A hospital pass

October 24, 2009
An ambitious plan to overhaul Golden Bay's health services is threatening to turn septic. Geoff Collett reports. --------------------
IF YOU have to grow old, this wouldn't be a bad choice of places to see out the end days: propped up in a comfy armchair, gazing down on a tranquil corner of Golden Bay, with only the comings and goings of the tide in the estuary below as a gentle reminder that time is sliding away.
In the world of elder care - with all its depressing stereotypes of underpaid, overworked staff, cheese-paring bean counters, corporate nasties wringing out their profits, and fading oldsters reduced to cost-and- income units on a head-office ledger - up on the hill above Collingwood, the Joan Whiting Rest Home gives every appearance of being a blissful sanctuary from all that.
But appearances, and pretty views, can deceive. Financial wolves have been pacing at the back door for years. Other discomforting forces are gathering, notably plans for a new order in the Bay's health services, plans that are wrapped up in the sector's jargon ("integrated health care" is the one you're going to keep hearing) and presented as the way to a brighter future, but that have caused unease throughout the community.
Even Struan Clark, the Takaka GP who triggered the integration plan, is almost rueful as he reflects on the fallout from the bright idea he had more than four years ago to bring the district's core health services together, born out of mounting despair at the pressures of being a rural doctor in a sparsely populated community.
Why wouldn't you, he thought, take an over-stretched GP-based service, a modest community hospital and a struggling rest home; pool their assets, build a single new central base for them all; and get all the nurses, doctors and caregivers working together. It could even provide a solution to intractable problems, such as how to attract new doctors to the Bay, and the frustrations the GPs faced having to operate on call 24/7 with no-one to screen late-night callouts for them.
The Nelson Marlborough District Health Board, which runs the community hospital, was keen. So was the Nelson Bays Primary Health Organisation, which represents the wider region's general practitioners. An enthusiastic local community health group came on board. An architect was commissioned, exciting plans drawn up, bold ideas brainstormed.
But as word got out, not everybody was so thrilled or enthused.
As Harry Holmwood - retired dairy farmer, veteran community politician and chairman of the trust that has helped pay for most of the Takaka medical centre's needs - recalls it, the group behind the integration plan called two public meetings. In Takaka, the group was told to go away, come up with more details, and bring them back to the community. In Collingwood, things were feistier, to his recollection. "They told them to bugger off, go away and leave them alone."
That doesn't seem to have been the message the integrated management group (as it's known) apparently took away. It beavered away and came up with a business plan and possible organisational systems, right down to legal structures and staffing. Now, after false starts and missed deadlines, it is a matter of weeks away from revealing its proposal for the future health services of Golden Bay. Except that in the meantime, suspicion and scepticism in the community has only hardened.
Even Dr Clark admits he's been taken aback. "I've been amazed that something that started hopefully as a positive and commonsense solution to an issue has become such a source of division and unpleasantness, " he says.
He admits that sometimes he looks at the conflict it has unleashed and wonders whether it is worth it: nastiness in the community; tensions between GPs; anxiety in the workforce, especially among nurses who fear redundancies and pay cuts; potentially messy legal arguments over who owns what of the district's health assets; suspicion about what's really behind the integration plan; and fears that the Joan Whiting could finally teeter and fall.
It hasn't helped his own peace of mind that one of his GP colleagues, Vic Eastman, has emerged as an arch-critic of the integration plan. The district has been treated to the two doctors jousting through the pages of the local community newspaper and both men admit that the atmosphere at work has become unpleasant. "Right now we're alienated from each other, " Dr Eastman says. "They see me as a horrible person - I'm an obstructionist."
Dr Eastman is an expatriate American, a long-serving Bay GP who highlights a long, successful career in medicine in the United States before that. His wife, Liza, and daughter, Samantha, are other key players in deconstructing and, it could be said, seeking to demolish the integration group's plans (as much as they insist that they think integration as a principle is right).
Dr Eastman has written lengthy essays and responses challenging the integrated management group's approach. He especially poo-poos the focus on new buildings and shifting all services to one site: "It must be remembered that any money spent in Golden Bay for facility upgrades is money that cannot be used otherwise, " as he wrote in one of his earlier ripostes to the plans. Co- operation, technology and smarter ways of working are his prescription; he sees many of the wider issues the integration plan is trying to tackle (such as the fate of the rest home) as having their roots in much bigger, structural issues that demand attention far beyond anything Golden Bay can manage.
He produces spreadsheets to show the financial burdens a new health centre could carry (estimated building costs have not been made public but are widely rumoured to be $6 million to $8 million). He speaks unyieldingly of his determination that his ethics and obligations to his patients will guide his decisions, and disdainfully of the lack of lateral thinking shown by the integrated management group.
"I'm totally befuddled by the direction they're taking. They've come up with so many plans and most of them are very defective or highly inadequate. They're reinventing the wheel, over and over and over, rather than coming at it from another direction."
Even Dr Clark - perhaps the biggest champion of the integration plan for Golden Bay - admits that the further it has gone, the tougher it has got. "It's complicated - more complicated than what I dreamed of when I started."
It is also, at times, emotional, not least when the fate of the Joan Whiting is the matter to hand.
While it has been a rest home proper for fewer than 20 years, the sprawling white building on the hill above Collingwood served as the local community's cottage hospital for two or three generations before that. Many of the locals were born there, or have had loved ones die there. The sense of ownership, particularly in the immediate environs, is deep and determined.
"It's a hugely emotional situation, " says Chris Mitson, who six weeks ago became chairman of the rest home trust, "because it seems whatever we do, somebody is going to hate us. If we close the rest home, everybody will hate us.
"If we go to integration, the people who cherish the Joan Whiting as a community asset will hate us. If we don't go into integration, people who see that as the brave new world will hate us.
"We're in a lose-lose-lose situation."

WHAT'S AT STAKE
Golden Bay Community Hospital - no emergency care, but provides geriatric and maternity services, among others. Owned and operated by the Nelson Marlborough District Health Board. About 15 years old and the DHB says it has no plans to reduce services there.
Golden Bay Medical Centre - general medical practice in Takaka, shared by the Golden Bay district's four GPs (who work as independent businessmen), who provide the core of medical and emergency care in the district. The premises are vested in the Tasman District Council but have been funded by the Golden Bay Medical Centre Trust, and the council and trust are negotiating over who will control the proceeds if the centre is sold. The centre is too small and showing its age, and the trust has been keen to build a new medical centre at nearby Rototai Rd.
Joan Whiting Rest Home - the Bay's only resthome, with 17 beds, owned by a community trust and funded solely by income from residents, plus various grants and occasional fundraising.

WHAT'S PLANNED
The Golden Bay integrated management group has drawn up detailed plans but has not yet made these public, although various versions have been circulated among interest groups. The plan is based around joining the three main health facilities on one site in or near Takaka; either Rototai Rd near Golden Bay High School, or at the community hospital (about 1.5km from Takaka town centre heading towards Nelson), or at Park Ave, East Takaka.
The new centre would be staffed 24 hours a day and include resthome beds, some medical care beds, maternity services, GP services and the like. The integration group is said to be registering a trust, which would be the overall owner of the new centre; and contract the Nelson Bays Public Health Organisation to manage it and employ the staff.
Services would be funded from various sources such as the DHB, the government (for resthome beds), and patient charges (for GP care), as happens now.
The proposal is expected to be unveiled in November and public consultation organised.
Mr Mitson, a former television journalist who lives in Collingwood and states his occupation as "beachcomber", keeps pointing out that the problems that have hobbled the rest home and the trust for so long are not Joan Whiting's burden alone.
Small rural rest homes everywhere struggle because they don't have the economies of scale to cope on the funding provided by the government, particularly not when basic costs have soared. In the cities, rest homes have been forced into all manner of strategies to survive - selling out to multinational conglomerates, getting into property development through building self-contained retirement "villas", screwing pay rates down.
At Joan Whiting, none of those options have been available. A new group, the Friends of Joan Whiting, has lately cropped up and is hoping to stitch together something to make the place more self-reliant. There is talk of adding more rooms to bring in more business, but no-one is sure if the demographics stack up. And it is running out of time.
Over the past couple of years, the gap between income and outgoings grew so wide that the rest home became all but insolvent. The DHB came to the rescue, agreeing - as it has been keen to make clear, with no legal obligation - to pay Joan Whiting about $11,000 a month to keep it afloat. The quid pro quo: the rest home had to join the investigation into an integrated care model.
The money flow stops on December 31. The DHB says that if the rest home commits to going with integration, it will help it find ways to stay afloat for as long as it takes to get a new health super-centre built, including rest home beds. Then, presumably, Joan Whiting will close, and the land and buildings will be sold. If Joan Whiting decides to go it alone, it really will be on its own.
It might sound like an offer they can't refuse, but DHB chief executive John Peters insists: "This isn't blackmail for them [Joan Whiting] to come into the integrated group. That is entirely and utterly their choice."
The DHB inevitably looms large above all that is going on around the Bay's health services, which may seem obvious given its dominance in the health sector, but which the DHB itself seems vaguely uncomfortable about.
Mr Peters' core message is that the integration project will stand or fall on community support. "We're an invited participant, if you like, more than being a driver behind it . . . We didn't initiate it; we've been very happy to support it and we'll continue to support it, but only if the people of the Bay want it."
As it is, Mr Peters has ended up chairing the integrated management group but is at pains to distinguish between that and his chief executive's role.
Over in the Bay, more than one of those in the thick of the debate describe his style at public appearances as "smooth". It may not be intended entirely as a compliment, but as should be expected from the region's senior health bureaucrat, he's an adept operator, unwavering in the line that there's no DHB takeover going on here.
But some in the Bay think that the DHB should step in and assume some more responsibility: nurses, for one.
They fear that all this talk of a community-driven service will leave the community carrying the can if a reorganised health service hits trouble - say, a big funding cut down the track, or if the debt burden proves unbearable.
Members of the nurses' union, the New Zealand Nurses Organisation, in the Bay last week issued a statement opposing the idea that a community- based trust may take over as their bosses.
Their organiser, Jackie McGrath, says the nurses want to stay employed by the DHB, and so stay part of the nationwide nurses' employment agreement with a public service employer. It gives them better security, certainty, and obvious strength in numbers. Assurances that no-one's pay will be cut in the first two years if the integration project goes ahead don't carry much comfort.
The experience just over the hill in Motueka hangs heavily here.
There, the community pitched in to build a new health centre and community hospital after the DHB announced it planned to pull out of the town. A trust was formed, a formidable fundraising drive organised, the result widely hailed - except by those dismayed when the town's nursing staff were told they would have to apply for new jobs for less pay.
Even John Peters admits Motueka's approach isn't a helpful example for those now trying to convince Golden Bay people to take more ownership of their health services.
"I wouldn't draw that parallel [with Motueka] because that parallel will raise visions of sausage sizzles and cake stalls, and that is one of the differences that I think characterises the Golden Bay situation compared to the Motueka one. We would be reluctant to have that reflected because I think that would be, A, inaccurate and, B, of concern to the community, because we've stated all along that there won't be sausage sizzles or cake stalls for this."
Doing it Golden Bay's way, though, means that Golden Bay's ways become unavoidably part of the stew. So it is that some deep-seated suspicions and arguments are bubbling up: for starters, arguments over who really, rightfully, owns the assets the integrated model will be relying on for its start-up capital.
The ancient enmities between the Takaka and Collingwood ends of the Bay will surely play out, for the umpteenth time. Meanwhile, there's a scrap yet to be had over the best site if a new one-stop health centre is eventually built. Old arguments about which parts of Takaka are flood-prone are being dusted off.
And, of course, there is suspicion about outsiders and newcomers, best summed up by Harry Holmwood: "A lot of people on the [integrated management group] are only five- minute wonders. They're self-selected. Apart from one, they haven't been in the Bay very long.
"Their intentions may be good, but I've seen it all before. They come here and try to change things, and then bugger off and leave us to fix the mess."
Back in Collingwood, Chris Mitson is obviously warming to the challenge he has accepted with the Whiting trust, as vexing as it may seem. He makes the point that the trust board "has a reasonable amount of business expertise - we aren't blind and we aren't naive". Still, he can joke that the rest home's best option, if it doesn't go with integration, would be a miracle.
The trust is not committed to integration, not yet - judging by others' comments, what it has seen of the plans so far seems to have caused it to balk, and Mr Mitson says the trust won't accept "a couple of corridors plonked down in the middle of a hospital" as adequate substitute for a proper rest home.
On the other hand, he won't let the Joan Whiting's magnificent setting and all the warm feelings that evokes sway matters either.
Then again, you could be forgiven for not being able to look past that setting. He dons a tidy jacket for a photograph - to look less the Collingwood beachcomber, more the guardian of a community's cherished rest home - and heads up the hill to Joan Whiting.
The sun comes out, the tide rolls in to the estuary below, and it becomes very hard to imagine a better place to spend the end days.
Everyone here, Mr Mitson accepts, is worried, even those who have "lived on the knife edge for so long that [they] seem almost to regard it as a normal state of affairs".
How are the residents coping? They can't help but be worried, he says.
"Because it's not a hospital. It's not a facility. It's their home. We're talking about their home."