Who says you can't teach an old dog new tricks....

Trip Start Oct 01, 2008
Trip End ??? ??, 2009

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Flag of New Zealand  ,
Tuesday, November 4, 2008

The hospital is only 4 years old and quite well designed - although, like the UK, everyone who works here thinks it is too small and cramped and corners were cut to save money. They have not demolished the old hospital and part of that is still used, mainly for administration although the clinical admin staff are in the main hospital block. There are two floors - medical ward at back end (appropriate) leading into the surgical ward, which leads to the Day Unit waiting area and second-stage recovery, which leads to the HDU/ITU and first-stage recovery and finally to theatres (4). The surgical ward has 42 beds covering all the specialties. We usually have about 5 urology patients as length of stay is shorter here. We have a house-officer and a 'registrar' neither of whom are experienced in urology and also cover general surgery. There are also students from Otago. Ward rounds are very relaxed and emjoyable. Also on this level is clinical admin, where the general surgeons and urologists share an open plan office, which is next to the open plan admin section and secretarial section together with seminar rooms etc. The ground floor has A&E (or ED), main reception, outpatients, rehab, cafeteria, diagnostic imaging, paediatric ward and a few other odds and ends such as a 'League of Friends' shop.
We have a superb CNS (Clinical Nurse Specialist) - Emma -  who organizes the clinics and maintains the operating waiting list. Emma triages all the referrals and organizes any preliminary investigations, many of which are done on the day of the appointment as people often travel from miles away. CT scans are the basic investigation rather than IVU for, for example, renal colic, haematuria patients etc. US does not seem to be used as much here. MRI is available and although nuclear medicine is available on site it depends if there is a radiologist around trained for this. I have just booked a renogram which will be done in 4 weeks time when the nuclear med radiologist comes! The clinic has it's own US machine and TRUS biopsy probe. I have already been trained in doing my own biopsies! There are also 5 flexible cystoscopes which are used in clinic and that is where the check cystoscopies etc are done. Real one-stop stuff! Clinic letter turnaround is 2-3 days - not as good as Lesley and Diane! Clinics are also relaxed as they are so well organized by Emma. Each patient is given a 15 min appointment (very occasionally overbooked) if urgent) so there is time to talk, explain and reassure. Also, time to to a cystoscopy or biopsy if needed. Follow-up patients are contacted nearer their follow-up day with reminders about any investigations that need to be done and a fixed day and time given - rather like our partial-booking system and works very well. Pathology is varied and plentiful and often a bit more advanced than in the UK due to the stoic nature of Southland patients and possibly because they have to pay to see the GP - see below. I look forward to clinics these days!

There is a mobile lithotriptor in a bus which comes every 5 weeks or so and once again I am now an expert in running this. It is a Dornier lithotriptor, about 2-3 years old and the cases are all done under GA with a choice of X-ray or US imaging, although almost exclusivley the latter. Notes, GP letters, prescriptions and discharge summaries all done automatically, there and then, in the bus. The bus is connected to the hospital IT system so patient records and x-rays can be viewed on board. Interestingly they have the same iPM and PACS system as St Helier but more advanced in that discharge summaries, clinic letters etc are all embedded in it. It has tea and coffee making facilities and very comfy chairs with friendly staff, so makes for a pleasant social day as well. There are tea and coffee facilities in every department - free, even in the cafeteria which also sells Starbucks type coffees which are excellent.

Theatre is well equipped and spacious. We have a laser lithotripsy machine - yet another skill I have developed! Storz equipment - irrigating scope, so thanks you young guys for making me use that before I left so that I could actually put it together myself. I have a dedicated bay in the theatre suite where patients are 'held' prior to entering theatre so I can review their notes, consent and speak to them etc. There is a dedicated nurse attached to this who ensures everything that is needed is present and patients are sent for in a timely manner so very little delay. Operating notes are dictated on a digital recorder, typed up and iput in the patient notes whilst they are still in recovery. 'Guestimates' of operating times are put on the waiting list forms and cases chosen to fill up the operating list. Patients are also given a score up to a 100 depending of clinical need e.g. everyone with a malignancy is scored at 80 and then additional points for pain, risk of complications, social needs etc.. Seems to work well. There is a wide range of operations with a mix of day-cases and in-patients on all lists. Usual mix of minor cases such TURPs, endoscopic and scrotal procedures as well as the more major procedures of nephrectomies, cystectomies and radical prostatectomies - not going to start learning the latter though! Partial nephrectomy and PUJ obstruction coming up in next few weeks.

Admin wise the hospital and health board is undergoing changes. There are 21 District Health Boards which were set up in 2001. They vary in size - the smallest covers a population of 32,000 whilst the largest covers 516.000. Southlands covers 110,000. They are run by 11 Board members, of whom 7 are elected at the time of the Local Government Elections and up to 4 others appointed by the Minister of Health. Their budgets range from $48million to $870million.  Like the UK there is an Act of Parliament (Health and Disabilities Act 2000) which lays down what services they have to provide and sets targets. Below this are the GPs  most of whom belong to PHOs (Primary Health Organizations) which are a bit like the PCTs used to be. More than 95% of the population are registered to a PHO which means they get free treatment if under 6 or on certain social security benefits. Others pay to see they GP - average is $25 but can vary as this is up to the GPs and PHO. Prescriptions cost $15 per item, or in certain cases only $3. You can go to a GP anywhere in NZ but, if not in your PHO, then you are not usually entitled to the cheaper prices and pay the going rate of the GP. As always, there are funding issues and the Southlands Health Board and Otago Health Board have just merged their management structure, which is not universally popular. Southlands Hospital itself is altering it's management structure with Divisional Clinical Managers linked with a Nurse Manager and a Business Manager - sounds familiar??? The reason for this is that there have been complaints of lack of clinical input into decision making. Deja vu??In the news last week it said that there are now more managers than beds in the health service here. Deja vu - again? We had a Surgical Division meeting today and guess what the main topic of conversation was - yes, parking!! This despite the fact that there is a huge amount and it is free. 

All in all, it is a pleasure to work in the hospital. It's not perfect, but there doesn't seem to be as much friction, hassle and pressure there is anywhere in the NHS in the UK. From what I have heard, it is not like this all over NZ and, as in the UK, the bigger the centre the bigger the egos. Would I have been happy to work here permanently? I think that is a no-brainer and would recommend it to anyone looking for great work-lifestyle balance, especially if you like the outdoor country life. Only working 3 days a week also probably helps...
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