I can say without fear of contradiction there is significant waste and inefficiency in Dunedin Hospital, but the reasons for this are not what politicians and Ministry of Health bureaucrats might have you believe. It is vital that the conditions that give rise to this are not repeated in the new hospital.
From my first day as a surgical registrar (trainee) in December 1983, through to my retirement from clinical practice at the end of November 2023, I have observed the serious deficiencies of Dunedin Hospital. Over that 40-year period, the body running the hospital (be that the Otago Hospital Board, Healthcare Otago, Otago DHB, Southern DHB or now HNZ/Te Whatu Ora Southern) has been perpetually in deficit, and this has been met from central government with threats, targets (usually punitive), restriction and sometimes reduction in funding, and the constant mantra that no new investment would be forthcoming until we "lived within our means".
With respect to those "means", the adequacy and fairness of the funding system (particularly the way in which the population-based funding formula was calculated) was always out of bounds in any discussion, but that is an issue for another day.
There are three fundamental components to the provision of healthcare at any level, and these are: people, plant and process. What does this mean for a hospital?
People: You need adequate numbers of people with the right skill sets to deliver care. The need to deliver emergency care for life-threatening conditions is the most pressing, but planned (elective) care is also an essential need.
Plant: This refers to the facilities — buildings, specialty equipment and fit-out and care spaces (beds) that are needed to deliver care. A critical issue here is matching capacity to demand.
Process: This refers to the systems and ways in which the hospital and its component parts do business.
Clearly all of these need to be coherent in order to deliver optimal care. If some aspects are functioning well but others are not able to keep pace then a bottleneck arises; i.e. a rate-limiting step in the process of care. The politicians and the ministry bureaucrats were in no doubt that our problems were all due to poor processes and if we got these sorted, the deficit would come right.
In good faith, I have committed thousands of hours over the last 40 years to trying to make our systems as efficient and effective as possible, and as a result have put my hand up for dozens of quality improvement (QI) initiatives over and above my already heavy clinical workload in two disciplines.
Some examples are.—
Four different projects over time to improve operating theatre flow and output, particularly for acute patients:
Surgical Outpatient project;
Surgical Acute System project;
ED — 6 hours, It matters;
Putting the Patient First.
All of these and many other failed projects had two things in common.
One was that those who held the purse strings were never fully committed to the project, despite almost every recognised QI methodology having this as an essential pre-condition. (Basically they remained at arm’s length. One suspects just in case the project group came to a position where money needed to be spent — see below).
The second was that these projects all progressed well, in very accurately determining the problems and their root causes based on robust data and sound evidence, up until a point where to make real change some investment was required, because the processes were rate-limited by the facility, or by staffing, or both.
The response from local managers right up to the ministry has almost always been "No, there is no money!".
Sometimes it was just a straight "No", but sometimes it was accompanied by some faint praise of the merit of the proposal and a promise to fund the solution, but only once we had got the deficit under control by improving our processes, which would then free up funding to make the changes.
This is the most extraordinary Catch-22, and utterly perverse. It’s a bit like identifying that we have an old car which is running on only three of its four cylinders, severely hampering efficiency, so asking "could we get the engine fixed?" — and being told the repair will only happen when we achieve better fuel efficiency ... and by the way we are taking some petrol away from you as you aren’t meeting your targets.
The inescapable reality that we kept being forced back to was that the capacity of Dunedin Hospital was simply inadequate to deliver what our patients need, and this is predominantly in two key areas: the operating theatres and the inpatient (ward) beds.
When I started in surgery in 1983, Dunedin Hospital had seven operating theatres in the main theatre complex and two very small day-surgery theatres. At that time there were also functioning theatres at Oamaru Hospital and Balclutha Hospital (which were closed in the mid-1990s.) A further main theatre (Theatre 8) was added in Dunedin in the 1980s and a ninth in the early 2000s.
Unbelievably, we have no more theatre space in Otago now than we had in the 1980s, despite a significant increase in demand for many reasons, only one of which is population growth.
We should have at least 16 operating theatres based on reasonably conservative estimates of demand and benchmarking with other regions, and it is scandalous this wasn’t addressed in long-term planning at least 30 years ago.
The consequence is that there is a constant tug of war for access to an operating theatre, particularly between acute and planned (elective surgery), and that surgeons have extremely limited allocation of planned surgical lists. Over the last couple of decades, we have recruited sufficient surgeons to be able to cover acute operating and after-hours call with tolerable call rosters and have sufficient subspecialty cover for most disciplines, but are not able to provide satisfactory operating access for elective surgery, which severely impacts on the ability of a highly trained surgeon to practise their craft and their satisfaction with their working life.
In general surgery, this has meant that each surgeon gets only two full-day operating sessions a month, a far from satisfactory situation. This has led to departures of surgeons to other regions where they get a better deal, or increasing the proportion of time spent in private practice, some of them exiting public practice completely. All of these have significant negative consequences on public services.
Despite ongoing heroic efforts by those running the theatres, allocating theatre time optimally between elective and acute surgery is extremely difficult to get right. When acute cases build up on the acute waiting list, and patients are waiting days in hospital for some acute operations, elective lists frequently have to be cancelled to clear the backlog, which is highly disruptive for patients, their families and the surgical teams. It also means a lot of re-work for booking administrators, pre-op nurses and others. This is both significant resource waste and a source of great distress.
Additionally, this impacts disproportionately on some surgical specialties and their patients, orthopaedics in particular, so their throughput of procedures falls, particularly joint replacements, and already unacceptable waiting times get even longer.
If a list is not cancelled to allow the acute cases to be cleared, then it may not be able to proceed anyway, because the beds are occupied by those acute patients waiting for surgery. When we did a count in 2021 as part of yet another QI project, the number of hospital beds occupied by acute patients waiting for surgery on any given evening averaged around 12. Any bed-day which does not add value to the patient’s care is waste.
Another extremely distressing cause of waste is when the hospital is simply full, with all inpatient beds occupied, and more patients waiting for admission from the ED. This causes the cancellation of planned operating lists as there are no beds to put the patients in post-operatively, and the theatre then is not used despite being fully staffed.
There is always an attempt made to use those theatres for acute patients but this often doesn’t work out, so a significant number of precious operating sessions simply go to waste and the fully-staffed theatre sits idle.
This can also happen if one essential role in the operating team cannot be filled on a particular day. This happens most frequently with anaesthetic technicians or anaesthetists. That theatre session then goes to waste. Even if the hospital as a whole is not full, similar cancellations occur virtually every week, often at the final moment, if the Intensive Care Unit is full, or there are no High Dependency beds and there are patients on any of the planned lists for the day who need this level of post-operative care. It is critical that these limiting conditions are not simply perpetuated in the new hospital.
The staff are crying out — "Give us the tools so we can do the job!". Is the government listening?
• Mike Hunter is a retired consultant general surgeon and consultant intensive care specialist.
