Those charged with managing health budgets must make hard choices. Everything is controversial, an exasperated MP was heard to mutter the other day, frustrated at the deep, sector-group conservatism at play when new policies are proposed. He was talking about welfare benefits but his comments also apply in health, where there is now criticism of an innovation at the Waitemata District Health Board to pay higher fees to obtain more time from surgeons to speed up waiting lists.

The health board has paid orthopaedic surgeons as much as $6600 a day to do more work in the public system and to help clear a backlog of knee and hip operations. The figure is calculated by the number of operations completed. Surgeons who might have instead been away from the hospitals working in their private practices were encouraged, for the new public rates, to adjust their private-public commitments. The winner from this is not the surgeon, who in some cases could still be claiming higher fees in private practice, but the patient. The public.

Productivity, or the number of operations, was up by a third, patients' time in hospital was down 40 per cent on average, and in total the savings from bringing outsourced surgery in-house was $3 million. The loser is not at all clear, although here comes the controversy.

Some doctors in fields other than orthopaedics, and the associated anaesthetists needed to complete that work, view the high payments to their brethren as "fundamentally unfair". One emailed the specialists at the DHB to complain dismissively of "proceduralists" - presumably those performing set-piece operations - receiving vastly inflated pay rates. His argument was that paying one group more, to fix a specific problem, devalued the work of the rest, who work hard for the board and patients all the time. It is a basic reaction found in any group of humans doing tasks they all value as important.


It ignores, however, the equally basic rules of demand and supply. The public has, indirectly through the mandate it has given its political leaders and through them the executives who manage the health system, made clear that waiting times for "procedures" are unacceptable. The Waitemata board has determined that hips and knees, so debilitating to so many, can be operated on more rapidly and patients' quality of life restored - for a sum. The demand for that particular health spending is deemed high and so the board has found a way of increasing the supply of specialist services to meet some of that demand.

None of that devalues others or the heroic roles they perform in accident and emergency care or in acute heart or brain surgery. The Government and health boards must prioritise; for example, they are trying to do so in cutting the treatment times for cancer patients through chemotherapy. Greater spending in that aspect of healthcare does not devalue the worth of those caring for, say, the elderly in hospitals. Ian Powell, the senior doctors' union executive director, criticises Waitemata's orthopaedic payment scheme, saying it is absurd because elective surgery "just happens to be the political flavour of the month".

That is precisely the reason why it is not absurd. Political "flavours" are inevitably shaped by public demand, and the desire to ensure taxpayer money is directed to the areas where it can make the most difference and ultimately reduce ongoing health costs. Undoubtedly every unit in the hospital system could make an argument for greater funding. Many could improve the results for patients. Those charged with managing health budgets must make hard choices. Because they choose to target one problem first does not automatically mean they neglect the others.

Waitemata board chairman Lester Levy made a name for himself more than a decade ago transforming some practices in public hospitals. The people in his new district are now the beneficiaries.