Air ambulance retrievals and road ambulance transfers from rural Waikato hospitals are so under-resourced at least one patient has been seriously harmed, doctors say.
The service is at crisis point despite Waikato District Health Board being aware of concerns for years, states a leaked internal memo seen by the Herald.
It comes amid an independent review of Auckland and Northland's air ambulance service after the country's 20 health bosses warned the Ministry of Health about problems with hospital transfers not being readily available.
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The Rural Hospital Retrieval Service Crisis Notification was sent to Waikato DHB Commissioner Karen Poutasi and chief executive Dr Kevin Snee in late September, expressing serious concerns about the service and of past and future harm to patients and staff.
It refers to one patient who suffered a serious adverse event because of the situation, but does not outline what happened or whether the patient survived.
The ambulances take or collect patients with serious or life-threatening conditions, either by road or air from three rural hospitals - Te Kūiti, Taumarunui and Tokoroa - to Waikato Hospital for specialist care.
In the memo, signed by Southern Rural Hospital Staff, it said no reliable, co-ordinated or clear retrieval service to expedite the transfer of vulnerable patients existed, despite repeated calls for one.
Instead each retrieval was done on an "ad hoc" basis with critical time spent by rural emergency department staff trying to arrange transfer to Waikato Hospital's intensive care unit [ICU].
"Patient harm continues to occur, and is recognised by the organisation as occurring," the memo said.
It said serious incidents continued to happen where transport was significantly impacted.
"Those documented are the tip of the iceberg of lesser harm events and near misses occurring."
But despite repeated subcommittee review, serious adverse event review panels, risk register entries and clinical governance escalation, nothing had changed.
"An ongoing fundamental systemic failure to address this acknowledged, pervasive and deteriorating situation remains.
"Patient and staff harm has, and in our clinical opinion, will continue to occur."
There have been projects since 2012 to address the problem and in March last year the Board of Clinical Governance minutes showed aim for a standalone retrieval service.
However one had not been developed and a "constant procession of change" in executive leadership at the DHB resulted in stalled decision-making and inaction.
There had been a "profound failure of prior regimes to create effective safe systems despite acknowledgement of need and recognition of harm".
The memo said blaming staff had not improved patient care.
"Inappropriate retrospective review bias of real time clinical decisions made continue to sidestep the root cause of poor time-critical transport systems.
"This perpetuates harm, seeks to blame individuals, and continues to allow diversion of seeking a systems solution."
It pointed to the DHB's 2016 Healthy People strategy which said 23 per cent of the population was Māori and 60 per cent rural.
"Yet rural people and Māori have poor access to services - they get sick and end up even sicker. This is not acceptable," the strategy stated.
It said services for rural patients did not align with the strategy.
"Health inequalities for people in rural communities has deteriorated under the stated DHB strategy."
Between July 2018 and July this year, 1092 emergency department patients were transferred from Tokoroa Hospital to Waikato Hospital - a rate of three transfers per day, the memo said.
During the same period 240 ward patients were taken to Waikato Hospital, for diagnosis not available at Tokoroa - an average of 20 per month.
The memo said such a large proportion of patients meant many were exposed to potential harm under the "fragile" retrieval service.
"Even a 5 per cent rate of poorly delivered service exposes 65 patients to avoidable harm annually."
Waikato Hospital's ICU is not obligated to provide retrieval services to the hospitals, the memo said, and requests were "not infrequently" declined.
"Rural patients have therefore continued to be significantly disadvantaged and receive a lower standard of care to their urban counterparts."
In a letter from Snee to the rural doctors on December 13, he said a working group to report on the situation to him had been set up.
A request for additional St John resource to be rostered at Taumarunui Hospital had already been agreed.
Waikato DHB community services and clinical support director Hayley McConnell said the DHB investigated an incident in April where a patient needing transport from Taumarunui to Waikato Hospital was delayed by several hours.
"The DHB is aware that staff are under pressure working in the relative isolation of our rural hospitals in general, and more when faced with seriously and critically ill patients.
"When transport assets are not readily available, this adds to those pressures."
She said at times the demand for transfer teams can outstrip supply and this undermined the DHB's commitment to fast access to services.
The DHB had recently dedicated project and service management resources to work with key clinical staff to improve rural hospital retrieval, she said.
"Waikato DHB's chief executive has communicated his commitment to resolving this long-standing system issue with a recommended outcome in February 2020."