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| Journal of the New Zealand Medical Association,
23-June-2006, Vol 119 No 1236
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The New Zealand Mobile Surgical Bus Service. What is it
achieving?
Kevin Bax, Susan Shedda, Frank Frizelle
People who are better educated, have professional
occupations, have higher incomes and do not live in socioeconomically-deprived
regions are likely to enjoy better heath and live longer. This association
between socioeconomic position and health is well-established.1
In
general, New Zealand society values equality, including equality of access and
provision of health care. Reducing health inequalities, particularly among
Māori and Pacific Islanders, is at the centre of the New Zealand
Government’s health agenda.2
Access to secondary and tertiary care for patients in rural
communities has deteriorated considerably over the last 20 years in part due to
hospital closures in rural communities. As a result of this there has been a
decrease in the availability of the procedural services available to these
communities within their own environment.
There
is also increasing concern about the delivery to the Māori
population.3 To combat these issues a mobile surgical service was
developed with the aim to provide mobile interventional surgical services and
try and address the issue of equable access to health care to rural communities
and ethic minorities. Experiences in other countries, such as Ecuador and Brazil
have shown the potential for mobile surgical service provision in isolated
areas.4,5
A mobile surgical bus is operated by Mobile Surgical
Services (MSS). The bus is a 20-metre long 39-tonne converted truck and trailer
unit. It houses modern operating theatre and telecommunication facilities. It
was built in Rotorua at a cost of NZ$5.2 million, the capital for which was
raised by private investors. The New Zealand Heath Ministry has agreed to fund a
pilot service project at a cost of $5 million per year for the next 5 years, a
total cost of $25 million. (This budget is for 1000 day case procedures and 50
½ day telepresence sessions per year.)
MSS produced a proposal document for the New Zealand Health
Ministry, in which it was stated that there were 22 potential project benefits;
they were:
Timely and community based access to a wide range of day
surgical procedures:
Many of these goals are impossible to
measure, however some are. This study reviews the initial 2 years’
experience with the bus and seeks to determine if it is achieving its stated
goals.
MethodData about the use of the bus is collected
prospectively by MSS, who has the service contract for the ‘Bus’.
This data was provided by MSS and we analysed it. There was an average of a
30-day follow-up, with a telephone interview by trained nurses, attempted after
every procedure (97% successful) (The service contract runs from October 1st to
September 30th; however, the first procedure, in the first service year, was
completed on March 8th 2002, and so for convenience 1 March 2002 was chosen as
the starting point for the 2-year assessment, with 28 February 2004 being the
endpoint.)
The outcome measures that we assessed were number and
type of procedure, length of
stay, complications,
services for Māori, upskilling for rural staff, social benefits, impact on
child health, improved training with telepresence surgery, and the
cost.
ResultsThe total number of procedures performed during the 2 years
was 1901. A third of the procedures were dental. General surgery contributed
over a quarter of the procedures, with the Ear Nose Throat (ENT) service
performing a little over 10% (Table 1).
Table 1. Number and type of operations undertaken
Average length of
stays—All procedures performed by the mobile surgical service are
day cases; however, many rural patients having day case surgery in metropolitan
areas require overnight stays because they, or their caregiver, cannot drive for
several hours postoperatively.
Eleven patients required hospitalisation after their surgery
in the 2 years; six because of bleeding and the remainder for a combination of
medical and social reasons. The longest single hospital stay was 5 days; a
paediatric patient, after a dental case.
Safety—Of the
1901 cases performed in the first 2 years, there were 57 complications, in
total. Details are provided in Figure 2. The most common complication was
infection with 40 cases reported. The General Surgical wound infection rate was
5.0%; which represents 25 out of 494 cases. Of the Other group, which consists
of 6 cases, the problems faced by the patients included pain, nausea, wound
dehiscence, and urinary retention (Table 2).
Table 2. Complications of operations
This is a quality improvement system, which is managed
in-house and allows rapid changes when needed. There is a system for reporting
and reviewing untoward events, and near misses. To ameliorate the increased risk
of operating in a remote setting, and a major problem occurs without the backup
of a base hospital, the bus is totally self-contained, and the surgery is on
low-risk patients having low-risk surgery. If a major event occurs, then the
patient can be transferred to the nearest base hospital after being stabilised.
Improved
services for
Māori—In
the 2 years, 627 New Zealand Māori and Pacific Islanders underwent
procedures; this represents 33% of all patients.
Upskilling of rural
staff—Rural doctors (working in the areas that the mobile surgical
service visits) have been invited to assist the visiting consultants when
procedures are undertaken on their patients. This provides the local doctor with
improved understanding of the potential of the service from both a surgical and
telepresence point of view. There is also upskilling of the local nurses at
small rural hospitals.
When the bus first arrived in rural areas, specific
introductory training (using simulation in conjunction with National Patient
Simulation Centre at Wellington) was undertaken. Rural staff are encouraged to
staff the surgical nurse and recovery positions, therefore upskilling and
maintaining the necessary expertise that may have been lost when many of the
small secondary surgical centres were closed (visiting consultant staff see
above). This contribution is intangible and immeasurable but appears to be a
consequence of the delivery of this service to more isolated communities and
their health providers.
Social
benefits—A rural lifestyle has many benefits but access to health
care is often limited by the ability to travel to major centre for more
specialised services. Less time off school and work for patients and
accompanying caregivers means that there is less disruption to the lives of
these members of the community. In addition, less time spent travelling and
staying overnight in motels in metropolitan equates to money saved. We have no
quantifiable data proving this, however,
The ability to target
services for child health gain—There were 754 paediatric patients
(under the age of 15 years) seen in the mobile surgical bus service,
representing 40% of all patients. Once again, this proportion is higher than the
proportion (23%) of under-15s in the New Zealand population (according to the
New Zealand census of 2001).
Improved training through
telepresence surgery—Each year, 50 ½-day telepresence sessions
are budgeted for; whether these sessions are national or international
telecommunications is left to the discretion of MSS, and the availability of the
necessary connections. In the period studied, 58 telepresence sessions were
undertaken of which 12 were international.
The NZ$1 million telepresence facilities are used by the
University of Otago for their Diploma of Rural Health Medicine. The virtual
assistant has a remote broadcasting station, which is couriered to them; and
through a joystick is able to control multiple cameras within the
‘bus’. A microphone and camera connect the assistant to two large
plasma screens in the operating theatre via broadband technology. This
technology has potential to improve education and service delivery in isolated
communities and to allow contact between larger New Zealand hospitals and
overseas hospitals.
Cost—Each case
is funded NZ$1900, irrespective of the type of procedure performed.
DiscussionMSS reports directly to the Health Ministry concerning the
performance of the mobile surgical service. Monthly, quarterly, and annual
reports are tabled and sent to the Ministry, for their assessment. Comparative
assessment of the service is difficult, as available data from an equivalent
mobile surgical service is to make comparisons is limited. Therefore, an
analytical, rather than a comparative assessment was undertaken.
MSS are contacted to provide 1000 procedures a year, during
the 2-year interval (1 March 2002 to 28 February 2004) the service did 1901
procedures. This disparity between aims and goals is most likely due to the
problems inherent with setting up the new service and should improve with more
time and experience.
The major advantages of the
mobile surgical
service are the social benefits it offers rural communities as well as its
ability to target Māori and child health issues. Some of these benefits are
difficult to measure, but the delivery of services to the rural population is
vital.
One in
three patients treated
were Māori. This is also significantly higher than the 20.1% that New
Zealand Māori and Pacific Islanders comprise in the general New Zealand
population (according to the 2001 census)—thus indicating that the
‘Bus’ is perhaps better
equipped to
target Māori health by virtue of its ability to visit rural and isolated
communities.
Recently, Ecuador has instituted a mobile facility and found
that the provision of surgical services through this method is sustainable. They
also concluded that this was a way of providing a high level of clinical
services.6 This has also been endorsed by the health care delivery in Ecuador.7
The mobile surgical service appears to be addressing the
important issue of equable access to surgical care.
Telemedicine is an important secondary use of the bus
facilities which allows either a surgeon at another New Zealand or overseas
hospital to watch and to verbally assist in procedures. Indeed, it appears to an
important and perhaps expanding role in the provision of continued medical
education and upskilling of services.8,9
The major disadvantage of the service is cost. At NZ$1900.00
per procedure, some procedures are expensive however providing equitable access
was never going to be cheap. What has not been taken into account is the
relative cost of sending rural patients to metropolitan areas for surgical
procedures. Also, whether this is the best allocation of rural heath services
was not assessed in this study.
ConclusionThe provision of specialist services to the rural
communities is a difficult problem faced not only in New Zealand. This has been
addressed by the introduction of an innovative service delivery method. Though
still on a trial basis the mobile surgical service bus has extended the
possibilities available and appears to be addressing one of the important goals
of the Government health policy—equitable access to surgical care.
Author information:
Kevin Bax, Surgical Registrar; Susan Shedda, Colorectal Fellow; Frank A
Frizelle, Colorectal Surgeon; Department of Surgery, Christchurch Hospital,
Christchurch
Correspondence:
Professor Frank Frizelle, Colorectal Unit, Department of Surgery, Christchurch
Hospital, PO Box 4345, Christchurch. Fax: (03) 364 0352; email: FrankF@cdhb.govt.nz
References:
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