There have been several recent public statements from mayors and citizens of our rural or smaller town communities suggesting that some of the proposed investment in the new Dunedin hospital should be diverted to their local hospitals.
Former Central Otago mayor Tim Cadogan suggested this might include the delivery of inpatient surgery in Dunstan Hospital. This is well-intentioned but misguided thinking, as is the proposition to build a hospital with surgical capability in Wanaka.
There are cogent reasons why the surgical services in places like Oamaru and Balclutha closed down in the 1990s. It was no longer possible for two surgeons on each site to provide a wide range of surgery at a comparable level to that provided in larger centres which had become more and more specialised; acute cover was increasingly difficult; and safe provision of anaesthesia and access to intensive care was increasingly problematic.
There are only about 350,000 people in the southern region, which barely reaches the critical mass for one hospital to provide comprehensive surgical services to manage complex major trauma, for example.
We actually have two hospitals providing inpatient surgery, but only Dunedin comes close to covering the necessary bases for all emergency surgery. Southland has significant gaps, requiring transfer of patients to Dunedin or Christchurch for quite a number of subspecialty interventions and for interventional radiology.
Being able to provide adequate cover for acute surgical emergencies is the primary and most important task for any inpatient surgical service, so the ability to sustain a tolerable acute roster both for consultant surgeons and for junior staff is a critical factor.
In subspecialties where the frequency of after-hours callout is low, consultants will tolerate a one-in-three roster and even a one-in-two in some subspecialties, but it is still a substantial burden to have to be available after hours that often and is a disincentive for specialists in some services to come to the South.
For specialties in services who do a lot of after-hours work, such as general surgery, a tolerable roster is around one-in-eight or better, recognising that, because of leave requirements, individuals are actually doing one-in-six when they are not on leave.
Dunedin Hospital has eight or nine general surgeons, but that has only been possible because they are not employed full time by the public system (Health New Zealand Te Whatu Ora ((HNZ)).
Many have university appointments as part of their employment, or do some private practice, so the actual full-time equivalents employed by HNZ is about five.
Southland Hospital services a population half that of Dunedin Hospital, but it has nearly as many general surgeons, because they still have to cover an acute roster 24/7, even though it is not as busy.
This means that any other hospital wanting to provide inpatient surgery would need to employ at least six general surgeons to staff an acute roster and a similar number of orthopaedic surgeons, as well as other subspecialty surgeons.
Add to this the requirement for a sufficient number of junior staff (registrars and house surgeons) to fully staff after-hours rosters, which are now almost all on a shift basis and are tightly regulated under their employment agreements.
This means, for example, that to provide cover for general surgery in Dunedin Hospital, even though it is shared with other surgical subspecialties, the pool of registrars required to staff a compliant roster is about 16. House officers require a similar number.
One of the consequences of the minimum workforce required to sustain acute surgical services is that they all have to have enough to do when they are not on acute duties.
This means an adequate volume of elective cases and a mix of complexity and challenge that maintain skills and interest in the case of consultant surgeons and provide sufficient training experience in the case of registrars and house surgeons.
These are clearly laid out by the Medical Council in the case of house surgeons and the specialty colleges in the case of registrars. Hospitals have to apply for accreditation from all of these bodies that the runs being offered have the right mix of experiences, learning opportunities and supervision.
We know that we are not training enough specialists across the board in New Zealand and we cannot afford to have significant amounts of surgery done in hospitals with no trainees or we will go backwards even further.
Additionally, consultant surgeons will simply not do the jobs of house officers or registrars, having to provide all of the assessments, workup, admissions, ward care and responding to the needs of patients on the wards day and night, so any ideas about having a consultant-only service in any of our rural hospitals is fanciful.
Finally, there are the issues of support services and safety.
No modern hospital should contemplate embarking on surgery which carries any significant risk of complications without specialist anaesthetists with a wide range of subspecialty experience within their pool of colleagues, or without an intensive care unit.
This is because if you do enough cases you will have things go wrong, often unexpectedly, and because our patients increasingly have compromised physical capacity and other co-morbidities.
When things do go wrong it’s a bit like a major trauma; you need all of the specialty assistance possible readily available (eg other surgeons with greater subspecialty expertise whom you can call to the operating room, ICU, cardiology, interventional radiology etc).
Planning to do surgery that carries significant risk where the plan if things go wrong is to rely on a helicopter transfer to Dunedin, and hope that the patient will arrive in time, is nothing short of reckless.
Given very little surgery in Dunedin currently is straightforward and low risk, establishing a new surgical service in one or more rural hospitals would not mean a significant amount of work could be transferred there.
The only surgery that is currently appropriate for rural centres is day surgery. The surgical bus has had most of this covered for several decades, in a very efficient manner, so building new theatres in rural hospitals or new private facilities appears redundant in terms of provision of publicly funded surgery.
There may not be enough day surgery being done to meet demand, but this is a consequence of funding from the ministry, not of the facilities.
There are definitely things that need improving in the provision of care in the rural areas, and after-hours care is clearly one of them, as is better access to accommodation and parking for families of patients that need to come to Dunedin for care.
However, there is no question that a well-functioning Dunedin Hospital of adequate capacity is vital for everyone in the region and efforts to try to pare back the new hospital build and invest in surgical services in any of the rural hospitals are inviting disaster.
They are an invitation to the politicians to divide and rule by pitting one locality against another, fighting over inadequate scraps.
No farmer in their right mind who is scraping by with a barely economic unit would propose splitting off 30% of the operation and then expect both units to survive. It’s magical thinking.
