Appendix Two

Evidence and background in support of the retention of

the local provision of acute medical care in Hawera

Dr Keith T Blayney MBChB, Dip Obst, FRNZCGP (General Practitioner)

k.blayney@bitworks.co.nz         http://home.bitworks.co.nz/blayney

August 2001

Hawera Hospital in its current or new site should be able to provide safe and cost-effective secondary acute medical care, providing appropriate resident specialist staff are recruited and supported more effectively than in recent times. Without resident specialists, the Emergency Department, support services (laboratory, X-ray Dept etc) and ambulance services face viability issues, leading to further downgrading of the hospital, town and district against the wishes of all sections of the South Taranaki community for very debatable high cost "gains" in New Plymouth. There is evidence that transferring acutely ill patients is dangerous and frequently unnecessary as much of the apparent safety of larger hospitals over smaller hospitals is the result of simple measures (such as the use of asprin), and indicate a need to maintain peer review and CME, and a greater transfer of information, rather than patients.

Contents:	you may go directly to a selected topic
[1] Political aspects	[5] Finding Physicians
[2] Legal aspects	[6] Clinical Safety & efficiency
[3] Maori perspective	[7] Technology & centralisation
[4] Evidence-based Objectives	[8] Other considerations

 

[1] Political aspects

The previous National administration recognised the need to maintain secondary services and that this was not always the cheapest option. The Hon Bill English stated "Government is already acknowledging the special needs of rural and provincial communities as a significant premium is paid to support rural hospital services. We will continue to do so if other services cannot be reached within an acceptable time. (Hospital Services Plan Securing better hospital services into the future Hon Bill English Minister of Health September 1998.

The current Minister of Health, the Hon Annette King released The New Zealand Health Strategy in December 2000, identifying the Government's priority areas. It aims "to ensure that health services are directed at those areas that will ensure the highest benefits for our population, focussing in particular on tackling inequalities in health.

This Strategy identifies seven fundamental principles that should be reflected across the health sector. Any new strategies or developments that are carried out should relate to those seven principles.

The principles are:

• acknowledging the special relationship between Maori and the Crown under the Treaty of Waitangi
• good health and well being for all New Zealanders throughout their lives
• an improvement in health status of those currently disadvantaged
• collaborative health promotion and disease and injury prevention by all sectors
• timely and equitable access for all New Zealanders to a comprehensive range of health and disability services, regardless of ability to pay
• a high-performing system in which people have confidence
• active involvement of consumers and communities at all levels.

It is my contention that none of these principals are met by the plan to permanently transfer all acute medical admissions to Taranaki base Hospital. Time constraints (luckily, for you the reader) prevent an extended discussion of each point, although I am more than willing to do so, either with the Independent Medical Advisor, or in a subsequent submission to the Board.

At the end of the Health Strategy document, there is a note

"There have been concerns expressed about consultation recently, including:

• a concern that despite consultation, the consulting agency is unwilling to change its intentions as a result of submissions
• a feeling that there is a lack of logic to the increasing range of subjects that are consulted on that results in some people feeling they are being over-consulted
• a concern that not enough time is given for compiling and presenting submissions
• lack of feedback about the final decisions taken and the reasons for these decisions."

In the current situation, there is real concern in South Taranaki that all four of these problems exist with the TDHB and its predecessors. The first is the obvious one, as no amount of logic, emotion or alternative suggestions have prevented the steady down-grading of Hawera Hospital over the last 15-20 years. There is confusion over what form and content submissions now and in November should take, and many people have not had time to prepare a submission. Finally, there will need to be some better reasons given for any adverse decision, or the community will be wanting to explore legal and political alternatives, ranging from court action through to some form of divorcing ourselves from North Taranaki, either alone or in co-operation with Wanganui.

We believe that an adverse decision would not be viewed in a positive light by the Minister, and she may well be sufficiently annoyed to support moves towards independence of South Taranaki from New Plymouth.

 

[2] Legal aspects

The statutory objectives of District Health Boards (DHBs) as outlined in Section 22 of the New Zealand Public Health and Disability Services Act 2000 (slightly abbreviated) include:

• Improve, promote and protect the health of individuals and communities [S.22(1)(a)].
• Promote effective care or support for those in need of health and disability services [S.22(1)(c)].
• Improve, promote and protect the health of individuals and communities [S.22(1)(a)].

I will attempt to show that the proposal to transfer all acute medical admissions is not consistent with these three requirements.

• Reduce health disparities (with a view to elimination) by improving health outcomes for Mäori and other population groups [S.22(1)(e)].
• Implement programmes and services to eliminate health disparities between population groups [S,22(1)(f)].

The above two objective requires Boards to assess health need (and consult), then determine and implement appropriate actions [S.3 and 38 (3)(a)]. Maori in South Taranaki have traditionally had difficulty using secondary services because of cultural, transport and whanau access issues, but many of these barriers have been reduced or eliminated in Hawera. To now expect this high risk group to accept care in New Plymouth away from their whanau and in a less sensitive environment is unrealistic and will being treated as a breach of this statutory requirement.

• Exhibit a sense of social responsibility with regard to the interests of people receiving services [S.22(1)(g)]

The 1994 case of Napier City v Health Care Hawkes Bay involved a decision by a crown health enterprise CHE) to establish a regional acute hospital at Hastings and to reduce services provided at Napier hospital. The decision was ordered to be rescinded by the Court and the CHE was required to give the plaintiff adequate opportunity for consultation. In particular, the CHE was required to adequately "communicate" with the plaintiff. The CHE was required to give the plaintiff the information to which it was entitled and a reasonable time to consult and make submissions. The Court recognised the social and political issues associated with the decision.

• Foster community participation in health improvement and in planning for services and changes to services [S.22(1)(h)].

This requirement has not been particularly evident in the current attempt to change services in South Taranaki. When the Chief Executive Officer presented his view of "Service Options" for South Taranaki at the Taranaki District Health Board Ordinary Meeting of Thursday, 28 June 2001, a resolution (E3) was minuted to permanently close the High Dependency Unit, transfer all acute inpatient admissions to Base, admit only low acuity inpatients under a Resident Medical Officer and establish a permanent visiting physician service. It was only the massive public opposition to these recommendations that forced the Board to consult the community.

Furthermore, it has been confusing for the public (and the South Taranaki District Council {STDC} and the General Practitioners {GPs}) as to when and how they can "participate in the planning". The "Process for Consultation" asks for submissions on the "Terms of Reference" for the Independent Medical Advisor (which is hard enough to understand for people of above intelligence), then a second clause requests input on alternative health service models and options (and this has gone unnoticed by most of the population, including myself and the STDC until recently). After this point, there is no possible public input until after the TDHB release their preferred options, one month before the final decision is made on the first meeting of the new Board. This forms another breach which could be legally challenged.

• Exhibit environmental responsibility [S.22(1)(j)].

It could be argued that transferring every acute admission by ambulance or helicopter is not environmentally friendly.

• To be good employers [S.22(1)(k)].

One of the reasons it has been hard to retain physicians is the failure of the Board to be good employers. The failure to provide locum cover for leave (annual, sick or conference/sabbatical) when there were only two physicians placed them under immense strain. There was a reluctance to go on leave, as this left the other alone on a 1:1 roster. This did little to assist with reducing the professional isolation that management frequently refers to as a reason to remove specialists from Hawera.

Section 27 of the New Zealand Public Health and Disability Services Act 2000 describes how Members of the Board must act:

• in good faith
• with reasonable care, diligence and skill
• with honesty and integrity
• in accordance with any code of conduct that applies to Crown entities.

I have, and continue to have no tolerance for any lack of honesty and integrity by the Board or its management. The issues are vital to the health and future of the South Taranaki community and must be fully open to public scrutiny. Any continued atmosphere of secrecy and subterfuge invites a response of distrust and bitterness which will result in audits and legal action, instead of co-operation to achieve the health results we all claim to espouse.

 

[3] Maori perspective

While not claiming any special qualifications to speak for Maori, I do have Maori patients who expect me to treat them and their values with respect. It is often frustrating to see an assumption that cultural considerations are in place by the simple reference to the term "Treaty of Waitangi principles", with no attempt to define what is meant by this. Is it a recognition that Maori have autonomy (mana motuhake) and sovereignty (tino rangatiratangi) in the field of health, or that Maori must be provided with Maori health workers or that recognition and respect for Maori values becomes a part of healthcare delivery or maybe as British subjects, they have the same rights and responsibilities as other New Zealanders?

Clearly the "principles of the Treaty of Waitangi" mean different things to different people, and is beyond the scope of this appendix. My submission, is that the TDHB must at least understand what is important to Maori and how that affects their access to health services as well as looking at the evidence on Maori health determinants.

Te Whare Tapa Wha or "The Square House Concept" is a concept of the four dimensions Maori describe in maintaining their health, like the strength of the Marae.

• Taha Whanau, or link to family, ancestors and descendants
• Taha Wairua or the spiritual essence
• Taha Hinengaro or the mind, thoughts, feelings and emotions
• Taha Tinana or our physical being

Taha Whanau	Taha Wairua	Taha Hinengaro	Taha Tinana

These form a holistic perspective that is totally consistent with modern medicine, and to ignore it by uprooting Maori from their whanau, paying no heed to their spiritual and emotional needs in an entirely physical approach is doomed to failure. I have confirmed with a number of patients that they would be unlikely to accept admission to Hawera if it meant automatic transfer to Base. If they were admitted under a local physician with some empathy for their Te Whare Tapa Wha needs and a clear need for more specialised investigation or treatment was understood by the patient and whanau, transfer would be more acceptable.

Of interest in the report Our Health, Our Future - Hauora Pakari, Koiora Roa: The Health of New Zealanders (Ministry of Health 1999), it was demonstrated that the rates of hospitalisation for Maori are about 20 percent higher than those for European/Others overall. However, once adjusted for socio-economic status, Maori rates are slightly lower for most age groups! It would seem stupid to put further economic barriers to Maori obtaining access to secondary care, when Boards are charged with reducing this inequity.

 

[4] Evidence-based Health Objectives

The New Zealand Health Strategy (King 2000) outlines a number of evidence based Health Goals and Objectives, which were based largely on the New Zealand Burden of Disease study (Ministry of Health 1999a), which analysed the size, modifiability and distribution of the (fatal and non-fatal) health burden associated with over 100 major diseases and injuries and eight chronic disease risk factors. This analysis provided a better evidence base for health objective development than has previously been available in New Zealand, especially with respect to the integration of fatal with non-fatal outcomes and the trade-offs between level and distribution of health (ie, it isn't just hot air).

[DALY = disability-adjusted life year]

Figures 1 and 5 taken from the study clearly show that even when adjusted for "equity" and "modifiability", Ischaemic Heart Disease (IHD) and smoking are far and away the most important the causes of reduced healthy life, for both Maori and non-Maori. While the TDHB can now make a greater impression on smoking, given its responsibilities in the public health field, it is the prevention and management of IHD that requires more attention than other diseases. Most of the studies I subsequently quote relate to management of acute IHD (angina, myocardial infarction) and stroke and the rôle of the rural or community hospital, and relevance and safety of transfers to larger secondary or tertiary units.

 

[5] Finding Physicians

Initial research can be viewed at Research.html#1) but the best material is in part of my recent submission literature review (Find & Retain))

[6] Clinical Safety and efficiency

Initial research can be viewed at Research.html#2 but the best material is in part of my recent submission literature review (MMO))

[7] Technology and centralisation

Initial research can be viewed atResearch.html#3 but the best material is in part of my recent submission literature review (small))

[8] Other considerations

Further research has been included here (see Research.html#5) along with Historical Documents (see Research.html#4)

 

It is unfair to justify downgrading Hawera because of higher costs faced by the TDHB for high tech cardiac, intensive care and emergency departments in New Plymouth and for expensive management costs. South Taranaki wasn't asked if it would prefer to trade its resident specialists for a bit more high tech an hour away.

 

Keith Blayney