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Helicopters, Consultation and Sacred Cows When Best Practice Conflicts with Public Opinion

Helicopters, Consultation and Sacred Cows When Best Practice Conflicts with Public Opinion. NZIHM Meeting 14 April, 2004 Dr David Rankin GM Healthwise - ACC. Sacred Cows. Rural Hospitals are Necessary Rural Surgery is better than nothing Helicopters – the closer the better

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Helicopters, Consultation and Sacred Cows When Best Practice Conflicts with Public Opinion

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  1. Helicopters, Consultation and Sacred CowsWhen Best Practice Conflicts with Public Opinion NZIHM Meeting 14 April, 2004 Dr David Rankin GM Healthwise - ACC

  2. Sacred Cows • Rural Hospitals are Necessary • Rural Surgery is better than nothing • Helicopters – the closer the better • Waiting Lists are always bad • Magic Rubs work • Expensive Equipment is desirable • Specialists know best • Clinicians always make correct calls • Pricing is simple • Doctors make the best Health Leaders • Only Anaesthetists are Safe • Stretch before exercising

  3. Principles of Sacred Cows • Firmly held community belief • Community contributes to service • Failure of service perceived to jeopardise community health • Supported by prominent community leaders • Self interest may not be declared • Arguments are emotive, not rational • Often contrary to best practice

  4. Communication Centres

  5. Part of Major Sector Change • Ambulance Sector Standards • Sustainable Funding Review • Dispatch & Delivery Protocols • Standard Contracts • Review Committees • ECCT Committees

  6. Status • 8 centres nationally • Varied ownership • Varied rules • 30% + of 111 calls dropped • Analog technology • Patchy QA • Variable technology

  7. Issues • Local knowledge • National response • Redundancies • Replication • Governance • Cost

  8. Currently • 3 national centres • ProQA in all • Vehicle tracking • Digital technology • Mapping software • Sector Governance

  9. HelicoptersIssues from “Current Status Report”

  10. History • Auckland Rescue Helicopter Trust • Life Flight Trust - Wellington • Ian Civil • Report for the College of Surgeons • Cull Report • Structure and location of air services • Roadside to Bedside

  11. Locations - Helicopters

  12. International Comparisons

  13. Funding • Emergency Trauma Response • Mainly (95%) ACC • Plus SAR, Police • Inter-Hospital Transfer • Mainly DHB • Corporate Sponsorship • Westpac, Lion Foundation, Philips etc • Community donations & Pockies

  14. Cost Efficiencies

  15. Trends • Reducing emergency volumes • Lower traumatic injuries • Better road service • Subsequent reducing ACC funding • Larger (more expensive) craft • Increasing technical and skill requirements • Paramedics, IFR, winch, lantern • Evidence does not support Scoop & Run

  16. Specialist Opinion is Always Correct

  17. Knee Surgery/Claim Rate

  18. Elective Surgery - Knee Intervention per 100,000 population

  19. GOP08 – RTW duration

  20. Use of MRI - Spinal Surgeons

  21. MRI - Sports Physicians

  22. MRI - Sports Physicians

  23. The Doctor Knows Best

  24. Average ToW by GP

  25. Standards • Who determines competence • What is better than nothing • What is good medicine • Communication vs. technical • Skills vs. judgement • Alternate treatments

  26. Ethnicity Drives Need

  27. Maori Treatment Claim Rate- per 100,000 per year

  28. Claim Rate by Age Group

  29. Utilisation of Primary Care Maori claims as a proportion of all claims (MFP claims for year ending June 2003) 20% % Maori 20% 1,000,000 Number of Claims (all Ethnic Groups) 18% 900,000 15% 15% 14% 14% 16% 800,000 13.5% 13% 13% 14% 700,000 12% 11% 12% 600,000 10% 10% Number of claims (all ethnic groups) % Claims with Maori claimants 9% 10% 9% 500,000 8% 8% 7% 7% 8% 7% 400,000 7% 6% 5% 6% 300,000 4% 200,000 100,000 2% 0% 0% 0% 0% 0 Podiatrist Leg Ulcer Radiologist Psychiatrist Osteopaths Chiropractor Optometrists Acupuncturist Hand Therapy Practice Nurse Physiotherapist PRIME Services Endorsed Physio Speech Therapist Counselling - Other General Practitioner A&M Clinic Services Prescription Charges Emergency Transport Rural Nursing Services Counselling - Groupwork Counselling - Sexual Abuse G.P. Receiving Rural Bonus High Tech Imaging Services Share of Census Population1

  30. Pricing is Simple Anyone can do it!

  31. Scatter of Price to Tender(9 providers, 240 procedures)

  32. Waiting Lists Are Bad

  33. Knee Surgery Timing< 3 Months From Injury

  34. Magic Rubs Are Good

  35. Treatment that does not work • Interferential • Heat lamps • Short wave laser • Massage • ? ICE • Back stretching machines

  36. Issues with Sacred Cows • Strong Community support • Strong Champions • May have conflict of interest • Biased by anecdotes (may be personal) • Loose Certification, Minimum standards • Funding pressures • Lack of a National Plan • Lack of available benchmarks • Poor rules around utilisation

  37. Consultation Who Should Decide?

  38. Consultation Issues • Technical Issues • Concept or detail • Champions • For and against • Preparation • Focus Groups • Representation • Format and Presentation • Pictures say more than words • Experts vs. the People

  39. Issues (cont.) • Who determines best practice • How wide is your frame of reference? • What is your outcome • Are RCTs the gold standard

  40. Lessons • Never plan into a vacuum • Don’t assume even distribution of knowledge • Beware of pictures • Be aware of community fears • Don’t assume silence implies no change • Consult before you consult • Peers, interested parties • Don’t consult on technical issues • Never go on holiday after releasing a major strategy

  41. Beware the sacred cow

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