Media release from Dr Ben Gray

Dr Ben Gray

Secrecy of Process
I wrote a letter in good faith to the Board to express my view that the Board had made a bad decision in cutting funding to NUHS by 7.8%. I argued that such a cut would result in less care for NUHS patients and that it was likely that any "savings" from cutting the NUHS budget would be counterbalanced by costs increasing at the DHB as a result of the cuts at NUHS.

The board undertook to investigate my assertions and discuss the issue at the following board meeting. A report was written (now released under an Official Information Act Request). This was not included in the papers for the second Board meeting.

As a result the Board made a decision that presumably relied to some extent on this report without my having an opportunity to discuss the content of the report. If the report was able to be released later then I would like to know why it was kept private at the time of the meeting.

Inadequate Report
I would suggest that this a seriously inadequate report for the following reasons:
1.    Clinical Input
There is no suggestion of there having been any clinical input into the writing of this report.     Given the absence of relevant reliable data the opinions of clinicians in the DHB who would be     affected by this decision should have  been sought. Dr Robinson has recently sat in on a     clinic at NUHS, Dr Krebs could give you  information about the diabetes programme, Dr Bryan Betty from the ICC chronic care team could have told you more about primary secondary integration, and in particular Dr Tuohy has publicly stated serious concerns about the DHB's ability to manage in the event that the NUHS stopped its obstetric  service.

2.    Diabetes Service
In my opinion the following statement is wrong.
"4.3.2 In the context of the DHB's savings plans, NUHS has indicated that it might reduce the CCDHB's separate primary care investment in diabetes, as it acknowledges this specialist service (provided by CCDHB clinicians) adds value and reduces the need for the current level of funding for diabetes education and management."

The effect of the specialist clinic has been to significantly increase access for our patients to specialist input and increased the knowledge and skill of staff in the practice.
This has meant that problems that previously were managed in secondary care are now managed in the practice. A very clear example of that is the initiation of insulin treatment which is very time intensive for nursing staff. Running the combined clinics is a significant cost to the practice compared to referring to outpatients: the practice does the administration and provides a room. Meetings are attended by 3-4 practice staff.  This clinic is a successful pilot of Primary/Secondary integration that improves care by having more of the work done in Primary care supported by Secondary care. This is a net transfer of workload from Secondary to Primary. The salary costs of the specialist remains the same, but much larger numbers of patients are managed and there are significant savings in administration for secondary care. Most importantly patient outcomes are improved. I am appalled that your planning and funding staff have no understanding of this and it bodes ill for any implementing of Secondary/Primary integration.

This is an example of innovative health care that NUHS developed without adequate funding support, that achieves all the goals of the DHB in relation to chronic care management. Such innovation will become impossible if you cut NUHS funding by 7.8%

3.    Obstetric Care
Your report notes that " The funding model doesn't lend itself to NUHS's integrated service delivery model" What it does not discuss is that the funding model does not lend itself to providing good care for the most disadvantaged women. There is a flat fee with no allowance for a practice such as NUHS that has high proportions of disadvantaged women. A competent report would have noted the section below from the Children's Commissioner's report on Child Poverty

Connect more pregnant women with maternity services earlier
A significant number of vulnerable pregnant women access maternity services late or not at all. In 2010, more than one third of all Pasifika women, just over one sixth of Asian, and nearly one sixth of Māori pregnant women were not seen by a community-based LMC (Ministry of Health,    2012). Early engagement can enable health providers to inform and support pregnant women to eat well, stop smoking and drinking, and offer other services, such as housing, mental health and addiction services and income support. Maternity Quality Teams, established in all DHBs, are responsible for monitoring and improving maternity services. In our view, the Government should require these teams to prioritise early engagement with women living in poverty.

A very simple issue is that there is no provision for funding interpreters for community midwives. NUHS has a high proportion of patients with limited English proficiency. The approach to midwifery care is exactly what the Expert Advisory Group is suggesting…..but the funding model does not support this. I acknowledge that maternity funding is generally done by central government, so why has the DHB not forcefully lobbied central government to providing funding for successful models such at that at NUHS.

No attempt was made to assess what costs the DHB would incur in the event that NUHS stopped providing maternity services.

This is an example of innovative health care that NUHS developed without adequate funding support, that achieves all the goals of the Ministry of Health in relation to obstetric care for at risk women. Such innovation will become impossible if you cut NUHS funding by 7.8%

4.    Immunisation
In section 4.5.1 of the report it is implied that the immunisation rates are achieved as a result of     funding for immunisation services, and that this funding is not affected by these proposals. Only     a person with little understanding of immunisation could make such a fallacious statement. The level of 6 week immunisation is directly related to how good the relationship is between LMC and primary care. Many other practices have trouble with this transition and have had to institute extra programmes to try to cover this gap. Having midwifery care integrated with primary care is an important strategy for achieving high rates at the 6 week immunisation. These funding changes absolutely threaten the NUHS immunisation programme.

5.    Meaningless use of statistics
AT 4.2.5 the report presents a graph of ED presentations for NUHS registered population. This illustrates the heart of the problem of planning and funding pretending that they can evaluate NUHS on the basis of routinely gathered statistics. It is impossible to reliably interpret this table without further detail. A simple example is that there was one registered patient who was visiting ED on average 20 times a month for a year. If she leaves town the rate goes down by more than 10%. Because NUHS is such a small atypical practice it is very hard to draw meaningful conclusions from such data. There is no meaningful "control" that you can compare NUHS with. Data was presented about increasing visits of NUHS patients to AMC, concluding that such an increase is putting pressure on funding at AMC, and by implication that some of the funding should be taken from NUHS. This could equally reflect that the extra access provided at AMC is improving care for our patients, and that it is a group of patients who prefer to go there than NUHS afterhours for some reason. The implication would be that it would be a good thing f they did not go to AMC. It might be good for the budget, but we have no idea whether this is good or bad for patient care without a lot more detail.

The final suggestion that:
"4.8.2 CCDHB will undertake to monitor the presentation and admission rates of NUHS'
enrolled population to determine changes from this modest reduction in funding. "
displays an ignorance of the usefulness of such monitoring. How do we know what the desirable level of presentation and admission rates for NUHS patients is? If it goes up or down how do we know whether this is as a result of improved care or deteriorating care? If it stays the same does that mean that quality of care of patients at NUHS is unaffected? If you are going to monitor then you should at least include deaths.

6.    Summary of Argument
In brief the argument the report seems to be running is that it is unfair that NUHS gets so much money. There is another high needs practice that does not get as much, and it is only a "modest reduction". This is like saying it is unfair that ICU gets more money per patient than a regular ward. If it is unfair that the other practice is not getting funding maybe they should be given extra funding, rather than taking it away from Newtown. There was no information in the report on what the impacts of this cut would be.
Referring to the cut of 7.8% as "modest" is rubbing salt in the wound, given that the board is unable to manage its own deficit within an annually increasing funding allocation( the board has a 3.4% deficit, and its funding has increased by 10.5% over the last three years)

Conclusion
I approached the board in good faith as I felt that a poor decision had been made. I have considerable expertise in the subject in question and provided detailed argument to support my contention. You asked for a report from staff that you kept secret, that failed to include any clinical advice and did not address my main argument: that such cuts will lead to poorer outcomes to patients and greater costs to the DHB. I am ashamed that my elected representatives have behaved with such bad faith. I hope that you might stop hiding behind secret sessions and secretly delivered reports so that we could have a proper dialogue on the issues affecting the most vulnerable people in our community.