"Risk register" documents obtained by the Weekend Herald reveal serious hospital infrastructure issues across the country, including cramped, leaky and outdated buildings, old wiring that poses a fire hazard, not enough theatre space and a lack of equipment to help transfer vulnerable newborns. Nicholas Jones reports on how that hurts patients.
The pain caused daily discomfort but would sometimes become so agonising that Sian Stewart would vomit.
Stewart's GP and hospital physicians suspected endometriosis, an inflammatory disease in which tissue similar to the lining of the uterus is found outside the womb.
She was referred to Middlemore Hospital's women's health service, but last year got back a letter saying because of limited resources the service couldn't accept the referral and to follow up with her GP if symptoms continued.
They did, and the mother-of-three found herself at times incapacitated with pain, which couldn't be managed even with heavy-duty painkillers. In May she was hospitalised with extreme pain and finally accepted into the service.
Laparoscopic surgery followed in September, which confirmed the 39-year-old was suffering severe endometriosis. Some remedial surgery was done but she will need another operation, which is being arranged.
"In the meantime the pain is manageable," she says. "I am taking it as it comes, really. I am aware that there are a lot of people waiting long-term and in severe pain, more so than myself."
Middlemore Hospital has the country's busiest women's health service and has had to prioritise surgery for the critically or acutely ill, or those with life-threatening conditions like cancer. Those not treated have included women with "non-urgent" but nonetheless serious and often debilitating gynaecological conditions, including suspected endometriosis, incontinence, pelvic pain and prolapse.
The service's clinical director has blamed the situation on prolonged underfunding and says the main obstacle to helping more women is a lack of operating theatre capacity.
Stewart is full of praise for the "amazing" Counties Manukau DHB staff and the care she received once in the system and believes the blame rests with a lack of investment from central government.
"Our DHB is expected to hit targets without the resourcing in place ... it is really concerning we are not valuing and supporting our healthcare staff, who have huge responsibilities and do an incredible job.
"I struggle to understand how such expansive growth in regions is sanctioned without having critical services and infrastructure planning in place."
Leaky pipes and failing equipment
Counties isn't alone; documents obtained by the Weekend Herald reveal more than half of the country's 20 DHBs identified infrastructure issues as a major risk to the treatment and safety of patients.
Risks identified include "extreme" age of buildings that aren't fit for treatment purposes, equipment on the brink of breaking down, leaky and earthquake-prone buildings, malfunctioning medication fridges and lifts used for urgent patient transfers, not enough beds in units over 100 per cent capacity and fire hazards related to old wiring systems.
Lakes District flagged a "risk of harm to patient and/or staff due to current limitations, clinical resourcing and equipment for neonatal transfer".
At Hawke's Bay, DHB hospital infrastructure was judged "cramped, ageing and outdated", which was "causing significant issues for patients and staff".
Waitematā DHB warned some buildings weren't meeting compliance standards and old buildings risked "impacting on patient safety and experience".
Northland DHB identified "ageing radiology equipment that could fail", and Wellington Regional Hospital will soon start repairs on pinhole leaks in hot water piping.
Health Minister David Clark says the Government is responding but a recent survey of buildings and facilities in the health sector has underlined a "huge" problem.
"The Treasury's best estimate is that about $14 billion will be needed to be invested over the next decade, and that may well yet prove to be a conservative estimate."
What keeps hospital bosses up at night
All DHBs keep high-level registers that record the biggest risks to the organisation, its staff and patients. These are regularly updated, each risk judged according to likelihood and severity, and mitigation actions put in place.
The Weekend Herald sought registers through the Official Information Act. Some DHBs including Auckland, Bay of Plenty, Canterbury and Southern refused to release that information, claiming doing so would discourage the future identification of risks.
However, most health boards were transparent and recognised the information was clearly in the public interest. They stress entries reflect potential risks and don't necessarily mean actual failure or harm has already happened.
Overall, there were more than 50 risks relating to infrastructure listed by the 13 DHBs that released recent registers.
The situation is particularly pressing in MidCentral DHB, which stretches from the west to the east coast of the North Island and includes Palmerston North.
Senior doctors at Palmerston North recently wrote a letter to bosses and Clark, warning "we cannot assure the safety, dignity and comfort of care provided to our patients when faced with such physical constraints".
The letter was leaked and the DHB's chief executive, Kathryn Cook, told media new facilities were planned but the city really needed a new hospital.
"The facilities are poor," she admitted. "What it means is the clinicians, including our doctors, have to work really hard to ensure they're delivering good-quality care. It puts pressure on them and they're feeling that."
MidCentral's risk register reveals more than 20 operational risk entries related to infrastructure, including renal, gastroenterology and ambulatory care units being too small to meet growing demand.
Malfunctioning medical equipment and medication fridges were listed, and a lack of hospital bed space during busy times. More serious problems: no dedicated emergency obstetric operating theatre and no cardiac facility, used for diagnostic angiograms and procedures, including putting in pacemakers.
The DHB says work is taking place or planned, such as more bed space, including in relocatable "pod" buildings next to the ED department and surgical suite. The planned acute services block will be a long-term solution to demand on ED, theatre and intensive care.
Isolation rooms and mental health
The measles outbreak that swept through South Auckland showed the threat from infectious disease, but some hospitals aren't properly equipped to respond.
The close proximity of patients, lack of isolation facilities and inability to care for more than two patients needing isolation in the emergency department worried MidCentral DHB, documents reveal, and no negative pressure rooms at Timaru Hospital meant there was a safety risk to patients and staff in the event of outbreaks of diseases like measles, chickenpox, pandemic flu and shingles. Whangārei Hospital acknowledged a risk from not having a positive pressure room in a ward.
Negative pressure rooms use lower air pressure to prevent internal air from leaving a space, allowing patients with infectious conditions to be isolated. In contrast, a positive pressure room keeps out germs and particles and thus protects from infection and disease.
Infrastructure problems often affect some of the most vulnerable patients. Six DHBs recorded major risks relating to demand on mental health facilities, or "not fit for purpose" buildings.
They include Waitematā, MidCentral, Tairawhiti, Capital and Coast, Hutt Valley and Lakes District. The latter warned of a "risk of harm to self or others in the inpatient mental health unit due to the acuity of patients in a suboptimal environment".
Auckland DHB refused to release its register, but other documents reveal seriously unwell patients were discharged from its acute mental health facility because there weren't enough beds for long periods. Staff reported "spending too much time fire fighting", "tension/angst amongst staff" and "no time for triage".
Waitematā DHB runs the region's forensic psychiatric services and is in the midst of rebuilding the leaky Mason Clinic, including a new $22 million, 15-bed medium secure unit expected to open towards the end of this year. The DHB estimates capacity at the clinic's Point Chevalier campus will need to double in the long-term and has previously warned the ministry of capacity problems, including intellectually disabled women sharing bedroom corridors with "predatory" men. It recently bought a block of land that will let the site expand by 2.8ha.
Its services have often run at 100 per cent bed capacity. In June, a hospital advisory committee report described how that affected care: "The adult inpatient units have experienced 85 per cent occupancy twice, lasting only a few days at a time. This is the first time the target has been reached in over three years ... benefits have been significant over the two brief periods with improvements in the quality of care for people both in the inpatient units and in the community."
At the other end of the country, a ward of Dunedin's Wakari Hospital, which holds people with an intellectual disability or with both an intellectual disability and mental health issues, recorded more than 500 physical assaults by patients on staff over 2017 and 2018 and 400 physical assaults by patients on patients.
The DHB's director of nursing outlined concerns about the state of Wakari buildings in a January 2019 report, saying, "these, for the most part, are original 1990s condition and do not support the delivery of safe (for patients and staff) contemporary acute and sub-acute mental health care".
New builds are planned in some areas, including MidCentral DHB, which will upgrade its acute adult inpatient mental health unit by 2022, and Tairawhiti. The ministry is also reviewing forensic mental health services, including the buildings they are currently using.
Hospitals 'on the edge'
Sarah Dalton, executive director of the doctors and dentists union the Association of Salaried Medical Specialists (ASMS), says infrastructure upgrades can "feel like a lolly scramble", with too little input from those working at the coalface.
"We have examples where DHBs agree to recruit senior medical officers and they can't actually give them proper or sufficient [surgical] lists to do the type of work they are employed to do, because they don't have the theatre space or available facilities."
ASMS recently released a "Hospitals on the Edge" report that found many hospital wards were running at or over 100 per cent bed occupancy, when the widely accepted safe level was 85 per cent.
Hospitals can't properly operate at 100 per cent capacity, because spare beds are needed to cope with changes in demand and make sure patients can move through the system. Being too full leads to delays in emergency departments, the cancellation of electives, spread of dangerous infections and more pressure to discharge people early.
Dalton says the union recently intervened after staff at one DHB developed kidney problems because they were working in uninsulated prefabricated buildings with no running water. Patients pay a heavy price too, she says. Many are treated only when their condition becomes severe.
"Our doctors aren't able to make treatment decisions that are optimal. And that has an impact on patients and their quality of life."
Survey reveals 'huge' problem
Budget 2019 set aside $1.7b for upgrading and building new hospital facilities. Projects already announced by the Labour-led Government include mental health facilities in Hamilton, Wellington, Christchurch and Gisborne.
A major upgrade of Taranaki Base Hospital will cost $300m, and Auckland City Hospital, Greenlane Clinical Centre and North Shore Hospital have received capital funding boosts for projects including new elective surgery and stroke units.
Whangārei Hospital gets $24m for new endoscopy and cardiac facilities.
In the South, new emergency department and outpatient facilities will be built at Queenstown's Lakes District Hospital, and Dunedin Hospital will be rebuilt at a cost of up to $1.4b - one of the largest infrastructure projects in New Zealand and due to be completed by November 2028. The current hospital is leaky and riddled with asbestos, meaning patient records are fetched by staff in hazardous materials suits.
Clark says he was "horrified" to learn the health system had no standardised register of assets and pulling one together was one of his first acts as minister. An early version outlines the scope of the problem, but he declined to give specifics.
"We have a lot of buildings across New Zealand that have seismic issues, that have leaky building issues or just simply are no longer fit for purpose and the job ahead is huge."
Finance Minister Grant Robertson recently announced the Government will spend an extra $12b on infrastructure, split across new roading, rail, schools and healthcare projects. About $300m will go to DHBs for asset renewal and bigger hospital projects will be separately budgeted for.
Key measures of New Zealanders' health, such as reduced death and disability, are improving at rates comparable to similar countries, despite us spending increasingly less. That can't continue without upgrading hospitals, Clark says.
"I take my hat off to and want to acknowledge the work of clinicians, nurses and allied health workers who continue to provide an amazing health service in facilities that often are not fit for purpose.
"There is no doubt that the very limited investment over the last decade has had an impact. Buildings which should have been replaced or refurbished were not."
National Party health spokesman Michael Woodhouse says those claims don't stack up and there was significant capital investment under National, including major hospital upgrades and rebuilds in Taranaki, Waikato and Christchurch.
The situation is complex, he says, but cash-strapped DHBs are choosing to spend on treating patients rather than fix up equipment and facilities.
"That's not to forgive it but it is to explain it. And that's got worse, not better, under this Government and the reason is [DHBs] are being starved of operational resources relative to the sorts of operational cost increases they are being required to incur, particularly in salaries."
A snapshot of DHB infrastructure will always show issues and capacity problems, he says, and dealing with them is "just the reality of being in government".
"We didn't blow trumpets and wave our arms around when we had to rebuild Christchurch or fund Hillmorton [Hospital] or plan for the replacement of Dunedin Hospital - that's just what has to go on. I think Dr Clark is showing a significant degree of naivety about the challenge - this is what we do."
Disorganisation also adds to pressure, Woodhouse says. He knows someone who was recently in Dunedin Hospital for 10 days, waiting for theatre space for a gallstone operation.
"What a complete waste; she is sitting there in a bed, consuming the resources that probably cost twice as much as the procedure would have done had it been done in a timely manner.
"I don't think it's only about the quantum of resources, it's also about the organisation of a system that is basically in disarray under this Government's leadership. It's not as if hundreds of thousands of people suddenly arrived when this Government took office or that those pressures weren't apparent before October 2017. They were there and they were being dealt with because hospitals were being held to account."
Women's health services at Middlemore Hospital are an example of facilities struggling to cope with booming demand, partly fuelled by poverty and obesity rates. As well as pressure on gynaecology, maternity services have at times failed; the death or stillbirth of babies in 2016 and 2017 were partly because of resource problems including not enough beds and theatre slots.
Auckland Mayor Phil Goff and local councillors have called for more Government help for the DHB, which got an extra $287m over four years in Budget 2019. In July, Clark indicated more help would be announced soon but none has.
Dr Sarah Tout, Counties Manukau's clinical director of women's health, says the ability to get enough theatre time "has been a challenge when managing our clinically lower-priority patients", and this applies across all surgery services.
"We are working collaboratively with the Ministry of Health and have plans in place for increased capacity at the Manukau Health Park and exploring what a women's health building might look like."
The hospital is trialling giving women assessed as "priority three" for urogynaecology conditions physiotherapy sessions, and then outsourcing some surgeries to the private sector.
In an earlier interview with the Herald, Tout was blunt about how turning away needy patients takes a toll on staff: "The DHB is made up of thinking, feeling, caring professionals. Everyone is trying to do the best with what they have. But we don't have enough to do what we want, or need, to do … the DHB has been underfunded for many years - it is at absolute capacity."
The four DHBs that make up the northern region – Northland, Waitematā, Auckland and Counties Manukau – made a case for a new hospital, possibly two, in their recent northern region long-term investment plan.
Over the next 20 years nearly 60 per cent of New Zealand's population growth will be in Auckland and Northland, the report found, meaning another 2055 beds and 41 theatres will be required.
There are no imminent announcements on new hospitals, Clark says, but those numbers clearly show the need to build more facilities.
"The issue of long-term planning for the wider Auckland region across transport, education, health and so on is certainly something being looked at by Government in a thoughtful way. Because that planning hasn't been done in the past."
Sian Stewart worries that the strain on the health system will worsen as the population ages and grows. New subdivisions in South Auckland are popping up like mushrooms, she says.
"Yet our health, education and transport are not being expanded at anywhere near the same rate."
Infrastructure risks listed on DHB registers
Registers are regularly updated, each risk judged according to likelihood and severity, and mitigation actions put in place. Entries reflect potential risks and don't necessarily mean actual failure or harm has already happened.
"Infrastructure: Facility failure due to extreme age, past useful life and lack of investment in critical facility upgrades."
"Ageing radiology equipment that could fail."
"Outdated and not fit for purpose facilities for clinical demand and seasonal pressure impacting on patient safety and experience."
"Some WDHB buildings no longer able to meet compliance requirements or fall short of the WDHB building standards leading to risk to occupants/services."
Counties Manukau DHB
"Failure of critical facilities (seismic risk, weather tightness, asbestos and issues with infrastructure) and clinical equipment and/or assets no longer fit for purpose, will not fulfil current or future operational needs, or assets that no longer comply with regulatory or legislative requirements."
"Lomas oncology building has insufficient capacity for clinics, chemo day-stay and SMO offices."
"Risk of harm to patient and/or staff due to current limitations, clinical resourcing and equipment for neonatal transfer."
"Malfunctioning of medication fridges restricting usability."
"Equipment failure negatively impacting on patient flow."
"Increased risk of fire due to degradation of aged PVC electrical wiring system."
"The hospital infrastructure is cramped, ageing and outdated, causing significant issues for patients and staff. HBDHB has actively engaged with MoH [Ministry of Health] on these issues and was a pilot site for the MoH national asset management plan review."
"Lifts are in need of replacement as shown by increasing incidents, outages and the need for repair."
"Seismically substandard buildings."
"Deferred building and infrastructure maintenance."
"Limited ICT systems resilience including disaster recovery."
Capital and Coast
"Extreme pressures on the capability and capacity on the national forensic sector."
"The Wellington Regional Hospital hot water pipes have pinhole leaks that require repair and this may have an adverse impact on clinical service delivery and budget."
South Canterbury DHB
"Potential health and safety risks to patients and staff within Timaru Hospital when we have an airborne isolation (eg measles, chickenpox, pandemic flu, TPB, disseminated shingles), due to there being no negative pressure rooms."
Refused to release:
Bay of Plenty
Source: August/September 2019 registers. Where possible, DHBs have confirmed risks remain on the register.