Wellington has been at the centre of the gynaecology oncologist crisis. Photo / Dom Thomas
Officials at Health NZ Te Whatu Ora investigated the costs and practicality of sending patients needing treatment from a gynaecology oncologist to Australia because of a shortage of specialists in New Zealand.
This is despite gynaecological cancers making up one in 10 of all cancer cases in New Zealand and one in 10 of all cancer deaths in women, according to Health NZ.
The plans were meant as a last resort if plans to treat patients, particularly those from Wellington, in New Zealand failed. Health NZ was forced to make contingency plans after Wellington’s last specialist resigned last year.
Health Minister Simeon Brown said that no “women in the Wellington region have been sent to Australia for gynaecological oncology care, and there are no plans to do so”.
“I am advised that Health New Zealand has a clear plan in place to ensure women receive the care they need here in New Zealand, and they are delivering on that plan,” Brown said.
The plan to investigate Australian options was included in a briefing in December to Health Minister at the time, Shane Reti, about New Zealand’s threadbare gynaecology oncologist staffing levels, which now mean women living between Wellington and Hawke’s Bay will have to travel to Christchurch for surgery.
In the paper, officials warned New Zealand has about half the number of gynaecology oncologists per capita as “international benchmarking” suggests are required.
Officials told Reti the international benchmark is for about three gynaecology oncologists per million people. To meet this benchmark, New Zealand would need 15-16 subspecialists.
As of mid-November last year, there were just eight staff (or 7.5 fulltime equivalent staff).
The number is going backwards. In mid-November the sole subspecialist working in Wellington resigned, leaving the system with four subspecialists working in Auckland and three in Christchurch.
The briefing received by Reti detailed Health NZ’s plans to deal with the shortage, particularly in Wellington.
According to the officials, the medium-term plan, which was made public earlier this year, is to deliver complex gynae oncology surgery in Christchurch and Auckland hospitals – although mainly Christchurch.
More than 100 Wellingtonians and people from central New Zealand – the Hutt Valley, Wairarapa, MidCentral, Whanganui, Taranaki and Hawke’s Bay healthcare delivery areas – needing surgery will now be flown to Christchurch.
Most women will not need to travel, and will instead be seen by a specialist who will fly up from Christchurch to Wellington regularly for clinics.
Brown appears to have pushed back on this plan, which initially did not envisage a return of these services to Wellington in the next five years.
Brown said he was “not satisfied with the current level of access to gynaecology oncologists in New Zealand, and strengthening recruitment is essential to addressing this”.
“This is key to strengthening access to gynaecological oncology services in Wellington, which I have made clear to Health New Zealand must be a priority,” Brown said.
Officials noted the plan to treat these patients elsewhere has “some risk” because getting Christchurch doctors to pick up the work of Wellington was “dependent on the goodwill and ability of the three Christchurch gynae oncologists to carry a significantly increased workload alongside travel and time away from their whānau”.
They already have a full workload in Christchurch, the officials said. Both they and their clinical and managerial leadership in Christchurch are clear that if the workload and additional travel puts any of the gynae oncologists at risk of overwork or burnout, it would “put the service for Te Wai Pounamu [South Island] at risk as well”.
The Cancer Society’s medical director, Kate Gregory, who works in oncology giving chemotherapy and drug treatments to women with gynaecological cancers, told the Herald the system was being held together by the “dedication of gynae oncologists who are working in this country”.
“They’re working way above what their time allows – they’re seeing more patients and doing more surgeries. It’s really only due to the dedication of them that things have kept going as they have for as long as they have.”
Officials warned that if the plan to cover Wellington’s workforce shortage failed, “the fallback position will likely include having to send patients to Australia for surgery“.
Health NZ was “investigating the practicalities and likely costs of this to ensure we are prepared for this contingency“.
Officials said it might be appropriate to consider centralising the national waiting list and consider “rationing of services” in the short term “to ensure that scarce specialist gynaecology oncology resources are focused on high-risk cases for appropriate management within recommended timeframes“.
The long-term health of these services will mean training a domestic workforce. This has been a challenge.
The relatively small number of training places in New Zealand meant it was difficult to create a future workforce, officials told Reti.
Currently, New Zealand-trained doctors undertake some of their training in Australia, but this was also causing problems. There is high demand for gynaecologist oncologists in Australia, causing most trainees to stay.
“Of the last eight trainees who have been New Zealand trained, only one has stayed in a fulltime role in New Zealand, with the others all accepting roles in Australia,” officials said.
Gregory told the Herald that sending people overseas for training could be difficult if the trainee has a young family or a partner who is tied to New Zealand for their work.
Gregory said that as conditions became more difficult for the existing workforce, it becomes harder to recruit new people.
“When you’ve got a service under stress, it’s not that attractive for people to come and work in it. They can see people working really hard and the on-call commitments are really onerous. That makes it difficult to recruit people from outside, because they can see what it’s really like,” she said.
Other concerns raised by officials include that surgery performed by the subspecialists was “physically demanding, leading to back problems for some surgeons, increasing the risks of sick leave or early retirement in this workforce”.
They also said that overseas, it was becoming increasingly common to perform surgery “using robotics”. This created a skills mismatch with New Zealand, where most surgery was still being done using more traditional techniques.
“This means that internationally trained surgeons may not have the required level of experience of surgical techniques required in the New Zealand sites which do not have access to this robotic technology,” the officials warned.
Labour’s health spokeswoman Ayesha Verrall, a former Minister of Health, said it was a “a huge blow for women’s health that there is no gynaecological cancer specialist in Wellington”.
“New Zealand’s women deserve better than this. Cervical cancer, ovarian and endometrial cancers are common cancers and women should be able to be treated in this city, just like people with other cancers can be.
“Rather than planning to send women to Australia as a fall-back option, the minister should direct officials to attract our trainee surgeons back from Australia.
“Everyone should be able to stay healthy and get care when they need it – close to home, without the cost or the wait. Unfortunately, Luxon’s cuts have hurt our health system, our doctors and nurses are stressed and it’s harder and more expensive to get the healthcare we all deserve," she said.
Brown said the Labour Government’s restructuring of the health system, merging the old district health boards into Health NZ, had distracted that Government from workforce issues.
“The previous Government left the health system in a state of uncertainty, focused on bureaucratic restructuring instead of recruiting the doctors and specialists we need.
“As a result, long-standing challenges like recruiting a gynaecological oncologist in Wellington were left unaddressed,” he said.
Brown said he had “requested further advice to ensure that New Zealand does not have unnecessary barriers to entry for specialised doctors”.
“The Medical Council of New Zealand does not allow separate scopes of practice, including for gynaecological oncology.
“That means that Specialist International Medical Graduates are not recognised for their subspeciality expertise,” he said.
“Since taking office, we’ve taken action – investing more into the health workforce, hiring over 2100 additional nurses, 600 more doctors, and growing the number of obstetricians and gynaecologists across the country," he said.