Healthy debate is needed

OPINION: Otautau Medical Trust director John Hicks writes in response to the article "Mutiny threats lead to backtrack over PHOs" in The Southland Times on October 30.

Even for those working in our health system, the political mechanisms whereby it is delivered to us seem bewilderingly complicated. The maze of acronyms don't make it any easier.

In my attempts to demystify the system, there is no doubt that I will be inviting criticism. I will gladly accept any that come my way in the spirit that the debate should be opened up – so that we all better understand the game currently being played out behind closed doors.

Here is how it works: The Government, via the Ministry of Health (MoH), funds the district health boards (DHBs). DHBs tend to be associated, in the public mind, at least, with secondary health care – namely, the hospitals central to their operations.

However, the DHBs are, less spectacularly but equally importantly, responsible for primary healthcare in their regions – ensuring that government funding is fairly allocated to subsidise the doctors and nurses in local medical practices and maintain the primary healthcare services they provide.

The new Government intends to improve efficiency by reducing the number of DHBs throughout the country from 21 to nine. This, it argues, will save duplication of effort and reduce some of the enormous administrative overheads involved in running hospitals.

That would seem to be a reasonable move.

But it is the battle for access to funds for primary healthcare that is the one we really ought to be watching.

Logic would suggest that it would be sensible for the DHBs to distribute these funds directly to the local medical practitioners without the need for another tier of bureaucracy. The problem is that DHBs, struggling with massive deficits, don't release their funds lightly and, to coin the new jargon, they heavily "topsliced" them before they finally did dribble out. Which is why, during the past few years, we have seen the establishment of PHOs (primary health organisations). These have been very effective at utilising funds for the primary healthcare sector.

The Takitimu PHO is just one example (see takitimupho.org.nz ). It includes the medical practices servicing Riverton, Tuatapere, Te Anau, Otautau, and Winton.

I have chosen Takitimu because the medical practices it represents service predominantly rural areas. These are the areas where the doctor shortage is being felt the most.

It is becoming increasingly difficult to employ doctors – for which reason many of these practices are now trusts, with communities owning the medical premises and facilities. It would seem reasonable, therefore, that these communities should have an input into primary healthcare funding, and they do. That is how PHOs work.

On PHO boards there is a balance of GPs, nurses, and Maori – as well as community representatives.

As with DHBs, PHOs also suffer from a certain amount of bureaucratic duplication, which is why there is, alongside a move to amalgamate DHBs, also a move to amalgamate PHOs.

However, this is a far more contentious issue. The needs of rural Southland, Queenstown, Dunedin and Invercargill are all very different. For instance, Queenstown has no trouble recruiting doctors, but has problems with a more itinerant population than, say, Winton.

But there is another player for DHB funds – SouthLink Health (SLH) – an organisation run specifically for the benefit of its general practitioner membership.

Southland DHB has indicated that SLH will "be an integral part" of any new DHB initiated primary healthcare structure. SLH will, undoubtedly, be a strong advocate for GP interests. But that won't be for all GPs.

Locum GPs, an important component of the rural GP mix, are only temporarily on the scene and not likely to be interested in medical politics, so the voice of the trusts is unlikely to be heard, even through the GPs working for them.

And so to that "mutiny" meeting.

To be fair, trustees were invited, at very short notice, to attend. However, those of us present had no voting rights and left the meeting concerned that SLH was manipulating its membership to "mutiny". It succeeded.

Whether there is one PHO or two for Southland or Otago is probably no longer the issue.

SLH has made its move and effectively dismembered the PHOs.

The issue now is to what extent rural communities will be disenfranchised by an SLH-DHB axis of power. The painful and costly process of restructuring will recommence.

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