Jay Kuten: Co-operation, not adversity, needed

Management of chronic illness, such as diabetes or heart disease, depends upon co-operative effort between care givers and patients. This project becomes complicated and costly if it has to involve hospital care, with greater risk of death or disability.
Prevention of these consequences can come about if patients receive adequate help in management of their illness through good primary care. Yet many patients forego visiting a GP. When their diabetes or heart disease becomes much more symptomatic, many patients report instead to the emergency room. This response is bad for the patient and for the health care system. For the latter it means increased cost and often more complicated care. If hospitalisation is necessary, still more costs are incurred and, for the patient, a greater risk of a poor outcome.
In the January 24, 2011 New Yorker, Atul Gawande described an approach to this problem in one of the poorest, most crime-ridden cities in the US - Camden, New Jersey. Instead of waiting passively for patients to come for services, Jeffrey Brenner used computer databases to find the patients who most often used emergency room facilities and were the centre of the most costly care.
It turned out to be a limited number of people, but they had in common difficult lives, complicated medical conditions, and limited access to primary care. As a consequence, they did not take their medications properly, often sought emergency care, were frequently hospitalised for long and expensive periods. Dr Brenner created a team of health care personnel, nurse practitioners and doctors who would make home visits to these complicated patients and, by gaining their trust, help them to more effective management of their health. It was no miracle, but it made an appreciable difference in both outcomes and costs.
Here in Wanganui, the DHB leaders told me of similar problems of overuse of emergency facilities and resultant hospital-based care. They were able to identify 35 "frequent fliers", but the approach to dealing with those patients took a different turn. A policy decision was made by the CEO, Julie Patterson, to discourage unnecessary ER visits. When a potential patient shows up at the ER she is seen initially by a triage nurse. The triage nurse decides which patients will be seen by emergency room staff (and hence pay nothing) and which will be referred immediately to a private general practitioner on site, and pay $58 for the service.
Having spoken with some folks in the community who found this approach to be punitive as well as costly, I determined to interview the clinician in charge of the ER, Athol Steward, to get his views of it and inquire why the Camden New Jersey approach was not being considered. Dr Steward could not or would not speak with me. He informed me that his contract included a confidentiality agreement and, therefore, I would need the CEO's approval to interview him. Assured by Ms Patterson that this would happen, I reapplied only to find that I would have to provide my questions in writing in advance. I was further informed that a communications officer would have to sit in on any interview.
The ostensible purpose of this minder was to help in event the questioning proved too challenging.
These responses raise the question of what do they have to hide?
More to the point, this hospital and hence its employees are not a private commercial enterprise.
The hospital is paid for by tax dollars and, in every way, belongs to the citizens. It needs to operate in complete transparency. That it obviously does not goes a long way to explaining why the service, particularly to Maori, is inadequate. If a trained physician like myself can't get simple answers to basic questions, how can one expect an average patient, Maori or non-Maori, to negotiate their way through a system which in so many ways demonstrates that it is not only unwelcoming but adversarial?
If any effect is to be had on those mortality statistics, it will take a heap of change.