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The World Health Organization (WHO) has identified lack of rural health workforce as a major barrier to universal and equitable health coverage.1 Rural hospitals throughout New Zealand and internationally face difficult challenges related to workforce retention and recruitment.2–5 Moreover, there has been a tendency within health services to focus on specialised, urban-based services in terms of policy, funding, reporting expectations and service planning. Internationally, rural hospital viability has been under threat from declining rural population and economic activity,6 and a reduction of rural health infrastructure and centralisation of services.4 When public hospitals were corporatised as Crown Health Enterprises, many New Zealand rural hospitals were closed as they were considered to be inefficient and expensive.6 Unsurprisingly, rural communities resisted changes to their healthcare services. Closure of the sole rural community hospital has been shown to be associated with increased local unemployment and reduction in per capita income,7 decreased access to healthcare for the population8 and increased travel time to health services.9

In response to health service centralisation, serious workforce shortages and high use of locums without formal qualifications or vocational training, the Medical Council of New Zealand (MCNZ) recognised a new rural scope of practice in 2008. The Division of Rural Hospital Medicine (DRHM) was created within the Royal New Zealand College of General Practitioners (RNZCGP).2 Since rural hospital medicine (RHM) was recognised as a specialist vocation, New Zealand rural hospital workforce levels have improved.10 ‘Rural generalism’ is often represented as a broad extension of community medical practice in remote rural areas to include, for example, some aspects of traditionally ‘specialist’ hospital practice, in keeping with the Cairns Declaration.11 Nevertheless, as Atmore notes, the term ‘generalism’ is not necessarily ‘settings-bound’, neither confined to medical professionals, nor to general practitioners (GPs) alone.5,12 For the purposes of this paper, the focus will be on rural hospital practice, where broad medical responsibility for all patients presenting to a rural hospital is regarded as a subset of a broader concept of rural generalism.

Ashburton Hospital is the sole community hospital providing care for the whole rural Ashburton District. Its tertiary referral centre is Christchurch Public Hospital, 88km North by road. Over the 10 years from 2008 to 2017 Ashburton Hospital changed its medical model of care from a secondary specialist to a rural generalist model, with a senior medical workforce populated solely by RHM fellows. The authors all have current Ashburton Hospital appointments and are RHM fellows, who had participated in the transition, working before, during and after the changes in a variety of roles, including as clinical directors. They collectively documented differences in the medical model of care before and after transition, based on their experiences, records and communications with other stakeholders, and here present their viewpoint on milestones in transition of the model of care, drivers for change, challenges faced in the process and lessons learned. Changes in hospital indices of capacity and outcome were obtained from hospital documents and DHB databases to compare the situation pre- and post-transition.

Medical model in 2008

In 2008 the specialist medical model had included an acute and elective general surgical roster led by three general surgeons and supported by four anaesthetists (three FTE). Four general physicians looked after acute medical and rehabilitation admissions, and ran outpatient clinics. An experienced and relatively stable medical officers on special scale (MOSS) workforce had replaced all resident medical officer (RMO) positions, and a two-tier roster was maintained, with admissions under the surgeon or physician on-call. Limited paediatric cover was provided and all but the mildest of paediatric cases requiring admission were transferred to Christchurch. Maternity services were midwife-led, focused on primary birthing of uncomplicated pregnancies, with occasional urgent Caesarean section operations performed by one hospital surgeon. Subspecialty outpatient clinics operated with the support of Christchurch visiting specialists.

Medical model in 2017

By 2017, the SMO workforce had evolved to eight part- or full-time vocationally registered RHM fellows, with six FTE in total, working a 1:5 acute roster, taking all medical, non-operative surgical and paediatric admissions during that period. The second tier of the roster was made up of a team of eight RMOs, ranging from PGY2 house officers completing their three-month ‘community rotation’ in Ashburton, to RHM trainees and other general registrars at post-graduate year (PGY) 3–5 level. After-hours one RMO on duty and one RHM SMO on call covered the hospital and acute assessment unit (AAU), and an RMO night shift was in place. Three inpatient teams consisting of two to three RHM SMOs, one registrar and one other RMO provided continuity of care from admission to discharge. No acute or elective surgery was conducted, but elective endoscopy services were maintained. Maternity services continued to be midwife-led and focused on uncomplicated deliveries, with no on-site acute Caesarean section service available. Maternal and neonatal resuscitation support was provided by the rural generalist team. Outpatient specialist surgical services were unchanged. A timeline showing milestones in transition is shown in Table 1.

Table 1: Milestones in changes in medical staffing and model of care.

Drivers for change

Key local drivers for the medical model change are listed in Table 2, both ‘negative’ drivers which essentially forced change (1–5), and ‘positive’ drivers which facilitated a change in the direction of rural generalism (6–9). The age of the workforce was a particularly pressing issue in surgery where all three surgeons were near retirement, and the retirement of one made sustaining acute surgical services difficult. A replacement was found, however pending retirements for the two others, the requirement for general surgical skills, and the narrowing scope of operations, made both acute and elective surgery less viable and the former was intentionally phased out. Anaesthetics was similarly vulnerable following the resignation of one SMO upon whom credentialing support depended. The February 2011 Canterbury earthquake compounded recruitment challenges as changes in the building code led to the existing operating theatres being permanently closed for structural reasons. There was also uncertainty of timelines for rebuilding and ongoing consultation around the scope of future surgical services. Replacement of general physicians also proved difficult, and provisions in the RMO’s 2002 Multi-Employer Collective Agreement (MECA), had earlier discontinued regular, guaranteed RMO support from Christchurch. In response to staff shortages, Medical Officers of Special Scale (MOSSs) were employed on contract or as locums to cover positions previously held by both specialist SMOs as well as RMOs. In the transitional situation of Ashburton, some MOSSs were employed in positions supervising other MOSSs.

Table 2: Drivers for medical model change.

*SMOs or Senior Medical Officers operate unsupervised in hospital settings. They are usually vocationally registered with the MCNZ, but they may have only general registration, particularly in some rural hospitals.**RMOs or Resident Medical Officers work under supervision in hospitals, have general registration, and many commence formal training in a vocational specialty. ***MOSSs or Medical Officers on Special Scale are not uncommonly employed and/or remunerated as SMOs in New Zealand rural hospitals, working fully or largely independently. They are usually generally registered and not in a vocational training programme.

Positive drivers for change included the opportunity presented by the new pathway to Fellowship in RHM, and the interest shown by several medical officers to undergo this training. This was augmented by strategic commitment of the hospital management towards a generalist medical model, and support of existing specialist SMOs for the training. Another key positive factor was a very engaged local community, with strong philanthropic organisations, who helped fund new developments, including extensive rebuilding required post-earthquake.

Challenges of transition

Key challenges arising during the transition are outlined in Table 3. A cascade in workforce issues, where a single loss of personnel affected the sustainable staffing and therefore viability of an entire service, was experienced on more than one occasion. These changes were often unexpected and necessitated rapid changes in service delivery, sometimes without a significant transition period. The qualification in RHM was new and largely unproven in the early stages of transition, which led to questions of credibility among some health professionals and uncertainty of future senior employment opportunities for trainees. Some stakeholders within and outside the hospital saw the move to generalism as a significant reduction in standards of care, with the loss of services such as acute surgery and emergency Caesarean sections creating considerable unease. In response, focused training on anticipated clinical needs was undertaken, which has resulted in the development of considerable skill and experience in emergency procedures, for example fracture manipulations under procedural sedation. The operating theatre has been rebuilt with community support, which will facilitate elective surgery to return in future, alongside its current utilisation for endoscopic and minor gynaecological procedures.

Table 3: Challenges identified.

Hybrid rostering, where some on call shifts were covered by generalists and some by physicians who needed support from generalist colleagues to cover for certain emergency situations (including paediatrics and trauma), led to a temporary increase in cost, both financial and in terms of rostering demands. A particular issue of controversy was whether to maintain the RHM SMO/RMO two-tier structure and focus on training, or to adopt a single-tier RHM system which moves focus towards service delivery. Alongside the medical staffing challenges, the departure of key managers at critical junctures made it difficult to sustain commitment to the future vision of the service.

Changes in overall hospital indices and outcomes

In terms of human and physical resource change, outlined in Table 4, most notable was the complete loss of surgical inpatient beds, with only a few day procedures remaining. The rehabilitation ward had four extra beds, and a much greater proportion of long-stay patients, non-weight-bearing as conservative or post-operative orthopaedic management. Acute medical beds, AAU beds and maternity beds have changed little. While overall medical workforce FTE numbers were decreased by one, the proportion of SMOs in relation to RMOs decreased considerably.

Table 4: Available physical and human resources.

*Figures derived from hospital management records from 2008 and 2017, and clinical staff consultation.

Table 5 shows several indicators of hospital service, comparing 2008 and 2017. Acute medical occupancy was unchanged between the two periods at 63%, while rehabilitation occupancy has risen from 56 to 83%. The total average length of stay has increased from 2.0 to 3.1 days, influenced heavily by the loss of day-stay surgical patients and an increase in rehabilitation patients, in particular the non-weight-bearing patients. A more comparable figure of length of stay is for acute medical patients, where the duration has decreased from an average of 3.9 to 3.2 days. While population increased by 17%, annual admissions decreased slightly from 2,355 to 2,278. However, total emergency presentations to the AAU rose from 3,518 in 2010 (the earliest year that these figures are available) to 7,326 in 2017. Triage 1 and 2 presentations increased from 262 to 659 during the same period. Transfers to Christchurch also increased, but not to the same degree, from 404 in 2008 to 454 in 2017. Direct acute admissions to Christchurch Hospital of people domiciled in Ashburton rose from 278 to 450. While general practitioner (GP) referrals to Christchurch Hospital for specialist care will represent some of this increase, most patients are still referred to Ashburton Hospital. Self-presentations to hospital increased over the period, especially since the end of 2016 when general practice after-hours cover was no longer provided after 8pm (previously 11pm). In addition, GPs no longer covered overnight calls to age-related care facilities. Overall deaths in hospital increased from 55 to 69.

Table 5: Output indicators (from CDHB Decision Support Unit).

*Population based on Statistics New Zealand online database figures,13 projected between and beyond the 2006 and 2013 census figures to obtain estimates for 2008 and 2017, based on a constant linear progression.**Figures from 2010, (earliest year available).

Lessons learned

The primary reason for change to Ashburton Hospital’s medical model, was the vulnerability of its medical workforce. Workforce stability has been significantly enhanced with virtually no current reliance on locum medical staff, following the transition. The opportunity for, and promotion of, Ashburton Hospital as a site to undertake ‘community attachments’ for PGY2 RMOs has aided RMO recruitment, with the RMO roster routinely fully staffed. PGY2 employment has had implications for increased, on-site SMO supervisory requirements. However, this has added to job satisfaction for SMOs and hopefully contributes to the training of a new generation of rural doctors. Transitioning to the RHM model of care in Ashburton allowed for more comprehensive SMO support around-the-clock in some respects than previously. In particular, paediatric management in Ashburton was ‘out of scope’ for physicians prior to the transition, and it took several years for paediatric admissions to reach acceptance among all hospital staff.

The challenge faced around credibility of the RHM qualification has lessened since nationally, as the qualification is now widely recognised and respected, and governing bodies are more aware of the need for rural exposure in undergraduate and postgraduate training. While some changes in Ashburton Hospital’s transition were considered and made following extensive consultation, others occurred suddenly and unavoidably, which often had the ripple effect of further staff losses, uncertainty regarding future workforce and services, and public perception of hospital downgrades. Perhaps the most important lesson learned through this transition process to a rural generalist model is that it takes time, and requires a long-term strategic commitment to change on the part of key stakeholders. It is hoped that some potential resistance to a process of change in the direction of rural generalism can be mitigated by exposure to this and other examples of rural generalist medical models of care in New Zealand hospitals.

Discussion

We believe this has been a demonstrably successful transition from a secondary specialist to a generalist model of care in a New Zealand rural hospital, over an extended period of 10 years. The medical workforce became more stable, and commitment to training in this rural setting promises increased sustainability. The new generalist model serves more acute (including high acuity) patients and a similar number of inpatients compared to the previous model. The decreased length of stay in acute medical inpatients can be seen as a marker for increased efficiency in this setting. This may reflect the benefits of the integrated generalist model, with no specialist ‘silos’ or compartments, where a small clinical team provides greater continuity of patient care from admission to discharge. A trend in medicine over the past decade has been for shorter length of stays, but this is unlikely to account for all of the reduction at Ashburton.14

This successful transition to a rural generalist model is not an isolated case. There has been a global move in recent years towards enhancing generalism, both in primary care as well as within specialist domains, such as surgery and medicine.15,16 In a systematic review in 2007, Pashen et al found a rural generalist model to be the most effective and suitable model for delivery of health services to rural Australia.17 Benefits of a generalist model of care on health services include: enlarged and inclusive scope of practice, holistic approach to patient care, responsiveness to local context and improved patient access to services.18 Rural community hospitals can provide effective and efficient care equivalent to larger hospitals, with improved patient experiences.19 In addition, with appropriate training, rural generalists can safely deliver a wide range of low-volume specialised services.17

Many of the medical workforce shortage problems described in Ashburton Hospital’s transition will be common to other rural health services elsewhere in New Zealand. The DRHM training pathway offers an ongoing pipeline for new SMOs appropriately trained for rural hospitals, that helps address shortages in a generalist model, which has inherent flexibility to adapt to local needs and priorities. The potential for hospitals to recruit registrars who are training for these roles, or RMOs who are doing their foundational ‘community’ attachments, also represents an opportunity for meeting service provision goals, while decreasing reliance on locums. However, it is important to consider the wider implications of such a two-tier system, including the necessary commitment to supervision and training and potential increase in medical staffing required, alongside anticipated positive outcomes for future workforce sustainability.

Alternative generalist or mixed specialist/generalist models of care are being proposed and/or trialled at various New Zealand rural and provincial hospitals, with differences in drivers and constraints of change, geographical distances from tertiary centres, population size and community needs. Developing the most appropriate model for each rural hospital is a key strategic and shared task for management, senior medical staff, community representatives and other stakeholders in rural areas.

Limitations

This study represents the viewpoint of RHM fellows, with current appointments in Ashburton, based on their experience of the transition and available documents. This is not a systematic sampling of a broad range of clinical and non-clinical informants affected by the transition such as specialists, other RMOs, other hospital staff and managers, GPs and community representatives for their opinions and for data regarding the transition and its outcomes. Statements made about historical movements in staff, their drivers, and significance have not been derived from or checked with all of those staff members, and would have benefitted from a wider consultation process. In addition, only a superficial analysis of output indicators has been possible, and the impact of the transition on the wider hospital community is not clear. Furthermore, the financial implications of a changed medical model of care would require a much more detailed analysis, considering all related inflation adjusted costs in comparison with outputs.

Conclusion

The transition of Ashburton Hospital’s medical model of care from a secondary specialist to a rural generalist model over 10 years has been successful. Key indicators of this include moving from high locum dependence to a stable, sustainable RHM SMO and RMO workforce and an efficient use of human and other resources, flexible enough to cope with a changing workload. Key factors in the success have been the new and increasingly recognised RHM qualification, the support of key stakeholders and long-term strategic commitment to change. Challenges faced have been considerable, and lessons learned may help others negotiate similar transitions. The rural generalist hospital model is a viable option to serve rural and provincial communities of New Zealand.

Summary

Abstract

Rural hospitals in New Zealand face difficult workforce challenges to maintain services and quality outcomes. Ashburton Hospital has undergone a 10-year transition from a secondary specialist to a rural generalist medical model of care. Current senior medical staff (rural hospital medicine fellows) here explore their experience of the process and outcomes of this transition. Key drivers for change included commitment and support from management, senior medical staff and the local community, the new rural hospital medicine qualification and a core group of doctors willing to train in it. Challenges included the need to adapt rapidly to even a single doctor’s departure, initial lack of credibility of the new qualification, and choice between a single or two-tier system of medical rostering. While acute and elective surgical services were lost, acute medical and rehabilitation services were maintained or increased. Presentations to the acute assessment unit, including high acuity cases, have more than doubled over the period described. Workforce stability has been enhanced and commitment to training contributes to future workforce sustainability. Long-term shared strategic commitment to transition was a key factor in successfully traversing challenges faced. Rural and provincial communities should consider rural generalism as a medical model to sustain and further develop their local hospital services.

Aim

Method

Results

Conclusion

Author Information

Steve Withington, Senior Clinical Lecturer, Rural Health Academic Centre, and Rural Hospital Medicine Fellow, Ashburton Hospital, Ashburton; Sampsa Kiuru, Senior Clinical Lecturer, Rural Health Academic Centre, and Rural Hospital Medicine Fellow, Dunstan Hospital, Clyde; Scott Wilson, Rural Hospital Medicine Fellow, Ashburton Hospital, Ashburton; John Lyons, Rural Hospital Medicine Fellow, Ashburton Hospital, Ashburton; Alexander Feberwee, Rural Hospital Medicine Fellow, Ashburton Hospital, Ashburton; Janine Lander, Rural Hospital Medicine Fellow, Ashburton Hospital, Ashburton.

Acknowledgements

Correspondence

Dr Steve Withington, Senior Clinical Lecturer, Rural Health Academic Centre, and Rural Hospital Medicine Fellow, Ashburton Hospital, 28 Elizabeth St, Ashburton 7700.

Correspondence Email

steve.withington@cdhb.health.nz

Competing Interests

Dr Kiuru and Dr Withington report grants from Advance Ashburton Trust during the conduct of the study.

1. World Health Organisation. World health statistics 2016: monitoring health for the SDGs sustainable development goals. WHO 2016.

2. Nixon G, Blattner K, Williamson M, et al. Training generalist doctors for rural practice in New Zealand. Rural Remote Health. 2017; 17(1):4047.

3. Schubert N, Evans R, Battye K, et al. International approaches to rural generalist medicine: a scoping review. Hum Resour Health. 2018; 16(1):62.

4. Rechel B, Džakula A, Duran A, et al. Hospitals in rural or remote areas: An exploratory review of policies in 8 high-income countries. Health Policy. 2016; 120(7):758–69.

5. Atmore C. The role of medical generalism in the New Zealand health system into the future. NZ Med J. 2015; 128(1419):50–5.

6. Barnett R, Barnett P. “If you want to sit on your butts you’ll get nothing!” Community activism in response to threats of rural hospital closure in southern New Zealand. Health & Place. 2003; 9(2):59–71.

7. Holmes GM, Slifkin RT, Randolph RK, Poley S. The Effect of Rural Hospital Closures on Community Economic Health. Health Serv Res. 2006; 41(2):467–85.

8. Reif SS, DesHarnais S, Bernard S. Rural Health Research Community Perceptions of the Effects of Rural Hospital Closure on Access to Care. J Rural Health. 1999; 15(2):202–9.

9. Fleming ST, Williamson HA, Jr., Hicks LL, Rife I. Rural hospital closures and access to services. Hosp Health Serv Adm. 1995; 40(2):247–62.

10. Lawrenson R, Reid J, Nixon G, Laurenson A. The New Zealand rural hospital doctors workforce survey 2015. NZ Med J. 2016; 129(1434):9–16.

11. Murray R. Cairns consensus statement on rural generalist medicine. November 2014. Available: http://www.acrrm.org.au/docs/default-source/documents/about-the-college/cairns-consensus-statement-final-3-nov-2014.pdf (Accessed 19 September 2019).

12. Lee KH. The Hospitalist Movement – An Adaptive Response to Fragmentation of Care in Hospitals. Ann AcadMed Singapore. 2008; 13(2):145–150.

13. 2013 Census QuickStats about a place: Ashburton District [Internet]. Stats NZ. [cited July 4th, 2019]. Available from: http://archive.stats.govt.nz/Census/2013-census/profile-and-summary-reports/quickstats-about-a-place.aspx?request_value=14909&tabname=Populationanddwellings

14. Kaboli PJ, Go JT, Hockenberry J, et al. Associations between reduced hospital length of stay and 30-day readmission rate and mortality: 14-year experience in 129 Veterans Affairs hospitals. Ann Intern Med. 2012; 157(12):837–45.

15. Turnberg L. Survival of the General Physician. BMJ. 2000; 320(7232):438–40.

16. Loefler IJP. The Renaissance of General Surgery. BMJ. 2000; 320(7232):436–8.

17. Pashen D, Murray R, Chater B, et al. The expanding role of the rural generalist in Australia-a systematic review. Australian Primary Health Care Research Institute. Brisbane, 2007.

18. Albritton W, Bates J, Brazeau M, et al. Generalism versus subspecialization: changes necessary in medical education. Can J Rural Med. 2006; 11(2):126–8.

19. Davidson D, Paine AE, Glasby J, et al. Analysis of the profile, characteristics, patient experience and community value of community hospitals: a multimethod study. Health Services and Delivery Research. 2019; 7(1).

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The World Health Organization (WHO) has identified lack of rural health workforce as a major barrier to universal and equitable health coverage.1 Rural hospitals throughout New Zealand and internationally face difficult challenges related to workforce retention and recruitment.2–5 Moreover, there has been a tendency within health services to focus on specialised, urban-based services in terms of policy, funding, reporting expectations and service planning. Internationally, rural hospital viability has been under threat from declining rural population and economic activity,6 and a reduction of rural health infrastructure and centralisation of services.4 When public hospitals were corporatised as Crown Health Enterprises, many New Zealand rural hospitals were closed as they were considered to be inefficient and expensive.6 Unsurprisingly, rural communities resisted changes to their healthcare services. Closure of the sole rural community hospital has been shown to be associated with increased local unemployment and reduction in per capita income,7 decreased access to healthcare for the population8 and increased travel time to health services.9

In response to health service centralisation, serious workforce shortages and high use of locums without formal qualifications or vocational training, the Medical Council of New Zealand (MCNZ) recognised a new rural scope of practice in 2008. The Division of Rural Hospital Medicine (DRHM) was created within the Royal New Zealand College of General Practitioners (RNZCGP).2 Since rural hospital medicine (RHM) was recognised as a specialist vocation, New Zealand rural hospital workforce levels have improved.10 ‘Rural generalism’ is often represented as a broad extension of community medical practice in remote rural areas to include, for example, some aspects of traditionally ‘specialist’ hospital practice, in keeping with the Cairns Declaration.11 Nevertheless, as Atmore notes, the term ‘generalism’ is not necessarily ‘settings-bound’, neither confined to medical professionals, nor to general practitioners (GPs) alone.5,12 For the purposes of this paper, the focus will be on rural hospital practice, where broad medical responsibility for all patients presenting to a rural hospital is regarded as a subset of a broader concept of rural generalism.

Ashburton Hospital is the sole community hospital providing care for the whole rural Ashburton District. Its tertiary referral centre is Christchurch Public Hospital, 88km North by road. Over the 10 years from 2008 to 2017 Ashburton Hospital changed its medical model of care from a secondary specialist to a rural generalist model, with a senior medical workforce populated solely by RHM fellows. The authors all have current Ashburton Hospital appointments and are RHM fellows, who had participated in the transition, working before, during and after the changes in a variety of roles, including as clinical directors. They collectively documented differences in the medical model of care before and after transition, based on their experiences, records and communications with other stakeholders, and here present their viewpoint on milestones in transition of the model of care, drivers for change, challenges faced in the process and lessons learned. Changes in hospital indices of capacity and outcome were obtained from hospital documents and DHB databases to compare the situation pre- and post-transition.

Medical model in 2008

In 2008 the specialist medical model had included an acute and elective general surgical roster led by three general surgeons and supported by four anaesthetists (three FTE). Four general physicians looked after acute medical and rehabilitation admissions, and ran outpatient clinics. An experienced and relatively stable medical officers on special scale (MOSS) workforce had replaced all resident medical officer (RMO) positions, and a two-tier roster was maintained, with admissions under the surgeon or physician on-call. Limited paediatric cover was provided and all but the mildest of paediatric cases requiring admission were transferred to Christchurch. Maternity services were midwife-led, focused on primary birthing of uncomplicated pregnancies, with occasional urgent Caesarean section operations performed by one hospital surgeon. Subspecialty outpatient clinics operated with the support of Christchurch visiting specialists.

Medical model in 2017

By 2017, the SMO workforce had evolved to eight part- or full-time vocationally registered RHM fellows, with six FTE in total, working a 1:5 acute roster, taking all medical, non-operative surgical and paediatric admissions during that period. The second tier of the roster was made up of a team of eight RMOs, ranging from PGY2 house officers completing their three-month ‘community rotation’ in Ashburton, to RHM trainees and other general registrars at post-graduate year (PGY) 3–5 level. After-hours one RMO on duty and one RHM SMO on call covered the hospital and acute assessment unit (AAU), and an RMO night shift was in place. Three inpatient teams consisting of two to three RHM SMOs, one registrar and one other RMO provided continuity of care from admission to discharge. No acute or elective surgery was conducted, but elective endoscopy services were maintained. Maternity services continued to be midwife-led and focused on uncomplicated deliveries, with no on-site acute Caesarean section service available. Maternal and neonatal resuscitation support was provided by the rural generalist team. Outpatient specialist surgical services were unchanged. A timeline showing milestones in transition is shown in Table 1.

Table 1: Milestones in changes in medical staffing and model of care.

Drivers for change

Key local drivers for the medical model change are listed in Table 2, both ‘negative’ drivers which essentially forced change (1–5), and ‘positive’ drivers which facilitated a change in the direction of rural generalism (6–9). The age of the workforce was a particularly pressing issue in surgery where all three surgeons were near retirement, and the retirement of one made sustaining acute surgical services difficult. A replacement was found, however pending retirements for the two others, the requirement for general surgical skills, and the narrowing scope of operations, made both acute and elective surgery less viable and the former was intentionally phased out. Anaesthetics was similarly vulnerable following the resignation of one SMO upon whom credentialing support depended. The February 2011 Canterbury earthquake compounded recruitment challenges as changes in the building code led to the existing operating theatres being permanently closed for structural reasons. There was also uncertainty of timelines for rebuilding and ongoing consultation around the scope of future surgical services. Replacement of general physicians also proved difficult, and provisions in the RMO’s 2002 Multi-Employer Collective Agreement (MECA), had earlier discontinued regular, guaranteed RMO support from Christchurch. In response to staff shortages, Medical Officers of Special Scale (MOSSs) were employed on contract or as locums to cover positions previously held by both specialist SMOs as well as RMOs. In the transitional situation of Ashburton, some MOSSs were employed in positions supervising other MOSSs.

Table 2: Drivers for medical model change.

*SMOs or Senior Medical Officers operate unsupervised in hospital settings. They are usually vocationally registered with the MCNZ, but they may have only general registration, particularly in some rural hospitals.**RMOs or Resident Medical Officers work under supervision in hospitals, have general registration, and many commence formal training in a vocational specialty. ***MOSSs or Medical Officers on Special Scale are not uncommonly employed and/or remunerated as SMOs in New Zealand rural hospitals, working fully or largely independently. They are usually generally registered and not in a vocational training programme.

Positive drivers for change included the opportunity presented by the new pathway to Fellowship in RHM, and the interest shown by several medical officers to undergo this training. This was augmented by strategic commitment of the hospital management towards a generalist medical model, and support of existing specialist SMOs for the training. Another key positive factor was a very engaged local community, with strong philanthropic organisations, who helped fund new developments, including extensive rebuilding required post-earthquake.

Challenges of transition

Key challenges arising during the transition are outlined in Table 3. A cascade in workforce issues, where a single loss of personnel affected the sustainable staffing and therefore viability of an entire service, was experienced on more than one occasion. These changes were often unexpected and necessitated rapid changes in service delivery, sometimes without a significant transition period. The qualification in RHM was new and largely unproven in the early stages of transition, which led to questions of credibility among some health professionals and uncertainty of future senior employment opportunities for trainees. Some stakeholders within and outside the hospital saw the move to generalism as a significant reduction in standards of care, with the loss of services such as acute surgery and emergency Caesarean sections creating considerable unease. In response, focused training on anticipated clinical needs was undertaken, which has resulted in the development of considerable skill and experience in emergency procedures, for example fracture manipulations under procedural sedation. The operating theatre has been rebuilt with community support, which will facilitate elective surgery to return in future, alongside its current utilisation for endoscopic and minor gynaecological procedures.

Table 3: Challenges identified.

Hybrid rostering, where some on call shifts were covered by generalists and some by physicians who needed support from generalist colleagues to cover for certain emergency situations (including paediatrics and trauma), led to a temporary increase in cost, both financial and in terms of rostering demands. A particular issue of controversy was whether to maintain the RHM SMO/RMO two-tier structure and focus on training, or to adopt a single-tier RHM system which moves focus towards service delivery. Alongside the medical staffing challenges, the departure of key managers at critical junctures made it difficult to sustain commitment to the future vision of the service.

Changes in overall hospital indices and outcomes

In terms of human and physical resource change, outlined in Table 4, most notable was the complete loss of surgical inpatient beds, with only a few day procedures remaining. The rehabilitation ward had four extra beds, and a much greater proportion of long-stay patients, non-weight-bearing as conservative or post-operative orthopaedic management. Acute medical beds, AAU beds and maternity beds have changed little. While overall medical workforce FTE numbers were decreased by one, the proportion of SMOs in relation to RMOs decreased considerably.

Table 4: Available physical and human resources.

*Figures derived from hospital management records from 2008 and 2017, and clinical staff consultation.

Table 5 shows several indicators of hospital service, comparing 2008 and 2017. Acute medical occupancy was unchanged between the two periods at 63%, while rehabilitation occupancy has risen from 56 to 83%. The total average length of stay has increased from 2.0 to 3.1 days, influenced heavily by the loss of day-stay surgical patients and an increase in rehabilitation patients, in particular the non-weight-bearing patients. A more comparable figure of length of stay is for acute medical patients, where the duration has decreased from an average of 3.9 to 3.2 days. While population increased by 17%, annual admissions decreased slightly from 2,355 to 2,278. However, total emergency presentations to the AAU rose from 3,518 in 2010 (the earliest year that these figures are available) to 7,326 in 2017. Triage 1 and 2 presentations increased from 262 to 659 during the same period. Transfers to Christchurch also increased, but not to the same degree, from 404 in 2008 to 454 in 2017. Direct acute admissions to Christchurch Hospital of people domiciled in Ashburton rose from 278 to 450. While general practitioner (GP) referrals to Christchurch Hospital for specialist care will represent some of this increase, most patients are still referred to Ashburton Hospital. Self-presentations to hospital increased over the period, especially since the end of 2016 when general practice after-hours cover was no longer provided after 8pm (previously 11pm). In addition, GPs no longer covered overnight calls to age-related care facilities. Overall deaths in hospital increased from 55 to 69.

Table 5: Output indicators (from CDHB Decision Support Unit).

*Population based on Statistics New Zealand online database figures,13 projected between and beyond the 2006 and 2013 census figures to obtain estimates for 2008 and 2017, based on a constant linear progression.**Figures from 2010, (earliest year available).

Lessons learned

The primary reason for change to Ashburton Hospital’s medical model, was the vulnerability of its medical workforce. Workforce stability has been significantly enhanced with virtually no current reliance on locum medical staff, following the transition. The opportunity for, and promotion of, Ashburton Hospital as a site to undertake ‘community attachments’ for PGY2 RMOs has aided RMO recruitment, with the RMO roster routinely fully staffed. PGY2 employment has had implications for increased, on-site SMO supervisory requirements. However, this has added to job satisfaction for SMOs and hopefully contributes to the training of a new generation of rural doctors. Transitioning to the RHM model of care in Ashburton allowed for more comprehensive SMO support around-the-clock in some respects than previously. In particular, paediatric management in Ashburton was ‘out of scope’ for physicians prior to the transition, and it took several years for paediatric admissions to reach acceptance among all hospital staff.

The challenge faced around credibility of the RHM qualification has lessened since nationally, as the qualification is now widely recognised and respected, and governing bodies are more aware of the need for rural exposure in undergraduate and postgraduate training. While some changes in Ashburton Hospital’s transition were considered and made following extensive consultation, others occurred suddenly and unavoidably, which often had the ripple effect of further staff losses, uncertainty regarding future workforce and services, and public perception of hospital downgrades. Perhaps the most important lesson learned through this transition process to a rural generalist model is that it takes time, and requires a long-term strategic commitment to change on the part of key stakeholders. It is hoped that some potential resistance to a process of change in the direction of rural generalism can be mitigated by exposure to this and other examples of rural generalist medical models of care in New Zealand hospitals.

Discussion

We believe this has been a demonstrably successful transition from a secondary specialist to a generalist model of care in a New Zealand rural hospital, over an extended period of 10 years. The medical workforce became more stable, and commitment to training in this rural setting promises increased sustainability. The new generalist model serves more acute (including high acuity) patients and a similar number of inpatients compared to the previous model. The decreased length of stay in acute medical inpatients can be seen as a marker for increased efficiency in this setting. This may reflect the benefits of the integrated generalist model, with no specialist ‘silos’ or compartments, where a small clinical team provides greater continuity of patient care from admission to discharge. A trend in medicine over the past decade has been for shorter length of stays, but this is unlikely to account for all of the reduction at Ashburton.14

This successful transition to a rural generalist model is not an isolated case. There has been a global move in recent years towards enhancing generalism, both in primary care as well as within specialist domains, such as surgery and medicine.15,16 In a systematic review in 2007, Pashen et al found a rural generalist model to be the most effective and suitable model for delivery of health services to rural Australia.17 Benefits of a generalist model of care on health services include: enlarged and inclusive scope of practice, holistic approach to patient care, responsiveness to local context and improved patient access to services.18 Rural community hospitals can provide effective and efficient care equivalent to larger hospitals, with improved patient experiences.19 In addition, with appropriate training, rural generalists can safely deliver a wide range of low-volume specialised services.17

Many of the medical workforce shortage problems described in Ashburton Hospital’s transition will be common to other rural health services elsewhere in New Zealand. The DRHM training pathway offers an ongoing pipeline for new SMOs appropriately trained for rural hospitals, that helps address shortages in a generalist model, which has inherent flexibility to adapt to local needs and priorities. The potential for hospitals to recruit registrars who are training for these roles, or RMOs who are doing their foundational ‘community’ attachments, also represents an opportunity for meeting service provision goals, while decreasing reliance on locums. However, it is important to consider the wider implications of such a two-tier system, including the necessary commitment to supervision and training and potential increase in medical staffing required, alongside anticipated positive outcomes for future workforce sustainability.

Alternative generalist or mixed specialist/generalist models of care are being proposed and/or trialled at various New Zealand rural and provincial hospitals, with differences in drivers and constraints of change, geographical distances from tertiary centres, population size and community needs. Developing the most appropriate model for each rural hospital is a key strategic and shared task for management, senior medical staff, community representatives and other stakeholders in rural areas.

Limitations

This study represents the viewpoint of RHM fellows, with current appointments in Ashburton, based on their experience of the transition and available documents. This is not a systematic sampling of a broad range of clinical and non-clinical informants affected by the transition such as specialists, other RMOs, other hospital staff and managers, GPs and community representatives for their opinions and for data regarding the transition and its outcomes. Statements made about historical movements in staff, their drivers, and significance have not been derived from or checked with all of those staff members, and would have benefitted from a wider consultation process. In addition, only a superficial analysis of output indicators has been possible, and the impact of the transition on the wider hospital community is not clear. Furthermore, the financial implications of a changed medical model of care would require a much more detailed analysis, considering all related inflation adjusted costs in comparison with outputs.

Conclusion

The transition of Ashburton Hospital’s medical model of care from a secondary specialist to a rural generalist model over 10 years has been successful. Key indicators of this include moving from high locum dependence to a stable, sustainable RHM SMO and RMO workforce and an efficient use of human and other resources, flexible enough to cope with a changing workload. Key factors in the success have been the new and increasingly recognised RHM qualification, the support of key stakeholders and long-term strategic commitment to change. Challenges faced have been considerable, and lessons learned may help others negotiate similar transitions. The rural generalist hospital model is a viable option to serve rural and provincial communities of New Zealand.

Summary

Abstract

Rural hospitals in New Zealand face difficult workforce challenges to maintain services and quality outcomes. Ashburton Hospital has undergone a 10-year transition from a secondary specialist to a rural generalist medical model of care. Current senior medical staff (rural hospital medicine fellows) here explore their experience of the process and outcomes of this transition. Key drivers for change included commitment and support from management, senior medical staff and the local community, the new rural hospital medicine qualification and a core group of doctors willing to train in it. Challenges included the need to adapt rapidly to even a single doctor’s departure, initial lack of credibility of the new qualification, and choice between a single or two-tier system of medical rostering. While acute and elective surgical services were lost, acute medical and rehabilitation services were maintained or increased. Presentations to the acute assessment unit, including high acuity cases, have more than doubled over the period described. Workforce stability has been enhanced and commitment to training contributes to future workforce sustainability. Long-term shared strategic commitment to transition was a key factor in successfully traversing challenges faced. Rural and provincial communities should consider rural generalism as a medical model to sustain and further develop their local hospital services.

Aim

Method

Results

Conclusion

Author Information

Steve Withington, Senior Clinical Lecturer, Rural Health Academic Centre, and Rural Hospital Medicine Fellow, Ashburton Hospital, Ashburton; Sampsa Kiuru, Senior Clinical Lecturer, Rural Health Academic Centre, and Rural Hospital Medicine Fellow, Dunstan Hospital, Clyde; Scott Wilson, Rural Hospital Medicine Fellow, Ashburton Hospital, Ashburton; John Lyons, Rural Hospital Medicine Fellow, Ashburton Hospital, Ashburton; Alexander Feberwee, Rural Hospital Medicine Fellow, Ashburton Hospital, Ashburton; Janine Lander, Rural Hospital Medicine Fellow, Ashburton Hospital, Ashburton.

Acknowledgements

Correspondence

Dr Steve Withington, Senior Clinical Lecturer, Rural Health Academic Centre, and Rural Hospital Medicine Fellow, Ashburton Hospital, 28 Elizabeth St, Ashburton 7700.

Correspondence Email

steve.withington@cdhb.health.nz

Competing Interests

Dr Kiuru and Dr Withington report grants from Advance Ashburton Trust during the conduct of the study.

1. World Health Organisation. World health statistics 2016: monitoring health for the SDGs sustainable development goals. WHO 2016.

2. Nixon G, Blattner K, Williamson M, et al. Training generalist doctors for rural practice in New Zealand. Rural Remote Health. 2017; 17(1):4047.

3. Schubert N, Evans R, Battye K, et al. International approaches to rural generalist medicine: a scoping review. Hum Resour Health. 2018; 16(1):62.

4. Rechel B, Džakula A, Duran A, et al. Hospitals in rural or remote areas: An exploratory review of policies in 8 high-income countries. Health Policy. 2016; 120(7):758–69.

5. Atmore C. The role of medical generalism in the New Zealand health system into the future. NZ Med J. 2015; 128(1419):50–5.

6. Barnett R, Barnett P. “If you want to sit on your butts you’ll get nothing!” Community activism in response to threats of rural hospital closure in southern New Zealand. Health & Place. 2003; 9(2):59–71.

7. Holmes GM, Slifkin RT, Randolph RK, Poley S. The Effect of Rural Hospital Closures on Community Economic Health. Health Serv Res. 2006; 41(2):467–85.

8. Reif SS, DesHarnais S, Bernard S. Rural Health Research Community Perceptions of the Effects of Rural Hospital Closure on Access to Care. J Rural Health. 1999; 15(2):202–9.

9. Fleming ST, Williamson HA, Jr., Hicks LL, Rife I. Rural hospital closures and access to services. Hosp Health Serv Adm. 1995; 40(2):247–62.

10. Lawrenson R, Reid J, Nixon G, Laurenson A. The New Zealand rural hospital doctors workforce survey 2015. NZ Med J. 2016; 129(1434):9–16.

11. Murray R. Cairns consensus statement on rural generalist medicine. November 2014. Available: http://www.acrrm.org.au/docs/default-source/documents/about-the-college/cairns-consensus-statement-final-3-nov-2014.pdf (Accessed 19 September 2019).

12. Lee KH. The Hospitalist Movement – An Adaptive Response to Fragmentation of Care in Hospitals. Ann AcadMed Singapore. 2008; 13(2):145–150.

13. 2013 Census QuickStats about a place: Ashburton District [Internet]. Stats NZ. [cited July 4th, 2019]. Available from: http://archive.stats.govt.nz/Census/2013-census/profile-and-summary-reports/quickstats-about-a-place.aspx?request_value=14909&tabname=Populationanddwellings

14. Kaboli PJ, Go JT, Hockenberry J, et al. Associations between reduced hospital length of stay and 30-day readmission rate and mortality: 14-year experience in 129 Veterans Affairs hospitals. Ann Intern Med. 2012; 157(12):837–45.

15. Turnberg L. Survival of the General Physician. BMJ. 2000; 320(7232):438–40.

16. Loefler IJP. The Renaissance of General Surgery. BMJ. 2000; 320(7232):436–8.

17. Pashen D, Murray R, Chater B, et al. The expanding role of the rural generalist in Australia-a systematic review. Australian Primary Health Care Research Institute. Brisbane, 2007.

18. Albritton W, Bates J, Brazeau M, et al. Generalism versus subspecialization: changes necessary in medical education. Can J Rural Med. 2006; 11(2):126–8.

19. Davidson D, Paine AE, Glasby J, et al. Analysis of the profile, characteristics, patient experience and community value of community hospitals: a multimethod study. Health Services and Delivery Research. 2019; 7(1).

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The World Health Organization (WHO) has identified lack of rural health workforce as a major barrier to universal and equitable health coverage.1 Rural hospitals throughout New Zealand and internationally face difficult challenges related to workforce retention and recruitment.2–5 Moreover, there has been a tendency within health services to focus on specialised, urban-based services in terms of policy, funding, reporting expectations and service planning. Internationally, rural hospital viability has been under threat from declining rural population and economic activity,6 and a reduction of rural health infrastructure and centralisation of services.4 When public hospitals were corporatised as Crown Health Enterprises, many New Zealand rural hospitals were closed as they were considered to be inefficient and expensive.6 Unsurprisingly, rural communities resisted changes to their healthcare services. Closure of the sole rural community hospital has been shown to be associated with increased local unemployment and reduction in per capita income,7 decreased access to healthcare for the population8 and increased travel time to health services.9

In response to health service centralisation, serious workforce shortages and high use of locums without formal qualifications or vocational training, the Medical Council of New Zealand (MCNZ) recognised a new rural scope of practice in 2008. The Division of Rural Hospital Medicine (DRHM) was created within the Royal New Zealand College of General Practitioners (RNZCGP).2 Since rural hospital medicine (RHM) was recognised as a specialist vocation, New Zealand rural hospital workforce levels have improved.10 ‘Rural generalism’ is often represented as a broad extension of community medical practice in remote rural areas to include, for example, some aspects of traditionally ‘specialist’ hospital practice, in keeping with the Cairns Declaration.11 Nevertheless, as Atmore notes, the term ‘generalism’ is not necessarily ‘settings-bound’, neither confined to medical professionals, nor to general practitioners (GPs) alone.5,12 For the purposes of this paper, the focus will be on rural hospital practice, where broad medical responsibility for all patients presenting to a rural hospital is regarded as a subset of a broader concept of rural generalism.

Ashburton Hospital is the sole community hospital providing care for the whole rural Ashburton District. Its tertiary referral centre is Christchurch Public Hospital, 88km North by road. Over the 10 years from 2008 to 2017 Ashburton Hospital changed its medical model of care from a secondary specialist to a rural generalist model, with a senior medical workforce populated solely by RHM fellows. The authors all have current Ashburton Hospital appointments and are RHM fellows, who had participated in the transition, working before, during and after the changes in a variety of roles, including as clinical directors. They collectively documented differences in the medical model of care before and after transition, based on their experiences, records and communications with other stakeholders, and here present their viewpoint on milestones in transition of the model of care, drivers for change, challenges faced in the process and lessons learned. Changes in hospital indices of capacity and outcome were obtained from hospital documents and DHB databases to compare the situation pre- and post-transition.

Medical model in 2008

In 2008 the specialist medical model had included an acute and elective general surgical roster led by three general surgeons and supported by four anaesthetists (three FTE). Four general physicians looked after acute medical and rehabilitation admissions, and ran outpatient clinics. An experienced and relatively stable medical officers on special scale (MOSS) workforce had replaced all resident medical officer (RMO) positions, and a two-tier roster was maintained, with admissions under the surgeon or physician on-call. Limited paediatric cover was provided and all but the mildest of paediatric cases requiring admission were transferred to Christchurch. Maternity services were midwife-led, focused on primary birthing of uncomplicated pregnancies, with occasional urgent Caesarean section operations performed by one hospital surgeon. Subspecialty outpatient clinics operated with the support of Christchurch visiting specialists.

Medical model in 2017

By 2017, the SMO workforce had evolved to eight part- or full-time vocationally registered RHM fellows, with six FTE in total, working a 1:5 acute roster, taking all medical, non-operative surgical and paediatric admissions during that period. The second tier of the roster was made up of a team of eight RMOs, ranging from PGY2 house officers completing their three-month ‘community rotation’ in Ashburton, to RHM trainees and other general registrars at post-graduate year (PGY) 3–5 level. After-hours one RMO on duty and one RHM SMO on call covered the hospital and acute assessment unit (AAU), and an RMO night shift was in place. Three inpatient teams consisting of two to three RHM SMOs, one registrar and one other RMO provided continuity of care from admission to discharge. No acute or elective surgery was conducted, but elective endoscopy services were maintained. Maternity services continued to be midwife-led and focused on uncomplicated deliveries, with no on-site acute Caesarean section service available. Maternal and neonatal resuscitation support was provided by the rural generalist team. Outpatient specialist surgical services were unchanged. A timeline showing milestones in transition is shown in Table 1.

Table 1: Milestones in changes in medical staffing and model of care.

Drivers for change

Key local drivers for the medical model change are listed in Table 2, both ‘negative’ drivers which essentially forced change (1–5), and ‘positive’ drivers which facilitated a change in the direction of rural generalism (6–9). The age of the workforce was a particularly pressing issue in surgery where all three surgeons were near retirement, and the retirement of one made sustaining acute surgical services difficult. A replacement was found, however pending retirements for the two others, the requirement for general surgical skills, and the narrowing scope of operations, made both acute and elective surgery less viable and the former was intentionally phased out. Anaesthetics was similarly vulnerable following the resignation of one SMO upon whom credentialing support depended. The February 2011 Canterbury earthquake compounded recruitment challenges as changes in the building code led to the existing operating theatres being permanently closed for structural reasons. There was also uncertainty of timelines for rebuilding and ongoing consultation around the scope of future surgical services. Replacement of general physicians also proved difficult, and provisions in the RMO’s 2002 Multi-Employer Collective Agreement (MECA), had earlier discontinued regular, guaranteed RMO support from Christchurch. In response to staff shortages, Medical Officers of Special Scale (MOSSs) were employed on contract or as locums to cover positions previously held by both specialist SMOs as well as RMOs. In the transitional situation of Ashburton, some MOSSs were employed in positions supervising other MOSSs.

Table 2: Drivers for medical model change.

*SMOs or Senior Medical Officers operate unsupervised in hospital settings. They are usually vocationally registered with the MCNZ, but they may have only general registration, particularly in some rural hospitals.**RMOs or Resident Medical Officers work under supervision in hospitals, have general registration, and many commence formal training in a vocational specialty. ***MOSSs or Medical Officers on Special Scale are not uncommonly employed and/or remunerated as SMOs in New Zealand rural hospitals, working fully or largely independently. They are usually generally registered and not in a vocational training programme.

Positive drivers for change included the opportunity presented by the new pathway to Fellowship in RHM, and the interest shown by several medical officers to undergo this training. This was augmented by strategic commitment of the hospital management towards a generalist medical model, and support of existing specialist SMOs for the training. Another key positive factor was a very engaged local community, with strong philanthropic organisations, who helped fund new developments, including extensive rebuilding required post-earthquake.

Challenges of transition

Key challenges arising during the transition are outlined in Table 3. A cascade in workforce issues, where a single loss of personnel affected the sustainable staffing and therefore viability of an entire service, was experienced on more than one occasion. These changes were often unexpected and necessitated rapid changes in service delivery, sometimes without a significant transition period. The qualification in RHM was new and largely unproven in the early stages of transition, which led to questions of credibility among some health professionals and uncertainty of future senior employment opportunities for trainees. Some stakeholders within and outside the hospital saw the move to generalism as a significant reduction in standards of care, with the loss of services such as acute surgery and emergency Caesarean sections creating considerable unease. In response, focused training on anticipated clinical needs was undertaken, which has resulted in the development of considerable skill and experience in emergency procedures, for example fracture manipulations under procedural sedation. The operating theatre has been rebuilt with community support, which will facilitate elective surgery to return in future, alongside its current utilisation for endoscopic and minor gynaecological procedures.

Table 3: Challenges identified.

Hybrid rostering, where some on call shifts were covered by generalists and some by physicians who needed support from generalist colleagues to cover for certain emergency situations (including paediatrics and trauma), led to a temporary increase in cost, both financial and in terms of rostering demands. A particular issue of controversy was whether to maintain the RHM SMO/RMO two-tier structure and focus on training, or to adopt a single-tier RHM system which moves focus towards service delivery. Alongside the medical staffing challenges, the departure of key managers at critical junctures made it difficult to sustain commitment to the future vision of the service.

Changes in overall hospital indices and outcomes

In terms of human and physical resource change, outlined in Table 4, most notable was the complete loss of surgical inpatient beds, with only a few day procedures remaining. The rehabilitation ward had four extra beds, and a much greater proportion of long-stay patients, non-weight-bearing as conservative or post-operative orthopaedic management. Acute medical beds, AAU beds and maternity beds have changed little. While overall medical workforce FTE numbers were decreased by one, the proportion of SMOs in relation to RMOs decreased considerably.

Table 4: Available physical and human resources.

*Figures derived from hospital management records from 2008 and 2017, and clinical staff consultation.

Table 5 shows several indicators of hospital service, comparing 2008 and 2017. Acute medical occupancy was unchanged between the two periods at 63%, while rehabilitation occupancy has risen from 56 to 83%. The total average length of stay has increased from 2.0 to 3.1 days, influenced heavily by the loss of day-stay surgical patients and an increase in rehabilitation patients, in particular the non-weight-bearing patients. A more comparable figure of length of stay is for acute medical patients, where the duration has decreased from an average of 3.9 to 3.2 days. While population increased by 17%, annual admissions decreased slightly from 2,355 to 2,278. However, total emergency presentations to the AAU rose from 3,518 in 2010 (the earliest year that these figures are available) to 7,326 in 2017. Triage 1 and 2 presentations increased from 262 to 659 during the same period. Transfers to Christchurch also increased, but not to the same degree, from 404 in 2008 to 454 in 2017. Direct acute admissions to Christchurch Hospital of people domiciled in Ashburton rose from 278 to 450. While general practitioner (GP) referrals to Christchurch Hospital for specialist care will represent some of this increase, most patients are still referred to Ashburton Hospital. Self-presentations to hospital increased over the period, especially since the end of 2016 when general practice after-hours cover was no longer provided after 8pm (previously 11pm). In addition, GPs no longer covered overnight calls to age-related care facilities. Overall deaths in hospital increased from 55 to 69.

Table 5: Output indicators (from CDHB Decision Support Unit).

*Population based on Statistics New Zealand online database figures,13 projected between and beyond the 2006 and 2013 census figures to obtain estimates for 2008 and 2017, based on a constant linear progression.**Figures from 2010, (earliest year available).

Lessons learned

The primary reason for change to Ashburton Hospital’s medical model, was the vulnerability of its medical workforce. Workforce stability has been significantly enhanced with virtually no current reliance on locum medical staff, following the transition. The opportunity for, and promotion of, Ashburton Hospital as a site to undertake ‘community attachments’ for PGY2 RMOs has aided RMO recruitment, with the RMO roster routinely fully staffed. PGY2 employment has had implications for increased, on-site SMO supervisory requirements. However, this has added to job satisfaction for SMOs and hopefully contributes to the training of a new generation of rural doctors. Transitioning to the RHM model of care in Ashburton allowed for more comprehensive SMO support around-the-clock in some respects than previously. In particular, paediatric management in Ashburton was ‘out of scope’ for physicians prior to the transition, and it took several years for paediatric admissions to reach acceptance among all hospital staff.

The challenge faced around credibility of the RHM qualification has lessened since nationally, as the qualification is now widely recognised and respected, and governing bodies are more aware of the need for rural exposure in undergraduate and postgraduate training. While some changes in Ashburton Hospital’s transition were considered and made following extensive consultation, others occurred suddenly and unavoidably, which often had the ripple effect of further staff losses, uncertainty regarding future workforce and services, and public perception of hospital downgrades. Perhaps the most important lesson learned through this transition process to a rural generalist model is that it takes time, and requires a long-term strategic commitment to change on the part of key stakeholders. It is hoped that some potential resistance to a process of change in the direction of rural generalism can be mitigated by exposure to this and other examples of rural generalist medical models of care in New Zealand hospitals.

Discussion

We believe this has been a demonstrably successful transition from a secondary specialist to a generalist model of care in a New Zealand rural hospital, over an extended period of 10 years. The medical workforce became more stable, and commitment to training in this rural setting promises increased sustainability. The new generalist model serves more acute (including high acuity) patients and a similar number of inpatients compared to the previous model. The decreased length of stay in acute medical inpatients can be seen as a marker for increased efficiency in this setting. This may reflect the benefits of the integrated generalist model, with no specialist ‘silos’ or compartments, where a small clinical team provides greater continuity of patient care from admission to discharge. A trend in medicine over the past decade has been for shorter length of stays, but this is unlikely to account for all of the reduction at Ashburton.14

This successful transition to a rural generalist model is not an isolated case. There has been a global move in recent years towards enhancing generalism, both in primary care as well as within specialist domains, such as surgery and medicine.15,16 In a systematic review in 2007, Pashen et al found a rural generalist model to be the most effective and suitable model for delivery of health services to rural Australia.17 Benefits of a generalist model of care on health services include: enlarged and inclusive scope of practice, holistic approach to patient care, responsiveness to local context and improved patient access to services.18 Rural community hospitals can provide effective and efficient care equivalent to larger hospitals, with improved patient experiences.19 In addition, with appropriate training, rural generalists can safely deliver a wide range of low-volume specialised services.17

Many of the medical workforce shortage problems described in Ashburton Hospital’s transition will be common to other rural health services elsewhere in New Zealand. The DRHM training pathway offers an ongoing pipeline for new SMOs appropriately trained for rural hospitals, that helps address shortages in a generalist model, which has inherent flexibility to adapt to local needs and priorities. The potential for hospitals to recruit registrars who are training for these roles, or RMOs who are doing their foundational ‘community’ attachments, also represents an opportunity for meeting service provision goals, while decreasing reliance on locums. However, it is important to consider the wider implications of such a two-tier system, including the necessary commitment to supervision and training and potential increase in medical staffing required, alongside anticipated positive outcomes for future workforce sustainability.

Alternative generalist or mixed specialist/generalist models of care are being proposed and/or trialled at various New Zealand rural and provincial hospitals, with differences in drivers and constraints of change, geographical distances from tertiary centres, population size and community needs. Developing the most appropriate model for each rural hospital is a key strategic and shared task for management, senior medical staff, community representatives and other stakeholders in rural areas.

Limitations

This study represents the viewpoint of RHM fellows, with current appointments in Ashburton, based on their experience of the transition and available documents. This is not a systematic sampling of a broad range of clinical and non-clinical informants affected by the transition such as specialists, other RMOs, other hospital staff and managers, GPs and community representatives for their opinions and for data regarding the transition and its outcomes. Statements made about historical movements in staff, their drivers, and significance have not been derived from or checked with all of those staff members, and would have benefitted from a wider consultation process. In addition, only a superficial analysis of output indicators has been possible, and the impact of the transition on the wider hospital community is not clear. Furthermore, the financial implications of a changed medical model of care would require a much more detailed analysis, considering all related inflation adjusted costs in comparison with outputs.

Conclusion

The transition of Ashburton Hospital’s medical model of care from a secondary specialist to a rural generalist model over 10 years has been successful. Key indicators of this include moving from high locum dependence to a stable, sustainable RHM SMO and RMO workforce and an efficient use of human and other resources, flexible enough to cope with a changing workload. Key factors in the success have been the new and increasingly recognised RHM qualification, the support of key stakeholders and long-term strategic commitment to change. Challenges faced have been considerable, and lessons learned may help others negotiate similar transitions. The rural generalist hospital model is a viable option to serve rural and provincial communities of New Zealand.

Summary

Abstract

Rural hospitals in New Zealand face difficult workforce challenges to maintain services and quality outcomes. Ashburton Hospital has undergone a 10-year transition from a secondary specialist to a rural generalist medical model of care. Current senior medical staff (rural hospital medicine fellows) here explore their experience of the process and outcomes of this transition. Key drivers for change included commitment and support from management, senior medical staff and the local community, the new rural hospital medicine qualification and a core group of doctors willing to train in it. Challenges included the need to adapt rapidly to even a single doctor’s departure, initial lack of credibility of the new qualification, and choice between a single or two-tier system of medical rostering. While acute and elective surgical services were lost, acute medical and rehabilitation services were maintained or increased. Presentations to the acute assessment unit, including high acuity cases, have more than doubled over the period described. Workforce stability has been enhanced and commitment to training contributes to future workforce sustainability. Long-term shared strategic commitment to transition was a key factor in successfully traversing challenges faced. Rural and provincial communities should consider rural generalism as a medical model to sustain and further develop their local hospital services.

Aim

Method

Results

Conclusion

Author Information

Steve Withington, Senior Clinical Lecturer, Rural Health Academic Centre, and Rural Hospital Medicine Fellow, Ashburton Hospital, Ashburton; Sampsa Kiuru, Senior Clinical Lecturer, Rural Health Academic Centre, and Rural Hospital Medicine Fellow, Dunstan Hospital, Clyde; Scott Wilson, Rural Hospital Medicine Fellow, Ashburton Hospital, Ashburton; John Lyons, Rural Hospital Medicine Fellow, Ashburton Hospital, Ashburton; Alexander Feberwee, Rural Hospital Medicine Fellow, Ashburton Hospital, Ashburton; Janine Lander, Rural Hospital Medicine Fellow, Ashburton Hospital, Ashburton.

Acknowledgements

Correspondence

Dr Steve Withington, Senior Clinical Lecturer, Rural Health Academic Centre, and Rural Hospital Medicine Fellow, Ashburton Hospital, 28 Elizabeth St, Ashburton 7700.

Correspondence Email

steve.withington@cdhb.health.nz

Competing Interests

Dr Kiuru and Dr Withington report grants from Advance Ashburton Trust during the conduct of the study.

1. World Health Organisation. World health statistics 2016: monitoring health for the SDGs sustainable development goals. WHO 2016.

2. Nixon G, Blattner K, Williamson M, et al. Training generalist doctors for rural practice in New Zealand. Rural Remote Health. 2017; 17(1):4047.

3. Schubert N, Evans R, Battye K, et al. International approaches to rural generalist medicine: a scoping review. Hum Resour Health. 2018; 16(1):62.

4. Rechel B, Džakula A, Duran A, et al. Hospitals in rural or remote areas: An exploratory review of policies in 8 high-income countries. Health Policy. 2016; 120(7):758–69.

5. Atmore C. The role of medical generalism in the New Zealand health system into the future. NZ Med J. 2015; 128(1419):50–5.

6. Barnett R, Barnett P. “If you want to sit on your butts you’ll get nothing!” Community activism in response to threats of rural hospital closure in southern New Zealand. Health & Place. 2003; 9(2):59–71.

7. Holmes GM, Slifkin RT, Randolph RK, Poley S. The Effect of Rural Hospital Closures on Community Economic Health. Health Serv Res. 2006; 41(2):467–85.

8. Reif SS, DesHarnais S, Bernard S. Rural Health Research Community Perceptions of the Effects of Rural Hospital Closure on Access to Care. J Rural Health. 1999; 15(2):202–9.

9. Fleming ST, Williamson HA, Jr., Hicks LL, Rife I. Rural hospital closures and access to services. Hosp Health Serv Adm. 1995; 40(2):247–62.

10. Lawrenson R, Reid J, Nixon G, Laurenson A. The New Zealand rural hospital doctors workforce survey 2015. NZ Med J. 2016; 129(1434):9–16.

11. Murray R. Cairns consensus statement on rural generalist medicine. November 2014. Available: http://www.acrrm.org.au/docs/default-source/documents/about-the-college/cairns-consensus-statement-final-3-nov-2014.pdf (Accessed 19 September 2019).

12. Lee KH. The Hospitalist Movement – An Adaptive Response to Fragmentation of Care in Hospitals. Ann AcadMed Singapore. 2008; 13(2):145–150.

13. 2013 Census QuickStats about a place: Ashburton District [Internet]. Stats NZ. [cited July 4th, 2019]. Available from: http://archive.stats.govt.nz/Census/2013-census/profile-and-summary-reports/quickstats-about-a-place.aspx?request_value=14909&tabname=Populationanddwellings

14. Kaboli PJ, Go JT, Hockenberry J, et al. Associations between reduced hospital length of stay and 30-day readmission rate and mortality: 14-year experience in 129 Veterans Affairs hospitals. Ann Intern Med. 2012; 157(12):837–45.

15. Turnberg L. Survival of the General Physician. BMJ. 2000; 320(7232):438–40.

16. Loefler IJP. The Renaissance of General Surgery. BMJ. 2000; 320(7232):436–8.

17. Pashen D, Murray R, Chater B, et al. The expanding role of the rural generalist in Australia-a systematic review. Australian Primary Health Care Research Institute. Brisbane, 2007.

18. Albritton W, Bates J, Brazeau M, et al. Generalism versus subspecialization: changes necessary in medical education. Can J Rural Med. 2006; 11(2):126–8.

19. Davidson D, Paine AE, Glasby J, et al. Analysis of the profile, characteristics, patient experience and community value of community hospitals: a multimethod study. Health Services and Delivery Research. 2019; 7(1).

Contact diana@nzma.org.nz
for the PDF of this article

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