If it ain't broke ...

Otago Daily Times

a day ago

Decisions about health services which have an impact on vulnerable people must always consider much more than the immediate bottom line.
Any changes need to cover whether some of the marginalised served might lose confidence and be unwilling to engage with a new service, and what the long-term cost of that might be to the people personally, and to the public purse.
With that in mind, it is hard not to be worried about news the longstanding free needle-exchange service for intravenous drug users in Dunedin, provided through the Dunedin Intravenous Organisation (DIVO) is one of the DISC Trust services which has lost its contract.
The trust also included the Southland Harm Reduction Programme, the Timaru Needle Exchange Trust and Nelson Injecting Community Health Enterprise, part of a network that had built a trusted programme which had run for decades.
But now Health New Zealand Te Whatu Ora (HNZ) has chosen Christchurch-based health service provider He Waka Tapu to deliver the service.
That organisation provides a variety of services including personalised health consultations, community health initiatives, mental health crisis intervention, addiction support services, reintegration programmes, family violence prevention and educational offerings to promote holistic wellbeing.
It has, however, drawn criticism from some in the existing programme because of its lack of experience in providing a service led by peers.
Getting the confidence of intravenous drug users, likely to be fearful of any authority because they know they are breaking the law, is not easy.
Workers in the current programme say it can sometimes take years, particularly when it comes to persuading drug users to use health services. (The Dunedin group also runs a free general practice clinic for its clients, and its future is unclear.)
While HNZ says the request for proposal (RFP) for regional needle-exchange and harm-reduction services clearly outlined the requirements including that people with lived and living experience had significant roles in the design, delivery and leadership of the programme, questions are being asked about how central lived experience will be to service delivery.
We note the brief overview of the RFP on the Government Electronic Tenders Service website makes no specific reference to the need for contenders to provide a peer-based service.
Peer-run services in this area are considered internationally best practice.
Public health academic Prof Michael Baker says the HIV response in New Zealand was among the most effective in the world and it would be a "grave step backwards" if any new provider moved away from a peer service.
It is hard to judge what, if any, consideration was given to the effect of a change on clients of the existing service and whether this might lead to less engagement and more disease. Fears have already been raised the change could lead to more HIV or hepatitis cases.
On the face of it, the decision looks like a cost-cutting exercise, with the funding for the South Island services reduced from the previous $1.4 million to $1m. HNZ has said the funding was based on a new population model. This seems a blunt tool to apply to such a programme.
That suggests that the number of people who might need such a service would be uniform throughout the country. Is there evidence of that or that existing services were getting more money than they needed?
Taieri member of Parliament, Labour's Ingrid Leary, is right to question the population approach rather than a needs-based one. As she says, funding these types of services purely on a population health basis is not necessarily the most logical, especially when specific communities within the broader population have demonstrably much higher needs.
The existing service is to wind up in September, but little is known about how the new service will operate.
It is difficult for members of a marginalised group such as intravenous drug users to speak up about their needs. That can make it too easy, and possibly even cynically convenient, for decisions to be made about them rather than with them.
If this move is expected to be as good as or better for them than the existing service, they and we need to know how.