The health system is under enormous strain and cracks are appearing - emergency departments are beyond capacity and surgeons at a major hospital are warning about cancer operations being dangerously delayed. Nicholas Jones investigates and finds record wait lists aren’t expected to dramatically improve until at least 2025.
Dave Moore’s hip didn’t cope with lockdown.
“I was an outdoor bowler, and I knew I had a bit of a problem, but I was bowling maybe once or twice a week - good as gold, five hours on the green each time, no problem,” says Moore, 78.
“As soon as we went into the first lockdown and I didn’t get that exercise, the old hip started to play up something shocking.”
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A fall down the stairs didn’t help. When restrictions eased, Moore tried physiotherapy without success. His GP asked North Shore Hospital specialists to urgently assess him.
That was around June 2020. In the following months Moore rang the booking office, only to be hung up on. His doctor followed up.
“But that didn’t do anything,” Moore says. “It became really, really bad. I started having to use crutches to get around, and couldn’t sleep.”
Moore, a Glenfield retiree who was chief executive of North Shore Taxis and a volunteer fisheries officer, lived in pain for the rest of 2020, and right through 2021.
New rounds of Covid restrictions put back hospital workloads, and the health system has yet to recover - in the past fortnight alarming reports have filled the headlines, including ambulances being sent away from overloaded emergency departments and crucial cancer surgeries being deferred.
It wasn’t until December 2021 that a surgeon assessed Moore. He received a successful hip replacement the following March.
The discomfort and loss of mobility is in the past, but health system delays remain front of mind for Moore, who is the vice-president of North Shore Grey Power.
“Every person you talk to about surgery has a story,” he says.
Hospital backlogs have worsened to record lengths, with 67,000 people overdue for treatment or a specialist appointment.
The situation has deteriorated since in May last year then-Health Minister Andrew Little announced a “high-powered” planned care taskforce.
Covid disruption trebled some overdue lists, and Little had been advised it could take three to five years to clear the backlogs, if significant changes weren’t made.
“That’s not in anyone’s best interest,” Little said in his speech at Parliament. “It is my expectation that we can clear the backlog in considerably less time.”
However, the Weekend Herald can reveal the current position of health officials is that while improvements could happen earlier, dramatic reductions in wait list times won’t occur until “at least” 2025.
“We are working hard to increase the number of surgeries and treatments, but currently, discharges are less than the numbers added each month, which is resulting in an increase to the overall wait list times,” says Jo Gibbs, director of system delivery, hospital and specialist services for Health NZ/Te Whatu Ora, which has replaced DHBs.
More optimistic is Andrew Connolly, a surgeon and chief medical officer at Counties Manukau who led the planned care taskforce.
He and a team including Professor Diana Sarfati, who has since replaced Ashley Bloomfield as Director-General of Health, delivered a report in August last year, containing 101 recommendations.
All were broadly accepted by the Government, and the taskforce disbanded.
In February Te Whatu Ora asked Connolly to join a steering group, set up to oversee the implementation of the recommendations.
He told the Weekend Herald there had been progress. That included significantly increasing specialist appointments, which reduced the number of people waiting more than 12 months for a first assessment.
That added to treatment backlogs, he says, but allows the most needy patients to be identified and moved up the queue.
Another positive is more co-operation between hospitals and regions.
However, huge challenges remain. The biggest: filling workforce shortages that mean operation theatres and recovery wards are often unable to run at capacity.
“We are struggling on the surgery waiting lists. The numbers are pretty static or increasing, depending how you look at them,” Connolly says.
“There have been areas of pretty good progress. Not as fast as we would probably want, or necessarily expected, but on the other hand I don’t think any of us expected quite the impact of the third wave of Covid that we had.”
There are nonetheless signs of hope, he says. In the northern region (greater Auckland and Northland) more nurses and anaesthetic technicians - a lack of whom is a big factor in holding back surgery capacity - are coming onboard.
Connolly thinks big improvements to wait lists can happen by next year - a timeframe ahead of what’s expected by Te Whatu Ora.
“We could really make huge inroads into the waiting list by only adding two or three extra cases per operating room, per week,” he says.
“To do that we obviously need nursing staff, we need the techs.
“None of us want this…I think, ultimately, we will get on top of it.”
How that can happen is set out in the taskforce’s “reset and restore plan”. As a starting point, it tried to figure out how bad delays were - a job that proved impossible.
“There is incomplete or inadequate information for diagnostic waiting lists to support meaningful analysis,” the taskforce concluded.
Blind spots included the true size of the waiting list for colonoscopy and gastroscopy procedures, needed to check for disease including cancer.
Te Whatu Ora says taskforce recommendations around improving data and analytics were among the first to be implemented, at the end of last year. (Problems remain, however: Te Whatu Ora apologised this month after publishing flawed information about ED wait times.)
A larger issue is the fact there’s no proper measure of what the taskforce calls “unmet need”.
When a person is referred for specialist help by their GP, hospital teams often give them a score, according to clinical and social need.
If the score reaches a certain threshold - set by each region according to capacity and demand - they will be accepted for a specialist appointment or treatment, which should then be carried out within four months (a timeframe set by the government).
When demand outstrips capacity, the threshold can be toughened, and vice versa.
This nationwide clinical priority assessment criteria (Cpac) booking system was introduced in 1998 as a way to provide transparency about who gets treated with limited health resources.
However, one consequence is that waiting lists represent only those people who have cleared the threshold. Those that don’t are sent back to GPs and primary care providers who are told to monitor them.
Thresholds often vary significantly by region, and can be very tough.
For example, some Southlanders with cataracts are forced to stop driving and working because of vision loss, and still not clear the threshold for surgery. If they lived in Auckland, however, they would.
Many GPs and optometrists don’t bother referring patients when they know the threshold is too high. This makes it difficult to know how much unmet need there is, the taskforce noted in its report.
“However, it is important to develop systems and processes to at least better inform the health system of this issue.”
A specialist at Te Whatu Ora, who asked to remain anonymous because they didn’t have permission to speak to media, told the Weekend Herald there’s huge frustration about needy patients not meeting treatment thresholds.
“These people are biffed back to GPs, and invariably continue to remain unwell - frequently deteriorating further - and often present to hospital services in a crisis, needing emergency interventions that are invariably more complex, costly, and utilise more clinical resources.”
A growing number of people don’t even have proper access to a GP, the specialist says.
“The wait lists are absolutely not a representation of the clinical need of patients. Many of my colleagues, as well as myself, are quite disenchanted by what’s happening.”
The Labour Government has scrapped 20 DHBs and replaced them with a single, centralised organisation called Te Whatu Ora/Health New Zealand.
It said this would allow services to be planned and delivered consistently, and eventually end the “postcode lottery” in which treatment can depend on where someone lives.
However, the reforms are in their infancy, and services are still being delivered by “localities”, with significant variation in access between some areas.
“Much of this variation is driven by capacity constraints, but the health reforms mean the system must now work towards national consistency,” the taskforce noted.
Doing away with DHBs has already led to better regional co-operation, Connolly says. Orthopaedic surgery patients were sent from Dunedin and Christchurch to Timaru Hospital, for example. Maxillofacial surgeries have also been done for the first time at Timaru Hospital, with a Christchurch-based surgeon supported by a local team.
Surgery teams in greater Auckland and Northland are working on “clinical consistency” guidelines, Connolly says, which will set out exactly who should get surgery, when.
For instance, under what circumstances must a hernia always be operated on. Resources can then be shared to ensure those patients are prioritised.
“You might say, ‘Why haven’t we been consistent before?’...but under the old DHB model resourcing really came into the mix - ‘Well, I’d like to fix it but there’s no chance we will get it done.’ [Now] we can share the resources regionally to get those done.”
Health leaders must decide how much variation between hospitals is acceptable, Connolly says.
“Do you say, it is okay to wait a few weeks longer for something, or is it okay to wait a few months longer? Somewhere there needs to be an answer to that.
“We are having that exact discussion up here around access to endoscopy - these are the telescopes to look for bowel or stomach cancer, and so on - and, indeed, we are likely to say, ‘We need to put more resource over there, because hospital A is struggling and hospital B is doing a lot better.”
‘Numerous examples of inequities’: taskforce
Address isn’t the only factor in how someone is treated. The taskforce found data showing a disproportionate number of Māori and Pasifika “waiting excessively long” for imaging scans (used to check for serious conditions including cancer) in some regions.
Māori and Pasifika children were suffering the most because current capacity in the paediatric oral health service can’t match demand, including for dentistry requiring sedation or general anaesthetic.
High Body Mass Index (BMI), poor control of diabetes and being a smoker can stop people from getting some surgeries, a stance that disproportionately affects Māori and Pacific.
This can be for legitimate clinical safety reasons, the taskforce said, but “blanket” barriers to access based purely on these factors aren’t acceptable.
“There are numerous examples of inequities in many planned care services,” the taskforce concluded. “Initiatives must be put in place to resolve this.”
How to dent wait lists
Fissures are appearing in the health system. The Herald this month revealed patients were held in overflow rooms and ambulances diverted from Auckland emergency departments, and on Thursday Christchurch surgeons raised the alarm over cancer operations being deferred, telling Stuff they’re choosing “who has the worst cancer and who won’t survive until next week without intervention”.
“Most of us see winter as basically coming early,” Connolly says.
“We are not full of Covid or anything, we are just full of people who seem to take longer to get better. There are lots of theories for this, and part of it might be their ability to see their GP - we just don’t know.
“Everyone is bloody tired - the workforce has done it pretty tough.”
Those shortages are severe: a confidential Te Whatu Ora briefing from September last year, released under the OIA, reveals nursing numbers were “significantly below required levels for the patient case mix” on 30-39 per cent of shifts on medical, surgical and assessment, treatment and rehabilitation wards.
Connolly believes such stress will ease as reinforcements arrive, in the form of overseas recruits and new graduates. As that happens, he says there must be a laser-focus on running operating theatres well.
In the northern region, for example, analysis showed Middlemore was behind in getting through some surgeries. The hospital was particularly short of anaesthetic technicians, but an efficiency gap remained even when that factor was adjusted for.
“Across the health system there are late starts or early finishes, or whatever, and so there is room to improve on that,” Connolly says.
“Better data will help us - knowing roughly how long we take to do cases means we can say, ‘Let’s add another case to the list because historically we will knock that original operating list out by 3pm rather than 5pm.’”
A lot of follow-up appointments don’t need to happen or could be done virtually to save time, the taskforce argued. Reducing follow-ups by 10 per cent would save 125,000 appointments over 12 months.
However, the belief that more efficiency can be squeezed out of a stressed health system isn’t universal.
“It’s fair to say that some of the workforce are sceptical that some of our recommendations are realistic, given the current staffing,” Connolly acknowledges.
“I would agree that we have to be realistic.”
Public hospitals are paying private facilities to do the operations they can’t, and Te Whatu Ora is increasing funding for this outsourcing.
The taskforce wants “improved collaboration” with the private sector, but noted many private facilities were hiking prices, in some cases by more than 20 per cent.
Another problem: more work sent to private hospitals risks those facilities poaching staff from public hospitals.
“We have got to be really careful we don’t then lose our staff,” Connolly says.
The taskforce backed a proposal by the NZ Orthopaedic Association to add a public patient to the private operating lists of about 200 surgeons, each month for an initial 10 months - an extra 2000 procedures.
The proposal hasn’t been taken up, despite orthopaedic representing a quarter of all patients waiting longer than four months.
“We are in the biggest trouble of everyone,” says Haemish Crawford, president of the Orthopaedic Association and an Auckland surgeon in both public and private systems.
“We are doing less elective surgery now than before Covid… we are going backwards. Every day that goes on, the waiting lists are getting bigger.”
At a December meeting, Te Whatu Ora said a decision couldn’t be made for at least six months.
“There were some legal and contractual reasons they had to work through,” Crawford says. “And they didn’t really have the personnel, or know who the personnel would be who would run it.”
That’s frustrating, Crawford says, given the promise of Te Whatu Ora was it would be a single entity capable of more quickly making decisions.
Te Whatu Ora says it has provided funding to increase the number of patients who are outsourced to be treated privately, and this includes orthopaedic surgery.
“The importance of what we are offering is something that’s ring-fenced outside of that,” Crawford says. “Yes, increase your outsourcing. But this is in addition to that, because we have got to get ahead, not behind.”
Dr Ayesha Verrall, who took over from Little as Health Minister in January, says the extra outsourcing “roughly corresponds to what was in the Orthopaedic Association proposal”.
She will meet the association, and is “very happy to hear their point of view”.
“I think the discussion here is about the mechanism…the intent of the proposal, which is to outsource surgeries to make sure people don’t wait too long, is what we are doing.”
The GP shortage bites
Another way to ease the burden on public hospitals is to let GPs and other primary care providers give more specialised treatment.
Current funding models limit innovation, the taskforce noted.
However, it gave examples of what could change. One concerned the fact women with abnormal bleeding must wait to see a hospital specialist.
This “is delaying diagnosis of those women who potentially have significant pathology,” the taskforce warned, and an alternative would be to train some GPs to perform a biopsy and order an ultrasound - a change successfully piloted in one region.
A national scheme would help serious disease be more quickly identified and those patients sent on urgently to hospitals - a pro-equity step given Pacific women have much higher rates of endometrial cancer.
Primary care specialists could take on other work including non-melanomatous skin lesion excision, medical termination of pregnancy, and diabetic retinal screening, and allowing this should be investigated, the taskforce recommended.
However, primary care has its own severe workforce problems - the number of GPs per 100,000 people is projected to fall from 74 in 2021 to just 70 In 2031, as many retire.
Some areas have no permanent community doctors. Other GPs are booked out for weeks.
“We have people call us who aren’t able to access GP care,” says Francesca Holloway, advocacy manager for Arthritis NZ.
“It is very, very difficult - they are living with increasing disability and pain levels, and their condition deteriorates while they wait.”
There are also hospital delays. Arthritis NZ received a recent appeal for help from a woman, under 50, who has arthritis in her hand so bad that work is very difficult. Her hospital told her it would take 8 months to see a specialist. After 4 months she checked again and learnt the wait was now 18 months.
The most recent figures on planned care backlogs that Te Whatu Ora could point to were to the end of November last year. Those show 66,837 people were waiting longer than four months for either treatment or a first specialist appointment.
Sixteen of the 101 taskforce recommendations were implemented at the end of last year, Te Whatu Ora says, which focused on booking the “long-waiters”, improving data and analytics and “establishing governance and networks”.
An further 47 recommendations are at various stages of implementation. These include around primary care, use of surgical theatres, management of outpatients and clinical prioritisation. Work on the other 38 recommendations hasn’t started.
National Party health spokesperson Dr Shane Reti says the recommendations are “nice words, nice things up on a whiteboard”, but he doubts there will be meaningful change.
“And that’s what I’m hearing from the sector - that loss of confidence that this Government will be able to change things any time soon.”
Reti is scornful of the recommendations around expanding primary healthcare.
“Who is this primary care who will do more - can you point them out to me? They are the GPs who you can’t get an appointment with this week; they are the GPs who are so exhausted, tired and under-resourced that they can’t open their doors to do after-hours.”
Covid contributed to delays, Reti says, but so did the Labour Government’s mistakes and indecision.
That included focusing on cannabis reform in its first 100 days, and failing to increase ICU capacity enough during the pandemic, which meant surgeries requiring intensive care recovery were postponed.
The Government was far too slow to add eligible nurses, midwives and specialist doctors to the straight-to-residency pathway, he says, and hasn’t funded enough increase in training positions.
“I wouldn’t be spending $486 million on health reforms in the middle of a pandemic. I would be using that on frontline services.”
However, Verrall views the reforms as “the only way we can address a problem of national scale”.
“Thank goodness we have a national approach to [workforce] rather than having 20 DHBs out competing in the international market against each other.
“This taskforce also shows we have the ability to disseminate innovations that work in one place to other places across the country incredibly quickly now.”
New Zealand’s health system must improve, the Health Minister says, but is in a stronger position to do so than elsewhere.
“In the United Kingdom, one in 10 people are on a wait list. That’s an order of magnitude worse than where we are, and we have started from a much better place.”