WILD CARDS: The rural hospital conundrum

During his travels as manager of Mobile Health, Mark Eager finds rural hospitals can be a bit like apple pie.

“Crispy and crunchy on the outside but, when you poke your finger into it, it’s frozen in the middle,” Mr Eager says. In other words, nothing is quite as it seems.

Rural health providers should aim to develop and put forward their own ideas for improvement

“Some of the DHB ones are well run, but it depends on the DHB and, in some areas, you get them arguing down to the cost of an evening meal – that’s the level of detail their contracts go to.”

Mr Eager has had 10 years at the helm of Mobile Health, which sends a mobile surgical bus and other services coun­trywide. He says rural hospitals’ fortunes have fluctuated, and went through a decline in the mid-2000s.

He is heartened that residents of some towns are taking greater ownership of their hospitals.

Dunstan Hospital in Clyde is probably the best example, he says. It’s owned by a trust, with highly motivated trustees, has a wide range of services, and is doing “really well”.

“Arguably, that could be because it’s an easier area to re­cruit to. In central Otago, you have the work–life balance, there are ski fields and the wine, compared with places like Taihape, where it is an old hospital, in constant battle against the DHB and with a declining population.”

Rawene Hospital in Hokianga is another example of a great rural hospital, part of a thriving rural area, and loved and owned by the community.

Mr Eager is “blown away” by the huge range of business models used across the rural hospital landscape.

“If you look at Southern [DHB], for example, there’s just about every variety of rural hospital there, from DHB to trust-owned and they’re all run slightly differently.”

Queenstown rural hospital doctor James Reid says the old adage, “if you’ve seen one rural town, you’ve seen one rural town” rings true for rural hospitals. No two are the same; no two provide the same range of services, Dr Reid says.

And that’s both a weakness and a strength.

Regions can set up the local health systems that suit them, but they lack national consistency for dealing with the prob­lems most troubling to rural health practitioners and academics, and rural communities themselves – workforce and resourcing.

Amid the Government’s pending health and disability sys­tem reforms, the future for rural hospitals remains unclear.

For a start, would-be reformers will find rural hospitals hard to define, because the definition of “rural” in health circles is fraught.

New geographical classifications of rural and urban for health purposes are sorely needed, say two stalwarts of rural health research, Garry Nixon and Ross Lawrenson. They’re working on new definitions.

Dr Nixon, associate professor in the department of rural health and general practice at the University of Otago, says there are at least 16 different ways to define “rural” in New Zealand, making it impossible to compare data on popula­tions across time and between studies.

RNZCGP president Samantha Murton says the college defines rural hospitals based on a combination of factors, such as size, location, service provision and distance from a major hospital.

By this definition:
•Whangaroa, Te Aroha, Morrinsville, Ōpōtiki, Te Puia Springs, Stratford, Taihape, Kaikōura, Ma­niototo and Chatham Islands have Level 1 hos­pitals; they have visiting medical cover.
•Rawene, Dargaville, Matamata, Te Kuiti, Wairoa, Dannevirke, Tākaka, Buller, Reefton, Gore and Balclutha have Level 2 hospitals; they have on-site medical cov­er during normal working hours.
•Kaitaia, Thames, Tokoroa, Tauma­ranui, Hāwera, Greymouth, Ashbur­ton, Ōamaru, Queenstown and Dunstan have Level 3 hospitals; they have on-site 24-hour cover.

Most of those hospitals are owned by DHBs. Exceptions in­clude Te Puia Springs (iwi-owned), Ōamaru (trust), Balclutha (com­munity) and Dunstan (trust).

Many are staffed by rural hospi­tal doctors, a breed of generalists trained under their own division of the college and apt to be under-appreciated (see “Who’d want to be a rural hospital doctor? (Me!)”, opposite).

Professor Lawrenson, professor of population health at the Univer­sity of Waikato, says that where ru­ral hospitals will sit, and what their role will be in the reformed health sector structure that’s starting next July, are crucial questions.

With DHBs dissolved, and new Crown entities Health New Zea­land and the Māori Health Author­ity, community and primary health services will come under locality networks which are yet-to-be created. Rural health leaders say they’re hopeful these will lead to greater integration and collaboration of services. It’s not clear whether DHB-owned rural hospitals will be transferred to Health NZ, or become part of locality networks where, it’s speculated, communi­ty-owned hospitals may be funded.

In episode 10 of System Fix, a podcast series from New Zealand Doctor Rata Aotearoa, Dr Nixon says part of the prob­lem is a lack of data highlighting the differences between rural and urban areas within a region.

“We know these differences are likely to be larger than those between DHBs.”

With health services currently siloed along “urban lines”, locality networks, with rural hospitals and community health at the centre, could be really helpful, he says.

Former NZMA chair and Wark­worth GP Kate Baddock suggests, on System Fix, one entity that brings together local iwi, hospital and primary care alongside its community, would remove barriers and seat all providers under the same structure at the same table.

This would mean “devising a plan looking at their own health need, then taking that up to the regional division”, Dr Baddock says.

Martin Hefford is the long-serving chief executive of great­er Wellington regional PHO Tū Ora Compass, and has been seconded to the Health and Disability System Transition Unit in the Department of the Prime Minister and Cabinet. Also speaking on System Fix, Mr Hefford says prototypes of different localities will be run in the next two years, and will include ones built around similar communities. They won’t all be based on geographical boundaries.

With an interim Health NZ to be running by September, he says rural health providers should aim to develop and put forward their own ideas for improvement.

Speaking to New Zealand Doctor from the east coast of the North Island, chief executive of Ngāti Porou Hauora PHO Rose Kahaki says discussions with other rural health groups have highlighted the importance of “not standing alone”.

Ngāti Porou Hauora runs seven community clinics across the region as well as the rural hospital at Te Puia Springs.

The country’s only iwi-owned and operated hospital, it serves a small, isolated community with a high proportion of Māori and high deprivation.

Ms Kahaki says it needs to become part and parcel of a “wider network”, like a locality.

“Every rural hospital is on its own to bargain and recruit for staff, and they’re not equally resourced,” she says. “We need to be collective in our approach to raise a larger voice.”

She would like to see medical students and registrars get a lot more experience in rural healthcare, and says rural doc­tors also deserve equal pay with their peers elsewhere.

Not being able to offer the same wage as a DHB puts Te Puia Springs Hospital in a precarious position. Of the eight full-time equivalent doctors based at the hospital, two are permanent and the rest are locums or contractors.

“Working in rural areas is not glamorous or attractive when you can make far more money [elsewhere].

“We need doctors who can do harder work, in a higher poverty bracket for longer hours, and be committed to whānau, all for less pay.”

While not entirely convinced Health NZ will solve all these issues, Ms Kahaki wants to believe associate health minister Peeni Henare when he says all New Zealanders should have access to the same care no matter where they live.

For Mr Eager, the reforms are a once-in-a-generation opportunity for change.

He has been impressed by the work of the Transition Unit, whose team members seem “really keen” to get this right for rural, and have been regularly meeting with rural groups.

“They’re truly asking for consultation, which I’ve never seen before, and saying some bold things. They know they won’t please everyone, and so they’re saying ‘how about we write the plan together?’”

A hospital like the one in Taumarunui, currently run by the DHB, could become the hub of the community if it ex­isted in a locality with shared services, says Mr Eager.

Add mobile services, like the surgical bus, to the equation and the sky is the limit, he says.

“Mobile diagnostics…cost a little more but overall, if you’re catching people early, it’s a good example of being able to get out there and do it.”

The benefit of a mobile surgical service is that it shares the latest equipment across communities that can’t always afford their own – by literally bringing it to their doorsteps.

What matters to Professor Lawrenson is addressing fa­cilities and service provision.

In Waikato, rural women have been bypassing local ma­ternity services that are “not that flash”. In Thames, births dropped to about 50 a year until a brand-new facility brought the numbers back up to more than 100 a year.

Te Kuiti faced similar issues, downgrading its primary birthing unit to a maternity hub after women chose to birth at a new birthing unit in Te Awamutu, or in Hamilton.

“In general, not a lot of money is spent on infrastructure [in rural healthcare],” Professor Lawrenson says.

Many buildings date back to the 1970s and, though they may be well equipped, they are still old buildings modified for new uses.

“We need to get rid of the postcode lottery: in Dunstan you can get a CT scan, but not in other areas.”

Professor Lawrenson points out healthcare demand changes, depending on communities’ changing needs.

“Lots of populations are ageing rapidly, so they might not need a birthing unit, but they need palliative care and elder­ly care. If you’re 80 and have a fall, you don’t want to be 80 to 150km away from a hospital, so you need beds locally.”

The man on the spot in Balclutha is Ray Anton. Mr Anton is chair of the Rural Hospital Network and chief executive of Clutha Health First, the organisation that runs Balclutha Hospital. For him, the glass is half full.

Ideally, rural hospitals need to be a part of localities, “not part of a DHB or Health NZ, or a district office”, he says. He hopes Health NZ will fund the health sector more “honest­ly and transparently”.

“The model of funding is broken. With DHBs that are losing money, this makes them even less willing to re­lease resources to rural, and services like primary mater­nity are hugely underfunded.

“Make the money follow the patient, find out what the best solution is for the com­munity and the patient, and eliminate the payment question,” Mr Anton says. Integration with primary care since 1998 has allowed Balclutha Hospital to build a “really nice model”, which redistributes staff and funding based on the needs of the community, he says.

“We always ask ourselves, ‘is there a need in the commu­nity that needs addressing?’ And, if there is, what does that need look like, how do we develop a service to address it, and who will pay for it? It either comes from the DHB, [pri­mary care] capitation, the patients themselves, or ACC.”

Rural hospital doctor Jeremy Webber, who works at Taupō Hospital, says that with health reforms coming around once in a blue moon, ensuring the rural voice is not lost in the mix is imperative.

Newly appointed by the NZRGPN as clinical directorrural health, Dr Webber hopes to give the rural sector appropriate representation among decision-makers.

Dr Reid, who works at Lakes District Hospital in Queen­stown, is deputy chair of the New Zealand Rural General Practice Network (NZRGPN). He admits change is “always scary”. But he says the health reforms will help to address equity issues by allowing the sector to be adequately re­sourced, and rural health professionals to work at the top of their scope and in coordination with other services.

The health sector is used to restriction, reduction, servic­es being used to fill gaps, and some areas having to go with­out, says Dr Reid.

But locality networks provide the tantalising prospect of being able to coordinate services locally, developing new services and supporting the training of rural health professionals.

LAST YEAR, WEST COAST DHB proposed staffing Greymouth’s Te Nikau Hospital mainly with rural hospital doctors, and supported by specialists in Christchurch.

An outcry ensued.

The DHB saw its plan as a long-term solution to reduce the West Coast’s high reliance on medical locums, ensure more senior doctors work in general practice, strengthen continuity of care and improve sustainability.

The senior doctors’ union, the Asso­ciation of Salaried Medical Specialists, was not happy. An ASMS research brief, published earlier this year, says there is no evidence to support the model at this stage; the hospital’s mixed model including a range of specialists is a better fit for a remote setting like the West Coast.

“While rural hospital medicine spe­cialists are trained to deliver a broad range of services, we suggest that lim­itations on their scope of practice re­quire other hospital specialists to be working on site to ensure the safe, high-quality service provision expected from a secondary hospital in a remote location,” the brief says.

The DHB, which had tested the idea well with local people, won the day. West Coast DHB’s clinical director Brendan Marshall, who rejects ASMS’ criticism, says the model is working and has created a more stable workforce.

Dr Marshall practises as a GP and also as a rural hospital doctor in Grey­mouth. He says a key goal has been to improve obstetrics and maternity services in the area.

Previously staffed by two specialists, the hospital now has six doctors, with no extra full-time equivalent positions needed. It’s “cost neutral”, he says.

Two staff members are based in Christchurch, while one specialist re­mains based at Te Nikau Hospital along with the three rural generalists, includ­ing Dr Marshall, who can work in ob­stetrics when needed.

Andrew Morgan, chair of the RN­ZCGP’s Division of Rural Hospital Med­icine, says the new West Coast model is potentially a good one, especially if the rural hospital doctors have extended scopes of practice.

New Zealand is churning out plenty of sub-specialists but not enough gen­eralist doctors, Dr Morgan says.

This creates immense challenges in recruitment and retention in rural areas, he says.

Staff turnover is high in most rural hospitals, including where Dr Morgan works at Wairau Hospital in Blenheim.

“No one wants a locum-based ser­vice: an over reliance on locums and in­ternational medical graduates is not associated with good outcomes.

“It’s stressful and lacks continuity of care,” he says.

“The current models are not work­ing.” For example, presentations to hospital on the West Coast show there isn’t much work in most of the second­ary care-level specialties.

“But truly recognising generalism in rural hospitals as a strategy going for­ward will provide much better care,” Dr Morgan says.

Queenstown doctor James Reid says rural hospitals have long been a threat­ened species.

Under-staffed and under-equipped, they have been seen as a “backwater”, especially as health services became more centralised during the health re­forms of the 1990s, says Dr Reid.

He says the rural hospital medicine programme has made a big difference to Lakes District Hospital in Queens­town, where he is based. It has built up to being fully staffed, with 10 full-time equivalent doctors.

The programme, created in 2008, had 26 registrars in 2020 and has 28 this year.

The former chair of the RNZCGP ru­ral hospital medicine division, Jennifer Keys, attributes the increase to having a specific training programme that lift­ed the visibility of rural medicine.

The Medical Council’s most recent workforce survey shows a big leap in the number of rural hospital medicine specialists, from 26 in 2010 to 120 in 2020. (Of these, 52.9 per cent are inter­national medical graduates.)

Balclutha Hospital, run by commu­nity organisation Clutha Health First, is one still relying on international medical graduates and locum staff, waiting for the effects of the training programme to kick in.

Clutha Health First chief executive Ray Anton says Balclutha is an attrac­tive environment, an hour from Dune­din and with the Catlins “just down the street”. So Mr Anton is baffled by how hard it is to find clinical staff – a chal­lenge he has grappled with for the past two decades.

“It’s my suspicion that there are not enough graduates, and they want to go to a place which already has a number of rural hospital doctors.

“We need to build a critical mass, and it’s hard to get started.”

Mr Anton has had high hopes when new rural training initiatives have been discussed in recent years. But, he says, governments “start to give it some legs and commit, then back off”.

“It’s frustrating. There’s a crisis in ru­ral health, with ageing staff, and we need to rebuild that community.”