Tom Belford interviews Kevin Atkinson as he contemplates leading our Hawke’s Bay DHB another three years.

“Any decision in health is a bloody hard decision,” says DHB Chairman Kevin Atkinson as he contemplates the challenges in bringing better health outcomes to the people of Hawke’s Bay. But he adds: “Improving the health of our community improves everything in our region, from educational achievement to worker productivity.”

Just re-elected to the Health Board, easily garnering the most votes of any DHB candidate, Atkinson is the most obvious – but not yet certain – choice to serve as chairman for another term.

Over that term, he expects the financial resources available to the HBDHB to grow marginally, perhaps 1% per year, falling behind in real terms when inflation is taken into account.

No wonder then that Atkinson treats the ongoing quest for cost savings as one of his top three priorities. The DHB budget now stands at $485 million, an amount that must cover every aspect of health care delivery in Hawke’s Bay – from the primary care delivered by your GP, to surgeries and emergency treatment, to mental health, substance abuse and health promotion programs.

Moreover, when capital investments are required – such as a new acute mental illness facility or an endoscopy suite or birthing unit – these too must be funded from the ‘surplus’ created by extracting savings – in the range of $10-$15 million per annum – from the overall operating budget.

Compounding the challenge, all savings must be sustainable year after year; not temporary ‘fixes’ that subsequently creep back into the spend. “We can only achieve these savings with the cooperation of the community and other providers,” says Atkinson.

Still, he is philosophical about the financial constraint, observing that New Zealand is one of the very few OECD nations that have not cut back its funding allocation to health care in recent years.

He notes that Hawke’s Bay’s funding allocation from the national pot – driven chiefly by a population formula – is essentially flattened by our region’s lack of population growth compared to the large urban centres. That formula makes little adjustment for special needs, like a sharply growing elderly population or a growing Māori/Pasifika population that lags in most health measures.

Another ‘top three’ priority will be meeting the targets set nationally by the health minister regarding ‘waiting times’ for specialist care and surgeries. By the end of 2014, no patient should wait more than four months from diagnosis for either specialist assessment or needed surgery.

And the final ‘top three’ priority, also involving stretching the resources further, will be planning and then achieving the $750 million in nation-wide health system savings targeted by the Government’s Health Benefits Limited program. This initiative aims to capture savings across the NZ health system by moving all DHBs into common financial and IT systems and consolidated procurement arrangements.

Meeting these financial and service delivery goals involves all sorts of trade-offs and long range planning.

Focus on children

Given his druthers, Atkinson would like to see more investment in the health of children, where early attention to health issues and healthy lifestyles would pay the greatest long-term dividends – both in quality of life for the individuals and in reduced medical care expense over their lifetimes.

He notes that by 2025 about half of all births in Hawke’s Bay will be to Māori and Pasifika mothers, many in poverty situations where early health issues can be anticipated.

About 80% of health dollars are devoted to the first and last year of life

Here the challenge is to identify the most vulnerable families early and approach their needs holistically. Kindergartens and schools have a key role to play, as children are their ‘captured’ population. One program underway involves routine throat swabs for kids … families of any child who tests positive for Group A streptococcus are visited by a social worker who, with whānau, assess and aim to address a wide range of factors, from healthier homes to required MSD services to appropriate primary care.

What this points out is that health improvement, particularly for disadvantaged populations, requires much more than additional ‘medical care’, narrowly defined. Housing quality, appropriate nutrition, cultural sensitivity and receptivity are additional factors that cannot be controlled by the DHB.

The solutions involve a much greater degree of multi-agency cooperation, an area that Atkinson sees as a priority. But he notes that even that cooperation – whose need is obvious – cannot simply be mandated by the DHB. It must be a priority embraced willingly by all the relevant agencies.

There’s no ‘new news’ in the fact that Māori and Pasifika health indicators lag in relation to our European population (national-wide, not only in Hawke’s Bay). So why hasn’t more progress been made in closing the gap?

Atkinson looks to wider engagement with iwi and perhaps more focus to the targets we aim to achieve. “Perhaps we’ve had too many targets for this population, when we should focus more intently on just a few.” He gives the example of nutrition. “Perhaps we should aspire to be the healthiest region in New Zealand as measured by the food we eat.” He notes that we live in a region – “we’re the bloody fruitbowl after all!” – that should have no difficulty ensuring that every person has ample fresh fruit and vegetables. So why not set a healthy nutrition goal and mobilize around that?

Hospital treatment

Apart from meeting the needs of vulnerable populations, the DHB of course must provide the day-to-day care any of us might require. And again, financial and technological realities pose challenges.

We can no longer routinely assume that each and every medical treatment can be provided within a region of 150,000 residents, says Atkinson. And it’s not just an issue of specialist staffing; complex procedures are now heavily dependent upon expensive, rapidly evolving state-of-the-art technology. Any DHB’s ability to provide the best care is dependent upon access to both the talent and the technology. And while the HBDHB spends a huge sum to transport patients out of Hawke’s Bay (we account for 30% of the NZ spend on medical transportation), that amount would not buy and enable the best level of service at our local level.

So there is no question but that Hawke’s Bay will be sending patients to Wellington and Palmerston North. That’s a reality patients and their families must adapt to. “I’d prefer to have the [highly technical] procedure in Wellington than not have it all … there’s a limit to what the country can afford,” says Atkinson. Fortunately, he suggests, for most of us this is a situation that might arise but once in a lifetime, if at all.

Kevin Atkinson

Atkinson says that increasingly Hawke’s Bay, from a health care perspective, operates in a larger ‘central region’ context – a region of 500,000 population served by six DHBs who are charged by government with finding more and more ways to collaborate and share resources. Our goal should be to organise and provide the highest quality of care that can be afforded for that region, partly enabled by a new shared patient information system to be accessible throughout the central region. Within that larger area, we are capable of delivering 99% of our health services needs.

But what about improvements or enhancements to service right here in Hawke’s Bay? Atkinson sees heaps of opportunities, from after-hours care to improved health literacy to incentives within the system for innovation.
One area Atkinson notes is length of hospital stays.

It seems that our DHB has longer average lengths of stay in the hospital for many treatments. More days in the hospital mean more expense and less availability of access for additional patients. At the same time, our longer in-hospital stays do not translate into lower re-admission rates, which arguably would be an offsetting benefit.

If HBDHB merely achieved the national averages for hospital stays across all procedures, it would save $2-3 million per year … money then available for other service enhancements. How is this being addressed? Delicately … would appear to be the answer.

DHB chief executive Kevin Snee in his September board report, commenting on a variety of performance issues, writes that internal consultation processes have “signaled a number of potential changes that would have an impact on the functioning of the hospital, with a key desire to change the culture of the organization to one which is better focused on the quality of patient care and productivity.” He goes on to mention “we have taken steps to bring in new service management for medicine and surgery, which will be in place by November, to bring some fresh eyes to the operational task.”

Atkinson perhaps put it more plainly in recent remarks to Grey Power, referring to the need to “improve weekend and evening hospital staffing so that we get better outcomes and shorter stays.”

Primary care

Another improvement would be to keep more people out of the hospital in the first place. At first blush, that seems a truism. But the argument is that, in the right circumstances, better and less costly care can be provided out in the community, especially in the primary care system – from GPs to Māori providers to home care for the elderly. Indeed, about half the health care funded by DHB is actually provided outside the hospital.

Atkinson believes that all of these relationships need to be expanded and improved in coming years, including, as he puts it “high trust contracts with Māori health providers”.

More resources and skills need to be built into primary care teams and settings, he says. He expects to see fewer individual primary care practices, with more clinics instead – pointing to Wairoa’s new health care centre – providing group care with ‘one-stop shopping’ for related basic services like your GP visit, blood tests and X-rays. And in rural areas, more use of technology to reduce travel for services.

All of this ‘improvement’ cannot come from DHB planners and bureaucrats. Atkinson foresees clinicians playing a stronger leadership role through the Clinical Council broadened to include clinicians outside the hospital. “Many of our clinicians [inside and outside the hospital] don’t even know each other,” he notes, adding that the goal should be to develop “common health care pathways” so that wherever or however a patient enters the system, they can expect the best possible treatment.

‘Patients’ have a role to play also, he emphasizes, starting by adopting healthier lifestyles and in fact showing up when they’ve scheduled clinic appointments – 20% of Māori and 12% of Pākehā simply don’t show up as scheduled, effectively wasting clinicians’ time.

And finally, speaking of patients, Atkinson is enthusiastic about the DHB’s Consumer Council, under the energetic leadership of Graeme Norton, which Atkinson would like to see as “the voice of patients in all strategic health service decisions”.

That’s quite a menu for the next three years. But Kevin Atkinson clearly has complete command of the issues involved – from global trends and macro-economics, to the detail of hospital stays and patient information systems, to the nuances of dealing with cultural sensitivities, to the role of good health in improving our overall social and economic wellbeing.

A true ‘Renaissance Man’ of health.

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