Future Options For New Zealand
It is clear that there will be a trend towards the centralisation of higher level surgical services in New Zealand. This is legitimate on safety, equity and quality grounds and may be inevitable on efficiency grounds. In such an environment, the strategies followed by the smaller American hospitals, listed above, provide a possible model for New Zealand.
There will be, of course, a difference in response depending on the size of hospital, its proximity to other hospitals, current facilities, and so on. At some larger rural hospitals, such as Masterton hospital, which in the original CHE establishment process was considered viable as a stand-alone CHE, it may be appropriate to maintain a higher level of surgical services. Even in such cases, though, it will be important to maintain close liaisons with regional centres such as Wellington Hospital.
Increased concentration of higher level surgical services requires two key elements if it to represent good access for rural residents: a good land and air ambulance service, and financial assistance for travel and accommodation where cost is a barrier. Clear criteria for travel assistance are necessary. The RHAs will be in a better position to achieve greater co-ordination and consistency of such assistance from 1 July 1995 when the Travel and Accommodation Cost programme of the Disabled Persons Community Welfare Act 1975 transfers to Vote: Health. Further community consultation will be required to achieve fairer access with such assistance.
One possible answer on the accommodation front, especially for those cases where a longer stay in hospital is required, is the provision of low-cost accommodation for family. Hostels could be provided by hospitals themselves, or on a voluntary/charitable basis, such as Ronald McDonald house.
Greater co-ordination of emergency retrieval services is also being addressed by RHAs. In the 1994/95 Policy guidelines it was noted that RHAs intend to purchase co-ordinated trauma and acute services and clear communications between ambulance, primary care and contracted surgical services. Further elaboration on the progress made in this area will be included in the 1995/96 Policy Guideline service obligations.
If there is a movement of higher level surgical services to regional hospitals, there could be a complementary movement of low-risk, lower level services to local centres. Further development of rehabilitation and disability support services could also be encouraged in local centres. Given the friendly atmosphere and possible lower cost structures often associated with smaller hospitals, there would be a further efficiency gain under this scenario. It would also help to ensure that loss of surgical services did not mean closure for smaller hospitals.
A continuum of services should be offered to people to maintain and improve their health. Much can be gained by focusing on increased integration of local and regional services. Maintaining good linkages between health care centres was a key recommendation emerging from the Midcentral study of services at Horowhenua, Dannevirke and Pahiatua. The services at Horowhenua were described as being so closely linked to the base hospital at Palmerston North as to be difficult to evaluate separately. Certainly Horowhenua area patients undergoing surgery at Palmerston North are able to recover at Horowhenua.
It is important not to underestimate the importance of being in familiar surroundings, with family and friends at hand, in speeding recovery and reducing stress. The Core Services Committee report endorses the return of patients to local care as soon as possible for this reason (Core Services Committee, 1993a:21). For some remote rural residents, it may not be practical to receive follow-up care at home, so return to a local hospital may be an efficient solution.
It is also important to remember that, through medical advances and new technologies, a number of surgical procedures are becoming simplified, and may now be carried out on a day-patient basis. This trend is likely to continue, and specialised operations may in future become more commonplace. These advances further increase the scope for outpatient and day-patient care which could potentially be performed in local centres.
Further possibilities would result from the use of visiting specialists. However, it is still necessary to have access to the appropriate level of support services and facilities. Where these are not available locally, they may be brought in. Already there are mobile surgical clinics and teams developing throughout New Zealand.
Close linkages with other centres also allows for the sharing of staff. This is another method to address services not needed full time, which in the American model was addressed by multi-skilling. Close links can also provide the necessary peer support for practitioners at smaller centres, and can even involve them in research projects, etc. carried out at the larger regional centre.
An option which may be available in the longer term is for smaller hospitals to maintain specialised equipment and staff by taking on private cases. This may be more viable where small centres specialise in a particular area of expertise. However, there are many complex issues involved in treating private patients within the public health system, and protocols for this are only at an early stage of development as yet.
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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