People with debilitating cataracts are being declined surgery that they would easily qualify for if they lived in Auckland. Nicholas Jones investigates.
Cataracts have blurred Elizabeth Kerslake’s world and often cause headaches.
On sunny days the glare makes her reluctant to drive.
“It is like you are continually looking out of a blurred lens,” the 72-year-old says.
Heavy-duty (and expensive) glasses help, but Kerslake is still worried her vision loss will interfere with her new job, as a home carer.
Last July she travelled from her Queenstown home to Dunedin Hospital and spent most of the day being assessed for potential surgery.
Finally, she was told she didn’t qualify.
“I said, ‘Are you joking?’”
Ten months on, Kerslake still hasn’t had the quick and straightforward surgery that would give her back her sight, and old life.
“It’s just getting worse, that blur,” she says.
Kerslake is suffering because of her address.
New Zealand’s fragmented health system means each region sets a different threshold for cataract surgery, which is decided by looking at demand and capacity and deciding how many operations can realistically be done.
The differences in thresholds mean some New Zealanders suffer much worse vision loss than others before the public system will help them.
If Kerslake lived in greater Auckland, for example, she would have been accepted for surgery when her vision loss was significantly less severe.
The situation is one of the worst examples of so-called “postcode healthcare”, when access depends on where someone lives.
The Clinical Priority Assessment Criteria (Cpac) booking system was introduced in 1998, and eliminating such long-standing differences was a major promise of the current Government’s health reforms, which scrapped 20 district health boards and replaced them with a single organisation, called Te Whatu Ora - Health New Zealand.
However, the reforms are in their infancy, and services are still being delivered by “localities” and, for now, the postcode lottery remains.
Mark Rudel, an ophthalmologist who recently assessed Kerslake, has seen many patients in similar, or even worse situations, who still don’t qualify for surgery.
Some have to give up work, and cannot do daily activities and hobbies. Driving becomes impossible - devastating for rural people with no public transport.
Rudel, who trained in Germany, says the situation isn’t the fault of local health authorities, who struggle with poor funding and a lack of national investment and strategy.
“It is depressing telling somebody like a truck driver [they don’t qualify], who has to lose his licence first - which I’ve seen a few times too - before he gets cataract surgery done,” says Rudel, who now works privately but still locums in the public system.
“They can’t continue doing their work. This is not just old, retired people. They are often still in the workforce. It’s ridiculous.”
People with vision loss from cataracts are more prone to depression, studies show. They are also more likely to fall over and need hospital treatment, Rudel says.
For the elderly, that can be debilitating and start a fatal decline in health.
“At the end of the day, we should have equal treatment options for all patients in New Zealand, independent of where they are living.”
A system to prioritise patients
Patients needing planned care (medical or surgical services that aren’t required immediately, often called electives) are frequently given a score from 0 to 100 (lowest to highest priority), according to clinical and social needs.
This is called the Cpac score.
If the score reaches a certain threshold, the patient will be accepted for cataract surgery, which should happen within four months (a timeframe set by the Government).
Thresholds are regularly changed, to try to ensure patients who are accepted are treated within the four-month wait time.
Problems including restricted operating theatre availability means the Cpac threshold in the Southern region, which covers Dunedin, Queenstown and Invercargill, is the harshest in the country, at 61.
The lowest is 46, in Auckland and Waitematā. Counties Manukau, Hawke’s Bay and West Coast (South Island) are slightly higher at 48.
Other regions with a high threshold for surgery include Capital & Coast (Wellington), Nelson Marlborough and Lakes, which covers Taupō and Rotorua.
People unlucky enough to live in areas with high thresholds - and who cannot afford the approximate $5000 cost to go private - endure major vision loss.
A recent study analysed all 44,000 patients referred for cataract surgery from 2014-2019.
“More than one-quarter of patients who were declined for surgery did not meet the visual acuity requirement for driving a private vehicle in NZ,” concluded the research, co-authored by James McKelvie, Stephen Ng, Corina Chilibeck and Jeremy Mathan.
“A small but significant number of patients [26] who were declined for public-funded surgery had such advanced visual impairment they would be eligible for registration with Blind Low Vision NZ (formerly the Blind Foundation).”
Māori and Pacific patients develop cataracts at a younger age, the research found, and “have worse visual acuity and typically severe visual impairment, compared to other ethnic groups at the time of prioritisation”.
We compare badly to other OECD countries. Canadian guidelines recommend surgery when visual acuity drops to 6/12 (the point at which driving is no longer legally allowed) with symptoms of glare, for example.
In New Zealand, just 35 per cent of patients had 6/12 or better in the operative eye at the time of prioritisation.
One national threshold
The Weekend Herald highlighted the unfairness of access to cataract surgery in a March 2019 investigation, and numerous follow-up stories.
One focus of that reporting was the fact people in Counties Manukau DHB had a much higher threshold for surgery than those up the motorway in Auckland or Waitematā (covering West and North Auckland).
That division, which sliced through Ōtāhuhu and was criticised as a “socioeconomic and largely racial divide” by ophthalmologists, has now been lessened.
That’s thanks to the old Waitematā, Auckland, Counties Manukau and Northland DHBs working closely together, as a single “Northern” region.
The cataract threshold in Counties was 55 in 2019, and has since dropped to 48.
The intention is to further reduce Counties’ threshold, and Northland’s (currently at 50).
However, in many other regions thresholds remain high, and the Royal Australian and New Zealand College of Ophthalmologists (Ranzco) has taken the rare step of calling on the Health Minister to set a nationwide surgical threshold.
The health reforms are an ideal chance to act, says Dr Peter Hadden, chair of the New Zealand branch of the college. Ranzco wants the national threshold set at 46.
“Not only do we want to see regions currently doing poorly do better, but we also do not want to see the Auckland regional services downgraded by a less innovative, centralised approach,” Hadden says.
“We haven’t had much feedback from the Government... I think it is realistic, because Auckland is doing it, and Auckland includes Counties Manukau and Northland now too. So it is a decent chunk of the population.”
Demand for eye services has soared as Kiwis age and sicken with conditions including diabetes, which if not well controlled can destroy eyesight.
New treatments such as injections for age-related wet macular degeneration have saved the sight of tens of thousands, but have increased strain on resources.
Backlogs worsened by Covid-19 disruption and lockdowns tipped some eye services into crisis.
Cataracts can be removed, but if other conditions aren’t treated vision loss can be permanent.
Last year clinicians raised the alarm about thousands of diabetics being overdue for eye checks, which are needed to detect any beginnings of damage that can cause blindness. Many were found to have vision-threatening disease when they were finally checked.
Other health services are creaking. Nationwide hospital backlogs have worsened to record lengths, with more than 75,000 people overdue for treatment or a specialist appointment.
Health officials say there won’t be dramatic reductions in waitlist times until “at least” 2025.
A major challenge is severe workforce shortages, including the nurses and anaesthetic technicians needed to run operating theatres.
Changes recommended by a taskforce set up to help clear waitlists are being made or explored, including allowing specialist GPs to do diabetic retinal screening.
Derek Sherwood leads Te Whatu Ora’s “reset and restore plan” for planned care, which is acting on the taskforce recommendations. He told the Weekend Herald that variability in access to cataract surgery “is greater than we would like”.
“Under the ‘reset and restore plan’, and improved commissioning, additional services will be provided in areas that currently have high Cpac thresholds, so over time we expect that degree of variability to decrease significantly.”
The Weekend Herald asked Health Minister Dr Ayesha Verrall whether the Government would commit to a nationwide Cpac threshold of 46.
She didn’t directly answer, but in a statement said the current situation is “an example of exactly why our health system needs to change”, and that was happening through the “reset and restore” changes.
“This work will improve access to cataract treatment and remove the impact of the ‘postcode lottery’ which arose as a result of the district health boards setting their own thresholds.”
National Party health spokesperson Dr Shane Reti said his party was committed to “one scoring system and one level at which people are placed on the surgical lists across the country”.
“Whether or not that level is 46 is a decision that will need to take resourcing into account along with substantial clinical input.
“A lot of the waiting lists for ophthalmology are for cataracts, and because of this, the wait lists have nearly doubled in the space of a year. There are also clear regional differences.”
The worker shortage is the main factor limiting the number of surgeries, Reti says.
“Spending half a billion on a bureaucratic health restructure in the middle of a pandemic was not the best use of the health budget... the money should have gone to the frontline.”
Optometrists ‘caught in the middle’
Many GPs and optometrists won’t refer people for surgery, if they know there’s no chance of them clearing the threshold.
That makes it impossible to know how many people are in need - waiting lists count only people who have been accepted for surgery, not those turned away.
“We get caught in the middle,” says Hadyn Treanor, vice-president of the New Zealand Association of Optometrists (NZAO). “When that [surgical] threshold is above the driving standard, that’s a really difficult situation.”
People often have cataracts on both eyes. How much vision they have out of their “good” eye is what determines the bulk of the points that make up their Cpac score, Treanor says.
A smaller number of points are given according to answers to questions around how vision loss affects daily life, and how well a person is supported.
“You can actually have someone with a really blurry eye - almost blind in one eye - but because their other eye sees well, they are then deemed to be not so bad. But they are still at real risk of falls, particularly the elderly.”
In regions with tough thresholds, people who get the worst cataract removed are then unlikely to get their other eye operated on, Treanor says, even when a cataract worsens.
“You are then wandering around with one eye that is really, really blurry. And while technically you can drive . . . most of us would feel a bit unsafe doing so.”
NZAO strongly supports the call for a national Cpac threshold of 46 and is disappointed with the pace of progress.
“We haven’t seen the effect of the health reforms come through,” Treanor says.
“The difficult thing is, really, nothing has changed.”