Advances in research and technology have put hospital physicians at the forefront of modern-day medical miracles. But has it been to the detriment of our grassroots healthcare? Teuila Fuatai reports.
According to patient projections for bed demand, Middlemore Hospital is operating on fumes.
The South Auckland hospital, run by the Counties Manukau District Health Board, services some of New Zealand’s most deprived and fastest growing communities. And according to 2012 forecasts, medical and surgical patient demands outstripped what the hospital could provide four years ago.
For Professor Harry Rea, a specialist in integrated care, trying to combat that service shortfall started with a pilot project involving about 1700 high-needs hospital patients seven years ago. In 12 months, treatment costs for those patients amounted to $31.5 million. The patients also accounted for nearly 10 percent of visits to Middlemore’s emergency department, despite making up less than 3 percent of all patients to come through the hospital.
“These people absolutely need GP primary care – not waiting until they’re so sick until they have to come in here,” Rea says.
Rea, who has been working in South Auckland for more than 30 years and is also Professor of Integrated Care at the University of Auckland, believes ramping up health care and services at community level is essential to improving health outcomes, and importantly, sustaining hospital services.
It’s not the most glamorous or easiest approach to medicine, but Rea says it’s the right one.
Since 2010, Rea’s programme has grown to include about 30,000 patients in Counties Manukau, and been rebranded the Planned Proactive Care plan (PPC). With an annual budget of only $5 million a year, it relies on utilising and coordinating existing health services.
At a “businessman’s level”, its aim is to prevent and reduce hospital admissions and readmissions in those high-needs patients. However, the less tangible but longer-term impacts of improving overall patient wellbeing and health literacy are just as important, Rea says.
“This is about improving patient coordination – even if you find it hard to evaluate in terms of statistical tests, if you can show better patient coordination, and if the patient … says ‘I feel more comfortable with my GP, I can assert myself, I think he listens to me, I’m not endlessly repeating myself’, it’s almost inevitable their care will improve. If they don’t like their GP, they won’t go.”
GPs, district health nurses, social workers, physiotherapists, mental health workers, pharmacies and home support workers work together to coordinate care and treatment of patients enrolled in the PPC. In New Zealand, similar integrated healthcare programmes are operating in Canterbury, Waikato and Palmerston North. Internationally, the approach is becoming increasingly popular, with the USA, UK and Australia among the countries developing and improving programmes.
Locally, Rea believes the community-centric focus is particularly valuable in South Auckland.
“The overlapping influence between age, ethnicity and deprivation is almost impossible to tease out. We have the biggest Pacific population in the world, but 36 percent of our population live in the worst deprivation.”
“Access to a GP and to pharmaceuticals – it’s huge for people who live in deprivation. They have difficulty navigating what is becoming a more and more complex system,” he says.
“You can’t argue against intergration – the issue is whether you can implement.”
Many high-needs patients often have four or five major health problems, have been prescribed thousands of dollars in medication, are seen by several health workers and specialists, and still fail to get better.
For some patients, it’s about setting up a regular process to ensure medication is taken, while others might benefit from having an in-house weekly nurse visit, or even working with a social worker to ensure their family receives proper support – all of which is coordinated through PPC.
An integrated, community-level approach lessens the likelihood of hosptilisation and more costly treatments. However, the overall benefit and savings that stem from it is difficult to measure – particularly in such a diverse community like South Auckland.
“It’s still being evaluated … and is continually being evaluated, but it’s common sense. You can’t argue against intergration – the issue is whether you can implement.”
Furthermore, not everyone is convinced it’s the best way to go, Rea adds.
Throughout the 1980s and 1990s, there was enormous growth in hospitals as treatment capabilities advanced.
“When I first came here, someone who had a heart attack had three weeks lying in a bed in coronary care and then they went home because there was nothing else we could do.
“Now, the number of [heart attacks] has increased dramatically, and people can get a coronary catheter and stent inserted, and that’s happened in all the specialities – there’s new miracles for Africa.”
As more money was diverted to hospitals, community health care dropped away. At the same time, the population increased, people’s health needs became more complex and social deprivation also worsened.
“In the hospital, some of the big specialities are concerned that [the PPC is using] money they might use for more colonoscopies, or cardiac operations, or a new MRI machine. They see this as diverting funding from them,” Rea says.
But the $5 million set aside for the programme is relatively “trivial”. It is also a necessity in reducing pressure on hospital services, he says.