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Young people walking through the door of Youth One Stop Shops around the country are offered a holistic, wraparound service that many nurses aspire to.
FIONA CASSIE learns that it comes at the cost of a continuous funding struggle to keep the – often nurse-led – youth health services running.

There is a nice circular ending to young mum Ella's* story.

As an 18-year-old, she had her positive pregnancy test with a nurse at Kapiti Youth Support (KYS), and after counselling, decided to continue her pregnancy. Ella was then supported by KYS antenatally, brought her baby to its massage classes, connected with KYS's young parent group and its vegie garden project, and went on to offer childcare for other groups that gather at the Youth One Stop Shop (YOSS).

Now a mother of a happy toddler, the young woman – with a complex family history of her own – came back to KYS the other day seeking advice and help on how to apply for nursing school. Not a bad outcome for a teenager who may have ended up as the wrong kind of statistic.

“That's just through us having continual contact,” says nurse and KYS general manager Raechel Osborne. “With the YOSS model, people can dip in and dip out as they need to. It's having that consistent relationship, which is important in young people's lives. She knew the door was always open.”

Cap in hand

Consistency and continuity of care is the aim of YOSS, but many of the centres live year-on-year, cap in hand, unsure which of the multiple contracts and grants they juggle to survive will be renewed, capped, or stopped.

YOSS run on the tightest of budgets and appears sometimes to only keep the juggling balls in the air through the sheer enthusiasm and sincere belief in the cause by the dedicated nurses, GPs, youth workers, peer support staff, social workers, counsellors, and clinical psychologists providing the services.

Sometimes dedication is not enough. Waves in Taranaki had to close the doors on their health service in 2012 when district health board (DHB) funding was pulled and Christchurch's 198 Youth Health Centre had to temporarily close its doors in 2010, also through lack of DHB funding, but resurfaced in 2012 in post-quake Christchurch as 298 Youth Health Centre. Invercargill's Number 10 also faced a funding crisis in 2010, which was not long after it first opened its door.

The problem is not new. A major 2009 evaluation of the then-12 identified YOSS around the country found that “in general, funding for YOSS is tenuous”. The report, carried out by consultants Communio for the Ministry of Health, went on to say the lack of a national funding model led to “inequalities in youth access to services” across the country, the current funding models were “complex and fragmented”, and short-term funding cycles led to “reduced certainty, sustainability, and a lack of ability to proactively plan services”.

The issue of YOSS sustainability was raised again as part of the Prime Minister's Youth Mental Health Project, and as a result, the Ministry of Social Development (MSD), working with the YOSS network, carried out a review of the ongoing financial needs of YOSS and looked at how to improve their sustainability.

An interim response in 2013 was a one-off $50,000 grant to each YOSS by the Ministry of Youth Development to support youth mental health services and help the more vulnerable YOSS. This year's Budget saw nearly $1.2 million (stepping up to $2.35 million a year in 2015–16) allocated through Vote Health to the ten YOSS that meet the MSD criteria of a YOSS (see below) and distributed according to the size and scale of each of the centres’ services.

Trissel Eriksen, who coordinates the national Network of Youth One Stop Shops (NYOSS), worked closely with MSD on the YOSS funding review, with the aim of centres not having to make media headlines and be on the brink of closing before they garner public and funding attention.

Eriksen, a social worker who has been a pillar of Palmerston North's YOSS centre (simply called YOSS) for 18 years and is also its director, says the 10 YOSS centres are all extremely grateful for the extra MSD funding for social service support to young people. However, ongoing sustainability issues remain an issue, as there was far from funding equity for YOSS across the country.

“We're all funded as individual centres, and at the moment, half of us look really healthy and the other half look a little bit unwell.”

No stranger to unhealthy funding levels is Dr Sue Bagshaw, founder of Christchurch's 198 (now 298) Youth Health Centre, who is now into her third decade of battling for YOSS funding.

“You just can't get used to it. It's about getting the system to work for you rather than against you. That's the skill … and it takes a lot of work for sure.”

The funding security of YOSS currently depends largely on the support – or lack of it – by the local district health board (DHB) and primary health organisations (PHOs).

The 2009 evaluation found that all of the then YOSS were either charitable trusts, incorporated societies, or both. All received some funds from their local DHB and 10 of the 12 from a PHO. All in all, health funding made up 70 per cent of their collective $6.8 million funding in the 2008–2009 year (annual YOSS budgets ranged from $200,000 to $1.35 million).

YOSS’s wraparound service means many YOSS have a range of social service, training, and MSD contracts, including some having contracts with Work and Income to work with NEAT (not in education and training) young people.

But health remains the major funding component for most, and while all DHBs are entrusted to provide youth health in their regions, it is up to each board to decide what youth health services they will fund.

The largest of the YOSS – Hutt Valley’s Vibe with 32 full-time equivalent (FTE) staff and 6,000 young people on its books – has had a very supportive DHB with a past Hutt Valley DHB chair also a past chair of the Vibe’s trust. With strong DHB backing, the YOSS delivers youth health and social services in its two bases and across 10 other sites, including five secondary schools, marae, and a teen parent unit.

Likewise, Palmerston North's YOSS, which employs 16 FTE staff across two sites, has close links with MidCentral DHB and the Central PHO. This includes a special contract with the DHB to transfer the triage 4 and 5 level young people from the local emergency department to the YOSS.

Eriksen describes the Palmerston North centre as one of the lucky healthy ones with a supportive DHB and PHO leading to healthy funding levels.

Why should we have YOSS?

Other centres struggle and some – like Waves – fail. Is that such a terrible thing?

Many communities with YOSS also now have school nurse services or polytechnic and university health centres for those in tertiary education; low-cost medical centres for the unemployed and low-waged; and family planning centres for contraception and sexual health. Do we also need YOSS on top?

Rebecca Zonneveld, a youth nurse practitioner, left low-cost Newtown Union Health Centre a decade ago to become the first nurse for Evolve, the YOSS serving Central Wellington. She says there is no such thing as an average YOSS client and the one-stop shops fill a much-needed niche for a wide range of young people – not just those who prefer the convenience, atmosphere, and anonymity of a free central city health centre for youth but also those who would otherwise not see anybody at all.

“There’s definitely a group of young people who come here who wouldn’t access their family doctors.”

Given this reluctance, their depression, addictions, or STIs would go untreated.

YOSS are good at building relationships with some of those more vulnerable, harder-to-reach, low health literacy, young people, Zonneveld says. Confidentiality is also a major drawcard for many attending YOSS who worry about going to the family doctor and seeing someone they know and having to explain why they are there.

Young people being too embarrassed to attend Family Planning was one of the motivations for
Dr Sue Bagshaw setting up Christchurch's original YOSS, 198 Youth Health. She had been offering a youth clinic at Family Planning in the early 1990s “but the kids still didn't come and when we asked them why, they said it was too embarrassing”.

She formed a trust in 1991, opened the doors in 1995 with two years funding that she eked out to three, and has been a YOSS advocate ever since.

Another pioneer, Raechel Osborne, who has been involved in KYS as a trustee since its founding in 1997, came to YOSS – like many nurses in youth health – from a public health nursing background.

She says while YOSS all evolved differently, at their heart, all centres have people passionate about working with and helping youth. Young people are the reason YOSS exist, and they are trustees and drivers of YOSS’s interdisciplinary services.

“YOSS is an amazing model because it holds the young person central to what it does.”

Having a one-stop-shop for health to employment issues means a young person doesn't have to retell their story again and again, they are not siloed, and they are not referred out of a YOSS into secondary services without someone tracking their progress.

“It’s about making sure that our service fits around the young people rather than the young person having to fit into our service.”

It appears YOSS are good at what they do. KYS's own expertise in offering innovative youth health services was recognised in the 2013 Capital & Coast District Health Board Quality Improvement and Innovation Awards, with KYS taking out both the Team of the Year award and the Supreme Award across the DHB. Other YOSS websites also list awards that their services, nurses, doctors, and other workers have won.

Maria Kekus, the past – and founding – chair of the Society of Youth Health Professionals Aotearoa New Zealand (SYPHANZ), says when it comes to youth health services, it is not a case of “either/or” but of young people having the right to access healthcare and ensuring there are not unmet needs.

Kekus, also a youth health nurse practitioner, until recently worked for HealthWest in West Auckland and was clinical lead for the Youth Health Hub, which opened last year in Henderson in league with Health West, Waitemata DHB, and a consortium of other services, including Youthline. Like the name suggests, it is not a YOSS but a hub for specialist and collaborative youth health services, including mental health and addictions. Although it doesn't offer walk-in services, it never turns away a young person in need.

She says YOSS is a great model but points out that with Waitemata DHB having 34,000 young people under 25, it would need five YOSS to serve West Auckland communities, let alone the North Shore and beyond. What she sees as most important is that New Zealand ensures young people's right to access healthcare and that cost is not a barrier to getting the healthcare they need, whether it is provided at secondary school, a YOSS, specialist DHB services, or general practice.

Bagshaw agrees that when it comes to youth health, it is not an “either/or” situation with, in particular, nurse clinics in schools being “absolutely vital”.

“The problem is that they don't cater for the young people who drop out early or the people who have left school. The most under-served people in our community, I believe, are the 18–22-year-olds because they don't have regular employment. They are casual labour, on cheap wages, or they are students and they can't afford a GP.”

Gill Alcorn, a nurse practitioner who has been working at Hutt Valley's Vibe for the past 11 years, stresses that YOSS are there to complement rather than compete with general practice. One caters for patients across the lifespan, while the other's specialty is young people from age 10 to 24.

Do they make a difference?

At present, YOSS are rich in anecdotal reports of making a difference and also efficient in reporting outputs to meet the requirements of their multiple contracts.

But a lack of robust data from YOSS on actual health outcomes was one of the findings from the 2009 YOSS evaluation report. The report also note, however, that, though that, despite the lack of evidence, YOSS managers strongly believed that their services improved the health and wellbeing of their clients, and 89 per cent of stakeholders and 94 per cent of clients surveyed agreed with them.

Osborne and the improvement-focused KYS decided to work in partnership with company Evaluation Works to develop an outcomes model and measure for YOSS.

“Anecdotally, feedback indicated that we were making a significant difference for the young people that use our service, but we needed a measure and reporting system that fully captured our integrated, interdisciplinary, and positive youth development approach to working with young people, and which was both robust and outcomes-based.”

Thanks to Health Research Council funding, KYS has been able to undertake an impact evaluation study (reporting findings shortly) and to further develop the outcomes measurement tool. Plus some additional MSD funding is being used to use the tool to develop a comprehensive monitoring and reporting framework.

“It is about measuring the difference we make to young people. It wasn't funder-driven, but it is a tool we can use to show funders what change we make.”

KYS was also deeply involved in trialling the self-help e-therapy tool SPARX and is part of both the international Pathways to Resilience research study and the longitudinal Youth Transitions Research study.

Smell of an oily rag

Talking to YOSS stalwarts, a common characteristic is positivity, which is probably an essential survival technique in a health service where funding certainty is never a given.

Osborne strongly believes that YOSS, like KYS and others, are delivering high quality and best practice youth health services not only of national but international standing.

But when pushed, she acknowledges it is challenging doing so knowing that the majority of KYS's nearly-a-dozen funding contracts expire in June next year.

Bagshaw says the Christchurch centre has to apply to two philanthropic trusts a month just to maintain their base income. “It's very time-consuming.”

YOSS around the country invest a large amount of time not only in building and maintaining relationships with funders but also in meeting the individual reporting requirements of their on-average 10-plus funding contracts.

Eriksen says for the young person walking through the door, it looks simple, but behind the scenes, it is a complicated scrabble of allocating subsidies and costs to different funding pots and spitting out outcomes reports at the other end that makes sense to the funder and satisfies their contract.

She adds that funders never want to fund “boring” back-office stuff like overheads.

“When the money comes in, absolutely everybody sticks it on the front line because that's what delivers outcomes.”

However, this is no good for long-term sustainability or capacity building.

Eriksen says after the Ministries of Health and Social Development scrutinised the finances of the YOSS, the feedback was something like “we know that you told us that you run on the smell of an oily rag … but you really do run on the smell of an oily rag”.

“I think we ran some figures and found that we run at about half the cost of a general practice,” adds Eriksen. They strive to keep nurses salaries aligned with nurses in the public sector but can struggle.

“Nobody does it for the money … and sometimes that's a good thing.”

Don't fit neatly into one box

Amongst the funding struggles YOSS face is having a client base whose needs straddle across primary health, mental health, and youth health, not to mention social services and education and training needs.

“We don't fit neatly into any one box,” says Osborne.

One box YOSS struggle to fit into, but have been encouraged to do so in recent years, is joining a PHO. The PHO funding model is built on population-based funding for each patient/client you enrol.

While many YOSS are now members of a local PHO, Eriksen points out that with PHO membership comes the tricky issue of how many young people need or want to enroll with a YOSS as their main health provider.

“Generally, enrolment doesn't work for young people, and it doesn't work for the business model of a YOSS,” says Eriksen.

She said Palmerston North trialled enrolments “but it doesn't really work” so it has stuck to being bulk-funded by its local PHO and agreeing not to “double dip” by claiming back the GMS (General Medical Subsidy) for clients enrolled in a general practice or provider elsewhere.

“If you have a generous bulk fund, you are not pushed to look for all the types of claiming that you can do,” acknowledges Eriksen.

“But if your bulk funding is bare bones, then you absolutely go for everything you can.”

This includes not only GMS, but also ACC, maternity co-payments, sexual health co-payments, and others.

Osborne agrees that joining their local PHO has been “quite challenging”, not least because of confidentiality issues if a young person goes back to visit their usual general practice with a parent who is unaware they are using YOSS services.

She says KYS has about 700 young people enrolled with them as their main health provider but the majority of their 5,000 registered clients choose to remain enrolled with their existing provider – which is likely in most cases to be their family's general practice. Likewise, PHO member Evolve has about 5,000 clients on its books, but only 800 clients of those are directly enrolled with them.

Nurses and NPs are now able to claim the General Medical Subsidy (GMS) for seeing clients enrolled elsewhere, and Osborne says it will start claiming shortly. Zonneveld says Evolve has already starting to claim GMS clawbacks for eligible PHO clients, which is having a positive impact on their income.

Vibe, one of the oldest and most sustainably funded of the YOSS, is also one of the exceptions in not having joined a PHO, thanks to a successful funding relationships, says Alcorn.

“There has been that willingness to fund and support us separately, so we haven't been made to go down the PHO track.”

Part of their income comes from claiming ACC and GMS subsidies, but Alcorn says it is minimal compared with the bulk funding that they receive.

Any easy answer?

Is there a simple solution to creating a sustainable YOSS model?

Alcorn thinks the model developed by Vibe with Hutt Valley DHB is one that could work across the country. But Vibe still doesn't escape from the same issue facing most YOSS – multiple short-term contracts – particularly since the three neighbouring DHBs started cooperating and Vibe's health contracts have gone from three-yearly to yearly.

A common wish expressed by a number of people Nursing Review spoke to is that funding should follow young people wherever they seek health services.

“There's always been that debate for a long time since I've been involved with youth space … that the money should follow the young person,” says Kekus.

“The problem is that we see general practice as the primary care home, but there are different models of primary healthcare that YOSS, and some of the iwi providers, have demonstrated.”

Kekus adds that rather than dividing and segregating off youth health, we need to “to start changing the mainstream system to help all our populations”.

Alcorn and Zonneveld agree that having YOSS doesn't absolve general practice GPs and nurses from the requirement of being skilled in engaging and working with young people – including the need to assure young people about confidentiality.

The pair of NPs believes for equity's sake there should be YOSS in sizeable communities.

“In my perfect world, I'd like to see a YOSS in every city and big cities to have several,” says Zonneveld.

The veteran youth health advocate Bagshaw sees the problem facing YOSS stemming from youth one stop shops being a ‘bottom-up’ community solution to meeting the needs of young people. Therefore, it clashes with a ‘top down’ government bureaucracy that doesn't know how to deal with them.

Meanwhile, YOSS keep on keeping on doing what they do best: caring for and supporting young people.

“We've had to survive, and it hasn't been easy for us,” sums up Osborne. “But it’s about how we face challenges. One door might shut, but it’s going to the next door…

“That's incredibly exhausting, but the work we do is incredibly satisfying, and I know that it makes a difference to young people's lives. That is what drives us.”

It’s an inspiring task – and one that would definitely be easier if the funding dollars flowed as simply and consistently as the number of young people who flow through the door. :