Thank you for inviting me to comment on the report of Dr Dennis Pisk (October-December 2001) concerning the provision of medical services at Hawera Hospital. Dr Pisk has undertaken an independent review and my task is to comment on the options for service provision in internal medicine with particular reference to sustainability, clinical safety and risk, and the credentialing of senior medical staff.

You requested that in my report I outline my credentials. My degrees and professional qualifications are shown in the letterhead. I am an Associate Professor in the Faculty of Medical and Health Sciences in the University of Auckland. I have been qualified as a specialist in internal medicine and pathology for thirty-five years. I was seconded from the University to the Royal Australasian College of Physicians for eight years (1986-1993) as Director of Continuing Education for New Zealand and in that capacity I was heavily involved in the development of programmes for the maintenance of professional standards. Since 1994 I have undertaken consultative work for several health providers in connection with clinical standards, clinical audit and medical credentialing. My work has included clinical audit in hospitals in rural settings.

When considering the options for medical services at Hawera Hospital, trends in the nature of the practice of internal medicine in New Zealand must be taken into account. In that context I have spoken with the Vice-President for New Zealand and other officers of the Royal Australasian College of Physicians, members of the Internal Medicine Society of Australia and New Zealand and members of the faculties of the Medical Schools of the University of Otago and the University of Auckland. I have also sought clarification of the situation pertaining to Medical Officers of Special Scale (MOSS) from the Medical Council of New Zealand.

Trends in the practice of internal medicine in New Zealand, the evolving situation with regard to the medical staffing of small hospitals and the requirement of the Ministry of Health with regard to the credentialing of senior medical staff of public hospitals are summarised in the following paragraphs. This information provides the context for my subsequent comments on the options for medical services at Hawera Hospital.

Trends in the practice of internal medicine
In line with trends in other developed countries there has been a progressive increase in the degree of subspecialization (i.e. development of special skill in a narrowed field) among consultant physicians who are practising in internal medicine in New Zealand. This trend has been relentless for the past thirty years and it has occurred in response to the ever-increasing body of knowledge in medicine as well as technological advances. There are now very few "general" consultant physicians in internal medicine of the type who have served the community well in small hospitals in the past. Nearly all consultant physicians who are competent in basic internal medicine have a major subspecialty interest as well (e.g. cardiology, respiratory medicine, rheumatology). Many consultant physicians in the larger centres practise solely in their specialty (e.g. cardiology, oncology, neurology). It is virtually impossible for a "general" physician to keep abreast with the advances in all aspects of internal medicine. Thus, to provide a balanced service in internal medicine and maintain contemporary standards "across the board" it is essential for physicians to work in groups. The group must not only be of sufficient size to provide necessary expertise, but also to provide adequate cover for acute call in general internal medicine and to permit physicians to take part in on-going activities to maintain their clinical competence.

Evolution in the staffing of small hospitals/Medical Officers of Special Scale
The Ministry of Health contracted the Council of Medical Colleges in New Zealand to undertake a "Review of Medical and Health Workforce Recruitment and Retention in Northland". It was envisaged that the solutions for Northland may also be applicable across other regions. The ill-defined position of Medical Officers of Special Scale (MOSS) who have a crucial role in the provision of services in small hospitals is highlighted in the review report (July 2001) and the section on Medical Officers of Special Scale (pages 22-23) concludes with the recommendation that the Medical Council of New Zealand "Clarify the situation pertaining to MOSS in terms of service and training expectations and obligations, supervision and oversight, and participation in organised vocational training and career development activities". The Registrar of the Medical Council of New Zealand is convening a meeting of the relevant people to discuss the issue in the first quarter of 2002.

Credentialing, of Senior Medical Staff
The Ministry of Health publication "Toward Clinical Excellence: A framework for the credentialing of senior medical officers in New Zealand" states that District Health Boards are required to have a credentialing process in place for the senior medical staff of public hospitals by' June 2002. Credentialing is defined as "a process used to assign specific clinical responsibilities (scope of practice) to health professionals on the basis of their training, qualifications, experience and current practice within an organisational context. This context includes the facilities and support services available and the service the organisation is funded to provide. Credentialing is part of a wider organisational quality and risk management system designed primarily to protect the patient".

To be credentialed, physicians in Taranaki and elsewhere must be involved in regular continuing education, clinical audit and peer review activities relevant to their individual practices.

Comment on the options for the internal medicine service at Hawera Hospital
Dr Pisk has presented three options, which he describes as:

• Resident physician option
• Single MOSS option
• Multiple MOSS option

My comments on the options are as follows:

1. Resident physician option

   Sustainability
   Dr Pisk has rated the sustainability and prospect for service development for this option as "low". In my opinion, both the sustainability and prospect for service development for this option are extremely low. In my view it will simply not be possible to recruit three internal medicine physicians of consultant status (either "general" or "subspecialist") with the necessary skills to be based in Hawera and to provide a balanced and largely independent service in internal medicine at Hawera Hospital. Even if it were possible to recruit three suitable consultant physicians in the short term, it is difficult to see how these consultants could maintain contemporary standards at Hawera in the longer term without substantial input from the physicians with expertise in the subspecialties of internal medicine at Taranaki Base Hospital.

   Clinical Safety and Risk
   Dr Pisk has rated the safety of this option as high. If there were three stable consultant physicians at post with junior medical staff support then the safety would be high. The more likely scenario in endeavouring to implement this option is, however, that there will be no consultant physician or transient physicians struggling to maintain the service at Hawera. In practice, unless there is Substantial back up from the physicians at Taranaki Base Hospital, there are likely to always be gaps in the consultant physician cover for the service at Hawera. Thus, while in theory this option has a high degree of clinical safety, attempting to implement the option in practice carries considerable clinical risk.

   Credentialing
   The only practical way for physicians based at Hawera Hospital to meet the on going educational and audit requirements set out in the Taranaki Health policy for credentialing would be for the physicians at Hawera and at Taranaki Base Hospital to function as one group, albeit with services in two locations. The Chairman of the Credentials Committee for Taranaki Health has already made it clear that if consultant physicians based at Hawera are to be credentialed, they will need to have more support by junior staff, and adequate arrangements to enable them to undertake clinical audit and participate in educational activities in Taranaki and elsewhere to maintain contemporary clinical competence.

2. Single MOSS Option
   

   Sustainability
   This option is probably sustainable in the sense that it should be possible to obtain a competent MOSS to fill the post, but with all of the downsides that are outlined by Dr Pisk.

   Clinical safety and risk
   The system whereby a single MOSS in internal medicine is left in geographic isolation at Hawera Hospital without formal supervision by a consultant physician and with no MOSS pool to provide cover raises serious concern with regard to clinical safety and risk.

   There is at present a single MOSS in internal medicine at Hawera Hospital but the incumbent is an experienced doctor who has worked in internal medicine at Taranaki Base Hospital for several years and who the physicians at the Base Hospital know well. There is a lot of informal communication and consultation between the MOSS and the consultant physicians. Thus, at the level of service that is provided the arrangement appears to work quite well because of the presence of this particular, MOSS. The model does, however, have inherent risk.

   Credentialing
   Provided that the internal medicine service at New Plymouth is adequately resourced to allow time for the physicians to take part in continuing education, clinical audit and peer review activities then the physicians who currently conduct the general and specialty outpatient clinics in internal medicine at Hawera Hospital should have little difficulty meeting the Taranaki Health requirements for credentialing.

   The credentialing exercise for physicians in Taranaki has not yet been undertaken by the Credentials Committee for Taranaki Health because of the uncertainty in relation to the internal medicine service at Hawera Hospital and hence uncertainty as to who exactly is to be credentialed and for what tasks. The physicians who are based at Taranaki Base Hospital are unlikely to wish to be credentialed to undertake responsibility for inpatients at Hawera Hospital unless the resources are adequate for the task and they are clear about their responsibility and authority.

   Arrangements would need to be made for the single MOSS to be involved in regular clinical audit and educational activities with the physicians of Taranaki Base Hospital to enable him/her to meet the standard for the credentialing of senior medical officers.

3. The Multiple MOSS Option

   Sustainability
   

   The sustainability of this option depends largely on the national recognition of the contribution that MOSS make in hospitals in rural areas and the development of a career pathway for MOSS. Without pre-empting formal decisions that are still to be made, It appears that the Medical Council of New Zealand and the professional Colleges are about to get to grips with this issue.

   Dr Pisk has pointed out that there is "a large pool of medical officers that could be appointed to MOSS positions". Many medical officers do not, however, wish to work in rural areas because of social factors and those factors apply as much to MOSS as to any other group. Thus, Taranaki Health will be in competition with other centres to recruit MOSS of the right calibre to staff Hawera Hospital. Dr Pisk has drawn attention to the organisation of medical services at Dunstan Hospital, which is staffed by a stable group of MOSS. A general physician from Dunstan visits the hospital on a regular basis. From independent inquiries that I have made the arrangement appears to be working well. If similar conditions which are attractive to MOSS can be developed at Hawera Hospital then Part I of the Multiple MOSS Option should be sustainable now.

   Part II of the Multiple MOSS option requires that "a further 5-6 MOSS be recruited so that a total pool of 8-9 MOSS are appointed at Hawera Hospital to cover both the Emergency Department and the inpatient unit". Part II is an ambitious development that requires not only the recruitment of a relatively large number of MOSS, but the multi-skilling of MOSS in Emergency Department procedures such as the management of trauma as well as in internal medicine. I have some reservation about the sustainability of Part II of the option at the present time, but it may well be feasible if and when the professional Colleges and Medical Council clarify the position with regard to a career path for MOSS in rural hospitals.

   Clinical safety and risk
   Dr Pisk has identified that "establishing optimal relationships between the MOSS and general physicians at Taranaki Base Hospital is a big component to patient safety" and the "Establishment of a MOSS workforce is not competitive to development of the physician base at Taranaki Base Hospital". I strongly support these statements. The arrangements in internal medicine at Hawera will work well only if the Department of Medicine at Taranaki Base Hospital is well resourced and the physicians (most of whom have subspecialty interests) outreach to Hawera and are involved in the education and training of MOSS as envisaged in Dr Pisk's report. In essence, there would be one Department of Medicine for Taranaki with the consultant physicians and their junior medical staff providing an inpatient and outpatient service at Taranaki Base Hospital and MOSS supported by visiting consultant Physicians providing the in-patient service for internal medicine (and Assessment, Treatment and Rehabilitation) at Hawera Hospital. The consultant physicians who are based at Taranaki Base Hospital would also conduct regular outpatient clinics in internal medicine and its subspecialties at Hawera Hospital.

   I confirm that the arrangements for inpatients and outpatients at Hawera Hospital as outlined in Dr Pisk's report would be clinically safe.

   Credentialing
   The MOSS who are involved in the internal medicine service at Hawera would be subject to credentialing by the Credentials Committee for Taranaki Health. Provided that the MOSS are involved in clinical activities under consultant supervision, audit and continuing education as envisaged by Dr Pisk they would meet the basic requirements for credentialing for Taranaki Health.

   The physicians from Taranaki Base Hospital would be credentialed for the work that they undertake at Hawera Hospital as part of the credentialing exercise for physicians of Taranaki.

Final Comment
From the points of view of sustainability, clinical safety and risk, and credentialing the medical staff of the internal medicine service at Hawera Hospital, whatever their status, should be viewed as a component of a single "Department of Medicine" for Taranaki. The internal medicine service at Taranaki Base Hospital should also be as a component of the Department of Medicine for Taranaki. With advances in medicine and progressive subspecialisation Taranaki is simply not large enough to run two independent internal medicine services and maintain contemporary standards in both. The arrangements outlined in the preferred option by Dr Pisk provide a practicable compromise between access to the internal medicine service and the wish of patients and their families for their care to be close to home on the one hand and the maintenance of contemporary standards of clinical care from a more technical viewpoint on the other.

Yours sincerely

John Buchanan
Auditor of Clinical Standards.