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Proposed Health Changes

I attended the Cromwell Community SDHB Meeting last week where the SDHB Primary Strategy was presented, along with some local health professionals, with a handful of members of the general public.

Attached are the SDHB bullet points we were presented with.

Below is my response which has been sent to the SDHB. 

In summary, I was extremely disappointed in the strategy as presented.

There was little focus on an improvement or increase in secondary/tertiary services. It was mainly about avoiding bed stays and ED visits to Hospital(s).

My overall impression is that it was poorly thought out, rushed, and the SDHB staff were at times condescending and apparently ignorant of much of primary care and General Practice. It was apparent that this strategy is really the SDHB telling primary care groups that the New Hospital rebuild is likely to result in significant secondary service cuts, with a shift in costs to the public and GP’s

There should be a large public interest in what happens. The SDHB has been managed terribly to date, and the public deserve better. The Government of the day also bears a large responsibility for putting the SDHB in the position it finds itself in.

To respond to the bullet points as presented;

• Why develop a strategy?

 

It seems apparent to me that the only reason is money. Budget overruns and the sacking of the Board, have placed massive pressure from the Ministry, on the SDHB, to cut costs. The effects of this are only being seen now, with massive safety issues and clinical problems in Urology and Eye departments the latest examples.

What has not been publicised to any extent is the apparently planned 30% reduction in beds in the new hospital rebuild, in at least some departments. The CEO Chris Fleming glossed over this, and I would think many members of the public would be dismayed at this. There is no good clinical reason for this, only budgetary, and it will severely hamstring Otago for a generation to come. Hence the apparently mad scramble to “revolutionise” primary care.

To put things in context, the DHB has had little influence or shown any concern for primary care. General Practices provide the majority of Primary Care, their strategy is driven by Wellsouth . We now see apparent deep interest that has not been there before. This plan to “revolutionise” the sector is coming entirely from Board and management and NOT from providers, or Wellsouth, although the latter are attempting to be constructive, in the face of a suck it and see approach. Primary Care is the poor cousin in many ways, yet NZ has a world class system of GP’s, nurses, and allied Health Professionals that just quietly go about their business without fuss. It is recognised as one of the most cost efficient systems in the world and provides excellent care.

The proclamation that Primary Care must make radical changes is not echoed nationally or by the sector, and is simply the SDHB telling us they are dumping patients back on our doorstep in my opinion.

As far as centering the system around people, primary care does this every day. The lack of patient – centered care is the problem of the DHB 99% of the time, not primary care. There are some issues around costs to patients in the community, and localised staff shortages, but on the whole GP’s provide a good service. Patients also have a choice when it comes to their GP, whereas we do not have any choice when it comes to secondary services, with a profound lack of insight into patients plight often demonstrated by Hospitals. I often have patients rung by the hospital and told to be at a clinic in 2 hours, when we live 3 hours away from Dunedin. Or having to make multiple trips and taking days off work, for a 5 minute consult to tell someone their results are normal. I find it absurd that the SDHB is now going to tell Primary Health professionals how to be more patient centered.

• Project timeframes

 

We seem to be on week 15 of this apparently sweeping plan, yet most at the meeting yesterday) have only just been made aware of it, and there is now only 6 weeks left until action is taken. This is a ridiculously short timeframe to apparently change how hundreds of organisations function and are funded, and on which to base a billion dollar infrastructure project. It seems apparent to me this is a plan conceived in the Boardroom with little input from those at the coalface.

 

• Stakeholder engagement

 

I quietly laughed when I saw that the future of a billion dollar hospital, and 300000 patients, is being decided following a few poorly attended public meetings, and a survey and feedback from perhaps 400 people in total. This might seem like a lot of work to the SDHB management on their exhaustive roadtrip, but looks like self-congratulatory back slapping at selling a plan that is already decided on. Holding meetings at inconvenient times (middle of the day) when actual stakeholders are working, suggests a distinct lack of willingness to engage.

Most in the room yesterday were offended by Richard Thompsons’ condescending jibe at health workers, indicating that they should be more flexible in their work arrangements and hours, and indicating unions were partly to blame for SDHB’s difficulties. Very rich coming from a failed board member who scheduled a “stakeholder” meeting in the middle of the day to suit himself and the CEO, meaning many interested parties could not attend. As some pointed out, an evening meeting would have been better, I presume this was inconvenient to the DHB management team.

Mr Thompson went on to further offend by questioning our lack of motivation as healthcare workers, as patients lack easy access to care outside office hours, comparing this to his apparently successful business empire that is open all the time. This astounding lack of insight into how healthcare teams work, and actual clinical demand, was highlighted by the CEO himself, pointing out that surgical outcomes are poor at 2 am, as a fleet of senior support staff and services are then unavailable. Perhaps he should talk to some actual frontline staff to see why most healthcare happens during the day.

 

• Stakeholder feedback

 

Inequity for rural patients, poor IT, previous similar exercises leading to nothing happening, criticizing Primary Care, barriers to care, high costs, and money being the rate limiting step for everything, are all well-trodden paths to failure to change.

From what I saw there is a desire for changes to Primary Care, nowhere did I hear about how the DHB are going to improve their care of patients, simply an edict that it is now everyones problem but theirs to solve.

Maori Health should remain a focus for improvement in both secondary and primary care.

 

• “Principles”

 

In my opinion, only SOME of these principles are applicable. Most are just feel good slogans that don’t represent any path towards positive change, despite the attempted rallying cry at the public forum.

This was the greatest source of amusement and dismay for me. I couldn’t put my finger on it at the time, but this seems to be straight from the pages of Marketing and Psychology texts ( eg “How to win friends and influence people”). This is the bandwagon effect, where if you make it apparent that this is what “everyone” is doing, it will pressure others to come on board. A few of the usual techniques are: Begin in a friendly way, get the other person saying “yes, yes”, let the other person feel that the idea is his or hers, be sympathetic, appeal to the noble motives, and last but not least, throw down a challenge for improvement.

 

• Strategic themes

 

Again its hard to know where these came from except a managers laptop to put on the slideshow. Some have merit but are low priority eg using new technology (see below).

I will pick them apart a little more;

• Increasing self-care. A worthy ideal to some degree. This would be great if everyone was a good little robot and did what they were supposed to. I have spent half my lifetime listening to people from all walks of life, at all hours of the day and night, in varying levels of distress. It is NEVER going to be possible to train 300000 people to only attend ED when exactly appropriate. People are also NEVER going to stop drinking , smoking, falling, fighting, copulating, join the gym, and all be shiny happy beings. This is corporate speak for “go away and don’t cost us money”.
• Increase Primary Care Capability. Again a worthy ideal, except it is at the cost of providers and consumers no doubt. General Practices, particularly in rural areas, already provide many services that used to be provided in hospital eg Emergency Care, IV antibiotics for infection, fracture and plaster management, methadone prescribing, Community antipsychotic administration, Zoladex injections for prostate cancer, skin lesion excisions, IUD insertions, Pipelle biopsies, iron and Aclasta infusions, early pregnancy care, requesting CT’s for kidney stones, Counselling and Mental Health care, and diagnosing and managing many medical and surgical problems that used to be referred. Some we get paid for some we don’t. GP’s have willingly stepped up, when asked. For myself, the “next level” of community care would perhaps involve access to high tech imaging such as CT and MRI. However at present I cant even get a simple Ultrasound for patients without a 9 month wait. The next level of upskilling would also involve access to hospital beds, an operating theatre, and performing surgery. If this is what is intended, then the whole system of medical training need changed. I did not train to be a surgeon. Patients don’t want an amateur surgeon. In summary, a massive shift of resources and skill is proposed, this is corporate-speak for shifting costs from the SDHB to GP’s and consumers.
• Better coordinate care. GP’s are experts at coordinating care, that is one of their core functions. Better coordination needs to come from within the hospital, this is telling GP’s how to suck eggs.
• Using new technology. Sounds great. But wrong. GP’s are so far ahead of many hospitals in the use of IT, again this is telling us how to suck eggs. In our clinic all patients have free access to their records via a portal, to access any time. Despite much exhortation of their benefits by myself and others, less than 10% make use of it. Funnily enough people prefer face to face meetings. 2 minutes in the room with someone will give me more information than 20 emails. As for telemedicine, some at the meeting pointed out that some specialists refuse to use it. It is only suitable for limited circumstances and requires a lot of investment in space and equipment.
• Developing team based ways of working. Again demonstrates a complete lack of understanding on the extensive networks and teams primary caregivers already work in. Sucking more eggs.
• New hubs etc. I will touch on below.
• An integrated health record sounds sexy and exciting but that technology is already here, but has limitations, as well as major privacy concerns. GP’s have had access to hospital records, and now vice versa for Hospital Staff. The rate limiting step in most primary/secondary care stepdown is the long delays in writing letters and receiving information from the hospital. General practices have fully functioning self-funded integrated paperless systems already, whereas the DHB still sends me letters by post that take a month or more to arrive after patients are seen. More sucking of eggs.
• Increasing capability of primary carers to “step up” care. Again, short of an operating theatre and my own hospital beds there is not a lot of “step up” care that can be provided in our community, except perhaps home or resthome-based short term respite for elderly patients. Most colleagues I know are working at the top of their scope of practice already. This is signaling a major shift in primary care in Otago that is out of step with rest of the nation, the College of GP’s, and medical training.
• “A vision of world leading primary care”. I did not see an aspirational goal to have a “world leading teaching hospital”. This implies that we don’t already have world class primary care. This suggests that somehow the deficiencies in the SDHB will be alleviated by GP’s and others in the community improving their game. This is condescending in my view and shows a lack of understanding of what already goes on in the community.

 

 

• The hub and spoke model

 

On the face of this it sounds good. Except this is what we already have in many areas. Again teaching Grandmother how to suck eggs. Many of these “hubs” are vague networks of providers and not bricks and mortar facilities. Whether they will even want to work together is unknown. What does this really mean? A smaller Dunedin hospital. 30% less beds. Dump the services out into the community. I see the final slide (and news headlines) promising a move of funding, up to 50% (!) into primary care, is “ *indicative of strategic direction only ”.

Regions such as Central Otago already have such a model, the rate limiting step is GP’s getting access to services in a timely fashion at such centres, transport issues, and only having specialists visiting a few times a year. Putting lipstick on it doesn’t make it prettier. When questioned about reconciling the budget cuts to Rural Hospitals, and then expecting them to provide more services, the CEO was evasive, and here is where the strategy begins to look pie in the sky. I think the reply was “well we all have to live within our means”.

When announcing the Queenstown Hospital upgrade, the management team reiterated the mantra “we have to get away from a bricks and mortar model”. This is corporate speak for not spending money on buildings and cutting bed numbers and facilities, and again dumping services out into the community, with no more money allocated. In recent times the Auckland Hospital and Christchurch Womens rebuilds have been inadequate due to this philosophy.

 

• Delivery

 

 

• Governance. Wellsouth are doing what they can to aid in changes. I cannot see any other groups on board. Given the SDHB was sacked, there is little or no regional governance or advocacy except from appointed commissioner and staff.
• Care models. As above, this is already there, the DHB management have just not bothered to find out what Primary Care is already doing.
• Care Clusters, as above, a way of dumping services out into the community and likely making others pay for it.
• ICT. As above, much of this future is already here, its just getting people to use it, and, as in education, sticking an iphone and a computer in front of someone doesn’t make things automatically work better.
• Funding. Funding. Funding. There is no concrete plan how funding will change. There appears to be no extra funding coming for our Rural Hospitals that are likely to be the “Hubs”. The management team commented they were constrained due to capitated bulk funding. Guess what! So is General Practice! If the DHB cant do it with exquisitely salaried managers, then how General Practices are supposed to do it is beyond me, with the same constraints.
• GP’s are stuck with a national contract that obliges them to provide certain levels of care. Until this changes (it hasn’t for decades), then these privately owned practices will not be able to upgrade facilities, employ and upskill staff, and see more patients, without major changes to our PHO contracts. It will take a lot of goodwill and engagement, and to date that is not happening. GP’s are private businesses and cannot be forced into models of care that aren’t doable.

 

While I appreciate the effort to hold a meeting, I think the SDHB are well short of the planning and engagement required to “revolutionise” Primary Care. Reliance on this strategy, to get out of building and funding a like-for-like Base and Teaching hospital, is likely to lead to problems for a long, long time. I would have thought the level of community anger at cuts to Rural Hospitals and Neurosurgery in the last few years might have alerted the SDHB to the likely outcome if they proceed.

So what should the SDHB do? Think harder. Talk to actual providers. Get out from behind the board table. Nail down funding plans first then see what can be done. Stop bulls*****g experienced professionals and the public. Sort out the Hospital clinical systems first before telling Primary Health Providers how to function efficiently. Stop making budget cuts the first thing to consider. Lobby the Minister for adequate funding.

Dr Greg White