The six central region District Health Boards are reviewing the hospitals in the region and how our health services will be delivered in the future. Over recent weeks, they have come up with two remarkably divergent plans.

The first Regional Clinical Services Plan was reported on 2 July by the Dominion Post. Let us call it Plan A. It was a drastic proposal to downgrade regional hospitals throughout the lower North Island. It would have “clustered” acute services in Wellington and just one other acute hospital, either at Palmerston North or in Hawke’s Bay, by 2020.

The inevitable result would have been a cut-throat fight between Manawatu and Hawke’s Bay to see which retained a significant facility and which did not. To the winner, the spoils. For the loser, an end to services such as Cardiology, specialist Diabetes services, Infectious diseases, Neurology, Cancer services, Respiratory medicine, Cardiothoracic surgery, Ophthalmology, specialist Paediatric services, Gynaecology and Radiology.

As for the other four regional hospitals in the lower North Island, they would provide emergency medicine, non-complex in-patient services, rehabilitation and some elective surgery.

Plan A, then, involved major down-sizing of facilities.

By contrast, the revised Regional Clinical Services Plan (‘Plan B’) is specifically described as not being a cost-cutting exercise. It assumes three acute hospitals, and avoids any face-off between Hawke’s Bay and Manawatu. The other, non-acute hospitals would not be downsized. Under Plan B they might actually be upgraded.

One could hardly have a more different proposition. And underlying the changes is a newer way of thinking.

Plan A – A failed model

Plan A was based on the philosophy of ‘clusters’. ‘Clusters’ go back to Milton Friedman and the Chicago School of Economics in the 1980s. They are part of a drive for the application of business models in every aspect of life. ‘Clustering’ may have merits for running businesses. In areas such as public health care, though, the starting point must be the needs people have and how they are best to be met.

The deficiencies of ‘clustering’ have been highlighted in recent times by the rising price of oil. Ideas of the 1980s assumed endless supplies of cheap oil. With some observers believing oil may reach $8 a gallon before 2020, does it make sense to continue to plan future health services on the assumption that everyone has access to cheap travel?

The ‘hub and spokes’ model on which Plan A is founded is very familiar to Hawke’s Bay. It is what was put in place here in the 1990s. As well as leaving only one acute hospital between Wellington and Hamilton, Plan A would have substantially downsized every other hospital in the lower North Island, turning each of them into something like the Wellesley Road health centre. Plan A suggests they would be left with emergency medicine, non-complex in-patient services, rehabilitation and some elective surgery. Compare that with what Napier was assured it would have after it lost its Hospital: ‘an active community hospital with a comprehensive range of services’.

Perhaps indeed Hawke’s Bay was the actual model for the suggestion. The Plan’s sponsor is named as David Meates, currently CEO of the Wairarapa Board. In 1997 he was Medical/Surgical Services Manager here, and involved in the closure of Shrimpton Ward at Napier Hospital which, as local doctors commented, was part of measures to restrict access to hospital care.

The problem with using Hawke’s Bay as a model is that the 1990s reforms have left a local situation in which polls show that the number one public concern in three of our four council areas – Central Hawke’s Bay, Napier and Wairoa – is health.

So Plan A would have spread what many believe to be a failed local model through the whole of the lower North Island. In reaction, Plan B is concerned with sharing and collaboration. It explicitly downplays the ‘hub and spokes’ model.

Where now?

In every respect, the more recent Plan B signals a significantly different direction.

It is not yet clear when and how the public will be consulted. Both Plans are about what clinical services can be developed and sustained. So far, though, only those already professionally involved are being asked to respond. To some extent, that is an exercise in navel-gazing. The real key question is, what services do the public need? And it is the public at large who need to be asked that.

Who are to be considered as ‘stakeholders’, specifically invited to comment? In the field of public health, sustained by our taxes, we are all stakeholders. There are certainly many groups outside the health sector who have every right to be viewed as specific stakeholders.

Take the situation of the elderly, since the plans consider the increasing demand from an ageing population to be a critical issue. The Napier Family Centre has reported a growing number of older clients unable to make ends meet after mortgaging their homes for medical treatment. On that basis it, and groups like Grey Power and Age Concern, should surely be considered stakeholders.

One thing is clear: with Plan B, we now have a far better basis for discussion about our future health services. That the health bureaucracy can throw up two such completely different versions of the same plan suggests that the sooner the public is brought into the discussion, the better.

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