This is a world with a bottomless bucket of medical needs. This is a workplace of strong unions and of strong characters. This is an environment of life-and-death decisions. You cannot hide in health, because it affects everyone closely and intensely at one time or another. It is, as well, the realm of public money and, as such, accountability must be high.
The people of the South, and particularly Dunedin, have always been comparatively well served by medical services. The presence of the Otago Medical School and, therefore, the ability to attract a wider range of specialties and specialists has been fundamental to what can be offered at Dunedin Hospital. In addition, it has been argued for years that Otago has been overfunded compared with the rest of the country.
It might well be that additional costs associated with the medical school are not always sufficiently compensated for. But, most significantly, the open-ended nature of health needs, limited health dollars and the steady introduction of "population-based" funding over more than a decade has put relentless pressure on budgets and conscientious staff. Resources under the funding model are, in relative terms, being switched year-by-year to the more populous north. As an aside, it is worth noting the appalling and disconcerting fact that even researchers have struggled to understand the detailed workings of how health money is divided. How ridiculous that something as basic as the allocation of billions of health dollars is so opaque. No-one seems to be able to ascertain if the weighting for matters like depravation, ages and rural spread are properly or fairly allocated.
The latest news on the Southern District Health Board's deficit is disappointing. Earlier predictions of a $10 million deficit - on a budget of about $800 million - seemed at first to be unduly pessimistic. Then came news that it has burgeoned to more than $15 million. According to deputy chairman Paul Menzies, the board overshot its spending on elective surgery. Crown monitor Stuart McLauchlan says the main reason for "overdelivering" is the outsourcing of surgery to Mercy Hospital without the finance department realising the cost implications. It appears extraordinary the outsourcing took place in the absence of reasonably accurate costings. Certainly one overspending area has been Otago medical staff , over budget by about $4 million. Because staff costs account for 70% of board revenue, axing $15 million from budgets must prompt staff cuts and/or lower staff costs. It can be argued that - and this seems to be one of the reasons some of the costs can be so high and flexible use of resources so difficult to achieve - the relevant collective agreements contain generous (at times perhaps even unreasonable) conditions.
There is a pointed irony in the current situation. Patients have usually been living with medical issues for a long time to make it up the list for elective surgery.
Chances are the matter is, or has become, grave. That is how public elective surgery rationing works, driving as many as possible to the private sector. So, while the "overdelivering" is a board failing, it has been wonderful for patients receiving procedures. The last thing they care about is the board deficit.
The easy cost-cutting took place long ago. In an organisation as complex as the health board, and in settings as labyrinthine as large public hospitals, however, there will remain fresh approaches to improve efficiency and save money. There is also the unfinished business of clinical integration between Otago and Southland.
It is just that - against inertia, an array of vested interests and in a complicated setting - the hurdles to worthwhile change are high and many.
Into this milieu comes chief executive Carole Heatly. Given the challenges of the National Health Service in Britain, from where she came, she will be well aware of issues arising from never-ending efficiency efforts, public complaints and difficult staffing issues.
By some accounts, early impressions of her and her work are positive. She will need impressive skills, however, to made the headway necessary to produce the best possible health outcomes for the people of Otago and Southland.
