For those on the coalface of health, it’s no news that the way we deliver healthcare has to change. The unsustainability of our current approach is manifestly evident.
When I speak with nurses from the hospital’s emergency department, they describe a health system in crisis, that’s breaking apart in every way. “We don’t go a week without being declared Code Red in ED,” one of them tells me. “And we’re blowing the budget on call-back rates.”
They speak of being over-run and overwhelmed, of being inundated with “GP stuff”, of “diabolical” dental issues, the end results of chronic illness, of social-related ills like domestic violence and alcohol abuse. They note the overflow from private residential aged care, where there’s no after-hours medical provision – “come 5pm or on any given weekend these patients become the hospital’s problem.” And they point to issues of access and affordability, of inconsistencies across primary health and poor communication between agencies.
All these issues that are highlighted in the DHB’s draft Clinical Services Plan (CSP), recently released for public consultation.
A beautiful document but …
Sue Revell, nurse practitioner and clinical coordinator in ED at HB Hospital, has 30 years’ experience in the field. When she arrived from the UK 13 years ago, ED was seeing on average 65 patients per day, with a 9-1 patient-nurse ratio, and she says she found the workload “huge”. The daily average has since doubled, and because increases in nursing staff and cubical capacity have not kept pace with the increase in presentation, patients now spend more hours in the waiting room, leaving one nurse to manage the needs of 15+ patients at any given time without adequate resources.
“Each day, each month, each year the standard of care is dropping,” says Sue. “Patients are rushed, they’re not listened to, we miss things, because we’re running all the time.”
While she says the CSP “makes perfect sense, it’s a beautiful document,” she’s sceptical about whether it will translate into change on the ground. And it’s scepticism, or a certain jadedness, I meet with almost everyone I interview.
“Yes, we do fundamentally need to change how we’re delivering our healthcare, but every year the annual plan talks about reducing inequities, improving Māori and Pasifika health, the need to engage more between secondary and primary care – it’s been written every year for I don’t know how long.”
She says, “We all believe in this,” but the trouble is the enthusiasm and funding tends to go in at the fact-finding stage; when it actually comes to “doing the hard yards, it seems there’s no money for it. Or there’s money for the trial, which shows it works, but then it’s not implemented in the same way, so they lose bits of the puzzle.”
Sue’s big concern is the ‘how’. “It’s the implementation they seem to fall down on.”
Sue says it’s not enough to look at the crowding in ED and say the patients should all be at their GPs. There’s a general lack of adequate health understanding and knowledge of the health system, for starters. But often they’ve already been to their GP and been sent on due to pressures, not having facilities, needing specialist services, or haven’t been served well in the past. There are a lot of inconsistencies in the capabilities and service provision of general practice.
“The GP might be the best place to send your patient but what if they can’t afford it?” It can cost $70 to see a GP (if it’s after-hours and you’re not enrolled in the medical clinic), with additional costs for treatments – in ED it’s all free.
Sue says while cost is a huge barrier, accessibility is just as influential.
“Can you get an appointment when you need it, which is usually today? You might not need it clinically, but it’s another day off work, because you’re not feeling very well or you need it sorted and now you’ve got the opportunity to do it.
“It’s accessibility, it’s the cost, it’s getting in to see the GP when you can. A lot of people who are on low wages have more than one job, and it’s difficult to find the right time… We get a lot of kids brought in at 10pm, because that’s when the car came back to the house, when one of the parent’s shifts ended.”
The rise of living costs is compounding the situation, as too job insecurity and poor housing. She says patients often don’t have any sick days and can’t afford to take time off to give their injury or illness the due recuperation required. These are the impacts of poverty and the statistics that disproportionately affect young, Māori and Pasifika families.
At the other end of the spectrum of pressure (with our aged population set to double over the next decade), 80-year-old Marie Dunningham is recovering at home from a hip replacement.
The former Plunket nurse and Grey Power secretary says, “The only time you get good service is when you’re deteriorating at a fast pace, or if they stuff up,” which happened in the case of her husband’s unchecked diagnosis last year.
Marie, who’s been fiddle-fit and contributed actively to the community all her life, waited years for treatment while she watched her mobility and independence diminish, despite all efforts to do ‘the right thing’. When she could no longer walk to the letterbox, she gave up on the public health system and went private – her family chipped in to fund the $30,000 operation at Royston. “I didn’t have a choice, but at least I was able to pay it – many can’t.”
She believes if she’d had surgery five years ago, she would have recovered quicker, with a better chance of returning to being a productive member of society. “They wait until it’s too late.” As the CSP outlines, earlier interventions (and preventions) will lead to faster turn-around and ‘bounce-back’, incurring less overall cost. “That has to make sense,” says Marie.
But she’s adamant that if the emphasis shifts to keeping elderly at home rather than in hospital/residential care, we will need a far better home care system – care is too short, it’s not done properly and people remain isolated, in her view. “The elderly need more support at home, they need more variety of support, and support that isn’t hurried.”
Broader avenues of access
The DHB representatives I speak to, CEO Dr Kevin Snee, Dr Colin Hutchison and secretary Ken Foote, say there’s broad recognition, not just locally, but internationally, that health systems need to do far more outside of the hospital than in it.
We need to think differently, to move away from the traditional one doctor, one patient model, explains Hutchison, to primary care teams delivering ‘modules of care’ for a cohort of people. “Often the most relevant primary care practitioner isn’t a doctor.”
By way of example, Snee points out that 16% of New Zealanders will experience mental health issues at some point in their lives, and yet, mental health services currently only cater for 5%. Those with mild to moderate mental health problems receive limited support; indeed there’s “not much in the way of public treatments even for relatively severe cases”.
Snee says the emphasis will be “on getting mental health workers into primary care”, alongside GPs for instance. “That’s a model we see successfully used in other parts of the world.” He says the challenge won’t be funding it so much as finding adequately trained people. “So we’re not going to be able to do it all at once, but we can do it over time.”
And that’s reflective of the broader plan, which is about what the DHB and its health partners are going to do over the next 10-15 years. Once the concept of ‘directional change’ is approved (December, all going well), an ‘implementation plan’ will be developed, with a staged approach, and alongside that Snee says the DHB will be working to make their case to central government for additional funding ($300-400 million) to upgrade the hospital, which is no longer fit for purpose. Looking at workforce requirements (such as more mental health practitioners) and IT “to support the model going out” will be a key focus.
But Snee is clear, there’s no more money coming in to fund “lots of additional staff”. “So we need to be looking gradually over time at how we shift our thinking and our resources to do things differently. When people tell me there’s no money, well actually we spend about $600 million per annum. If you just rethink 2% of that, that’s $12 million. There is money there, it just needs to be well deployed.”
Community flexibility to services
As to how change might look, Snee brings up the Havelock North water crisis, during which, by necessity, general practices in the area “adapted really quickly to work in a different way” – they used the telephone more to consult and triage patients, delegated certain treatment procedures to nurses, made use of community pharmacists. And some of that has continued on.
Last year the Community Pharmacy Contract introduced more community flexibility to the way services can be commissioned and run, and the DHB is rethinking the way community pharmacists can work as part of the health system, says Snee. “What you’ve got in community pharmacies is an under-utilised, highly trained group of clinical professionals”, who in the past spent a lot of time counting out pills.
With robotics on the horizon, the move by supermarkets into the pharmacy space, and a profession that’s relatively young (average age: mid-30s) and female, there’s appetite to develop new roles. Pharmacists could become the first-point of call for minor ailments and “the whole nine yards”.
Evidence from elsewhere indicates that if primary care is broadened out, providing ready availability and same-day access, then the pressure on ED services is bound to decrease.
Similarly, Snee wants to make sure that those things that really need to be done in the hospital are high quality and efficiently done. He notes that surgical procedures are becoming less and less invasive and rehabilitation services work to get people back onto their feet as quickly as possible to counter ‘PJ paralysis’ – the rapid deconditioning that happens for patients left sitting in bed.
Not enough GPs
If you’re registered with a GP, good for you; if not, best of luck. Many general practices no longer take new patients, most have waiting lists. GPs are also an ageing force. At the Hastings Health Centre, there are at least four GPs who’ll retire within the next 5-7 years. “There’s no guarantee we’re going to be replaced,” says Dr Alan Wright.
Attracting and retaining doctors in the provinces is an issue, “It’s not just about sunshine and fly-fishing”. Dr Wright says he hasn’t had a salary increase in 10 years, despite mounting expectations on GPs to deliver more, with ever bigger responsibilities and without the required tools or funding. He says he’s seeing burn-out in general practice, and like teachers, “we’re at the point where we’ve had enough.”
He says, while Hastings Health Centre is already making changes to its model, employing nurse practitioners and primary care assistants (who are not fully trained doctors) to take up certain elements of urgent care, it’s still contingent upon GPs being “the default situation”, both for patients as well as for the professional oversight.
“Until you can get a situation where those practitioners are mandated to work independently, you’re still going to need GPs to provide the back up for that service. You’d have to change everything about the way health care is delivered in New Zealand for the numbers of GPs to be sufficient.”
Many will argue that this is exactly what needs to happen – a radical, fundamental overhaul. But whether there is the willingness and the foundation of trust required is questionable.
What the Hastings Health Centre would like to see is more care, which the DHB funds in hospital, being funded instead in the community. If a patient comes to the GP with chest pain, for example, it will cost them about $250 (for ECG and an x-ray). Until the DHB transfers costs over for urgent care services, says Wright, you’d be a fool not to “short-circuit your doctor, get an ambulance and head straight to ED.”
He says there are models already for this kind of partnership, like the Coordinated Primary Options (CPO), a programme that’s developed individual pathways over time to keep people out of ED. “So if you’ve got a suspected clot in your calf, a DVT, you don’t go to ED anymore because they can’t manage you any better than us. You come to us; we’ve got the ability to provide that care free of charge, including the scan, including the treatment, because the DHB have given us money to do that. We’ve just had it audited, it’s brilliantly successful. We need to do more and more of that stuff; it just requires a bit of trust and funding.”
One of the biggest drawbacks, says Wright, is GPs don’t have access to diagnostic investigations – Wright can’t order an MRI for a patient of his, for example, the patient has to be referred to a specialist. “GPs are actually quite good at working out what’s wrong, and what’s right, for their patients … The DHB needs to release things like the diagnostics into primary care so we can see whether we can do it more appropriately.”
Wright would like to see an honest conversation on surgical priorities. He says he has lots of patients with “simple, fixable problems, like hernias and carpal tunnel syndrome and ganglions, which interfere with their work capabilities … Yet I’ve got other people who are not going to achieve a great deal from having their surgical procedure and yet a lot of money is spent on them and then we can’t do the simple stuff … Let’s do more of the simple stuff and say no to some of the complex stuff. We have to be honest with people – it doesn’t matter what you call it…but there is rationing in this society.”
For those in the ‘trenches’ – the nurses, GPs, patients like Marie – it’s difficult to imagine the plan having any teeth for change if it isn’t properly resourced, and funded. They tend to be sceptical about the DHB’s intention to redeploy funds as just another exercise in cost cutting.
But for those involved in the big picture perspective, who are looking with an eye to systemic change, which is what this plan signals, we don’t require more dollars, but better use of the ones we have, as Snee commented above.
Graeme Norton, chair of a national collective of consumer councils, is adamant “the funding is there, we just need to stop doing stupid stuff.”
Over 80% of our health spend now is on long-term conditions, and as Norton points out, “the drivers are not in health at all … Income status, behaviours, social connectedness, housing, etc – it’s these social determinants that determine your degree of wellbeing.” Shifting focus to a more holistic approach sits at the heart of the government’s ‘wellbeing budget’, he notes.
Norton cites data that shows over a 15-year period we spent more than two thirds of our health spend for the over-65s on the 9% of the population who are in aged residential care. The average stay was 8 months. That industry has largely been captured by corporations. “We’ve got this really perverse system which is ratcheting up the cost of the last years of life when actually most people would prefer to be supported at home.”
In contrast, only 2% of the health system spend is on prevention. “There’s a whole bunch of worried well-off who clog the patient rooms of GP sessions because they can afford to pay the co-payment – they don’t need to be there.”
Personally, he’s frustrated that he has to pay to go to a doctor or online every three months to order the prescription medication he will need every day for the rest of his life, along with a 6-monthly blood test. “I could go to a hole in the wall and get the pill; my phone would have a QR code on it that would approve me getting it. All that stuff’s doable, but we’re not doing it and we’re not incentivised to get there.”
Norton believes the current health system routinely disempowers people, whereas it should partner with people over time so that they make the right choices and are well supported. While we train and recruit for skill, a clinician’s capacity to ‘coach’ people may ultimately be more important. “We leave the best player on the bench. We do stuff to people or for them, or sometimes with people, but it’s hardly ever enabling them to continue to do it themselves without support.”
The CSP doesn’t go far enough for Norton – “It’s not grounded in our acceptance that we’re miles away from where we need to be. And it’s not brave enough to accept that things have changed.”
More consumer engagement
Rachel Ritchie, chair of HB Consumer Council, is more diplomatic: “In the big scheme of things, we think the CSP is going in the right direction.” They see the inclusion of person/whanau-centred care in the plan as positive, but ultimately, as with most people I speak with, it’s change on the ground that they’re more interested in, and that’s often “hard to see in the DHB world.”
“To date the system has been about providing what the DHB and health services, clinicians, the Ministry of Health decide needs to be provided. I say, talk to your community, find out from them what’s needed. And then change the service provision to fit what the consumer needs for their best health outcomes.”
Currently, explains Ritchie, health is streamed, and it’s a vertical, top down direction, creating very siloed approaches, “because that’s the way the money flows.” But people don’t move like that – their needs are eclectic and ranging. We need a more horizontal, across board approach, with a focus on different demographics (youth, men’s health, older populations, etc), rather than on services, per se.
Bayden Barber, Hastings District councillor and chair of Health Hawke’s Bay – Hawke’s Bay’s amalgamated primary health organisation (PHO), an umbrella for general practices – agrees. “For too long,” he says, “plans have followed the provider, those delivering services.”
What’s identified as important to Māori in terms of health, is often whānau, whānau relationships, culture, says Barber, with the patient and the health practitioner communicating on equal terms, not in a hierarchical doctor-patient paradigm.
Barber is impressed with the Nuka South Central Foundation in Alaska, a self-determined indigenous healthcare model, which is included in the CSP. He notes there are no ‘patients’ but rather ‘customer owners’. “They own the health system, they own their own health.”
The biggest difference in the Nuka model, he says, was the way health professionals engaged with people on a one-to-one basis or as a group-whānau. “Their whole philosophy is around respectful relationships” where ‘customer-owners’ are part of the healthcare solution, not just a patient or another number walking through the door. “How we relate to our whānau translates into health outcomes, and they’ve shown that in Alaska with some of the health improvements they’re seeing, just by changing the way they engage with individual families, iwi.”
“If you don’t get the relationship side of things right, people don’t engage. And we have high disengagement with healthcare in many communities – they might be enrolled but they don’t engage.”
Health Care Home, a NZ primary healthcare model tabled in the CSP for Hawke’s Bay, incorporates aspects similar to the Nuka system: holistic, person-whānau centred, wrap-around care. Barber sees this as a “major development”.
Investing in young, poor, brown
Dr Taemumu Richardson has a wide spectrum of GP experience in both rural and urban communities, including working for Māori health providers, and has been on both the PHO and DHB’s clinical councils.
When we meet up, she hands me a post-it note: The differential access to the goods, services and opportunities of society. “That’s a definition of racism,” she explains, and for her, that’s the white elephant in the room.
As she sees it, the health inequities at the heart of the health system, consistently affecting Māori, are symptomatic of institutional racism and the ongoing legacy of colonisation. She says it’s a striking omission that neither word is mentioned in the CSP.
Richardson says the CSP doesn’t acknowledge the work the health sector will need to do on those upstream determinants of health, beyond just clinical services, in order to have equitable outcomes. However, she does see a lot of positives in the plan.
The CSP states an objective to have no difference in health outcomes between Māori and the general population – a pretty radical statement. She observes that you never actually see a goal of ‘no disparity’ written in an official document.
Although we have all the evidence we need regarding health inequities, Richardson doesn’t think people really understand the level of unmet need in the community and the kind of investment and disinvestment that will be required.
Politically, the disinvestment discussion is a hot potato, and it will be very hard for a DHB to undertake in isolation. It’s not that there’s “no fat in the system,” says Richardson. “If we genuinely commissioned with health equity as our goal, we would actually be able to make quite significant gains with the money we have already.”
But doing this would require strong and consistent leadership commitments across the whole of Hawke’s Bay, “which is more than saying that on a document”. It would mean being clear about investing in young, poor, brown families, with health equity as a priority, having an understanding that institutionalised racism and colonialism are the barriers to us being able to realise that vision, and seeing that we all stand to gain a better health system, a more equitable society, if we address this.
What’s become apparent to me through the prism of the CSP (a dry policy document), is that health is a much bigger conversation than ‘clinical services’. Like climate change, it’s almost overwhelming in the degree to which it permeates all aspects of our social structure and the extent of what needs to change on all levels. And it’s a conversation we all need to be having.
The Clinical Services Plan is just that … a piece of paper. But most I spoke to agree that it’s a fairly bold first step down a road we have to take. No one disputes that we cannot continue as we are. And it’s not just the ‘system’ that needs to change. As individuals we must change how we frame health and partner in our own healthcare.