Caring on the margins of society is costly: Profit not the point for central city high-needs practice

The Calder Health Centre on Hobson Street in central Auckland has made a bigger loss than last year, and “one size fits all” funding is being blamed.

Capitation works if practices serve an “average slice” of the population, but three-quarters of Calder Health’s 1855 enrolled patients have high and complex needs, says Jacqui Dillon, health and social services general manager at the centre’s owner, Auckland City Mission.

“We need a model that acknowledges the nuance of [delivering] on the promise of equity,” Ms Dillon says.

The mission has reported to the Charities Services that the practice’s revenue was $623,641 in the year ended 30 June 2022 and expenses were $1,422,452, meaning a loss of $798,811. That’s up from a loss of $584,645 the previous year.

Overall, the mission made a surplus of $16.83 million in the year, down from $37.8 million the previous year, mainly due to lower donations to its new Hobson Street multipurpose property, HomeGround.

Ms Dillon says she is deeply concerned because money donated by Aucklanders is offsetting the deficit instead of resourcing new and emerging desperate need. HomeGround has a fully equipped dental clinic but no funding for it.

Many patients of the Very Low Cost Access clinic have traumatic brain injuries, and deep and complex trauma histories, leading to mental health issues and addictions. Most are Māori or Pasifika.

On average, consultations take 45 minutes and patients visit six times a year. Many have trust issues and come to the Calder Health Centre for the relationship, the mission’s “superpower” for 102 years, says Ms Dillon. Fifteen-minute “clip-the-ticket” appointments aren’t long enough. A broad, psychosocial approach is required because patients have housing and other needs alongside their medical issues.

The practice has two full-time nurses and one full-time outreach nurse, who brings people in. There are also four part-time doctors, a health practitioner, and a social worker. The centre is looking for a full-time-equivalent doctor. One day a week, CareHQ doctors do consultations via telehealth.

For homeless people, the intervention of the Calder Health Centre can mean the difference between life and death. One man in his 60s was sleeping rough and had an infected foot just before the Auckland floods. He didn’t want to come into the practice, so a doctor went out and convinced him to. Once there, he was sent to hospital and put on intravenous antibiotics.

Patients can put money aside every week so they can pay the $16 charge but, says Ms Dillon: “It would be great if healthcare was free for those who can’t afford it.”

Specialist GP Ngaire Kerse, one of Calder Health’s doctors, says many patients can’t afford the fee. Appointments take longer because of mental health problems and addictions, says Professor Kerse, who holds the Joyce Cook chair in Ageing Well at Auckland University.

“Most have such a traumatic history, which has ruined their lives,” she says. The mission provides wrap-around services, but everything is expensive and must be paid for.

Many “501s”, forced to leave Australia because of their criminal history or links, are treated at the practice. “They arrive here but all their connections are in Australia, they’re just lost and have a combination of medical problems and drug addiction,” Professor Kerse says.

There are a lot of people like that in the central city, she adds: “[The Calder Health Centre will never] break even or make money because of the complexity of the clients.”

Ms Dillon would like to see the centre become a locality, saying it could be a model for treating people who live “on the margins”.

“Enabling the cost-neutral delivery of healthcare to Auckland’s most vulnerable would be an obvious demonstration of equitable access to healthcare,” she says.

Its critical decision-makers realise what’s involved in delivering a service like Calder Health Centre.

“Until you have walked among the complex, and at times utter desperation of the patients, it is difficult for members of the public or politicians to understand,” she says.