The leader of the country's busiest women's health hospital service has issued an extraordinary plea for help - saying distressed doctors are turning down desperate patients because of a lack of capacity.
Middlemore Hospital's clinical director of women's health, Dr Sarah Tout, was blunt in describing why the Government must step up.
Women with "non urgent" but nonetheless serious and often debilitating gynaecological conditions, including suspected endometriosis, incontinence, pelvic pain and prolapse, are declined because of a lack of theatre capacity.
Urgent cases include women critically ill or with potentially life-threatening conditions like cancer. Others are sent back to their GP and told to re-refer if things get worse.
"We have had to make a choice as to who we see," Tout said. "These conditions that we are not seeing are highly significant, and affecting women's lives on a daily basis.
"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".
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In a wide-ranging interview Tout also:
• Addressed an independent report, delivered in March and obtained under the Official Information Act, that found doctors "very disillusioned" amidst "relentless" workload and rostering problems that risked safety.
• Conceded some staff "didn't really want to come to work" last year, but said improvements had boosted morale.
• Called for a shift from the population-based funding formula, to more strongly account for health need or deprivation. Using the Census to estimate population also didn't work, she said: "Do you want to tell the Government that you have got people living in your garage?"
• Spoke of the emotional toll after three babies died or were stillbirth in 2016 and 2017, partly because of issues like a lack of bedspace and staff: "In a workforce already feeling vulnerable and perhaps undervalued...you put a death on top of that and it's extremely distressing."
• Warned obesity-related illness had "reached a new level" in the past 18 months: "I guess we were always compensating and compensating, and now we have reached the point where we are - so much - at capacity."
Sue Claridge, of the Auckland Women's Health Council, backed Tout's calls for more support.
"These conditions may not be terminal, but they can lead to a really severe loss of quality of life and function. Women can't function and can barely walk to the letterbox, can't look after their families, work is affected."
The Herald spoke to Tout after obtaining findings of a review, delivered in March and based on interviews with senior medical officers from obstetrics, gynaecology, anaesthesia, general surgery, management and nursing staff.
They were dedicated and competent, concluded reviewer Dr John Tait, who chairs national maternity watchdogs and is chief medical officer at Wellington's Capital & Coast DHB.
"However, there was significant emotional distress amongst those interviewed. A series of adverse outcomes [incidents when patients are seriously harmed in treatment], the loss of a colleague, resignation of two senior colleagues and the relentless nature of 'on call' has resulted in a very disillusioned workforce.
"There is a feeling of no time to think, rushing from one gap to another."
The women's health service was "unique in New Zealand", Tait concluded: "It is the busiest service, has the most pathology, looks after women with significant obesity issues and has a variety of demographics".
In 2018 there were 593 emergency caesareans performed from 10pm to 8am - nearly as many as from 8am to 5pm, and 265 of which were on obese and high risk women.
The service's diabetic clinic was overwhelmed by demand, Tait found, and didn't have enough resourcing to follow care guidelines. Staff were "continually worried that they will miss something".
"My final comment is that I found it quite distressing to see the emotional distress of my colleagues," he wrote. "I hope change can happen to alleviate this distress."
That change was well underway, Tout said, with all Tait's recommendations completed or addressed. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists had visited since and praised "excellent" culture and innovations.
Rosters had been strengthened and were going electronic, and a boost to the diabetes clinic planned. More C-section theatre lists were secured, and 150 hysteroscopy cases (looking for problems in the lining of the womb, including cancer) outsourced, with more to follow.
"All the surgical services are in a similar situation," Tout said. "The DHB needs more funding to expand its theatres. That won't happen overnight, but if there was more funding then we could [outsource] more to private."
Associate Health Minister Julie Anne Genter, who is responsible for women's health, said hearing about the emotional distress of staff "is certainly concerning", and blamed the previous Government for underfunding in health.
Counties Manukau received an extra $287 million over four years in Budget 2019, Genter said, and more money had been given for LMC (lead maternity carer) midwives, which would help relieve pressure on hospital services.
Health Minister David Clark has previously indicated some support may be announced soon. It's understood that relates to neonatal intensive care capacity.