The Future for Rural Hospitals
From the above discussion, it is clear that there is a trend to centralise complex secondary and tertiary services. This is on the grounds not only of efficiency, but also safety and quality. As the Minister of Health has stated;
In meeting the needs of a small population with a large geographic spread, it seems increasingly that the answer does not lie in duplicating services but in providing more appropriate means of accessing those services, and ensuring that the services are of the highest quality. (Core Services Committee, 1993a:3)
On the other hand, a key aim of the reforms is the integration of primary and secondary care. There is also the explicit aim to move more surgery to a daypatient basis. For example, Midland RHA is aiming to increase day cases to 60% of all surgery, from the current level of 30-35 %. Several CHEs are currently investing in the technology to allow a move in this direction. These trends offer considerable opportunities for smaller/rural hospitals.
Before returning to the issue of what opportunities exist for rural hospitals under the new regime, it is worthwhile to first look at a few other issues relating to the provision of surgical services at rural hospitals, and also to see what is happening in other countries.
Is New Zealand Over-Bedded?
Several people consulted in the preparation of this report commented on the fact that New Zealand had a very high number of hospital beds relative to its small population. This can be attributed partly to geographical spread, and partly to historical development. Both these factors account for the South Island having a higher ratio of beds to population, as well as a higher proportion of small hospitals.
Table 4 shows the total number of hospital beds per 1000 population in selected countries. The most recent year for which full statistics are available is 1989. It is clear that, compared to Canada, the USA and the UK, New Zealand in 1989 had a high bed/population ratio. This ratio had fallen by 1991, but the trend in other countries is also downwards.4
On the other hand, the table also shows that the level in New Zealand is comparable to the level in Australia on a per capita basis. Furthermore, there are several OECD countries wiffi much higher ratios than New Zealand. In 1991, the Nordic countries had 12-15 beds per 1000 population, while Japan had an amazing 16.
| Table 4 Total In-Patient Care Beds Per 1000 Population
1 1990 figure Source: OECD, 1993: Vol 1 Table 5.2.1 and Vol 11 Table A1. 1.1 |
It should also be noted, however, that total inpatient hospital beds really only serves as an indicator of availability. It does not tell how well those beds are being used. A more valid comparison with other countries would also identify utilisation rates and the context in which beds are used. The lack of up-to-date data also impedes useful analysis.
The view of health officials is that there is considerable scope for more efficient use of beds in New Zealand. In briefing papers prepared for the CHE Advisory Committees who were evaluating the configuration of future CHEs, the following advice is given:
New Zealand hospitals are as a whole over-bedded by international standards, albeit some specific services are under-bedded. Structures which reduce inpatient bed numbers are favoured. (CHEEU, 1993b: Annex 7, p 2)
It is food for thought that for New Zealand to move to a ratio of, say, 6.5, hospital beds would have to drop from the current 26,000 to 22,000 (assuming no population growth). However, it is also worth pondering how much more community based health and disability services could be provided with the money freed up by such a move.
Access
One of the key concerns regarding the loss of surgical services from rural hospitals is the feared increased difficulty of rural dwellers gaining access to those services.
The term "access" has many dimensions. It can mean the time it takes to travel to a services location under normal circumstances; the time it takes to receive treatment in the case of accident or sudden illness; the ease with which family and friends may visit the patient to offer support; or the waiting time to receive treatment for non-emergency needs.
A fifth aspect, and one which is often overlooked in considering the issue of access, is the quality of services obtained. An incident at a small hospital, where an incorrectly set broken leg led to gangrene and the eventual need to amputate the leg, raises questions about the level of service in smaller hospitals (Edgar, pers.comm.). Obviously there are occasional lapses at any hospital, no matter what size, but generally speaking where support services are lacking, volumes are low, or peer support for practitioners is lacking, the risk of surgery increases.
The Core Services Committee addressed this issue directly in their consultation document, "Seeking Consensus". People were asked straight out, which is more important - better results for patients or local access to services? (Core Services Committee, 1993b:20). "Most people considered that it is more important to locate services where they will give the best results, provided access is assured, than to maintain local access to services" (Core Services Committee, 1993a:9).
People, including those in rural areas, then support the move towards increased centralisation of secondary and tertiary level services where this means an increase in the quality of those services. But there are conditions attached.
Access to services is of great concern especially in rural areas. People accept that they may not have access to specialist services in their own community, but want some recognition of the need for assistance with such things as transport and accommodation costs, and support in their community as a follow-up to specialist treatment carried Out in regional centres. (Core Services Committee, 1993a:9)
RHAs are working on improving access to surgical services for people in rural areas. The transfer of funding from DSW to RHAs for transport and accommodation assistance on 1 July 1995 should allow greater co-ordination of such assistance. The need for follow-up care may present an opportunity for rural hospitals, and is discussed below.
Rural communities have been assured that land and air ambulance services will be improved to provide the needed emergency access to regional hospital services. It is worth noting that a high percentage of the demand for higher level services is from victims of accidents or violent illness, where it is better to receive full treatment as soon as possible, rather than be stabilised at a local facility and then transferred (Haynes and Bentham, 1979:2). As noted above, the improved provision and coordination of ambulance services is an area which RHAs have been instructed to address.
Before concluding the discussion on access, it is worth noting that, if looked at in terms of hospital beds and usage of facilities on a per capita basis (and this is clearly only one aspect of access), rural residents are currently favoured over their urban counterparts. A greater percentage of rural residents use hospitals, and they tend to stay for longer. There is also a strong north/south variation, with a proportionately greater number of hospitals and beds available for residents in the South Island. (Ministry of Health, 1993:33)
The inequities in access across a number of fronts was a pronounced finding in the first report of the Core Service Committee, and one which they intend to revisit in the current year (1993a:7).
Community Concerns
It is also important to recognise that loss of surgical services is not the only concern to a rural community when it is proposed that a hospital scale down operations. The hospital may be a large employer, if not the largest, and a major fear is the loss of jobs which will not easily be replaced. The hospital also tends to be an important part of the overall infrastructure, and its loss or downsizing may affect whether other business are viable, and whether new businesses can be attracted to the area.
These are legitimate concerns. However, health care purchasers and providers must focus on providing optimal health care, and impacts on community will necessarily come second. This makes it doubly important that the local community be a partner in any decisions regarding a major change of services. The 1994/95 guidelines for RHAs require them to consult with affected communities on any CHE plans to alter or withdraw services. An example of this is seen in the project team which has been set up to examine the future of surgical services at Dannevirke Hospital.
Overseas Examples
These same issues are facing other countries as they struggle with burgeoning health costs and declining rural populations.
In the UK the issue was recognised 20 years ago, and a policy introduced by the Department of Health and Social Services to move to a structure of district hospitals supported by a network of smaller community hospitals. The district hospitals offered specialised care, generally had 600-800 beds and serviced a population of 100,000 to 150,000. The community hospital had 50-100 beds, and offered a non-specialised service which complemented rather than duplicated the district hospital.
The main focus of the community hospital was an extension of primary care, with surgery offered to no greater level than would be performed by a GP in his or her surgery. Local GPs were encouraged to be part of the staff, thus promoting continuity of care.
By being a focus of health care at the local level, the small hospital might help to foster greater contact and coordination between the health and social services and also between those services and the public, so facilitating early diagnosis and treatment (Haynes and Bentham, 1979:2).
It was recognised that small hospitals had loyal communities and often a strong volunteer base. They fostered a friendly an informal atmosphere that was conducive to recuperation. Familiarity and accessibility were key strengths. They were particularly suited to handing the elderly, chronically ill and those recovering from major treatment in the district hospitals.
This process is now quite advanced in the UK, and many of the community hospitals have now been picked up by community trusts. But it has also been recognised that many of these smaller hospitals are located in older buildings which are costly to maintain, so there has been a move away from "bricks and mortar" to an emphasis on services. The epitome of this is the formation of mobile surgical teams, which bring their own equipment and support services to rural areas. (Edgar, pers.comm.)
In the USA, the problem faced by rural hospitals was even more acute, as unless they met certain standards of staffing, services and facilities, they were not eligible to receive funding from the national Medicare scheme. There were also legal requirements which small hospitals found difficult to meet. However, complete closure of facilities would have seriously reduced access to essential care in many areas.
A study by the US Department of Health and Human Services (Agency for Health Care Policy and Research, 1991) found three interrelated problems common to rural hospitals: low volumes of in-patient services; shortages of skilled personnel; and financial distress. The study looked at the developments undertaken by six hospitals/areas to overcome these problems. The solutions found in the six cases used some or all of the following strategies:
- reduce/eliminate in-patient beds
- discontinue costly/complicated services requiring technology or staff which were then underutilised
- focus on primary, emergency and long-term care
- cross-train staff to handle multiple tasks
- develop close relationships with other hospitals
In general, the smaller hospitals moved out of surgery which required general anaesthesia, reduced their maternity care services (as they were no longer able to perform Caesarian sections), and offered specialist clinics on a regular basis.
4A recent Canadian study shows that the total number of inpatient beds in that country has fallen to 2.75/1000, and further that 40% of these beds are inappropriately used (Working Group, 1994).
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
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