Southerners encountering the tyranny of the majority

Dunedin surgeon Mike Hunter, in the final part of a six-part series, uncovers the political machinations and motives behind the processes geared towards removing neurosurgical services from the South, and glances to the future. Mr Hunter is clinical leader in intensive care at Dunedin Hospital and responsible for rescue helicopter medical retrieval.

• Manipulation of the process
As a clinician, I was not directly involved in the early part of the process undertaken by the South Island District Health Board's group in discussions over the South Island Health Services Plan until it became apparent that there was a major threat to our neurosurgical service.

Since that time, I have had the opportunity to examine the political manoeuvring and several interesting observations arise.

The first is the process of getting the Otago (Southern) DHB representatives to agree with propositions that were essentially "motherhood" statements, as exemplified by:"The South Island District Health Boards (DHBs) have agreed to the development of a South Island Health Services Plan, recognising the need to collaborate to support sustainable health and disability services for the population of the South Island.

"The South Island DHBs agree that access to timely and accessible health and disability services, of a high quality, is a right that all New Zealanders have regardless of where they live."

Then began the process of manipulation of that agreement which had two main thrusts, the first being the attempt to establish unquestioning acceptance that a unit in Dunedin was neither viable nor sustainable by constant repetition of the assertion as if it were a self-evident truth, which would then lead to the unfortunate but inevitable conclusion that all the services would just have to be in Christchurch:

"Services will only be accessible if they are sustainable. Services will only be sustainable in the medium to long term if they are of a high quality and reflect contemporary evidence-based practice. The correct balance of accessibility, quality and sustainability may be difficult to achieve when determining the optimal configuration of health and disability services across the South Island, as is the case throughout New Zealand.

"This dichotomy ultimately results in the need to balance demands of local provision of services in an unsustainable environment with that of centralised services which are of high quality and viable but may be less conveniently located for patients in the regions."

The second was the great emphasis placed on the importance that all the DHBs had to support whatever conclusion was reached.

The group which produced the first report was then stacked with Christchurch representatives (at least a two to one ratio), and the report itself was interspersed with a running commentary by Martin MacFarlane. Not surprisingly, his longstanding views dominated the conclusions.

Despite being persistently unhappy with the process and outcomes, the Otago representatives who included the CEO and CMO continued down the agreed path to engage an independent mediator to try to achieve agreement.

Dr Ian Brown was unable to do so, but he did chip in with his own opinion (not part of the agreed process incidentally) which was to support the Christchurch 6-0 model.

• Attitudes of the other DHBs
Much has been made by Chris Fleming (CEO of South Canterbury DHB and chairman of the South Island planning group) of the fact that other South Island DHB CEOs supported the Canterbury model.

What needs to be appreciated here is that all the other regions have nothing to lose, except perhaps South Canterbury itself if the promised outreach from Christchurch proves to be illusory.

In terms of emergency care, the West Coast and effectively all of Canterbury drain to Christchurch anyway. Nelson and Marlborough do not. They are readily reached by air from Wellington within the hour and it is impractical and far more difficult to fly to Christchurch.

Having all six neurosurgeons in Christchurch stands to benefit all other South Island DHBs at the expense of Southerners. It smacks of a tyranny of the majority over a substantial minority just because they have the numbers.

It did nothing to convince any of us of the integrity of the process or the level at which this is being argued.

• Authority to decide
It astounds me that any of the DHB CEOs or the Christchurch lobby think that this sort of manipulation of process can force the Southern DHB into abandoning provision of neurosurgical service.

Co-operation and the formation of a single service can only work successfully by clinical agreement supported by administrative action that is sincere, generous and public-spirited. That agreement has not been reached, and it will not be until the Christchurch neurosurgeons abandon the 6-0 bottom line.

Efforts to undermine recruitment of either foreign-trained or Australasian-trained neurosurgeons to the Dunedin unit must also cease.

There is no justification (nor legal authority) for invoking central interference in the way in which the Southern DHB wishes to provide its services by either the Director-general or the Minister of Health.

To do so would be an arrogant overriding of the wishes of the people and the democratic process. Only matters of significant national interest or consequence could justify such a move.

• Where to from here?
The Expert Advisory Panel is meeting stakeholders, deliberating, and will report to the Director-general of Health, whoever that may be, in October. The constitution of the panel itself has been challenged, by me and others. The terms of reference include a statement that its conclusions will be binding.

This has also been challenged, and may well end up in court if an attempt is made to force the Southern DHB to comply with destruction of its own neurosurgical service.

The Christchurch neurosurgeons, particularly Mr MacFarlane, have a longstanding desire for a sole South Island unit in Christchurch.

I simply do not believe that the one-site service offers any improvement in quality of service, despite the numerous statements that it will.

The southern clinicians are, I am sure, willing and indeed enthusiastic to improve regional co-operation, but that can only be on a basis of mutual trust, which has been badly damaged by the actions of the Christchurch group and the behind-the-scenes machinations.

If and when there is at least an acceptance that the Dunedin unit will continue, we can start to put forward constructive ideas about how the arrangements, support, quality measures, training opportunities and subspecialty development can occur.

I believe there are some novel and daring strategies that may well work in our environment but no-one is going to put these up for discussion if there is any chance they will be picked to pieces and used as grounds for attacking the service.

To get a service that works best for our people, we may need to challenge some of the holy cows of the Australasian specialty group. That requires a united front.

If the Government wishes to bully the Southern DHB into submission on this issue, it will buy itself a fight of monumental proportions.

It will make an utter mockery of its own slogan of Better, Sooner, More Convenient and it will set a precedent for the self-interest of powerful specialty groups dominating hospital service provision.

I know that any finding that does not retain a neurosurgical capability here will not find acceptance with the clinical staff. I for one will never accept it and will go on fighting for its retention or reinstatement.

I will never give in, for to do so would be to abandon our people and their safety.


• John Armstrong's political column will run on Monday's Opinion page.

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