KEY POINTS:
A frail, elderly lady lies on a trolley in a corridor at North Shore Hospital, clutching her handbag. She is plainly ill and uncomfortable. There are around 30 similar patients in cubicles and another five parked in the corridor, including a young woman who came in an hour ago with severe abdominal pain.
Next day, when we return to take a photograph, the young woman is still there, still in pain, still too ill to eat, and after 22 hours, still waiting for a bed in a ward upstairs.
This is the reality of North Shore's Emergency Care Centre and is the hospital's ugly, open wound. Patients go here after admission to be "triaged" or sorted into a priority list for treatment (see box). The dangerously ill - heart attacks, stroke, seizures, haemorrhaging wounds - are seen reasonably quickly. The rest, especially the elderly and those referred from other hospitals, wait - some up to several days. Some get bedsores after days on 2in-thick mattresses designed to be used for a couple of hours at most. Many aren't fed in emergency and once up in the ward often miss 5.30pm dinner - and are told there is nothing available until breakfast at eight.
But at North Shore, that's the way it is. As Rachel Haggerty, General Manager Adult Services says, with a rueful smile, "The Emergency department is the release valve on the pressure. We know we have a problem. It's not ideal by any means, but ... "
And yes, she stresses, there is food handed out by St John's ambulance volunteers. Sometimes it just doesn't get to patients.
Haggerty, who graduated in health management 18 years ago, has been at Waitemata DHB for eight years. She favours primary care and is resigned to the deprivations and humiliations suffered daily by hospital patients.
Like many people in the sector, she rationalises complaints with the rejoinder that this is the reality for all of our DHBs: overcrowded hospitals, overworked doctors, not enough nurses. No, it is not ideal, they say, but it is the norm - the way it is.
"We fall quite low [in efficiency statistics] because our bed occupancies are in excess of 90 per cent and managing bed turnover is a significant operational workload that people deal with every day. We manage that by people waiting in our Emergency Care Centre. Basically the lower risk you are, the longer you'll wait," says Haggerty.
So, every day, there they are, the trolley dwellers, most elderly and obviously uncomfortable, often hungry, scared of making a fuss, waiting for hours on end. And, continues Haggerty, "If it was up to me, getting ED to the point where no one waits is not where I would put my money. It doesn't make a difference to the long-term gain of the population. It means that people have a better experience, but when it comes to making people well I'd rather be out with the diabetes and obesity problems in our population so they stop coming to our hospital."
Director of Clinical Training for North Shore Hospital, Dr Pat Alley points out however, that "investment in primary care with the expectation you'll have less expenditure on secondary care, is false."
A "foundation member" of North Shore Hospital where he has worked as a general surgeon since it opened in 1984, Alley points out that primary care (trying to keep people well and healthy in the community) does not work for the surgical problems he deals with.
"All the stuff we do here - appendectomy, acute gall bladder, large bowel cancer surgery, road trauma and other cancers - there's not a thing you can do about them with primary care."
Having said that, he points out that despite the problems, once people get into the operating theatres and wards, North Shore delivers an excellent service. "Our doctors and nurses work hard and extremely well against the odds."
Back when Alley started, outsiders saw the fledgling hospital as a political move by then-MP George Gair, rather than a necessity. No one could say that now. North Shore's catchment is over half a million, growing furiously - and changing fast. Some 56,000 more people (the size of a small town) cram in every five years, making Waitemata the second-fastest-growing DHB in the country. The normally extraordinarily healthy population is aging, meaning hospital admissions are growing 8-10 per cent a year. And North Shore Hospital is clearly bursting at its pressure points like a flimsy, over-stuffed pillow.
"The average age in our surgical wards is 78," says Alley. "And the co-morbidity index is five on average."
Co-morbidity means a patient is suffering from several things at once. Elderly people routinely arrive at hospital with a list of problems. "They'll present with bowel cancer and, in addition, will have heart disease, high blood pressure, diabetes, mild kidney failure and early dementia".
This makes management complex and time-consuming. "Patients can come in on Monday and won't get surgery till Friday." The other big problem for North Shore is dealing with people whose bodies are giving out altogether, but whose minds are "sharp as a tack", leaving the hospital caught up in sensitive, time-consuming "end-of-life decisions".
At the other end of the life cycle, North Shore women have more caesareans than those in Auckland and Manukau. Then there is the chronic nursing and doctor shortage.
"This is the worst pressure situation I can remember since I started at North Shore," says Alley, who regularly strides through the hospital cheering on over-worked staff. "And, until we get more space, it can only get worse. In the Tower Block we're 60 FTEs (full-time equivalent nurses) short, so every one of the nine wards in the Tower block is missing six or seven nurses."
And there is no end in sight. Serious expansion of the hospital by adding another tower block is still at the planning stage and not due until around 2012.
Despite the recent pay jolt , which saw Registered Nurses' salaries rise by up to 17 per cent, young people are not joining the profession. The average age of nurses at North Shore is 54. Alley's daughter's 7th Form class at Epsom Girls' Grammar had only two girls going into nursing. Worst of all, he says, comprehensively trained nurses are not as keen on mundane ward work as those who trained in hospitals and viewed the job as a vocation as well as a career.
The nurses respond: "I wonder where the funding goes. We seem to have a lot of managers and not enough frontline staff. On the other hand they seem to be putting a lot of effort into making it better at the moment."
Annie Hallar, RN, who manages North Shore's Emergency department, says the struggle is all about patients who get stuck in Emergency.
"It's difficult to manage them. People need to be showered, fed and taken to toilets".
I can hear the sigh down the phone. "Our hands are completely tied."
Hallar started the job 15 months ago and is trialling new, thicker mattresses and extra cleaners to keep the toilets and bathrooms in reasonable shape. But nothing can alleviate the chronic overcrowding, which is due to explode when winter starts in earnest. Right now they admit around 140 patients a day - which would be manageable if they then moved on to wards.
But it simply doesn't happen. "We're a holding pen," says Hallar. "Our nurses work exceptionally hard and get upset at the lack of patient movement. In an ideal world we'd have another 40-60 beds."
The department is fully staffed with 140 nurses in total. But in reality with an 18-bed observation unit, plus a further 24 patients on trolleys in cubicles and 15 more in the corridor, "a young girl having a fit comes before a lady on a trolley who hasn't eaten for six hours".
The problems show in the statistics. The latest March 2007 figures, obtained through questions to the House by opposition Health Spokeperson, Tony Ryall, show that Waitemata is going backwards. It scores worst in the country - 77 per cent - for meeting recommended guideline times for Triage 1 care - and well behind both Auckland and Counties Manukau DHBs on 100 per cent. Auckland's three hospitals (Waitakere is bracketed with North Shore) receive around $3 billion a year from the Government.
An extra $4 billion, which the Government assures us has been pumped into health, has not made it to elective operations - or to waiting lists.
"There's billions of dollars extra being poured in to the health system," grumps Ryall. "And here's a basic part of the service that isn't working."
But the thing that bothers Ryall most are Waitemata's scores for Triages 2 and 3.
"No major hospital in New Zealand is meeting the Government's own benchmarks for emergency departments," he says.
"The Government's information shows Waitemata as the most under-pressure ED in the country.
When only half of people with 'imminent threat to life or limb' (54 per cent of Triage 2) are seen on time, people have to wonder why nothing's been done about it."
Both Haggerty and Waitemata DHB's new and affable chief executive, Dave Davies, are reasonably relaxed about these figures. Haggerty, who answers 90 per cent of my questions, insists that "there is no delay at all in Triage 1" but delays start in Triages 3, 4 and 5 where patients' illnesses are not immediately life threatening.
The problem is compounded by North Shore's practice of using its Emergency department for both discharging patients and acute medical admission.
"This means that electronically we can't separate those patients," say Heggerty. "We note the problem but it's not easily rectifiable."
It is certainly not the way it is over at Waitakere Hospital, the other arm of the Waitemata territory. When the new part of Waitakere opened in February 2005, 27 more beds were added to the mix. Acute orthopaedic services were transferred from Auckland to North Shore and some patients went from North Shore to Waitakere.
At Waitakere there's a sparkling and much more welcoming hospital alongside the old tower block. Parking is free. The wards are called things like Piha and Te Henga. To find your way round you follow the paua shell or bird symbols. Davies, who started his career as a psychiatric nurse, has already presided over the opening of a new $14.5 million acute mental health unit. Called Waiatarau, it was blessed at dawn last Friday and is a fabulous facility, streaming with natural light, built solid with all the latest security and electronic gear (despite the fact that the old unit was not running at 100 per cent occupancy).
"We're providing more so the pressures come off," says Davies. Patients won't be moving in until the end of August, so they wait in the old unit, just across the grass. Although it has been tagged for future mental health needs, they still haven't been decided exactly what the old building will be used for.
Back at North Shore the afternoon's swag of patients waiting on their trolleys to take over beds from discharged patients, have a haunted look in their eyes.
Why is North Shore in such a bad way? According to former chief executive, Dwayne Crombie, the pressure on Waitemata has increased since the Government subtly changed the way our hospitals are funded.
"The main reason Waitemata loses funding is because it has the highest income average of any DHB in the country," he says.
"The population-based funding formula of allocating money is based primarily on the number of people [in each DHB], their age, gender, ethnicity and deprivation. But it then has an [unmet needs] adjuster that swings funding up to plus or minus 10 per cent. A place like South Auckland would probably swing plus-10 per cent because it's got a lot of poor people, and those poor people theoretically drive worse health outcomes.
"Richer people [as in North Shore] have better health outcomes: they live longer so they deserve less money. The difference per head of funding is probably as much as 20 per cent per head."
He is unsurprised that latest figures show that Waitemata is the lowest-funded DHB in the country, coming in 14.1 per cent below the national average.
"That'd be around $90 to $100 million a year on a straight per head basis."
The new adjustor method is driven by Government philosophy. Rolled out in 2003, it replaced funding based on mortality ratios. Now, says Crombie, "It's explicitly socio-economic - based on the number of people you have in your bottom quintile."
Crombie, the country's longest-serving DHB chief, spent much of his time arguing with the Health Ministry that the adjustment was too much.
"It seemed to me there was too much money swinging on the deprivation ideology," he says. "Because it wasn't clear to me that shifting health resources will solve unemployment, illiteracy and some of those fundamental basic health behaviours they're trying to address. You might patch them up at the end but it's not health service resources that are going to solve those sorts of issues. "That's why I wasn't that popular with the current Government."
"We don't see it like that," says Haggerty. "It's not an argument we use with the Ministry for funding purposes. We argue that our population is growing so fast that we're not keeping up, and that's the bigger issue."
Adds Davies with a broad smile: "For the first time this financial year, we got our population's share of the funding."
Partly true, agrees Crombie, who argued for years, that while Waitemata's population was surging, the Government was funding it using out-of-date census information. "It wasn't getting its adjusted level. Now it's better than it was."
Crombie's other complaint was the never-ending amount of compliance and monitoring in the public system. As he said just after he left Waitemata - and the public health sector - last year, "It's become an industry in itself and a lot of the time I wonder if some of it is more about protecting the system rather than making a difference to whether people die in hospital or elsewhere.
"It takes a huge amount of resources."
According to Ryall, the "malignant" spread of the health bureaucracy "is the biggest problem in health today - consuming huge amounts of money and drowning the morale of doctors and nurses who work at the frontline. Since 1999, health bureaucracy has grown by 2000 extra employees - one for every two nurses - and now costs more than $500 million a year."
SO what are Waitemata managers doing as they move into the busy winter months? According to Haggerty, the DHB has approval for hiring a nursing discharge co-ordinator (to help people get back to the community more easily) plus additional cleaners to cope with the volumes in Emergency. They have upgraded two community mental health buildings ($2 million), and are starting building 20 new beds in Waitakere due in July 2008, "because this is where we can build them more easily", despite the fact that the congestion is at North Shore. They are also building an eight-bed high dependency unit (for patients between intensive care and the ward) at North Shore, four due next February and four in September 2008.
"Maternity's next on the block," says Davies.
"And then we'll do North Shore mental health inpatients unit."
Then, and only then, they will implement a building programme to refurbish and rebuild. North Shore Hospital. Estimated finish date is around 2012.
"By next winter we'll have different beds open so we'll be able to cope better," says Haggerty. "But we'll still get spikes in our system and that's normal."
HELL ON WHEELS
The views of North Shore Hospital patients as they felt it - and as they told us about it
56-year-old art director, May 2007:
Admitted after a knee replacement at Ascot Hospital became infected. Assessed then parked in a wheelchair in the corridor, terrified his knee would be bumped by passing trollies, for five hours."It was absolutely chocker. You just get left. I was on IV fluids, holding the bag in my hand, my daughter standing in front of the chair to protect my knee." After the operation he was transferred to a general ward where the nurse muddled his IV medication. Two machines used to keep his knee mobile didn't work. A request for an icepack produced a cube of ice in a flannel. The physio hadn't read his notes. The shower was littered with plasters. "It was just scary, just like a factory."
78-year-old man, April 2007:
Admitted Thursday night, perilously ill. Despite his growing distress and terrible discomfort at being on trolley, had to wait six hours to be seen by a doctor. Next morning, at 10, his wife and daughter found him still on trolley bed in emergency with excruciating pain in his urinary tract. The staff did not believe he had developed a new symptom and the doctor responsible for his case refused to to come down and re-examine him. Daughter: "The family had to rise merry hell to get attention in that emergency department. If we hadn't arrived that morning, I reckon he'd have died in that cubicle."
Kitty Callan, 93, September 2006:
Admitted with cellulitis in her leg. Because it was infectious she was put in a room on her own. Nursing was inadequate. She was not turned and checked. She left North Shore with three bedsores, one of which she died with.
Jillian Ewart, 60s, August 2006:
Admitted with suspected pneumonia. After a day being treated on a trolley in the emergency department, moved to ward. Discharged, still ill, after six doses of IV antibiotics. Re-admitted to the emergency department four days later with an acute relapse. Treated with IV antibiotics on trolley in corridor alongside 17 other patients. Second dose refused because no medical registrar available. Admitted to Ward 3 after 30 hours on trolley. Discharged after four days and nine courses of IV antibiotics.
Lynn Tucker, 50s, September 2006:
Admitted with suspected peritonitis and spent three days and two nights on a trolley in the emergency department corridor, constantly being moved and jolted; developed a bedsore. Eventually diagnosed with acute diverticulitis. "There was no privacy or dignity. People were crying out for a bottle to do a pee in. If I was ever in that situation again I'd make the ambulance take me to Auckland [where she works in the trauma department]."
Genevieve Becroft, 70s (arts patron, former long-term North Shore councillor):
Easter 2005. Helicoptered to North Shore after 10 days in Whangarei Hospital with peritonitis. Her drips were disconnected and she was transferred to an isolation room in case she had brought hospital bugs from Whangarei. Ten hours later transferred to ward (no lunch or dinner and no hydrating drip) and told nothing but half a teaspoon of Marmite in hot water was available.
May 2006: readmitted with a twisted bowel. After most of a day writhing on a trolley taken to theatre. Later, on the ward she was asked to keep the same stained nightdress and sheets because of a laundry strike.
