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Health Care Delivery on Life Support

Issues

Tom Belford05 April 2020

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Editor’s Note: This article was written in mid-February, when the coronavirus was ‘merely’ a gathering storm. Today it might seem unduly critical at a time when our Hawke’s Bay health care workers are doing a herculean job of preparing for and managing the pandemic. So I want to emphasise my huge admiration for their devoted and dangerous efforts. However, the reality is that their efforts to care for us will be all the more remarkable given the underlying structural and capacity constraints they will need to contend with, as this article discusses. 

Anyone who tries to paint a rosy picture of health care delivery in Hawke’s Bay is disingenuous at best.

Not that our region’s health system is unique in this regard.

Consider just a few key barometers, gleaned from a series of reports and critiques prepared by health authorities in the last year.

At the primary care level, workforce issues are paramount. The Sapere report (a thorough consultancy review for the HBDHB) observes: “The overriding concern of health professionals in primary care appears to be workforce. Both nursing and medical workforces are ageing and the need to train, attract, and support younger professionals weighs upon the mind of the current workforce.” 

Out of HB’s 31 primary care practices, 12 have closed books, 12 are enrolling patients who meet certain criteria (such as new to the area), and the remaining seven have open books. 

The estimated unmet need for hospital care in New Zealand – surgical, non-surgical, dental, and mental health – is estimated at 9% of the total population, or about 430,000 patients. I emphasise ‘estimated’ because there is no systematically collected national data on this key performance measure. Applying that percentage to Hawke’s Bay yields about 14,000 unserved. 

Hawke’s Bay has the 2nd worst access to orthopaedic surgery in NZ. Elective surgery at our hospital has been increasing 3% per year, but nevertheless the shortfall in surgical theatre hours by 2020 is estimated at 2,721 hours, which translates into 1,500 procedures not performed. 

By another measure, Ministry of Health data indicate that nation-wide 30,000 patients per year are rejected for hospital treatment despite having been assessed as needing care. 

Our Emergency Department (ED), designed to care for 37,000 presentations per year, presently sees 45,000. And that number has increased 34% over the past ten years. Nationally, ED admissions are growing at twice the population growth rate.

Once admitted

Those entering a hospital will find a facility that is already over-used, whether that be in terms of Emergency Department use or overall bed capacity. Experts consider an 85% occupancy rate as the maximum for safety (patients and staff), while our hospital often reaches and even exceeds 100%. “Hospital wards consistently operate with occupancy at or close to 100% exhibiting a lack of resilience when demand surges.” (Sapere Report) Hence beds in corridors, etc. The norm in Europe is 77%. Astonishingly, NZ also does not collect occupancy data nation-wide as a performance measure.

Photo: Tom Allan
Whatever the unmet health care need is in Hawke’s Bay – be that surgical access, child health, mental health, or whatever – the bottom line is that our local DHB has no power to raise additional funds to address its own priorities.

Operating at such ‘at the brink’ levels creates a harmful scenario. For example, over-crowding forces staff to speed-up care – discharging patients too early from wards so that others can be moved out of the ED. But premature discharges lift the rates of ‘un-planned’ re-admission (12% nation-wide), and the circle begins again.

As bad as occupancy rates are, they don’t tell the full story. ‘Bed days’ (time in the hospital) are increasing at even higher rates due the complexity of cases (measured as ‘case weight’). More and more patients present with multiple and more demanding treatment needs.

In the meantime, the clinical staff – doctors and nurses – are grossly over-worked in terms of sheer patient numbers, in the face of chronic under-staffing. Our hospital has a 22% shortfall in senior medical doctors. Nationally that figure is 24% or 555 doctors. Not surprising then that 88% of senior medical doctors report they work while themselves ill and 50% report burn-out symptoms. Accidents waiting to happen!

Complications

It must be stressed that Hawke’s Bay’s health care workforce is without question professionally competent and dedicated to providing the best possible care for individual patients and the entire community. 

Rumours do persist regarding negative ‘culture’ issues with the DHB, but from the outside, it is difficult to know the extent of dissatisfaction, and whether it stems from the stress of extremely difficult clinical working conditions, bureaucratic frustrations, or generic workplace problems like bullying.

That said, assuming a competent, positively-motivated workforce, what are the obstacles to better care? 

Three issues arise in reports and conversations with practitioners: money, population demographics and inadequate self-care, and insufficient collaboration/integration between primary/community care, specialists and the hospital. Any one of these deserves more in-depth treatment than I can give in this overview article (stay tuned).

Money. Money is the most political of factors. The Ministry of Health via Health Vote provides the bulk of NZ’s health care funding (exclusive of ACC) – $19.871 billion in 2019/20, about a fifth of government spending. Of that, about $525 million comes to HBDHB (with all sorts of strings attached). To match the 2009/10 spending level (as a percentage of GDP), another $1.7 billion would need to be added.

Using objective Treasury data, the incoming Labour Government asserted a $2.3 billion gap in real Core Crown Expenditure between 2009/10 and 2017/18. Using the term “negligence” to describe the situation, the Assn of Salaried Medical Specialists projects that $14 billion in health infrastructure spending would be required over the next ten years just to get medical facilities in proper shape. 

The Labour Government has struggled with health care worker wage demands, operating budget deficits across all DHBs, as well as increased funding for capital needs – be those in-patient mental health facilities, radiation treatment facilities, surgical capacity etc. And local practitioners insist that announced budget increases for various services, like mental health, have yet to be seen or felt ‘on the ground’.

And all of this leaves plenty of room to haggle over which regions and which services get the biggest pieces of pie. For example, the Government’s most recent announcement of $300 million in additional health infrastructure spending will deliver about $12.8 million to Hawke’s Bay, including $10 million that had already been announced for interventional cardiology and $1.6 million for replacement of four dental vans.

In the meantime, some commentators say the total NZ public health spend (i.e., including Corrections, Education, Social Development, and local bodies) is appropriate or ‘acceptable’ when looked at in macroeconomic terms. That figure was 7.4% of GDP in 2017/18, whereas the spending of Scandinavian countries (with strong well-being policies) was just under 9%.

Whatever the unmet health care need is in Hawke’s Bay – be that surgical access, child health, mental health, or whatever – the bottom line is that our local DHB has no power to raise additional funds to address its own priorities. And very limited discretion to re-allocate funds it does receive from Wellington. And the call from Wellington for greater ‘efficiencies’ – with most DHBs, including ours, already squeezing blood from the rock – continues a head-in-the-stand prescription for ever-more failing health services. Neither major party seems to get that.

Without doubt, the level of health spending in NZ will be a major campaign issue in this year’s Parliamentary elections … or certainly should be.

Demographics. The Hawke’s Bay health system struggles against two demographic forces over which it has no control – a rising elderly and super-elderly population and a severely health-disadvantaged Maori/Pacifica population. 

Hawke’s Bay’s age 75+ population is projected to increase 80% in the next fifteen years. Those in that cohort who enter the hospital will be the most expensive patients our health system carries. Here’s where the ‘bed days’ and ‘case weights’ will really add up. At the same time, the home care need (mostly elderly) already at 2,200 clients, with 1,600 visits per day, is rising, forcing unseemly, sharply-criticised ‘triage’ letters to senior residents.

Most of these super-elderly patients will be Pakeha, because, frankly, Maori and Pacifica just don’t live that long. Which points to the social end of the health care conundrum – gross inequities in health care for Maori and Pacifica, having especially adverse impact on children. 

Over the next fifteen years, HB’s Maori population will increase to 33% and our Pacifica population to 5% … together nearly 4-in-10 of our people. In twenty years, nearly two-thirds of HB children will be Maori or Pacifica, with many of those living in poverty households that are unhealthy in so many ways.

Everyone looking at this end of the equation bemoans the inequities in medical care access and/or the unsuitability of ‘European’ medical constructs to meeting the cultural differences around health maintenance.

The HB health system – with a new Maori chair of the DHB and a Maori chair of Health Hawke’s Bay (the primary sector arm) – should be able to crack the nut of better access and access to more suitable modalities. If not, that systemic failure indeed rests with our health bureaucracy, clinicians and alternative service providers.

But what the ‘health system’ cannot control is the underlying poverty affecting a significant portion of our population – 27% of HBDHB’s population lives in the most deprived areas (deciles 9 or 10). Poverty delivers patients.

Nor can the ‘health system’ by itself achieve the behavioural changes we must make as individuals so we do not unnecessarily burden our health care providers. Increased ‘population health’ expenditure aimed at educating and encouraging people toward better lifestyles (no smoking, reduced alcohol, sound nutrition, adequate exercise) is valuable and urgently needed. As the Hospitals on Edge report observes:

“The evidence shows policies with the greatest impact on reducing the need for hospital services relate to tax and regulation aimed at reducing smoking and consumption of alcohol and unhealthy foods.”

Collaboration. Every health report I’ve seen in the last decade – whether produced in Wellington or Hawke’s Bay – has pointed to the need for much tighter and intelligent integration and collaboration between our primary care providers and the DHB. With each successive report, the urgency seems further heightened.

From the Sapere Report: “System level integration is much weaker. Health Pathways are not well embedded in practice. GPs are still working in a model with significant wasted time and lack of productivity and there is no sign of a medical home strategy to modernise primary care. There are a large number of referrals through to the hospital that could be managed in primary care utilising emerging models, e.g. nurse led clinics.” 

One can detect little or no intellectual disagreement amongst the parties as to what a more seamless future should look like and how it would benefit both patients (with better and more timely care) and the health system (with greater productivity and macro-outcomes).

Photo: Tom Allan
Improving services within the hospital is a “huge focus”, but so is the DHB’s role in improving lifestyles to avoid the hospital.
SHAYNE WALKER, DHB CHAIR

The reasons given for the glacier pace in achieving such improvements generally relate to dysfunctional payment systems (with blame laid in Wellington at the Health Ministry), lack of ‘whole of patient’ data sharing, and the ‘normal’ turf protection and change resistance of the various players in any bureaucratic system. 

The now year-old examination of the HBDHB (Sapere Report) described the relationship between our primary care providers and the DHB as “fraught”. I’ve heard worse, yet all parties, including new DHB chairman Shayne Walker, insist they are working hard on courtship. He lists “a collaborative and integrated health system” as one of his three main hurdles to overcome to make a real difference (alongside financial sustainability and workforce development).

At what point might there be an orgasmic convergence? I have no idea. 

Unfortunately, this is the process that is least open to public oversight by mere consumers/patients or media. It is entirely in the hands of the health bureaucrats and practitioners, unless some Board member of the DHB or Health Hawke’s Bay is brave and determined enough to make a public crusade out of this challenge. Any volunteers?

New team

Our 2019 local elections saw (combined with Ministerial selections) the appointment of 7 new members to the 11-person HBDHB Board, including Shayne Walker as chairman. This represents a significant injection of new blood into HB’s health care governance, and change will be even more amplified by the Board’s selection of a new chief executive and chief operating officer in the next few months.

But even as this team gets grounded and moves up the learning curve, pundits are debating whether the Government will pull the plug on elected DHBs. The final report of the Health and Disability Review, due in March, is expected to weigh in on the matter. The interim report demurred, saying: “…communities need more effective avenues for guiding the direction of health service planning and delivery. The Panel has not formed a definite view on whether DHB elections are an effective or an essential way of achieving this”, and included these questions for further discussion: 

• “Is continuing with governance by majority-elected boards, the most effective way to improve accountability or foster real community engagement? 

• Is the best way to achieve more efficiency and more equitable outcomes within available resources to have fewer DHBs, DHBs with different functions and/or more sharing of resources at regional or national level?”

I interviewed Shayne Walker for this article, and he too (an appointed, not elected chair) demurred on future structural change, commenting that he and his Board have plenty of issues to contend with right now, without speculating on matters they wouldn’t decide. Fair enough. But he did emphasise the new Board would be more dedicated and proactive in engaging with the community. We’ll watch for that.

At the top of Walker’s agenda are these issues: equity in health service for Maori and Pacifica, child health, mental health and financial sustainability. He cites primary care and population health as areas “where we’ll make the biggest difference over time, reducing need to come to the hospital.” Improving services within the hospital is a “huge focus”, but so is the DHB’s role in improving lifestyles to avoid the hospital. 

In terms of Maori health, this probably means more community-based delivery of service, improving access and adopting a whanau-based approach to care.

In the face of the daunting health issues and adverse trends confronting Hawke’s Bay, Walker expresses confidence and a determination to bring “more urgency” to the issues that by now are familiar. 

He is “excited” over progress made in the last year with respect to DHB/PHO collaboration. “It’s changed dramatically” since the (Sapere) report, and “it’s real, authentic and genuine.” He points to “new thinking, new attitudes, new personalities and opportunties” all inspired by the urgency all parties perceive.

He seems resigned to the current dollar equation, referring to “the resource we are privileged to receive”, but also notes historic capital under-investment. He says the DHB’s focus must be on “changing how things are done” with the funds and assets available. “Make the most with what we can get.”

In terms of accountability, “Yes, I report to my Board and the Health Minister,” says Walker, “but I have an ethical and moral responsibility to our community. We’re here to serve, to do the best we can and make a difference.”

Amen. 

Shayne Walker has the hardest public service job in Hawke’s Bay. We should all wish him good health! 

For more information:

Hospitals on the Edge, report by Association of Salaried Medical Specialists

Hawke’s Bay Health System Baseline Report, Sapere Research Group

NZ Health and Disability System Review – Interim Report

Tom Belford05 April 2020

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