RHA Purchasing Decisions
CHE decisions regarding service provision will be influenced by the performance monitoring process, and by quality and safety issues such as may be raised by use of the role delineation model. But most of all, they will be determined by the decisions of the RHAs as to what health services they will be purchasing, and what conditions will be placed on those purchases. This then is the third topic needed to be discussed in order to provide a fuller picture of factors affecting surgical services in rural hospitals.
The Core Services Committee
The Minister of Health outlines the services the Government requires RHAs to purchase on behalf of their populations. To aid in the process of setting these guidelines, the National Advisory Committee on Core Health and Disability Support Services (the Core Services Committee) was established. The overall objective of the Core Services Committee is "to advise the Government on the fairest and most effective use of the public money we spend each year on health and disability support services" (Core Services Committee, 1993a:3).
One function of the Committee is to advise the Minister each year on the services to be purchased, their relative priority, and the terms on which they should be available. In its first year, the Committee recommended that the status quo be held. However, it has now had the opportunity to carry out further study and consultation, and this year has begun to shift the focus for health purchasing decisions (for 1994/95).
A key focus for the Core Services Committee this year has been the question of configuration of services, particularly high level services (e.g. neurosurgery, heart transplants). Given the need, for safety and quality reasons, for clinicians to perform a certain volume of operations to maintain their proficiency, as well as the wish to avoid duplication of expensive technology, the Core Services Committee has recommended that key services will be performed only in a given number of centres with suitable facilities. For example, they recommend that kidney transplants be performed at no more than two centres nationally, and care for babies under 1000 grams be provided at no more than five centres. For some procedures, such as liver transplants, the recommendation is that they not be performed in New Zealand at all, but that we make use of overseas facilities (as is currently the case).
So far, the Committee has focused on nationally based services, but they have recommended that RHAs do the same at regional level.
Recommendation 9: Where there is evidence that significantly better outcomes can be achieved for health care by providing a service at a regional or national level, RHAs contract with regional or national centres for that service (Core Services Committee, 1993a: 12).
However, they also ask that consideration be given to the needs of family where services are concentrated in only a few centres:
Recommendation 10: RHAs take into consideration the provision of family/whanau support, on fair terms in cases of need, when purchasing regional/national services (p.12).
The Core Services Committee intends to undertake further work to determine which services are best provided at national or regional centres only, while recognising in some cases it will be up to the RHA, in conjunction with its local community, to determine which services are best rationalised.
Overall, the trend to centralise higher level secondary and tertiary services is clearly signalled.
RHA Purchasing Guidelines
The Policy Guidelines for RHAs for 1994/95 draw on recommendations of the Core Services Committee (Ministry of Health, 1994). This document sets the Government's priorities for health services, which is intended to guide the RHAs in the development of their Purchase Plans and Statements of Intent.
In the general discussion section of the Policy Guidelines many issues are raised which are pertinent to the surgical services provided by smaller hospitals. Confirming the trend identified above for increased centralisation of higher level services, RHAs have been asked to co-ordinate their purchase of tertiary level services. They are also to outline the conditions for provision of family support and assistance with travel and accommodation costs. In addition, they are to comment on their intentions with regard to the provision of ambulance services, both land and air. It is important to note that the 1994/95 Policy Guidelines require RHAs to consult with the affected communities on CHE plans to alter or withdraw services and to consider all alternative proposals, including any community health initiatives.
The Policy Guidelines also state the service obligations for RHAs, detailing the range of health and disability services to be purchased; the coverage and/or terms of access to those services; and standards for safety and quality. While time and distance criteria are set out for primary services (see Table 3), no such indicators have yet been set for secondary services.3 RHAs are undertaking work to make criteria for access to secondary medical services more explicit, and to specify acceptable waiting times. It is anticipated that time and distance criteria for secondary and tertiary services will be further developed in the 1995/96 Policy Guidelines.
| Table 3 Terms of Access Criteria for Primary Care: Travel Time
|
RHAs will also consult their communities in the preparation of their Purchase Plans. For example, Central RHA has released a discussion document indicating its purchasing intentions for 1994/95 (Central RHA, 1993). In terms of secondary care, it seeks to encourage continuity of care and improve communication between primary and secondary caregivers. The RHA also intends to increase the amount of day surgery, particularly at rural hospitals, and increase access to outpatient services. They also plan to examine geographical access to surgery within the region and make necessary changes to ensure fair access (p14-15).
3 Although a briefing paper for CHEACs defined 'ready access" as 45-60 minutes driving time (CHEEU. 1993b: Annex 7, p 3).
Contact for Enquiries
Rural Affairs Coordinator
Sector Performance Policy
MAF Policy
Ministry of Agriculture and Forestry
PO Box 2526
Wellington
NEW ZEALAND
Phone: +64 4 894 0675
Fax: +64 4 4 894 0745
Contact this person
