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Why do people who need healthcare the most have to rely on charity to get it? asks Pauline Norris.

Why is the public health system not meeting the needs of the most vulnerable? Imagine a fire service that only attends little fires, but leaves the difficult ones to burn, or a hairdresser that only cuts straight hair.

Late last year, I had the pleasure of meeting and talking with people who work for social services for vulnerable people in Christchurch. They described their clients as mostly having mental health problems, and often addiction problems. Clients relied on volunteer doctors, and on pharmacies who waive the $5 prescription charge, to get basic healthcare. In Dunedin, Servants Health Centre in Princes St provides free services to people with some of the greatest healthcare need and is almost entirely run by volunteers and funded by donations.

There is no doubt about the high level of need among Servants Health Centre clients. Lik Loh’s University of Otago PhD research found patients at Servants were much more socio-economically deprived than patients at a usual GP clinic.

They were more likely to have to rely on charity (such as food banks) and go without food, heating or adequate shoes. Lik Loh found they were also more likely to have gone without healthcare (doctors, dentists and prescription medicines) because of cost and they visited the Emergency Department more often than patients at the other clinics.

Despite being younger, they were sicker, with COPD (chronic obstructive pulmonary disease) and mental health problems much more common. Lik Loh looked at 21 patients with diabetes, and found that 16 had at least one other chronic physical condition, and 16 had a mental illness or substance abuse problem. In one year, this group were admitted to hospital around 30 times (i.e. an average of 1.5 times each).

Several years later, research by University of Otago medical student Sharmaine Sreedhar found a similar pattern. Most patients at Servants Health Centre had three or more long-term health problems and around a quarter had five or more health problems.

Patients at Servants had complex and difficult lives, and commonly had housing difficulties, relationship problems, including domestic violence, and encounters with the justice system.

In response, Servants Health Centre provides more than just free healthcare. People can drop in without an appointment and the staff provide support and advocacy for dealing with poverty-related problems, such as insecure housing and lack of food, as well as spiritual support and counselling.

Lik Loh points out that these patients are likely to be unhappy with the care they receive in traditional general practice and other mainstream services. Research suggests that poverty leads people to focus on short-term goals rather than long-term goals such as staying healthy. Their many competing needs (having a place to stay, keeping safe, avoiding cold and hunger) may drown out the attention they can pay to their own health.

Lik Loh also points out that specific skills are needed by the healthcare team in dealing with these patients and he stresses the importance of creating an environment where people feel welcome. His research at Servants Health Centre showed that patients valued the friendliness, the wider range of services and the ability to drop in for coffee and chat.

This suggests that there are big advantages in having specific clinics such as Servants that serve vulnerable patients and understand the challenges they face. But it seems very strange that looking after those with the biggest and most complex should depend on voluntary efforts rather than be a key part of our health system.

 - Pauline Norris is a research professor at the Centre for Pacific Health, Va’a O Tautai, and CHeST: the Centre for Health Systems and Technology, in the University of Otago Division of Health Sciences. This column reflects her opinion and not necessarily that of Servants Health Centre.