Southern health questions abound

Dunedin-based National MP Michael Woodhouse and National's No 4-ranked Steven Joyce regularly state the city is too negative.

They seem to believe the future of Dunedin is being undermined by pervading negativity.

To a degree, they have a point. Change of almost any sort is often unwelcome and obstacles put in the way.

There is a caution and fearfulness of upsetting the status quo in matters large and small.

But, whatever Messrs Woodhouse and Joyce might claim, Dunedin has too much experience of being left out in the cold not to be wary.

Too often, government or quasi government decisions have impacted badly on jobs and services.

Too often, Dunedin has had to fight to try to retain services as they are centralised in Christchurch, Auckland or Wellington.

Against this background, the South is correct to be cautious about the Southern District Health Board's draft strategic health services plan, about the effort to tackle ongoing deficits and, supposedly, improve services.

At the same time, and despite the plan largely being so general that it will be difficult to engage with, the South will need to do its best to understand what it could mean.

All sorts of questions arise, for example over the issue of sustainable specialist services.

Does this mean the South will become more an outpost of Christchurch?

The neurosurgery debate showed that what can seem like an overwhelming case for centralisation can be faulty.

It showed the value of public input and debate, which health officials seem so often keen to avoid.

And if Dunedin increasingly becomes a satellite or secondary hub, what governance safeguards will there be to ensure it will influence decision-making?

This risks empire building in Christchurch, with the original neurosurgery proposals indicating this is an ever-present danger.

And what would potentially downgrading Dunedin Hospital mean for long-term recruitment of clinical leaders to the South and for the medical school?

Dunedin, many years back, fought hard for cardiothoracic surgery.

The strategic plan states a national mandate will be needed to redirect patients to the South because of the capacity here.

Who is going to provide the leadership to make this happen?

The plan is big on community care and GPs doing more, which sounds good in theory. It can be a lot messier in practice.

The plan also acknowledges momentum was lost when the nine southern PHOs were bundled into one. Clinical pathways (agreed paths through care to speed things up for patients and to improve communication and understanding between hospitals and GPs) have been extremely slow off the mark, and Otago and Southland are behind other regions.

Again, who is going to lead the change in this area?

Healthcare operates like a large complex organism, and it's especially difficult in such a vast area like the South.

Part of the problem is lack of access to hospital services, so it doesn't really matter how many ''pathways'' there are if the next steps on the patient ladder are inaccessible, for example diagnostics.

There is discussion on cutting ''low value'' procedures. What exactly are these? Shouldn't these be decided nationally?

Even if the board is following a recognised authorities' cost-benefit analysis, the risk is that access to operations becomes even more of a post code lottery.

There are also fundamental questions about population-based funding, a mystery which some doctors believe disadvantages the South.

The system would appear to take insufficient account of servicing New Zealand's largest geographic area, and there have to be doubts that enough cognisance is given to the proportion of elderly.

They are far and away the heaviest users of health services and are found in disproportionate numbers across much of Otago and Southland.

It is too long since the system has been reviewed.

While the draft plan is a starting point, it does raise a host of questions.

Lots of issues will have to be worked through, and national as well as local leadership provided.

The South is going to have to be on guard to make sure crucial health services do not deteriorate.

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