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Author Archives: William Taylor

Hospitals are part of community too

The 274-page full report New Zealand Health and Disability System Review has been recently released (June 16, 2020). While the main headlines refer to the creation of a new overarching entity ‘Health NZ’, a new entity responsible for Māori health and a smaller number of District Health Boards, there are some other interesting and somewhat implicit themes that emerge.

The report heavily, but implicitly, emphasizes a Tiered structure of healthcare. I obviously missed this basic foundational concept somehow, since I was initially unsure exactly what was meant by Tier 1, 2, 3 services. At first, I thought it was just new terminology for primary, secondary, and tertiary care, which admittedly has its problems too, but there seem to be important differences. One recommendation of the report is to move Tier 1 services provided by hospitals out into the community. What would those services be? On page 98, Tier 1 services are defined:

“Tier 1 encompasses a broad range of services and other activities that take place in homes and communities, in marae and in schools, delivering most of the health services that most people need, most of the time. Tier 1 includes, but is not limited to self-care, mental health services, general practice, maternity services, Well Child / Tamariki Ora, outreach services, oral health, community pharmacy services, health coaching, medicines optimisation, district nursing, aged residential care, hauora Māori services, community paramedic services, school based services, home-based care and support, rehabilitation and palliative care. It also includes laboratory and radiology services and other allied health care that takes place outside of hospital, such as podiatry, physiotherapy and dietetics. Most kaupapa Māori services are in Tier 1.”

Note that rehabilitation and palliative care are counted as Tier 1 services. What does ‘moving out into the community’ mean for rehabilitation services? The report refers to services provided in homes, marae, and in schools – presumably also workplaces, sports fields, churches, and shopping malls. But obviously not hospitals since somehow hospitals are not part of the community. Although some rehabilitation services already do operate out in the community many others do not and could not successfully transition to such locations. Some rehabilitation services have evolved to work best as inpatient facilities because of the efficiencies of specialist staff, better client outcomes and access to multiple health professionals in a timely and organised way. Spinal cord injury is an obvious example, but stroke units are also examples of where concentrated expertise has been clearly shown to work better than distributed generalism. Having said this, the Review is a little ambiguous with regards to rehabilitation services since they do not appear in the list of Tier 1 services in Table 7.1.

I wonder whether it would not make more sense to bring the community into the hospitals. Why should hospitals be some kind of space apart? There is a strong unspoken sense that hospital structures mainly benefit the people that live close by i.e. in cities or provincial centres, to the relative disadvantage of rural and remote communities; but this tends to ignore the valuable contribution that smaller community rural hospitals have made but which have been progressively pared back because of efficiency concerns.

This separation of ‘community’ from ‘hospital’ is an interesting phenomenon; what is the underlying basis for excluding hospitals from their communities? An immediate thought is this need for efficiency – that it is somehow cheaper to provide similar services in different settings. Often, that just means cost-shifting to the consumer. Instead of obtaining free care from hospital-based specialist clinics, consumers get that care from general practices or other providers trying to run a business, for which there is a significant direct cost. But there probably are other more ideological reasons too. Hospitals are traditionally places where overnight healthcare is provided, that is, patients are ‘admitted’, which means staying in for 1 or more nights to receive 24-hour care that cannot be easily provided in the patients’ home. But they became monolithic institutions that de-personalised and disempowered the people they were meant to serve. The shift from hospitals to community can be seen as part of the same process that characterised the de-institutionalisation of mental health hospitals and care-homes for people with disabilities, especially intellectual disabilities.

But hospitals are not places where people/patients actually live, in contrast to the mental hospitals and care-homes of the past. And they no longer provide solely overnight care either. Space for outpatient clinics is probably the resource of shortest supply in many hospitals. Ambulatory care is a major function of hospitals, not just overnight care. People using these services are still in their community. It is misleading to consider that a hospital-based emergency department is fundamentally different from an accident and medical after-hours clinic. More severe accidents are managed at a hospital ED, but this is a difference of degree rather than substance. There is no intrinsic reason that I can see for not allowing more community-oriented services into hospitals. Let’s make hospitals feel more part of their community!

Rehabilitation and risk

When I teach medical students about giving advice to patients about returning to usual activities, I tell them to think about 2 related but distinct key concepts. The first key concept is whether the patient is actually able to perform the usual activity. This involves the assessment of function, and the ICF provides a really useful framework for what function is (but doesn’t tell us how to go about it). The second key concept is how risky it is for the patient to undertake the usual activity. Risk assessment is tricky. It demands a knowledge of the underlying pathology (rugby players might perform fine after a concussion but the risk of a second ‘hit’ is too much) as well as the ways the risk might be managed.

Management of risk is a common strategy in life as well as in rehabilitation clinical practice. This photo shows Kime Hut in the Tararua’s a couple of days ago. I was up there by myself, which is risky. But I (and my family) are reasonably happy with the management of that risk – well-equipped with warm gear, personal locator beacon, GPS, and an attitude to bail out when things turn dodgy (especially weather). Tragically, people die in this place, just 5 or 6 hours walk from civilisation. Kime Hut, itself is named after a tramper who died from hypothermia after being rescued and warmed too quickly.

Perception of risk is another interesting issue. The chances of death from driving in a car in the next year is 1 in 17,000 (2002) yet I encourage my teenage son to learn to drive. What are the risks of harm for a person living alone who needs assistance to get out of bed and into their motorised wheelchair? The overall risk of dying in a house fire in the next year are 1 in 90,000 (about 5 times less likely than dying in a car crash). There is a strong connection between autonomy and risk-taking so that the disability community can sometimes advocate for ‘the right to take risks’. If you are interested in reading more about this, take a look at this report from the Joseph Rowntree Foundation.

EULAR Congress Report

At the top of some mountain or other.

I was in Madrid in June for the European League against Rheumatism (EULAR) annual congress. This is the major European conference for rheumatology. Apart from the extreme heat, the major highlights were chairing a meeting of gout experts which helped arrive at some consensus decisions around gout terminology and listening to a presentation from Nottingham, UK that described a randomised controlled trial of nurse-led care for people with gout compared to usual care from their general practitioner. People who received nurse-led care did much better, in terms of gout control and medication use, reinforcing the benefits of structured education and frequent support and monitoring. In addition, I took advantage of the weather and the geographical proximity and went hiking in the Swiss alps between La Sage and Zermatt, covering about 75km in 5 days and about 7000m of climbing up over the passes and down into the valleys. Beautiful views of the Matterhorn and other mountains as well as mountain villages and their postcard perfect chalets.