‘Generalism’ should not be cost-cutting option

Will Dunedin Hospital retain the ethos of being a teaching hospital? Photo: Getty Images
Will Dunedin Hospital retain the ethos of being a teaching hospital? Photo: Getty Images
The Southern District Health Board’s proposal to adopt ‘‘generalism’’ at Dunedin Hospital raises plenty of questions, writes  Gil Barbezat.

The ODT (4.1.20) article on ‘‘generalism’’ in Dunedin Hospital raises many important points.

Having received my undergraduate and some postgraduate training in a hospital with both strong generalist and academic traditions, I am very conscious of the many opportunities and benefits provided by a generalist system.

However, as the article indicated, that system also has many potential traps.

The clinical benefits of having a generalist service greatly outweigh the pitfalls, provided the system is integrated into a well co-ordinated and balanced health delivery service. If it is just a cheap option to ensure short bed stay at low cost, it will fail miserably.

Where the primary aim of American ‘‘hospitalists’’ was to have the shortest admissions with the lowest cost as primary focus, the standard of patient care was significantly compromised.

If ‘‘generalism’’ is viewed as a primary system where most patients are triaged and managed from a generalist base, with some referred for tertiary opinion or management only when indicated, that works well.

The aim is to treat patients with dignity, not bodies with pathology. But that begs the question of how much tertiary presence is required to maintain the efficacy of that balance?

Presumably Dunedin Hospital will remain a tertiary referral centre required to deal with the growing 250,000 plus population of our region. Not all specialist procedures can be performed everywhere, so some centralisation will have to continue.

Christchurch is already a centre for some specialties
(e.g. paediatric oncology), and Auckland for others (e.g. liver transplantation). But how much needs to remain in Dunedin, and how will that be integrated into the generalist system?

Tertiary expertise must be retained in medicine (e.g. aged care, cardiology, endocrinology, gastroenterology, neurology, oncology, respiratory medicine and rheumatology) and also surgery, (e.g. ENT, colo-rectal, general, ophthalmology, orthopaedics), paediatrics and o&g. We could argue about the priorities, and how those services would be provided and where. Each bears a cost structure, but dire consequences if not available.

Southern DHB has the additional significant challenge of integrating the Southland service into the team.

A notable and ominous omission from the article, were key words such as teaching, learning, training, research, Medical School and Polytechnic.

Unless these activities and institutions are incorporated into the planning of the new hospital and the way it is planned to function, it will not fulfil its requirements. That is unless any pretence to preserve teaching and research activities is being abandoned in the rush to save costs. If that is true, transparency of the process must be clear in all further negotiations.

If academic requirements are recognised in future planning, integration of clinical care with training of our country's future medical workforce is essential.

A previous detailed study confirmed that the DHB and Medical School were of mutual benefit to each other.

In short, will we retain the ethos of being a teaching hospital? Staffing quality, numbers and distribution must be compatible with these requirements. From my experience, the benefits to teaching and learning in a generalist environment are immense; however, they also require the back-up of expert tertiary care to fulfil the required teamwork of modern medical practice. A rapidly evolving health environment benefits greatly from a flexible modern teaching hospital environment.

But how would this new system be staffed, and at what level?

More than one specialist is required for each specialty, provided all medical staff work as a unified team. Ideally, some of these specialists would also work as generalists. Research, though important, has become the territory of a select few. Teaching warrants greater shared responsibility in hospital practice.

The late Prof A. John Campbell (previously Professor of Medicine at Otago and also Chair of the NZ Medical Council) proclaimed that it was a Hippocratic responsibility of all medical professionals to teach their art and science.

As students, we were taught by both generalists and specialists. Obviously, some had a much greater responsibility and ability than others, but there was a clear ethos of life-long learning among all students and staff. We worked in an atmosphere of positive co-operation.

Funding of our health services will eventually determine what is possible.

Viewing the requirements of medical practice and medical education together as integral parts of the delivery of quality healthcare in our teaching hospitals will yield the most productive long-term results. Integrating these factors into the planning of a new teaching hospital creates the potential to deliver the highest level of current and future care to our community.

Sadly, this integration has not been part of our New Zealand health system in the past, but are we not being asked to do things differently to achieve better results? Is this a realistic vision, or will a political straitjacket and restrictive funding formula continue to keep us from developing the teamwork required for effective health delivery and education?

Gil Barbezat is Emeritus Professor of Medicine and was previously head of the gastroenterology service.

Comments

The decisions about what services will be offered at Dunedin hospital are far more important than those about the size shape and design of it.
The shambles around maternity care in the south has already shown on a small scale the risk and tragedy that can occur when people need to travel for medical care. This cannot be allowed to magnified with people being forced to Auckland or other "centers".
If designers are close to a final size and design of the hospital, then they are working to a plan of services to be delivered. We need to be told the truth of planned services now. No more excuses, tell us the truth today.

I think both Gil's and KeithMcC's comments above are very pertinent even if I quibble about some of the finer points. The design of the hospital is absolutely predicated on what services are to be provided and the bricks, mortar and concrete are frequently a red herring which fixates minds on "what we had". If "what we had" is no longer fit for purpose what should we realistically be providing to subserve the WHOLE DHB and its geography coast to coast. This will mean examining the clinical and fiscal viability of any number of services as they are being provided currently. I am a great fan of generalism and I have come to this conclusion despite once being a niche subspecialist. In my view there is far too much dependence on single organ "ologists" as the complete picture is often (tragically) overlooked. There is far too much weight given to the number of beds question. The questions should start with How do we best provide a service to the benefit of the consumers? and devolve as much care as possible to a community infrastructure. In terms of DHB budget in some regards this may be more expensive than the current centralised model but makes health economics sense. More anon.

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