Medical questions confront

The Dunedin medical establishment has been challenged in a new report which takes aim at a claimed use of public sector resources for research and private work.

Released yesterday, the report was written by consultants as part of the planning of the delay-ridden $300million Dunedin Hospital rebuild.

It is the second time a strategic service report has been produced. The first, 18 months ago, cost $300,000 - but officials commissioned another one.

The other potentially controversial aspect of the report is a suggestion that some rural hospitals could do with fewer beds.

The report says some clinicians are involved with research and consequently perform "cutting-edge'' treatments that patients do not need.

It meant too many resources were tied up in Dunedin Hospital, rather than being shared across the region.

"The magnitude of this kind of impact of research upon service delivery is not clear, but there is a consistent message from a number of stakeholders that some of these effects are seen in Dunedin.''

For hospital-based clinicians, their "primary orientation'' must be public health services, even if they also work for the University of Otago or in private practice, the report says.

"Overall, there is an impression that there is not clarity in where time is spent and in particular what is happening to the non-clinical component of paid DHB time.

"In some cases it was felt that these issues were exacerbated by the additional private practice load of senior consultants.''

Submitters, quoted anonymously, warned that changing things would be hard. One submitter talked about the existence of "several distinct tribes'' within southern healthcare.

Another said "all hell would break loose around the specialists'' if management of the likes of diabetes and respiratory conditions was shifted further into the community.

"The capacity to make change happen in the Southern DHB and in Dunedin in particular is less than in other DHBs,'' the report says.

"The medical staff are committed in several directions, with some having commitments to private clinics and teaching appointments as well as working in or around the hospitals,'' the report says."A clinician's feedback indicates the perceived or actual conflicts of interest and opaque allocation of time by colleagues are both issues needing to be addressed,'' the report said.

In some wards Dunedin Hospital operated a more specialised model than was "the norm'' elsewhere.

The report suggests rural hospitals are "incentivised'' to hold on to bed numbers under their contracts with SDHB.

"The levels of [need] managed in these beds is appropriately lower than we would expect to see managed in Invercargill and Dunedin and likely these patients would be managed in the community in many areas of the country with equal or better results,'' the report says.

Lack of progress in "decentralising services'' was because of a fear of "stranded overheads'' in Invercargill, and the desire to preserve patient numbers in Dunedin.

Association of Salaried Medical Specialists executive director Ian Powell was annoyed by the report when contacted for comment.

He believed the criticism over non-clinical time was "simply wrong''.

"It's a red herring in terms of the redevelopment of the new hospital. It seems to reflect some other rather petty agenda.''

Doctors had a specific entitlement under their public health employment agreement to undertake clinical audits, mortality reviews, and professional development as part of non-clinical time, Mr Powell said.

"[The report writers] are perpetuating a negative ill-informed leadership culture in the district health board.''

He believed the clinical research issue was exaggerated.

Chief executive Carole Heatly said she hoped the report sparked a debate. She said use of clinicians' time was an issue, but she did not think it was a problem "across the board''. She declined to say whether she believed the issue had been overstated.

Ms Heatly expects the rural hospital issue to be controversial, but she did not think they had anything to fear.

In a press release, Southern Partnership Group chairman Andrew Blair said the plan looked at future population and demographic forecasts, and "considers challenges and potential solutions at a high level''.

The report included input from SDHB, the University of Otago, Otago Polytechnic, and the region's primary health organisation, said Mr Blair, who was appointed to lead the group that oversees the rebuild.

Health sciences pro-vice-chancellor Prof Peter Crampton released a short statement in response to a request for comment, saying the report raised "important points'' for discussion.

Dunedin North MP David Clark said the report contained some interesting perspectives, but gave no sense of what kind of facility might be built, and did not look at the board's underlying funding problems.



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