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Anne Else: The Wrong End Of The Stick, Again?

Anne Else's Letter from Elsewhere

The wrong end of the stick, again?
An open letter to Capital and Coast District Health Board


I see you’re calling for submissions on “Next Steps: Integrated Home and Community Care”. I’ve read the package of information available HERE and HERE (and you did kindly offer to post them to me instead). And I’ll make sure to fill in the submission booklet and get it back to you before 5 pm on 29th November.

But before I do that, I want to raise a few issues with you that don’t seem to be covered anywhere in the booklet or in all that information.

I’ve had a look back at the reports you’ve put out going right back to 2004, when you started discussing integration, up to Benedict Hefford’s November 2006 report to your (now departing) CEO on “Future Delivery of Community Based Health and Care Services”. (To view report click here.)
And I have to say I don’t feel very confident that you know what you’re doing.

To help deal with the expected growth in older people and in chronic health problems, you want to reduce (expensive) hospital and rest home admissions by changing how you provide in-home care services. But to do that, you want to make another move towards “integrated services”.

So you’re very concerned about the fact that there are now two main kinds of in-home services. The community nursing and allied care team operate out of the hospital. As well as specialist nursing, they provide district nursing, palliative nursing, advanced personal care, physiotherapy, occupational therapy, and other therapies, mostly to people who need short-term services.

For example, the hospital team assesses an elderly in-patient and decides that when she comes out she’ll need showering, special equipment like a walking stick and toilet seat, and physiotherapy. Its staff then provide these services.

Meanwhile you also contract three non-government organisations to provide longer-term “restorative services”. These are delivered as a “package of care approach”, through support workers, community nurses and allied health professionals. People using these services might also need, for example, showering, equipment, and physiotherapy.

Now you want to join the two together and base them in the community, away from the hospital, keeping only the specialist nursing there. This is not because you’re concerned about how well the hospital-based (HHS) provision is working. No, you want to do it “to improve the primary and community care sector’s infrastructure and organisational capacity”. The Hefford report puts it very clearly:

A re-balancing of the division of responsibilities between the HHS and primary and community providers is required if we are to improve the primary and community care sector’s infrastructure and organisational capacity. Services need to be structured so that the default providers are in primary and community care, rather than the HHS. The scope of primary care is constrained through the HHS having broad service delivery responsibilities in the community. Likewise, community providers, such as home care NGOs, have difficulty delivering a package of services focussed on restoration and goal achievement when most of the clinical workforce is HHS employed through separate funding arrangements. Many HHS community services came into being to address needs which could not be met in the community sector. This is no longer the case…

But what you don’t seem to know is that for many of the people who’ve experienced both services, this seems to be completely the wrong way round. They would certainly not agree that the community sector is now capable of taking over.

The hospital-based system is working very well indeed. Well-trained professionals working together promptly supply an excellent “package” of services. A support person who’s worked for this service for a long time thinks she can explain why it’s so successful.

First, it’s thoroughly professional, offering both annual training and updated specific training. Working alongside district nurses is invaluable in itself. Support workers learn a lot, there are clear lines of accountability, and they have a sense of “shared care” because they can report directly back to a district nurse if they have any concerns for a patient.

Their conditions of work are good too. They get the use (not guaranteed, but pretty regular) of a fleet car, and mileage if they use their own car. They get regular (though small) pay increases. And they get merit pay if they do extra training and carry additional responsibility. Being directly employed by the DHB gives them both support and authority.

Most importantly, they’re employed as “permanent part-time”, and guaranteed five paid hours each week day – so they have some certainty of income. They do not work for more than eight hours a day, or more than six days a week.

The community-based service starts with the Care Co-ordination Centre (contracted to Nurse Maude). It sends out someone to assess the patient (otherwise known as the client) when the HHS provision is due to stop (for example, after they’ve been out of hospital for a few weeks) and work out what they need. Then the CCC contacts the providers to supply this “package”. For personal care, like showering, the provider’s own assessor then turns up and draws up an agreed contract for service with the person needing it.

So far, so good. But that’s when the problems start. Assessing needs is just the beginning. Services then have to be supplied to meet those needs. I’ll say that again, in bold, to make sure you heard me: Services then have to be supplied to meet those needs.

As the DHB’s own consultation documents point out, there is an acute and growing shortage of health sector workers, as well as of the funding to pay for them. This shortage seems to be really bad in the community sector.

Community physiotherapists are stretched so thin that unlike the hospital-based ones, they don’t have time to actually take people through their exercise programme, even once. Instead they provide paper instructions for some of the exercises, and tell them to get instructions for others (like the Otago Falls Prevention Programme) off the internet.

Above all, there seems to be a huge problem keeping up with the need for passably competent personal caregivers, even in central Wellington suburbs. When a provider can’t supply someone to meet the assessed need for care, it seems to rely on the hospital-based service continuing to send their staff.

When they absolutely cannot go on doing this, the community service can be reduced to sending anyone it can find to fill the gap, even if they’re completely inexperienced and untrained (and therefore unsafe).

It’s not surprising that support workers are hard to get. Unlike their hospital-based counterparts, agency support workers are not guaranteed any hours, they just have to be available as and if required. Nor is there any cap on the number of hours they can work a week. If their patient is in hospital, they don’t get paid. So if they take on another one, they either can’t fit the original patient back into their roster, or they have to add extra hours.

Another problem is the lack of accountability. I don’t think CCC even knows if, months later, the designated provider has still not been able to meet the needs CCC has so carefully assessed.

You seem to think that shifting the current hospital based services to the community sector will help you solve workforce shortages – although you never mention the difficulties NGOs are already having in finding suitable staff. Nor do you discuss how these difficulties could be overcome.

What you do say is: “We want to improve our ability to recruit and retain nurses, support workers and therapists. We hope to achieve this by further developing an integrated team approach and community specific information systems. We also want to provide investment to support education, research and training in relation to home and community care services.”

Does that mean you’re going to make sure that community-based staff get the same kind of training, support and funding that the hospital-based teams already have? And the funding to cover this?

I doubt it. Because all your paperwork contains almost nothing positive about the excellent service the hospital-based teams provide now. All you focus on are the difficulties that their being hospital-based is supposed to be causing.

So I’m sorry, CCDHB, but I just can’t go along with your rosy “vision” of an “integrated” service. It’s perfectly clear from your previous reports that the main driver for wanting this change is cost. You expect to save money by cutting the community nursing and allied health service adrift from the hospital.

You don’t seem to have noticed what one of your own major reports states very clearly: “Cost savings from hospital diversion, hospital-at-home, home rehabilitation and (early) discharge services should not be expected” – not if these are properly done, anyway.

But here and there I found hints of how you intend to save money. You expect the changes you want to make will enable patients to take on more “self-care” - and unpaid family caregivers and low-paid support workers to do even more than they do now. For example, the Hefford report says:

In this type of sector we can expect to see visible changes to the way people work. Patients would firstly be expected and supported to self care wherever possible, and carers would be pro-actively supported in their role [my emphasis]. Professional boundaries and roles would shift, with more advanced nursing, allied health, and home and community support/carer roles. The model of care would become less task orientated and more patient goal focussed. This would see community nursing and allied health practitioners leading care teams by training, delegating, and supervising patients, carers and homecare workers wherever appropriate.

In other words, once they’d been “trained”, patients would almost never see a trained professional person any more? Doesn’t sound like an improvement to me.

As you know, it’s vital to measure the outcomes of any change. What worries me most is the answer you give to the vital question: “How will we know the new service model has made an improvement?” You say you will measure:

  • Number of referrals to the service by local areas and ethnicity

  • Number of packages (services) in place by local areas and ethnicity [do you mean actually in place, or just assessed as meant to be in place?]

  • Number of unplanned admissions to hospital including by ethnicity, identified conditions [presumably fewer is better? Yet we already know that Maori, for example, are not admitted as often as their health status requires]

  • Number of unplanned admissions to emergency department for identified conditions

  • Staff incidents [meaning?]

  • Patients incidents [meaning? And who will report these?]

  • Cost of community care per year and cost of residential care per year [what if there’s no difference?]

I need bold type to say what’s wrong with this:

There is absolutely nothing here to do with when or how the various kinds of care are delivered, or how the patients experience these services, or whether they and their family caregivers actually have improved wellbeing as a result.

Nor is there anything to do with staff recruitment, retention and job satisfaction.

But I guess I’m wasting my time, aren’t I? It’s perfectly clear from all your paperwork that you want me to tick Option 1, “Expand and develop Community Health Services by the Hospital forming a partnership to deliver fully Integrated Care Services (acute and chronic).” And if I do, you can’t even promise that your “partner” will be a not-for-profit organization - because you’ve asked me if I think it should be.

You’ve also made it obvious that Option 5, “Continue existing model that does not support full Integrated Care Services”, is not an option at all. All those reports plainly indicate that you made up your mind months ago, and now you’re just going through the motions so you can say you’ve consulted the community.

One more thing: the community nursing and allied care service currently has its own space at the old hospital. I gather that the plans for the new hospital don’t have any space allocated for it.

But I don’t think you’re going to get the answer you want from the community. And you might not have heard the last of us yet.


- Anne Else is a Wellington writer and social commentator. Her occasional column will typically appear on a Monday. You can subscribe to receive Letter From Elsewhere by email when it appears via the Free My Scoop News-By-Email Service

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