Change needed, but caution desirable

The perceived conservatism of Dunedin’s medical fraternity is being challenged in the early planning phase of the Dunedin Hospital rebuild, health reporter Eileen Goodwin discovers.

To Dunedin's medical establishment, it was something approaching an insult, an existential challenge even.

Dr Nigel Millar. Photo: Peter McIntosh
Dr Nigel Millar. Photo: Peter McIntosh
The then new chief medical officer at Southern District Health Board, Dr Nigel Millar, was the speaker at a regular lunchtime medical forum at Dunedin Hospital.

Dr Millar joked he did not want to be a ''Canterbury bore'', a reference to how the area is held up as the poster child of how to shift care away from hospitals.

He then proceeded to talk up the changes in Canterbury, over which he presided as chief medical officer.

Dr Millar's talk was seen as a signal of where the cash-strapped and troubled Southern DHB is likely to head, especially with a hospital rebuild focusing Wellington's attention on the area.

For many listening, there was a glaring omission.

''He never mentioned the medical school once in 45 minutes,'' an irate Associate Prof Gordon Sanderson would later tell the Otago Daily Times.

The ODT spoke to several doctors who expressed similar indignation at the perceived slight.

The proud institution, the bedrock of medical care and innovation in Dunedin for 130 years, seemed of little import to the region's new top doctor.

A few days after the July 6 talk, a report emerged from the Dunedin Hospital rebuild group that effectively rebuked a group of powerful clinicians who detractors say call the shots at Dunedin Hospital and enjoy a far too privileged position.

It offended many people at the school, because, as Dr Branko Sijnja said at the time, it made their work arrangements sound ''dodgy''.

It is generally agreed the medical school attracts high-flying clinicians who would otherwise not come to Dunedin. Its backers say the DHB should hitch its wagon even more closely to the medical school.

But Southern DHB is being increasingly squeezed by a narrow health funding formula that will not do it any favours in the coming years as its population ages but does not grow much.

Vague on the specifics, the report suggested Dunedin had too much high-level care for its population. The seemingly ''opaque'' arrangements of some clinicians let them work in the public hospital and the medical school and do private work without being held to account for their time, it was claimed.

Some of the anonymous criticism conveyed in the report was from clinicians, highlighting the divisions among doctors and in the school itself.

One person told the report-writers ''all hell would break loose around the specialists'' if management of the likes of diabetes and respiratory conditions was shifted further into the community.

Modernisers say health has advanced and change should be seen in that light rather than trying to take something away. Critics say GPs have not been brought into the system the way they have in Canterbury.

Shifting services to GPs does not necessarily mean a hospital is downgraded, but the South is in a unique position in New Zealand.

Hospital services need a certain number of patients in order to run staffing rosters, meaning that shifting part of the work to general practice is problematic for some services.

One person told the ODT theatre schedules at Dunedin Hospital were dictated by surgeons performing high-end procedures, which then meant less time for general surgery.

There are numerous agendas and rifts, both within and between the entities that will have a say in the Dunedin Hospital rebuild.

Above all, no-one knows what the Ministry of Health is really planning and what impact it will have on settling the long-standing medical rows in the South, but more importantly, how it will affect patients.

Medical ego and long-standing feuds certainly do not serve patients' interest.

But while the Canterbury system is held up as the model, it has a down side.

That's because hospital services are free for patients, but GP visits are not.

''There are some different attitudes in Christchurch, there is no question about that,'' says Mike Hunter, Dunedin general surgeon and intensive care specialist.

He admires Canterbury - ''we're miles behind ... we're trying to sort of drag on their coat-tails'' - but that system can effectively exclude people. It pushes patients towards GPs and private providers, Mr Hunter says.

''There are a lot of conditions they won't treat, and they say 'you will have to go private'.''

Mr Hunter believes some change is needed to how specialist care is configured in Dunedin, especially after hours.

''I think there is a place for a shift back towards better generalist cover for acute work.

''I don't think we need to have eight different sub-specialties on call every night.

''Most of them never have to come in at night.''

A general physician could assess patients after-hours, and refer them to the right specialist in the morning.

''It's not a new debate, but I think it's got a new lease of life.

''Especially in medicine [as opposed to surgery], we have had a gradual culture of sub-specialisation here which is difficult to sustain with the size of the hospital.''

Change has to be carefully handled.

''One of the risks of turning back or changing a system ... is that the people in it may become disenchanted and angry and leave.

''And we could end up throwing out the baby with the bathwater. We could end up losing some very good sub-specialists because they see their importance and their contribution being eroded,'' Mr Hunter says.

He says a bigger rethink is happening in medicine anyway, in favour of generalist medicine, because patients present now with so many diseases.

Sometimes there is a ''fight over where the boundary is'' in respect of where a patient belongs.

''I think it does need to be tidied up. I don't think we do the patients a great service.''

One on-call specialist is Dr Ben Brockway, a respiratory consultant and senior lecturer.

Dr Brockway was surprised by the July rebuild report. The picture it painted was ''not something I recognise''.

The relationship between the two is in good shape, he believes, and allows the South to have a round-the-clock respiratory service.

Dr Brockway's service has three specialists, two of whom are jointly employed by the university.

''We do have a high-quality 24-hour a day [respiratory] service just the same as they do in Wellington, or Christchurch, or Waikato, or Auckland.

''It's not a particularly high cost to run the respiratory on-call service, and I think we provide a good service,'' Dr Brockway says.

One senior figure, speaking shortly after the July report was released, said its intention was veiled but pretty clear.

''The Crown is basically saying 'Dunedin, you can't afford, and the country can't afford, for you to have what you had in the past going forward into the future'.''

The person, who declined to be named, said hospital services in Dunedin had been heavily influenced by the medical school.

''From day one, the Otago-Southland people's view is that the public system will always look after them because the public system needed teaching material to support the educational system.''

The person was critical of some southern doctors for whom it is ''all about power''.

''Some of the names, Joe Public would probably say they are fabulous ... some of them are so belligerent against the management structure.

''It will always be a battle with some of them. Their ultimate weapon is disengagement.

''They are allowed to get away with that because doctors are still generally held by Joe Public as being on a pedestal and it's always management that's wrong and that's not the case at all.

''I'm flabbergasted by the lack of clinical leadership and innovation that appears to be absent in the DHB here compared to other DHBs.

''There seems to be something fundamentally wrong here with the doctors here in Otago and Southland.

''You have the vascular guys, that don't talk to the colorectal guys, that don't talk to the liver guys.

''There are lots of political games,'' the person said.

While reporting anonymous comment is always fraught - some would say unfair - it shows the depth of animosity in the medical fraternity.

Into all this stepped the no-nonsense Dr Millar earlier this year. The northern Englishman spent 24 years working in Canterbury.

He is described as a ''remarkably gifted individual'' by his former boss, Canterbury chief executive David Meates, who spoke to the ODT.

Dr Millar's specialty, geriatrics, is a great fit for the region.

He is fascinated by data, one of the many areas in which the South is said to lag.

Asked about the July talk, Dr Millar rejects any suggestion he intended to slight the medical school.

''I didn't set out to talk about the medical school, I was talking about an exemplar or a path ...''

Far from it being cut out, the changes were an opportunity for the medical school.

''When you are changing health systems, one of the most important things is to get good evaluation of what happened.

''The great thing about being in Dunedin for me is we get a high level of academic rigour and debate.''

On the question of whether the Canterbury model loads cost on to patients, Dr Millar says hospital visits can entail cost, like taking time off work.

''It's not as free as it looks, particularly if you have to travel a long way.

''People have to think it through a bit more, and make sure we are doing the best for patients by getting them the best treatment, as close to home as possible, obviously in an affordable way.''

eileen.goodwin@odt.co.nz

Add a Comment

 

Advertisement