Six hospital services in Auckland and Northland have been deemed "vulnerable" after a major review of the regional health system following Covid-19 lockdowns last year, the Weekend Herald can reveal.
The services, which treat thousands of patients in areas such as oncology, dentistry and ophthalmology, will be overhauled after the pandemic's unprecedented disruption aggravated long-standing pressures.
Hundreds of pages of review documents outline how patients - many of them children - have been caught in delays, amidst inequities including gaps between Pākehā and Māori/Pacific, and glaring examples of "postcode healthcare", where what DHB catchment somebody lives in affects their treatment.
Officials are now planning reforms to fix those complex problems - changes that could affect how patients in Auckland and Northland are treated for years to come.
The review, obtained under the Official Information Act, examined at-risk services in the four northern region DHBs - Northland, Auckland, Waitematā and Counties Manukau -which increasingly act from a single perspective. Findings include:
• In one service, a lack of co-operation between DHBs and workforce pressures meant "a cost to patients in the form of delayed/limited access to treatment";
• South Auckland children with ear, nose and throat conditions experienced longer wait times than those living in central Auckland suburbs;
• "Dysfunctional interpersonal relationships" affected co-operation between medical specialists in one service.
The vulnerable services are otorhinolaryngology (ear, nose and throat conditions), maxillofacial surgery (reconstructive face, head and neck surgery), eye services (ophthalmology), oral health including children's dental care, sarcoma (rare cancerous tumours), and vascular surgery.
The review illustrates starkly how frailties in the health system have come under even more pressure as resources shifted to fighting Covid-19, with tens of thousands of procedures and appointments postponed during lockdowns that have stretched into 2021.
"Covid has shone a harsher light on some of the existing issues," said Sarah Dalton, executive director of the Association of Salaried Medical Specialists union.
"Maybe Covid gives people permission to admit, or to talk about it. It's a little circuit-breaker to say, 'We're not coping'. But it's not because we had six weeks at level 4 lockdown. All of that stuff was there long before that."
Dalton welcomed the "overdue" regional approach, but said there were other services not yet included in the review, such as mental health, which were also struggling.
Criteria used to define a service as "vulnerable" includes "not able to maintain or develop capacity resulting in a patient access and safety impact", "service risks completely failing" and, "clear opportunity to take a specific regional action to maintain safe or equitable care".
Dr Mike Shepherd, director of provider services at Auckland DHB, told the Weekend Herald that "vulnerable" didn't necessarily mean that the whole service was stressed. It could, for example, mean that certain treatment "pathways" within those services weren't functioning as well as they should.
He insisted that the services were not at risk of stopping or failing and that patients' safety was not at risk. But the review highlighted systemic issues that need to be addressed, he said.
"I don't think you can look at this data and not feel a sense of urgency."
This is the first phase and more services are likely to be overhauled. Changes will differ, but will all be regional - unrelated to but foreshadowing government plans to merge some of the country's 20 DHBs.
One area set for change is vascular speciality services at Auckland and Counties Manukau DHBs, which cover diseases of arteries, veins and lymphatic vessels, including a growing number of diabetes-related amputations.
"Vascular services in the northern region are vulnerable due to an ongoing lack of integration in services between DHBs and a vulnerable workforce that - at various times in the past few years - has threatened the sustainability of service delivery," an August 27 2020 report warns.
"This has come at a cost to patients in the form of delayed/limited access to treatment, continued health inequity with, for example, lower limb amputation rates for Māori twice the rate of non-Māori, long and expensive commutes to outpatient clinics for those living in Northland and Waitematā, and potentially poorer patient outcomes for some.
"Other services which require support from vascular services due to an injury or trauma are also affected by the current ad hoc arrangements for emergency and urgent vascular cover, especially in Northland and Waitematā."
An overhauled "hub and spoke" model is proposed, with a single site for major surgery, linked to spoke sites in each of the DHBs.
Inequities have also been identified for children with ear, nose, throat and head and neck problems, given "variation in access to surgery due to long wait times within some DHBs and variable admission and patient oversight practices".
In Counties Manukau, "intervention rates for paediatrics is not good, with increasing waiting lists and waiting a long time in comparison to Starship", the review documents state.
The regional service for sarcoma - a rare cancerous tumour in the bones and soft tissue - operates a split site across Counties Manukau and Auckland, but there's been little work to combine or co-ordinate the highly-specialised workforces, facilities, funding or workload.
"A key consequence is that the time-critical nature of sarcoma surgery has displaced other patients within the orthopaedic service at ADHB who are already disadvantaged by disproportionately long waiting times for elective surgery," outlines one document, which also warns services can be under-resourced and poorly organised and, in South Auckland, are "highly vulnerable to the loss of a single individual".
In the case of complex head and neck surgery, the documents reveal, "longstanding dysfunctional interpersonal relationships within the specialist workforce has hampered the ability to develop a more integrated regional approach". That's badly needed - there haven't been enough specialist staff in at least one DHB "to provide timely access to assessment and treatment services during periods of planned or unplanned leave".
The DHB documents frequently cite the need to improve outcomes for Māori and Pacific. One example: those groups are over-represented in the more than 1700 Auckland children who are stuck in a backlog for tooth extraction surgery, after Covid-19 put more strain on an already overburdened oral health service.
The threat of a widespread Covid outbreak saw the northern region DHBs work with groups including iwi and Pacific health providers to make major decisions rapidly, and the vulnerable service work seeks to build on that.
How eye services will change
Ophthalmology is "vulnerable", partly because care has depended too much on where somebody lives - it's been harder to get life-altering cataract surgery in South Auckland, for example, which has meant some patients who could no longer drive weren't accepted, whereas they'd get surgery at Auckland DHB.
Counties Manukau has made strides in treating more cataract patients, but eye services as a whole will remain under huge strain, because of an ageing population, sickening with conditions like diabetes, and needing new treatments that require more appointments.
Demand has been more than three times population growth, and about 40 per cent of cataract procedures are now outsourced to private clinics.
Changes now proposed as part of the vulnerable services overhaul include setting the same thresholds for surgeries across the region and expanding community clinics to overcome the problem of most optometrists being located in more affluent suburbs.
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