Poverty, unemployment and socioeconomic conditions were described by some as
A list was compiled (primarily from Central R}iA s provider and community data bases and the Porirua City Council s Directory of Community Health Services), and providers were approached between November 1993 and February 1994. 2 Detailed information obtained on the types of service offered, personnel, opening hours, cover outside opening hours and whether the after hours arrangements are satisfactory is included in chapter 4.
91 underpinning all health problems, and some argued that if the health status of the Porirua population is to improve it first needs to improve its socioeconomic status. "Health is not seen as a priority when the basic necessities are lacking." "When people do not have a discretionary income, food as a necessity outweighs health care, particularly for women."
"Not having access to primary health care leads to children not being seen until they are very sick." New immigrants, particularly if they are not entitled to or do not receive social services and benefits, are seen to be a group at risk of not receiving care.
All the pharmacists and two thirds of the GPs interviewed commented that clients have problems paying for pharmaceuticals and general practice visits. The pharmacists stated that many people are not paying, or not picking up prescriptions even where people have Community Service Cards and credit is offered if necessary. This is especially significant in the first half of the year before high users are entitled to full subsidies for payment. Selective drug taking was mentioned by one pharmacist, who observed, that people were willing to pay for and use asthma relievers but not preventers.
The high cost of services such as specialist and equipment for people with disabilities was also mentioned. The former were seen by some as a significant barrier to people at the lower end of the socioeconomic scale of Group 3 CSC holders or for those who earn just above the limit for a CSC. The cost of a GP visit is around $30 and $45 for a prescription for these people.
The dental health providers noted that people could often find the money for treatment if they had toothache, but their services were not being used in a preventative way.
A significant number of providers mentioned that they recognised and tried to accommodate the financial circumstances of the local population. Many try to be affordable, supply medicines to patients who are unable and sometimes unwilling to pay, and turn no-one away. Some GPs will treat people for no cost if necessary and rely on the GMS and Promed 1 for some compensation. Another mentioned that even with a Community Services Card the $8.00 cost is too much for some people.
A maternity service provider reported targeting lower socioeconomic groups through the Union Health Clinic.
A GP suggested that health services should be provided free of charge to children and adolescents until they leave school. "This would help also in an area such as contraception where many adolescents do not want to discuss this with their parents."
Promed is a church based charity which pays for primary health care, covering GP visits and pharmaceuticals. The patient obtains a slip from Promed and an account is sent to the agency by the provider.
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Inequities in affordability were identified. For example, physiotherapy for people with illness is often provided at a charge to the consumer, but the costs for people injured in an accident will be met by the ACC. A minority of providers thought finance was not a major barrier to clients obtaining services because these would be subsidised or provided free for those who needed (and asked for) them. One primary care provider justified the higher than average fees charged by having provided an above average service quality.
8.2.2 TRANSPORT Transport was seen as an issue for access to services by more than half the providers. The most significant concern was the cost of transport to Wellington and the Hutt Valley for specialist treatment not available in the Porirua area. For example, the closest rheumatology unit is at Hutt Hospital, childbirth specialists and alternative care, sexual health clinic, neurological, hearing and wheelchair specialists are all at Wellington Hospital. Access to Wellington Hospital by public transport (one way) requires one train and two bus rides. Taxis are available but are expensive.
Kenepuru was said by staff to have good access in terms of public and private transport. Other services identified as unavailable locally or difficult to access via public transport were: • colcoscopy, tuba] ligation and vasectomy, which are available only at Wellington, but with long waiting lists • diagnostic imaging and ultra sound facilities • Puketiro Centre.
Lack of transport was seen as particularly relevant to people with disabilities and ongoing or acute illnesses. The community service van was reported as not able to meet the demand. One GP commented that people would use such services if they were more available, and saw a need for four or five vehicles. Organisations seen to be of assistance in providing funds for transport were the Department of Social Welfare and Promed.
Several providers saw a need to go out to the community and visit clients, such as delivering medicines to the elderly.
8.2.3 WAITING TIMES Several services were commended for providing quick and efficient responses. These included: • domiciliary nurses • physiotherapists • occupational therapists • social workers • acute services • the ambulance service • Kenepuru and private hospitals.
The opening of a sexual health clinic in Porirua has since been announced.
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Six of the seven GPs interviewed commented on long waiting times for some outpatient services at Kenepuru Hospital. ENT services were mentioned by all of these providers as being unacceptable, with an up to two year waiting list. The incidence of glue ear in the community made ENT a particular priority. "It gets firustrating with the long waiting list for grommets. Because it takes too long to get an appointment, the patients have lost interest in the examination or do not perceive it to be important any longer. In the meantime the child has become a problem... learning abilities delayed or hearing is lost." Other outpatient services criticised for long waiting lists were orthopaedics, ophthalmology, rheumatology and dentistry.
8.2.4 KNOWLEDGE OF AND SKILLS FOR ACCESSING SERVICES When asked to identify any gaps, the responses were varied. The biggest gap was identified as lack of information about services available. Many providers commented that people do not appear to know what services exist. For example, several providers considered that women were not aware of the choices available to them during pregnancy, and that the public and some ambulance drivers were not aware that acute medical services are available at Kenepuru after 4.30pm. This can lead to some Porirua patients being taken unnecessarily to Wellington or Hutt Hospital.
At least one Maori provider argued that even when services are provided at an appropriate site (marae) those with the greatest need might not come - the marae should go to people s homes or the service provided ought to be mobile.
8.2.5 UNDER-REPRESENTATION OF SOME POPULATION GROUPS Age/sex registers and reports are kept by some provider groups such as GPs, some disability support groups, CHEs maternity services, family planning and some Maori health services. Although not discussed in depth in interviews, it was clear that some providers were much more actively committed to and skilled in monitoring and analysing data on their clients than others, and hence were also more active in recording necessary information.
At least five providers mentioned low Maori and Pacific Island client numbers, especially in physical disability support services. Howver, one provider reported a higher proportion of Maori and Pacific Island clients with arthritis and rheumatoid conditions such as gout.
Although the elderly and younger Pacific Island people were mentioned by some private dentists as among their clients, the majority described their clientele as predominantly PakehafEuropean and "middle-aged". One provider reported that the number of Maori using mental health services for adolescents was not indicative of the need. One pharmacist reported seeing fewer Maori and Pacific Island people in the past few years due to "socioeconomic conditions" and observed that they are staying away from the Porirua city centre.
Several explanations for this under-representation were offered: • Maori and Pacific Island people may provide support from within the family • they may not know how to access services (due to a lack of appropriate information)
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• Pakeha had a higher expectation that they would receive or access services than Maori and Pacific Island people.
Staff at Kenepuru reported that more than 50% of their clientele were Maori and Pacific Island people. This proportion reflects the general population characteristics of the immediate community, but not the wider area served by Kenepuru, including the Kapiti coast. This figure, therefore, may reflect greater need in these groups.
8.2.6 SERVICES FOR MAORI AND PACIFIC ISLAND PEOPLE AND NEW IMMIGRANTS Views on cultural barriers were diverse. In keeping with earlier remarks, nine providers commented on cultural barriers. However, three believed there were no barriers and nineteen did not comment at all.
A quarter of the providers interviewed referred to inadequacies in their contact with or involvement in their services of non-Pakeha groups. Maori and/or Pacific Island people were most commonly mentioned, but a small number also referred to Asian refugee groups. Both health and disability support, CHE and non-CHE providers mentioned these issues.
Culturally appropriate services The most common cultural barrier mentioned by providers was distrust or inappropriateness of a Pakeha service. One provider commented that if Maori/Pacific Island utilisation is low then we do not view services as being appropriate. The services offered by providers may be less culturally appropriate because they have been set up by Europeans. Two providers also saw a conceptual barrier where different cultures might not understand how the system operates. Another stated that until recently there was no word for disability in the Maori language, so the Maori concept of disability differs from Pakeha.
Empowerment was seen as the ultimate means by which people would ensure their own well- being. Continued growth of culturally and community appropriate health services and an adequate standard of living were required so that health concerns could be considered by those in poverty.
Ora Toa does not offer services/programmes unless staff feel conversant in that area and there is funding already available. The importance of follow up, support and education as a model for success has ensured they have kept their services focused. Strong links with the Community and health professions, contracting in the best people available and encouraging staff to seek further training were seen as important in ensuring. Ora Toa services are the best they can be." One Maori health provider stated that they were very mindful that statistics show Maori health status is poor and as such endeavour to tackle specific health issues in innovative and community-appropriate ways, for example K-mart clinics.
The lack of a culturally appropriate workforce The cultural identity of the provider was the second most common focus of comment. Many felt that there were not enough health professionals of the same culture as the clients.
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Some providers considered that they lacked an appropriate staffing mix or skills. One provider commented on the apparent lack of Pacific Island and Maori women counsellors, noting that it is difficult to break down barriers and recruit people. The need for a Pacific Island diabetes nurse was one example given.
However, several providers commented that Maori, and Pacific Island people in particular, do not always like to use providers from their own ethnic group due to concerns about privacy. One provider remarked on the large number of young Samoan females becoming pregnant, arguing that they did not want their families to know about their pregnancy, choosing abortion but not accessing specialist skills. They concluded that Pacific Island professionals tending to the care of these young women would not necessarily be appropriate - sexual health services need to be entirely safe.
Language barriers Staff interviewed at Kenepuru felt that language and culture formed a definite barrier. This was particularly so for those whose first language was not English. The lack of formal interpreter or translation services at the hospital needed to be addressed. At present kitchen staff, cleaners and others can sometimes be called on to assist, but this was seen as inadequate. "What is needed is an interpreter who is equally fiamiliar with the two cultures and has the health skills and knowledge to be able to translate better and bridge the miscommunication between providers and patients." Another provider identified a need for interpreter services for older Pacific Island people. At least one general practitioner also identified the Pacific Island community as one with whom the language barrier was a big stumbling block in the promotion of health.
Community links One provider saw health education for Maori and Pacific Island people in east Porirua as an area which should be addressed. Three disability support service providers identified the need to develop better links throughout the whole Maori community in Porirua, extending contacts into the Maori and Pacific Island communities. They saw the establishment of a Pacific Island worker as a priority because they already had whanau workers for Maori. "The perception is the Maori community do not have access to the health services they need because the services provided are not necessarily what the people want. Those who believe they have the mandate of the community often don t know what the people want."
"Whanau needs are not being catered for appropriately"
Other issues A disability support service provider argued that attendant care needed to be made "more visible to Maori and Pacific Island people", because "the extended family may pick it up, which can be stressful for the family, and the service isn t known to exist".
Another source stated that paid interpreters were brought in some instances. It appears, however, that this does not occur as a matter of course, and that the policy may be unclear to some staff. I
A child health care provider felt that Pacific Island people appeared not to see them as appropriate.
Other cultural barriers were seen to be low expectations of services, lack of confidence to approach providers, general negative perceptions of the system , and lack of culturally appropriate information concerning services.
8.2.7 SERVICES FOR PEOPLE WITH DISABILITIES Gaps or weaknesses in provision of services for people with disabilities were commonly mentioned by providers working in these areas.
Information about how to access services, and culturally appropriate information were identified as a key issue by most of the disability support providers. One provider stated that cultural needs were not being met.
Respite and alternative care One provider commented that, regardless of age or level of disability, there was a need for comprehensive home care for people, but nothing seemed to be available. A service is sought that embraces all tasks required to keep a person at home.
Respite care and support for families with a disabled person were seen to be restricted. For example, there was said to be more chance of getting respite care if the individual is intellectually disabled. Physically disabled people seem to have more problems finding respite care - quite often ending up in an acute paediatric bed or open home foundation. The acute ward is not appropriate. Adolescents with disabilities do not have access to appropriate intermittent care from Puketiro Centre. Some providers felt that family members should be able to be paid for the provision of alternative care as they are often well placed to provide safe care of a high quality.
Services for people with multiple disabilities Problems experienced by people with multiple disabilities when they needed to access services were mentioned by a number of disability support service providers. Examples given included obtaining services for an individual with a primary diagnosis of intellectual disability but who also had a psychiatric disability and problem behaviours. The lack of community support for an individual coming from Porirua Hospital who was sight impaired was another example. One provider commented that people with epilepsy and an intellectual disability do not get the same services as an individual with epilepsy but no intellectual disability. If they cannot advocate for themselves then they miss out on services, and are not treated the same, with the exception of Family Planning who are seen as providing a good service.
Disability providers generally thought that these coordination problems led to gaps in services, difficulty and cost. It was noted on more than one occasion that these ultimately became difficulties and costs to the wider community.
Services for people with psychiatric disabilities For individuals with a psychiatric disability living in the community, isolation was a problem. The person is alone in a flat or in a group (who are grouped for convenience and not
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friendship) and services are not constant (having contact with 6 domiciliary nurses in a year, for example). Stability is required. Services were described as being in a mess in the area in both quality and quantity - initial access has improved (clinical care and dealing with family issues in acute phase) but there are still problems from time-to-time. The quality of clinicians varied and there was a perennial problem of providers disagreeing on whether patients should be moved from one treatment to another.
It was said that some psychiatric patients may not be ready to be out in community and they don t always have 24 hour supervision. People who have been under psychiatric care are still suffering - community based services are inadequate and voluntary organisations have a lack of understanding and are stretched - therefore people with psychiatric problems are falling through the bottom of the bucket and the current system is not working.
One general practitioner commented on a lack of psychiatric care for adolescents and long waiting times for psychiatric counselling services at Puketiro.
Adequate training on mental health issues was emphasised by a number of providers. This was relevant to providers who do not have the necessary training to deal with mental illness.
Difficulties were mentioned by several providers in relation to Porirua Hospital. One general practitioner reported a "difficult relationship" with hospital based psychiatric services. Another general practitioner found it difficult to refer patients back to Porirua Hospital once they were discharged to the community.
Several providers observed that people with psychiatric disabilities are often discharged into the community with no backup. One provider felt that there were inadequate acute services for people with psychiatric disabilities, although in general providers seemed to think that access to acute services for people with disabilities was relatively good.
Housing Rental housing provision was criticised by two providers of support services for people with physical disabilities. Accommodation in Porirua City is often two storied, while people in Wellington and the Hutt Valley fare better with single levelled accommodation. The issue is not the availability of a state house but its suitability/accessibility. A major problem is delays in getting home alterations - six months at minimum. Maintenance is also behind so that people may be living in accommodation of a poor standard. It was noted that this has implications for wellbeing/standards of health.
8.2.8 OTHER VULNERABLE POPULATIONS Young people Adolescents and young people were seen by many providers as a group that are at risk of not receiving adequate or appropriate care. Reasons included lack of information, money and confidentiality.
There was a perceived lack of clinical services for young people in Porirua, in areas such as sexual health and education. STDs were thought to be a significant problem among young people. Actual figures are not available, but this indicates poor sexual health and a lack of
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contraceptive/safe sex education. Antenatal care for adolescent mothers was seen as fragmented
Puketiro Centre was seen to be clogged up with long stay patients, and disabled adolescents were sometimes admitted into medical wards because they fall out of the children s age category.
Mental health and family planning services for youth were mentioned by several providers as areas of weakness.
Single parents Single parents are another group at risk. One provider argued that there was a reservoir of single parent families where family input and parenting skills are lacking and many are products of dysfunctional families themselves, so child based education programmes would be relevant. Nutrition and health education for children was also seen to be lacking.
New mothers and infants One public health provider felt there was a gap in service between midwife and Plunket - mothers may not be seen until 21 days after birth. Maternity services do not have knowledge of post neonates any more. Mothers used to stay in hospital after birth for 5 to 7 days, now it can be 12 to 24 hours, with a maximum of 72 hours unless there are complications. If there were any problems with breastfeeding there was no support. Mothers were missing Plunket services if not referred on by maternity services. Immunisation might be missed for children at 15 months because children are seen at one year of age by Plunket and not again until 18 months. Doctors might be part of the problem if they fail to follow up children who have been declined immunisation because of contraindications due to short-term illness such as a runny nose or wheezing. (A lot of mothers will request immunisations when they are visiting the doctor with a sick child). It would be good to link immunisations with well-child clinics so that children be presented for immunisations when they are well. (See also 1.2.10).
The elderly and housebound Several providers observed that the elderly and housebound need help reaching activities, and with meals and home care. Although hospice services are offered at Russell Kemp, at least one provider perceived hospice services as insufficient for the area and argued that because of this the medical ward at Kenepuru Hospital had beds taken up which could be used by acute medical patients.
One provider commented that a lot of elderly like professional help that is not personal.
Single elderly in isolation were believed to have difficulties. They frequently did not have many children around to support them, though this observation was more relevant for the Pakeha group because Maori and Pacific Island elderly tended to live in extended families. Women The availability of breast screening and mammography for women were seen as an area of major deficiency by one or two providers, and were argued to be just as important as cervical screening "because they are all big killers". The cost of mammography in Wellington is $70.
8.2.9 COMMUNITY-BASED SERVICES
Areas of extension or improvement in the delivery of community based services were suggested by several providers. These included: • more work in the community following up on such things as immunisation, diabetes, and contraception • more nursing hours to implement these and other programmes • more preventative measures and education is required in schools, by Plunket, churches etc • pharmacies should be becoming involved in the wider community, possibly in the form of home visits particularly to those with special needs.
Two providers commented on the possible benefits of extending the home visiting capacity of Plunket nurses. This theme was evident in many other comments, including those advocating the provision of more paediatric nurses and other community- and family-oriented staff.
One GP feared that hospitals are placing an emphasis on improving institution-based services to the detriment of primary and community services funded by the CHE.
8.2.10 HEALTH EDUCATION Education was given priority by a wide range of providers.
Asthma and diabetes Some GPs and Kenepuru health workers commented on asthma and diabetes educators and dietitians. One general practitioner pointed out that: "Two years ago there was a fullyfunded asthma nurse but the funding had now been stopped and there is now a dearth of coordinated community asthma education. Ora Toa and Whare Rapuroa organ/se groups." The diabetes educator was seen to be particularly relevant but there is only one in the area. Cost was seen to be a barrier to many clients.
Nutrition Poor nutrition was associated with obesity, iron deficiency among newborns, heart disease and dental problems. Nutrition was not always attributed to a monetary problem but could be caused by poor budgeting or eating the wrong kind of food. One provider thought it would be helpful for Dental Nurses or Nutritionists to visit schools. There have been some good measures by local schools with tuck shops changing to better foods, but fish and chip shops are very popular in this area."
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A community dietitian s work was seen as valuable, but more of this service was wanted. Population based education was seen as the way to address a lack of knowledge in the community.
Parenting skills Several providers felt that parenting skills should be emphasised. "We have a population of young women bringing up children alone. They require support and parenting training to give them skills to manage and organise their life and build their self-esteem." One provider commented that no parenting education was available on television. What they wanted to see is education on diet, developmental progress of children (physical and mental), safety, immunisation and mothers well-being.
Immunisation Immunisation was regarded as another issue requiring education in the community. Several GPs considered public health nursing and Plunket services should be strengthened. Mothers who did not have their child immunised and finally approached their GP already felt that they had failed as a parent. GPs must make a point of not judging them. Health professionals should not have a paternalistic attitude. Other groups to comment on immunisations were dental health providers, maternity service providers, Plunket and CHE staff.
Other areas for health education Kenepuru staff commented on the value of their paediatric nurse in serving the health and health education needs of families, but again saw the quantity of service available (one nurse) as inadequate.
Educational activities were also mentioned in relation to family planning and sex education.
8.2.11 DENTAL SERVICES Dental nurses miss out on seeing preschoolers where they could teach nutrition and dental hygiene routines. They are not at schools and a child s dental nurse may change often. Also relevant is that dental nurses only work school hours and have school holidays and are thus not available to children over these periods. Dental nurses are not trained for preventative dentistry such as reading X-rays.
The Dental Benefit system was seen to be archaic by many providers. It has not been updated since the 1940 s. The fees are too low and don t take into account the cost of modern materials and sterilisation techniques. There is no incentive to actively enrol adolescents - private adult patients end-up subsidising this service. Dental benefits helped get children into the dental service, but missed the mark by not providing treatment such as composite fillings and fissure sealants.
8.2.12 AFTER HOURS ACCESS At least one general practitioner and staff at Kenepuru mentioned attempts to extend after hours services. These included negotiations to establish an after hours general practice service
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in the centre of Porirua, and possible utilisation of Kenepuru s accident and emergency facility by GPs after hours (where they could also draw on other support facilities).
8.2.13 CLIENT RELATIONSHIPS Relationships with clients and a client-centred approach were very frequently mentioned by providers as important in providing a high quality, effective service. Key terms used by many providers were: user friendly friendly informal don t intimidate flexible family/whanau oriented address individual needs highly personalised service personal continuous care good customer relations listen explain things seek their trust holistic care lifestyle oriented try to educate give honest advice
Respondents felt that providers should not exclude anyone but needed to have an Ongoing commitment. Only a few providers highlighted confidentiality.
Maori providers emphasised the importance of their ability to offer a service to Maori by Maori, and working with a Maori kaupapa. Some other providers mentioned their ability to relate sympathetically or appropriately to Maori and Pacific Island clients, and/or having established a trusting relationship with them. Larger providers tended to mention having a multicultural work force (although in some instances they also mentioned the uneven participation of different cultural groups across the occupational levels of their organisation).
A few providers mentioned their ability to provide a woman-to-woman service.
One provider thought there was a control/power struggle still apparent amongst some service providers because they felt threatened and seemed unwilling to share important information, and that lack of rapport between the service provider and client could lead to barriers.
8.2.14 COMMUNICATION AND RELATIONSHIPS AMONG PROVIDERS A review of relationships with other services yielded positive comments about community nurses, Ora Toa, Age Concern, CCS, Attendant Care, Care and Craft group, churches, Pacifica and the Asthma Society.
Communication and liaison with other providers was an important issue with nearly half of the providers (12 of 28). Team work and rapport were seen to be important and one pharmacist remarked that their effectiveness, and the care of patients, was enhanced by cooperation received from local GPs and close liaison with others such as district, oncology, Plunket and domiciliary nurses. Maori health providers commented that communication with others involved in Maori health was good although time has been required to build up rapport and trust.
Not all providers were wholly positive about current relationships, however. Nearly a fifth commented on communication problems or deficiencies in interaction between providers.
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Coordination between service providers was considered a problem area by a mix of disability support and health service providers. One general practitioner commented that: "GPs are confused about where the interface with the disability services should occur. The information that was given to them was full ofjargon and too ponderous."
8.2.15 PERCEIVED SCOPE FOR IMPROVEMENT A few providers, including two GPs, felt that they currently provided all that could be expected, either because their service was already of high quality or because they felt they had no more capacity to expand. However, most clearly felt there was room for improvement.
Although accessibility was mentioned by a good number of providers as one of their strengths, it was also commonly mentioned as an area of weakness. Comments indicated that physical, financial, cultural and psychological aspects of access were sometimes difficult to separate. A need was recognised by many providers to offer more out-of-hours care. Others acknowledged that appointments were not always seen on time, perhaps indicating a need to look at waiting times. Education of customers needed greater investment although it is presently often restricted by lack of time, locality and opportunity. Access for people in real economic need was a barrier, but some felt that there are other alternative services available for these people.
Kenepuru staff identified a wide range of potential areas of enhancement. These included a Pacific Island diabetes educator, an asthma educator, an increase in physiotherapy, occupational therapy and speech therapy, more paediatric nurses, a paediatric social worker and dietitian services. A fuller use of operating and other facilities, and a 24 hour accident and emergency service were also identified. Improved gynaecological services, and a reduction in the 4-6 months waiting list for the orthopaedic ward and up to two years for grommets, were also sought.
More screening at surgery, to complement screening in schools, was proposed by one GP.
No providers thought there were areas of over servicing in Porirua City, or that there were services not adding value to the community.
8.2.16 IDENTIFIED PRIORITIES
Major health conditions Asthma, respiratory diseases, chest infections and smoking were seen as the biggest key group of health issues, identified by most of the GPs, all of the pharmacists and CHE groups interviewed. These conditions were followed by diabetes and glue ear/ear infections/hearing.
Other specific heath concerns mentioned were alcohol related diseases, hypertension, cancer, contact and non-contact skin diseases such as scabies and head lice, rheumatic fever, back problems and accidents.
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Health service development Providers suggested the following as priority health services improvements: • provision of preventative programmes and education • provision of culturally acceptable information • more accessibility of services • extension of Accident and Emergency services at Kenepuru Hospital • provision of services for people with chronic illnesses and people with disabilities and illness, or with multiple disabilities • lowering cost barriers to lower Group 3 Community Service Card holders • less cost barriers to the elderly • provision of mammography screening at Kenepum • provision of free clinics for adolescents, • reducing waiting lists for outpatients particularly ENT • provision of radiology and radiotherapy services at Kenepuru (high cancer rate in area) • provision of renal dialysis at Kenepuru • no decrease in services at Kenepuru • more female doctors trained in maternity • visits to schools and maraes for immunisation.
Disability support service development Providers were also asked to look at disability support services in their community more generally, and were asked to give their opinion on the priority services. These included: • provision and development of domiciliary/attendant care to keep people at home for as long as possible • ensuring that services and support are available for all people with disabilities • provision of acceptable and accessible information • provision of services for psychiatric disabled in the community • improved rehabilitation, acute services, long term stay, day programmes, and community development with real education in these programmes • establishment of a day hospital • provision of coordinated services • provision of units for respite care.
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9. Conclusion and recommendations
This chapter summarises the key features bearing on health and disability status and service provision in Porirua, and discusses their implications for service (and other) strategies to improve health and disability outcomes.
9.1 Key population and access features
9.1.1 A DIVERSE POPULATION Porirua has one of the most complex population mixes in the region. It is home to three major ethnic groups, and within its city boundaries encompasses both very high and very low socio- economic groups. It has a large Maori population, representing many different iwi. In addition, a large minority of Maori do not affiliate with any iwi. It has a large Pacific Island community, representing at least six Island groups. PakehafEuropeans, drawn from both extremes of the socio-economic spectrum, make up the third major group. South East Asian immigrants, many originally refugees, make up a small but significant fourth group, which is currently being augmented by refugee settlers from other regions. The diversity of need which accompanies this overall population mix poses a fundamental challenge to service providers.
9.1.2 AGE AND FAMILY SIZE The age and family structure of southern Porirua is distinctive. It has a large proportion of children and adolescents, with between 35-40% of Maori and Pacific Island people aged under 15 years. It also has an unusually large number of one-parent families. Balanced against this are traditions of extended family interaction and support among some of the ethnic groups present in Porirua. Hospital admission data for southern Porirua confirm a very high birth rate relative to the general WellingtonlWairarapa area. It is clear that the average household size is large compared with many other parts of the region. This has a number of possible health and disability-related implications. It may mean that the main caregiver (usually the mother) finds it difficult to give close attention to the needs of a particular child. It may also have implications for the high incidence of close- contact communicable diseases. While the statistics examined in this report do not allow us to estimate levels of overcrowding, this can be assumed to be a problem in some households . A large family and/or household, perhaps including grandparents and others, may also mean that the care of young children or support for members with a disability can be shared.
9.1.3 INCOME LEVELS In the three southern wards of Porirua, and in Porirua East, in particular, people are poorer than in many other parts of the region. They are more likely to be unemployed, and they generally have less disposable income for expenditure on health or other services. Cost was frequently cited as a barrier to services use.
The quality of the housing stock has not been evaluated for this report.
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Young people are in a particularly poor economic situation, with more than a third of Maori and Pacific Island youth aged under twenty-five being unemployed. Households here also have poor access to private transport, with up to a third of dwellings having no car. Transport difficulties are frequently cited in Porirua as limiting access to services. A telephone is available in only two thirds of Pacific Island homes, with implications for ease of contact with service providers and others.
9.1.4 CULTURAL BARRIERS Language-based communication problems are experienced by a significant minority of Pacific Island and South East Asian people, especially older people who have migrated to New Zealand as adults. Although staff in Kenepuru Hospital do from time to time utilise interpreter services, which are paid for by Capital Coast Health, this does not appear to occur in any systematic way. Many other providers also commented on inadequacies in this area. Wider cultural barriers are relevant to others for whom English language in itself may not be a problem. Service providers in Porirua widely recognise these obstacles, but are not always sure how to overcome them, or lack the skills or means to do so (for example, by providing staff of the same ethnic group, or by taking services to the client, in a familiar and culturally safe environment). When given the opportunity to express a preference on the matter, many consumers indicate that they would feel more comfortable approaching a service offered by people of their own ethnic community, or a service in which providers go to some trouble to meet them on their own ground, figuratively if not literally.
9.2 Key health issues
In assessing the health status of the people of Porirua, care is needed not to automatically take the available data - particularly hospital admissions - at face value. While, for lack of other indicators, hospital morbidity data are often used as indicators of health problems in particular regions, they tell us nothing directly about the much greater number of problems picked up at the primary health care level, or problems which simply are not presented to a GP or other health worker. Moreover, as noted in chapter 4, hospital records do not always reliably record the ethnicity of Maori, and possibly Pacific Island people. Accordingly, much of the existing data on these major groups in Porirua needs to be interpreted with caution.
9.2.1 Low OVERALL HEALTH STATUS What can be said, on the basis of the data reviewed in this report, is that a substantial number of conditions appear more common in southern Porirua than in other parts of WellingtonlWairarapa, that overall health status (as indicated by general measures such as age- standardised death rates) is lower than in many other areas, and that the differences are sufficiently systematic to be a serious cause of concern. This applies to all ethnic groups, including the (largely low socio-economic status) European population in southern Porirua. Some major features are set out below.
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9.2.2 CHILD HEARING LOSS Child hearing loss is a major problem in Porirua. While detection and primary treatment of ear infections is a vital area of activity, equally significant problems have occurred at a later stage, with very long waiting times for insertion of grommets. Central RHA has purchased additional services to clear existing lists of children waiting for the minor surgery required for grommets. However, long waiting lists for clinical assessment also occur, and pose an equal obstacle to improvements in child health in this area. Weaknesses in the provision of both assessment and surgery need to be addressed.
9.2.3 COMMUNICABLE DISEASE Vaccine preventable and other close contact communicable disease rates are high. Factors relevant to these conditions include low immunisation rates, overcrowding and other living- standard and lifestyle-related issues. More, and better targeted health education, extension of health services in certain areas, better coordination of services, client tracking and a variety of other measures can make an impact on immunisation levels. However, socio-economic conditions which cannot be directly addressed by health service provision also have an important bearing on non-vaccine-preventable conditions.
9.2.4 YOUTH NEEDS Health needs among the large adolescent population in Porirua have a number of focal points, including drug and alcohol issues, related and other mental health problems, sexual health and family planning.
9.2.5 DIABETES Southern Porirua has a high incidence of diabetes, and this is more likely than in other areas to result in admission to hospital. Given that we know its incidence is high among Pacific Island people elsewhere, their relatively low level of self-reporting of diabetes in our household survey data suggests the possibility of a higher than average level of undiagnosed illness in this community. (The small sample numbers involved make this a tentative conclusion only, but it is in keeping with other indicative evidence regarding awareness of factors affecting health and services which can be accessed for assessment and treatment).
9.2.6 ALCOHOL RELATED PROBLEMS Admission rates for alcohol-related conditions are very high, and alcohol abuse can underlie a range of other physical, psychological and social problems, including intentional and unintentional injury. Head and other injuries relating to motor vehicle and other accidents in turn impact on both health and disability service needs.
9.2.7 ASTHMA Asthma is a very common problem in southern Porirua, and mortality rates and other evidence indicate it is not well controlled in a significant minority of cases.
9.2.8 SMOKING Smoking stands out as a major health risk factor in Porirua. There is strong evidence that rates are well above those elsewhere. It is very common across all ethnic groups, but is especially so among Maori, where two thirds of all households contain at least one smoker.
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Given that smoking is strongly linked with asthma, other respiratory disease, heart disease and some cancers, it is a factor which must be addressed if significant inroads are to be made into the incidence of a range of conditions.
9.2.9 OTHER LIFESTYLE FACTORS Knowledge about lifestyle and nutrition-related factors affecting health appears weak in some areas, among some population groups. This includes factors affecting the health of pregnant women and their children (especially, judging from survey results, among Maori in relation to smoking), the onset of asthma attacks, and heart disease.
9.3 Service provision - health: the current situation
9.3.1 LEVEL AND TYPE OF PRIMARY HEALTHCARE The review of services available for people in Porirua indicated that the level of service provision in many primary health areas is generally acceptable relative to its population size. The per capita provision of GPs is slightly below the mean for the region, but not so dramatically as to suggest that the community is under-serviced. (Employment of practice nurses by GPs, however, is noticeably lower than the regional average.) The number of Plunket nurses, public health nurses and others appears in keeping with levels provided in comparably sized communities. However, observations such as these - made in terms of gross volumes of providers and population - take no account of the particular nature of the community or the character of the services currently provided.
Low utilisation of some services The low socio-economic status of the community, the age structure and other demographic features, and its multi-cultural character all impact on access to and utilisation of the services available. Low utilisation of services, whether from cost, cultural or other reasons, is indicated by benefit claims. While expenditure on GMS in southern Porirua is slightly higher than the regional average, many other indicators of service use are lower. Practice nurse subsidies are 21% lower than the regional average, immunisation benefits 11% lower, pharmaceutical benefits 31% lower, and maternity benefits 8% lower. Utilisation of dental services is also low, even where these are free. More than half of Maori and three quarters of Pacific Island pre-school children do not enrol with the school dental service until first going to school. Nor do Pacific Island and Maori teenagers readily access the general dental benefit scheme. An apparently high level of non-attendance for appointments was reported by a major provider of mother and child care.
Appropriateness of service delivery Twenty years ago, in a benchmark study of the community, George Salmond argued that the failure of some key providers of maternal and child health services in Porirua to reach and meet the needs of many poorer, and Maori and Pacific Island people, originated in the very character and orientation (essentially middle class and monocultural) of the provider
This may reflect high use of the Community Services Card.
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organisations. Although significant change has occurred in Porirua over the last two decades, it is sobering to hear echoes of Salmond s findings in the results of the present study. There is a negligible Pacific Island presence in the health services in Porirua, and only limited Maori representation. There are no GPs of either group. This is not to imply that current service providers are insensitive to cultural, language and other barriers to service use. On the contrary, many are acutely aware of these factors, -but lack the means, characteristics or knowledge to overcome them. When providers have the time, knowledge and skills to take services into the community, homes or other places where people feel comfortable consulting and being consulted, there are strong indications that they are well received and effective. Where Maori have been resourced to provide quality services to other Maori this has been particularly welcomed and effective. A Maori mental health service operates in Porirua Hospital, and a Maori unit participates in provision of Public health services in Porirua. However, there is currently only one Maori general primary health/health promotion service, based at Takapuwahia marae. This does not cater to the large Maori population in Porirua East. As noted, Pacific Island people are even more thinly provided with services identifying specifically with that community.
Young people s needs Youth are a further population group whose needs are recognised but not adequately met. Both this and other needs assessment project findings2 indicate that youth are frequently poorly catered for by the net of existing services, which are usually either targeted to other groups, or too generally pitched to the community as a whole for their particular needs.
9.3.2 EXACERBATING FACTORS Exacerbating problems associated with the nature of the service or service environment, are issues of knowledge, cost and transport.
Knowledge about services Knowledge about services which can be accessed to address particular needs is weak in some areas and among some groups. A general confusion about the situation in relation to emergency services is noted below. Knowledge about primary services, especially those addressing particular areas such as alcohol and drug problems, or sexual health, is also variable. Language, cultural, educational and other socio-economic factors compound to make some groups less well-informed than others. Pacific Island people in Porirua in particular appear less aware than other groups of who they can approach for specific health and disability support needs. The same may also be true of refugee settlers and their families. Cost The household survey, focus groups and input from community groups all identified the cost of general practitioner care and prescription items as major barriers to access to care. Providers also identified the cost of services as being an issue, with many identifying the group just above the CSC income cut-off point as being particularly at risk.
Salmond. G C (1975) Maternal and infant care in Wellington - a health care consumer study, Department of Health, Wellington. 2 Youth needs assessment project summary report, in preparation. Central Regional Health Authority.
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While they need to be interpreted with caution, per capita expenditure on pharmaceuticals and uptake of other benefits appear to support the view that cost is a very real barrier to service utilisation in southern Porirua. Moreover, the general perception that care is too expensive seems to have influenced views about services which are actually provided without charge. Hence a small proportion of those interviewed during the household survey identified free services such as Plunket as being too costly.
Transport The relatively high proportion of households without private transport, the cost of alternatives (often taxis), the distance of some areas, especially parts of Porirua East, from the centre, and the time, distance and cost involved in attending services in Wellington all combine to make transport a major issue in Porirua. While some limited assistance, in the form of free or subsidised van transport, has been available to health and disability support service users, the recent withdrawal of the Porirua Health Project van service has raised the profile of this issue further.
9.3.3 SPECIFIC AREAS IN WHICH THE CURRENT LEVEL OF PROVISION HAS BEEN QUESTIONED Having made the above points about general barriers to accessing services, it is also important to acknowledge that there are areas, including aspects of health education and promotion and some specialist services, in which the level of provision appears inadequate, or has been highlighted as such by groups.
Asthma services Diagnosis and treatment of asthma is currently provided through primary health care services. with backup treatment at Kenepuru Hospital. Existing education and advice services are provided by the Asthma Society (delivered by an educator responsible for the wider Wellington area), and through Ora Toa. This level of asthma education is low relative to the size of the problem in Porirua. Providers have pointed to (and other evidence supports) the particular need for additional services for patients with poorly managed asthma.
Diabetes services There is currently one FTE nurse educator serving the needs of Porirua. Providers and others have indicated that this level of provision is inadequate relative to the incidence of diabetes and the level of need for information and education in the local population. Sexual health services Sexual health services have been lacking in Porirua. Relative to the size and composition of the population this has been important area of under-servicing. This is in process of being corrected, with the introduction in 1994 of a CHE-provided clinic, described in more detail later in this chapter.
Specialist services An examination of waiting times for specialist assessment and treatment at Kenepuru Hospital reveals a situation in which unacceptably long periods elapse before some services can be
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accessed by non-urgent patients. One of the most serious in terms of likely permanent effects on health and life chances, has been ear, nose and throat services which need to be accessed for specialist hearing assessment. (Assessment is carried out at Kenepuru, and insertion of grommets in cases where this is required, is carried out at Wellington hospital). The waiting list for appointments at Kenepuru has been over two years long. A blitz on grommet waiting lists, initiated by Central RHA earlier in 1994, is eliminating the current waiting lists for surgery, but there is a need to set in place longer term solutions for the provision of both assessment and surgery within reasonable time periods. Other areas in which there is scope to examine the appropriateness of current levels of provision include ophthalmology, gynaecology and rheumatology.
After-hours and accident and emergency services Provision of urgent out of hours and accident and emergency services were commonly mentioned as an issue in the course of this study. There are a number of points of confusion which surround this issue however. The first line of urgent treatment for a community is normally the GP. After-hours medical attention has been available through several GP roster systems operated in different parts of the city. Some difficulties have been reported with answering services and multiple calls before contact with the duty doctor can be made, but there is no indication of the system being notably deficient relative to provision elsewhere. With the creation of a central city after- hours surgery, due to open by mid 1994, southern Porirua will gain a centrally located after- hours facility adjacent to the urgent pharmacy. It is estimated that the service will be approached for an average of around 12 - 15 consultations per night. For the smaller number of very serious emergencies which may be experienced after hours people require direct access to hospital services. Access to ambulance services appears to be good, with one of the region s ambulance stations located in Porirua East. Acute medical admissions (for example to cope with severe asthma attacks or diabetic coma) are available 24 hours per day at Kenepuru a fact of which many families, groups and organisations in the community are unaware. Serious accidents and medical emergencies do require treatment at Wellington hospital outside weekday working hours. This is obviously less convenient for Porirua residents than treatment at Kenepuru, but the time involved in reaching Wellington hospital by ambulance is not unreasonable relative to that experienced by many other communities in the Central region. A more significant issue is the difficulty and expense reported in returning home independently after treatment at Wellington.
9.4 A strategy for improving health status
This section outlines the action Central RHA intends to take in response to the health issues that have been identified. It forms a three year strategy to be implemented between 1994/95 and 1996/97. A timetable for implementing the strategy is set out in the following section.
There had previously been interest expressed by Kenepuru in general practitioners using the hospital A and E department after hours, but this option was not taken up by general practitioners. Both options would involve some patients in a greater local travel time than previously to access alter-hours treatment.
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9.4.1 THE FRAMEWORK For the most part the issues identified by this project as requiring attention are not susceptible to easy, single initiative solutions. They are likely to be resolved only by concerted, well coordinated actions in a number of areas. The strategies proposed as a result of this report draw strongly on existing services. They also involve the input of new resources. These new resources are aimed partly at the purchase of additional service volumes in key areas, but more centrally, at purchasing primary health care environments and arrangements within which existing providers can more effectively deliver services, and in which consumers feel more motivated and enabled than at present to utilise those services. It is also necessary to acknowledge that there are areas with a strong bearing on health status and service utilisation in Porirua in which Central RHA does not have a mandate to act directly. These include the provision or subsidy of transport for non-emergency purposes, and some aspects of public health. In these areas Central RHA will actively seek the cooperation of other agencies with a legitimate interest or role, including the Porirua City Council and the Public Health Commission, and will work with them to coordinate steps they may take with those of Central RHA.
9.4.2 A MAORI PRIMARY HEALTH SERVICE FOR PORIRUA EAST In 1994/95, Central RHA will seek to purchase a community-based primary health service (or services) for Maori in Porirua East. The service will have the support of local marae, but may be based elsewhere in the community. It must be provided in a culturally appropriate manner, and have the capacity to serve Maori who are not affiliated with an iwi or a marae, as well as those who are. It is envisaged that the service will have a whanau health focus. Although likely to start on a small scale, the service could expand its range of services and activities over two to three years. Services initially sought would cover the following areas. Key well child components of health education and promotion, including: • immunisation • preschool dental health education and enrolment • hearing testing and education.
Adult services will include: • lifestyle skills and health education, including smoking • asthma management (for themselves and children) • women s health issues • parenting education • maternity care • diabetes awareness and management. Provision has been made elsewhere in this plan for additional training for staff in asthma and diabetes education in 1995/96 and 1996/97 respectively. Good liaison and cooperation with other general and specialist services will be essential. The RHA will also review the feasibility of providing some adolescent health services targeted specifically to Maori youth. The exact mix and focus of services will be informed by the outcome and recommendations of a regional youth needs project due to report later in 1994.
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9.4.3 PACIFIC ISLAND PRIMARY HEALTHCARE SERVICES Recognising that the Pacific Island community has expressed a need for assistance with proposal development, Central RHA will purchase a workshop or workshops for potential provider groups in Porirua in 1994/95. In the meantime, Central RHA has negotiated to purchase a Pacific Island Well Child Health Project from the Regional Public Health Service (Hutt Valley Health Corporation). The project was developed in consultation with Pacific Island communities and includes provision for the training of community health workers from the six Pacific Island groups. Hearing loss and immunisation are among the first health issues to be addressed. The project will cover the Wellington region, but a significant component of the activity will be undertaken in Porirua East. Central RHA will also allocate a resource specifically for purchase of a community-based primary health service (or services) for Pacific Island people in Porirua in 1995/96. The service/s should have the support of all major Pacific Island communities. Services must be provided in a manner appropriate to all Island groups and to Island-born and New Zealand- born Pacific Island people. Key well child components of health education and promotion will include: • immunisation • hearing • preschool dental care and enrolment.
Adult services may include: • lifestyle issues (including nutrition and weight control) • diabetes awareness and management • asthma management (for themselves and children) • women s health issues • maternity care • parenting skills.
Provision has been made elsewhere in this plan for additional training for staff in asthma and diabetes education in 1995/96 and 1996/97 respectively. Good liaison and cooperation with other general and specialist services will be essential. Central RHA will also review the feasibility of providing some adolescent health services targeted specifically to Pacific Island youth. The exact mix and focus of services will be informed by the outcome and recommendations of a regional youth needs project due to report later in 1994.
9.4.4 ASSISTING NEW SETTLERS (REFUGEE MIGRANTS AND THEIR FAMILIES) Although making up a small part of the overall community, the new settler population (estimated at up to 500 - 600) is characterised by significant physical and mental health problems, in some cases compounded by difficulties in utilising services effectively. In 1994/95 Central RHA will explore with new settler organisations in Porirua, and elsewhere in the Wellington region, and with key providers, strategies for further assisting them to meet
113 their health needs. A resource equivalent to a part-time nurse educator will tentatively be allocated for commitment in 1995/96.
9.4.5 RELATED INITIATIVES The planning of a family centre in Porirua East, funded by the Community Funding Agency, has been followed closely by Central RI-IA. The centre, intended to serve all ethnic groups, will be managed by a community based group, and will have education, lifestyle, parenting and health components. Core health services that it is intended be provided from the centre are family planning, well child and public health nursing services. These may be arranged through existing RHA contracts with providers. However, until negotiations have proceeded further it is not possible to comment in detail on the final range of services and the supporting arrangements. Liaison will be maintained with relevant parties to ensure that initiatives are coordinated and complementary.
9.4.6 SERVICES IN SCHOOLS Preschools and schools provide an important context within which to carry out hearing and other screening, monitor health status generally, provide health education and advice, and provide a setting for some direct treatment. Schools in the area have an active interest in their children s health. In 1994/95 Central RHA will hold discussions with the Public Health Commission to identify areas of possible cooperation within the framework of the Commission s proposed Healthy Schools programme.
9.4.7 YOUTH SERVICES The services presently (part) targeted to adolescents include family planning and the forthcoming sexual health service. Targeted mental health and alcohol and drug services are lacking. There is not as yet a comprehensive or holistic service which aims to meet all the needs of young people in a non-threatening atmosphere. Central RHA will explore the need for and feasibility of a one stop shop health service located within the city centre. 2 Rather than being a new service, it is envisaged that this will be linked to and host existing services and utilise existing providers. Services may include: • advice on general health issues, including dental health • advice on sexual health issues and/or referral to appropriate service (sexual health service, family planning) • advice on general lifestyle issues, including smoking
It should also provide an environment for the delivery of or maintain strong links with, alcohol and drug, and mental health services.
The centre will be one of six pilots established by Government in targeted communities. One other, in Motueka, falls within the Central region. 2 This proposal has been guided in part by initial findings of a Youth Needs Assessment project sponsored jointly by the Central RI-IA and the Ministry of Youth Affairs. The further development of this and other proposals for addressing youth needs in Porirua will be informed by the full findings and recommendations of the project, which is due to report in mid 1994.
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An appropriate cultural mix of staff would be required. The service would not necessarily be open full-time, but would provide sufficient, and appropriately timed, opening hours to meet the needs of the target population. Providers would be expected to have very close relationships with other services providing primary health care services to adolescents: GPs, Family Planning Association and the new sexual health service. Services will be expected to commence from Year 2.
9.4.8 GENERAL ACCESS ISSUES
Knowledge about services While other initiatives set out in this report will provide important channels for conveying accurate information about services to the community, there is also a need for a central source of service information for the community. Several agencies, including the Porirua City Council and the Citizens Advice Bureau, provide a partial service in this area, but there appears to be scope for a more systematic, better publicised information source, probably oriented to providing information through a number of media, including telephone and print. In the first year Central RHA will seek discussions with the above agencies, the Community Health Group and other interested potential providers, with the objective of identifying a strategy for providing an enhanced health and disability support service information system in Porirua.
Information needs The need for improved information about health services has already been identified as a priority. This information needs to indicate the range of charges which do apply, the services which are available to users without charge, and the assistance available to those who do not have the means to pay immediately necessary services.
Accessible services The modest increase in the range of primary health care services proposed in this report (including a Maori community health service in Porirua East, support for Pacific Island health care providers and an increase in asthma education service), while not intended as substitutes for existing services, will increase the opportunities of residents to seek early assistance and better manage their health problems without fear of fee barriers.
User charges regime The present user charges regime reflects Government policy. Central RHA has scope to alter the regime only if it: has the approval of the Minister of Health can generate sufficient savings elsewhere in the system. Some further review and refinement may be required in order to target services more efficiently to those in greatest need. At a regional level, Central RHA is implementing programmes to manage demand driven primary health care expenditure (especially pharmaceuticals, laboratory services and maternity services). During the next year:
115 • we will seek proposals from local GPs and pharmacists on efficiencies which might be made in order to reduce the cost of access to primary medical care • we will invite Promed, and other appropriately positioned agencies, to offer their advice on, and expressions of interest in, arrangements which would allow additional support to be provided by Central RHA in meeting the costs of the lowest income users of primary services in Porirua.
Transport Initiatives set out elsewhere in this chapter should have the effect of lessening the impact of transport availability on service use locally, especially in Porirua East. To help address remaining difficulties, Central RHA will discuss strategies to improve transport availability to enable residents to access health and disability support services with the Porirua City Council and the Porirua Community Health Group. Direct purchase of non- emergency transport, however, is not a core service activity in which R.HA can become involved.
9.4.9 GENERAL PRACTITIONER QUALITY FACILITATION: IMMUNISATION COVERAGE Central RHA has recently initiated a project to support the delivery of clinical preventative services by GPs throughout the region, including Porirua City. The quality facilitation initiative will focus initially on improving immunisation coverage in the region. The initiative involves assistance to general practices within localities such as Porirua to join in local general practitioner networks . Each network will employ a facilitator (generally an experienced practice nurse) to assist each practice to establish an up-to-date age/sex register of patients; identify under-immunised children using the register; operate an efficient recall system and conduct regular audits of immunisation coverage and recall procedures. The facilitator will also feed back comparative performance information to network practices; assist them to make changes as required; coordinate the network with other local providers such as the CHE to promote immunisation in the community as well as assist in tracking and offering immunisation to children who have missed recalls. In Porirua Central RHA hopes to contract with a single network representing a high proportion of local general practitioners. The cost of employing a half-time nurse coordinator/facilitator will be subsidised by Central RHA. The level of subsidy will depend on the network size and other factors. Central RHA hopes to open negotiations with Porirua practices in mid 1994, with the expectation that an operational network will be in place by the end of 1994. In extending the focus of this work beyond immunisation, priority will be given, in the case of Porirua, to improved monitoring of clients with diabetes, or at risk of developing diabetes.
9.4.10 ASTHMA
Asthma educator It is proposed to purchase an additional asthma educator, to assist those whose asthma is particularly severe and/or difficult to manage. The service is to be available via referral from other health professionals, with community and self referrals also being accepted. Although
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one full time equivalent position would be involved, two or more part-time workers may be employed to ensure acceptability to recipient groups. To avoid fragmentation of services, it is envisaged that the new service be provided by one Of the existing providers of related services, such as Capital Coast Health or the Asthma Society. The service would be located in Porirua, but provided from a range of sites, including medical centres and community health centres, in order to reach those in greatest need. This service will be provided in the first year, dependent on resources being made available in other areas.
Community asthma education Asthma education will also be purchased as a component of broader, community based health services including Pacific Island and Maori health services. Such components will be added in the second or third years, when organisations are well established and are in a position to broadentheir range of services. Services are likely to include: •identification and modification of risk factors • information on asthma and advice on its management • liaison and co-ordination with other providers of related services
Discussions will be held with relevant groups during the first year with a view to establishing the services in the time frame suggested above. Provision will be made for special training costs. (Ongoing staff and training costs will be built into proposals for community based services). Both proposals require integration with broader services. In particular, it is envisaged that the asthma educator work with, or be part of, medical or treatment services, while community asthma education services be an integral part of new community based services. Any asthma education services purchased by Central RHA must be well coordinated and work closely together.
9.4. 11 SMOKING The Central RHA proposes to initiate strategies aimed at reducing the prevalence of smoking, especially among youth, in households with asthmatics, during pregnancy and among young mothers. It will liaise closely with the Public Health Service, other providers, and non- provider local organisations in further developing and implementing these strategies.
General practitioners and other primary care providers Central RHA will purchase an enhanced level of smoking cessation advice and counselling from GPs and other primary care providers in the locality. This will include assistance with the installation and maintenance of patient records that enable smoking status to be recorded and intervention to be monitored. This requires bringup systems that prompt practices to provide smoking cessation services opportunistically, and age/sex registers that allow smokers to be proactively identified and monitored. Such records systems also allow practices to carry out audits of their patient smoking rates and intervention activities at regular intervals.
The relationship of this activity to that of the GP network facilitator is noted. The improvement and use of age/sex registers has many applications in improving health status.
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Primary health care providers may also require additional training in smoking cessation techniques, and support materials such as smoking cessation kits. It is not proposed to subsidise nicotine replacement therapy or referral to intensive smoking cessation clinics.
Smoking coordinator/educator As well as assistance to people who are already smokers to quit, primary health care providers and health promoters will be supported to educate young people not to start. There is much evidence that most smokers are recruited as teenagers, and if initiation can be postponed, smoking rates in adulthood will decline dramatically. This will be achieved by purchasing a full time tobacco coordinator or advocate. Central RHA will approach key local organisations with a view to seeking joint funding of this position. The position would involve acting as the focal point for tobacco control in Porirua. It would involve collecting data on all aspects of the problem and existing services, communicating this information to relevant stakeholders and the community at large, monitoring the quality of the community s efforts to control the problem, and generally advocating and inspiring what could become a campaign against smoking in the community.
Smoke free policies In addition to these purchase recommendations, Central RHA will encourage major local organisations to set an example of a smokefree workplace and encourage other major employers to do so. Encouragement should also be given to the smokefree activities of the CFIE (ie Hutt Valley Health) Public Health Unit, including in particular surveys of retail outlets and prosecutions as necessary for infringement of the law regarding sales to minors. These policies will require I FTE anti smoking coordinator and a 0.5 FTE smoking cessation advisor for the GP network and other primary care providers (to facilitate and coordinate smoking cessation services and assist with audits and feedback of comparative performance information). The latter position would align with the GP network immunisation coordinator. The cost will include non-personnel expenses such as health education materials, but it is not intended to subsidise the actual investment in hardware and software by primary care providers, and it is also anticipated that assistance with publicity would be available from key local bodies. The above initiatives will be established in Year 1, with the first full year of operation being Year 2.
9.4.12 DIABETES Central RHA will continue to purchase the current CHE-based diabetes education service (and associated dietetic service). The level and type of provision of this service will be reviewed in Year 1 in conjunction with a consideration of the capacity of community-based services to enter this field. (See below). Additional, community-based diabetes education will be purchased from Maori and Pacific Island health services as these organisations become more established and are able to extend their range of activities. Services may be provided by a mix of professionals and trained local people. Services are expected to include:
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• awareness raising as regards symptoms, with a view to improving detection • advise on modification of risk factors • screening for at risk adults • advice on the management of non-insulin diabetes, and in particular, on nutrition and diet • liaison and co-ordination with other providers of services, including hospital specialists, community health services and the Diabetes Society.
It is envisaged that services will be provided from community health bases and in other locations as appropriate. Community based services will be provided from Year 2 or 3 depending on the readiness of community based organisations. Provision will be made for special training costs. (Ongoing staff and training costs will be built into proposals for community based services). Following an initial focus on immunisation, the work of the GP network facilitator in Year 2 will include an emphasis on the development and use of age/sex registers and related systems for educating and monitoring clients with diabetes or at risk of developing diabetes.
9.4.13 FAMILY PLANNING AND SEXUAL HEALTH SERVICES The service provided by the Family Planning Association in Porirua is generally perceived positively by consumers and other providers. While they have gone to some lengths to make their service accessible, there are other factors which nevertheless inhibit accessing by some groups. Youth of all ethnic groups and Pacific Island people of all ages appear to face particular access problems. The initiatives set out in this chapter will provide additional, acceptable channels through which family planning services may be offered. Specialist sexual health services have previously been unavailable in Porirua. To fill this gap the Central RHA has recently announced the purchase of a clinic from Capital Coast Health, to be provided in Porirua from May. At the time of writing the service is being established with the Family Planning office in central Porirua. This service too faces a challenge to find ways of accessing young people and particular groups who for reasons of culture or other reasons are least likely to approach them. Both the above services would play key roles in the proposed integrated youth service.
9.4.14 MATERNITY SERVICES Maternity services throughout New Zealand are the subject of an inter-RHA review. A consultants report setting Out policy issues and recommendations has been released , and the project team is working toward a final report and implementation plan. Pending this, detailed proposals affecting maternity services for Porirua have not been attempted in this report. However, it should be noted that principles for effective and appropriate delivery of services that are set out in the First Steps report are reflected in a number of general
Coopers and Lybrand (1993) First steps towards an integrated maternity services framework, Regional Health Authorities
119 recommendations in this report. Our proposals for inclusion of maternity services among those provided by or through Maori and Pacific Island primary health services (9.4.2 and 9.4.3) are among these. The findings of the Porirua project have been made available to Central RI-IA staff involved in the review.
9.4.15 DENTAL HEALTH The decline in utilisation of services, and consequent poor dental health among many adolescents and adults, needs to be addressed by increasing awareness of the services that are available, and promoting the importance and consequences of good dental health during adolescent and adult years. While purchase of discrete new services is not envisioned, strategies which will be promoted include the following. Dental health will be included in the health promotion and education component of the Maori and Pacific Island community based services. Kohanga Reo, marae and Plunket can make also an important impact in promoting enrolment in school dental services before children starts school. We will seek the Capital Coast Health s cooperation in feeding back to early childhood education centres participation rates by type of pre-school centre (kohanga reo, kindergarten etc). Promotion and reminders to utilise dental benefit scheme should be incorporated in the healthy schools programme (Public Health Commission). Other community based services targeting Maori and Pacific Island groups will be encouraged to include dental health promotion and education in their programmes. Central RI-IA will continue to purchase a dental service for adults at the current levels.
9.4.16 SPECIALIST SERVICES - EAR, NOSE AND THROAT Hearing problems among children will be addressed at one level through more extensive testing, monitoring and follow-up services provided through the primary health care strategies described above. However, the effectiveness of these strategies will be severely limited if referral services are available only after a wait of many months. In line with its 1994/95 purchase plan, Central RHA will negotiate to purchase additional specialist assessments for Porirua residents.
9.4.17 OTHER SPECIALIST SERVICES Central RHA will continue to purchase at least the level and range of services currently available at Kenepuru Hospital. It will ask Capital Coast Health and Hutt Valley Health to explore and report on the possibility of increasing the level and range of secondary services provided in Porirua. Services which need to be considered include: • ENT services (increase, as above) • ophthalmology services (increase) • gynaecology surgery (consider introduction) • rheumatology clinic (consider increase).
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The cost and exact timing of the above will be determined in consultation with Capital Coast. It is not envisaged that overall levels of CHE services will be increased. Rather, some existing services may be provided from a different location.
9.4.18 DIAGNOSTIC IMAGING SERVICES Diagnostic imaging services are an important adjunct to GP diagnosis and management. More affordable, accessible diagnostic imaging services are required for Porirua residents. The shape of any new purchasing arrangements will be determined in Year 2 in the context of an overall Central region review of purchase arrangements for diagnostic imaging services scheduled for 1994/95.
9.4.19 EMERGENCY AFTER-HOURS ACCIDENT AND MEDICAL SERVICES As noted elsewhere in this report, there have been frequent calls for emergency accident services at Kenepuru to be extended. This has come through as an issue in the feedback obtained during this study. It has been given careful consideration in relation to the strength of concern in the community, the current development of an after-hours general practice clinic in central Porirua, the cost of extending the Kenepuru service relative to the cost of other possible initiatives, and its likely impact on the health of the community relative to the impact of other possible initiatives. While acknowledging the genuine concern of the community, Central RHA does not believe that an extension of emergency accident services at Kenepuru can be justified relative to the factors listed above, especially as, even with 24 hour provision of services equal to those currently provided during weekday working hours, some serious cases would still need to be transferred on to Wellington hospital. The emergency medical services offered at Kenepuru Hospital should continue at their current level. There is a need to try to further clarify for the public, and even some service providers, what is and what is not offered at Kenepuru on a twenty-four hour basis. Survey findings and information gathered from other sources shows that some members of the community believe that they can go to Kenepuru at any hour for accident treatment, while others know that they cannot - but are unaware that emergency medical services are available. Publicising what is available is in the first instance a task for Kenepuru Hospital, but others can also help. Central RHA will discuss with Capital Coast Health, the Porirua Community Health Group and Porirua City Council staff ways in which accurate information can be disseminated more effectively.
121 9.5 Timetable and resources - health services
Maori primary health service(s) Porirua $100,000 East Workshop(s) for potential primary $10,000 Pacific Island service providers Detailed assessment of new settler No cost in Year I needs General practice facilitator/coordinator $10, 000 (subsidy on 0.5 FTE from (immunisation) January 1995) Smoking cessation advisor for GP $12,500 (0.5 FTE plus some non- network and other primary care personnel costs from January 1995) providers Anti-smoking community $25,000 (half share of 1 FTE, with coordinator/educator remainder to be negotiated with local orgs.) Asthma educator $60,000 (1 FTE salary plus resources and running costs) Additional ENT specialist services $30,000 (based on approximately 90 new assessments per year) Review levels of provision of No cost in Year 1 gynaecology, ophthalmology and rheumatology services Sexual health services Cost included in contract ($195,816) with Capital Coast for additional sexual health services. Assessment of requirements for No cost in Year 1 establishing a youth health service Community needs for health service No cost to Central RHA information - joint assessment with local agencies TOTAL YEAR ONE 500
1 Not inclusive of the cost of sexual health services clinic or other services to be determined.
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Year Two Health initiative Resource requirement Maori primary health service(s)- $100,000 Porirua East Pacific Island primary health $100,000 service(s) New settler initiative $25,000 (one .5 FTE)
General practice $20, 000 (subsidy on 0.5 FTE) facilitator/coordinator (immunisation and diabetes)
Smoking cessation advisor - GP $25,000 (0.5 FTE plus costs) network/other primary care providers
Anti-smoking coordinator/educator $25,000 (half share of 1 FTE)
Asthma educator $60,000 (1 FTE salary and costs)
Training for community based $20,000 asthma services
Additional ENT specialist services $30,000
Gynaecology, ophthalmology and To be determined in Year 1 rheumatology services
Sexual health services Cost included in wider contract with Capital-Coast
Youth health service(s) $40,000 Review purchasing arrangements No cost in Year 2. for diagnostic imaging services (in light of regional needs review findings)
TOTAL YEAR TWO $455 Not inclusive of the cost of sexual health services clinic or other services to be determined. 23 I I
...... Year Three Health initiative Resource requirement
Maori primary health service(s) - $100000 Porirua East
Pacific Island primary health $100,000 service(s)
New settler initiative $25,000 (one 0.5 FTE) General practice $20, 000 (subsidy on 0.5 FTE) facilitator/coordinator (immunisation and diabetes) Smoking cessation advisor - GP $25,000 (0.5 FTE plus costs) network/other primary care providers Anti-smoking coordinator/educator $25,000 (half share of 1 FTE) Asthma educator $60,000 (1 FTE salary and costs) Training for community based $20,000 diabetes services Additional ENT specialist services $30,000 Gynaecology, ophthalmology and To be determined in Year 1 rheumatology services Sexual health services Cost incorporated in wider contract with Capital Coast Health Youth health service(s) $40,000 Diagnostic imaging services To be determined in Year 2
TOTAL YEAR THREE $455,000
Not inclusive of the cost of sexual health services clinic or other services to be determined.
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9.6 Key disability service provision issues
While the range of services available to Porirua residents is similar to that provided in other communities, there are distinctive features, relating to the socio-economic status and location of the community, its demographic mix and the presence of a major psychiatric institution, which mean particular service needs are highlighted. Despite the paucity of good data, a number of key issues have been identified. Some of these overlap with issues identified as important for the Porirua population generally, while others are distinctive to the disability sector. • Large Maori and Pacific Island communities, and the presence of other non-European groups, mean that the cultural appropriateness of services, and cultural and language barriers to accessing information and services, are particularly important. • Low socio-economic status compounds the difficulties and barriers which people with disabilities face relative to others. As noted, in southern Porirua incomes are low and unemployment high. • The presence in Porirua of a major psychiatric hospital and the needs of those discharged into the local community mean that there are some distinctive needs in this area. • Transport and other communication difficulties (eg access to a telephone) facing the general community have even more serious implications for people with disabilities. • Cost was frequently mentioned as a general barrier to using a range of services. Major issues arising from the needs assessment are summarised below.
9.6.1 INFORMATION The limits or unavailability of information were consistently recognised by all stakeholder groups consulted during the course of the project as a key disability issue. Users, or potential users of disability support services want information presented in language that is clear and jargon-free. There is need for information about service availability, including how to access services and what they cost. There is also need for information on how well a service may meet cultural needs. Purchasers have information needs related to more accurate information about the users or potential users. Not only do they need to know about users expressed needs, preferences and priorities but they also need to know about the range of disability services currently available including access, price, volume, quality and uptake. Further they need to be able to place specific disability issues in the context of wider disability issues.
9.6.2 TRANSPORT In Porirua, there are particular issues around access to transport for people with disabilities. The need for transport, and particularly disability-appropriate transport, has implications for access to both health and disability services. Transport to either type of services can be limited by the availability of suitable transport. Public transport is often not accessible to people with disabilities, and private transport services (taxis etc) are not always suitable either (for example, taxis with CNG tanks cannot always fit a wheelchair into the boot). The cost of such private transport, which may be needed frequently, can be prohibitively expensive. Ownership of an accessible vehicle is beyond the means of most people with disabilities, as assistance with purchase and running costs is limited.
125 9.6.3 HOME BASED SERVICES Disability support services that enable people to live at home are usually preferred over residential services such as rest home care. Increased access to services such as assistance with household management and with personal care, and meals on wheels, and greater availability of such services, is strongly advocated by individuals with disabilities and carers.
9.6.4 EQUIPMENT The availability of equipment can also help to maintain a person in living at home. This includes a range of mobility, hearing, sight and activities-of-daily-living devices. The need for equipment availability is pronounced for the parents of children/young people with disabilities, including incontinence supplies.
9.6.5 DEINSTITuTI0NALIsATI0N Deinstitutionalisation has implications for living in the community. More people with disabilities, and notably with psychiatric disabilities, will be living in the community as deinstitutionalisation progresses. The focus of mental health services resource allocation into community based services rather than into the centralised Porirua Hospital facility will begin to address the issue of community support for these clients.
9.6.6 HEAD INJURY The impact of head injuries upon both health and disability support needs is considerable, and often service needs are wide ranging. Service coordination over this range is required.
9.6.7 COSTS People with disabilities are often faced with additional costs related to their disabilities (e.g. to purchase equipment, transport and other services), in addition to higher than usual health costs. It can mean that medical treatment or prescriptions are either irregularly sought or not sought at all. The affordability of prescriptions is very important for many people with psychiatric disabilities who require regular medication. This medication may support their life in the community, and its absence can severely disrupt that option.
9.6.8 PSYCHIATRIC SERVICES There is a strong perception in the community that people with psychiatric disabilities who have been discharged into the community do not have sufficient support, even though there are a higher number of services per head in Porirua compared with locations in the rest of the Central region. Better access to support with day-time activities, emergency intervention (when this is required), and general assistance with household and other activities required for independent living.
9.6.9 YOUTH ISSUES The high youth population in Porirua and the particular needs of this group were highlighted by the project. Few health or disability support services are targeted to young people. Yet this is a group that faces particular barriers, and feels particularly diffident about accessing general services, especially those which relate to sexual health, relationships and other personal matters.
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9.6.10 CULTURALLYAPPROPRIATE SERVICES The multi-cultural mix of the community provides a similar challenge to both disability support and health service. What a service consists of tends to be based around Pakeha conceptions, so that even when a service is provided, use by a cultural group can be limited. Interviews with providers and feedback from community-based disability support groups showed that they are aware of cultural and language barriers faced by consumers, but they do not always have the personnel, expertise or other resources required to bridge these barriers. Agencies have made progress in some areas - for example, through employment of non- Pakeha field-workers, - but it is acknowledged that there is some way to go in providing fully culturally appropriate services.
9.7 A strategy for improving disability support
9.7.1 BACKGROUND A strategy for improving disability support in Porirua must be referenced to broader changes under way in disability support service provision. In the following sections, these broader activities are described before comment is made on their application in the context of Porirua itself, since they are strongly related to the needs identified in the study, either directly or indirectly.
9.7.2 ASSESSMENT AND SERVICE Co-ORDINATION Individual needs assessment for people with non-age related disabilities is due to be introduced progressively from July 1994. This assessment process is complementary to the SNAP process(support needs assessment protocol) already in use for older people with disabilities. Individual needs assessment is a coordinated process for identifying disability support needs, which has been developed following extensive consultation with consumers, service providers and government agencies. The needs assessment process is used to determine, in partnership with the individual, their range of current abilities, resources, skills, goals and needs. The assessment will determine broad areas of support need rather than focus on the prescription of a particular service. Specialist assessment will be drawn on during this phase, as required. It does not follow that every need identified will not necessarily be met by services purchased by Central RHA. Needs assessment is followed by a service coordination process, through which options for meeting the needs identified are discussed, and a package of services that best meets the individual s needs is drawn together. It is expected that there will be differences both in settings and developmental processes for different disability groups. For instance, assessment services for people with psychiatric disabilities will be purchased through community mental health teams.
9.7.3 HOME SUPPORT Central RHA will purchase home support management services in the Central region from July 1994 on. These will be pivotal in making support for living at home a viable option for people with disabilities.
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The service will co-ordinate and manage the provision of home support services to people with disabilities. Core elements are personal care (assistance with activities of daily living) and household management (help to maintain and organise the household). Caregiver support (such as relief care), meals on wheels, professional community services (such as district nursing and physiotherapy), attendant care and social support services will not form part of the range of services purchased through home support management services in 1994/95, but they will form part of the package of home support that is required by clients. Home support management will liaise with such service providers. It is expected that this package of services will expand in succeeding years, as programmes in Part II of the Disabled Persons Community Welfare Act such as Aid to Families transfer to R.I-IAs at 1 July 1995.
9.7.4 EQUIPMENT Of particular note are the changes related to the provision of equipment. At present equipment is available both through CHEs and through the Disabled Persons Community Welfare Act, administered by NZISS. Equipment from this latter source is prescribed through the accredited equipment assessment process. From 1 July 1995, RHAs will be responsible for equipment purchase from both of these sources, enabling greater coherency in the basis for provision. This will require an intermediate stage, and from 1 July 1994 equipment issued by CHEs will also be through the accredited equipment assessment process.
9.7.5 PSYCHIATRIC DISABILITY In 1994 a Central RI-IA initiated review of general adult mental health services in greater Wellington was completed. It indicated the need for re-development of clinical and community services to respond to the needs identified in this, and in previous reports. The review made recommendations in a wide range of areas. Those recommendations pertaining directly to Porirua are outlined in the disability action summary (see section 9.8 below).
9.7.6 YOUTH Services for young people with disabilities are largely contained within general disability support services, rather than specialised to this group. Young people both with and without disabilities would generally find youth-dedicated services more acceptable. Exploration of a "one stop shop" youth health service, as proposed in section 9.4.7, should explore ways to include young people with disabilities. The issue of youth disability support services requires further exploration.
9.7.7 HEAD INJURY SERVICES A 1994 national working party on head injury made recommendations related to the development of a head injury service structure.2 Such a service would encompass a range of
Central Regional Health Authority (1994) A Better Life, Wellington 2 Head Injury Working Group (1994) The Review of Support Needs of People with Severe Head Injury - a multi-agency report involving representatives from The Head Injury Society, ACC, and Regional Health Authorities
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core services. There is also a framework for the availability of these services at local, regional or national level. The service delivery would need to be based on individual needs assessment and service co-ordination, and standards for service delivery, developed in the working group would be recognised. The development of a head injury service is likely to be ongoing.
9.8 Disability action summary
The disability initiatives outlined above, which comprise a combination of government policies, RHA developments and completed reviews will, in combination with other identified initiatives, produce the following actions and/or service directions:
9.8.1 ASSESSMENT AND SERVICE Co-ORDINATION The formulation of individual needs assessment and service co-ordination processes which are culturally appropriate for Maori and for other cultural groups is particularly relevant to Porirua. These needs assessment processes will also be disability group specific.
9.8.2 HOME SUPPORT Providers of home support management services that cover Porirua will be expected to sub- contact with at least one Maori provider.
9.8.3 EQUIPMENT From July 1994, CHE providers of equipment such as wheelchairs, will be expected to prescribe in accordance with standards for accredited equipment assessment. This should increase choice, and access to the equipment a CHE provides.
9.8.4 PsYcHIATRIc DIsABILIT, Of particular relevance to Porirua are the following recommendations: • the focus of resource allocation to be shifted from the centralised facility at Porirua Hospital to a de-centralised community based service • one of three acute in-patient hospital services units in the Central region, comprising 15-20 general beds, 3-5 intensive care beds and 10-15 day hospital places is to be located at PorirualKenepuru • a community mental health team is to be based in Porirua • specialist services, linking with mainstream services, are to be established for Maori, and for Pacific Island consumers • supported housing, and appropriate clinical support are to be provided to support the transfer of those long-stay patients at Porirua Hospital who are able to live in the community with this assistance • the present forensic services that are based at Porirua are to be maintained as a regional service • supported housing, day services and specialist services for Maori are to be developed.
A detailed implementation plan for the proposed changes is to be produced following public consultation on the review recommendations, which is currently under way.
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9.8.5 YOUTH Further exploration of disability support services and how these can best meet the needs of young people with disabilities will be undertaken.
9.8.6 HEAD INJURY While no immediate changes or additions to local service delivery is envisaged in 1994-95, the introduction of individual needs assessment and enhancement of service co-ordination is likely to provide a positive impact. A training package to expand the skills of those concerned with delivery of head injury services is to be introduced later in 1994.
9.8.7 PHYSICAL DIsAB!ur, The community support needs of people with physical disabilities currently in long term residential care need to be investigated The location and delineation of this consumer group, together with a description of their support needs, provides a basis for planning their transfer into the community with the provision of appropriate home based support.
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9.9 Timetable and resources: disability support services
ement
Implementation of home management support Within existing budget provision service: home management support contacts with one Maori provider
Development of individual needs assessment Within existing RHA funding proposals services for non-age related disabilities; mixture of community and hospital based services, depending on disability group
Equipment for disability issued from CI-lEs Within existing contracting arrangements conforms to principles of accredited equipment assessment
Establish process for efficient purchase and To be finalised - set-up costs estimated at tracking of equipment $10,000 for the Central region
Review of requirements for disability support $20,000 services for young people
Review of levels of rheumatology services to To be determined be undertaken by health services also to include disability rehabilitation needs
Assessment of community living needs for Within existing budget provisions people with physical disabilities currently in long stay care
Training package for carers and providers of Within existing budget provisions, $45,000 head injury services for the Central region
Pacific Islands disability information services To be finalised, up to $10,000
Services of one further interpreter (1 FTE)for Within existing budget provisions deaf people TOTAL YEAR ONE $125,000
No recommendations on specific services for people with psychiatric disabilities are included here, as an implementation plan is still under discussion. based on consideration of the recommendations contained in "A Better Life" (op cit)
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Ito rt initiative
Further develop appropriate assessment To be determined services options, particularly assessment services for people with intellectual disabilities
Range of home support options is expanded as further home support Cost to be incorporated into contracting services transfer to RHAs to purchase-at least 1 Maori and 1 Pacific Island provider
Central RHA-wide review of service provision for To be determined, est $25,000 - Client/carer support - Attendant care - Disability information services
Head Injury support services $20,000 Disability support services for young people initiative $30,000
Review of needs of profoundly deaf in relation to interpreter and social work To be determined, est $30,000 services, and development of services TOTAL YEAR TWO $1 05,000
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Head injury support services $10,000
Review of respite care services (Central $30,000 RHA-wide)
Further development of assessment To be determined, and linked to the costs and services outcomes in year 2
Further development of home support To be determined services through home management. services with priority to identification of Maori and Pacific Island service providers as appropriate
Disability support services for young $ 20,000 TOTAL YEAR THREE
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10. References
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Central Regional Health Authority (1993) Report on the Maori Consultation Hui at Maraeroa Marae, Porirua, November 1993, Wellington
Central Regional Health Authority (1994) Morbidity and mortality profile of the Central region, Wellington. (unpublished)
Central Regional Health Authority (1994)A Better Life, Wellington
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Crampton P (1992) Iron deficiency anaemia in infants - Porirua Study (This study found iron deficiency anaemia in 10 of a sample of 43 infants).
Elwood, M (1993) Prevention of neural tube defects; clinical and public health policy New Zealand Medical Journal, 106: 517-518.
Graham P, Jackson R, Beaglehole R (1989) The validity of Maori mortality statistics. New Zealand Medical Journal, 102:124-6.
Grainger J (1990) Asthma services in the West Coast district of the Wellington Area Health Board. Wellington Area Health Board. A more coordinated approach by general practitioners and hospital staff appears to have been effective in reducing admissions.
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Head Injury Working Group (1994) The Review of Support Needs of People with Severe Head Injury - a multi-agency report involving representatives from The Head Injury Society, ACC, and regional health authorities
Isaacs R D, Scott D J (1987) Diabetic discharges from Middlemore Hospital in 1983 New Zealand Medical Journal; 100:629-31.
Joyce P (1991) The non-recognition of depressive disorders. a continuing public health concern! New Zealand Medical Journal; 104: 7-8.
Malcolm L (1993) Trends in primary medical care related services and expenditure in New Zealand 1983-93 New Zealand Medical Journal, 106:470-4.
Mansoor 0 (1991) Does control ofpertussis need rethinking? CDNZ, 91:43-8.
Metcalfe S, Ratcliff B, Nye J (1992) Analysis of new entrant and pre-school hearing testing data Public Health Service, Wellington Area Health Board.
Metcalfe S, Roseveare C (1993) "Overs and Unders": a comparison of Health Goal indicators, Wellington Area Health Board vs the rest of New Zealand Regional Public Health Service, Wellington Area Health Board.
National Research Bureau (1994) Assessment of Health and Disability Needs in the southern Porirua area, a report of a household survey, prepared for the Central Regional Health Authority, Wellington.
Public Health Commission (1993) Our health, our future: the state of the public health in New Zealand, Wellington.
Roberts A (1992) A study of the 1991 measles epidemic in the Wellington Area Health Board region. costs, complications and problems Regional Public Health Service, Wellington Area Health Board.
Robson B, Burgess C, Pearce N, et al (1993) Prevalence of asthma symptoms among adolescents in the Wellington region by area and ethnicity Zealand Medical Journal, 106:239-41.
Salmond G C (1975) Maternal and Infant Care in Wellington - a health care consumer study, Special Report No. 45, Management Services and Research Unit, Department of Health, Wellington.
Scragg R, Baker J, Metcalf P (1990) Factors associated with development of diabetes mellitus: results from a cross-sectional survey in Kawerau Zealand Medical Journal, 103:575-7.
Statistics New Zealand (1993) New Zealand Standard Classification of Ethnicity, Statistics New Zealand, Wellington. (see page 26)
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Statistics New Zealand and the Ministry of Health (1993) A Picture of Health, Wellington.
Strack M F, Wells J E, Joyce P R, Hornblow A R, Oakley-Browne M A, Bushnell J A (1989) Factors affecting the use of mental health services in people with alcohol disorders New Zealand Medical Journal, 102:601-3.
Te Puni Kokiri (1993) Nga Ia o le oranga hinengaro Maori, Wellington.
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APPENDICES
Acknowledgments
Groups that have made a valuable contribution have included the Porirua Community Health Group; the Public Health Unit of Hutt Valley Health, members of which contributed material for the chapter on health status (chapter 4); the Nursing and Health Studies Department of WhitireiaPolytechnic which organised and implemented the focus group meetings (chapter 6); the National Research Bureau, which carried out the household survey; the Porirua City Council, which cooperated with the Central RHA in carrying out the survey, and whose staff provided useful information and advice.
A great number of other organisations and individuals were informed about and contributed to this needs assessment through the consultation and submission processes described in Chapters 6, 7 and 8.
The Bridgeport Group provided an independent analysis of submissions received. Pip Aimer provided research assistance, and Adele Carpinter provided organisational and editorial assistance.
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Porirua City, population by age, sex and ethnic group, 1991
Ethnic Group: European Maori Pacific Islands Total Sex: Male Female Male Female Male Female Male Female Age (yrs) 0-4 1,125 1,014 723 726 705 660 2,634 2,457 5-14 1,914 1,833 1,080 996 1,116 1,089 4,278 4,050 15-19 1,122 1,020 492 561 558 606 2,241 2,253 20-24 909 900 450 504 465 525 1,869 1,989 25-34 2,124 2,301 606 759 735 840 3,618 4,074 35-44 2,229 2,238 414 483 549 576 3,321 3,444 45-59 2,178 2,073 369 381 474 459 3,120 3,006 60-64 567 522 60 60 63 87 705 690 65-74 675 759 48 57 78 90 831 942 75-84 213 369 9 18 15 36 249 447 60 159 85+ 1 48 141 1 0 3 1 3 6 1 Age total 13,095 13,170 4,248 4,545 4,758 4,980 22,926 23,514
Source: 1991 Census of Population and Dwellings, Department of Statistics
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Comparative Profile, Porirua City by ward, 1991
T,tahi Bay Cannons Plimnier-ton Porirua City Central Tairangi 1-lorokir, Creek - Region Usually Resident population 10,725 7,608 12,843 7,263 7,950 46.440 856,629 Under 15 25 34 34 23 27 29 23 15to24 17 22 21 14 14 18 17 25to44 30 29 27 35 37 31 31 45to64 17 13 14 21 18 16 18 65&over 10 2 4 8 4 6 11 Born Overseas 17 29 31 20 20 24 16 European only 61 30 27 92 92 57 80 NZ Maori ethnic group 26 25 26 5 4 19 13 Pacific Is. (excl. Maori) 10 41 41 1 1 21 3 Married (Including Dc Facto) 50 51 49 68 72 57 58 Income Support (Excluding Family 47 40 47 26 18 37 43 Benefit only) Highest Qua]: Universit y 4 2 2 16 13 7 9 Highest Qua]: Other Tertiary 24 20 18 34 36 26 27 Highest Qua]: School 19 19 18 24 27 21 23 No Qualifications 37 45 46 15 14 33 29 Personal Income: $30.001 and over 15 10 7 34 39 20 18
Gainful],,, Employed 88 83 80 94 95 88 90 Unemployed and actively seeking 12 17 20 6 5 12 10 work -
Women in the Labour Force 49 49 49 46 45 47 46 Professionals 11 7 7 19 16 13 13 Private Dwellings: Owned with a 43 47 33 49 67 47 38 mortgage
Private Dwellings: Owned without 17 6 9 37 23 18 34 mortgage Private Dwellings: Rented 38 45 55 13 9 33 27 Households: Persons Aged Under 5 22 35 35 16 22 26 17 Years
Households: Superannuitanls 23 8 15 22 10 16 27 Households: Two or More Persons in 42 48 39 52 62 47 42 the Labour Force Households: One Person 17 6 9 16 9 12 21 Households: At least One Solo 21 32 31 6 6 19 12 Parent Family
Households: Non-Family Household 4 3 4 4 2 3 6
Households Income: $30,001 and 46 43 34 67 75 52 46 over
Source: 1991 Census of Population and Dwellings, Department of Statistics (Generated from Supermap 2)
Actual numbers presented in this row, all other figures are column percentages
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Comparative Profile, Porirua City by ward: ratio to the Central Region, 1991
Titahi Bay Cannons Plinmier-ton Porirua City Central -. Tairangi Horokiri Creek Region Usually Resident population 10,725 7,608 12,843 7.263 7,950 46,440 856,629 Under 15 1.10 1.48 1.45 0.99 1.15 1.25 1.00 15to24 1.04 1.30 1.26 0.84 0.85 1.08 1.00 25 to 44 1.00 0.95 0.90 1.14 1.22 1.02 1.00 45 to 64 0.90 0.71 0.75 1.14 0.98 0.88 1.00 65 & over 0.91 0.19 0.38 0.67 0.36 0.51 1.00 Born Overseas 1.07 1.80 1.92 1.28 1.23 1.49 1.00 European onl y 0.75 0.38 0.33 1.14 1.15 0.71 1.00 NZ Maori ethnic group 2.10 1.98 2.11 0.41 0.32 1.51 1.00 Pacific Is. (excl. Maori) 2.97 12.06 12.04 0.29 0.37 6.10 1.00 Married (Including Dc Facto) 0.86 0.89 0.84 1.18 1.24 0.98 1.00 Income Support (Excluding Family 1.11 0.94 1.11 0.61 0.43 0.88 1.00 Benefit only)
Highest Qua]: University 0.48 0.25 0.24 1.70 1.44 0.76 1.00 Highest Qua]: Other Tertiary 0.89 0.74 0.67 1.26 1.30 0.94 1.00 Highest Qual: School 0.82 0.83 0.79 1.06 1.15 0.91 1.00 No Qualifications 1.26 1.53 1.56 0.53 0.46 1.11 •1.00 Personal Income: $30,001 up 0.80 0.57 0.39 1.88 2.12 1.07 1.00 Gainfully Employed 0.98 0.92 0.89 1.04 1.06 0.98 1.00 Unemployed and actively seeking 1.23 1.72 2.04 0.60 0.48 1.19 1.00 work
Women in the Labour Force 1.06 1.08 1.06 1.00 0.99 1.04 1.00 Professionals 0.80 0.55 0.55 1.43 1.19 0.94 1.00 Private Dwellings: Owned with a 1.13 1.23 0.88 1.28 1.75 1.22 1.00 mortgage
Private Dwellings: Owned without a 0.52 0.18 0.26 1.10 0.70 0.55 1.00 mortgage
Private Dwellings: Rented 1.43 1.70 2.06 0.48 0.35 1.25 1.00 Households: Persons Aged Under 5 1.34 2.13 2.09 0.96 1.34 1.56 1.00 Years
Households: Superannuitants 0.85 0.30 0.53 0.80 0.37 0.60 1.00 Households: Two or More Persons in 1.01 1.14 0.93 1.25 1.48 1.14 1.00 the Labour Force Households: One Person 0.81 0.30 0.44 0.77 0.42 0.57 1.00 Households: At least One Solo 1.77 2.62 2.54 0.53 0.50 1.61 1.00 Parent Family
Households: Non-Family Household 0.61 0.42 0.70 0.61 0.40 0.56 1.00
Households Income: $30,001 and 0.99 0.94 0.74 1.45 1.62 1.13 1.00 over Source: 1991 Census of Population and Dwellings, Department of Statistics (Generated from Supermap 2)
Actual numbers presented in this row, all other figures are ratios to the Central region. A ratio of 1.00 means that the proportions are the same as for the Central region as a whole. For example, the proportion of people in Tairangi who are under 15 yrs is 45% higher than in the Central region as a whole. The proportion of sole parent families is more than two and a half times higher in Tairangi and Cannon Creek than in the Central region.
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List of submissions received from community groups
Age Concern Wellington Assembly of God Church, Porirua Arthritis Foundation of New Zealand, Wellington Division Barnardo s Community Services Care and Craft Centres, Wellington CCS Wellington Clifford Foundation Trust Diabetic Group Diabetic Service, West Coast District, Kenepuru Hospital Holy Family School IHC Family Support Service Kapi Mana School Kapi Mana Stroke Club Kapiti Mana Victim Support Service Mana Business and Professional Women s Club Maraeroa School Mental Health Resource Centre Motor Neuron Disease Association of New Zealand National Society on Alcoholism and Drug Dependence New Settler Service New Zealand Foundation for the Blind, Mana District New Zealand Society For Music Therapy Ngati Toa School Pacific Island People With Disabilities Trust Porirua Citizens Advice Bureau Porirua City Council Porirua Community Health Group Porirua Gospel Chapel Porirua Maori Women s Welfare League Porirua Sexual Abuse Healing Centre Pukerua Bay Senior Citizens Club Rangikura School Royal New Zealand Plunket Society Russell School St Anne s Anglican Parish St Vincent de Paul, Titahi Bay Stroke Foundation of New Zealand, Wellington region Te Kupenga (Horizons - Ic Whiti 0 Te Ra) Te Whare Rapuora (oral submission) Tokelau Health Collective Wellington Asthma Society Wellington Multiple Sclerosis Society Whitford Brown Community Workshop Trust Whitireia Community Polytechnic Health Clinic
PU8LIC HEALTH COMMISSION LIBRARY 9.4.3 PACIFIC ISLAND PRIMARY HEALTHCARE SERVICES Recognising that the Pacific Island community has expressed a need for assistance with proposal development, Central RHA will purchase a workshop or workshops for potential provider groups in Porirua in 1994/95. In the meantime, Central RHA has negotiated to purchase a Pacific Island Well Child Health Project from the Regional Public Health Service (Hutt Valley Health Corporation). The project was developed in consultation with Pacific Island communities and includes provision for the training of community health workers from the six Pacific Island groups. Hearing loss and immunisation are among the first health issues to be addressed. The project will cover the Wellington region, but a significant component of the activity will be undertaken in Porirua East. Central RHA will also allocate a resource specifically for purchase of a community-based primary health service (or services) for Pacific Island people in Porirua in 1995/96. The service/s should have the support of all major Pacific Island communities. Services must be provided in a manner appropriate to all Island groups and to Island-born and New Zealand- born Pacific Island people. Key well child components of health education and promotion will include: • immunisation • hearing • preschool dental care and enrolment.
Adult services may include: • lifestyle issues (including nutrition and weight control) • diabetes awareness and management • asthma management (for themselves and children) • women s health issues • maternity care • parenting skills.
Provision has been made elsewhere in this plan for additional training for staff in asthma and diabetes education in 1995/96 and 1996/97 respectively. Good liaison and cooperation with other general and specialist services will be essential. Central RHA will also review the feasibility of providing some adolescent health services targeted specifically to Pacific Island youth. The exact mix and focus of services will be informed by the outcome and recommendations of a regional youth needs project due to report later in 1994.
9.4.4 ASSISTING NEW SETTLERS (REFUGEE MIGRANTS AND THEIR FAMILIES) Although making up a small part of the overall community, the new settler population (estimated at up to 500 - 600) is characterised by significant physical and mental health problems, in some cases compounded by difficulties in utilising services effectively. In 1994/95 Central RHA will explore with new settler organisations in Porirua, and elsewhere in the Wellington region, and with key providers, strategies for further assisting them to meet
113 their health needs. A resource equivalent to a part-time nurse educator will tentatively be allocated for commitment in 1995/96.
9.4.5 RELATED INITIATIVES The planning of a family centre in Porirua East, funded by the Community Funding Agency, has been followed closely by Central RHA. The centre, intended to serve all ethnic groups, will be managed by a community based group, and will have education, lifestyle, parenting and health components. Core health services that it is intended be provided from the centre are family planning, well child and public health nursing services. These may be arranged through existing RHA contracts with providers. However, until negotiations have proceeded further it is not possible to comment in detail on the final range of services and the supporting arrangements. Liaison will be maintained with relevant parties to ensure that initiatives are coordinated and complementary.
9.4.6 SERVICES IN SCHOOLS Preschools and schools provide an important context within which to carry out hearing and other screening, monitor health status generally, provide health education and advice, and provide a setting for some direct treatment. Schools in the area have an active interest in their children s health. In 1994/95 Central RHA will hold discussions with the Public Health Commission to identify areas of possible cooperation within the framework of the Commission s proposed Healthy Schools programme.
9.4.7 YOUTH SERVICES The services presently (part) targeted to adolescents include family planning and the forthcoming sexual health service. Targeted mental health and alcohol and drug services are lacking. There is not as yet a comprehensive or holistic service which aims to meet all the needs of young people in a non-threatening atmosphere. Central RHA will explore the need for and feasibility of a one stop shop health service located within the city centre. 2 Rather than being a new service, it is envisaged that this will be linked to and host existing services and utilise existing providers. Services may include: • advice on general health issues, including dental health • advice on sexual health issues and/or referral to appropriate service (sexual health service, family planning) • advice on general lifestyle issues, including smoking
It should also provide an environment for the delivery of, or maintain strong links with, alcohol and drug, and mental health services.
The centre will be one of six pilots established by Government in targeted communities. One other, in Motueka. falls within the Central region. 2 This proposal has been guided in part by initial findings of a Youth Needs Assessment project sponsored jointly by the Central RI-IA and the Ministry of Youth Affairs. The further development of this and other proposals for addressing youth needs in Porirua will be informed by the full findings and recommendations of the project, which is due to report in mid 1994.
114 An appropriate cultural mix of staff would be required. The service would not necessarily be open full-time, but would provide sufficient, and appropriately timed, opening hours to meet the needs of the target population. Providers would be expected to have very close relationships with other services providing primary health care services to adolescents: GPs, Family Planning Association and the new sexual health service. Services will be expected to commence from Year 2.
9.4.8 GENERAL ACCESS ISSUES
Knowledge about services While other initiatives set out in this report will provide important channels for conveying accurate information about services to the community, there is also a need for a central source of service information for the community. Several agencies, including the Porirua City Council and the Citizens Advice Bureau, provide a partial service in this area, but there appears to be scope for a more systematic, better publicised information source, probably oriented to providing information through a number of media, including telephone and print. In the first year Central RHA will seek discussions with the above agencies, the Community Health Group and other interested potential providers, with the objective of identifying a strategy for providing an enhanced health and disability support service information system in Porirua.
Information needs The need for improved information about health services has already been identified as a priority. This information needs to indicate the range of charges which do apply, the services which are available to users without charge, and the assistance available to those who do not have the means to pay immediately necessary services.
Accessible services The modest increase in the range of primary health care services proposed in this report (including a Maori community health service in Porirua East, support for Pacific Island health care providers and an increase in asthma education service), while not intended as substitutes for existing services, will increase the opportunities of residents to seek early assistance and better manage their health problems without fear of fee barriers.
User charges regime The present user charges regime reflects Government policy. Central RHA has scope to alter the regime only if it: has the approval of the Minister of Health • can generate sufficient savings elsewhere in the system. Some further review and refinement may be required in order to target services more efficiently to those in greatest need. At a regional level, Central RHA is implementing programmes to manage demand driven primary health care expenditure (especially pharmaceuticals, laboratory services and maternity services). During the next year:
1 115 • we will seek proposals from local GPs and pharmacists on efficiencies which might be made in order to reduce the cost of access to primary medical care • we will invite Promed, and other appropriately positioned agencies, to offer their advice on, and expressions of interest in, arrangements which would allow additional support to be provided by Central RHA in meeting the costs of the lowest income users of primary services in Porirua.
Transport Initiatives set out elsewhere in this chapter should have the effect of lessening the impact of transport availability on service use locally, especially in Porirua East. To help address remaining difficulties, Central RHA will discuss strategies to improve transport availability to enable residents to access health and disability support services with the Porirua City Council and the Porirua Community Health Group. Direct purchase of non- emergency transport, however, is not a core service activity in which RHA can become involved.
9.4.9 GENERAL PRACTITIONER QUALITY FACILITATION: IMMUNISATION COVERAGE Central RHA has recently initiated a project to support the delivery of clinical preventative services by GPs throughout the region, including Porirua City. The quality facilitation initiative will focus initially on improving immunisation coverage in the region.
IM The initiative involves assistance to general practices within localities such as Porirua to join in local general practitioner networks . Each network will employ a facilitator (generally an experienced practice nurse) to assist each practice to establish an up-to-date age/sex register of patients; identify under-immunised children using the register; operate an efficient recall system and conduct regular audits of immunisation coverage and recall procedures. The facilitator will also feed back comparative performance information to network practices; assist them to make changes as required; coordinate the network with other local providers such as the CHE to promote immunisation in the community as well as assist in tracking and offering immunisation to children who have missed recalls. In Porirua Central RHA hopes to contract with a single network representing a high proportion of local general practitioners. The cost of employing a half-time nurse coordinator/facilitator will be subsidised by Central RHA. The level of subsidy will depend on the network size and other factors. Central RI-IA hopes to open negotiations with Porirua practices in mid 1994, with the expectation that an operational network will be in place by the end of 1994. In extending the focus of this work beyond immunisation, priority will be given, in the case of Porirua, to improved monitoring of clients with diabetes, or at risk of developing diabetes.
9.4.10 ASTHMA
Asthma educator It is proposed to purchase an additional asthma educator, to assist those whose asthma is particularly severe and/or difficult to manage. The service is to be available via referral from other health professionals, with community and self referrals also being accepted. Although
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one full time equivalent position would be involved, two or more part-time workers may be employed to ensure acceptability to recipient groups. To avoid fragmentation of services, it is envisaged that the new service be provided by one of the existing providers of related services, such as Capital Coast Health or the Asthma Society. The service would be located in Porirua, but provided from a range of sites, including medical centres and community health centres, in order to reach those in greatest need. This service will be provided in the first year, dependent on resources being made available in other areas.
Community asthma education Asthma education will also be purchased as a component of broader, community based health services including Pacific Island and Maori health services. Such components will be added in the second or third years, when organisations are well established and are in a position to broaden their range of services. Services are likely to include: • identification and modification of risk factors • information on asthma and advice on its management • liaison and co-ordination with other providers of related services
Discussions will be held with relevant groups during the first year with a view to establishing the services in the time frame suggested above. Provision will be made for special training costs. (Ongoing staff and training costs will be built into proposals for community based services). Both proposals require integration with broader services. In particular, it is envisaged that the asthma educator work with, or be part of, medical or treatment services, while community asthma education services be an integral part of new community based services. Any asthma education services purchased by Central RHA must be well coordinated and work closely together.
9.4. 11 SMOKING The Central RHA proposes to initiate strategies aimed at reducing the prevalence of smoking, especially among youth, in households with asthmatics, during pregnancy and among young mothers. It will liaise closely with the Public Health Service, other providers, and non- provider local organisations in further developing and implementing these strategies.
General practitioners and other primary care providers Central RHA will purchase an enhanced level of smoking cessation advice and counselling from GPs and other primary care providers in the locality. This will include assistance with the installation and maintenance of patient records that enable smoking status to be recorded and intervention to be monitored. This requires bringup systems that prompt practices to provide smoking cessation services opportunistically, and age/sex registers that allow smokers to be proactively identified and monitored. Such records systems also allow practices to carry out audits of their patient smoking rates and intervention activities at regular intervals.
The relationship of this activity to that of the GP network facilitator is noted. The improvement and use of age/sex registers has many applications in improving health status.
117 Primary health care providers may also require additional training in smoking cessation techniques, and support materials such as smoking cessation kits. It is not proposed to subsidise nicotine replacement therapy or referral to intensive smoking cessation clinics. Smoking coordinator/educator As well as assistance to people who are already smokers to quit, primary health care providers and health promoters will be supported to educate young people not to start. There is much evidence that most smokers are recruited as teenagers, and if initiation can be postponed, smoking rates in adulthood will decline dramatically. This will be achieved by purchasing a full time tobacco coordinator or advocate. Central RHA will approach key local organisations with a view to seeking joint funding of this position. The position would involve acting as the focal point for tobacco control in Porirua. It would involve collecting data on all aspects of the problem and existing services, communicating this information to relevant stakeholders and the community at large, monitoring the quality of the community s efforts to control the problem, and generally advocating and inspiring what could become a campaign against smoking in the community. Smoke free policies In addition to these purchase recommendations, Central RHA will encourage major local organisations to set an example of a smokefree workplace and encourage other major employers to do so. Encouragement should also be given to the smokefree activities of the CI-IE (ie Hutt Valley Health) Public Health Unit, including in particular surveys of retail outlets and prosecutions as necessary for infringement of the law regarding sales to minors. These policies will require I FTE anti smoking coordinator and a 0.5 FTE smoking cessation advisor for the GP network and other primary care providers (to facilitate and coordinate smoking cessation services and assist with audits and feedback of comparative performance information). The latter position would align with the GP network immunisation coordinator. The cost will include non-personnel expenses such as health education materials, but it is not intended to subsidise the actual investment in hardware and software by primary care providers, and it is also anticipated that assistance with publicity would be available from key local bodies. The above initiatives will be established in Year 1, with the first full year of operation being Year 2.
9.4.12 DIABETES Central RHA will continue to purchase the current CI-IE-based diabetes education service (and associated dietetic service). The level and type of provision of this service will be reviewed in Year I in conjunction with a consideration of the capacity of community-based services to enter this field. (See below). Additional, community-based diabetes education will be purchased from Maori and Pacific Island health services as these organisations become more established and are able to extend their range of activities. Services may be provided by a mix of professionals and trained local people. Services are expected to include:
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• awareness raising as regards symptoms, with a view to improving detection • advise on modification of risk factors • screening for at risk adults • advice on the management of non-insulin diabetes, and in particular, on nutrition and diet • liaison and co-ordination with other providers of services, including hospital specialists, community health services and the Diabetes Society.
It is envisaged that services will be provided from community health bases and in other locations as appropriate. Community based services will be provided from Year 2 or 3 depending on the readiness of community based organisations. Provision will be made for special training costs. (Ongoing staff and training costs will be built into proposals for community based services). Following an initial focus on immunisation, the work of the GP network facilitator in Year 2 will include an emphasis on the development and use of age/sex registers and related systems for educating and monitoring clients with diabetes or at risk of developing diabetes.
9.4.13 FAMILY PLANNING AND SEXUAL HEALTH SERVICES The service provided by the Family Planning Association in Porirua is generally perceived positively by consumers and other providers. While they have gone to some lengths to make their service accessible, there are other factors which nevertheless inhibit accessing by some groups. Youth of all ethnic groups and Pacific Island people of all ages appear to face particular access problems. The initiatives set out in this chapter will provide additional, acceptable channels through which family planning services may be offered. Specialist sexual health services have previously been unavailable in Porirua. To fill this gap the Central RHA has recently announced the purchase of a clinic from Capital Coast Health, to be provided in Porirua from May. At the time of writing the service is being established with the Family Planning office in central Porirua. This service too faces a challenge to find ways of accessing young people and particular groups who for reasons of culture or other reasons are least likely to approach them. Both the above services would play key roles in the proposed integrated youth service.
9.4.14 MATERNITY SERVICES Maternity services throughout New Zealand are the subject of an inter-RHA review. A consultants report setting out policy issues and recommendations has been released , and the project team is working toward a final report and implementation plan. Pending this, detailed proposals affecting maternity services for Porirua have not been attempted in this report. However, it should be noted that principles for effective and appropriate delivery of services that are set out in the First Steps report are reflected in a number of general
Coopers and Lybrand (1993) First steps towards an integrated maternity services framework, Regional Health Authorities
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recommendations in this report. Our proposals for inclusion of maternity services among those provided by or through Maori and Pacific Island primary health services (9.4.2 and 9.4.3) are among these. The findings of the Porirua project have been made available to Central RHA staff involved in the review.
9.4.15 DENTAL HEALTH The decline in utilisation of services, and consequent poor dental health among many adolescents and adults, needs to be addressed by increasing awareness of the services that are available, and promoting the importance and consequences of good dental health during adolescent and adult years. While purchase of discrete new services is not envisioned, strategies which will be promoted include the following. Dental health will be included in the health promotion and education component of the Maori and Pacific Island community based services. Kohanga Reo, marae and Plunket can make also an important impact in promoting enrolment in school dental services before children starts school. We will seek the Capital Coast Health s cooperation in feeding back to early childhood education centres participation rates by type of pre-school centre (kohanga reo, kindergarten etc). Promotion and reminders to utilise dental benefit scheme should be incorporated in the healthy schools programme (Public Health Commission). Other community based services targeting Maori and Pacific Island groups will be encouraged to include dental health promotion and education in their programmes. Central RHA will continue to purchase a dental service for adults at the current levels.
9.4.16 SPECIALIST SERVICES - EAR, NOSE AND THROAT Hearing problems among children will be addressed at one level through more extensive testing, monitoring and follow-up services provided through the primary health care strategies described above. However, the effectiveness of these strategies will be severely limited if referral services are available only after a wait of many months. In line with its 1994/95 purchase plan, Central RHA will negotiate to purchase additional specialist assessments for Porirua residents.
9.4.17 OTHER SPECIALIST SERVICES Central RHA will continue to purchase at least the level and range of services currently available at Kenepuru Hospital. It will ask Capital Coast Health and Hutt Valley Health to explore and report on the possibility of increasing the level and range of secondary services provided in Porirua. Services which need to be considered include: • ENT services (increase, as above) • ophthalmology services (increase) • gynaecology surgery (consider introduction) • rheumatology clinic (consider increase).
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The cost and exact timing of the above will be determined in consultation with Capital Coast. It is not envisaged that overall levels of CHE services will be increased. Rather, some existing services may be provided from a different location.
9.4.18 DIAGNOSTIC IMAGING SERVICES Diagnostic imaging services are an important adjunct to GP diagnosis and management. More affordable, accessible diagnostic imaging services are required for Porirua residents. The shape of any new purchasing arrangements will be determined in Year 2 in the context of an overall Central region review of purchase arrangements for diagnostic imaging services scheduled for 1994/95.
9.4.19 EMERGENCY AFTER-HOURS ACCIDENT AND MEDICAL SERVICES As noted elsewhere in this report, there have been frequent calls for emergency accident services at Kenepuru to be extended. This has come through as an issue in the feedback obtained during this study. It has been given careful consideration in relation to the strength of concern in the community, the current development of an after-hours general practice clinic in central Porirua, the cost of extending the Kenepuru service relative to the cost of other possible initiatives, and its likely impact on the health of the community relative to the impact of other possible initiatives. While acknowledging the genuine concern of the community, Central RHA does not believe that an extension of emergency accident services at Kenepuru can be justified relative to the factors listed above, especially as, even with 24 hour provision of services equal to those currently provided during weekday working hours, some serious cases would still need to be transferred on to Wellington hospital. The emergency medical services offered at Kenepuru Hospital should continue at their current level. There is a need to try to further clarify for the public, and even some service providers, what is and what is not offered at Kenepuru on a twenty-four hour basis. Survey findings and information gathered from other sources shows that some members of the community believe that they can go to Kenepuru at any hour for accident treatment, while others know that they cannot - but are unaware that emergency medical services are available. Publicising what is available is in the first instance a task for Kenepuru Hospital, but others can also help. Central RHA will discuss with Capital Coast Health, the Porirua Community Health Group and Porirua City Council staff ways in which accurate information can be disseminated more effectively.
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9.5 Timetable and resources - health services
Maori primary health service(s) Porirua $100,000 East Workshop(s) for potential primary $10,000 Pacific Island service providers Detailed assessment of new settler No cost in Year 1 needs General practice facilitator/coordinator $10, 000 (subsidy on 0.5 FTE from (immunisation) January 1995) Smoking cessation advisor for GP $12,500 (0.5 FTE plus some non- network and other primary care personnel costs from January 1995) providers Anti-smoking community $25,000 (half share of 1 FTE, with coordinator/educator remainder to be negotiated with local orgs.) Asthma educator $60,000 (1 FTE salary plus resources and running costs) Additional ENT specialist services $30,000 (based on approximately 90 new assessments per year) Review levels of provision of No cost in Year 1 gynaecology, ophthalmology and rheumatology services Sexual health services Cost included in contract ($195,816) with Capital Coast for additional sexual health services. Assessment of requirements for No cost in Year I establishing a youth health service Community needs for health service No cost to Central RHA information - joint assessment with local agencies TOTAL YEAR ONE $248,500
Not inclusive of the cost of sexual health services clinic or other services to be determined.
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......
Health initiative Maori primary health service(s)- $100,000 Porirua East Pacific Island primary health $100,000 service(s) New settler initiative $25,000 (one .5 FTE)
General practice $20, 000 (subsidy on 0.5 FTE) facilitator/coordinator (immunisation and diabetes)
Smoking cessation advisor - GP $25,000 (0.5 FTE plus costs) network/other primary care providers
Anti-smoking coordinator/educator $25,000 (half share of 1 FTE)
Asthma educator : $60,000 (1 FTE salary and costs)
Training for community based $20,000 asthma services
Additional ENT specialist services $30,000
Gynaecology, ophthalmology and To be determined in Year 1 rheumatology services
Sexual health services Cost included in wider contract with Capital-Coast
Youth health service(s) $40,000 Review purchasing arrangements No cost in Year 2. for diagnostic imaging services (in light of regional needs review findings)
TOTAL YEAR TWO
Not inclusive of the cost of sexual health services clinic or other services to be determined.
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...... - Year Three Resource requ
Maori primary health service(s) - $100,000 Porirua East
Pacific Island primary health $100,000 service(s)
New settler initiative $25,000 (one 0.5 FTE)
General practice $20, 000 (subsidy on 0.5 FTE) facilitator/coordinator (immunisation and diabetes)
Smoking cessation advisor - GP $25,000 (0.5 FTE plus costs) network/other primary care providers
Anti-smoking coordinator/educator $25,000 (half share of 1 FTE)
Asthma educator $60,000 (1 FTE salary and costs)
Training for community based $20,000 diabetes services
Additional ENT specialist services $30,000
Gynaecology, ophthalmology and To be determined in Year 1 rheumatology services
Sexual health services Cost incorporated in wider contract with Capital Coast Health
Youth health service(s) $40,000
Diagnostic imaging services To be determined in Year 2
TOTAL YEAR THREE
Not inclusive of the cost of sexual health services clinic or other services to be determined.
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9.6 Key disability service provision issues
While the range of services available to Porirua residents is similar to that provided in other communities, there are distinctive features, relating to the socio-economic status and location of the community, its demographic mix and the presence of a major psychiatric institution, which mean particular service needs are highlighted. Despite the paucity of good data, a number of key issues have been identified. Some of these overlap with issues identified as important for the Porirua population generally, while others are distinctive to the disability sector. • Large Maori and Pacific Island communities, and the presence of other non-European groups, mean that the cultural appropriateness of services, and cultural and language barriers to accessing information and services, are particularly important. • Low socio-economic status compounds the difficulties and barriers which people with disabilities face relative to others. As noted, in southern Porirua incomes are low and unemployment high. • The presence in Porirua of a major psychiatric hospital and the needs of those discharged into the local community mean that there are some distinctive needs in this area. • Transport and other communication difficulties (eg access to a telephone) facing the general community have even more serious implications for people with disabilities. • Cost was frequently mentioned as a general barrier to using a range of services. Major issues arising from the needs assessment are summarised below.
9.6.1 INFORMATION The limits or unavailability of information were consistently recognised by all stakeholder groups consulted during the course of the project as a key disability issue. Users, or potential users of disability support services want information presented in language that is clear and jargon-free. There is need for information about service availability, including how to access services and what they cost. There is also need for information on how well a service may meet cultural needs. Purchasers have information needs related to more accurate information about the users or potential users. Not only do they need to know about users expressed needs, preferences and priorities but they also need to know about the range of disability services currently available including access, price, volume, quality and uptake. Further they need to be able to place specific disability issues in the context of wider disability issues.
9.6.2 TRANSPORT In Porirua, there are particular issues around access to transport for people with disabilities. The need for transport, and particularly disability-appropriate transport, has implications for access to both health and disability services. Transport to either type of services can be limited by the availability of suitable transport. Public transport is often not accessible to people with disabilities, and private transport services (taxis etc) are not always suitable either (for example, taxis with CNG tanks cannot always fit a wheelchair into the boot). The cost of such private transport, which may be needed frequently, can be prohibitively expensive. Ownership of an accessible vehicle is beyond the means of most people with disabilities, as assistance with purchase and running costs is limited.
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9.6.3 HOME BASED SERVICES Disability support services that enable people to live at home are usually preferred over residential services such as rest home care. Increased access to services such as assistance with household management and with personal care, and meals on wheels, and greater availability of such services, is strongly advocated by individuals with disabilities and carers.
9.6.4 EQUIPMENT The availability of equipment can also help to maintain a person in living at home. This includes a range of mobility, hearing, sight and activities-of-daily-living devices. The need for equipment availability is pronounced for the parents of children/young people with disabilities, including incontinence supplies.
9.6.5 DEINSTITuTI0NALI5A TION Deinstitutionalisation has implications for living in the community. More people with disabilities, and notably with psychiatric disabilities, will be living in the community as deinstitutionalisation progresses. The focus of mental health services resource allocation into community based services rather than into the centralised Porirua Hospital facility will begin to address the issue of community support for these clients.
9.6.6 HEAD INJURY The impact of head injuries upon both health and disability support needs is considerable, and often service needs are wide ranging. Service coordination over this range is required.
9.6.7 COSTS People with disabilities are often faced with additional costs related to their disabilities (e.g. to purchase equipment, transport and other services), in addition to higher than usual health costs. It can mean that medical treatment or prescriptions are either irregularly sought or not sought at all. The affordability of prescriptions is very important for many people with psychiatric disabilities who require regular medication. This medication may support their life in the community, and its absence can severely disrupt that option.
9.6.8 PSYCHIATRIC SERVICES There is a strong perception in the community that people with psychiatric disabilities who have been discharged into the community do not have sufficient support, even though there are a higher number of services per head in Porirua compared with locations in the rest of the Central region. Better access to support with day-time activities, emergency intervention (when this is required), and general assistance with household and other activities required for independent living.
9.6.9 YOUTH ISSUES The high youth population in Porirua and the particular needs of this group were highlighted by the project. Few health or disability support services are targeted to young people. Yet this is a group that faces particular barriers, and feels particularly diffident about accessing general services, especially those which relate to sexual health, relationships and other personal matters.
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9.6.10 CULTURALLYAPPROPRIATE SERVICES The multi-cultural mix of the community provides a similar challenge to both disability support and health service. What a service consists of tends to be based around Pakeha conceptions, so that even when a service is provided, use by a cultural group can be limited. Interviews with providers and feedback from community-based disability support groups showed that they are aware of cultural and language barriers faced by consumers, but they do not always have the personnel, expertise or other resources required to bridge these barriers. Agencies have made progress in some areas - for example, through employment of non- Pakeha field-workers, - but it is acknowledged that there is some way to go in providing filly culturally appropriate services.
9.7 A strategy for irliproving disability support
9.7.1 BACKGROUND A strategy for improving disability support in Porirua must be referenced to broader changes under way in disability support service provision. In the following sections, these broader activities are described before comment is made on their application in the context of Porirua itself, since they are strongly related to the needs identified in the study, either directly or indirectly.
9.7.2 ASSESSMENT AND SERVICE Co-ORDINATION Individual needs assessment for people with non-age related disabilities is due to be introduced progressively from July 1994. This assessment process is complementary to the SNAP process(support needs assessment protocol) already in use for older people with disabilities. Individual needs assessment is a coordinated process for identifying disability support needs, which has been developed following extensive consultation with consumers, service providers and government agencies. The needs assessment process is used to determine, in partnership with the individual, their range of current abilities, resources, skills, goals and needs. The assessment will determine broad areas of support need rather than focus on the prescription of a particular service. Specialist assessment will be drawn on during this phase, as required. It does not follow that every need identified will not necessarily be met by services purchased by Central RHA. Needs assessment is followed by a service coordination process, through which options for meeting the needs identified are discussed, and a package of services that best meets the individual s needs is drawn together. It is expected that there will be differences both in settings and developmental processes for different disability groups. For instance, assessment services for people with psychiatric disabilities will be purchased through community mental health teams.
9.7.3 HOME SUPPORT Central RHA will purchase home support management services in the Central region from July 1994 on. These will be pivotal in making support for living at home a viable option for people with disabilities.
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The service will co-ordinate and manage the provision of home support services to people with disabilities. Core elements are personal care (assistance with activities of daily living) and household management (help to maintain and organise the household). Caregiver support (such as relief care), meals on wheels, professional community services (such as district nursing and physiotherapy), attendant care and social support services will not form part of the range of services purchased through home support management services in 1994/95, but they will form part of the package of home support that is required by clients. Home support management will liaise with such service providers. It is expected that this package of services will expand in succeeding years, as programmes in Part II of the Disabled Persons Community Welfare Act such as Aid to Families transfer to RHAs at 1 July 1995.
9.7.4 EQUIPMENT Of particular note are the changes related to the provision of equipment. At present equipment is available both through CI-lEs and through the Disabled Persons Community Welfare Act, administered by NZISS. Equipment from this latter source is prescribed through the accredited equipment assessment process. From 1 July 1995, RHAs will be responsible for equipment purchase from both of these sources, enabling greater coherency in the basis for provision. This will require an intermediate stage, and from I July 1994 equipment issued by CHEs will also be through the accredited equipment assessment process.
9.7.5 PSYCHIATRIC DISABILITY In 1994 a Central RHA initiated review of general adult mental health services in greater Wellington was completed. It indicated the need for re-development of clinical and community services to respond to the needs identified in this, and in previous reports. The review made recommendations in a wide range of areas. Those recommendations pertaining directly to Porirua are outlined in the disability action summary (see section 9.8 below).
9.7.6 YOUTH Services for young people with disabilities are largely contained within general disability support services, rather than specialised to this group. Young people both with and without disabilities would generally find youth-dedicated services more acceptable. Exploration of a "one stop shop" youth health service, as proposed in section 9.4.7, should explore ways to include young people with disabilities. The issue of youth disability support services requires further exploration.
9.7.7 HEAD INJURY SERVICES A 1994 national working party on head injury made recommendations related to the development of a head injury service structure. 2 Such a service would encompass a range of
Central Regional Health Authority (1994) A Better Life, Wellington 2 Head Injury Working Group (1994) The Review of Support Needs of People with Severe Head Injur y a multi-agency report involving representatives from The Head Injury Society. ACC, and Regional Health Authorities
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core services. There is also a framework for the availability of these services at local, regional or national level. The service delivery would need to be based on individual needs assessment and service co-ordination, and standards for service delivery, developed in the working group would be recognised. The development of a head injury service is likely to be ongoing.
9.8 Disability action summary
The disability initiatives outlined above, which comprise a combination of government policies, RHA developments and completed reviews will, in combination with other identified initiatives, produce the following actions and/or service directions:
9.8.1 ASSESSMENT AND SERVICE Co-ORDINATION The formulation of individual needs assessment and service co-ordination processes which are culturally appropriate for Maori and for other cultural groups is particularly relevant to Porirua. These needs assessment processes will also be disability group specific.
9.8.2 HOME SUPPORT Providers of home support management services that cover Porirua will be expected to sub- contact with at least one Maori provider.
9.8.3 EQUIPMENT From July 1994, CHE providers of equipment such as wheelchairs, will be expected to prescribe in accordance with standards for accredited equipment assessment. This should increase choice, and access to the equipment a CHE provides.
9.8.4 PSYCHIATRIC DISABILITY Of particular relevance to Porirua are the following recommendations: • the focus of resource allocation to be shifted from the centralised facility at Porirua Hospital to a de-centralised community based service • one of three acute in-patient hospital services units in the Central region, comprising 15-20 general beds, 3-5 intensive care beds and 10-15 day hospital places is to be located at PoriruafKenepuru • a community mental health team is to be based in Porirua • specialist services, linking with mainstream services, are to be established for Maori, and for Pacific Island consumers • supported housing, and appropriate clinical support are to be provided to support the transfer of those long-stay patients at Porirua Hospital who are able to live in the community with this assistance • the present forensic services that are based at Porirua are to be maintained as a regional service • supported housing, day services and specialist services for Maori are to be developed.
A detailed implementation plan for the proposed changes is to be produced following public consultation on the review recommendations, which is currently under way.
129 9.8.5 YOUTH Further exploration of disability support services and how these can best meet the needs of young people with disabilities will be undertaken.
9.8.6 HEAD INJURY While no immediate changes or additions to local service delivery is envisaged in 1994-95, the introduction of individual needs assessment and enhancement of service co-ordination is likely to provide a positive impact. A training package to expand the skills of those concerned with delivery of head injury services is to be introduced later in 1994.
9.8.7 PHYSICAL DISABILITY The community support needs of people with physical disabilities currently in long term residential care need to be investigated . The location and delineation of this consumer group, together with a description of their support needs, provides a basis for planning their transfer into the community with the provision of appropriate home based support.
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9.9 Timetable and resources: disability support services
Implementation of home management support Within existing budget provision service: home management support contacts with one Maori provider
Development of individual needs assessment Within existing RHA funding proposals services for non-age related disabilities; mixture of community and hospital based services, depending on disability group
Equipment for disability issued from CHEs Within existing contracting arrangements conforms to principles of accredited equipment assessment I
Establish process for efficient purchase and To be finalised - set-up costs estimated at ri tracking of equipment $10,000 for the Central region Review of requirements for disability support $20,000 services for young people
Review of levels of rheumatology services to To be determined be undertaken by health services also to include disability rehabilitation needs
Assessment of community living needs for Within existing budget provisions people with physical disabilities currently in long stay care
Training package for carers and providers of Within existing budget provisions, $45,000 head injury services for the Central region
Pacific Islands disability information services To be finalised, up to $10,000
Services of one further interpreter (1 FTE)for Within existing budget provisions deaf people TOTAL YEAR ONE $125,000
No recommendations on specific services for people with psychiatric disabilities are included here, as an implementation plan is still under discussion, based on consideration of the recommendations contained in "A Better Life" (op cit)
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Year Two Disability support initiative Rpsop.rce requirement
Further develop appropriate assessment To be determined services options, particularly assessment services for people with intellectual disabilities
Range of home support options is expanded as further home support Cost to be incorporated into contracting services transfer to RHAs to purchase-at least 1 Maori and 1 Pacific Island provider
Central RHA-wide review of service provision for To be determined, est $25,000 - Client/ca rer support - Attendant care - Disability information services
Head Injury support services $20,000 Disability support services for young people initiative $30,000
Review of needs of profoundly deaf in relation to interpreter and social work To be determined, est $30,000 services, and development of services TOTAL YEAR TWO $105,000
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Year Three Disability support initiative Resource requirement
Head injury support services $10,000
Review of respite care services (Central $30,000 RHA-wide)
Further development of assessment To be determined, and linked to the costs and services outcomes in year 2
Further development of home support To be determined services through home management services with priority to identification of Maori and Pacific Island service providers as appropriate
Disability support services for young people $ 20,000 TOTAL YEAR THREE $60,000
133 10. References
Barwick H (1991) The Impact of Economic and Social Factors on Health, report prepared for the Department of Health by the Public Health Association of New Zealand.
Brown C R S, Hilder P N, Scott R S, Maipress W A, Beaven D W (1984) Diabetes mellitus in a Christchurch working population New Zealand Medical Journal, 97:487-9.
Central Regional Health Authority (1993) Report on the Maori Consultation Hui at Maraeroa Marae, Porirua, November 1993, Wellington
Central Regional Health Authority (1994) Morbidity and mortality profile of the Central region, Wellington. (unpublished)
Central Regional Health Authority (1994) A Better Life, Wellington
Central Regional Health Authority (1994) A Healthy Future for Wairoa, Wellington.
Department of Health (1976) Health in Porirua: The Porirua Health Care Survey (1976) Report to the People of Porirua City. Wellington, New Zealand.
Department of Health (1980) Community Attitudes to Sickness and Health: Stimulus and Response, Volumes 1, 2 and 3, Special Report Series No. 56, issued by the Management Services and Research Unit, Department of Health, Wellington, New Zealand.
Crampton P (1992) Iron deficiency anaemia in infants - Porirua Study (This study found iron deficiency anaemia in 10 of a sample of 43 infants).
Elwood, M (1993) Prevention of neural tube defects, clinical and public health policy New Zealand Medical Journal. iQ: 517-518.
Graham P, Jackson R, Beaglehole R (1989) The validity of Maori mortality statistics. New Zealand Medical Journal, 102:124-6.
Grainger J (1990) Asthma services in the West Coast district of the Wellington Area Health Board. Wellington Area Health Board. A more coordinated approach by general practitioners and hospital staff appears to have been effective in reducing admissions.
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Head Injury Working Group (1994) The Review of Support Needs of People with Severe Head Injury - a multi-agency report involving representatives from The Head Injury Society, ACC, and regional health authorities
Isaacs R D, Scott D J (1987) Diabetic discharges from Middlemore Hospital in 1983 New Zealand Medical Journal; 100:629-3 1.
Joyce P (1991) The non-recognition of depressive disorders: a continuing public health concern! New Zealand Medical Journal; 104: 7-8.
Malcolm L (1993) Trends in primary medical care related services and expenditure in New Zealand 1983-93 New Zealand Medical Journal, 106:470-4.
Mansoor 0 (1991) Does control ofpertussis need rethinking? CDNZ, 1:43-8.
Metcalfe S, Ratcliff B, Nye J (1992) Analysis of new entrant and pre-school hearing testing data Public Health Service, Wellington Area Health Board.
Metcalfe S, Roseveare C (1993) "Overs and Unders": a comparison of Health Goal indicators, Wellington Area Health Board vs the rest of New Zealand Regional Public Health Service, Wellington Area Health Board.
National Research Bureau (1994) Assessment of Health and Disability Needs in the southern Pôrirua area, a report of a household survey, prepared for the Central Regional Health Authority, Wellington.
Public Health Commission (1993) Our health, our future. the slate of the public health in New Zealand, Wellington.
Roberts A (1992) A study of the 1991 measles epidemic in the Wellington Area Health Board region: costs, complications and problems Regional Public Health Service, Wellington Area Health Board.
Robson B, Burgess C, Pearce N, et al (1993) Prevalence of asthma symptoms among adolescents in the Wellington region by area and ethnicity New Zealand Medical Journal, 106:239-41.
Salmond G C (1975) Maternal and Infant Care in Wellington - a health care consumer study, Special Report No. 45, Management Services and Research Unit, Department of Health, Wellington.
Scragg R, Baker J, Metcalf P (1990) Factors associated with development of diabetes mellitus: results from a cross-sectional survey in Kawerau New Zealand Medical Journal, 103:575-7.
Statistics New. Zealand (1993) New Zealand Standard Classification of Ethnicity, Statistics New Zealand, Wellington. (see page 26)
135 Statistics New Zealand and the Ministry of Health (1993) A Picture of Health, Wellington.
Strack M F, Wells J E, Joyce P R, Hornblow A R, Oakley-Browne M A, Bushnell J A (1989) Factors affecting the use of mental health services in people with alcohol disorders New Zealand Medical Journal, 102-601-3.
Te Puni Kokiri (1993) Nga Ia o te oranga hinengaro Maori, Wellington.
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APPENDICES
Acknowledgments
Groups that have made a valuable contribution have included the Porirua Community Health Group; the Public Health Unit of Hutt Valley Health, members of which contributed material for the chapter on health status (chapter 4); the Nursing and Health Studies Department of WhitireiaPolytechnic which organised and implemented the focus group meetings (chapter 6); the National Research Bureau, which carried out the household survey; the Porirua City Council, which cooperated with the Central RHA in carrying out the survey, and whose staff provided useful information and advice.
A great number of other organisations and individuals were informed about and contributed to this needs assessment through the consultation and submission processes described in Chapters 6, 7 and 8.
The Bridgeport Group provided an independent analysis of submissions received. Pip Aimer provided research assistance, and Adele Carpinter provided organisational and editorial assistance.
137 Porirua City, population by age, sex and ethnic group, 1991
Ethnic Group: European Maori Pacific Islands Total Sex: Male Female Male Female Male Female Male Female Age (yrs) 0-4 1,125 1,014 723 726 705 660 2,634 2,457 5-14 1,914 1,833 1,080 996 1,116 1,089 4,278 4,050 15-19 1,122 1,020 492 561 558 606 2,241 2,253 20-24 909 900 450 504 465 525 1,869 1,989 25-34 2,124 2,301 606 759 735 840 3,618 4,074 35-44 2,229 2,238 414 483 549 576 3,321 3,444 45-59 2,178 2,073 369 381 474 459 3,120 3,006 60-64 567 522 60 60 63 87 705 690 65-74 675 759 48 57 78 90 831 942 75-84 213 369 9 18 15 36 249 447 85+ 48 141 0 1 3 1 3 6 1 60 159
Age total 13,095 13,170 1 4,248 4,545 1 4,758 4,980 1 22,926 23,514
Source: 1991 Census of Population and Dwellings, Department of Statistics
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Comparative Profile, Porirua City by ward, 1991
Tithhi Bay Cannons Plimmer-ton Porirua City Central Tairangi Horokiri - Creek Region Usually Resident population 10,725 7,608 12,843 7,263 7.950 46.440 856.629 Under 15 25 34 34 23 27 29 23 15to24 17 22 21 14 14 18 17 25to44 30 29 27 35 37 31 31 45to64 17 13 14 21 18 16 18 65&over 10 2 4 8 4 6 11 Born Overseas 17 29 31 20 20 24 16 European only 61 30 27 92 92 57 80 NZ Maori ethnic group 26 25 26 5 4 19 13 Pacific Is. (excl. Maori) 10 41 41 1 1 21 3 Married (Including Dc Facto) 50 51 49 68 72 57 58 Income Support (Excluding Famil y 47 40 47 26 18 37 43 Benefit only) Highest Qual: University 4 2 2 16 13 7 9 Highest Qual: Other Tertiary 24 20 18 34 36 26 27 Highest Qua]: School 19 19 18 24 27 21 23 No Qualifications 37 45 46 15 14 33 29 Personal Income: $30.001 and over 15 10 7 34 39 20 18
Gainfully Employed 88 83 80 94 95 88 90 Unemployed and actively seeking 12 17 20 6 5 12 10 work Women in the Labour Force 49 49 49 46 45 47 46 Professionals 11 7 7 19 16 13 13 47 Private Dwellings: Owned with a 43 33 49 67 47 38 mortgage Private Dwellings: Ownedwithout a 17 6 9 37 23 18 34 mortgage
Private Dwellings: Rented 38 45 55 13 9 33 27 Households: Persons Aged Under 5 22 35 35 16 22 26 17 Years Households: Superannuitants 23 8 15 22 10 16 27 Households: Two or More Persons in 42 48 39 52 62 47 42 the Labour Force Households: One Person 17 6 9 16 9 12 21 Households: At least One Solo 21 32 31 6 6 19 12 Parent Family
Households: Non-Family Household 4 3 4 4 2 3 6
Households Income: $30,001 and 46 43 34 67 75 52 46 over
Source: 1991 Census of Population and Dwellings, Department of Statistics (Generated from Supermap 2)
1 Actual numbers presented in this row, all other figures are column percentages
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Comparative Profile, Porirua City by ward: ratio to the Central Region, 1991
Tihi BayCannons Plier-ton , Porima City Central - Tairangi Horokiri Creek Region Usually Resident population 10.725 7.608 12,843 7.263 7,950 46,440 856,629 Under 15 1.10 1.48 1.45 0.99 1.15 1.25 1.00 15 to 24 1.04 1.30 1.26 0.84 0.85 1.08 1.00 25 to 44 1.00 0.95 0.90 1.14 1.22 1.02 1.00 45 to 64 0.90 0,71 0.75 1.14 0.98 0.88 1.00 65 & over 0.91 0.19 0.38 0.67 0.36 0.51 1.00 Born Overseas 1.07 1.80 1.92 1.28 1.23 1.49 1.00 European only 0.75 0.38 0.33 1.14 1.15 0.71 1.00 NZ Maori ethnic group 2.10 1.98 2.11 0.41 0.32 1.51 1.00 Pacific is. (excl. Maori) 2.97 12.06 12.04 0.29 0.37 6.10 1.00 Married (Including De Facto) 0.86 0.89 0.84 1.18 1.24 0.98 1.00 Income Support (Excluding Family 1.11 0.94 1.11 0.61 0.43 0.88 1.00 Benefit only)
Highest Qua]: University 0.48 0.25 0.24 1.70 1.44 0.76 1.00 Highest Qua]: Other Tertiary 0.89 0.74 0.67 1.26 1.30 0.94 1.00 Highest Qua]: School 0.82 0.83 0.79 1.06 1.15 0.91 1.00 No Qualifications 1.26 1.53 1.56 0.53 0.46 1.11 1.00 Personal Income: $30,001 up 0.80 0.57 0.39 1.88 2.12 1.07 1.00 Gainfully Employed 0.98 0.92 0.89 1.04 1.06 0.98 1.00 Unemployed and actively seeking 1.23 1.72 2.04 0.60 0.48 1.19 1.00 work
Women in the Labour Force 1.06 1.08 1.06 1.00 0.99 1.04 1.00 Professionals 0.80 0.55 0.55 1.43 1.19 0.94 1.00 Private Dwellings: Owned with a 1.13 1.23 0.88 1.28 1.75 1.22 1.00 mortgage
Private Dwellings: Owned without a 0.52 0.18 0.26 1.10 0.70 0.55 1.00 mortgage Private Dwellings: Rented 1.43 1.70 2.06 0.48 0.35 1.25 1.00 Households: Persons Aged Under 5 1.34 2.13 2.09 0.96 1.34 1.56 1.00 Years
Households: Superannuitants 0.85 0.30 0.53 0.80 0.37 0.60 1.00 Households: Two or More Persons in 1.01 1.14 0.93 1.25 1.48 1.14 1.00 the Labour Force Households: One Person 0.81 0.30 0.44 0.77 0.42 0.57 1.00 Households: At least One Solo 1.77 2.62 2.54 0.53 0.50 1.61 1.00 Parent Family
Households: Non-Family Household 0.61 0.42 0.70 0.61 0.40 0.56 1.00
Households Income: $30,001 and 0.99 0.94 0.74 1.45 1.62 1.13 1.00 over Source: 1991 Census of Population and Dwellings, Department of Statistics (Generated from Supermap 2)
Actual numbers presented in this row, all other figures are ratios to the Central region. A ratio of 1.00 means that the proportions are the same as for the Central region as a whole. For example, the proportion of people in Tairangi who are under 15 yrs is 45% higher than in the Central region as a whole. The proportion of sole parent families is more than two and a half times higher in Tairangi and Cannon Creek than in the Central region.
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List of submissions received from community groups
Age Concern Wellington Assembly of God Church, Porirua Arthritis Foundation of New Zealand, Wellington Division Barnardo s Community Services Care and Craft Centres, Wellington CCS Wellington Clifford Foundation Trust Diabetic Group Diabetic Service, West Coast District, Kenepuru Hospital Holy Family School IHC Family Support Service Kapi Mana School Kapi Mana Stroke Club Kapiti Mana Victim Support Service Mana Business and Professional Women s Club Maraeroa School Mental Health Resource Centre Motor Neuron Disease Association of New Zealand National Society on Alcoholism and Drug Dependence New Settler Service New Zealand Foundation for the Blind, Mana District New Zealand Society For Music Therapy Ngati Toa School Pacific Island People With Disabilities Trust• Porirua Citizens Advice Bureau Porirua City Council Porirua Community Health Group Porirua Gospel Chapel Porirua Maori Women s Welfare League Porirua Sexual Abuse Healing Centre Pukerua Bay Senior Citizens Club Rangikura School Royal New Zealand Plunket Society Russell School St Anne s Anglican Parish St Vincent de Paul, Titahi Bay Stroke Foundation of New Zealand, Wellington region Te Kupenga (Horizons - Te Whiti 0 Te Ra) Te Whare Rapuora (oral submission) Tokelau Health Collective Wellington Asthma Society Wellington Multiple Sclerosis Society Whitford Brown Community Workshop Trust Whitireia Community Polytechnic Health Clinic
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