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Published Evidence

A Compilation of Medical Evidence obtained from published literature on the provision of acute specialist medical care in smaller hospitals. This has been updated to include research identified after the first submissions to the Taranaki District Health Board (TDHB) on 24 August 2001(marked NEW or for the very latest, NEW)

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

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

19th October 2001

Contents: click a title to go directly to topic
[1] Finding & Keeping Physicians
[2] Clinical Safety and Efficiency
[3] Technology and Centralisation
[4] Historical Documents
[5] Other Considerations

Use the symbol to return to the main Contents (above) and the symbol to return to each Section Contents.

 

back to contents [1] Finding and Keeping Physicians

Section Contents:
Extensive Advertising?
Shortage of Specialists?
Attracting Physicians
Retaining physicians

back to Section Contents [1.1] The principal argument given by the Taranaki Health CEO for not replacing Hawera Specialist Physicians was that "Specialists cannot be found despite extensive advertising". This was challenged and the claims referred to the Auditor General.

  1. NEW The TDHB then performed an internal audit, subsequently called the Nel/Naughton Report which I have summarised as a MS Excel document TDHBAdverts.xls. This revealed that only two ads were placed overseas for Hawera MOSS or Specialist positions between Feb 2000 and the 19 April 2001 announcement that the HDU was to close because of an inability to attract doctors, and none were in South Africa, despite the fact that increasing numbers of senior doctors are leaving South African rural hospitals for overseas jobs [Magda Naudé "Understaffing at rural hospitals" South African Medical Journal, April 2001, Vol. 91, No. 4, pp 284]. [This is unfortunate for South Africa, but if physicians are choosing to leave, they won't come to Hawera unless they know we want them!]

  2. NEW The reply from the Auditor General's office stated "we are assured that there has been no fraud associated with this advertising." but also "We are unable to comment on the suitability of the advertising for the position, nor on whether applicants for advertisements for New Plymouth hospital were to be directed to the Hawera Hospital" (see http://home.bitworks.co.nz/Audit.htm). Merus Cochrane from the Audit Office has been asked to rephrase her response, given the misuse the TDHB management put it to.

back to Section Contents [1.2] A shortage of Specialists in Internal Medicine has been promoted as a reason for not finding any suitable applicants. This has to be questioned when:

  1. NEW Two appropriate specialists have been discouraged. Dr S Anandaraja (previously worked at Taranaki Base Hospital) wanted to come and Dr Faisal Qureshi wanted to stay but was only offered a six month contract, so he had to make other arrangements [Personal correspondence].

  2. Specialists have been recruited from USA for New Plymouth, but there doesn't appear to have been any advertising for the Hawera jobs in the US.

  3. NEW The Medical Council of NZ reports 30 new additions to the Internal Medicine Vocational Register for the year to 31/3/01. To obtain an idea where general registrations of overseas trained doctors are coming from, it is worth noting the percentage registering last year from each country of training (and the percentage of all current NZ registrations from each country):

    4. Origin of overseas trained NZ registrations
    Training CountryRegistered 2000-1Total Active Reg
    Britain49.8%42.3%
    S Africa12.2%17.8%
    USA9.5%2.4%
    Canada4.2%1.8%
    India4.8%7.4%
    Bangladesh2.5%1.2%
    Australia2.1%7.4%
    Iraq1.6%2.7%
    Sri Lanka1.5%5.3%
    Pakistan1%0.6%
    All others (<1%)10.8%11.1%

    [Annual Report 2001 Medical Council of New Zealand http://www.mcnz.org.nz]

    It would appear that Britain, USA and South Africa are the places to look at yet the previous "extensive overseas advertising" alloted these countries a total of one advertisement (in the BMJ).

back to Section Contents [1.3] Attracting Physicians to a rural hospital will be the main problem facing South Taranaki once the TDHB agree to reinstating resident specialists and supporting MOSS positions. This may involve incentives, perhaps a "salary "top up" or low rent accommodation supplied by the District Council, but it is clear that advertisements need to be not just in the right places, they must be made more attractive. The GPs of South Taranaki and the South Taranaki Health Group are more than happy to help with targeted appealing advertising.

These two recent studies are of paediatricians, but the problems, barriers and suggestions are the same for adult physicians.

  1. NEW OBJECTIVES: To determine the knowledge of vacant country specialist positions, the main barriers to filling country specialist positions, the acceptance of hypothetical creative employment models and to gain understanding of what would it take for respondents to accept a country position.
    METHODOLOGY: Mailed self-report questionnaires to all 103 Queensland paediatricians and finishing paediatric trainees (response rate 93.1%) to explore reasons for the long-term vacancy of the Staff Paediatrician position at the Mount Isa Base Hospital, North-west Queensland, Australia.
    RESULTS: Specialist positions, such as the advertised position, are well known, but remain unfilled because they are considered unsustainable. The lack of adequate locum cover for leave (97.8%), on-call load (92.2%), professional isolation (91.4%), and family commitments (91.4%) were identified as the four most frequently recognized recruitment barriers. However, the response to hypothetical creative employment models suggests this [unsustainability] could be changed, provided specialist training is kept general and the younger consultant is given consideration. [Gorton SM, Buettner PG "Why paediatricians rural out going to the country but support opportunities for change." J Paediatr Child Health 2001 Apr 37 (2):113-7]

  2. NEWThe near doubling in [US] general pediatrician numbers from 1981 to 1996 yielded only a modest increase in pediatrician availability for rural children. The discrepancy between urban and rural pediatrician supply increased during this period and should continue growing based on the increasingly urban location of recent residency graduates and the continued growth of women in pediatrics. New policy strategies are needed to improve rural pediatrician availability, including focusing on larger rural counties and addressing barriers to rural practice for women. [Randolph GD, Pathman DE "Trends in the rural-urban distribution of general pediatricians." Pediatrics 2001 Feb 107 (2): E18]

[ In order to attract physicians, a better on-call load, allowance for leave, and a commitment to reducing professional isolation need to be worked out and the family benefits of a medium sized town need to be identified.].

back to Section Contents [1.4] Retaining physicians may involve incentives, but also:

  1. NEW As well as greater generalist training by Medical Schools and Colleges, there needs to be funding resources and local programs offered to make it easier for rural doctors to attend CME courses [Rourke JT; Strasser R "Education for rural practice in Canada and Australia" Acad Med 1996 May;71(5):464-9] [ It comes down to management recognising that it must make allowances for reducing professional medical isolation, rather than use it as an excuse to downgrade rural hospitals].

  2. NEW Hospital Staff surveys can identify specific areas of job dissatisfaction that best distinguish those who anticipate leaving in 1 year from those committed to remaining in their present job for 5 years. This obviously aids in decisions on staff conditions and retention policies. [This may be more appropriate for nurses than physicians] [Muus KJ et al "Retaining registered nurses in rural community hospitals" J Nurs Adm 1993 Mar;23(3):38-43].

 

back to contents [2] Clinical Safety and Efficiency

Section Contents:
Safety of Small Hospitals
Outcome Not Improved in Big Hospitals
Transfer Issues

The only real argument that can justify this proposal to transfer all acute medical admissions on a permanent basis is one of clinical safety. The CEO has implied that transfer to and care in a Base Hospital is safer than remaining in a small rural community hospital.

back to Section Contents [2.1] Safety of smaller (rural/community) hospitals

  1. There is no good evidence that care of acute medical conditions is more dangerous in smaller hospitals. In fact a large study of 43,000 patients across 166 US hospitals, including 83 small hospitals that had a relatively unspecialized range of services, revealed that small rural hospitals generally make appropriate transfer decisions for severely ill patients and provide quality care for retained patients, having the same or frequently lower risk-adjusted mortality rates as urban hospitals. [Glenn LL, Jijon CR. "Risk-adjusted in-hospital death rates for peer hospitals in rural and urban regions." J Rural Health 1999 Winter;15(1):94-107].

  2. Australian models of avoiding inter-hospital transfer have proven successful in saving lives without overusing Coronary Care units [Edmonds E, Kelly AM. "Managing potentially ischaemic chest pain and coronary care beds effectively." Aust Health Rev 1997;20(4):40-8].

  3. Other than major trauma, burns, critically ill and neonates (<1500gm), there is no clear evidence that regionalization provides a benefit for more common disorders requiring intensive care [ S Surgenor, H Corwin, and T Clerico "Survival of patients transferred to tertiary intensive care from rural community hospitals" Crit Care 2001; 5 (2): 100-104]. full article on-line here

  4. Recent studies reveal better trauma survival with rural stabilisation before transfer. [Rogers FB, Osler TM, Shackford SR, Martin F, Healey M, Pilcher D "Population-based study of hospital trauma care in a rural state without a formal trauma system." J Trauma 1999 Feb;46(2):328-33 AND Rogers FB, Osler TM, Shackford SR, Cohen M, Camp L, Lesage M. "Study of the outcome of patients transferred to a level I hospital after stabilization at an outlying hospital in a rural setting." J Trauma 1999 Feb;46(2):328-33]. [It would appear that previous figures about rural trauma outcome did not allow for the fact that rural RTAs are generally more severe (higher speed) than urban accidents, one must control for severity in any outcome comparison.].

  5. Resident physicians in rural community hospitals are just as capable of selecting appropriate patients for transfer to a tertiary ICU as physicians within the tertiary-care hospital. The few patients at community hospitals who develop a need for tertiary critical care are just as likely to survive as those admitted directly (ie they haven't been disadvantaged). [S Surgenor, H Corwin, and T Clerico "Survival of patients transferred to tertiary intensive care from rural community hospitals" Crit Care 2001; 5 (2): 100-104]. full article on-line here

  6. There are some good reports of safe laparoscopic surgery in rural hospitals [Kreuder K, Chown M: Laparoscopic cholecystectomy in the rural setting. J Laparoendosc Surg 1992; 2:89-92 ; Furman R, Dean C, Frazier H, et al: One hundred consecutive laparoscopic cholecystectomies performed in a rural hospital. Am Surg 1992; 58:55-60 AND Tietz C: "Laparoscopic-assisted hysterectomy in a rural Minnesota hospital" Minn Med 1995; 78:31-32 AND Eleftherios S. Et al "Early Experience With Laparoscopic Anti-reflux Surgery in the Rural Setting" South Med J 94(1):43-46, 2001].

  7. NEW Community and rural Hospitals can safely use "state of the art" treatments for ischaemic stroke. In a large, retrospective evaluation of community hospital practice, the use of IV tissue plasminogen activator (tPA) and inpatient mortality rates among IV tPA-treated patients were consistent with those of other studies. In fact, patients treated in rural hospitals were more likely to receive IV tPA (OR 1.80, 95% CI 0.99 to 3.26), but did not show any increased mortality. [Reed SD; Cramer SC; Blough DK; Meyer K; Jarvik JG Pharmaceutical Outcomes Research and Policy Program, School of Pharmacy, Department of Neurology, School of Medicine, University of Washington, Seattle, Washington, USA. "Treatment with tissue plasminogen activator and inpatient mortality rates for patients with ischemic stroke treated in community hospitals." Stroke 2001 Aug;32(8):1832-40]"

  8. Acute management of Myocardial Infarction can be safe in peripheral hospitals. [Jacobs IG, Fatovich DM. "The use of thrombolytic therapy in patients presenting to a peripheral metropolitan emergency department with acute myocardial infarction" Aust NZ J Med. 1996 Aug;26(4):539-42 Comment in: Aust NZ J Med.1997 Apr;27(2):192] or at least no worse (for Cardiogenic Shock) as larger centers. [ Goldberg RJ, Gore JM, Alpert JS, et al. "Cardiogenic shock after acute myocardial infarction. Incidence and mortality from a community-wide perspective, 1975 to 1988." N Engl J Med. 1991 Oct 17;325:1117-22].

    NEW Mortality rates for acute myocardial infarction (AMI) in the province of Manitoba were studied by a retrospective, randomized survey of urban and rural hospital records. Urban hospitals had formal coronary care unit (CCU). Selected rural hospitals lacked CCUs but usually possessed portable monitoring and defibrillation equipment. The mortality rate for unequivocal AMI was 14% to 15% to both urban and rural hospitals. Patients with possible AMI had high mortality rates in both facilities (41% to 45%). Subgroup analysis of the definite AMI population failed to reveal statistically significant differences in urban vs rural mortality. [Morris AL et al "Acute myocardial infarction: survey of urban and rural hospital mortality." Am Heart J 1983 Jan;105(1):44-53].

    NEW Where policies and protocols are in place in rural Intensive Care Units to ensure that current 'best practice' is followed where possible, mortality figures are as good or better than the best urban teaching hospital figures. Wimmera Hospital in Victoria, Australia reports in-hospital and 30 day myocardial infarction mortality rates of 7.95% (less than half that of US, Irish and German best rates). [Phelps G; O'Sullivan M Wimmera "Myocardial infarction in a rural hospital". J Qual Clin Pract 1995 Jun;15(2):99-104]. See also differences due to teaching & Asprin

  9. NEW Many medical short stay admissions can be safely cared for by generalists in a low-tech unit. A hospitalist-run medical short-stay unit (MSSU) was created at a university-affiliated teaching hospital in Montreal in 1989. Its primary aim was to provide efficient and high-quality care to patients requiring a brief stay in hospital for short-lived medical conditions. Care in the MSSU is provided by a rotating group of hospitalists. MSSU patients had a shorter length of stay, lower rates of in-hospital complications and lower rates of readmission within 30 days of discharge compared with clinical teaching unit (CTU) patients. [Abenhaim HA, Kahn SR, Raffoul J, Becker MR "A hospitalist-run, medical short-stay unit in a teaching hospital." CMAJ 2000 Nov 163 (11): 1477-80].

back to Section Contents [2.2] Outcome in large hospitals not improved

  1. There is evidence that despite all the costly advances in medical care, there has been no improvement in outcome for:
    • Cardiopulmonary resuscitation success rates for 30 years [ Schneider AP 2d, Nelson DJ, Brown DD. "In-hospital cardiopulmonary resuscitation: a 30-year review." J Am Board Fam Pract. 1993 Mar;6:91-101].
    • Non-Q wave Infarction survival for 22 years [Furman MI, Dauerman HL, Goldberg RJ, Yarzebski J, Lessard D, Gore JM. "Twenty-two year (1975 to 1997) trends in the incidence, in-hospital and long-term case fatality rates from initial Q-wave and non-Q-wave myocardial infarction: a multi-hospital, community-wide perspective" J Am Coll Cardiol 2001 May;37(6):1571-80].
    • Cardiogenic Shock survival for 13 years [ Goldberg RJ, Gore JM, Alpert JS, et al. "Cardiogenic shock after acute myocardial infarction. Incidence and mortality from a community-wide perspective, 1975 to 1988" N Engl J Med. 1991 Oct 17;325:1117-22].
    • Overall inpatient myocardial infarction survival for 10 years (despite an increasing uptake of the "proved" treatments) [ N Brown, T Young, D Gray, A Skene, J Hampton, "Inpatient deaths from acute myocardial infarction, 1982-92: analysis of data in the Nottingham heart attack register" BMJ 1997;315:159-164 (19 July)].
  2. NEW However, overall coronary mortality has been falling, but not because of any high-tech advances. Declining out-of-hospital death rates, declining incidence and recurrence of AMI in the population, and marked improvements in the survival of AMI patients all contributed to the 1985 to 1997 decline of CHD mortality in the Minneapolis/St Paul metropolitan area. The effects of early and late medical care seem to have had the greatest contribution to rates during this time period. Of the in-hospital contributions (increased use of thrombolysis, ACE inhibitors, beta-blockers, heparin, aspirin and emergency angioplasty) only the later would not be available in a small hospital [like Hawera, and there is no evidence given that it has made a difference.] [McGovern et al "Trends in acute coronary heart disease mortality, morbidity, and medical care from 1985 through 1997: the Minnesota heart survey." Circulation 2001 Jul 104 (1):19-24].

  3. NEW This year, a study on the impact of the changes on rural residents' access to care, their health status, and the viability of rural communities after the 1993 closure of 52 small rural hospitals in Saskatchewan, Canada. revealed that these closures did not adversely affect the health of residents. (It could be claimed that this study justifies closing or downsizing small hospitals like Hawera. However, the hospitals in this study were small rural hospitals, all less than eight beds, not of hospitals serving 30,000 people.) Good rural health requires creative approaches to the provision of primary care, good emergency services, and good communication with the public on the intent and outcomes of change. [Liu L et al, "Impact of rural hospital closures in Saskatchewan, Canada." Soc Sci Med 2001 Jun;52(12):1793-804].

  4. NEW It has been argued that a good example of high tech centralisation is the provision of primary angioplasty as this is becoming the preferred strategy for myocardial reperfusion. However, a meta-analysis of studies reveals that there is only a short-term clinical advantage over thrombolysis which may not be sustained, and that this advantage is only demonstrable when primary angioplasty is given "promptly" and at experienced centres [Taranaki Base is not experienced and South Taranaki patients cannot get "prompt" treatment.] In most situations, however, optimal thrombolytic therapy should still be regarded as an excellent reperfusion strategy. [Cucherat M, Bonnefoy E, Tremeau G. "Primary angioplasty versus intravenous thrombolysis for acute myocardial infarction (Cochrane Review)" In: The Cochrane Library, 3, 2001. Oxford].

    5.
  5. NEW The availability of catheterization facilities is irrelevant to the prognosis of acute coronary syndrome if effective pharmacological treatment with tirofiban is given according to this Canadian study. Treatment effects of tirofiban were examined in a Canadian cohort of 834 patients enrolled in the Canadian Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) trial. Benefit was seen regardless of transfer status, with no statistically significant interaction between treatment, hospital type, and catheterization for any end point at any time point. The incidence of Thrombolysis In Infarction defined major bleeding with respect to therapy was not significantly different between hospital types. Thus, upstream treatment with tirofiban plus heparin confers clinical benefits in unstable angina and/or non-ST-segment elevation infarction patients regardless of whether initial presentation is to a hospital without catheterization facilities or to a hospital with such facilities. [Théroux P et al "Upstream use of tirofiban in patients admitted for an acute coronary syndrome in hospitals with or without facilities for invasive management. PRISM-PLUS Investigators." Am J Cardiol 2001 Feb 87 (4): 375-80].

back to Section Contents [2.3] Transfer Issues

  1. The false assumption that a larger hospital is a safer place costs lives, as it has been shown that transferring ill patients increases mortality (independently of disease severity) [Kerr HD, Byrd JC. "Community hospital transfers to a VA Medical Center." JAMA 1989 Jul 7;262(1):70-3 AND Clough JD, Kay R, Gombeski WR Jr, Nickelson DE, Loop FD. "Mortality of patients transferred to a tertiary care hospital." Cleve Clin J Med 1993 Nov-Dec;60(6):449-54 AND Borlase BC, et al "Elective intrahospital admissions versus acute interhospital transfers to a surgical intensive care unit: cost and outcome prediction." J Trauma 1991 Jul;31(7):915-8; discussion 918-9].

  2. NEW Rural Australian experience of patients requiring inter-hospital transportation, usually by air ambulance to a metropolitan critical care unit, highlights the anxiety and confusion experienced by rural people transferred. [Johnson P "Rural people's experience of critical illness involving inter-hospital transportation: a qualitative study." Aust Crit Care 1999 Mar 12:12-6].

  3. Acute interhospital transfer (allowing for severity) is associated with a delay in ICU admission and a longer stay in ICU and hospital, but no statistically significant difference in mortality, in a recent three year Melbourne study. At best, the results indicate that acute interhospital transfer does not affect hospital outcome; at worst, they suggest that it may adversely affect the outcome of one in every 25 critically ill patients transferred. Extrapolating the results to the metropolitan region, acute interhospital transfer may adversely affect the outcome of 15 patients (95% CI, 0-48) per annum, and require an additional 1100 hospital bed-days (95% CI, 960-1266 days) per annum -- half in ICU, where the primary resource limitation exists. [Graeme J Duke and John V Green "Outcome of critically ill patients undergoing interhospital transfer" MJA 2001; 174: 122-125].

  4. NEW While there is a vast amount of evidence to support the early use of thrombolysis in myocardial infarction, the assumption that following thrombolysis, a patient is "stabilised" and suitable for transfer is open to question. These patients now face a significant risk from a broad spectrum of arrhythmic and haemorrhagic complications (seen in 68% of postmortems) [Leone A "Causes of death from myocardial infarction before and after thrombolysis era: a pathologic study". Singapore Med J 1996 Jun;37(3):270-2], with bleeding requiring transfusion (5%), stroke (1.8%), and Ventricular Fibrillation common enough to advise ambulances be double-manned and carry defribrillators [White HD; Van de Werf FJ "Thrombolysis for acute myocardial infarction". Circulation 1998 Apr 28;97(16):1632-46]. A German study had lower complication rates (cerebral bleeding (0.4%), bleeding requiring transfusions (0.9%), left ventricular rupture (0.6%) and anaphylactic shock (0.1%). In-hospital death rate was 17.2%.) [Rustige J et al "The 60 minutes myocardial infarction project. Treatment and clinical outcome of patients with acute myocardial infarction in Germany". Eur Heart J 1997 Sep;18(9):1438-46]. Two cases of hemopericardium and tamponade out of 26 treated are described. [Mohammad S; Austin SM "Hemopericardium with cardiac tamponade after intravenous thrombolysis for acute myocardial infarction". Clin Cardiol 1996 May;19(5):432-4]. [These complications are not an argument against the use of thrombolysis, but question the safety of post-thrombolysis one+ hour transfers, as complications would be better managed in a Community Hospital ICU/HDU than in the back of an ambulance at Midhurst.]

  5. Back transfer of chronically ill or convalescing patients however, would appear to be safe and cost-effective [Farel A, Kotelchuck M, Metzguer K, Fullar S "Mortality of patients transferred to a tertiary care hospital.Back transfer: capability of community hospitals to serve chronically ill and convalescing infants." J Perinatol 1993 Mar-Apr;13(2):132-6].

The major reason for moving a critically ill patient is to provide more care. Because the period of transfer may impose risks on the patient, transfer should not be considered unless some resulting benefit is expected. [S Surgenor, H Corwin, and T Clerico "Survival of patients transferred to tertiary intensive care from rural community hospitals" Crit Care 2001; 5 (2): 100-104]. full article on-line here.

 

back to contents [3] Technology and Centralisation

Section Contents:
To Centralize or De-Centralize
High Tech Medicine
Differences low tech

According to the CEO "Internal Medicine is swiftly becoming technology dependent... leading to fewer, more specialised hospitals...fiscal accountability does not permit hospital services in small centers" This view is not consistent with recent medical literature.

back to Section Contents[3.1] To Centralize or De-Centralize

  1. Currently there is little direct evidence to support regionalization of adult medical and surgical critical-care services [Crippen, D: Regionalization, prioritization, and sailing ships in the year 2010. New Horizons 1999, 7:218-228].

  2. NEW A review of all US towns in which a sole community general hospital had closed between 1980 and 1988 found that in more than three-quarters, the physicians surveyed considered the quality of care provided by their facilities to be average or better, suggesting that many of the closed hospitals could have continued to provide valuable services to the residents of their communities. Efforts must be made to ensure that rural communities are not losing viable and useful facilities. [Pirani MJ, Hart LG, Rosenblatt RA. "Physician perspectives on the causes of rural hospital closure, 1980-1988." J Am Board Fam Pract 1993 Nov-Dec;6(6):556-62].

  3. NEW Application of a computer model of a 2,500-square-mile community containing community hospitals and a pediatric critical care center demonstrates the shortest times to stabilization of critically ill children occur in systems that maximize the number of hospitals that decentralize pediatric emergency care. [Alfred Sacchetti et al, "Should Pediatric Emergency Care Be Decentralized ? An Out-of-hospital Destination Model for Critically Ill Children" Academic Emergency Medicine Volume 7, Number 7 787-791].

  4. NEW In Manitoba, (Winnipeg, Canada), the government adopted a strategy of shifting hospital care from more expensive urban hospitals to less expensive rural facilities. At present existing capacity raises issues of feasibility, but theoretically a significant percentage of care delivered to rural residents by Winnipeg hospitals might be redirected to rural institutions. [Black C; Burchill C "An assessment of the potential for repatriating care from urban to rural Manitoba." Med Care 1999 Jun;37(6 Suppl):JS167-86].

  5. NEW There is a move in many countries to not only de-centralise, but to train more doctors and physicians in "rural medicine". Ontario (Canada) is to establish a new medical school-its first in 30 years-with a curriculum focussing on rural practice [David Spurgeon "New medical school to focus on rural practice" BMJ 2001;322:1270 (26 May )]. This year the Australian Federal Health minister announced locations for nine new clinical schools and two new University Departments of Rural Health. The AU$117.6 million rural clinical school initiative will strengthen the rural focus in medical training by enabling at least 25 per cent of all medical students to receive a minimum of 50 per cent of their clinical training in rural and remote areas. ["OZ Rural Training CANBERRA" Society of Rural Physicians of Canada FEB 6, 2001 http://www.srpc.ca/issue303.html].

  6. NEW The US approach to reversing centralization includes the Rural Hospital Flexibility Program, a Federal initiative that provides funding to State Governments to strengthen rural health by allowing small hospitals the flexibility to reconfigure operations and be licensed as Critical Access Hospital (CAHs), which are limited service hospitals (Emergency Room and general acute admissions) that receive cost-based reimbursement.
    To be designated a CAH, a rural hospital must meet defined criteria. It must be licensed as a general acute care hospital located in a rural area more than 35 miles (56km) from a hospital or another CAH or the facility is a necessary provider of health care services to residents in the area. They must have no more than 25 beds and average less than 96 hours per acute inpatient care period. They must be part of a Rural health Network, have defined patient referral and transfer protocols, develop and use of communication systems including telemetry and electronic sharing of patient data and have provisions regarding credentialing and quality assurance. [Jan 2000 http://www.ruralhealth.hrsa.gov/IssueBrief1.htm].

    There has been significant enthusiasm for the RHFP with one hundred seventy hospitals designated as CAHs in the first year (as of May 31, 2000). The median population of communities with CAHs is 9,752 -much smaller than the "all rural hospital" median of 23,826. [A Hagopian & G Hart "Rural Hospital Flexibility Program Tracking Project 23 January 2001 http://www.rupri.org/rhfp-track/year1/execsum.html] [Hawera would be classed as a Rural Hospital, much bigger than a CAH, yet we face greater downgrading to below the level of US rural hospitals serving one third the population].

  7. Community Hospitals are more cost effective for cerebrovascular events [Reed SD, Blough DK, Meyer K, Jarvik JG. "Inpatient costs, length of stay, and mortality for cerebrovascular events in community hospitals" Neurology 2001 Jul 24;57(2):305-14 AND Feigenson JS, Feigenson WD, Gitlow HS, McCarthy ML, Greenberg SD. "Outcome and cost for stroke patients in academic and community hospitals. Comparison of two groups referred to a regional rehabilitation center" JAMA 1978 Oct 20;240(17):1878-80 AND Briggs DE, Felberg RA, Malkoff MD, Bratina P, Grotta JC. "Should mild or moderate stroke patients be admitted to an intensive care unit?" Stroke 2001 Apr;32(4):871-6].

  8. In an effort to reduce barriers faced by Aboriginal people from remote communities in the Northern Territory (NT) when accessing hospital-based specialist medical services, a six year study of over 5,000 consultations revealed that the Specialist Outreach Service (SOS) significantly reduced the number of transfers to hospital outpatient clinics and reduced the cost (average cost per consultation only 61% of cost at the Royal Darwin Hospital and 77% of the cost at the closest regional hospital). Outreach has reduced barriers relating to distance, communication and cultural differences. [Gruen RL, et al Improving access to specialist care for remote Aboriginal communities: evaluation of a specialist outreach service. Med J Aust 2001 May 21;174(10):507-11].

back to Section Contents[3.2] High Tech Medicine

  1. Six month survival after cardiogenic shock is improved after high tech intervention (angiography, angioplasty, and intra-aortic balloon counterpulsation) but not by much (mortality of 80% vs 90%) [Barbash IM, Behar S, Battler A, Hasdai D, Boyko V, Gottlieb S, Leor J. "Management and outcome of cardiogenic shock complicating acute myocardial infarction in hospitals with and without on-site catheterisation facilities." Heart 2001 Aug;86(2):145-9]

  2. NEW Hospital is not always the best place for stroke patients, but if hospitalisation cannot be avoided, because there is no alternative (such as nursing at home), surely a local hospital is preferable to a distant one? A recent UK study raises real questions about the place of hospitals after a stroke. It showed that hospitalized stroke patients may have poorer survival and disability rates than those who remain at home, even after adjustment for case mix. There may be some aspects of acute hospital care that may be detrimental to outcome in certain groups of stroke patients. [Bhalla, A; Dundas, R; Rudd, AG; & Wolfe, CD "Does admission to hospital improve the outcome for stroke patients?" Age Ageing 2001 May 30 (3):197-203]

  3. The argument that high tech medicine requires patients to be transferred to the technology is fast becoming outdated with the advent of telemedicine (telehealth) where it is the information, not the patient that is transferred. [Lehoux P, Battista RN, Lance JM. "Telehealth: passing fad or lasting benefits?" Can J Public Health 2000 Jul-Aug;91(4):277-80 AND Lee JK et al "Effect of real-time teleradiology on the practice of the emergency department physician in a rural setting: initial experience." Acad Radiol 1998 Aug;5(8):533-8].
    NEW A review of fifteen papers evaluating oncology outreach programmes, tele-oncology programmes and rural hospital initiatives revealed that although the studies were small, it appeared that shared outreach care was safe and could make specialist care more accessible to outlying patients while tele-oncology was useful and an acceptable adjunct. [Campbell NC, Ritchie LD, Cassidy J, Little J. "Systematic review of cancer treatment programmes in remote and rural areas." Br J Cancer 1999 Jun;80(8):1275-80].

    4.
  4. Contrary to the CEO's assertions, overseas Acute Care use has reduced over the last decade, particularly recently and for all ages. [ McGrail KM, Evans RG, Barer ML, Sheps SB, Hertzman C, Kazanjian A. "The quick and the dead: "managing" inpatient care in British Columbia hospitals, 1969-1995/96." Health Serv Res 2001 Feb;35(6):1319-38].

  5. NEW Of the three major pressures on health services worldwide--changing demography, growing expectations, and new technologies - the last is generating the most concern and the most dramatic responses. New healthcare technologies are becoming more numerous, more expensive, and possibly more effective than ever before. [Andrew Stevens et al " Keeping pace with new technologies: The Impact of New Technologies in Medicine" BMJ 1999;319;1291 (13 November ). To make best use of scarce healthcare resources the diffusion and adoption of new technologies should be linked to evidence of their clinical and cost effectiveness. However, adoption of new technologies continues with little reference to research. Managerial decision makers are influenced more by such forces as clinician enthusiasm, media campaigns, public opinion, manufacturers' inducements, hospital developments, and government regulations than objective health technology assessment. [Rebecca Rosen & John Gabbay "How do new technologies get into practice? Linking health technology assessment to practice" BMJ 1999;319:1292 (13 November)].

  6. NEW One of the main reasons for the acceleration of health care costs in the 1980s was the success of biomedical research, which led to the introduction of new, highly effective but very expensive diagnostic and therapeutic procedures. In the United States, excessive use of high technology (fed by excessive expectations of insured populations and the risk of malpractice suits) led to US health care costs reaching 15% of the gross national product (the highest in the world) by1998. Attempts to control this with managed care has seen an explosion in administrative costs and Chief Executive Officers becoming millionaires. [James E. Dalen "Health Care in America: The Good, the Bad, and the Ugly" Arch Intern Med. 2000;160:2573-2576]. [New Zealand needs to step back from blindly following this recipe for disaster. Each hospital cannot offer every procedure available, but they can and should provide basic acute care].

  7. Taranaki Base Hospital is a secondary hospital without the numbers or experience to be offering high risk, costly "tertiary" proceedures. Money is better spent on providing basic surgical and medical (at Hawera and Base) care. The literature supports transferring patients needing high risk infrequently performed proceedures to tertiary units. These studies support the concept that TBH should limit its services to those it does well and frequently, and accept that a few patients will need transfer to Waikato, Auckland, Palmerston North or Wellington.
    NEW If "Leapfrog" volume standards were implemented, many surgical deaths for high-risk procedures such as Coronary-artery bypass graft, abdominal aortic aneurysm repair, coronary angioplasty, esophagectomy, and carotid endarterectomy could be prevented. In other words, hospitals which do not do enough of these operations should pass those patients on to hospitals that do. [Birkmeyer JD, Finlayson EV, Birkmeyer CM. "Volume standards for high-risk surgical procedures: potential benefits of the Leapfrog initiative." Surgery 2001 Sep;130(3):415-22]. The same argument can be applied to lung cancer surgery. Patients who undergo resection for lung cancer at hospitals that perform large numbers of such procedures are likely to survive longer than patients who have such surgery at hospitals with a low volume of lung-resection procedures. [Bach PB, Cramer LD, Schrag D, Downey RJ, Gelfand SE, Begg CB. "The influence of hospital volume on survival after resection for lung cancer." N Engl J Med 2001 Jul 19;345(3):181-8].

back to Section Contents [3.3] The Differences are Low Tech

  1. Many studies do reveal that larger, urban teaching hospitals tend to have better quality of care and reduced mortality than smaller, nonteaching, rural hospitals, although this tends to be more true for specialist areas, rather than general medicine or surgery. However, when this difference is analysed, it has been repeatedly shown to be a consequence of the teaching, not the technology. A study by Keeler et al suggested that quality of care improved with the size of the hospital but that quality of care was strongly related to teaching activities. [Keeler EB, Rubenstein LV, Kahn KL, et al: Hospital characteristics and quality of care. JAMA 1992; 268:1709-1714]. Hartz et al also reported that mortality was lower in urban hospitals and hospitals with teaching activities [Hartz AJ, Krakauer H, Kuhn EM, et al: Hospital characteristics and mortality rates. N Engl J Med 1989; 321:1720-1725].

    2. A more recent study showed that admission to a hospital ranked high on the list of "America's Best Hospitals" (with cardiac catheterization, coronary angioplasty, and bypass surgery) was associated with lower 30-day mortality among elderly patients with acute myocardial infarction compared to unranked and community hospitals. However, the survival advantage of the top ranked hospitals lost its statistical significance when mortality figures were adjusted for aspirin and beta-blocker use. [Chen J, Radford MJ, Wang Y, Marciniak TA, Krumholz HM. Do "America's Best Hospitals" Perform Better for Acute Myocardial Infarction? N Engl J Med 1999:340(4):286-92].

    NEW Further studies showing that when mortality in non-metropolitan or rural hospitals is found to be higher than in metropolitan hospitals (after adjustment for patients' severity), the difference seems to relate more to choice of medication (particularly asprin and Beta-blockers), than to access to technology.

    • "Regardless of disease severity, metropolitan hospitals had a higher percentage of patients for whom drugs shown to decrease mortality after AMI were used (streptokinase, asprin, ACE inhibitor); a lower percentage of patients received drugs shown to have no benefit or even a detrimental effect (calcium channel blocker)." [Lim LL; O'Connell RL; Heller RF "Differences in management of heart attack patients between metropolitan and regional hospitals in the Hunter Region of Australia". Aust NZ J Public Health 1999 Feb;23(1):61-6].
    • "Government hospitals were least likely to thrombolyse a patient as compared to private, industrial and voluntary hospitals......Hospitals attached to medical colleges follow guidelines for use of thrombolysis and beta-blockers more closely than non-teaching hospitals." [George E et al, "Treatment of acute myocardial infarction: does the type of hospital make a difference? PPAMI Study Group." Indian Heart J 1999 Mar-Apr;51(2):161-6].
    • "After adjustment for severity....the odds of death in non-metropolitan hospitals was significantly higher than in metropolitan hospitals.... The addition of the use of effective cardiac medications to the model resulted in the difference between hospital type becoming non-significant" [Vu HD et al "Mortality after acute myocardial infarction is lower in metropolitan regions than in non-metropolitan regions." J Epidemiol Community Health 2000 Aug;54(8):590-5].

  2. NEW A UK National Audit of 42 hospitals with 400 or more acute beds by a multidisciplinary working group revealed that the rising number of emergency admissions and the increasing specialisation of medicine is causing problems in the organisation of care for patients admitted as emergencies to medical beds. The most significant problems that emerged were the suboptimal involvement of consultants in acute care, the frequent lack of appropriateness of the admitting specialty to the patient's condition, and confusion about policies for admitting elderly patients. [Houghton A, Hopkins A. "Acute medical admissions: results of a national audit." J R Coll Physicians Lond 1996 Nov-Dec;30(6):551-9].

  3. The Health Policy Unit of The Royal Australasian College of Physicians has stated that there is too much sub-specialisation in Australia and New Zealand with dangers of poor management of co-morbidities. They outline plans to re-establish General Medicine in the provision of secondary and tertiary care over the next decade. [I Scott and P Greenberg, "General Medicine in Australia and New Zealand - a renaissance" MJA 1998; 168: 104-105].

  4. NEW However, when studies do show the benefits of centralisation, it isn't from centralising basic community medical admissions to a larger regional hospital but centralising high tech. interventions from the regional hospital to a major Tertiary Hospital. An example is the centralization of coronary revascularization procedures in Calgary being associated with increased population rates of procedures being performed, on sicker patients, with shorter hospital stays, and, for CABG patients, a trend toward more favourable short-term outcomes. [Brenda R. Hemmelgarn, William A. Ghali, Hude Quan, "A case study of hospital closure and centralization of coronary revascularization procedures" CMAJ 2001;164(10):1431-5]. The future General hospital will treat only those conditions that have less exacting requirements for equipment and training, but complex specialty procedures of high risk will be shifted to hospitals that are, or will become, centres of excellence. [Charles B Wilson "The impact of medical technologies on the future of hospitals" BMJ 1999;319:1287 (13 November)].

 

back to contents [4] Some historical documents with relevance to the current Hawera Hospital crisis

Section Contents:
NEW RACP recommendations 1982
NEW The Small District General Hospital in NZ 1982
NEW The Future of Hawera Hospital Submission (Dr Arnold et al) 1996
NEW Acute medical admissions in New Zealand 1998

back to Section Contents NEW [4.1] Royal Australasian College of Physicians (RACP) advice on the staffing of provincial hospitals in 1982. The New Zealand Committee of the RACP advised the Minister of Health on the staffing of provincial hospitals Dept of Health Circular Letter (Hosp) No. 1982/27, 22 Feb 1982 after Dr David Richmond, director of continuing education, RACP visited nearly all provincial hospitals. The college considered that isolation was the most important factor inhibiting recruitment of physicians to these centres and that general medical training (as opposed to specialty areas) should be encouraged to help staff the provincial hospitals. A goal of one physician to 8,000 population was recommended.

Difficulties in training and retaining specialist physicians were related to an excessive service workload and compounded by negative decisions being taken by some hospital boards about conference and refresher leave, exacerbating feelings of isolation.

The Committee recommended increasing the physician establishment in provincial hospitals which were below the national average, including creating posts for trainee physicians and improving provincial physician visiting opportunities in adjacent metropolitan hospitals. The college's continuing education program sought to overcome the sense of isolation. (NZMJ p195 24 Mar 1982)

back to Section Contents NEW[4.2] A number of medical, social and economic advantages of small hospitals were outlined in J W Mandeno's paper "The place of the small district general hospital in the New Zealand medical scene" p662-3 NZMJ 22 Sept 1982, including the vital rôle of the Medical Superintendent in maximizing efficient bed utilisation and reducing waiting times. A more personal, friendly hospital and community can attract specialists and often take pressure off more expensive metropolitan hospitals, yet offer high quality care, usually by specialist, rather than a registrar. A minimum size for efficient district hospital serving a community of 20,000 was judged to be 100 beds!!

The replacement of the Medical Superintendent - Matron - Accountant by managers and a steady centralisation of services to Base then followed, each apparently justified in its own right, until all surgery, paediatrics, gynaecology and specialist obstetrics was gone. An attempt to remove all medical acute admissions in 1996 was met with stiff opposition from the public and the then current physician, Dr M Arnold.

back to Section Contents NEW [4.3] Available in the Hawera public library is a substantial report/submission to the Midland Regional Hospital Authority titled Future of Hawera Hospital (FHH) authored by Dr M Arnold, Mrs S Bourke, Mrs L Caddick, Rev M Springett and Mr N Walker (undated, but including a supporting letter from Kiwi's Chairman E J Young (now CEO of Fonterra) dated 21 May 1996).

FHH makes very interesting reading. Here are some of the main points:

The 100 bed Hawera Hospital is now reduced to absolute bare essentials and looks to be finally converted into a Health Centre, without public mandate or scientific basis to justify the move. Health costs have meanwhile spiralled without good evidence of improved health outcomes.

back to Section Contents NEW [4.4] Facts on acute medical admissions in New Zealand A critical appraisal of the literature NZHTA REPORT 6 August 1998 New Zealand Health Technology Assessment Clearing House (NZHTA) [http://nzhta.chmeds.ac.nz/acute.htm]
(A synopsis)

Are acute medical admissions rising?
A number of studies have confirmed that there has been a steady increase in the absolute number, as well as the rate, of acute medical admissions over the last decade and is particularly pronounced for acute medical admissions and is less apparent with acute surgical admissions or arranged/waiting list admissions.

Why are acute medical admissions increasing?
Most of the increase in acute admissions is related to an increase in medical admissions among the elderly, and primarily for cardiac or respiratory conditions.
♦ Probable reasons for the increase in acute admissions include: demographic changes....
♦ Possible causes of the increase in acute medical admissions include increasing distance for patients to the nearest hospital associated with the closure of some hospitals.

Are acute medical admissions appropriate? [not really answered]

What interventions reduce acute medical admission rates?
♦ Good evidence exists (from randomised controlled trials) that the following interventions are effective at reducing admissions: hospital at home schemes, comprehensive geriatric care, and the placement of GPs in the ED. It also appears that the introduction of various guidelines, certain new technologies and the provision of prospective funding have been proven to reduce admissions.
♦ Some evidence exists that several other interventions are probably effective at reducing admissions. These initiatives include various public health interventions, home alarms, increased options for long-term care for the elderly, drug education for patients and practitioners, and hospital outreach services. The provision of senior staff in the ED and the development of ED-based observation units and chest pain units are also probably effective at reducing admissions. [The availability of on-call specialist physicians to the ED staff has previously prevented unnecessary medical admissions.

 

back to contents [5] Other considerations

Section Contents:
Disadvantage to Elderly & Maori
Non-specialist Admissions
Economic Considerations
Medical Demoralisation
Lose or Win

back to Section Contents [5.1] Loss of specialist care for elderly and Maori not transferred

  1. Evidence reveals that elderly patients, particularly with co-morbidity often do not get transferred from community hospitals to specialist hospitals (for various reasons).[Mehta RH, Stalhandske EJ, McCargar PA, Ruane TJ, Eagle KA. "Elderly patients at highest risk with acute myocardial infarction are more frequently transferred from community hospitals to tertiary centers: reality or myth?" Am Heart J 1999 Oct;138(4 Pt 1):688-95].

  2. The use of Streptokinase is cost effective in elderly patients, who often do not get transferred. [ Krumholz HM, Pasternak RC, Weinstein MC, et al. "Cost effectiveness of thrombolytic therapy with streptokinase in elderly patients with suspected acute myocardial infarction." N Engl J Med. 1992 Jul 2;327:7-13.]

  3. NEW Many Maori patients who would benefit from specialist care would refuse to transfer away from their whanau (family), but would accept that care in Hawera [personal communication]

back to Section Contents [5.2] Non-specialist medical admissions to the rural hospital

  1. NEW Alternatives to acute medical admission (eg GP beds, urgent Outpatient appointments) are appropriate in only 10% of admissions as assessed by panels of consultants (5.5-9%) or panels of GPs (8-14%). Doctors with different backgrounds made similar overall assessments of most appropriate forms of care. [Joanna Coast, Abby Inglis & Stephen Frankel,"Alternatives to hospital care: what are they and who should decide? ." BMJ 1996;312:162-166 (20 January)] full article on-line here

  2. NEW Patients at high risk of developing acute myocardial infarction within 24 hours of hospital admission may be identified by a history of chest pain and electrocardiographic evidence of acute coronary ischaemia at admission. Such patients may experience suboptimal treatment and delays to thrombolysis if admitted to nonspecialist wards, but this may be reduced by admitting all 'high risk' patients directly to a high dependency cardiac ward for the first 24 hours after presentation. [AD Mumford and AP Banning,"Minimising delays to thrombolysis in patients developing acute myocardial infarction in hospital." Postgraduate Medical Journal, 1997, Vol 73, 491-495].

back to Section Contents [5.3] Financial and economic considerations

  1. A rural hospital that has been downsized to a freestanding emergency department, with or without outpatients and a "skilled-nursing facility" may sound like a viable model that offers a solution to a community's need to have emergency-care services locally available. However a California Healthcare Association analysis reveals that this model lacks financial viability and requires a subsidy from the community or affiliated hospital or network. [Avery S. "A limited-service rural hospital model: the freestanding emergency department." J Rural Health 1999 Spring;15(2):170-9].

    2.
  2. Rural hospitals represent almost half of all short-stay non-federal general hospitals in the United States and are relatively inexpensive, representing only 6 percent of total expenditures for hospital care. They play a central role in supporting the provision of health services to rural areas and have been shown to treat appropriate conditions.[Hart LG, Amundson BA, Rosenblatt RA. "Is there a role for the small rural hospital?" J Rural Health 1990 Apr;6(2):101-18].

  3. NEW Average costs were higher among stroke patients treated in community teaching hospitals compared to community nonteaching hospitals for each cerebrovascular event (10 to 29%). [Shelby D. Reed, et al "Inpatient costs, length of stay, and mortality for cerebrovascular events in community hospitals" Neurology 2001;57:305-314].

    4.
  4. NEW Community hospitals have been supported by the general public and by professionals as one means of increasing choice between local, low technology, care and high technology care at the district general hospital. Now NHS statistics in the Bath Health District (UK) reveal that availability of community hospital beds is associated with reduced use of central inpatient services in the city of Bath. The reduction was most apparent for medical and geriatric beds. [Hine C; Wood VA; Taylor S; Charny M Health Commission for Wiltshire and Bath, Devizes, England "Do community hospitals reduce the use of district general hospital inpatient beds?" J R Soc Med 1996 Dec;89(12):681-7]".

  5. Hospital downgrading in a rural community affects the locale's economic prospects as well as the health of its residents. [McDermott RE, Cornia GC & Parsons RJ "The economic impact of hospitals in small communities" J Rural Health 1991 7: 117-33] AND [Bindman AB, Keane D, Lurie N. "A public hospital closes. Impact on patients' access to care and health status." JAMA 1990 Dec 12;264(22):2899-904] AND [McDermott RE, Cornia GC, Parsons RJ. "The economic impact of hospitals in rural communities." J Rural Health 1991 Spring;7(2):117-33].

  6. NEW Running a 70-bed rural US hospital at a 5% annual operating loss would require a subsidy of $450,000 but the economic return to the local economy is estimated at $3.7 million. [McDermott RE, Cornia GC & Parsons RJ "The economic impact of hospitals in small communities" J Rural Health 1991 7: 117-33].

  7. NEW 1992 budget cuts for Manitoba's hospitals of approximately 7% were smaller proportionately than the number of beds closed resulting in the care becoming relatively more, not less, costly, and less than 1% change in hospital expenditures. [Shanahan M, Brownell MD, Roos NP. "The unintended and unexpected impact of downsizing: costly hospitals become more costly." Med Care 1999 Jun;37(6 Suppl):JS123-34]. An audit of consequences of acute bed number reduction in a Middlesex (UK) hospital revealed a reduction in GP referrals, but an increase in self-referred admissions and an almost doubling of geriatric admissions to acute medical beds, with important adverse economic results. [Petty R, Gumpel M. "Acute medical admissions: changes following a sudden reduction in bed numbers at Northwick Park Hospital." J R Coll Physicians Lond 1990 Jan;24(1):32-5].

  8. Fiscal Fairness for South Taranaki. Past closure of specialist surgical and obstetric services has resulted in many patients (or their care givers) being faced with significant transport costs to get to those services in New Plymouth. Family and other visitors also face considerable costs in time and money to visit them. [Personal Communications]. Even when the cost of transportation is met by the TDHB, it is identified as health costs incurred for South Taranaki, which is unfair as the specialist services were removed against the wishes of the South Taranaki community.
    NEW A study (in North Carolina, USA) looked at the perceptions of health professionals who were located in six rural communities where hospital closure occurred, regarding the impact of closure on community residents. Respondents perceived increased travel times to most significantly affect vulnerable populations, such as the elderly, the disabled and the economically disadvantaged. Respondents in the majority of comparison areas also reported access barriers for vulnerable populations. [Reif SS; Des Harnais S; Bernard S "Community perceptions of the effects of rural hospital closure on access to care." J Rural Health 1999 Spring;15(2):202-9].

back to Section Contents [5.4] Medical Demoralisation

  1. NEW A review of New Zealand medical politics in the British Medical Journal this year notes that "Evaluation plays little part in health sector restructuring in New Zealand. A commitment to evaluation in terms of equity, efficiency, and acceptability would improve the accountability of politicians and might avoid frequent, disruptive, and costly U.turns in policy" [Nancy Devlin, Alan Maynard, Nicholas Mays "Education and debate: New Zealand's new health sector reforms: back to the future? " BMJ 2001;322:1171–4. (full article on-line here).]

  2. NEW Andrew Hornblow, dean of the Christchurch School of Medicine (University of Otago) also summarised the health reforms in an earlier BMJ report. He suggests that the demoralisation and disempowerment of the health workforce have been attributed to tensions arising from the clash of managerial and clinical cultures, and we have seen this very clearly in Taranaki. "Clinical and commercial cultures became polarised and must now re-establish cooperative decision making." [Andrew Hornblow "New Zealand's health reforms: a clash of cultures" BMJ 1997;314:1892 (28 June)(full article on-line here).]

back to Section Contents [5.5] Lose or Win

  1. NEW Approximately 10% of the New Zealand population is served by rural hospitals without resident medical specialists (admitted under MOSS or GP care), now either "health centers" or "Subacute units". There are 36 such hospitals with an average bed number of 8, an average time by car to base hospital of 79 minutes and serving an average population of 9,453. There are only two serving 20,000 or more, Te Awamutu (20,000, 4 beds only 30 minutes from Hamilton) and Kawakawa (30,000, 29 beds, 45 minutes from Whangarei) [R Janes "Rural hospitals in New Zealand". NZ Med J 1999; 112: 2970-9] [If Hawera remains in its current situation, it would rank a close second to Kawakawa for having the biggest population without resident specialist physicians but as we have fewer beds (23), and a longer (60 minute) drive to base hospital, we would take the booby prize as the worst cared for significant population group in the country]. See the Hospital Chart comparing Hawera to similar sized NZ hospitals.

  2. NEW A study of changes in all community hospitals in the continental United States from 1981 through 1994 revealed that risk of closure is increased by peripheral organisational changes (eg downsizing and leadership change) while change in specialty, a core change, was beneficial for hospitals, because it reduced closure risk [Lee SY; Alexander JA "Managing hospitals in turbulent times: do organizational changes improve hospital survival?" Health Serv Res 1999 Oct;34(4):923-46].

  3. NEW In the 1990s, many hospitals will continue to be confronted with financial, regulatory, and medical staff issues that threaten their survival. Inadequate funding, certification problems, and attracting and keeping medical staff are just a few examples of the many difficult issues health care institutions face today and that have contributed to the phenomenal number of failing hospitals. Failing hospitals must consider all their options, such as turnaround process, modification of service mix, change to a specialty hospital, transfer to a new owner, or closure. Selection of the most appropriate option hinges on the hospital's goals and mission, its need in the community, and its owner's and sponsor's desire or ability to continue in the health care business. The transfer of ownership (eg TDHB to Community Trust or Wanganui DHB) option can be an antidote. [Zun LS. "Transfer of ownership: antidote to closure." Physician Exec 1994 Mar;20(3):26-7].

  4. One possible new rôle for Hawera Hospital would be as an ideal training placement for generalist physicians (as opposed to a specialised city unit). [Reid SJ, Chabikuli N, Jaques PH, Fehrsen GS. "The procedural skills of rural hospital doctors." S Afr Med J 1999 Jul;89(7):769-74] Many physician jobs require a general physician with maybe an interest in some other field (renal, endocrine, respiratory, rheumatology etc), so there is a need for experience in a small general hospital setting. (Two specialists and a senior registrar position would provide a more stimulating environment for all three.)

  5. NEW The rural hospital is a vital component of the rural health care delivery system and an important institution in rural communities. However, the future will remain precarious for rural hospitals and that they can hope to improve their economic viability only if they are able to determine where they fit as part of the large health care system. [Moscovice I, Rosenblatt RA. "A prognosis for the rural hospital. Part I: What is the role of the rural hospital? Part II: Are rural hospitals economically viable?" J Rural Health 1985 Jan;1(1):29-40 AND J Rural Health 1985 Jul;1(2):11-33].

back to contents  

Conclusion

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 and support services are put at risk, 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 and that much of the apparent safety of larger hospitals over smaller hospitals is the result of simple (and cheap) measures (such as the use of asprin and agreed "best practice" methods), indicating a need to support peer review and CME, and a greater transfer of information, rather than patients.

Should the TDHB refuse to reinstate acute medical admissions to Hawera Hospital there will be considerable support for a community request to the Minister of Health to proceed with a redrawing of the District Health Board Boundaries so we come under the Wanganui District Health Board, who are likely to be happy to guarantee resident specialist physicians in return. (Yes, she is already aware that this may occur.)

This information on published evidence is provided for the Independent Medical Advisor to the Taranaki District Health Board to assist in providing a report that is evidence based.

Most references cited are available (at least as an abstract) on-line at each journals’ Internet Website or by searching Medline or Cochrane Reviews (see links on my Website). All others are held personally.

 

back to contents Keith Blayney

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