Speaking to New Zealand Doctor from the east coast of the North Island, chief executive of Ngāti Porou Hauora PHO Rose Kahaki says discussions with other rural health groups have highlighted the importance of “not standing alone”.
Ngāti Porou Hauora runs seven community clinics across the region as well as the rural hospital at Te Puia Springs.
The country’s only iwi-owned and operated hospital, it serves a small, isolated community with a high proportion of Māori and high deprivation.
Ms Kahaki says it needs to become part and parcel of a “wider network”, like a locality.
“Every rural hospital is on its own to bargain and recruit for staff, and they’re not equally resourced,” she says. “We need to be collective in our approach to raise a larger voice.”
She would like to see medical students and registrars get a lot more experience in rural healthcare, and says rural doctors also deserve equal pay with their peers elsewhere.
Not being able to offer the same wage as a DHB puts Te Puia Springs Hospital in a precarious position. Of the eight full-time equivalent doctors based at the hospital, two are permanent and the rest are locums or contractors.
“Working in rural areas is not glamorous or attractive when you can make far more money [elsewhere].
“We need doctors who can do harder work, in a higher poverty bracket for longer hours, and be committed to whānau, all for less pay.”
While not entirely convinced Health NZ will solve all these issues, Ms Kahaki wants to believe associate health minister Peeni Henare when he says all New Zealanders should have access to the same care no matter where they live.
For Mr Eager, the reforms are a once-in-a-generation opportunity for change.
He has been impressed by the work of the Transition Unit, whose team members seem “really keen” to get this right for rural, and have been regularly meeting with rural groups.
“They’re truly asking for consultation, which I’ve never seen before, and saying some bold things. They know they won’t please everyone, and so they’re saying ‘how about we write the plan together?’”
A hospital like the one in Taumarunui, currently run by the DHB, could become the hub of the community if it existed in a locality with shared services, says Mr Eager.
Add mobile services, like the surgical bus, to the equation and the sky is the limit, he says.
“Mobile diagnostics…cost a little more but overall, if you’re catching people early, it’s a good example of being able to get out there and do it.”
The benefit of a mobile surgical service is that it shares the latest equipment across communities that can’t always afford their own – by literally bringing it to their doorsteps.
What matters to Professor Lawrenson is addressing facilities and service provision.
In Waikato, rural women have been bypassing local maternity services that are “not that flash”. In Thames, births dropped to about 50 a year until a brand-new facility brought the numbers back up to more than 100 a year.
Te Kuiti faced similar issues, downgrading its primary birthing unit to a maternity hub after women chose to birth at a new birthing unit in Te Awamutu, or in Hamilton.
“In general, not a lot of money is spent on infrastructure [in rural healthcare],” Professor Lawrenson says.
Many buildings date back to the 1970s and, though they may be well equipped, they are still old buildings modified for new uses.
“We need to get rid of the postcode lottery: in Dunstan you can get a CT scan, but not in other areas.”
Professor Lawrenson points out healthcare demand changes, depending on communities’ changing needs.
“Lots of populations are ageing rapidly, so they might not need a birthing unit, but they need palliative care and elderly care. If you’re 80 and have a fall, you don’t want to be 80 to 150km away from a hospital, so you need beds locally.”
The man on the spot in Balclutha is Ray Anton. Mr Anton is chair of the Rural Hospital Network and chief executive of Clutha Health First, the organisation that runs Balclutha Hospital. For him, the glass is half full.
Ideally, rural hospitals need to be a part of localities, “not part of a DHB or Health NZ, or a district office”, he says. He hopes Health NZ will fund the health sector more “honestly and transparently”.
“The model of funding is broken. With DHBs that are losing money, this makes them even less willing to release resources to rural, and services like primary maternity are hugely underfunded.
“Make the money follow the patient, find out what the best solution is for the community and the patient, and eliminate the payment question,” Mr Anton says. Integration with primary care since 1998 has allowed Balclutha Hospital to build a “really nice model”, which redistributes staff and funding based on the needs of the community, he says.
“We always ask ourselves, ‘is there a need in the community that needs addressing?’ And, if there is, what does that need look like, how do we develop a service to address it, and who will pay for it? It either comes from the DHB, [primary care] capitation, the patients themselves, or ACC.”
Rural hospital doctor Jeremy Webber, who works at Taupō Hospital, says that with health reforms coming around once in a blue moon, ensuring the rural voice is not lost in the mix is imperative.
Newly appointed by the NZRGPN as clinical directorrural health, Dr Webber hopes to give the rural sector appropriate representation among decision-makers.
Dr Reid, who works at Lakes District Hospital in Queenstown, is deputy chair of the New Zealand Rural General Practice Network (NZRGPN). He admits change is “always scary”. But he says the health reforms will help to address equity issues by allowing the sector to be adequately resourced, and rural health professionals to work at the top of their scope and in coordination with other services.
The health sector is used to restriction, reduction, services being used to fill gaps, and some areas having to go without, says Dr Reid.
But locality networks provide the tantalising prospect of being able to coordinate services locally, developing new services and supporting the training of rural health professionals.