Whakaaro: An inconvenient response
I have not wanted to debate the health service integration issue in the pages of The GB Weekly, but Dr Eastman’s Whakaaro in last week’s GB Weekly deserves a comprehensive and informed response.
“Inconvenient truths”:
These “truths” may be the truth as he sees it, but others see this issue differently.
The traditional model of general practice in New Zealand was that of small businesses owned by doctors who practised mostly reactive medicine – that is, dealt with patients’ illness as they presented, and provided some opportunistic health advice. Worldwide, this model is being replaced by one where primary healthcare teams focus more on illness prevention and health promotion, and practice nurses and other professionals are far more involved in patient care. Many of you will have experienced this through the Care Plus and cardiovascular risk assessment schemes now operating at the medical centre. Most young GPs now expect to work as part of a team and few want to run a business.
Under the changes proposed in the integration project, the GPs would work as employees of Nelson Bays Primary Health Organisation (NBPHO), in much the same way as hospital specialists are employed by District Health Boards (DHBs). This would free the doctors to focus on patient care and allow us to work in a team where individual skills and contribution can be made full use of.
The doctors will lose control of their practice but will still have significant input into issues of patient care, of course. The PHO and DHB recognise that we are specialists in rural medicine and will rely heavily on our expertise. But we will no longer set the agenda – rather, we will be a part of it. I personally am happy with that – I do not believe the private business model in isolated rural general practice is sustainable, and feel the benefits of such change will outweigh any disadvantage. Employed GP colleagues have described the ability to focus solely on patient care as “liberating”.
Under the integration plan, there would be a local trust board, similar in many ways to the Golden Bay Health Group, but with DHB and PHO representatives, which would set priorities and direction for health services in Golden Bay. Local members would work with the “outside” members – words such as “power” and “overwhelm” are not really helpful in this context. The presence of these outside members will also help with health service and budgeting expertise – we can’t do everything ourselves.
Dr Eastman mentions increased information technology capacity to provide better co-ordination of care. Undoubtedly, all health care workers in Golden Bay using the same computerised records system will be a major advantage, and will be the case if we are all working in one facility. However, I believe the best means of communication is to talk to each other face to face, and to make this happen - with us all working on the same site - is one of the primary objectives of the integration project.
It is true that incremental changes have halted. One of the fundamental goals of the project was to take a far more strategic view of what would best serve Golden Bay into the future, with all the health care funders and providers co-operating towards a shared objective. When this project started, the Golden Bay Medical Centre Trust had no plan for a new medical centre on Rototai Road or anywhere else. The plan was for a further modification of the existing building. One of the reasons for initiating the integration project was, yes, we needed to upgrade the medical centre, but we needed to look at the bigger picture.
There is a crisis in recruitment and retention of GPs to rural areas of New Zealand.
“…attraction is one thing, but retention is just as important, and that seems to be where things fall down again and again,” Damien O’Conner quoted in the Christchurch Press, 22/8/09, in a story about the shortage of GPs in Westport.
Need more evidence? Last year we had two rural GP senior trainees - who have had to demonstrate genuine interest in rural practice to be appointed - attached to GBMC. Both now work in Nelson city. This year, we have no rural registrars.
Over the past five years we have hosted seven senior house surgeons for three months’ rural general practice experience. Of the ones I keep in touch with, two are GPs in Nelson city, one a GP in a Whanganui, one went to Australia, one to Ireland, one is doing an MBA at Harvard…..
How can you say the system “ain’t broke” if no doctors want to come and work in it?
To attract new health professionals we have to offer them an attractive package – a forward-thinking, interesting work environment where they feel they can progress and develop their interests, new ideas are welcomed, feel supported and valued. All this in a beautiful place and welcoming community. And well paid, let’s not forget – remuneration must be at least as good as their urban counterparts. It is this positive attitude that we hope will attract people. Oh yes - and an attractive, functional building to enjoy coming to work in.
We do not have a magic wand to fix recruitment, but at least we have some good ideas.
The high standard of medical and health care in Golden Bay is achieved and maintained through the efforts of the individual staff, in spite of the fragmentation of services. This high standard is not sustainable in the future as the current model does not attract new doctors.
One good example is after hours care, currently provided by a single doctor on duty, who sees patients alone, often meeting them at the darkened medical centre; often having to care for a very ill patient, or perhaps a very drunk or disturbed patient, with no nursing support. Again, we wonder why we can’t attract new doctors – let alone a female!
Contrast this with a patient arriving at a lit, staffed facility, where a nurse can provide initial care whilst the doctor is on his or her way, and the doctor and nurse can work together to look after the patient in a safe and controlled environment. I know which I would prefer if were me or my family.
In an integrated health centre – let’s give it its name – Golden Bay Community Health – Te Hauora o Mohua; rest home beds and hospital beds will not be “mingled” – there will be some which can be used interchangeably if needed, but the rest home and hospital will be separate areas with their own, appropriate characters and identity. The medical centre will, similarly, be a separate area but with an emergency area shared with the hospital. As it is currently, people visit all three facilities all the time, without precipitating uncontrolled outbreaks of disease. Admission of infectious disease to hospital is avoided if possible, and strictly controlled if it becomes necessary. The image drawn of people circulating freely spreading infection is rather ridiculous.
Similarly, the natural disaster risk. This seems to be conveniently moved in and out of play as it suits. Risk of flooding on Rototai Street site? Never! Major earthquake/tsunami/meteor strike directly onto integrated facility - a risk to be taken very seriously. Neither risk can be quantified, and is only one consideration of many when deciding where to build a new health centre.
Dr Eastman considers that Golden Bay Medical Centre and Golden Bay Community Hospital function “adequately” – I agree, most of the time, but believe the people of Golden Bay deserve better.
And to have a rest home in Golden Bay. One where the nearest available doctor is not often over 30km away. One where residents who become unwell can be cared for overnight without having to be transferred by ambulance to the community hospital in Takaka, due to the shortage of trained staff at the rest home.
Integration
Dr Eastman has stated in the past that he is not opposed to integration; he just does not believe it will work. Certainly, for it to work requires willingness to work as a team where other staff’s contribution is valued and respected.
In the first nine years that I worked at GBMC, our relationship with NMDHB was characterised by confrontation. With the integration project I hoped to change that.
This does not mean that Golden Bay does not fight its corner, and certainly in competition for health resources you have to stick up for yourself. But this can be done in an atmosphere of co-operation and mutual respect which the IMG has achieved.
The issue of staff wages is very topical – the reports of Motueka Hospital staff reapplying for jobs at lower pay rates have caused a lot of anxious speculation. I am as aware as Dr Eastman of this concern. The integration business case is based on current pay rates for all staff. We will not achieve our aim of recruitment and retention of staff by offering low wages.
Golden Bay health professionals will not become the poor cousins of urban health workers.
“Golden Bay will not get additional funding…” - This is not entirely true. The new Government is very keen to establish “Integrated Family Health Centres”. Sound familiar? There may well be some funding available to assist in the setting-up stages; we are currently applying and the Ministry of Health is watching developments here closely. We are in a very favourable position, as we have already done most of the work involved.
Cost
One of the reasons why a new medical centre was not proposed earlier is that it was always dismissed as too expensive.
One purpose of the business case developed by the IMG has been to test whether our vision is affordable. There are ongoing discussions regarding funding. Not all investors seek a market return on investment, and as stated above, there is possibility of Government support. There is no intention that the Golden Bay community funds this project itself. It may yet prove too costly. Let’s give it a chance, work through the options, and see. Certainly, we will achieve nothing if we don’t try.
Convenience
Removing the need for ambulance transfers between the medical centre and hospital; allowing doctors to be close at hand to review a hospital patient if their condition changes; creating the existence of “one point of contact” for most primary health care, in and out of hours – these are just some of the conveniences offered by this project.
Closer ties with Nelson-based services will hopefully lead to more visiting specialist services – this certainly fits with the concept of Integrated Family Health Centres.
X-ray will remain as part of a new facility, and the surgical bus will come, just as it does now.
Controversies
The decision that services should be provided by NBPHO was taken precisely because of the lack of expertise in health service management locally. The trust will provide direction and guide priorities.
The DHB is committed to supporting health services in Golden Bay. Ultimately they have responsibility for health service provision – it is certainly not in their interests to let services fail in Golden Bay, then try to pick up the pieces.
Conclusion
It is very easy to criticise others’ ideas for progress and improvement without venturing your own suggestions. We are looking ahead at how to continue to provide a high standard of health care in Golden Bay in the decades beyond 2010.
We have an opportunity to create something here that really works for Golden Bay – let’s not throw it away.
Dr Struan Clark
