Editorial: Money saved on operations a good move

5:28 AM Thursday Jan 10, 2013

Any health service must seek to provide the maximum gain for the community from the resources available to it. The availability of resources changes from time to time, but so, too, does the clinical prescription for certain conditions. This dictates an ongoing re-examination of priorities. In this context the National Health Committee's investigation into limiting access to a number of common surgical procedures is more than a cost-cutting exercise.

The government group must find savings of $30 million this financial year from elective procedures deemed to be of little benefit. That money will be used in other parts of the health system. Inevitably, the committee's eventual decisions will prompt anguish and some anger from those denied access to what have been regarded as effective everyday procedures. One of them, already identified by the committee for "disinvestment" is the use of ear grommets - tiny ventilation tubes placed in an incision in the eardrum to treat glue ear.

The direction of the committee's thinking can be seen in the fact that it is drawing on a 2010 Welsh health system report. It assessed 550 elective procedures deemed to be of "relatively low priority". The committee says the top 25 procedures on that list receive public funding in this country of about $641 million. The Welsh report's specific procedures are listed under 17 surgical and dental headings, including tonsilectomy, grommets, varicose veins, haemorrhoids, hysterectomy, caesarean section, circumcision, eye-lid surgery and surgery to correct protruding ears.

The report's recurring theme is that common procedures for these conditions are, at best, only partly effective or may be essentially cosmetic. It notes, for example, that the benefit of grommets on children's hearing gradually decreases in the first year of insertion. Harm to the tympanic membrane is also common.

Similarly, the report says there is no high-quality evidence in adults for the effectiveness of tonsilectomy, and that surgery for children not badly affected by tonsilitis may be outweighed by the risks. For varicose veins, it suggests restricting surgery, most notably to those whose quality of life is severely affected. Eye-lid surgery, likewise, should be to correct a functional impairment, not purely for cosmetic reasons. Using public funding for the latter purpose cannot be justified in a system that must allocate limited resources as effectively as possible.

While saving money is the main driver of the changes being orchestrated by the National Health Committee, there are other reasons for them. There is little point in pursuing invasive procedures when there is limited evidence of effectiveness. Often, there will also be unnecessary risk and, potentially, increased time spent in hospital. The continued use of ineffective procedures also means longer waiting times for other types of surgery.

The contents of the Welsh report should come as no surprise to most of this country's surgeons. Nonetheless, New Zealand's rate of grommet use is about 75 per cent greater per capita than that of Britain. The difference, according to the committee, represents a cost to this country of about $4.4 million a year.

Dr Muralitharan Mahadevan, of Starship children's hospital, says our rate for grommets had already fallen, and it has become more common for doctors to apply the "watchful waiting" approach advocated by the Welsh report. But, just as that report identified considerable variance in the approach of Welsh health boards, it is clear more can be done to reduce wasteful spending here. This should involve a better targeting of procedures, not making them unavailable in cases where they are merited. Done well, this will save millions of dollars while treating more patients more effectively.