Two-unit fall-back option promoted by Rousseau

If there is insufficient goodwill to develop a single service offering neurosurgery in both Dunedin and Christchurch, the fallback position should be two separate units with three neurosurgeons each, Southern District Health Board chief executive Brian Rousseau says.

This is revealed in his submission to the South Island neurosurgery service expert panel, which he released to the Otago Daily Times this week under the Official Information Act after an earlier refusal to release it.

In his submission, he recommended neurosurgeons in Christchurch and Dunedin be "challenged" to implement a sustainable single South Island service with four neurosurgeons in Christchurch and two in Dunedin working as a team.

If the goodwill was not able to develop such a "clinically networked" service, then he recommended two separate three-neurosurgeon units.

Governance of the proposed regional service should be shared between the Canterbury and Southern district health boards in the long term, but short-term independent governance should be provided until "the service is up and running and relationships have improved".

Effective governance of a single South Island service would require leadership at both clinical and non-clinical level.

"It is unfortunate that the current dispute over service configuration will inevitably have damaged relationships between some key Southern DHB and Canterbury DHB staff.

"It will take time to mend these relationships and rebuild trust between key individuals required to ensure a successful regional service."

Mr Rousseau said at this stage there was unlikely to be sufficient trust between the two boards for either party to accept or adopt a position as the "lead DHB" for the service.

In his two and a-half page submission, Mr Rousseau said he did not consider the various options had been given a balanced assessment against the South Island health service planning principles.

These include that services should provide equity of access, clinical and financial sustainability, quality and safety, and be patient-centred.

He looked at the six neurosurgeons in Christchurch model, one with four neurosurgeons in Christchurch and two in Dunedin (the status quo but in a regional service), and a three-each model in a regional service, and ranked them according to the nine principles.

With his rankings the 4:2 model got the most favourable score (23 points), narrowly followed by the 3:3 model (20), whereas the six neurosurgeons in Canterbury model (11) ranked much lower.

The Christchurch-only model was the most beneficial for the individual surgeons and the specialty, but failed to meet acceptable levels of safety (particularly for acute patients), equity of access, and was the most expensive, he said.

An added disadvantage was no clinical support in the hospital where the surgeons were not working, and "a number of other clinical safety concerns" which were addressed by other submissions.

While he agreed that in a one-site model, aspects such as training registrars and sub-specialisation were inherently easier to manage, "I maintain where there is sufficient goodwill, these goals can be achieved in the 4:2 model".

An example of this was the South Island training rotation for anaesthetic registrars.

Mr Rousseau suggested better sustainability could be achieved by having more surgeons in a two-site model, but each of them working less clinical time, allowing for involvement in such activities as research, teaching, training and private practice.

The 4:2 configuration was superior to the 6:0 model with regard to safety, equity of access and financial sustainability.

"I remain totally convinced that with the required goodwill, this model can achieve most, if not all, the benefits of the 6:0 model without the negative elements of the 6:0 model."

Referring to the 3:3 model, Mr Rousseau said it would preserve acceptable levels of safety and an improvement on the 6:0 model for equity of access.

However, it would be more expensive than the 4:2 model because some patients north of Timaru would have to travel to Dunedin for elective surgery.

Even so, it would be less expensive than the 6:0 model, where all patients south of Christchurch would have to travel to Christchurch.

Mr Rousseau's submission did not include any financial analysis.

In all of the options, the greater the distance communities were from the hospitals at which neurosurgeons were based, the greater the potential for a poor outcome, he said, acknowledging this aspect would be covered in other submissions. elspeth.mclean@odt.co.nz