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COMMENT: A Herald Fair Care series is examining whether doctors in dual practice contribute to long waits for elective surgeries. Former Health Ministry deputy director-general Kathy Spencer outlines why long waits are not inevitable and could be addressed.

A close friend of mine recently underwent a four-hour operation on her back.

When the surgery finally happened, she had been waiting for more than eight months.

During the wait, her spinal cord was being squeezed, causing her a lot of pain. She couldn't walk far, and she was living with the possibility of paralysis.

When surgery was prescribed, she was given
the option of waiting for up to eight months in the public system, or paying $50,000 to have her operation within two weeks in the private sector.


My friend's operation was one of around 170,000 waiting-list procedures done in the public system each year.

These are operations that are provided seven days or more after the decision to treat.

Surgeries like having a hip, knee, or heart valve replaced, a cardiac bypass, or major back surgery, all fall into this category.

The current maximum waiting times for these procedures are four months to be assessed by a specialist after a patient is referred by their GP, and a further four months to be treated following assessment.

With some waiting-list procedures, for example cardiac bypass, there is a risk that patients will die while waiting.

For my friend there was a steady decline in her health and mobility and increasing pain.

For the last five months of her long wait, she could not lie down and had to sleep in a chair. She also became reliant on a walking frame.

For most of 2018 she was on an array of heavy painkillers that will take months to safely reduce.

She has suffered nerve damage in one leg and has bladder problems. As a self-employed person, her loss of mobility also meant she had to turn down a number of work opportunities.

Due to the long wait her operation was more complex than it should have been, lasting an extra hour, and she spent eight nights in hospital instead of the 4-5 usually expected for that procedure.

As well as dealing with the physical symptoms, the uncertainty and lack of information while waiting can be very stressful and disempowering.

When she asked how long she would have to wait, my friend was informed of the maximum waiting time.

She ended up with five weeks' notice of her surgery, only to have it deferred when she was about to leave home for the hospital. The date was later changed again to avoid a junior doctors strike.

Health expert Kathy Spencer says New Zealand can't afford not to address the
Health expert Kathy Spencer says New Zealand can't afford not to address the "elephant in the waiting room" that are conflicts of interest faced by dual practice specialists. Photo / Supplied

Long waits also increase costs for the public system. Operations that are more difficult or longer, and extra days spent in hospital, mean higher costs.

Patients waiting long periods sometimes deteriorate to the point where their treatment has to be done urgently, often leading to other waiting-list surgeries being deferred, as happened to my friend.

Patients waiting for surgery need extra visits to GPs, physiotherapists, specialists, and other health professionals, and they need extra drugs; all of which increase costs to the system as well as for patients.

More ambition is needed

Because long waits have been a feature of our public health system for so long, many people believe they are inevitable.

This belief is reinforced when GPs and specialists use the maximum waits to create a very low expectation of our public health service, encouraging some people to pay for private treatment if they can afford it.

Private health insurers reinforce the belief when they use long public waits to promote insurance and private hospital treatment.

But the long waits that cause so many people pain, disability, and distress, are not inevitable.

A set of waiting time measures is in place, together with tools for prioritising patients, and thresholds for treatment.

Now we need more ambitious targets. NHS England, for example, provides the right to be treated within four months from GP referral, compared to eight months here.

If the hospital cannot deliver in time, the patient must be offered faster treatment with another provider.

The system is being reviewed

The health review being led by Heather Simpson, adviser to former Prime Minister Helen Clark, is an opportunity to address the inequitable system that sees my friend, and thousands of other New Zealanders, suffer months of pain and disability, while someone with enough money is treated in two weeks.

Solving the problem will certainly require more funding as well as changes to the way DHBs organise their services.

For example, changes are needed to stop the continual disruption of waiting-list cases by urgent cases.

The needed improvements can happen within the existing DHB system. Major structural change is extremely disruptive and has derailed attempts to reduce waits for surgery in the past.

Back in the mid-1990s, the National government invested many millions to reduce backlogs of patients, provide certainty through booked appointment times, and significantly reduce waits.

But in the course of two changes of government and two major overhauls of our health system, ambitious targets were quietly dropped, and the impetus to do better for patients was lost.

The expert panel reviewing our system could start to turn the situation around by, for example, recommending that 90 per cent of patients should be treated within four months of referral by their GP [instead of the eight months it is now].

It could also aim to give patients certainty so that they can plan their lives. DHBs would do this by booking appointment times for patients when they are first referred by their GP.

So that we can all see what's happening, the Ministry of Health would update the information on its website about DHB waiting-time performance.

The current government has shown a willingness to tackle difficult problems like housing, mental health, and more recently, gun law reform.

It needs to be equally ambitious about unacceptably long waits for surgery.

Kathy Spencer was a deputy director-general in the Ministry of Health, a general manager in ACC, and a manager in the Treasury. She has also worked as a senior adviser to a Minister of Health and a Minister of Revenue.