Amputations caused by diabetes are "a burgeoning problem" and health systems are partly to blame, a Ministry of Health official warned colleagues.
The ministry says improvements have been made, amidst a wider push to stem the tide of amputations - legs, feet and toes - that topped 1000 last year.
That includes making sure proper assessment systems are used to check feet when diabetics turn up to their GP.
Documents obtained under the Official Information Act reveal frustration from health workers about prevention efforts.
Sian Burgess, the ministry's programme manager for diabetes, outlined the situation in a memo, prepared in February and seeking funding.
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Without change it would continue to be hard to monitor treatment gaps, she said.
"Maori are over represented in amputation mortality and hospitalisations ... improving the accuracy and consistency of the diabetic foot risk screen and podiatry services is a real opportunity for significantly improving equity in health outcomes."
If diabetes isn't controlled over the long term, too much glucose in the blood ravages nerves, leading to loss of sensation in the feet and legs. Injuries go unnoticed and fester, because poor blood flow delivers fewer infection-fighting cells. Amputation is a last resort to stop infection spreading.
Research has shown more than 80 per cent of diabetic amputations are preventable, if problems like ulcers are detected and treated early.
Diabetes amputation horror: 'I was clawing at the walls'
All diabetics should have an annual foot examination to check for loss of feeling and any wounds, and those at high risk should be checked every time they see a health professional. If a problem is found, the patient should be fast-tracked to see specialists.
Often, that doesn't happen; amputations surged in some areas where more than half of type 2 diabetics didn't get their annual foot check. Even when problems are picked up the referral process can fail - patients have died shortly after amputations that came too late because of years-long delays or lost referrals.
Identifying high risk patients and referring them correctly is key to preventing amputations, and guidelines for health workers were published early last year.
However, those are always used, and Burgess sought funding to help embed the screening guidelines in patient management systems used by GPs, by July 2020.
"The sector has expressed frustration with lack of clear direction from the ministry and vendors have begun to implement [the guidelines] without checks and balances that will provide accurate and consistent data," Burgess wrote in the February 28 memo.
"There is a clear call to action from clinical leaders and academics for implementation of the diabetic foot risk screening tool and referral pathway to direct and standardise foot screening and referrals to ensure the right care by the right person at the right time."
The funding bid was for $50,000, about double the hospital inpatient costs for a single lower leg amputation. It was rejected as not detailed enough.
In a statement, Burgess told the Herald that after more consideration it was considered extra money wasn't needed, as most primary care systems had already updated software to include the screening tool.
"The screening pathway remains an issue in some PHOs (primary health organisations) and we are working on this with PHOs and DHBs."
Other work is ongoing, Burgess said, including helping people control their blood sugar levels, which helps prevent complications like diabetic foot disease.
"The ministry requires all DHBs to self-assess their foot screening and podiatry services, along with other standards for diabetes care...referral to community and specialist foot care services is an important focus."
Burgess signalled groups like Maori and Pacific New Zealanders could be given extra help, saying, "we are looking to improve access to diabetes services for key populations".
More than 250,000 New Zealanders have diabetes, and diabetic foot disease has been estimated to account for up to a third of the total cost of treating the disease.
An ongoing Herald investigation into diabetic amputations has found some services buckled under diabetes' rapid advance, leading to fatal delays; one Northland man who wasn't properly referred later showed up with bone showing through a toe, and died soon after amputation.
About 90 per cent of New Zealand's diabetes cases are type 2, the sort mostly brought on by lifestyle and linked to obesity.
Associate Health Minister Peeni Henare last month told the Herald he believes measures like warnings on packaging and a sugar tax should be considered.
Henare, also MP for Tāmaki Makaurau, spoke of how his own relatives had lost legs to diabetes, and said he wanted a major public health campaign around diabetes.
Several DHBs have called for Government action, including restrictions on junk food and drink advertising and a sugar tax - the latter ruled out by Health Minister David Clark and Prime Minister Jacinda Ardern.