Is Bellingen hospital safe?

I received an email during the week from a colleague concerned that the campaign to save/redevelop Bellingen Hospital was losing traction in the face of national changes to health services, apparent promises from the authorities and, I suspect, sheer tiredness.  In this context, the Bellingen Hospital Action Group (BHAG) apparently put out a statement at the end of last year saying they had a commitment from the North Coast Area Health Service to keep the acute beds in the hospital and that the job was done. You will find some of my past posts on this campaign here.

I am not close enough to on-ground issues to make a response on the specifics in the email. However, noting that the BHAG web site is now down, I thought that I should make some general comments based on my own experience. In particular, I feel that now is just the time when those served by the Hospital need to be most focused. This post explains why.

Impact of National Changes  

Back in April last year in Implications for New England from health reforms I took Bellingen Hospital as a case study. There I said in part:

One of the problems for New England from the changes is just what the changes might mean at local level. This is quite complicated, but I think that locals need to watch this like a hawk 

Since that post, I have tried to monitor the on-ground effects of the changes across New England, but it is quite difficult without detailed investigative reporting of a type beyond the resources of a part time blogger. However, my view remains the same. We just don't know how things will work in practice.

Mid North Coast Local Health Network & the formation of Government Policy

The new Mid North Coast Local Health Network came into operation on 1 January 2011. Very little information is yet available on its web site. Members of the Governing Council are listed, but no information is provided that I could find as to their background.

In two Armidale Express columns last year,  Belshaw's World - true wisdom rarely the sum of bland numbers and then Belshaw's World - round holes, square pegs and a region cruelled, I looked at the way Government policy is formed. 

While the new Network is smaller and has its own Council, while there is meant to be greater local input, the reality is that it is still operating in a highly centralised system, all the statistical data and planning reports on which past policies were based are still there, as are the people who made the planning decisions.

All the national agreements governing the new system with their myriad of performance statements were negotiated and will be implemented by just the same officials involved with previous policies. You can think of all this as an inverted pyramid whose point rests on the hospital. It would be unrealistic to expect much to change.

Continuity of Official Memory

Officials have quite long memories. If they fail to get things up one way, they will do so another. Let me illustrate by example.

Some years ago, the Commonwealth Government formed the view that Australia needed fewer but larger tertiary institutions. As so often happens in health, this was applied as a one size fits all approach.

As part of the process, the Government announced that the Armidale College of Advanced Education and the University of New England should merge. There was no justification for any small centre to have two tertiary institutions. Further, merger would save money by reducing the overhead associated with two institutions, the economies of scale argument.

I was opposed to the decision because the culture and missions of the two institutions were different, while I doubted the validity of the policy arguments. A friend and I organised a protest that culminated in a public meeting attended by several thousand people. The proposal was shelved. However, the official view had not gone away.

The proposal was resurrected a little later by the subsequent Hawke Government on advice from the same officials. This time it went through. Since it was intended in part to achieve economies of scale, the combined funding of the two institutions was reduced by an amount equal to the expected savings. No allowance was made for the costs of merger. The end result of all the changes was something of a disaster that almost destroyed the University of New England.

The Importance of Persistence

If what I say is true, why bother? Surely locals are powerless? Not so.

If you want to do something new, if you want to achieve change, then you have to be persistent. It may be that you will fail in the longer term, in which case you only get some short term gains as happened in the Armidale case. Still, in writing the history of the broader New England as I am at the present time, a remarkably large number of things were achieved by local or regional action undertaken in the face of entrenched opposition.

The Problem of Capture

Anybody dealing with Government faces a problem of what we call capture.

Ministers and officials have positions, refined arguments and lots of supporting information. Faced with entrenched opposition on a matter, they try to find find a path through. This includes giving concessions. 

On the other side, those dealing with Government generally cannot help being influenced by discussion and argument. Depending on persistence and relative power positions, the outcome moves towards some form of compromise. One side-effect of this is that the opposition actually ends up being captured by official thinking.

This is not necessarily wrong. However, it carries the risk that people will give up at just the time they should be persistent.

I am not suggesting opposition for the sake of opposition, nor that compromises should not be reached. Indeed, from my experience, one major problem with local activism can be the unwillingness to accept any middle path. Sometimes this works. More often, it can lead to total failure. It's a matter for judgement as to the best path.

The key thing is to be aware of the strategic issues involved. Some issues, a dam for example, may be yes/no. Others like a hospital are much longer term. These issues inevitably involve both compromise and persistence.

Burn-out and the Long Term Activist

Unlike governments, lobby groups or political parties with their full time staff, community activism depends upon volunteers. This makes it very difficult to keep long term pressure up. People, and I am speaking from my own experience, just burn out.

There is no easy answer to this. Sometimes it just happens. At other times, changes in direction are required to give people a break. Bellingen may well be in this position now.

Looking Forward

I think that BHAG has actually done a pretty good job through its own efforts and in providing a centre around which others could coalesce through, among other things, the Facebook page. There is no doubt in my mind that Bellingen Hospital would have lost more services without this effort. However, the story does not end here.

The fight over Bellingen Hospital was never about a single service. Rather, it was an attempt to maintain the best range of possible services. The fact that the old North Coast Area Health Service has given an undertaking re emergency beds is a first step that needs to be monitored. The focus should now shift to other services and the maintenance of community  support for the hospital.

I have written this post just from a Bellingen perspective. However, there is a broader issue.

Australia is short of doctors. The desire of the NSW Government to save money, to gain greater economies, has actually led to a sharp decline in certain types of medical training. The positions have gone.

Here we have a conflict between two objectives, immediate economy and efficiency on one side, longer term doctor supply on the other. Today, there is a fair bit of discussion about the best way of re-building medical training to increase supply. This requires new approaches.

Training cannot be done just at major base hospitals. We need a hierarchy of hospitals linked to different types of training. This is where a hospital like Bellingen could come in.

Update on The Save Bellingen Hospital Campaign

It's been a while since I reported on the campaign to Save Bellingen Hospital.

If I understand the campaign Facebook page and official website correctly, real action on the official side appears to have been in a state of stasis pending the formation  of the area health network, with campaign actions focused there plus continuing efforts to help the hospital.

In the meantime, problems at Coff's Harbour continue the pressure to re-open Bellingen Hospital's Emergency Department. I thought here that I would just quote a recent entry from the Facebook page.

Jenny Edman: Have just read todays Advocate, so a few weeks ago Coffs Campus was inundated with sick people, surely that should send a message to the NCHS that Bellingen needs to open it's ED department, if our locals had to travel all the way from Dorrigo or Bellingen to have to wait up to 9 hrs to be seen by a Dr is ridiculous, shame a 100 fold on NCHS, until next year it is still working for the mid north coast.

Frank Bolte: What do you mean Dorrigo people can't even get to bello or C/h Monday to fridays during the day. Waterfall way is closed. I feel sorry for them

Mary Peters: i waited five hours / ambulance refused to take me to bello hosp! i wasnt seen i got back to bello myself for injection because of anaphalactic reaction! im disgusted... as i could see for myself how many ppl in waiting and in ed / no one saw anyone in that five hours where was the doctors! four nurses pushing an empty bed laughing and police standing there with ambos discussing how bad the system is all in earshot of the patients / simply a disgrace really!

Tasha Lee: What about dundurrabin thats 20 mins from dorrigo. i am due to give birth in febuary thats a looong drive to a woman in labour and i read last week there wasnt even a peadeatrician on duty for a full week they were sending women to john hunter hospital to give birth. now if i even make the hour and a half trip down the mountain into coffs im not going to make it to john hunter especialy considering my last daughter was born in bello 20mins after i arrived total labour time 1hour 20 mins. not knowing where my baby will be born is causing a great deal of anxiety for me

For those who don't know the area at all:

• When the mountain road is closed, the nearest hospital to Dorrigo is in Armidale, 124k or 1hour 40 away by car. 
• When the mountain road is open, Dorrigo is 29k, roughly 21 minutes, from Bellingen. If you come from other parts of the Dorrigo such as Dundurrubin, then extra travel time is involved; Dorrigo sits at one side of the Plateau adjacent to the escarpment to the coast.
• Bellingen is 35k, 32 minutes from Coffs. Dorrigo is 64k from Coffs, 53 minutes, plus any travel time from elsewhere on the Plateau.

All distances and drive times are approximate depending on location and weather.

Some of these drive times may not so sound long to Sydneysiders with the city's traffic congestion. However:

• Those in the area have seen the closure first of the Dorrigo hospital and then the downgrading of Bellingen Hospital through centralisation of services, adding to the time and difficulty of accessing hospital services. Obviously, those on the Dorrigo plateau have suffered the greatest impact.
• Coffs Harbour Hospital is large and over-stretched. There are simply not the alternative nearby base hospitals that you would find in Sydney. John Hunter, the other hospital mentioned, is in Newcastle, a five hour drive away. If you have to travel that distance, I would have thought Armidale a better option, although it may not have the capacity.
• Not everybody has access to cars. Public transport is limited, taxis expensive. I am not sure how many ambulances are available, but I would have thought that the number was not large relative to potential peak demand.

The crux of the Bellingen argument, then, is not just that they have been losing services, but that everybody in the Valley and on the Plateau, and indeed the whole Coffs Harbour hospital catchment area, would be better off if certain services were restored to Bellingen Hospital.

Proposed boundaries for the NSW Local Health Networks

The NSW Government has announced proposed boundaries and operating arrangements for the NSW Local Health Networks required under the Rudd-Gillard national hospitals plan. The following graphic shows the boundaries and towns covered.

At this point I have not had a chance to make my own assessment of the proposals. Those who wish to make their own assessment can find the discussion paper here. 

Update on Tamworth GP shortage

In February, in Tamworth GPs close their books I reported on the growing shortage of GPs in Tamworth. Two stories from the Northern Daily Leader provide an update - here and here. 

A few statistics from the two stories:

• There are currently 42 GPs in Tamworth including part time professionals, equating to 32 full time GPs. Tamworth is short at least 12 GPs.
• Between 1997 and 2007, 1.5 specialists joined the work force for every GP, while the number of specialists in training doubled.
• The GP ratio for NSW is one GP for every 1035 people. In Tamworth, the ratio is one GP for every 1699 people.
• Nationally 88 per cent of GPs live in cities where they provide services to 66 per cent of the population.

The GP shortage is not, of course, limited to Tamworth.

I discussed a few of the reasons for the shortage in my February post.

One of the key issues, one referred to in the latest stories, is life style. This is not so much a question of city v country, although that is an issue, but rather changing expectations and gender structures in both city and country. This means that we need more GPs than before to service the same population. Where, as is the case in many country areas, the existing medical workforce is aging, then problems compound.

There are no easy solutions. Even with increased training in regional areas, it will take a number of years before the problem starts to ease. Just to put this in perspective, UNE's School of Rural Medicine (the closest) presently has around 118 students. The current Tamworth GP shortage alone equates to 10 per cent of this number.

New England hospitals under threat Rudd reforms

The following is a list of New England hospitals that are reported to be under threat as a consequence of the Rudd Government health proposals.

Inclusion does not mean that they are, simply that locals need to focus on them. 

District Hospitals

Ballina, Bulli, Casino and District Memorial, Cessnock, Gunnedah, Inverell, Kempsey, Kurri Kurri, Macksville, Maclean, Moree, Murwillumbah, Muswellbrook, Narrabri, Singleton, Bellinger River, Byron Bay, Glen Innes, Gloucester Soldiers' Memorial, Quirindi, Scott Memorial Hospital, Scone, Wauchope.

Community acute surgery

None

Community acute non surgery

Bonalbo, Bulahdelah, Campbell Hospital Coraki, Cobar, Coonabarabran, Mullumbimby War Memorial, Nelson Bay and District Polyclinic, Tenterfield, Walgett, Wee Waa.

Community non acute

Bingara, Dunedoo War Memorial, Dungog, Guyra, Manilla, Merriwa, Tingha, Walcha, Warialda, Wilson Memorial Hospital, Murrurundi.

Psychiatric hospitals

Morisset

Nursing Homes

Bourke District Hospital,

Multi-Purpose Hospitals

None

Sub Acute

'None

Continuing troubles at Bellingen Hospital

Just a very short one today.

I see that the problems faced by Bellingen Hospital have now made the Sydney Morning Herald. Reading this story and all the previous stories over recent months, I do wonder about the North Coast Area Heath Service.

I don't mean anything sinister by this, nor is it a criticism. It's a genuine question.

Looking back, it's an interesting case of a problem that seems to have spiraled out of control. The Area Heath Service has made several statements and has apparently sent representatives to Bellingen, but things just seem to get worse.

I don't believe that North Coast Area Health Service staff are either incompetent or uncaring, yet they really seem to have been blind-sided. In saying this, I accept that I am working from imperfect information.

The North Coast Area Health Service is a big organisation. I do wonder whether in trying to run a big system under financial constraints that effectively force them to rob Peter to pay Paul, the small Bellingen Hospital was simply so far down the pecking order that they couldn't focus until too late. And then they tried to temporise.

Looking at the newspaper reports on obstetric services, for example, the Area Health Service appears to have stated that it did not intend to close them, but were struggling to find trained staff. There were no reports that I found that explain what they were doing to resolve the problem. In the meantime, obstets at Bellingen has been effectively closed.

From the viewpoint of locals, there appears to have been a constant gap between official statements and the way that things are actually working out on the ground. The result is a loss of trust.

In saying all this, I emphasise again that I am working from limited knowledge. While I know a bit about the world in which the North Coast Area Health Service has been forced to work, I simply don't know enough about its internal workings to be sure of the dynamics.

Tamworth GPs close their books

The Tamworth Statistical District - this includes the main urban area and its immediate surrounds - had a population of 42,499 at the 2006 census, so we are not talking about a small centre.

The Northern Daily Leader now reports that existing Tamworth GPs have effectively closed their books, unable to accept new patients. The story takes place at the same time as debate about the future of Bellingen Hospital reaches a new peak (here and here). As an aside, the Save Bellingen Hospital Facebook page has now reached 2,440 fans!

The NDL story includes some very thoughtful comments from Graeme Kershaw, CEO of the North West Slopes Division of General Practice.

I thought that I might take Graeme's comments as an entry point for some comments of my own, focusing on the different elements of the complicated mess we have created for ourselves. These draw from my own experience as CEO of a specialist medical college, as well as later work force analysis.

Graeme refers to the monumentally stupid decision of the Federal Government to cut back on the number of places for doctors in training back in the 1990s. Then Minister for Health Michael  Michael Wooldridge concluded that there were too many GPs and that this was leading to over-servicing, increasing Medicare costs. Training places were cut as a result.

While this was a silly decision, Graeme is correct to suggest that it is only part of the problem. He says first:

“Many trainee doctors are going into the specialities like surgery and internal medicine – not surprising really; while they are training in hospitals they are taught by these same specialties that encourage them to follow in their footsteps”

“Even in doctors who are raised and trained in rural areas, up to 50 per cent choose not to become GPs.”

Let's disentangle this one a little.

In general, not always, specialists get more money than GPS and attract higher prestige, so it's understandable that doctors, and especially those with an academic bent, should be interested in specialisation.

The attempt to create a speciality of general practice has not, to my mind, worked very well. This "specialisation" has in fact added to the hoops that those interested in general practice have to jump through, without affecting the relativities between general practice and the more traditional specialities. To this extent, it may have actually reduced the incentive to become a GP.

I can't judge the validity of the comment on rural training without knowing the equivalent figures for metro trainees.

The extension of medical training at non-metro universities is actually quite recent. My feeling is that things such as the new rural medicine course run by the Universities of Newcastle and New England in combination will have a positive impact.

A central problem, one that applies even more to longer specialist training, is the interaction between partner and family formation and the location and length of training.

People acquire partners from those they are in contact with. As time passes, it is more likely that partner relationships will become long term, including marriage and kids. Increasingly, locational decisions have to take partner considerations into account.

It seems clear that metro born kids are less willing to move to regional areas than country kids. The longer the training in metro centres with their heavy preponderance of metro students, the more partnerships form, the less likely subsequent movement.

This actually affects less prestigious areas in the metro centres as well, with surpluses of doctors and other health professionals in some areas, major deficits in others.

Graeme continues:    

Doctors from the “baby boomer” generation received their medical education for free.

“Generations X and Y come out of their training with large HECS debts to repay and they won’t feel the same obligation to the give back to the community that ‘boomers’ once did,” Mr Kershaw said.

This one is hard to measure, although I suspect that Graeme is right. People are influenced by a sense of altruism and community obligation. If you have paid for yourself, the obligation is reduced.

Graeme then looks at service cut backs in local hospitals:

A lot of hospitals in small communities no longer provide obstetric services locally, so they won’t attract the type of rural doctor they once would; someone who wants to deliver babies as well as look after the diabetes and the heart problems.

This is part of the Bellingen Hospital case. Take obstetrics away, and you reduce the practice range of local doctors. However, there is a broader issue as well.

The "specialisation' of medicine in combination with changing approaches to medical indemnity has reduced the willingness and probably capacity of GPs to provide certain services. My tonsils were removed by a GP. Today my parents would have taken me to a specialist. That's fine, but doesn't help much if a specialist is not available.

Graeme finishes:    

“GPs are treating much more complex problems, often associated with long-term diseases, than they were 10-20 years ago,” Mr Kershaw said.

“They are doing this at a time when hospitals are developing therapies that mean that people are not in hospital as long as they used to be, and they are discharged back into the care of their GP.

“As a result, GPs cannot see as many people per day as they may have been able to 20 years ago and so, with less people seen and less doctors available, waiting times are increasing.

“GPs realise that they have an ongoing obligation to their existing patients and because of this, have to stop taking new patients.”

Again, I suspect that Graeme is right and the that the problem is going to get worse with an aging population. This adds to the complications, especially in inland areas with limited doctors and an aging population. 

Bellingen Hospital, Facebook and the costs to the community

Yesterday in Bellingen organises to save hospital I reported on the campaign to save services at Bellingen Hospital.

It's been very interesting watching the unofficial Facebook page formed to support the official campaign site. This was created on Tuesday 9 February. As of this morning, it had 812 fans. That's a very rapid growth in such a short time.

The first challenge in a local campaign of this type is to demonstrate local support. The Facebook provides a tangible measure of this.

The second challenge is to spell out the reasons why people want the particular result, in this case saving the hospital's facilities. The official campaign has been doing this, but the Facebook page provides lots of specific examples. It personalises the general arguments.

It also provides information that can be used directly in scoping need. Let me illustrate this by example.

  Health planners work with the statistical data they have. This includes census data and health system data including hospital admissions. They are concerned not just with the now, but also the future. Here they use projections that by their nature reflect the past.

There are several difficulties with this approach: one lies in the weaknesses of the statistics themselves; a second is the inability to identify and properly analyse the on-ground effects of decisions.

Looking at the Facebook comments, the examples might be used to draw up a table of adverse effects.

It is clear from the comments that Bellingen Hospital serves a catchment extending from Ebor in the west to Urunga in the east. This broadly but probably not exactly equates to the LGA boundary. In broad terms, the catchment boundaries are set by the travel time to Bellingen compared to the bigger hospitals in Armidale on the west, Coffs in the east.

The first effect of any reduction in services will be an increase in travel time. This will be differential across the catchment and can be mapped.

Dorrigo, for example, is roughly 29k or 26 minutes by car from Bellingen, 124k or 1hr 40 from Armidale, 66k or one hour from Coffs. So any reduction in Bellingen services means increased travel time for Dorrigo people of 1hr 14 in the case of Armidale, 74 minutes in the case of Coffs. The extra cost to patients can be calculated. 

Travel times then need to be adjusted for the availability of public transport for those who do not have cars or who must travel by public transport or, alternatively, taxis. Extra time and costs here can also be roughly estimated. Another health cost may be the failure of people to seek treatment when they should, simply because its too difficult.

Travel times also need to be considered in terms of type of illness or accident. Again, the Facebook pages provides personalised examples to be considered. For example, what happens if your child has a sudden asthma attack?

The extra costs of ambulance travel can also be roughly estimated.

This analysis addresses just the direct costs. There are also broader community costs, including access to other Government services. For example, the supply of social housing may be affected because one of the key criteria here is access to services.

No doubt many of these issues have already been picked up by those fighting to save services at Bellingen Hospital. However, the new Facebook page provides extra evidence.

Finally, one of the points that I always try to make in cases like this is that Government policy focuses on the savings to Government on one side, the broad nature of services on the other. The cost shifting to local communities is rarely taken into full account simply because it is harder to measure.   

Bellingen organises to save hospital

While I have never lived in Bellingen, I have known the town all my life and written about it on this blog a number of times.

Bellingen now faces a threat to its hospital services and the locals have organised to try to save it. You will find the Save Bellingen Hospital web site here.

The Bellingen Hospital case is an example of the increasing conflict that has arisen between the needs of centralised service delivery on one side, local needs and indeed history on the other.

To health planners concerned about value for health dollars at a time of budget stress, the idea of rationalising services across broader areas appeals greatly and has done so for a number of years. However, there can be a fundamental conflict between this and local aspirations and needs.

To the health planner, a local hospital is a piece on a chess board to be moved or given up in the interests of the greater game. To the local, the hospital is an integral part of their life. They have worked for it, they were born there, their children were born there, family and friends have died there, they have visited it many times, they know the staff.

You can see this clearly if you look at the newly established Save Bellingen Hospital public Facebook page. Just a few quotes:

• Marguerite: Bellingen Hospital was a very decisive factor in my sea change from Sydney to Bellingen over a decade ago. As a single mother with a young asthmatic child I needed to know that I could access an emergency service, that was close by, no matter what time of day or night. I have indeed used the service many times and wou...ld feel that the community would be robbed of this asset . Although my daughter has since grown up and moved away. I would like to see the hospital survives this senseless closure, ensuring its fantastic care for others with high health risks.
• Briony: I broke my shoulder bone, from a horse riding accident way back when I was about 12. I was treated at Bellingen hospital, they were very good to me!!
• Hannah: I had may major asthma attacks at Bello , they saved my life more than once, and there was never a wait x.
• Laura: My mother and auties were born in Belligen Hospital, all my 7 brothers and
  sisters and I were born at Bellingen Hospital, 2 of my 4 children were
  born at Bellingen, For 1 i was forced to go to coffs due to bellingens
  services being down graded and just 7 months ago I gave birth at home
  because it was the only option that suited my family situation. Neither me or my husband drive and many a time we have needed to catch a taxi to make the 4minute trip to the hospital in
  the middle of the night when our little pumpkins have been ill. Catching a taxi to coffs or having to wait for a ambulance in the middle of the night is not only unnecessary but could be life
  threatening. Please keep the hospital services we have and my wish is
  that they will go back to what they were.
• Tokana: I know that I've always gone to Bellingen Hospital, even f I needed to be transferred. I will have my children at Bellingen Hospital one day. I love and appreciate the wonderful staff who put in long hours and never complain at what they do -but they do complain about the wages not being enough for the amount of time they put into the hospital and their patients. They also make you feel welcome and important. They're always friendly to patients and each other, and they tend to your needs. SAVE BELLINGEN HOSPITAL!!!!
• Carol: They should go back and read or listen to the The Elders from the Indiginous people of this land as a lot of our relatives use to walk the back road from Bowraville to Bellingen Hostpital to have there babies. My three grand children were born in Bellingen Hostpital and all the Doctors and Staff have always been there for me when I neeed there help SOOOOOO p[LEASE don't close our wonderful hostpital down as the whole Community needs the doors to be kept opened.
• David: As we recently had our hospital closed down in Cowes, I feel for you. Can't these idiots get their priorities right?

If you look at these comments, you can see the way people still love and trust their local hospital at a time when distrust in health services and hospitals has been on the rise.

Over time, the inexorable centralisation of health services has weakened local hospitals. All country people know this. They have seen services withdrawn, forcing them to travel increasing distances for service if indeed they can travel. Not everyone has a car, and public transport is often poor.

This has economic and social effects and actually increases the normal dangers of life. If the Bellinger River floods as it does so often, then access to Coffs may be cut. It becomes harder to attract people to live in specific communities. It becomes harder for older people who may need care to stay in their communities.

One might accept some of these outcomes if country health services were delivering better results. However, the reality appears to be a growing gap in health outcomes between country and metro areas.

Given the fundamental disconnect between the models currently used in health planning and community needs and aspirations, the only weapon available to locals is protest. This is the reason why the Bellingen community is looking to attract as much support as possible for the preservation of the local hospital.

You can help them and also follow the cause by joining the Save Bellingen Hospital Facebook page.