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In the first of a three-part series analysing health issues, Eileen Goodwin looks behind the scenes of the Dunedin Hospital rebuild and finds there is no model for health and education to work together on hospital builds.
Flogging off bits of land around Dunedin Hospital to make up health budgets must have made sense in the 1980s and 1990s, but it set up a headache for hospital planners in 2017.
The University of Otago snapped up some of the land, beside the hospital’s Fraser Building.
With site options short, it could be the best spot for a new hospital. A central question is what the university would get for relinquishing the holding. There has been talk of a land swap, but the university will expect financial recompense for the buildings on the land.
The university is in an awkward position. It’s a potential vendor, in a way, but also a bit like a lodger, and will be expected to pay for part of the new hospital if it wants space for teaching and research. It chipped in for the cost of the ward block in the 1970s for that purpose.
Aside from bland assurances it is a valued "stakeholder", the university is kept at arm’s length from the Ministry of Health-controlled hospital redevelopment. In some quarters there are hopes of using the development to foster tighter links between the hospital and the medical school, resulting in a better-resourced hospital than the population level would otherwise support.
But health and education do not collaborate on hospital builds any more in New Zealand. Under Treasury’s business model, the university is a separate entity, with its own self-interest to pursue.
Eager to push its idea of a health-education precinct, the university also needs to be cautious about expenditure. It already has a costly programme of capital spending over the next few years, and could probably do without the cost of replacing buildings. Former vice-chancellor Sir David Skegg spelled out the dilemma in a recent Otago Daily Times opinion piece.
"This land is occupied by Cumberland and Hayward Colleges (housing nearly 500 students), not to mention the School of Surveying and the marine science department.
"Replacing such facilities could cost up to $100 million. I cannot believe the Ministry of Health would countenance such an investment before starting to build any new health facilities."
If the Government decides on total replacement of Dunedin Hospital - it is dithering about whether to replace the ward block, or just the clinical services building - the site needs to be large, preferably two hectares or even three hectares.
The ward block is less than 40 years old, but it has been affected by a lack of maintenance dating back to the time when spare bits of land were being sold off. What is almost certain is that the project’s $300 million price tag will increase.
The university has other bits of land it could proffer, but the 2ha Fraser Building block has the benefit of having no private holdings. The Cadbury factory site has been a talking point since news the manufacturing plant is shutting down.
The timing of the sale by Mondelez is unlikely to fit the ministry’s timeframe for acquiring land.
If the site was secured, the Government would probably keep some services on the current site, some at Wakari, making the Cadbury’s footprint a third Dunedin Hospital site. While the health ministry talks about perhaps basing hospital services on different sites, that is generally a way to keep land acquisition costs down, and securing Cadbury would not be cheap, so it looks unlikely.
Prime Minister Bill English told the Dunedin City Council that land cost was crucial in determining whether the hospital stayed in the central city.
His comment was seen by some as a warning to the university to make the transaction affordable, or risk losing the hospital’s proximity to the medical school.
Rebuild boss Andrew Blair has said the university’s financial contribution "depends on the extent" of involvement it wants.
But it has not been easy for the university to be involved. There has been disappointment that university chief operating officer Stephen Willis, who has a background in hospital redevelopment in Australia, is not invited to Southern Partnership Group rebuild meetings.
The politically appointed group meets each month in Wellington, along with a host of officials from Treasury, Southern District Health Board, and the Ministry of Health.
A source involved with the rebuild, who declined to be named, says there was no model in New Zealand for health and education to collaborate on a big hospital build.
Since the 1980s economic reforms, entities look hawkishly at their own bottom line, avoiding the bigger picture.
"I think the Ministry [of Health] has said: ‘Let’s get the hospital sorted first’, and I suspect they wouldn’t have wanted the university over the last six months, but I can pretty well guarantee that they’re absolutely going to have to get involved."
"I’m pretty sure the university’s going to start to make the running on this.
"When the current hospital was built, education and health collaborated on this sort of thing."
The rebuild could be a catalyst for the university to rethink its relationship with the hospital, the person said.
One option is the university building and owning its own premises to house lecture theatres, research space, and offices, instead of having dedicated space in the hospital. The university and the partnership group had only occasional communication.
"If there’s an issue that needs to be sorted out between them they’ll talk to each other.
"I think it’s more constructive if you have regular discussions so you can develop thinking as you go."
Southern doctors with an interest in the rebuild have been invited on to advisory groups which has the effect of silencing them in public, as the invitation comes with a media ban. Fifteen clinical leaders wrote to the DHB last year complaining about a lack of engagement with them on the rebuild, a concern the board says has been addressed.
Those who have not been appointed to groups are subject to the DHB’s general media restrictions. Some doctors worry that wishful notions about "new models of care" will result in a hospital that is too small to meet the needs of an ageing population.
There is also a feeling the big rebuild draws the focus away from the dire state of the hospital, particularly the clinical services building, which has to limp along for another few years. Not every doctor is hung up on the idea of a central city rebuild. Some favour a greenfield site and say they are more concerned about what is built, rather than where.
The partial sidelining of doctors is compounded by having no elected DHB board members — they were sacked in 2015 and a politically appointed commissioner installed. By default, the main Dunedin interests in the project are the university and the city council.
The city council undermined its argument that the entities should work together for the public good by entering its own commercial agreement for the possible sale of the Frederick St car park.
It has however assured the public it can pull out if need be after a due diligence period, and not sell the potentially strategic piece of land to the Accident Compensation Corporation.
Its campaign Dunedin Hospital SOS is designed to turn up the heat on the issue in election year.
The car park land could house a hospital car parking building, educational facility, or other auxiliary building linked to a new hospital.
This complicated project needs all of these publicly funded bodies — the ministry, city council, and university — to put aside narrow commercial and political concerns and work together. Hopefully, with co-operation, a new hospital is commissioned at least within the already generous and delayed timeframe of 2022 to 2025.