Back To The Future

Small Communities Point The Way?

- Maire Leadbeater

Recent Watchdog articles have highlighted the fact that transnational companies have assumed a dominant position among the providers of residential care of the elderly. I reviewed this situation in an earlier article “Who Should Look After Older People Who Need Residential Care?’ in Watchdog 125, December 2010, In Watchdog 126, May 2011, it was announced that a large provider of residential care services, BUPA (British United Provident Association), was the runner up for the 2010 Roger Award for the Worst Transnational Corporation Operating in Aotearoa/New Zealand (the full Judges’ Report can be read online at Ed.). In the same May 2011 issue Alastair Duncan of the Service and Food Workers Union put forward a case that Australian-owned Oceania care provider would have been a more deserving winner! (“The Roger Award Finalist That Never Was!”,

Alastair pointed out that Oceania (owned by Macquarie Bank) is the largest corporate provider of aged care facilities in New Zealand. He outlined the history of Oceania’s (initial) failure to pass on District Health Board (DHB) funding increases to staff, inadequate arrangements for staff training, and hard ball approach to union bargaining. Alastair’s analysis is especially valuable because it establishes that where there is a high level of union cover; staff are not only better paid but also better trained and better informed about their rights and those of their patients.

While researching my earlier article I was interested to note that some long-stay care facilities remain in public sector ownership around the country. I have now obtained from the Ministry of Health a detailed list of the about 20 facilities, (1) which survive against the trend to privatisation. In general they are small facilities, in small communities. Most offer a modest number of long-stay beds - as few as four - in conjunction with other services including short term rehabilitation care for the elderly. One or two are close to being phased out. How have these hospitals and rest homes survived? One reason is that small communities do not offer the “economy of scale” that the profit-driven private provider requires. Community resistance to closure or relocation has been a factor in the survival of several facilities. What follows is a brief overview of these facilities, and a discussion about whether this model of public sector care should be replicated more widely.

Introducing Some Taxpayer Funded Facilities: Hidden Taonga? (2)

Counties Manukau (South Auckland) has two small, well-regarded hospitals for long stay care: Franklin Memorial and Pukekohe Hospital. Both also offer short-term rehabilitation care. Waikato has small hospitals: one in Te Awamutu: Matariki Hospital, and the other in Morrinsville: Rhoda Read. There is also an “overflow facility” at Te Kuiti Community Hospital. Rhoda Read, according to the Waikato DHB Website: ”is situated in mature, landscaped grounds, offering a restful environment for its residents and clients”. It offers a mix of services from long term care to maternity services.

Canterbury District Health Board has long stay care facilities at six locations – Darfield, Ellesmere, Kaikoura, Oxford, Waikari and Tuarangi in Ashburton. Essentially these are small community hospitals which offer services as diverse as surgical rehabilitation and maternity services along with a small number of long-stay beds for the elderly. The Canterbury District Health Board Website illustrates its profile of each hospital with a photo and most seem to be very well appointed and located. For example Waikari Hospital is “set in beautiful grounds overlooking the Alps”.

The situation in Nelson-Marlborough has been subject to some community controversy. In Golden Bay the District Health Board’s Community Hospital and the Trust-owned Joan Whiting Rest Home in Collingwood are to be combined with the local medical centre, 2.5 kilometres from Takaka township. All the staff will come under one employer, the publicly funded Nelson Bays Primary Health, with the land and buildings owned by a community trust. I am told that some in the community fear that the integrated centre might be privatised at some future date, and that there has been concern, particularly from Collingwood residents, about the loss of the 17 bed Joan Whiting Rest home. It is a much loved facility, and understandably so as it overlooks a picturesque bay.

According to the Website of the Golden Bay Family Health Centre Project, (3) the management of the new structure will include the Tasman District Council, Golden Bay Community Board, and local iwi as well as the Nelson Bays Primary Health organisation. Under its trust deed the new Golden Bay Community Health, Te Hauora o Mohua Trust's principal charitable objective will be: “To meet the long term health needs of the people of Golden Bay by creating a purpose-designed integrated facility that will attract professionals to provide team-based preventative, primary (GP), acute, maternity and residential aged care”. Hopefully, it will not be the kind of facility to attract a profit-hungry corporate while expensive preventative and primary health care are in the mix.

Over in Richmond more change is coming. The Alexandra Hospital, a specialist psychogeriatric facility, currently under the Nelson Marlborough District Health Board, is on the way to closure. The elderly patients are to be accommodated by the privately owned Tasman Park dementia care facility probably from the end of August 2011. Some other services offered from Alexandra will in future be provided by Nelson Hospital. (4) Murchison also has a hospital and rest home combined with a Health Centre.

The West Coast District Health Board continues to provide long stay care for elderly patients in the small towns of Reefton and Westport. Reefton offers both Rest Home care and Hospital level care at Reefton Hospital. In Westport there is Buller Hospital which has Kynnersely Rest Home (on site) and Dunsford Ward to provide for long term hospital level care. The Grey Base hospital in Greymouth has a purpose built dementia unit which serves the whole of the Coast, and is effectively a replacement for the services once provided at the old Seaview Hospital. Specialist psychogeriatric care is also offered.

South Canterbury has a hospital for long stay care called Talbot Park in Timaru. As far as I can see, at 78 beds for both hospital level and specialist dementia hospital care, it is the largest of the facilities described here. While not owned by a District Health Board, Pohlen Hospital in Matamata is worth a mention, because of its close integration with its community. It is run by a non-profit Charitable Trust. It offers long and short stay beds and is co-located with a general practitioner (GP) practice. Waikato District Health Board clinics operate on site and other community services are also based at Pohlen. I am told it is very well regarded.

In terms of payment, all long-stay residents are subject to the same rules and must pay at least part of the cost of their care unless they meet the income and asset test and receive a Residential Care subsidy. I confirmed with the Ministry of Health that the funding regime is identical whether the patients are in private or District Health Board long stay care. As I lacked the resources to undertake a personal tour of all of these facilities, I have talked with a number of people with relevant experience and expertise, including geriatricians with long experience of changing ownership patterns.

Quality Of Services Maintained

Green MP Kevin Hague, formerly Chief Executive Officer of West Coast District Health Board, told me how he worked hard to maintain the quality of the services for the elderly in the face of financial stringency imposed by the Ministry of Health. In Westport there has been a proposal to combine the Trust-run O’Conor Rest Home with the District Health Board’s Kynnersely Rest Home as both struggle with maintenance costs. However the staff, residents and their families express a very high commitment to the two separate facilities and have been resistant to change.

Kevin told me that the local communities are in general very supportive of all the West Coast long-stay facilities which provide care of a high clinical standard in a “homely” environment. My informants offered me differing views on the issue of “co-location” or providing long-stay care in conjunction with other services. Apparently co-location does not necessarily mean lower costs, but it can mean that long-stay care patients have easier access to trained staff in an emergency. For example a rest home “co-located” with community hospital or GP practice will have easier access to a registered nurse and a doctor than a stand-alone rest home.

The professionals I talked with could see some of the benefits of these small public facilities, but I cannot report that they agreed with my suggestion that we consider bringing long-stay care back into public ownership. Several commented that generalisations are very difficult – some “corporate” facilities are providing care above the norm while some non-profit facilities are not managing well. There was agreement that a mix of rehabilitation and long-stay care on the same site would potentially offer advantages. A common complaint from families about the care in private hospitals is that the physiotherapy services are very limited or non-existent. Many patients in long-stay care can still expect to make some gradual gains in their wellbeing and with their overall functioning if they are offered ongoing physiotherapy, speech therapy and so on. This expensive help can often be extremely limited in the “for profit” sector.

A fear was expressed that that if long-stay care were to be brought back into the public system long-stay care would be the “poor sister”, which only attracted less able staff. There is a strong view that more public resources should go towards providing regular specialist input to all long term care hospitals and rest homes. This should include education and upskilling for consulting GPs and other staff. If the specialist input was regular and ongoing this would help to avoid medical and medication complications and it is likely that there would be fewer admissions to public hospitals for acute treatment.

On the other hand a view was expressed that when long-stay care was provided “in house” the referring specialist could follow up his or her patient very easily given established colleague relationships and shared databases. “For profit” private hospitals are accountable for the service they provide to the respective District Health Boards under a standard contract and without this contract they cannot receive funding. The wording is complex and lacking in specifics in many areas. Like all “contracting out” arrangements it is difficult for consumers to establish when a provider is in breach of the contract. (5) I accept that we are not likely to be able to sell the idea of publicly provided aged care to our current political masters, and that I am not in a position to draw firm conclusions from this overview.

Escaping Privatisation Drive

But I am encouraged by indications that many of these facilities are providing good care in close collaboration with their communities. So, however utopian, I will continue to support the ideal of greatly increased access to publicly funded long-stay care. I am hoping that a “genuine” researcher with adequate resources will undertake further research into these small “pockets” of public sector care around the country. Does anyone out there know a health science student looking for a topic for a post-graduate thesis? It might be especially interesting to consider the models which involve a not-for-profit community health trust. Although the sample is small it would be very interesting to know if they are providing a higher standard of care on measurable indices such as admissions to acute hospital care. Also I would be interested in any feedback or comments, which might help to expand the story of the facilities that have escaped the privatisation drive.

(Before my recent retirement I was a social worker working with older people and their families, a role in which I gained a lot of experience with the issues around long term residential care).

1. Letter from Ministry of Health, 15/2/11
2. More information about these facilities is obtainable on the respective District Health Board websites or from the Eldernet site:
4. Email from Keith Rusholme Project sponsor Psychogeriatric Services 31/5/11

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