Hospitals still seeking a cure for the perennial problem of waiting

By CHRIS BARTON

Waiting is a drag. Not just for the patient parked for a day in a hospital corridor because there are no beds. Or for the one pacing in exasperation in an emergency room because he's been there for hours.

Or for the harried staff seemingly immune to the plaintive cry of "Nurse!" from a distant ward. Or for the specialist twiddling his thumbs at a morning clinic because his patient appointments have been messed up.

It's more than a drag for the elderly woman alone at home going blind with no prospect of her cataract operation this year.

And for the professional itching to get back to work, but hampered while an ACC bureaucrat umms and aahs for weeks about whether to finance her ligament surgery. Or for the knee replacement patient who is bumped off a surgery list because the private hospital's ACC funding allocation for the month has been used.

Waiting. The universal constant of our hospital system. No matter what the formula - public, private, ACC - waiting is always part of the equation. But while waiting lurks at every corner, it's in public hospital elective surgery that its presence is most felt - despite bureaucrats' creative attempts to call it something else.

On the Elective Services website (www.electiveservices.govt.nz) seven stages of waiting are displayed - not unlike Dante's Divine Comedy's nine circles of hell. Here, one can track patients' progress to purgatory and, if they're lucky, paradise.

Some 24,000 don't even make it to the front door, unable to get an appointment with a hospital specialist for more than six months. Others wait in limbo, not knowing if they will be treated.

Or wait, as sinners, with no plan of care. More than 9000 are sent back to their GP to be reviewed at a later date that never comes. Another group are taunted with the promise of surgery but, six months later, it still hasn't happened.

Some of the stages of waiting overlap, so it's not possible to simply total all the numbers. But with some prompting, a Ministry of Health official agrees we can say that in June there were at least 45,000 people waiting, in some form or another, to get elective surgery in our public hospital system.

The number sounds much better than the 77,555 in 1994. But it was around then that hospitals and the Government decided to be rid of the waiting list embarrassment forever.

Not by clearing the backlog, but by changing the way waiting was recorded and upping the threshold for whether patients would get surgery in the first place. Waiting would be swept under a bureaucratic carpet of red tape. But although long lists are now largely unseen, the new lists still have problems.

"If we have 40 patients removed from a waiting list and transferred to us for surgery," says North Shore Hospital orthopaedic department clinical director John Cullen, "you would think we could phone up those people and get them to come in and have an operation. We probably have a strike rate of four in 10."

The reason? Waiting list management that doesn't accurately reflect demand and lists that become badly skewed because they're still missing those who have been waiting much longer than they should.

"It means you have to keep revising the list. Some hospitals are better at that than others."

Ministry deputy director-general Colin Feek describes the new regime as a "waiting system" rather than "the traditional waiting list", and admits it was totally arbitrary that six months would be the cut-off between acceptable and unacceptable waiting.

"The policy intention was to be more honest about what we're doing and to make sure the people with the greatest need were dealt with in a timely fashion."

He claims the number of people treated within six months has improved dramatically and that people are no longer waiting the barely credible 10 or 12 years as they were under the old system.

"At least we're saying this is what we can afford at the moment. This is what we can do. I acknowledge there are people we are not treating, but they were never going to be treated under the old system anyway."

In this game of semantic tag, ask, if your hospital has a waiting problem and Auckland City Hospital general manager Nigel Murray says it depends how you define "problem". He points out he "produced 100 per cent to contract" for the year to July.

"We run the public system in New Zealand with a quantity of waiting lists. The expectation is you don't get immediate access. The private sector markets itself on immediate access, but you pay for that."

But sometimes patients in the public system do get to paradise - miraculously finding themselves transferred to a private hospital for their surgery and post-operative care. That is happening this year for 170 orthopaedic patients at North Shore who are to sample Southern Cross hospitality after the Waitemata District Health Board decided to spend about $500,000 clearing some of its elective surgery backlog via private hospitals.

The same happened for about 200 orthopaedic patients in the Counties Manukau area who partook of the facilities and fine food at the upmarket Ascot Hospital in Greenlane. Auckland Hospital also routinely uses Ascot-Mercy and Southern Cross for orthopaedic, cardiac and general surgery operations.

"It helps us to manage some peaks when we want to access some extra capacity and not bring on our own capacity [build more beds, theatres, etc]," says Auckland Hospital's Murray.

"A good relationship between public and private can be quite symbiotic and helpful to one another."

So if it works, why not do more? The question is asked by Andrew Blair, president of the New Zealand Private Hospitals Association, who says although hospitals with capacity problems and under pressure to reduce waiting lists are increasingly turning to private facilities, the spare capacity is not used as well as it could be.

And there's no certainty of supply from the district health boards, just an expectation to respond to peak demands.

"We believe the private sector should have greater access to performing all elective surgery, regardless of the funding source. We've demonstrated we can deliver on quality timeliness and efficient pricing.

"Why does the Government not consider allowing the Vote Health elective surgery budget to be more contestably allocated?"

Blair backs his argument with the fact that 81 per cent of accident-related elective surgery funded by the Accident Compensation Corporation is now carried out in private hospitals.

For ACC, which began fully funding such operations in 1997, the effects have been dramatic, halving the number of days for an average claim from 60 to 31 days.

As a way to deal with waiting problems, Blair says ACC's buying from private hospitals for more timely surgery, coupled with better case management, is a glowing success story, further evidenced by its $875 million surplus this year.

Although the logic says more contracting out of surgery to the private sector makes sense, it isn't happening.

"At the moment we don't see it as the best way to develop comprehensive health services," says the general manager of North Shore and Waitakere Hospitals, Rachel Haggerty.

Says Counties Manukau District Health Board chief executive Steve McKernan: "At Manukau we have more than enough facility as we bring on the resource [more surgeons] to provide what we can afford to buy - so we're not anticipating to contract surgical activity to the private sector in the course of the next year or so."

Haggerty and McKernan see the use of private facilities as only a short-term solution while they build up capacity in their respective hospitals - a stance that fits with government policy.

"The public sector is not there to sustain the private sector. We are very happy for DHBs to go into arrangements with the private sector, providing they maintain their core public business," says Feek.

But Murray sees the sense of long-term private-public relationships and how the two sectors are not mutually exclusive. "In designing the capacity of this hospital, I assumed there would be a vibrant private sector in Auckland so I have, in effect, reduced the total physical capacity because of the private market share."

He points to the contract with postnatal stay facility Birthcare, which will take National Women's overflow when it moves to the Auckland site in October. The arrangement meant he could save on 15 beds.

Murray is also quick to point out the differences. Private hospitals don't provide the full range of intensive care and emergency facilities. And mostly they don't train medical staff. And if anything goes wrong in private care, those patients are immediately transferred to a public hospital.

"So I'm carrying the infrastructure that supports the private sector. The private sector couldn't exist in the present cost structure without the public system."

Murray argues, too, that public hospitals need the production line elective surgery to balance costs for the more complex procedures because funding is based on average prices rather than actual costs.

It's a balancing act not helped by a tendency to "maximise throughput for an expensive infrastructure" by running hospitals at "mid-90 per cent" occupancy.

With comprehensive services come creeping inefficiencies - a point not lost on Treasury, which noted last year the total district health board deficit for the year to last December was $44.1 million, $4.1 million (10 per cent) worse than planned.

And that despite a 6 per cent funding increase in 2003/04 (including demographic funding to provide increased services to match increased demand), output volumes are static, if not declining. In other words, more money hasn't meant more operations.

Orthopaedic surgeon and Wellington School of Medicine professor Geoffrey Horne says there is increasing concern that the ability to provide services in the public system is being continually curtailed. In part that's because of systems for privacy, occupation health and safety issues.

"You go through a thing called pre-assessment. Three people ask you the same questions and all fill out pieces of paper and they all look very earnest. And when you come into the hospital, more people ask you the same questions again - the triplication of effort to ensure safety - whatever that means - is strangling the place."

He says the obsession with process "notionally to do with risk reduction" is grinding down the public sector and costing a fortune in salaries and lost productivity.

"You only have to go to a private provider and make a comparison on how easy it is to get your operation done in an administrative sense to recognise that."

Horne says the ethos in the private sector is so radically different from the public sector that if you were simply counting dollars rather than looking at philosophies, public-private partnerships are a perfect answer - "because you'll get much more bang for your buck".

He supports more being done in the public sector, and in particular Government initiatives to build long-term capacity to provide orthopaedic services.

But he is equally supportive "of the notion that the public sector needs to address efficiency issues" - urgently.

"The reason I'm talking to you now is because I still can't get into the operating theatre and it's now 10am for an 8am start. And one of the reasons for that is there are far too many cooks stirring the pot. And I'm sitting here being paid a reasonable amount of public money, but I can't work."

Waiting. It's a drag.



WHAT'S ON THE LIST


Elective Services Performance Indicators - June 2004.

Translation: Stages of waiting for elective surgery in public hospitals at the end of June 2004.

1) Number of services acknowledging referrals within 10 days - 0 of 28 (Auckland District Health Board)*.

Translation: The Auckland District Health Board takes longer than 10 days to respond to referrals from doctors for elective surgery.

2) Patients waiting for FSA (first specialist assessment) for more than six months - 24,008. (Nationwide)

Translation: 24,008 people are waiting longer than six months to see specialists in our public hospital system.

3) Active Review or Residual patients whose priority is higher than those being treated - 14,521. (Nationwide)

Translation: 14,521 patients are likely to receive treatment in the next six months, but have not yet been told that will happen.

4) Patients waiting without a plan of care (residual status) - 1384. (Nationwide)

Translation: There are 1384 patients assessed for surgery who have not been told what plan there is for their treatment.

5) Patients given a commitment to treatment but not treated within six months - 7260. (Nationwide)

Translation: 7260 patients have been told they will have surgery but are waiting longer than six months for surgery to happen.

6) Active Review patients not reviewed within six months - 9309. (Nationwide)

Translation: 9309 patients are waiting under "active review" who have not been checked up on within six months to see if their condition has worsened or improved.

7) Number of patients with priorities above the ATT (actual treatment threshold) waiting longer than six months - 7405. (Nationwide)

Translation: 7405 patients should have received treatment within six months but are still waiting for surgery.

* Since corrected in July with 26 out of 28 services compliant.


* Email Chris Barton