Health has hit the headlines as rural communities are concerned about Southern District Health Board cuts to rural hospitals. Health reporter Eileen Goodwin looks at the issue.
It's a sight dreaded by politicians and Wellington officials - well attended public meetings called in response to threatened health service cuts.
About 1700 people attended meetings in Wanaka, Cromwell, and Alexandra last month, where Central Otago Health Services Ltd (COHSL) has been particularly vociferous in opposing a funding cut to Dunstan Hospital.
The region's rural hospitals are in the Southern District Health Board sights as it tries to urgently remove a $42 million projected deficit in 2015-16.
Negotiations are fraught, the process described by Clutha Health First chief executive Ray Anton in an interview last week as having ''gone haywire''.
Rural hospitals were taken by surprise just months after the board said they would play a bigger role.
It is understood the board has been forced into short-term cuts which did not fit the strategy it embarked on after public consultation last year.
Ironically, the cuts have sparked debate the board had said it hoped for during that consultation.
What little comment the plan generated tended to focus on its bureaucratic language, and the board subsequently issued a plain English version.
With the spectre of real service reductions in outlying areas, the spotlight has turned on the beleaguered health board and fingers of blame are being pointed.
Rural doctors have blamed Dunedin Hospital for using up resources, while rural National MP Jacqui Dean maintains the board is not spending its money correctly.
The board has been in a public row with Dunstan over its funding, the entities disagreeing over whether COHSL has had much of an increase in real terms.
Patients in outlying areas have complained they already pay more, because some places do not have free emergency care.
The board supports a high-level teaching hospital in Dunedin with sub-specialties serving a relatively small population.
The South's population growth has fallen behind the national average, which is contributing to the board's funding crisis, because health is largely funded on a head count.
Perversely, areas bucking the trend, like the one served by Dunstan Hospital, could to be hardest hit by cuts, despite a growing population.
At the Wanaka meeting, doctors, including Dunstan Hospital clinical director Dr Rob Visser, reportedly drew applause for suggesting cuts to Dunedin Hospital emergency department and specialist services.
In his presentation, Dr Visser suggests a shift away from ''unsustainable'' specialist health services, and towards a rural generalist model that suits the South's population and geography.
But the 2010 neurosurgery campaign demonstrated wide regional support for maintaining access to highly specialised services, so downgrading Dunedin Hospital would also be resisted.
The delayed plan to rebuild Dunedin Hospital, the design of which will determine the shape of health services for a generation, means no-one knows what the future holds.
Big questions remain unanswered, but in the meantime the board is scrambling to balance next year's budget to the satisfaction of its Wellington funders.
In an interview on Friday, board chairman Joe Butterfield said the board would target its own services with further cutting, and would not rule out job losses.
''We will not get [the deficit] down substantially by just attacking, if that's the right word, the rural hospitals.''
Many people are still upset by the decision to outsource hospital kitchens for 15 years, approved last month, despite strong public opposition.
It will see many meals trucked from Auckland. The same plan was last week thrown out by Hawkes Bay DHB.
''We're going to have to upset people, unfortunately, if we're going to cut our deficit.
''Given the attitude we've experienced in the past, over the physio pool and over the food, I can't see how we will be able to do anything without upsetting people,'' Mr Butterfield said.
Public resistance would be managed through how changes were communicated.
''It depends on how well we sell the changes that are going to be necessary.
''If we don't sell it well, people will be unhappy. If we do sell it well, they won't.''
Mr Butterfield's departure from the role was announced in February, after Health Minister Dr Jonathan Coleman decided it was time for someone new.
However, no appointment has been announced, prompting speculation no-one wants to the job at a time of unpopular decision-making.
Mr Butterfield declined to comment on the matter, saying he would serve as long as necessary.
Dr Coleman's office last week told the ODT there was still ''no update'' on a new appointment.
Someone well acquainted with community disquiet over health services is Dunedin man Simon Smith, who is running a successful social media page with more than 13,600 ''likes''.
Mr Smith and his social media followers' ire has been gradually shifting away from the board and towards the Government.
''These guys are the fall guys who are told what to do by the big boys on a budget that is far from achievable and get no support from the guys at the top whilst receiving bad reviews from the public,'' Mr Smith told the ODT.
The shift was helped in part by board member Richard Thomson, who answered questions, many of them hostile, on the Facebook page after the unpopular kitchen outsourcing. He urged questioners to consider the board's desperate need to save money.
''A lot of people are quick to blame the SDHB and I am guilty of the same charge, but as I speak to the more experienced people and listen to their views and tough decisions they are in, the more I see that some people are in a hard place,'' Mr Smith said.
He took a dim view of an element of ''personal attack'' aimed at health board chief executive Carole Heatly over her salary and other matters, and has blocked a few people from the page.
''The SDHB are not monsters. They are people with a job, trying to do their job on a string budget that hasn't grown with inflated prices.''
Mrs Dean, dealing with Waitaki constituents who no doubt remember the 1990s rural health cuts, is understandably reluctant to let the focus shift from the board.
She praises the efficiency of the rural hospitals, three of which are in her electorate, and believes the board is not spending enough in areas with growing population levels.
''We [in rural hospital areas] are being expected to pay for the mismanagement of the Southern District Health Board.''
She is lobbying senior colleagues behind the scenes, but does not accept the Government is under-funding the board.
Mrs Dean has accused the board of a ''panic reaction'' after not managing its funds properly.
However, the board has hardly been making decisions in Dunedin without close oversight.
Intensively monitored for years by the Ministry of Health, it has also had a specially-appointed Crown monitor since its inception in 2010.
''What's pretty obvious here is the measures that have been put in place aren't getting the desired result,'' Mrs Dean said.
Mr Anton, of Clutha Health First, told the ODT the organisation would give some of its surplus money back to ''subsidise'' the board.
Surpluses reflected Clutha First's efficiency, and were ideally invested in local services.
There was confusion a couple of weeks ago when Ms Heatly told two of the Central Otago meetings that Clutha had reached agreement with the board.
It had not, but the two are getting close to that point, Mr Anton said.
''I don't normally negotiate contracts in public. So this has all gone haywire. Not from our doing, we wanted to just deal with them one on one.''
A board spokesman said Ms Heatly could not be interviewed for this story, because of the negotiations.
