Introduction

 

The purpose of this submission to the Board on the provision of medical services at Hawera Hospital is to provide some research based information to contribute towards deciding the final policy adopted on the 28th February. The fact that the people of South Taranaki wish to have their hospital care, where possible, in their own community and the particular importance this is to tangata whenua has been made very clear in recent consultations and submissions to the Independent Reviewer, Dr Dennis Pisk {Pisk 2001} and to the RHA in its 1996 Taranaki Report. That report revealed almost total Taranaki public apathy for every proposal made except the proposal to reduce inpatient services at Hawera (95% of 818 submissions rejected this, while the next most responded to submission [rejecting the proposal on GP contracting] only attracted 65 submissions) {Midlands 1996}.

 

As you are undoubtedly aware, my initial submission to Dr Pisk {Blayney 2001} was in support of his Option One (Three Specialist Physicians), although for practical reasons, this would have probably become two specialists and an experienced non-specialist Medical Officer of Special Scale (MOSS), while the TDHB management seemed to prefer either Option Two (low level admissions, single MOSS day only care with all acute medical admissions to Base) or no in-patient facility at Hawera. Dennis Pisk advised the South Taranaki GPs that a compromise between these two positions would be necessary, and came up with a rather elegant and (I believe) workable solution in his Option Three which I am pleased to see has been accepted by the Board as the "Preferred Option".

 

However, it is a compromise, and so the loss of resident specialist physicians to the South Taranaki community has to be met by management also "coming to the party" and supporting the effective recruitment of a pool of Multi-skilled Medical Officers (MMO) and ensuring all the specialist, educational, financial and other support necessary to retain them is made available. If management has difficulty in meeting those requirements, such as ensuring daily visiting physician presence at Hawera Hospital, they may need to ensure that at least one of the MMOs has specialist qualifications.

 

I accept that Hawera has had difficulty in finding and retaining specialist physicians, and it shares this difficulty with many rural and peripheral hospitals, however the reasons for and solutions to this difficulty has been well researched and identified. I intend to demonstrate in this submission how the literature supports the care of people in community hospitals, with only complicated cases being transferred to larger hospitals (both in terms of cost and outcomes), how MMO or "hospitalist" care is safe and effective, and what conditions are required to succeed in recruiting doctors to rural hospitals and retaining them.

 

I have already described some of the New Zealand political and legal directives (to DHBs) supporting the retention of basic in-patient care in rural communities to ensure access to health care for all, particularly those with the highest health needs, and the requirement to act openly and in good faith {Blayney 2001, Appendix2}. I believe that providing the Option Three model is allowed to succeed, the Board will be able to meet those expectations for the people of South Taranaki without compromising services to the rest of the province

 

 

[1] Safety and Cost-effectiveness of the smaller hospital

 

1.1 Admissions

Acute hospital admissions in NZ are increasing, with the increase primarily related to an increase in medical admissions among the elderly, particularly for cardiac or respiratory conditions. In addition, most of the increased number of admissions is due to an increase in the number of people admitted rather than the more frequent admission of a small number of very sick individuals, according to an extensive literature review by NZHTA (a University of Otago research unit under contract to the HFA and the MoH){NZHTA 1998}. One would expect that the smaller community hospital would be the most appropriate way to meet this health need.

 

In Australia and New Zealand, there is an increasing recognition on the place of the small hospital and the generalist physician. The Health Policy Unit of the Royal Australasian College of Physicians recommends Health Boards should "Expand general medical units in smaller hospitals" in its recently released document on the Specialist Physician workforce "General Medicine in Australia and New Zealand: The Way Forward" {Graham & Larkins}. The new Internal Medicine Society of Australia and New Zealand (IMSANZ)is promoting a return to the generalist physician as the increased cost of managing general patients by sub-specialists doesn't improve outcomes except in their area of their subspeciality. While the need for subspecialisation in consultative physician practice is recognised and supported, it seems the pendulum has swung too far. Our health care systems stand to benefit from a more vigorous contribution by well-trained and committed general physicians" {Scott & Greenberg 1998}.

 

Of course, prevention of admission in the first place needs to be addressed, and the provision of effective and available primary health care is the cornerstone to this. I will cover some issues on that in Section Three (Recruitment and Retention of rural physicians), as well as the falling numbers of South Taranaki GPs. It is useful to note that the NZHTA review found that good evidence exists (from randomised controlled trials) that hospital at home schemes, comprehensive geriatric care, and the placement of GPs in the ED are the most effective interventions at reducing hospital admissions {NZHTA 1998}. The current cooperation between White Cross and South Taranaki GPs allows the latter to occur, while the other two interventions link well with a locally based community hospital.

 

 

1.2 Costs

American health care costs skyrocketed in the 1980s and early 1990s, reaching 15% of their gross national product. Reasons included the introduction of new, highly effective but very expensive diagnostic and therapeutic procedures and an aging population, common to other countries but {Dalen 2000} describes some "unique" American causes, including:

• Excessive administrative costs
• Excessive malpractice costs
• Excessive use of high technology
• Excessive use of futile care
• Excessive expectations
• Lack of health insurance, primary care, and prevention and
• Lack of continuity of care

All of these are valid for New Zealand (but read "ACC monopoly" instead of malpractice costs). We expect the best, but unlike the US and Canada, we cannot (or will not) pay for it! Furthermore, the move by medium sized hospitals like New Plymouth to do more complex procedures is likely to be increasing the need for high cost critical-care services. It has been demonstrated that the increased demand for critical care is generated from within hospitals {Ridley et al 1999}.

Attempts to control the acceleration of health care costs in the US has seen an explosion in administrative costs and Chief Executive Officers becoming millionaires {Dalen 2000}.

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 {Rosen & Gabbay 1999}.

1.2.1 Rural hospitals in Virginia (US) achieve lower costs, better efficiency and productivity level than urban hospitals and are more profitable {Wang et al 2001}. In Manitoba, (Winnipeg, Canada), the government has adopted a strategy of shifting hospital care from more expensive urban hospitals to less expensive rural facilities {Black & Burchill 1999}.

1.2.2 Reducing beds can lead to a paradoxical increase in costs as expensive "teaching hospital" beds become relatively more expensive {Shanahan 1999}. The "downsizing" that occurred in about 15 percent of all US rural hospitals between 1983-1988 was not associated with improved financial performance {Mick & Wise 1996}.

1.2.3 Inpatient costs for patients with cerebrovascular disease are up to 29% less in non-teaching hospitals {Reed et al 2001} and 50% less in community hospitals {Feigenson 1978} with no statistically significant difference in functional outcome or length of stay, compared to academic hospitals.

1.2.4 The availability of Community Hospitals in the Bath Health District (UK) was associated with reduced use of central inpatient services in the city of Bath. This was most apparent for the medical and geriatric but less for the surgical beds {Hine et al 1996}

 

 

1.3 Safety

The argument that high cost high technology medicine must be centralised to help reduce costs is apparently self-evident and seems to be supported in the literature. A parallel argument that fewer centres doing complex medical procedures more often is also safer, is also supported, but only for certain conditions like high risk surgery and angioplasty and only comparing medium (low volume) to large (high volume) hospitals {Black & Johnston 1990}, {Maynard et al 2000}, {Bach et al 2001}, {Birkmeyer et al 2001}, {Hemmelgarn et al 2001} & {Maynard et al 2000}. However, literature review findings and results of analyses using secondary data for several conditions suggest few if any volume/outcome relationships pertain to small rural hospitals {Schlenker et al 1996}, {Glenn & Jijon 1999}. It would appear that smaller hospitals generally know their limits, but medium hospitals sometimes don't! Where a procedure is done regularly by a local provider such as endoscopy by Drs D Taylor and M Arnold locally or by surgeons performing regular routine endoscopic surgery, there doesn't appear to be any increase in mortality or morbidity {Kreuder & Chown 1992}, {Furman et al 1992}, {Tietz 1995}.

An increased risk is faced by the patient who cannot or will not travel to a larger center to obtain care, and this is happening regularly at Hawera {personal experience and private communication with ED staff}. There is also evidence that medium to large hospitals have their own particular risks to patients not seen in smaller units

 

1.3.1 Medium to large hospitals are not necessarily safer

Very large hospitals will often have patients in highly specialised units with non-generalist physicians, so co-morbidities are missed or managed poorly {Houghton & Hopkins 1996}, {Scott & Greenberg 1998}, {Egan et al 2000}. A randomised study comparing admission under specialists, generalists or "hospitalists" (see 2.1 below) revealed half the mortality in the later two groups {Palmer et al 2001}.

The acute (medical) team in a large hospital can be just one registrar (often quite junior) and one house surgeon with the consultant "on-call" (asleep) {Egan et al 2000}. Having worked in that situation as a medical registrar at Green Lane Hospital (part of my Family Medicine Training Program), I know one was expected to cope, and only call the consultant if one was "well out of depth". It is therefore quite likely that the Hawera Casualty Officer and an experienced MMO would together have greater experience and skill than the resident acute medical team of a large hospital, yet still have the ability to consult and transfer to Base Hospital under the specialist consultant

While overall coronary mortality has been falling, it is not because of any high-tech advances {McGovern et al 2001}. In fact virtually all the medical advances that have been associated with reduced coronary death are low tech and available at Hawera Hospital (Education on life style, Asprin, Beta-blockers, ACE inhibitors etc). Not only that, despite all the costly advances in medical care, there has been no improvement in outcome for (1) Cardiopulmonary resuscitation success rates for 30 years {Schneider et al 1993}, non-Q wave Infarction survival for 22 years {Furman et al 2001}, Cardiogenic Shock survival for 13 years {Goldberg et al 1991} and overall inpatient myocardial infarction survival for 10 years {Brown et al 1997}. Even the claimed advantage of primary angioplasty over thrombolysis for myocardial reperfusion has been shown in a recent Cochrane reviewed meta-analysis of studies to be short-term and not sustained {Cucherat et al 2001}.

A study last year of medium sized US metropolitan hospitals performing 5 high-risk surgical procedures (CABG, AAA repair, coronary angioplasty, esophagectomy, and carotid endarterectomy) revealed that if patients were "Leapfroged" to hospitals meeting "Volume Standards", 2581 lives would be saved yearly in the US. {Birkmeyer et al 2001}. Centralization of coronary revascularization procedures (such as percutaneous transluminal angioplasty) in the Calgary Regional Health Authority (Canada) resulted in increased numbers of procedures for the involved communities, shorter stays and reduced deaths.

Therefore, if New Plymouth accepted the same "Volume Standards" argument used to close Hawera in-patient surgery for itself and referred on all "high risk" procedures that would survive transport (as it does for CABG), one could argue that lives would be saved AND money currently tied up providing those services (eg angiography/angioplasty) would be available to reduce the motivation to downsize and reduce services at Hawera! Transporting a few patients to tertiary units makes more sense than transporting all South Taranaki acute admissions. The risk to patients argument (eg leaking Abdominal Aortic Aneurysms (AAA)) has to be questioned, as a recent UK study reveals that community mortality after ruptured AAA is unrelated to the distance from the surgical centre {Cassar 2001}.

In the 1998 Hospital Services Plan {English 1998}, Hawera Hospital was defined as a "Sub-acute Unit" providing inpatient medical beds and day surgery, while Taranaki Base was a Secondary Hospital (not a lower level tertiary Hospital). The evolving concept is that small and medium general hospitals will continue to be needed to manage those conditions that have less exacting requirements for equipment and training, but complex specialty procedures of high risk will be shifted to tertiary hospitals that are, or will become, centres of excellence {Wilson 1999}

1.3.2 Small rural hospitals are not necessarily less safe

Many studies do reveal that larger, urban teaching hospitals tend to have better quality of care and reduced mortality than smaller, non-teaching, 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 {Keeler et al 1992}, {Hartz et al 1989}. The survival advantage of the top ranked US hospitals and metropolitan teaching hospitals loose their statistical significance when mortality figures are adjusted for aspirin and beta-blocker use {Chen et al 1999}, {Vu et al 2000}, again suggesting better CME, communication, protocols etc are needed, more than transfers to larger hospitals

1.3.3 Acute Rural Paediatrics

Using a model with the ability to modify multiple EMSC (emergency medical services for children) system variables has demonstrated the shortest times to stabilization of critically ill children occur in systems that maximize the number of hospitals that meet EDAP (emergency departments accepting pediatrics) standards and decentralise pediatric emergency care {Sacchetti et al 2000}.

1.3.4 Acute Rural Medicine

In a 1999 review of 43,000 US admissions, 83 small rural hospitals that had a relatively unspecialized range of services were compared to results from 83 peer hospitals in metropolitan areas. The rural hospitals had the same or lower adjusted mortality rates than urban hospitals, consistent with the view that small rural hospitals generally make appropriate transfer decisions for severely ill patients and provide quality care for retained patients {Glenn & Jijon 1999}.

Acute management of Myocardial Infarction can be safe in peripheral hospitals {Jacobs & Fatovich 1996}, {Morris et al 1983} and no worse for Cardiogenic Shock as larger centers {Goldberg et al 1991}. It may even be safer - 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 1995}.

Many medical procedures and managements (including intensive care) can be effectively described in a "best practice" protocol and excellent and sometimes better results are possible in small hospitals following these established protocols {Phelps 1995}, {Reed et al 2001}. Community and rural Hospitals can safely use "state of the art" treatments using protocols as 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 tPA-treated patients were consistent with those of other studies. In fact, patients treated in rural hospitals were more likely to receive tPA but did not show any increased mortality {Reed et al 2001}.

Is it less safe to be cared for in a rural community hospital if there is a possibility one may develop the need for intensive care in a Base Hospital? A recent study compared the outcomes of 178 transfers from the general wards to ICU of a New Hampshire tertiary hospital with that of 147 transfers to the same unit from 29 rural community hospitals (8 with less than 50 beds). The transfers from the community hospitals are just as likely to survive as patients who develop ICU needs on the wards of the tertiary-care hospital. {Surgenor et al 2001}.

The need to transfer many patients should be questioned as a recent three year Melbourne study showed that acute inter-hospital 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 {Duke & Green 2001}. As the reason for moving a critically ill patient is to provide more care, and as the period of transfer may impose risks on the patient, transfer should not be considered unless some resulting benefit is expected {Surgenor 2001}. In fact, other than in major trauma, burns and the critically ill, there is little direct evidence supporting the regionalisation of adult medical and surgical intensive care services {Crippen 1999}, {Thompson 1994}. However, I am not suggesting we retain critical care in Hawera, just the uncomplicated care.

 

As an interesting aside, the large tertiary-care hospital involved in the {Surgenor et al 2001} study is the Mary Hitchcock Memorial Hospital, part of the massive Dartmouth-Hitchcock Medical Center (DHMC), Medical School and research unit. The DHMC has a staff of 4,366 but is located in a rural town (Lebanon) the size of Hawera/Normanby (12,500), 85km from the nearest city (Manchester, NH) and 200km from Boston. See a fuller description at: http://home.bitworks.co.nz/blayney/Lebanon.htm.

 

1.3.5 GP bed hospitals

A number of studies have examined the use of community hospitals (usually GP run) as a substitute for acute hospital care. These studies have concluded that between 5-60% of patients admitted to a general hospital could be treated in a community hospital (see 2.3). However, overall costs were higher in community beds because the length of stay was usually longer {NZHTA 1998}. This problem should be answered by using the MMO/Hospitalist model.

There is an argument that areas like the Bay of Islands manage with a 30 bed hospital (Kawakawa)servicing 30,000 without specialists by transferring most acute cases to Whangarei. However, it is only 45 minutes from their Base and transfers are either by helicopter or ambulance using a mobile ICU called the Patient Care Bridge {Nagappan et al Dec 2000}. Helicopter transfers tended to be the more serious with over 90% of the non-obstetric adult patients being ventilated {Nagappan et al Jul 2000}. In South Taranaki our ambulances tend to be in transit or at Stratford when we need them and they are not mobile ICUs! Current reviews on the transfer of critically ill patients recommend the use of a specialist transfer team to improve the acute physiology and reduce early mortality in ICU. {Bellingan et al 2000}, {Braxton et al 2000}. If we can't get ambulances, what chance do we have of mobile ICUs or Transfer Teams??

 

1.3.6 Specialist outreach and telemedicine

Rural hospital oncology outreach and tele-oncology programmes appear to be safe and make specialist care more accessible to outlying patients {Campbell et al 1999}.

A NZ RTC of teledermatology demonstrated that this was a more cost-efficient use of resources than conventional hospital care {Loane et al 2001}.

Telemedicine videoconferencing is successfully allowing remote rural physicians to "attend" conferences they would not otherwise have attended with large majorities noting high levels of effectiveness {Callas, 2000}.

A Specialist Outreach Service (SOS) in Australia's Northern Territory 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 and cultural differences {Gruen RL, et al 2001}.

These studies support the use of specialist outreach (to South Taranaki) and the increased use of telemedicine.

 

 

1.4 The US Critical Access Hospital Scheme

Jan 2000

The US approach to reversing centralization includes the Rural Hospital Flexibility Program (RHFP),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. (See full brief on-line at http://www.ruralhealth.hrsa.gov/IssueBrief1.htm).

There has been significant enthusiasm for the RHFP with one hundred and 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 {Hagopian & Hart 2001}.

In the US, Hawera Hospital would be classed as a Rural Hospital, yet we are having to convince the TDHB to allow it to function like a CAH but serving three times the population.

 

 

[2] Safety & Cost-effectiveness of the MMO (Hospitalist)

Dr Dennis Pisk {Pisk 2001} proposes a team of Multi-skilled Medicals Officers (MMO) rather than the non-descriptive salary scale term Medical Officer of Special Scale (MOSS). He identifies Dunstan Hospital in Central Otago as a successful working model and describes how the Illawarra Area Health Service in NSW (Australia) has developed a MMO career structure. However, in published literature from Canada, the United States, Germany and even Australia, the equivalent term seems to be the somewhat ugly "Hospitalist". Dr Pisk and TDHB management confirm the concept of MMO is equivalent to the "Hospitalist"

 

2.1 Definition and description

A hospitalist system was developed at Park Nicollet Clinic in 1993, was implemented in 1994, and remains in existence today {Freese 1999}. The term "hospitalists" (first used in 1996 by Wachter & Goldman of the UCSF Dept of Medicine {Wachter 1999} has developed to describe a class of physician who specialize in the care of inpatients, performing the same roles of senior or chief residents but replacing the visiting primary physician (US) or consultant (UK,NZ). They tend to be recently graduated residents, often recruited straight out of houseofficership possessing cutting-edge technologic and pharmacologic skills {Wachter & Goldman 1997}, {Fitzgerald 1997}.

The large US Hospitalist provider Inpatient Management Inc (IMI) defines a "Hospitalist" as "A physician dedicated to coordinating and managing the care needs of hospitalized patients" [with a number of specific attributes listed in the appended Web information on IMI {Appendix 1 p2} or on-line at www.inpatient.com/hospitalist.html].

Economic forces have stimulated a growing role for physician "hospitalists" in caring for patients hospitalized by other physicians and there is a move (in the US) to have this type of physician fulfill the major criteria for a medical specialty (scientific legitimacy, the development of training pathways, and the existence of academic departments {Kelly 1999}.

Hospitalists in the USA now have a nation-wide political and educational organisation, the National Association of Inpatient Physicians (NAIP), which affiliated with the American College of Physicians in 1997 and at their first national conference it was estimated that the number of hospitalists could grow from the (then) current 1,200 to 1,500 to anywhere between 3,000 to 30,000 {Wachter 1997}. By 2001, the number of US hospitalists was estimated at 4000 {Hoff et al 2001} and they are becoming increasingly visible both in academic and community hospitals, with more than 10% of advertisements for general internists in major medical journals now specifically seeking hospitalists {Wachter 1999}.

One reason this new specialty is alluring for doctors who practice it full time is that it offers regular hours. When they're off, they're off, so they can have a life away from the job. That's a big plus for doctor parents who enjoy the challenge of hospital care, but still need predictable blocks of time to spend with their kids. What qualifications do you need? Prospective hospitalists tend to be general internists, skilled in caring for hospitalized patients, with some critical-care-unit experience. But since many inpatients are older adults, it certainly doesn't hurt your chances if you have a specific interest or training in geriatrics. Finally, excellent communication skills and a flair for diplomacy is needed {Cejka 1998}.

A survey of 820 dues-paying members of the NAIP received 393 responses (48%). This revealed hospitalists as a group of younger, mostly male, early-career individuals with high levels of job satisfaction and autonomy, low levels of burnout, and a long-term commitment to remaining in the role. According to the survey, the biggest reason hospitalists chose their field was intellectual stimulation followed by the excitement of an emerging discipline and the potential for a more predictable lifestyle. Hospitalists also reported very favorable social and professional experiences with high levels of camaraderie within their group, cooperative [professional] relationships with nurses, social workers etc and recognition by patients and families. However, it is worth noting that annual compensation averages $US140,970 [approx $NZ316,000 Feb 2001] {Hoff et al 2001}.

 

2.2 Cost savings

One of the first randomised controlled trials (RCT) on what is now know as hospitalists looked at alternate day admissions to either a traditional service or the hospitalists. The study involved over 800 in each group and resulted in "significant resource savings with no changes in clinical outcomes or patient, faculty, and house staff satisfaction {Wachter 1998}.

Other studies have shown the institution of hospitalist groups generally leads to reductions in hospital charges of roughly 12%-20% regardless of local market characteristics, with no worsening of outcomes. {Lindblad 1996}, {Moore 1997}, {Nelson 1997}, {Diamond et al 1998}, {Simmer et al 1991}, {Davis 2000}, {Halpert et al 2000}, {Hackner et al 2001}, {Michota 2001} & {Palmer et al 2001}. Not only is length of stay (LOS) typically reduced, but the readmission rate is reduced or the same (half in Diamond et al's study).

Two very recent prospective RCTs are enlightening. In one, using a hospitalist service with nurse discharge planner resulted in a cost savings of 20%, a 15% reduction in LOS, half the mortality and the same level of satisfaction compared to a specialist led service in the same hospital [remember the patients were randomised to each group] {Palmer et al 2001}, while in the other, there was no cost saving nor improved outcome by just increasing supervision of residents by 400% {Kearns et al 2001}. Paediatric Hospitalists are also cost effective {Bellet & Whitaker 2000, 2001}, {Ogershok et al 2001} & {Wells et al 2001}. All studies show no apparent compromise in clinical outcomes or patient satisfaction.

 

2.3 Quality

However, the emphasis on cost cutting, LOS, hospital days per 1000 members, actual hospital costs, etc as justification for the existence of hospitalists is shifting towards quality of care issues and outcomes.

A survey of 380 US Internal Medicine Board-certified physicians admitting patients to the 591 bed Beth Israel Deaconess Medical Center reveal that only 6% felt more comfortable caring for inpatients than outpatients, although they still wanted to care for their own patients {Auerbach et al 2001}. UK and Australasian GPs have long ago found it better to admit under a physician or surgeon, as we elected to "specialise" in primary, generalist non-hospital medicine on choosing the General Practice career.

An improved quality of care by hospitalists is suggested by studies showing lower unnecessary use of antibiotics for viral respiratory infections compared to specialists {Stone et al 1999} and twice the rate of beta blocker use after myocardial infarction [best practice] compared to two large cohorts {Dall et al 2000}.

Hospitalists have made a significant improvement in inpatient education for students and residents {Halpert et al 2000}. "The major effect of the hospitalist movement on academic centers is the creation of a cadre of physicians committed to critical pathways; clinical guidelines; quality assurance; risk management; clinical re-engineering; and the use of the inpatient service as a laboratory for developing, evaluating, and implementing initiatives to improve patient care" {Goldman 1999} [no doubt about that diagnosis, Goldman has a bad dose of "management speak"!]

 

2.4 Why not a primary care physician (GP) beds model?

A 1996 (English) review of acute medical admissions by a mixed panel (GPs without experience of GP beds, GPs with experience of GP beds, and consultants) estimated that only about 10% (8-14% by GPs, 5.5-9% by specialists) of hospitalised patients could have received alternative care (eg GP bed or urgent outpatient appointment){Coast et al 1996}. However, the South Taranaki community would like to see an option where 80-90% of all medical patients are cared for at Hawera.

US studies comparing cost and outcomes of hospital care under hospitalists vs primary care physicians invariably show lower cost and similar or better outcomes with hospitalists. However, employing GPs in accident and emergency departments to manage patients with primary care needs seems to result in reduced rates of investigations, prescriptions, and referrals {Dale et al 1995}. The Hawera ED currently uses a mix of GPs and casualty officers, and in weekends most "triage code" 4 and 5 patients attending the ED (which is also the GP "After-hours" site) are seen by "second-on-call" GP.

 

2.5 Negative US experience of Hospitalists

The only real concerns raised in the literature have been about health plans which make transfer to hospitalists compulsory (mandatory hand-off) and the perceived Hospitalist's threat to internists {Harold 1999}, {Sox 1999}. The problem of possible loss of continuity of care has been identified and apparently avoided by the Hospitalists movement itself with good communication with primary care physicians (GPs) {Appendix 1 pg 4}.

 

2.6 International experience

2.6.1 Canada

A hospitalist-run medical short-stay unit (MSSU) was created in a teaching hospital in Montreal in 1989, with ED staff selecting suitable patients for admission. The 5 most common MSSU discharge diagnoses were asthma and chronic obstructive lung disease, pneumonia, congestive heart failure, urinary tract infection and cellulitis. Only 1 in 5 patients later required transfer to other hospital wards. The MSSU patients had a shorter length of stay, lower rates of complications and lower rates of 30 day readmission compared with general ward patients. The main problem identified was admission of appropriate patients during non-daytime hours {Abenhaim et al 2000}.

2.6.2 Australia

A big review of the concept was published in the Medical Journal of Australia in 2000 and is available on-line {Egan et al 2000}. Hospitalists in Australia are more commonly known as Career Medical Officers and this new model is proposed as an alternative to the traditional Visiting Medical Officer (usually a specialist physician) who delegates responsibility to junior medical staff in a hierarchical manner (registrars & RMOs). In the traditional model, acute emergencies, such as cardiac arrests, are handled by unsupervised and often quite junior staff. They propose that the hospitalist be a generalist, rather than a sub-specialist because of the varied problems that admitted ill patients may have. They do have reservations about the GP or consultant relinquishing primary responsibility. They describe a "blind spot" in the recognition of CMOs in the Australian hospital scene, despite an estimate of 2,000 CMOs throughout Australia with their own organisation (CMOA).

In different parts of Australia doctors in this role have different designations: Senior Medical Officer (SMO: Qld, WA, SA, NT); Hospital Medical Officer (HMO: Vic); Career Medical Officer (CMO: NSW, but this title also known and occasionally used in other states). In practice, awards for these medical officers range from registrar to staff specialist range.

2.6.3 Germany

German "hospitalists" are salaried employees of predominantly non-profit hospitals, providing care solely to hospitalized patients. The German experience has been an almost complete and unfortunate uncoupling of inpatient and outpatient services with little communication between hospitalists and ambulatory physicians (GPs). It is common for tests, obtained by the ambulatory physician, to be duplicated by the admitting physician, even when tests are obtained on the same day [sound familiar?]. Inability to provide seamless continuity of care has resulted in German length of stay being among the longest in Europe. General Practitioners in the UK [and NZ] provide no inpatient care, but have a historical legacy as superb ambulatory clinicians, whereas, American internists emerging from traditional, hospital-based training programs are notoriously ill prepared to assume roles as outpatient physicians {Jackson 1997}.

The lesson here is to improve communication between the Hospitalist and the Primary Care Physician, and this is exactly what leading US Hospitalist providers are doing. In the appended Web information on Inpatient Management Inc (IMI), you can see a description and flow chart of their Inpatient Delivery Model {Appendix 1 pg 3} or find it at on-line], where there is an almost excessive emphasis on continuity with the primary care physician (GP). But then, if we operated in a private competitive US style system, those hospitals that didn't provide this may not survive!

 

 

[3] Recruitment and Retention of rural physicians

 

There is an exodus of New Zealand graduates (some would say a haemorrhage), with no reassurance that many intend to return. 82% of Christchurch School of Medicine students intend to leave NZ within two years of graduation. Financial opportunities overseas and level of debt were the Best motivating factors to leave {Gill et al 2001}. The predicted size of Auckland Medical School students' graduation debt was significantly related with plans to practice medicine overseas {O'Grady & Fitzjohn 2001}.

As recruitment and retention issues are crucial to the success of Option Three, I have included here information from recent world literature on the subject of recruiting and retaining rural (primary care [GP] and hospital) physicians.

 

3.1 Historical note

The New Zealand Committee of the Royal Australasian College of Physicians (RACP) advised the Minister of Health in 1982 on the staffing of provincial hospitals 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. Difficulties in training and retaining specialist physicians were related to an excessive service workload and compounded by negative decisions being taken by hospital boards about conference and refresher leave, exacerbating feelings of isolation {Richmond 1982}. Little has changed in twenty years and the two physicians at Hawera were experiencing similar problems and opted to leave when an opportunity arose before they "burnt out"!

The decision to close the Hawera Hospital HDU and transfer all acute admissions to Taranaki Base Hospital was announced publically on 19th April 2001 because of an inability to attract specialist physicians to Hawera after the two resident physicians decided to leave. This failure was no doubt related to the fact that almost all the advertisements were for Taranaki Base or for MOSS positions! Of the six ads (to that date) which specifically mentioned the specialist position(s) at Hawera, only two were in international journals, and these were not particularly attractive {Nel/Naughton Report 2000}, {Appendix 2}. There were none in the South African Medical Journal, despite the fact that increasing numbers of senior doctors are leaving South African rural hospitals for overseas jobs {Naudé 2001}, and we have traditionally had success finding physicians there {Med Council 2001}.

This led to complaints from the public and myself, forcing a number of reviews and audits, including the {Nel/Naughton Report 2000} and two from the Audit Office which are available on-line {Appendix 2}.

Unfortunately, we appear to be making some of the same mistakes, with the current advertising for a "Medical Officer of Specialist (sic) Scale", which would make a prospective Multi-skilled Medical Officer (MMO) ignore if he/she hasn't specialist qualifications! I must admit that the advertisement paints South Taranaki in a much more positive light, although it could be improved with some mention of the MMO team concept, the removal of the confusing "NEW PLYMOUTH" near the top and adding the word "excellent" before "schools".

The origin of overseas trained NZ registrations clearly indicates Britain and South Africa far exceed all other countries put together {Med Council 2001}, yet the list given by Andre Nel at the Feb 11 Public Forum includes the British Medical Journal but not the South African Medical Journal.

 

3.2 Rural GPs

The mean number of people per general practitioner in Australia is 707, ranging from 551 to 1887, with an estimated need for an increase of 13% to achieve an equitable distribution accounting for community health need. {Wilkinson & Symon 2000}. This converts to a national average of 14 per 10,000 (ranging from 18.1 to 5.3), which is very generous compared to the NZ national average of 8.3. It is 7.2 for Taranaki and 5.1 for South Taranaki {Public Health Consult. 2001}. With the departure of two GPs from South Taranaki, this ratio (already worse than the worst Australian figure) is likely to fall to 4.4 this year! There are rumours of even more going! GP (as well as physician) retention will be an issue for the Board as it now has responsibility for primary as well as secondary health care.

The current management invitation to local GPs to become MMOs may increase the chances of filling the Option Three positions, but it will worsen the GP shortage!

In a survey of rural and semi-rural NZ GPs in Nov 1999, 338 rural GPs (Rural Ranking Scale score 35) replied. Over two thirds rated lack of locum relief, onerous on call, and rural GP shortages as 'important' or 'very important' problems {Janes 2000}

 

3.3 Female Physicians

Female physicians (primary and secondary) are significantly under-represented in rural areas in the US {Doescher et al 2000} and NZ {Elley 2001}. Elley conducted an "exploratory study" of North Island rural GPs published last year in the NZMJ. Major issues identified from the interviews included (1) on-call duty, (2) difficulty finding locums, (3) isolation and (4) continuing medical education. Suggested solutions included amalgamation of adjacent town's after-hours cover, nurse triaging and basing the after-hours service at local hospitals to reduce the on-call problem [currently all in use in South Taranaki, which I suspect has become a model other small towns may copy], the rural locum scheme to tackle the time off problem [yet to be implemented, but see 3.4], financial assistance to compensate isolation and local training and distance learning to reduce professional isolation and CME difficulties.

A study of Auckland female medical graduates reveals that the majority have managed to combine a career with family and 64% had worked part time. More women are moving into specialties other than general practice. As about half of all medical graduates now are women, most of whom will want to have children, training agencies and employers [like the TDHB] should continue to develop their programmes and jobs to facilitate the combination of work and family life {Lawrence & Poole 2001}.

 

3.4 International studies and responses

3.4.1 Australia

A 1996 postal survey identified outcomes for 91 Western Australian rural doctors who in 1986 had indicated their intentions to stay in or leave rural practice. Professional satisfaction was the main reason for doctors staying in or leaving rural practice. Doctors' main concerns in 1986 were overwork, lack of locum relief, professional contact with colleagues, specialist backup in emergencies, downsizing of hospital facilities, continuing medical education, and income. By 1996 stayers had solved most of these professional problems and felt they were doing a special job which made a difference to their community. Conversely, more than half the leavers were unable to solve these problems and felt disempowered and dispirited. Their most potentially solvable problems were overwork, forced deskilling and conflict with other healthcare professionals {Kamien 1998}.

A 1997 postal questionnaire of members of the Provincial Surgeons of Australia residing in towns with fewer than 50,000 inhabitants had 137 surgeons reply (response rate of 59%). They work long hours, and nominate as their major concerns difficulty in finding locum cover, continual on-call work, peer isolation, children's schooling, and lack of privacy. Rural surgeons and general practitioners share similar characteristics and concerns. {Bruening & Maddern}.

A qualitative study of GPs who had left western Victoria supported the conclusions of a similar study in North Queensland. Conflict and dissatisfaction with aspects of rural GP hospital work appeared to be a relatively frequent trigger factor that is immediately amenable to intervention. A model of rural retention through improvement in negotiation and conflict resolution with hospital administration is proposed. Other factors identified include employment (mean length of stay over double if self-employed), excessive workload, poor access to CME (partly addressed by satellite TV) and professional isolation. There is a trend to move to larger rural centers allowing access to community facilities (eg schools) while retaining many rural attractions {MacIsaac 2000}.

The four most frequently cited reasons given by 103 Queensland paediatricians and finishing paediatric trainees for not applying to the long-term vacancy of the Staff Paediatrician position at the Mount Isa Base Hospital, North-west Queensland, Australia were: The lack of adequate locum cover for leave (97.8%), on-call load (92.2%), professional isolation (91.4%), and family commitments (91.4%) {Gorton & Buettner 2001}.

 

Strategies for recruiting to rural practice Financial incentives/remuneration to recognise rural GP skills and after-hours work Support for medical defence insurance Support for schooling and housing Locum relief Continuing medical education Training for rural practice, medical student exposure to rural practice Promotion of rural lifestyle Promotion of rural experience as time limited {MacIsaac 2000 Table 3}

 

3.4.2 Canada

At its October 2000 Annual Meeting, the Canadian Medical Association (CMA) unanimously approved a policy on rural and remote practice issues. The CMA policy outlines specific issues and recommendations that may help retain and recruit physicians to rural and remote areas of Canada. The CMA policy contains 28 recommendations on training, compensation and work/lifestyle support issue areas. The Society of Rural Physicians of Canada, the Assembly of First Nations and the Office of Rural Health, Health Canada, were consulted in the development of this policy. It has been prepared to help governments, policy-makers, communities and others understand the various professional and personal factors that must be addressed to retain and recruit physicians to rural and remote areas of Canada. {CMA 2000}. As it is such a good over-view of the subject, I have included the full document as {Appendix 3} and an Adobe Acrobat version is available on-line.

3.4.3 USA

A 1991 survey of 1,600 US non-metropolitan primary care physicians revealed that retention of rural physicians was independently associated only with physicians' satisfaction with their communities and their opportunities to achieve professional goals, although there was some relationship to satisfaction with income {Pathman et al 1996}

An overview paper of US rural physicians recruitment and retention {Phillips & Dunlap 1998} stated that rural US populations are older, poorer, sicker, less educated, have higher infant mortality and injury-related mortality rates, fewer hospital beds and physicians per capita, are much less likely to have private or public health insurance but access medical services less (except major surgery) than urban residents. Non-metropolitan physicians work more and earn less than their metropolitan counterparts

They identified undergraduate discouragement of generalist careers and supported promoting rural graduate training to enhance rural physician recruitment and retention through rural selectives, rural training tracks and rural emphasis.

 

POLICY RECOMMENDATIONS [abbreviated and excluding government related & NZ irrelevant issues Recruitment: Encouragement post-graduate rural selectives, and rural training tracks. Lessening specialty and geographic differentials in physician income. Establish relocation grants, especially for remote areas. Locum relief Retention: (dependent on perception that physician’s life needs are satisfied) Decrease professional isolation by supporting teleinformatics and outreach education programs and by the use of non-physician providers. Increase retention through more appropriately rural-trained candidates. Assist rural hospitals where access to care would be threatened by hospital closure and reduction in physician professional skill utilization. Develop and use innovative delivery systems that emphasize coordination and cooperation among providers, institutions and communities. Develop programs allowing rural clinicians to undertake periodic updating rotations through academic hospital services (with locum tenens backup). Maintain enhanced reimbursement [of various schemes]. Support... initiatives to offer periodic locum tenens to rural practitioners for purposes of continuing medical education or family vacations. Programs should be developed (and communities urged to adopt them) for support of the physician, spouse and children of the physician. This should include work and social opportunities for the spouse. Work to create innovative plans to share the workload through aggressive network building, partnering over distances, and sharing of resources. Adapted from {Phillips & Dunlap 1998}

 

The National Health Service Corps (NHSC) program places physicians in medically underserved areas, with the hope that many will stay after contractual obligations cease. However little is done to enhance the retention of these physicians, so once they complete their service obligations, they are faced with the same factors of low reimbursement, overwork and professional isolation that created the shortage. The NHSC does offer the potential of providing locum tenens coverage for isolated rural physicians to have time off for CME, vacations etc. In both Australia and Canada, government-sponsored coverage such as this has been one of the most popular retention tools in Rural Incentive Programs.

International medical graduates have a role but often need retraining, tend to leave once immigration requirements are met and are often recruited from countries with even grater rural physician shortage.

Community members, as stakeholders in this process, have combined local resources with state and federal resources to develop and operate community-based training programs and to provide financial incentives to new recruits. A number of studies show that community support is integral to recruitment and retention and needs to be encouraged.

The problem of the spouse employment (the "Trailing Spouse Syndrome") and education for children is too often neglected yet are major factors in retention. Professional isolation is often cited as a reason to leave a rural area. Outreach organizations that provide continuing medical education and the Internet and teleinformatics can be useful.

 

3.5 Answers

Effective physician recruitment in rural areas requires commitment from hospital and community leaders, a plan for identifying candidates who are likely to put down roots in a rural area, adequate financial and other professional incentives, and community support after a new physician arrives {Manecke & Edwardsen 1994}. An emphasis on the advantages of small-town practice and a thoughtful and organized recruiting strategy will increase the odds for successful rural physician recruitment {al-Assaf AF 1991}.

3.5.1 Rural residency programs

A number of studies affirm the need for increased rural and provincial residency rotations in the early postgraduate years to increase the number of rural physicians (primary care and hospital) subsequently electing to practise in rural settings {Stearns & Stearns 2000}, {Iredell 1992}. The Rural Training Tracks (RTT) residency program in New York state has proven very effective {Catalano 2000}.

However, a rural background was overwhelmingly the most important independent recruitment predictor of rural practice in Pennsylvania (1972 to 1991 graduates) {Rabinowitz et al 1999b}, and in Ontario (1977 to 1991 graduates) {Easterbrook et al 1999}, but I suspect selection of rural applicants for NZ medical schools is beyond the power of the TDHB, but I don't believe it would do any harm to try to influence the universities, as it has been done in parts of Australia and Canada. Undergraduate rural medicine programs have also proven very effective in increasing the number of graduates selecting rural work {Rabinowitz et al 1999a}, {Jones et al 2000}. It could be possible for the TDHB to liaise with both the Medical and Family Medicine training programs to attract registrars to Taranaki to obtain generalist skills which are currently being demanded by the Internal Medicine Society of Australia and New Zealand and The Royal Australasian College of Physicians {Scott & Greenbeck 1998}.

A combined government, Health Board, Medical School and Medical Association "Rural Physician Action Plan" in Alberta has resulted in 87% of medical students and 91% of residents in family medicine now experiencing 4 weeks or more of rural practice {Wilson et al 1998}.

3.5.2 Reducing professional isolation and improving CME opportunities

Collegial support for physicians is important in creating work environments that promote professional satisfaction {Ramsbottom-Lucier et al 1995}.

Recruitment and retention of physicians to a rural north Florida community needed to address issues of professional isolation, job security and professional autonomy, and lack of cooperation among the major providers of health care {Conte et al 1992}.

Education incentives are a smart choice {Barton 1997}.

How can rural hospitals continue to attract physicians to their facilities? For most rural hospitals, the number of dollars they spend in medical education equates to the number of physicians they are able to retain on staff {Harriott 1996}.

There needs to be funding resources and local programs offered to make it easier for rural doctors to attend CME courses {Rourke & Strasser 1996}.

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.

3.5.3 Income & Workload

Rural background is the most important independent recruitment predictor of rural practice but retention appears to be more related to practice issues such as income and workload. {Rabinowitz et al 1999b}. Hospitals can increase their chances of success by... providing a competitive compensation package {Ingram 1992}.

The Medical Society of Nova Scotia and the provincial government hope to solve the physician shortage in rural parts of the province with a recruiting effort that includes monetary incentives to fill some positions, a new locum service is designed to improve physician retention by making it easier to take vacations and pursue education programs, and a coordinator of medical recruitment {Robb 1996}. Physicians (mainly GPs) who fill the incentive positions qualify for the province's incentive package, which provides a minimum annual salary of $138 000 [NZ$206,000], a $50 000 bonus [NZ$75,000], moving expenses and other assistance.

 

The Marathon story Two years ago, the 5500 residents of Marathon, Ont., had 1 overworked physician to look after their medical needs. Today, they have 7 physicians [primary (GP) and hospital] to share the load. What steps did the town take to attract new doctors? It offered a financial incentive and also worked to revitalize its hospital. Marathon found that a new generation of physicians has much different career aspirations than past generations. For years Marathon, like many small Canadian communities, had found doctors were hard to come by and even harder to retain (75 in a 10-year span). However one physician did return, because he liked the area but told the hospital board and fellow physicians that “for my own health, and for the long-term health of the community, I was only going to work [on call at the hospital] 1 day in 4. I'd done 1 in 3 when I was here before and got burned out. I knew I couldn't do it, so something had to change." The problem was that there were too few doctors working far too hard. There was the need for a paradigm shift to break the cycle of physician loss. However the hospital board had some new faces changes and was in agreement: something had to change. A Doctor Crisis Coalition was formed with the aim to attack the root causes of the problem, not just the symptoms. "We had to understand why our physicians left, and then had to find ways to change that." The problems that were driving physicians away fell into 3 areas: quality-of-life issues, finances and professional support. One solution was to bring in additional doctors, which the coalition managed by political lobbying for approval for more doctors. The alternative payment plan (APP), the quality of life (no more than a 1 in 4 call), sessional fees for emergency work and a new concept of a group practice were introduced. Then the 25 year old hospital was renovated and the administration restructured. At the municipal level, the town was convinced to kick in $10,000 [NZ$15,000] for each new doctor and to provide inexpensive housing. The idea of a rural practice appealed to doctors, but they did not want the typical small-town work environment. "We wanted to go to a place where we didn't have to kill ourselves working." {OReilly 1997}

 

Income guarantees are hospitals' lure of choice when trying to reel in physicians to their facilities. More than 90% of hospitals responding to a recent survey offer the income guarantees, which recruiters say physicians have grown to expect {Perry 1991}.

Hospital, managed care companies and other employers competing for physicians have found that landing the doctors has gone from an amateur hobby to a professional sport. The winners have learned that it takes money, perks and a lot more to obtain this valuable resource {Conklin 1994}.

As well as offering financial incentives, successful rural recruitment schemes have found that they must be able to offer reasonable time off with "on-call" no more than 1 in 4 [see "The Marathon Story" above] {OReilly 1997}.

"Supportive colleagues, a reasonable income, appropriate time for holiday and study, and a call schedule less than 1 in 4 provide a good foundation for developing medical services for rural and isolated communities... Marathon has the basics right" {Newbery 1997}.

3.5.4 Hospital Facilities

An analysis of effectiveness of several physician recruitment strategies in 60 short-term general hospitals in rural Minnesota suggests that rural hospitals should continue to attract physicians with quality facilities and services and increase efforts to facilitate group practice opportunities {Connor et al 1995}.

3.5.5 Physicians to target

Looking for doctors with a rural background is likely to prove the most rewarding in finding candidates for rural practice {Rabinowitz et al 1999b}, {Easterbrook et al 1999}, but how this translates into where and how one advertises is debatable. However, rural medicine journals and journals of countries with a large rural population might prove more fruitful avenues than big city newspapers.

A 1994 study of 50 rural Kentucky hospitals revealed that hospitals that target physician candidates with more work experience display lower physician vacancy rates. {Hyde & Fottler 1994}. This suggests that we should be seeking out the experienced over the newly qualified who may be cheaper, but are less likely to make a long-term commitment.

Using IT for "Headhunting" by cross-tabulating lists of physicians with membership lists of sport-fishing associations, alpine clubs etc may be a novel but successful way to identify candidates as described by {Gray 2001}. Hospital IT departments can support physician recruitment activities by helping identify the type of physician the institution needs and describe the type of medical practice a physician can expect along with the institution's strategic plan for the future [presumably on the Website] {Poggio 1992}

Some physicians may wish to work part-time with a small private practice. A Missouri (US) study revealed a significant increase in availability of physician services in rural areas where "second offices" were established. {Hicks et al 1997}.

3.5.6 Community facilities

In addition to strictly professional issues, such as access to hospitals, a reasonable work load and a good level of procedural work, other issues, such as the availability of good social and cultural facilities, work opportunities for one's partner and good educational facilities for one's children, have a great bearing on the doctor's decision where to practise {Alexander 1998}.

3.5.7 Honesty and Trust

Physicians tend to base their final decision not only on the combination and culmination of all of the information that they gain about the location and the practice opportunity, but it seems that the final decision is mainly based on a trust factor. This trust factor lies in the belief that comments the administrator may have made while walking the halls with the candidate were true. Many physicians comment that they decide to go to one location over the other when both are equally as impressive in terms of quality of life and quality of practice style, because they trusted and had a higher comfort level and established a rapport more quickly with one administration or medical staff over another {Singleton 1992}. Mmmmm, maybe we need Dennis Pisk for this job too!

Healthcare executives must make a personal investment in physician recruiting. A manager must sit down with a physician and say, "We need you" {Peltzie 1993}.

3.5.8 Accessing Government Support

The current government claims to recognise that isolated rural areas and providers in those areas need extra support and claims that this is currently available, or will shortly be made available, for rural health services. This includes funding of programmes for:

• ongoing clinical education, and training for rural health care practitioners [PC for nurses and doctors]
• a bonus for providers in rural areas [only for those with a high RR score]
• funding for locum support
• increased support for retention of services in communities facing special difficulties

{King 2000}

If this is true, it would be sensible for the TDHB to access that funding to support locum retention (perhaps someone to be available for either GP or MMO cover), CME outreach to South Taranaki and find out what is meant by "support" and "special difficulties".

 

3.6 Overview

Successful strategies for recruitment of medical staff to country areas include determining if the position is truly required, designing an advertising campaign that reaches the target audience and addressing the significant regional and medical factors influencing the attractiveness of positions {Wolff 1997}

Success as measured by the change in size of the medical staff and employment occurred only after the emphasis changed from meeting hospital needs to meeting physician needs {Catalano 2000}.

Four conceptual models underlie physician recruitment and retention programs for small towns and rural communities. These include affinity models, which attempt to recruit rural persons into training or foster interest in rural practice among trainees; economic incentive models, which address reimbursement or payment mechanisms to increase economic rewards for rural practice; practice characteristics models, which address technical, collegial, referral, and other structural barriers to rural practice; and indenture models, which recruit temporary providers in exchange for scholarship support, loan forgiveness, or licensure.An optimal model for the recruitment of physicians to rural practice includes the promotion of medical careers among rural high school students, the provision of financial and cultural support for their training, the development of technical and collegial support systems, and the limited use of indenture mechanisms. {Crandall et al 1990} The Taranaki District Health Board could become involved in each of these areas. It could offer medical scholarships to medical students from rural areas with a work bond requirement, it could establish and support medical training programs in Taranaki with a Hawera rotation and it could ensure that there are enough Hawera MMOs to ensure adequate CME, peer review and time off.

 

 

[4] Pisk Recommendations

District Health Boards have been instructed by the Minister of Health to seek active involvement of consumers and communities at all levels.(Principal 7, NZ Health Stategy), and to be open to monitoring and evaluation {King 2000}. The Boards are bodies corporate owned by the Crown and are required by the New Zealand Public Health and Disability Services Act 2000 (NZPHD Act 2000) to operate in a co-operative and very transparent manner.

It is therefore quite unacceptable for any of the debate on the Pisk recommendations to be held "in committee" or for advice, recommendations and workbooks from management to be unavailable to public viewing and comment, otherwise it should be "inadmissible evidence" which should not influence any policy decisions.

I do not intend to review each Pisk recommendation made in the report by Dr Dennis Pisk {Pisk 2001}, as I have been a prime contributor to the South Taranaki GP response {Appendix 4}. However, my overall view is that the Taranaki District Health Board should accept all of Dr Pisk's recommendations except where a more efficient or more acceptable method is available to achieve the success of the Multi-skilled Medical Officer team concept.

This would mean some practical, but not philosophic changes. Specifically, and in addition to the changes recommended by the South Taranaki GPs {Appendix 4}, I would like to see changes to:

•   [03] For the discharge summary to be completed on discharge is a very sore point for GPs. When we were House Surgeon/Physicians, it was considered negligent not to do so, but somehow this has slipped and two or three weeks can go by ...but I digress. My point (other that B support), is that this discharge summary must be on the patient's electronic record and available on-line by Hawera MMOs and the owner GP. Otherwise, it is always "in the mail" and patient continuity suffers. The US Hospitalist movement recognises that lack of continuity of care is the "Achilles tendon" of their service and go to near extreme measures to ensure continuity {Appendix 1 pg4}.
•   [08] Monthly would be fine, I have no problems with less management
•   [13] Many of my patients would like to see the word "minimum" before "configuration", as the skill-mix of the MMOs may eventually allow even greater numbers of acute cases to be admitted and managed locally
•   [23] Giving out cellphones is probably a bit risky. The South Taranaki Health Group idea of an 0800 number sounds more practical
•   [36] The establishment of 3 MOSS positions and re-naming (re-badging) MOSS to Multi-skilled Medical Officer (MMO) is, I believe the crucial recommendation. Although management claim to have agreed to this recommendation (at the Feb 11 Public Forum), there was no mention of the "re-badging", they continue to use the term MOSS (which is a pay scale) and the new advertising is for a "Medical Officer of Specialist (sic) Scale" (see comment in Section 3.1). If we don't ask for what we want, we won't get it!
•   [43] A 5 weekly rotation for the MMOs at TBH should be a swap with a senior House Officer or registrar to provide a mutually beneficial learning experience (sub-specialty vs generalist -see [2.1]) and without excessive disruption to either hospital. Failing a direct swap, there would need to be some facility for providing a locum to avoid increased on-call (more than a 1:3), or retention of MMOs will become a problem
•   [57] It is important that GPs and a community representative are involved in the "Steering Committee" as soon as possible, to ensure the recruitment strategy is aimed at succeeding in obtaining and retaining suitable MMOs. At present I suspect the strategy is "planned failure" (see [3.1]). However, I would like to be proven wrong!

 

 

Conclusion:

There has been a political change of direction for DHBs, with a return to a familiar public service model after the failure of the quasimarket approach (which was more a failure to introduce competition, a conflict between clinical and commercial cultures and a blow-out of administrative and contracting costs). Boards are now expected to deliver health outcomes cooperatively, not profits {Hornblow & Barnett 2000}, {Devlin et al 2001}.

It is disappointing, but not surprising that the recent Te tirohanga hauora o Taranaki health review only identified Stratford and Taranaki Base as providers of secondary health care, although one could guess the existence of Hawera Hospital from the map on page 33! {Public Health Consult. 2001}. Hawera Hospital does exist and the new almost $7.9 million hospital can and will be used effectively to provide better inpatient care for the South Taranaki community.

The concept of a core group of Multi-skilled Medical Officers, analogous to the US "hospitalist" concept, taking clinical responsibility for less complex acute admissions to Hawera Hospital is potentially sound and safe. It has the ability to reduce unnecessary transfers to Taranaki Base, and allow for the early transfer back after complex conditions settle, or post-operatively. There will continue to be the need to travel to Base for some investigations, but with visiting specialists available for consultations and advice, the South Taranaki community will once again be able to expect most basic non-surgical secondary care to be provided locally.

The ability of District Health Boards to provide generalist in-patient services in community hospitals is of much greater importance than the provision of complex tertiary care which is safer and more cost-effective in a few centres of excellence outside our small province. To waste money on the provision of these services at the expense of basic care to a community who have clearly and repeatedly expressed their desire to see this care remain in Hawera is to invite political intervention in the form of directives, dismissal of the Board or even the forced amalgamation with Wanganui (and subsequent downgrading of New Plymouth and Wanganui hospitals with Palmerston North as the Base Hospital).

 

“For a winning team, we need outstanding players -- some with specialised talents and others who are versatile. World wide hospitals, health care managers and funders are reconsidering the likely benefits to both quality and efficiency of health care when medical services are provided by a team in which the "breadth" skills of generalists complement the "depth" skills of subspecialists.” {Nash & Nash 1997}

 

However, the success of the Option Three concept is very much dependent on obtaining a "critical mass of staff" [Pisk, at the February 11 Public Forum]. Evidence presented above indicates that the successful recruitment and retention of physicians (MMOs) will depend on the conditions we provide, and the people who provide them. There will need to be early input from GPs and community representatives into the "recruitment strategy" to ensure these conditions are conducive to both recruitment and retention and a willingness by the Board and management to seriously support those conditions, specifically those relating to remuneration (which is one reason for dropping the MOSS title), educational support and locum provision. If the Board doesn't provide locums (external or exchanged from TBH), the 1 in 3 roster, which is already less than is recognised as ideal (1 in 4 or better), frequently becomes a 1 in 2 and disillusionment and burnout will result as it did with the two previous specialist physicians

It is therefore my contention that the Board accept the recommendations of Dr Dennis Pisk, with modification only where a more effective or efficient method can achieve the desired objective of developing and supporting a team of Multi-skilled Medical Officers capable of caring for the majority of acute medical admissions in the new Hawera Hospital. I would propose that this goal be made the most important objective for secondary service provision to the South Taranaki community and therefore all other secondary clinical expenses would take second place and non-clinical expenses (such as management) taking third place, if necessary on a reduced budget. Of course (being a GP), I believe effective primary health care is even more important, but that is another story and will keep for another day!

 

 

Dr Keith Blayney

 

 

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Credentials

 

As well as the support of the South Taranaki GP Group, my "credentials" for offering advice and criticism on the Hawera Hospital issue include over twenty years as a General Practitioner in Hawera, the first ten working part-time as a non-specialist MOSS physician at Hawera Hospital. I am a Fellow of the Royal NZ College of General Practitioners and the current South Taranaki GP Peer Review Co-ordinator. I provide General Oversight for a number of local GPs who have yet to obtain their Vocational Registration. "Evidence Based Medicine" has become a particular interest of mine and a guide to best practice and it is the evidence on the quality, safety and cost-effectiveness of Community (and/or Rural) Hospitals and the finding and retaining physicians for them which is outlined in this submission Contact: Dr K T Blayney PO Box 447, Hawera 4800 or e-mail kblayney@ihug.co.nz Competing Interests: Hawera Resident and GP (obviously biased!) Funding of research: $50 donation by appreciative patients K & N Ogle

 

Appendix 1

Inpatient Management Inc (IMI) description, definition of Hospitalist and flow chart of their Inpatient Delivery Model.

 

Appendix 2

"Keeping Health Board Honest about Hawera" Media Release and "Analysis of the Nel/Naughton report" MS Excel format.

 

Appendix 3

Canadian Medical Association "Rural and Remote Practice Issues" policy document. Download in Adobe Acrobat format.

 

Appendix 4

South Taranaki GP observations on Pisk Report recommendations 22 Jan 2002.