Journal of the New Zealand Medical Association, 23-June-2006, Vol 119 No 1236
The New Zealand Mobile Surgical Bus Service. What is it achieving?
Kevin Bax, Susan Shedda, Frank Frizelle
People who are better educated, have professional occupations, have higher incomes and do not live in socioeconomically-deprived regions are likely to enjoy better heath and live longer. This association between socioeconomic position and health is well-established.1
In general, New Zealand society values equality, including equality of access and provision of health care. Reducing health inequalities, particularly among Māori and Pacific Islanders, is at the centre of the New Zealand Government’s health agenda.2
Access to secondary and tertiary care for patients in rural communities has deteriorated considerably over the last 20 years in part due to hospital closures in rural communities. As a result of this there has been a decrease in the availability of the procedural services available to these communities within their own environment.
There is also increasing concern about the delivery to the Māori population.3 To combat these issues a mobile surgical service was developed with the aim to provide mobile interventional surgical services and try and address the issue of equable access to health care to rural communities and ethic minorities. Experiences in other countries, such as Ecuador and Brazil have shown the potential for mobile surgical service provision in isolated areas.4,5
A mobile surgical bus is operated by Mobile Surgical Services (MSS). The bus is a 20-metre long 39-tonne converted truck and trailer unit. It houses modern operating theatre and telecommunication facilities. It was built in Rotorua at a cost of NZ$5.2 million, the capital for which was raised by private investors. The New Zealand Heath Ministry has agreed to fund a pilot service project at a cost of $5 million per year for the next 5 years, a total cost of $25 million. (This budget is for 1000 day case procedures and 50 ½ day telepresence sessions per year.)
MSS produced a proposal document for the New Zealand Health Ministry, in which it was stated that there were 22 potential project benefits; they were:
Timely and community based access to a wide range of day surgical procedures:
Many of these goals are impossible to measure, however some are. This study reviews the initial 2 years’ experience with the bus and seeks to determine if it is achieving its stated goals.
Data about the use of the bus is collected prospectively by MSS, who has the service contract for the ‘Bus’. This data was provided by MSS and we analysed it. There was an average of a 30-day follow-up, with a telephone interview by trained nurses, attempted after every procedure (97% successful) (The service contract runs from October 1st to September 30th; however, the first procedure, in the first service year, was completed on March 8th 2002, and so for convenience 1 March 2002 was chosen as the starting point for the 2-year assessment, with 28 February 2004 being the endpoint.)
The outcome measures that we assessed were number and type of procedure, length of stay, complications, services for Māori, upskilling for rural staff, social benefits, impact on child health, improved training with telepresence surgery, and the cost.
The total number of procedures performed during the 2 years was 1901. A third of the procedures were dental. General surgery contributed over a quarter of the procedures, with the Ear Nose Throat (ENT) service performing a little over 10% (Table 1).
Table 1. Number and type of operations undertaken
Average length of stays—All procedures performed by the mobile surgical service are day cases; however, many rural patients having day case surgery in metropolitan areas require overnight stays because they, or their caregiver, cannot drive for several hours postoperatively.
Eleven patients required hospitalisation after their surgery in the 2 years; six because of bleeding and the remainder for a combination of medical and social reasons. The longest single hospital stay was 5 days; a paediatric patient, after a dental case.
Safety—Of the 1901 cases performed in the first 2 years, there were 57 complications, in total. Details are provided in Figure 2. The most common complication was infection with 40 cases reported. The General Surgical wound infection rate was 5.0%; which represents 25 out of 494 cases. Of the Other group, which consists of 6 cases, the problems faced by the patients included pain, nausea, wound dehiscence, and urinary retention (Table 2).
Table 2. Complications of operations
This is a quality improvement system, which is managed in-house and allows rapid changes when needed. There is a system for reporting and reviewing untoward events, and near misses. To ameliorate the increased risk of operating in a remote setting, and a major problem occurs without the backup of a base hospital, the bus is totally self-contained, and the surgery is on low-risk patients having low-risk surgery. If a major event occurs, then the patient can be transferred to the nearest base hospital after being stabilised.
Improved services for Māori—In the 2 years, 627 New Zealand Māori and Pacific Islanders underwent procedures; this represents 33% of all patients.
Upskilling of rural staff—Rural doctors (working in the areas that the mobile surgical service visits) have been invited to assist the visiting consultants when procedures are undertaken on their patients. This provides the local doctor with improved understanding of the potential of the service from both a surgical and telepresence point of view. There is also upskilling of the local nurses at small rural hospitals.
When the bus first arrived in rural areas, specific introductory training (using simulation in conjunction with National Patient Simulation Centre at Wellington) was undertaken. Rural staff are encouraged to staff the surgical nurse and recovery positions, therefore upskilling and maintaining the necessary expertise that may have been lost when many of the small secondary surgical centres were closed (visiting consultant staff see above). This contribution is intangible and immeasurable but appears to be a consequence of the delivery of this service to more isolated communities and their health providers.
Social benefits—A rural lifestyle has many benefits but access to health care is often limited by the ability to travel to major centre for more specialised services. Less time off school and work for patients and accompanying caregivers means that there is less disruption to the lives of these members of the community. In addition, less time spent travelling and staying overnight in motels in metropolitan equates to money saved. We have no quantifiable data proving this, however,
The ability to target services for child health gain—There were 754 paediatric patients (under the age of 15 years) seen in the mobile surgical bus service, representing 40% of all patients. Once again, this proportion is higher than the proportion (23%) of under-15s in the New Zealand population (according to the New Zealand census of 2001).
Improved training through telepresence surgery—Each year, 50 ½-day telepresence sessions are budgeted for; whether these sessions are national or international telecommunications is left to the discretion of MSS, and the availability of the necessary connections. In the period studied, 58 telepresence sessions were undertaken of which 12 were international.
The NZ$1 million telepresence facilities are used by the University of Otago for their Diploma of Rural Health Medicine. The virtual assistant has a remote broadcasting station, which is couriered to them; and through a joystick is able to control multiple cameras within the ‘bus’. A microphone and camera connect the assistant to two large plasma screens in the operating theatre via broadband technology. This technology has potential to improve education and service delivery in isolated communities and to allow contact between larger New Zealand hospitals and overseas hospitals.
Cost—Each case is funded NZ$1900, irrespective of the type of procedure performed.
MSS reports directly to the Health Ministry concerning the performance of the mobile surgical service. Monthly, quarterly, and annual reports are tabled and sent to the Ministry, for their assessment. Comparative assessment of the service is difficult, as available data from an equivalent mobile surgical service is to make comparisons is limited. Therefore, an analytical, rather than a comparative assessment was undertaken.
MSS are contacted to provide 1000 procedures a year, during the 2-year interval (1 March 2002 to 28 February 2004) the service did 1901 procedures. This disparity between aims and goals is most likely due to the problems inherent with setting up the new service and should improve with more time and experience.
The major advantages of the mobile surgical service are the social benefits it offers rural communities as well as its ability to target Māori and child health issues. Some of these benefits are difficult to measure, but the delivery of services to the rural population is vital.
One in three patients treated were Māori. This is also significantly higher than the 20.1% that New Zealand Māori and Pacific Islanders comprise in the general New Zealand population (according to the 2001 census)—thus indicating that the ‘Bus’ is perhaps better equipped to target Māori health by virtue of its ability to visit rural and isolated communities.
Recently, Ecuador has instituted a mobile facility and found that the provision of surgical services through this method is sustainable. They also concluded that this was a way of providing a high level of clinical services.6 This has also been endorsed by the health care delivery in Ecuador.7
The mobile surgical service appears to be addressing the important issue of equable access to surgical care.
Telemedicine is an important secondary use of the bus facilities which allows either a surgeon at another New Zealand or overseas hospital to watch and to verbally assist in procedures. Indeed, it appears to an important and perhaps expanding role in the provision of continued medical education and upskilling of services.8,9
The major disadvantage of the service is cost. At NZ$1900.00 per procedure, some procedures are expensive however providing equitable access was never going to be cheap. What has not been taken into account is the relative cost of sending rural patients to metropolitan areas for surgical procedures. Also, whether this is the best allocation of rural heath services was not assessed in this study.
The provision of specialist services to the rural communities is a difficult problem faced not only in New Zealand. This has been addressed by the introduction of an innovative service delivery method. Though still on a trial basis the mobile surgical service bus has extended the possibilities available and appears to be addressing one of the important goals of the Government health policy—equitable access to surgical care.
Author information: Kevin Bax, Surgical Registrar; Susan Shedda, Colorectal Fellow; Frank A Frizelle, Colorectal Surgeon; Department of Surgery, Christchurch Hospital, Christchurch
Correspondence: Professor Frank Frizelle, Colorectal Unit, Department of Surgery, Christchurch Hospital, PO Box 4345, Christchurch. Fax: (03) 364 0352; email: FrankF@cdhb.govt.nz
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