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Right in the PRIME of LIFE

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Posted 02 August 2016 - 03:58 PM

With thanks to NZ Doctor

Right in the PRIME of LIFE
Liane [email protected] 21 July 2016, 10:24AM

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The public might not know it, but the accidents and emergencies they suffer in the large swathe of rural New Zealand soak up a huge amount of human and financial commitment. Southern correspondent Liane Topham-Kindley takes a look at the rural sector’s PRIME (Primary Response in Medical Emergency), a service now under review.

Photographs by Martin London

Wellsford GP Tim Malloy vividly recalls trying to save a young boy’s arm that had been ampu­tated in a milking machine.

It was his first weekend on call, more than 30 years ago. The boy’s arm was put on ice, while Dr Malloy coor­dinated a landing site for a helicopter at a nearby farm­house. He then dispatched the patient and severed limb to Middlemore Hospital in the hope surgeons might be able to reattach it. It was not to be.

Dr Malloy has lost count of the hundreds of emergen­cies he has since attended, especially the motor vehicle accidents in Dome Valley, south of Wellsford. He can still reel off the names of some of those who have died on that notorious stretch of road.

The milking machine accident happened long before a funding and training scheme was introduced to cover accidents and emergencies in rural New Zealand, known as Primary Response In Medical Emergency (PRIME). Dr Malloy came from a cohort of rural doctors and nurses who considered it part of their job to respond 24/7 to their community’s needs.

These days, not all health practitioners are prepared to be on call around the clock, and Dr Malloy expects it will become increasingly difficult to provide such a service in future.

Rural GPs say they are stressed out by the difficulty of attracting and retaining clinicians to their practices, and trying to run viable businesses on the subsidies and fees available. PRIME brings its own pressures, including problems with funding and access to training.

The arrival of alliances – new primary and second­ary care organisations starting to reform services – has thrown up further challenges. After-hours services are now centralised and some communities have lost their “rural” status, and hence no longer qualify for a PRIME service.

Dr Malloy believes PRIME is suffering because many rural communities do not have the right skills and staff to do the job.

Becoming too much of a burden for many providers

“It’s becoming too much of a burden for many of the providers, who have found it difficult to provide after-hours care as well as PRIME,” he says.

In at least one recent case, a volunteer fire brigade unit was the first responder at a medical emergency because medical practitioners and volunteer ambulance staff were not available.

Emergency , Ambulance , Accident , Stretcher

PRIME review

Hearing the concerns, the national rural advisory group to the Ministry of Health has agreed to undertake a review of PRIME (, ‘News’, 22 June). The review is led by national ambulance sector officer Jared Stevenson.

PRIME was set up to improve prehospital emergency care by having primary healthcare practitioners and am­bulance services together attend accident and medical emergencies in rural areas. It is recognised that timely access to clinical skills has the potential to improve out­comes for medical, surgical, trauma, mental health or obstetric emergencies.

The PRIME programme is funded by the ministry and ACC, and administered by St John. A PRIME practitioner carries a pager and is contacted by the ambulance clinical control centre team following an emergency call.

Semi-retired GP Trevor Walker has been referred to as the “father” of PRIME. In the mid-1990s, he took time out from his practice in Te Anau to write a report for the then Southern Regional Health Authority, Health Fund­ing Association (HFA) and ACC to design a system focus­ing on prehospital care.

Dr Walker says he decided to become involved because he was impressed by the emergency response service then operating in Fiordland between ambulance, fire brigade, doctors and nurses.

“I couldn’t understand why it wasn’t working in other places,” he says from Franz Josef, in South Westland, where he is spending three months as a locum GP.

“Prior to PRIME, we just did it (provided an emergency service) really, because that’s what we did.”

Prime Crash Helicopter

Series of localised, haphazard arrangements in place

Dr Malloy says a series of localised and haphazard arrangements had been in place between ambulance ser­vices and local primary care providers, so PRIME was an attempt to align the process across the country, of­fering standardised access to training, equipment and remuneration.

Dr Walker’s report was a catalyst for the development of the policy document Roadside to Bedside, which became the basis for the PRIME scheme.

Back then, Dr Malloy was representing the New Zea­land Rural General Practice Network, so he led the ne­gotiation process for the first PRIME contract in the late 1990s. This was a lengthy affair, remuneration being the main hurdle in the way of agreement. GPs were unhappy with the $20-a-day fee for practices to remain on call.

Agreement was eventually reached and PRIME rolled out in the South Island in July 1999 and in the North Island in 2000. ACC funded callouts to accidents, while the HFA and later the ministry paid for GPs to be on call for medical emergencies.

Almost 20 years later, remuneration for PRIME services is a fraught topic for GPs.

There are two funding streams – one for accident-relat­ed callouts (PRIME ACC) and another for medical emer­gencies (PRIME Medical).

Lumsden GP Mathew Stokes was one of the first GPs to sign the PRIME contract when it was agreed in the late 90s.

PRIME ACC well-designed and adequately funded in most cases

Dr Stokes says PRIME ACC is a well-designed process and adequately funded in most cases.

For accident-related incidents, ACC pays practitioners for travel to and from an event ($180 an hour) and for the distance they travel (73 cents per km), as well as pay­ing for consultations and/or procedures provided. ACC spends about $200,000 annually on the travel side, but detail about medical costs is not available.

ACC spends about $250,000 annually on training. This covers half the cost of a PRIME course for PRIME practi­tioners and the full cost of a PRIME course for rural GPs.

Medical payment simply does not cover cost of service

The medical payment, however, is a significant is­sue for Dr Stokes. His Southland practice is paid $30 a day for this, and it simply does not cover the cost of providing the service.

As a solo GP, it is costly for him to have to respond to an emergency during the day; the practice almost shuts down without him there.

“Businesses need to be able to sustain themselves, but being away [to an emergency] for four hours is not sus­tainable for a solo practice,” he says.

Dr Malloy agrees remuneration has been an ongoing problem.

“Funding has always been somewhat inadequate, par­ticularly for medical emergencies. There was an attempt to bulk-fund us, so that it would be more equitable, but the value has eroded over time.”

St John receives about $1.8 million a year from the ministry to administer PRIME and deliver PRIME train­ing. About $1.2 million of this funding is passed on to PRIME practices to respond to medical-related incidents. It is this sum that is intended to cover every medical call­out in the rural community in a year.

Each practice receives funding based on the number of responses the year prior. Assuming 24/7 cover, funding amounts to approximately:

- $13,300 to practices for up to 20 responses annually

- $18,400 for 21 to 40 responses, and

- $23,600 for more than 41 responses.

Practices providing large number of callouts disadvantaged

Rural general practice network chair Sharon Hansen points out that practices attending a large number of medical callouts are disadvantaged.

The network has calculated that practices attending up to 20 medical emergencies a year receive 38 per cent of the funding but undertake just 16 per cent of attend­ances. They get about $1200 for every callout they attend.

By comparison, practices attending more than 41 medi­cal callouts a year receive 35 per cent of the funding, even though they undertake 61 per cent of attendances. And they are getting only about $300 per callout.

Dr Malloy says many GPs are committed to providing the service regardless of the payment, but this is unlike­ly to continue.

“In the future, subsequent generations of providers may not see it in this way,” he says. “It will be more and more difficult to provide the workforce if it is not remu­nerated appropriately.”

In many areas, local rural service level alliances made up of primary and secondary clinicians, managers and community representatives, can decide whether practic­es are deemed rural or not. Places like Temuka in South Canterbury can find themselves no longer considered rural and unable to work under PRIME.

Ms Hansen, a nurse practitioner in Temuka, explains that PRIME contracts are also affected by after-hours ar­rangements. There have been significant changes to the way after-hours services are delivered in many areas, she says. If these are provided by a hospital emergency de­partment, then local PRIME contracts are not awarded.

Confusion about who is on PRIME, who is rural

“There is confusion about who is on PRIME and the ar­rangements being made, and who is rural and who isn’t,” Ms Hansen says.

Initially, the PRIME contract was aimed at GPs as the medical provider; it also gave the GP the ability to allo­cate the role to another appropriately qualified clinician.

Rural nurse specialist Kirsty Murrell-McMillan says nurses were integrated into the contract as PRIME pro­viders in the first major contract review in 2005. Nurses were already leading the service in many rural areas, Ms Murrell-McMillan says.

An experienced nurse with a master’s degree in rural and remote nursing, she began her career as a PRIME nurse in Roxburgh, Central Otago, in 2003. The nurse-led service had been established by the local community health trust, which operates Roxburgh Medical Centre, as a way of retaining the GP workforce by taking the pres­sure off them for providing after-hours and on-call work.

Ms Murrell-McMillan, a former chair of the NZRGPN, is now a locum PRIME nurse working not only in Rox­burgh, but in other remote South Island areas such as Reefton, Haast and Twizel.

She has attended numerous motor vehicle accidents and medical emergencies, and is a strong advocate for PRIME.

Doctors and nurses attending emergencies usually assess and stabilise patients, administer pain relief if necessary and help coordinate care.

'Under the radar, but actually we save lives'

“This is what we do, it is under the radar, but actually we save lives, and we know that, with the ‘hardy annuals’ of not enough bods working in rural health, that some­times our ability to provide these services is stretched,” Ms Murrell-McMillan says.

“We need the Government not to take their eye off the ball and not throw this off to the alliances to sort out…St John has no way in hell of doing this on their own; they have volunteers who are absolutely dependent on having PRIME practitioners turning up.”

Dr Malloy says PRIME gives people involved in accidents or medical emergencies a better chance of surviving.

“We do the best we can for each of our patients – wheth­er we save their lives or not is not the point. What we hope we do is provide services in a timely manner, so we are able to give people a better chance of success.”

Funding the only issue needing to be resolved

For Colville GP Kate Armstrong, funding is the only is­sue she believes needs to be resolved through the review.

“We certainly wouldn’t want to lose PRIME in our area, as it’s very valuable,” says Dr Armstrong, who provides the PRIME service on the northern Coromandel Peninsula alongside practice nurses Emma Dillon and Diane Morrell. The peninsula is a hot spot ripe for accidents in summer, when the population swells from 700 to 10,000 people.

Dr Armstrong established the Colville Community Health Centre 14 years ago, later helping to set up the local volunteer ambulance service; the nearest ambulance service was located about a half-hour’s drive away in Co­romandel.

As well as turning out in their PRIME role in conjunc­tion with ambulance volunteers, the Colville team mem­bers also work as ambulance volunteers themselves when not rostered on call at the health centre. This means two people can always crew the ambulance.

It is a double whammy for the health practitioners, Dr Armstrong admits, but she says the benefits outweigh the alternative – no service at all – and the other volun­teers feel supported.

“It’s a small community – it’s just what you do,” she says.

Ms Murrell-McMillan, too, says she is always working as part of a team with volunteer ambulance officers and fire brigades – even when stranded in the Lewis Pass, 50km from the nearest medical centre.

“You are never on your own – what makes this job is that you are part of a wider team and you get to know the ambulance and fire volunteers – you work with them and train with them.

“I’ve made some very good friends in ambulance and that sustains you – you are working for communities.”

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