Health Charitable Trust to Fund and Provide Acute Care

Integrated Healthcare (possibly Whakakotahi Hauora) aims to use a charitable health trust structure to provide high level acute (unscheduled) care to the community (initially Franklin is to be the most likely location).

In July 2017, the decision was made by Pukekohe Family Health Care (PFHC) to close their GP-led Urgent Care (Accident and Medical) as staffing issues finally took their toll on the provision of general practice services to its registered patients.

Franklin is a growing area of South Auckland that may add as many as 250K to its population. While the CMDHB provides emergency level care at Middlemore Hospital, this is located along the northern border of the DHB in South Auckland and impairs access for the southern population of the DHB as they must fight heavy traffic except for the most off-hours journey. The minimal drive time to Middlemore Hospital is still 30-45 minutes from the Franklin region.

Funding for Emergency level care is provided by the Government through the DHBs (a system that may be changing given the recently announced health and disability sector review). Any NZ citizen or permanent resident will receive ‘free’ care in the funded services provided in the public hospital and tertiary clinic systems. The services provided by the Emergency Departments are of a very high standard, but wait times for lower acuity patients is usually extended at best given the limitations of available resources in the hospital setting. A majority of these lower acuity cases could seek care at any number of ‘Urgent Cares’ in the region but these services come at a cost some patients cannot afford.

Given the extended commute time and the potentially excessive wait times, South Auckland/Franklin would be best served by a facility that is able to provide Emergency Department level services so that both patients and ambulances could stay local. Currently, there is no funding scheme to support Emergency services outside of public hospitals. Such a facility would likely have to be a ‘private’ urgent care but staffing should be such that the higher level of emergency services could be provided especially after a ‘purpose-built’ site was established with proper radiology, point-of-care ultrasound, and laboratory services.

Eventually, this facility would need to be 24-hours and this could allow limited overnight observation if these services were ‘economical’ either through after-hours subsidisation, possible funding grants (from other charitable trusts), or self-funding through donation-fees.

The advantage of a health charitable trust is that care could be provided with the fees (comparable with normal urgent care charges) charged for services provided to be considered as donations. This would likely mean that paying the fees could be considered ‘optional,’ but relying on the good will of people to be part of the ‘giving economy.’ If the patients/family fail to donate sufficient funding, the operational budget would require additional sources of funding. These additional sources could include subsidies from the DHB (to off-load the Emergency Department-done for ‘local’ urgent cares near MMH via vouchers) or from the Ministry of Health. Additional operational funds could be generated by ‘non-service provision’ donations or through subscriptions like is currently done by St. John or grants to the health trust to serve various goals of other similar charitable organisations.

Any ‘excess’ operational funds of the charitable trust could then be put back into provision of care for disadvantaged or appropriately needy individuals or families at the time they require care. Any additional excess funds could then be used to help improve the health of individuals with particularly unsubsidised health needs or to serve segments of the populations that need additional education or services to contribute to improving their overall health and that of the greater South Auckland community.

As noted above, another important aspect of a charitable trust is the ability to apply to other trusts for grant funding. Grants are one-off (or occasionally on-going) funding mechanisms that allow the other trusts to achieve various aspirations. Integrated Care would be looking beyond provision of acute care services as its capabilities grew to further provide educational and medical training as well as improving the health of the surrounding community. If sufficient grants could be obtained, then it may be possible to further lower direct costs (donations) to the patient population or possibly expand care options within the region.

Tentative Terms of the trust deed or set of rules:

Name: Integrated Health trust (or some other variant)

Purpose: To improve the availability of acute care services within the South Auckland region and support the efforts of the population to have access to high quality emergent and general practice care

Board Make up: largely to be determined, but would include a chair, possibly representatives of General Practices in the region, the Clinical and Nursing Directors, representatives from the Franklin Locality through Counties Manukau DHB (or other representative to ensure service continuity), Maori representation, the Clinical Leader of Emergency Medicine at Middlemore (or their chosen alternative), and 1 or more civically minded individuals who would represent the wider community (no fewer than 5 board members, no more than 9)-again, this is tentative

Property management: the Board would manage leases, appointment of the Clinical Director of medical operations and the funds from donations, grants and generated funds from the Clinical operations (Urgent Care/ECC) as well as distribution of funds in line with the goals of the Trust (medical grants, supportive services, etc). The Trust would publish summary financials to allow the wider community to be aware of the activities and financial stability of the Trust.

Powers and Duties of Trustees: The Board would meet no less that 2 times per year and more often if needed. The Board would review clinical operations against desired goals of the Trust. The Board would address any relevant concerns or potential problems with the Clinical Director and Director of Nursing. Review of the Trust’s financial position every 6 months and adjustments in operations as needed to be fiscally responsible (this may include looking for additional funding streams in keeping with the goals of the Trust). Any funding requests would be considered and either granted, denied or deferred to allow additional information to be gathered relevant to the request.

Meetings: The Board will meet no less than every 6 months. Quorum would require two-thirds of the trustees to be present. Meeting would be posted on the Trust’s website, on-site of clinical operations and local GP surgeries. The meetings would be open to the public

Financial affairs and reporting: There will be an administrative team that reports to the Board at all meetings. Standard accounting practices and good business practices will be used to ensure all funds are managed responsibly and sustainably. All efforts will be undertaken to ensure that the financial health of the Trust is communicated to the wider community on a regular basis not less than yearly.

Seal: A common seal and other identifying materials will be developed for the Trust

Alterations/amendments: to the Trust Deed and Rules: any proposed or necessary changes to the Rules of operation or the Trust Deed itself will be advertised on the website and through other appropriate channels deemed necessary for wider community feedback and involvement. Any changes will require a 2/3’s super majority vote of the Board. The results of all such votes would be recorded in the minutes and available through the website and electronically if requested (provision of printed copies if deemed appropriate)

Distribution of surplus assets on winding up or dissolution: if the Board of Trustees decides that the Trust is no longer the most appropriate way of managing the health needs of the community or the services are not fiscally sustainable, (after public notice and consultation) the Board can vote to wind up the Trust. Subscription funds will be returned in a pro-rated manner and grants returned to their source. Any remaining funds will be donated or granted to other trusts in line with the goals and rules of Integrated Healthcare Trust.

Drafting the Trust Deed and/or the set of rules are legal documents and will need to be properly prepared. Any ambiguity could contribute to problems and later be expensive to resolve (decreasing the goals of the Trust). Formation of the Trust will require some work with a solicitor and contribute to the costs of forming the Trust. Among the legal documents that will be required is an application for incorporation. Further details on operations will be determined at the Boards first meeting that set out goals and rules. Community consultation and involvement will be sought to ensure the Trust is meeting the needs of South Auckland/Franklin.