Patients’ needs first, commissioners say

Commissioner Kathy Grant. Photo: ODT
Commissioner Kathy Grant. Photo: ODT
Ongoing criticism of Dunedin Hospital and the Southern District Health Board has prompted SDHB commissioners  Kathy Grant,  Richard Thomson and Graham Crombie to write this public response.

We hear and are aware of serious concerns from the members of our community around access to healthcare. We sincerely apologise to those whose wait for treatment has been too long, and acknowledge the impact this has on your lives. 

Thank you for sharing your stories, and reinforcing why a high-performing healthcare system is essential for our people.

The issues raised recently have led to much discussion of the relationship between money and outcomes in the health system. It’s an important point - and money indeed matters - but it risks being oversimplified.

Richard Thomson.
Richard Thomson.

As the commissioner team, we have committed to securing a long-term, sustainable future for Southern DHB. This means placing the needs of patients at the centre of what we do. We live in this community, and know the importance of first-class healthcare for us all.

It is true that when the commissioner team was appointed there was a serious concern about the board’s deficit. But more than that, there was a lack of confidence that the board really understood its deficit. Access to data and analysis was limited. It couldn’t answer the "please explain" questions from the ministry. The former board  -  and then the commissioner team  -  truly didn’t know what we didn’t know.

If we had wanted to reduce our deficit quickly, we could have done that - by simply reducing services. But we knew that was not the right answer. The commissioner team took a view from the beginning of our tenure that we were not prepared to slash and burn and that the focus had to be on maintaining and/or growing services by removing waste, not services.

So we made the case to the Ministry of Health that we would commit to progressively bringing down the deficit in manageable steps, while at the same time investing in the building blocks that would enable Southern DHB to improve its services and be sustainable in the long term.

Graham Crombie
Graham Crombie

Just as the challenges facing the DHB did not surface overnight, we knew they would not be quick to resolve. There would be progress, and hurdles.

Part of our role over the last two years has been to turn over a lot of rocks and some of what we have found under them has not been pretty. We have responded to each of those in a proactive way. Where it is clear that additional resources are required, we have been prepared to spend them. This has been seen in our commitment to investing resources to address the significant backlog in ophthalmology services and our agreement with clinicians to spend significantly more on ICU staffing, as examples.

During the first year, our performance against ministry health targets went up, and our deficit went down by the agreed amount. And many initiatives were launched, including an important programme to build a stronger internal culture based on a strong understanding of patient priorities.This second year has also seen important successes, including improved performance against our Faster Cancer Treatment target. But there are real challenges, including around meeting specialist services and elective surgery targets in some areas.

Losing 1500 outpatient appointments and 179 elective surgeries to strike action was a setback, but not the full story. Again, what has been exposed is some variable practices in some services, and the sensitivities of a hospital system that operates in such a finely balanced environment that a challenge in one area (such as beds being full)  affects  another (such as the ability to  use  theatre time).

Would throwing money at this problem solve it? Yes and no.

Where the answer is yes, we have. This includes adding an extra ICU bed to support cardiac surgery and approximately $15 million of capital expenditure - supported by the Ministry of Health - to upgrade the ICU/HDU facilities. In addition, the commissioner team approved a significant increase in clinical staffing in this area (progressively increasing medical staffing by 80% and nursing by close to 40%) to secure better patient outcomes. We are investing in a medical assessment unit to provide more appropriate care, especially for our older patients presenting at ED with multiple medical conditions. All these investments, of course, take a while to put into practice and for results to be visible.

But it’s not just about money, and if we simply throw more money at something without fixing what we find to be wrong then we will be wasting resources that would provide healthcare for others. A prime example of this is our urology service. As we became aware of mounting problems in urology, we also realised that  while some of that was about resources and we will need to invest, some of it was also about the way we work. To evaluate those issues we asked urology experts from outside the DHB to review what we do; we will release that report publicly.

Even as we plan to bring the deficit down further this year, we have included more than  $6 million of new investment in the 2017-18 budget to continue to reshape our health system.Again, this means looking at the health system as a whole. How can we support primary care better so our people are less likely to find themselves waiting in ED, or spending days in hospital beds? This is not about alleviating pressure in the hospitals, but doing what is right for our people. This is why the investments we have made in past years, and have budgeted for the future, include:

Clinical pharmacists, to help manage the care of those on multiple medications to reduce the risks they face, including higher incidence of falls and loss of cognitive function;

•  Launching HealthOne, a shared patient records system, so health providers in the South Island can see important, life-saving information about our people, including conditions, test results, medications and any allergies they may have;

• HealthPathways, to ensure greater consistency and clarity in how conditions are managed in both primary and secondary care;

• Primary and Community Strategy and Action Plan, to increase our efforts to provide more integrated care;

• Developing our telehealth services so patients can avoid travelling for some specialist appointments;

• Medical Assessment Unit:   to provide a more comfortable, patient-centred facility to assess people with multiple medical conditions,  particularly our older patients, enabling them to avoid long waits in ED;    

• Increasing theatre capacity through lengthening the theatre day, adding additional weekend lists and working on productivity initiatives;

• Improving our facilities. As well as the development of the ICU/HDU suite and gastroenterology facilities now under way, we have celebrated the opening of the new audiology unit at Wakari Hospital, a new education centre in Southland, and the installation of a new MRI scanner in Dunedin. Plans are in place to refurbish and improve Lakes District Hospital in Queenstown. And of course, we have focused on the planning for the redevelopment of Dunedin Hospital, with the Indicative Business Case now completed awaiting Government’s approval which is expected imminently;

• Establishing a Community Health Council to ensure the voice of patients and the community remains at the centre of what we do;

• Developing leadership and a strong internal culture at Southern DHB through our Southern Future programme of work. This is essential, and at the background of our future success. None of the challenges we face can be addressed by any individual, or only by clinical staff, or only by management. But there is great power in the collective capability of our 4500 outstanding staff, when we work together.

We continue to face some significant limitations as a result of a very old and unsatisfactory hospital, and we cannot change that overnight. But we have been prepared to invest as a way of coping as best we can while we wait for a new facility.

Is there enough money? Never. Could we use more? Of course. But we are playing the hand we have been dealt and believe the investments we are making will improve the overall service the people of our community receives. Just as importantly, rebuilding the systems and processes at Southern DHB means  when we do look at our resources, we will have confidence that they are making the greatest possible difference to the people we serve.       

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