The prospect of a shake-up of Southern health services has again raised the spectre of whether the Otago Medical School is an asset or a burden to Dunedin Hospital. Health reporter Eileen Goodwin looks into the issue.
When market-driven health was at its peak in the 1990s, health bosses commissioned a report into whether the Dunedin School of Medicine was a drain on Dunedin Hospital.
The answer surprised Healthcare Otago: both entities were benefiting, and it was best to leave the arrangement intact.
Then, the thinking was that institutions had to solely look out for their own best interest - co-operation was out of fashion, and cost accounting the order of the day.
Healthcare Otago and some of the more extreme ideas of that era are long gone, but the same question over the medical school has resurfaced with the financial failure of the Southern District Health Board.
This week, the Otago Daily Times contacted the writer of the 1997 report, Wellington economist Suzanne Snively, who says an ''unholy alliance'' exists between health and education.
She says the intangible benefits captured in her report for the Crown Health Enterprise are still routinely unmeasured and ignored in the sector.
Just this year, a visiting chief executive told the ailing Southern District Health Board it should challenge the University of Otago over the financial impact of joint clinical-academic appointments.
''The needs of the university are often cited as reasons why configuration of services cannot change, as such the university should be challenged to face the implications and pressures this [places] on the Southern District Health Board,'' Nelson Marlborough DHB chief executive Chris Fleming's report says.
''Configuration of services'' might be bland health jargon, but it is crucial to the future of both Dunedin Hospital and to a lesser extent the medical school.
Mr Fleming's report reflects the view of those who believe the medical school props up hospital specialties which would otherwise not be in Dunedin.
He could not be contacted for comment.
With the sacking of board members in June, a reorganisation of health services will happen with no democratic oversight at board level.
There is persistent rumour in Dunedin of the medical school being snatched by another centre.
While that fear is unrealistic, the question over Dunedin's future as a high-level health centre affects the medical school.
Whether the ''configuration of services'' in Dunedin is appropriate goes to the heart of questions over health planning in New Zealand; should the South Island, with a population smaller than Auckland's, have one or two main health centres?
''Service configuration'' is a term also used by Prof Peter Crampton, the university's health sciences pro-vice-chancellor.
In an interview, he was at pains to emphasise the complexity of health planning and that it always meant trade-offs.
DHBs provide on-the-job training for medical students, and it was essential to have a good relationship with them and understand their needs.
''They're just looking after their bottom lines and they're held accountable for service delivery.
''Whereas if you talk to chief executives, they are absolutely cognisant of their obligation to train the next generation of workforce.
''It's just that their own performance criteria and their own legislation does not place emphasis on that.''
Prof Crampton does not want to oversimplify this issue, and is ''anxious about little soundbites'' that could mislead people.
Big centres carry out more procedures, meaning a higher quality service, he insists.
Centralisation of South Island paediatric oncology in Christchurch was a case in point.
But too much centralisation could fail the ''resilience'' test, a problem amply demonstrated by the Christchurch earthquakes, he says.
Losing services at Dunedin Hospital would have no direct impact on teaching medical students, but it could threaten research, Prof Crampton concedes.
He does not want to overstate the ''threat'', which he immediately clarifies as ''potentially negative implications''.
''Over many generations we have invested ... in world-leading research infrastructure in Dunedin.
''[Losing specialties in Dunedin] has potentially big implications for the research capacity of the university insofar as a significant number of the researchers have joint appointments across both institutions.''
In a separate role, Prof Crampton is dean of the Otago Medical School, encompassing the Dunedin, Christchurch and Wellington divisions.
''The message I want to convey to the people of Dunedin is the medical school is strong, vibrant, and has massive dispersed infrastructure.
''Its base and heart is in Dunedin. Everyone can feel really positive about that - it's not going to change.''
Being spread over three centres meant the Otago Medical School coped with the increase in medical student numbers in recent years.
The close-knit Dunedin medical research scene is a drawcard for students.
A ''magic nexus'' of neuroscience research in Dunedin blossomed further with the arrival of neurosurgeon Prof Dirk De Ridder in 2013.
His input energised neuroscience research by allowing more ideas to be tried in patients.
''We are delighted with our two academic neurosurgeons,'' Prof Crampton said.
While there are now fears over neurosurgery's future, the Otago Daily Times understands that taking it away from Dunedin is considered politically unpalatable because the public outcry over its possible removal is too recent.
The solution was to create two academic neurosurgery roles which provided enough work for three clinical positions at the hospital.
Even a modicum of uncertainty creates stress, especially for doctors with young families, Prof De Ridder told the ODT.
Other neurosurgery units are asking the Dunedin surgeons about their future prospects.
''Which, of course, creates some anxiety in the unit.
''Nobody likes to work in an uncertain situation where today you might still have a job but maybe in the future there might not be a job.''
Prof De Ridder has numerous research projects running, collaborations involving local and international researchers.
The research projects are going well, he says.
He appears to be the kind of person Ms Snively has in mind when speaking about intangible benefits revealed by her 1997 research.
''The nature of the people who are attracted to doing clinical and research work at the same time are the kind of people who are really devoted to their work.
''They were more than happy to be putting those extra hours in even though they weren't paid for them.''
She told health bosses at the time: ''Don't complain about the clinicians' delivery because you're getting a great deal from them - they're currently overdelivering for you, most of them''.
There had been a ''strong expectation'' of a different finding.
''People were parroting unsubstantiated evidence that training and teaching hospitals were always a drag on the hospital.''
Dunedin was one of several New Zealand centres that allowed tight links between hospitals and universities, which was unusual internationally and should be considered a strength, she says.-
It was difficult to get education and health to have the conversations needed to make the most of their collective strength.
''You have people in Wellington only worried about the financials. And people in the hospitals trying to care about the outcomes and the state of delivery, but there's an empty middle in between.''
Ms Snively has a suggestion for the successors of the people she advised back in 1997: Before cutting services ''to the quick'', questions should be asked about how to use the strengths of Dunedin as a research hub to shore up services.
''We need to regard [researchers] as a very important asset.
''We need to figure out how to utilise that asset and not lose it.''
