Some specialist services at Dunedin Hospital may not be viable as stand-alone services because they do not have a sufficient population base to support them, a health plan out for consultation today says.
The Southern District Health Board's draft strategic health services plan says the board is at a ''pivotal'' point in its history.
More services are likely to be provided on a South Island-wide basis, possibly involving Dunedin clinical hubs run in other centres.
But patients may have to travel further, in some cases.
''Overall, Dunedin Hospital's performance may be adversely affected by trying to maintain its own low volume specialties and high levels of clinical support services without sufficient population catchment to warrant adequate specialist staffing,'' the plan says.
''There is increasing South Island DHB collaboration in low volume specialties, driven by recognition that the South Island population is too small for duplication of stand-alone services, and that regionalisation is likely to assist in ensuring ongoing access.''
Business cases for South Island-wide services would consider the need to balance patient and specialist travel; effects on teaching, research and training; and necessary arrangements for rapid response to help patients in life-threatening conditions.
General practice would provide more procedures and services, while ''locality networks'' of community health teams would co-ordinate local services.
The role of rural hospitals would be strengthened, and an acute care network established linking local, district and regional South Island services.
The changes would remove the board's persistent financial deficit, reduce treatment rates when they are higher than New Zealand averages, and cut spending on ''low value'' procedures.
The board could then invest in new equipment and services, and afford the Dunedin Hospital rebuild.
Because the plan is strategic, it lacks specifics, and what it points to in terms of Dunedin Hospital's status as a tertiary-level health provider is unclear.
Its six priorities are. -
• Develop a coherent Southern system of care.
• Build the system on a foundation of primary community care.
• Secure access to sustainable specialist services.
• Strengthen clinical leadership, engagement and quality.
• Optimise system capacity and capability.
• Live within our means.
Some clinical specialty services at Dunedin and Southland hospitals are struggling to maintain enough volumes and staffing levels for clinical viability.
Specialists were increasingly attracted to bigger centres, making recruitment to the South an issue.
A list of ''characteristics'' of the Southern region influencing health planning includes the challenge of ''reconciling district aspirations for specialised services with rational service design''.
Southern was the sixth-largest board by population, but because of low in-flows from other health boards served a relatively small catchment.
The plan includes a case study on cardiothoracic surgery, but otherwise there is a lack of detail about affected specialties.
It includes some ''core secondary services'' (less complex), as well as highly specialised ones. In an interview yesterday, patient services medical director Dick Bunton was adamant the plan did not signal a downgrade of services at Dunedin Hospital.
However, he admitted that without a Government directive to send patients to the South for services like cardiothoracic surgery, some will not be viable in the long term.
On Friday, Mr Bunton told TVNZ the board needed support from Health Minister Jonathan Coleman to make required changes, some of which would be ''unattractive, and quite controversial''.
Yesterday, he said that comment meant some patients could baulk at receiving the same services in the community they were used to receiving in hospital.
Planning and funding director Sandra Boardman said the board was trying to attract more patients to the South for its specialist services, which would alleviate the low population problem.
In services like cardiothoracic surgery, it required a national mandate, because of knock-on effects for other health boards from losing access to patients.
Talks were under way at a high level about that issue.
Mrs Boardman also insisted the plan did not signal a downgrade of Dunedin Hospital, and said the Otago Daily Times was too focused on the specialist services aspect.
Developments in community healthcare were more relevant to the needs of southern patients, she said.
Various specialties would be identified for analysis, but this did not mean they would be reviewed.
''I guess as soon as you start jumping up and down about reviews, everybody goes: 'Oh they're going to cancel it', and that's not want this is about.
''This is about saying that at the moment we have some services where there is a real need to focus on sustaining them.''
Medical staff wages had increased by 41% since 2009, the plan shows.
The board would be in surplus if medical wages were at the same level of overall spending as in comparable health boards.
The reason for the higher cost was unclear.
The Association of Salaried Medical Specialists has reacted strongly to the board pinpointing medical wages.
In a press release, it accused the board of using doctors as scapegoats for the board's financial problems.
''Ironically, the draft plan reports that in terms of quality and accessibility of care, Otago and Southland patients overall do well compared with other DHBs,'' executive director Ian Powell said.
''Instead of commending their doctors (and their other health professionals) for this achievement, the plan unfairly blames them for the deficit.''
The board would reduce funding for interventions deemed to be less clinically effective, following recognised guidelines.
An example was implantable cardioverter defibrillators, on which the board spent $1.1 million in 2012-13.
The board had made progress reducing rates of grommet insertion, which were historically higher than the national average.
While some procedures were provided at higher rates than average, others, including knee replacements and prostatectomies, were provided at lower rates than the national average.
When it could afford to, the board would set up a strategic investment fund to invest in ''prioritised services and models of care''.
At a glance
• Develop stronger rural hospital network.
• Establish acute care network linking local, district and regional (South Island) services.
• Consider establishing a Medical Assessment and Planning Unit at Dunedin Hospital to improve access to urgent care.
• Develop Southern health workforce plan, starting with a stocktake of its estimated 9000 health workers.
• Establish locality networks to support delivery of well co-ordinated local services.
• A planned approach to upskilling GPs.
• Reduce spending on interventions that are either ineffective or not cost-effective.
• Target areas of high spending, such as community pharmaceuticals.
• Ensure clinical leaders have the time and skills to deliver on the performance expectations of their roles.
Source: SDHB draft strategic health services plan
