South Taranaki GP response to pisk

South Taranaki GP observations on some of the Pisk Report Recommendations

[please refer to Independent Reviewer’s Report by Dr Dennis Pisk]

On the evening of 22nd January 2002 eight South Taranaki GPs discussed some of the recommendations made by Dr Dennis Pisk in his Independent Reviewer’s Report to the TDHB. There is a general acceptance that Option Three has the best chance of success and that the team of Multi-skilled Medical Officers (MMOs) could care for a much greater number and complexity of patients safely in Hawera than at present. In fact we believe that this option should not preclude the possibility that one MMO could have (or gain) specialist qualifications but remain happy to restrict his/her practice to general and less complicated cases, ie a mix of Options One and Three.

However, there was considerable concern that senior management would not provide the support necessary for Option Three to work. Also, there has to be a change in the way the MMOs are attracted and supported once they come to Hawera.

In particular we have concerns about the following specific recommendations of the report:

The recommendation “That a virtual ward round be conducted daily......” [5] has been misinterpreted as costing an extra hour of a Cardiologist’s time per day ($16,000 p.a.). We presume Dr Pisk intended this to be a short review of each cardiac patient in the monitored beds, which would normally only take a few minutes of the Base CCU consultant’s time while he was in the (Base) hospital. If, because of some uncertainty by the Hawera MMO, the patient had to be transferred to Base, the consultant would need to see him/her anyway, and this would undoubtedly take more time. We believe that this recommendation should be accepted as it should save (not cost) consultant time. The $130 cost of a speaker is recovered by avoiding the transport costs of one patient.
The recommendation “That the outpatient clinics ... be increased.... to provide physician presence at Hawera Hospital on a daily, Monday to Friday basis. The day schedule should include 1 hour availability for ward consultations and 1 hour for GP teleconference consultation...[and] MOSS [/MMO] CME......” [16] has likewise been interpreted as requiring an additional 1 FTE physician. It is a little difficult for us to understand how this is derived from an estimated requirement of an additional 5 days medical staffing per month. However we believe that:

• if some of some days were spent at Stratford or Patea (as well as some time each day at Hawera), the number of additional hours may prove insignificant (and could well reduce pressure at TBH clinics).

• the need for 1 hour daily for GP teleconference consultation is probably unnecessary.

• a daily availability of a specialist to give a consult/opinion for the odd “difficult” in-patient will provide elements of support, safety and education needed for the whole scheme to succeed.

• this recommendation is fairly crucial to maintaining support (clinical, peer review and CME) and reducing professional isolation for the Hawera MMOs (and to a lesser degree, the GPs).

• if MMOs of sufficient skill and experience are found, the amount of clinical support required from visiting physicians would be proportionally less.
The recommendation on establishing weekly pre-anaesthetic clinics at Hawera Hospital [19] is apparently awaiting the appointment of a “Pre-Admission Co-ordinator” and sufficient anaesthetists. Why is another manager needed? Why more anaesthetists? Most GPs and/or the MMOs (once there are three) could provide pre-anaesthetic checks, providing a clear protocol was given by the anaethetists so only complicated cases would then be seen by them, perhaps at Base with more investigations being available there.
The recommendation “that the CEO and Chairman publicly state that under no circumstances will the option of closing the inpatient unit at the new Hawera Hospital during the next 5-10 years be considered” [25], is unlikely to be accepted by the CEO. However, we feel it is better to know who is honestly opposed to Hawera maintaining basic inpatient acute care than to have the public promises of continued basic (“bread and butter”) services of some previous administrators, who knowingly planed to break their promises. However, Option Three needs management support to succeed, and it would contribute to healing some distrust if the Board made a commitment here, overriding the CEO and Chairman if necessary.
The recommendation “that senior management at both TBH and Hawera Hospital conduct themselves in a manner such that...[if] a staff member speaks disparagingly of providers of either TBH or Hawera Hospital, then that staff member is immediately censored” [27] should be agreed to as there has been too much unwarranted criticism between hospitals (and GPs). Hawera staff are already responding to this and modifying their criticism of what appears to be some rather shoddy care Hawera patients were receiving at Base. South Taranaki Doctors have for some time been trying to encourage direct communication, rather than criticising colleagues to patients as we have to work together and with ER staff.
The recommendation on Recruitment strategy [37] is flawed. Previous efforts by the Human Resource Manager and Director of Medical Services were largely unsuccessful. Aside from the now historical debate over specialist advertising, advertising for MOSS positions did attract 32 applicants BUT 23 withdrew or made “No further contact after job pack sent”. We believe that:

• a South Taranaki GP and perhaps a representative from the South Taranaki District Council (or the Mayor’s health group) should be involved in the recruitment strategy as in recommendation [57].

• the “job pack” must be reviewed and made more appealing.

• the new advertisement appearing on the TDHB Web site is a huge improvement on previous versions but needs at least three changes:

(1) the URL for the link "For further information" (http://www.tdhb.org.nz/Careers/www.tdhb.org.nz) is still broken and the obvious error needs correcting.

(2) Medical Officer of Specialist (sic) Scale should be changed to Multiskilled Medical Officer

(3) The phrase “primary and secondary school educational facilities” should be changed to “excellent pre-school, primary and secondary school educational facilities”. Many studies show that good educational opportunities for their children is a critical factor in a doctor’s decision to accept a rural position, and the schools in Hawera are excellent. In fact the High School achieves better Bursary and subsequent University success rates than achieved by New Plymouth schools despite some of the district’s brighter students attending outside boarding schools.
The recommendation on “that one of the MOSS [/MMO] positions at Hawera Hospital becomes the Medical Director of Hawera Hospital.....” [41] is confusing with all the variety of managers and directors. We actually want the position to be a Medical Superintendent and to take over the role of Hospital Manager, reducing the need for as many visits outlined in recommendations [8].
The recommendation “that 5 weekly rotations for MOSS [/MMO] be organised at TBH....” [43] might be seen as taking staff from TBH to support Hawera (if rotations were direct swaps instead of extra staff for Base). However, even if it were organised as a “swap”, with an experienced SHO or registrar, it would provide some “generalist” ward & ED experience for that medical officer which studies show is an important part of medical training as most NZ & Australian physician positions require some generalist skills. Again, some effort to support the Hawera MMOs and reduce professional isolation is required.
The recommendation “that the Director of Medical Services ....organise a monthly educational forum at Hawera for South Taranaki GPs and MOSS [/MMO].” [48] has been questioned presumably on the basis of the estimated $2,500 p.a. cost. We cannot see how the meetings could cost this if GPs, MMOs and various visiting specialists contributed, unless this was for catering lunch meetings. At present we have voluntary meetings with Fulford Radiology (up-skilling on X-Rays) and some specialists (eg Ophthalmologists - use of the slit lamp). Visiting physicians would be ideal “resource person” for medical topics. Again, these meetings would be essential to MOSS/MMO (and GP) retention and reduction of professional isolation and should not involve management who appear to be attempting to make Option Three fail.
The recommendation “that a memorandum of understanding be established between Wanganui DHB and TDHB......” [54] is an essential as many South Taranaki patients find their only real access to secondary medical services is to the south. Cross boundary issues need sorting out.

We hope that the Board looks at how the major Pisk recommendations can be made to work, rather than restricting the chance for it to succeed, both for the benefit of South Taranaki, and for the freeing up of inpatient facilities at TBH by maximising the use of the new Hawera facility.

Dr Keith Blayney

PS This is not the evidence based submission I have promised, but a commentary on behalf of the eight South Taranaki GPs present, who may well be wishing to add individual feedback to the Board. A "hard copy" of this report will be mailed to Board members.