If it's broke, don't fix it

By MARTIN JOHNSTON

If you don't like the look of your nose and want it remodelled, don't even bother asking a public hospital. Go private.

Likewise if you need a new hip and want it done immediately, you probably need to see a private surgeon and check your bank balance or health insurance policy.

But where do you go if your leg is smashed in a car accident, or if you slip at home and break a hip? A public hospital.

Governments have encouraged this public-private split. They have fostered the idea that while you must pay your own way for add-ons, when you need basic medical attention, such as mending a broken leg, New Zealand's good-quality public system will take care of it.

But statistics from Auckland Hospital, New Zealand's largest centre for treating major injuries, challenge this notion. They show that many patients wait longer than they should to be treated for injuries that are painful and in some cases potentially fatal.

Middlemore Hospital in South Auckland says its delays are probably worse.

Bruce Twaddle, Auckland Hospital's director of orthopaedic trauma, says his department's service is substandard and seriously injured patients with broken bones are regularly put at risk. He blames shortages of money and staff - and a policy that prevents all surgery after 10pm for orthopaedic patients, except those expected to die or lose a limb without it.

His concerns have prompted him to speak out publicly, risking censure from managers.

The management of Auckland Hospital, which handles 3000 acute orthopaedic cases a year, yesterday acknowledged the existence of the orthopaedic problems and said it had a plan to fix them. But this scheme will simply make other patients, who are less sick, wait longer.

And it is standing firm on overnight surgery, saying staff perform less well during those hours.

The Accident Compensation Corporation, which pays for injury treatment, says it is greatly concerned by Twaddle's findings because inadequate treatment of orthopaedic patients compromises their rehabilitation and ultimately costs ACC more.

Twaddle, an orthopaedic surgeon, says a recent case shows how delaying surgery can compromise patient health.

A young man arrived in hospital at 6am with a fractured thigh bone from a car accident. An orthopaedic surgeon was available but the man's operation could not be scheduled until 6pm because under the hospital's procedures, his case was judged insufficiently urgent.

Meanwhile, a major leg nerve stopped working and a blood clot or piece of fat jammed in a lung blood vessel. He suffered breathing difficulties and was sent to the intensive care unit to save his life.

Twaddle says the problems have been developing since the addition of liver transplant and vascular services at the hospital in the 1990s without sufficient resources. His concerns spilled out publicly after the father of 15-year-old Tony Chester spoke in the Herald this month about his son lying in an Auckland Hospital bed untreated for six days with a broken collarbone.

He was eventually treated at a private hospital. Auckland Hospital blamed winter overcrowding, but Twaddle says the problems go much deeper.

He has compiled a report measuring the delays in treating patients for the first six months of this year.

Worst off were those with a fractured thigh bone. Nearly 65 per cent had to wait longer for surgery than they should have done.

Twaddle's guidelines - based on a review of orthopaedic research and endorsed by the hospital - say patients needing surgery for this injury should get it on the day of admission.

Early surgery for these injuries, he says, minimises the risk of complications from blood clots or pieces of fat in the bloodstream.

"There is evidence to suggest patients mobilise faster and have a faster rate of returning to work if they are operated on within 24 hours."

Compound fractures, where broken bone pokes through skin, are prone to infection.

These patients, too, should receive surgery on the day of admission under Twaddle's guidelines. But at Auckland Hospital, a third have to wait until the next day and a handful are forced to wait even longer.

Fractures in the neck of the femur (essentially a broken hip) occur mostly in elderly patients. Of the 189 of these patients in Twaddle's report, the average age was nearly 80. Twaddle recommends they get surgery on the day of admission or the next day.

The average delay was 2.4 days. Nearly 37 per cent were treated outside the guidelines.

Twaddle says the risks of complications, including death, are especially high for patients with a broken hip.

"A recent study by the Ministry of Health shows a significantly increased mortality rate in patients operated on greater than 48 hours after admission."

Fifty-five per cent of fractured-ankle patients are treated outside the guideline, which is for surgery on the day of admission or the next day. Delays are not so serious for this group, but if not operated on within 24 hours, there can be significant delays since the resulting swelling makes surgery unsafe.

"This leads to expensive additional days in hospital and increased risk of other complications," Twaddle says.

At Middlemore Hospital, the clinical head of orthopaedic surgery, Garnet Tregonning, says he has not compiled figures on delays, but he acknowledged that his department also was less than adequate.

"It would not be unfair to say that we have had probably greater problems than Auckland, given our volumes, for a very significant length of time.

"The difficult times are particularly at night where there are limited nursing staff, anaesthetic technicians and theatres for us to be able to operate on all the patients we want to."

He attributes this to an international shortage of these staff and a shortage of money.

Elderly patients with broken hips are often a particular problem, Tregonning says.

Delay surgery and the risks rise of complications like pneumonia, urinary infections, pressure sores and death.

Auckland Hospital management has come up with a plan to solve the problem by shuffling existing resources within the hospital, rather than finding more money.

When there is a flood of patients with broken bones, elective surgery patients - people not considered acutely sick - will be forced to wait longer than usual.

Chief medical officer David Sage says these surges occur on average monthly.

He says the elective surgery patients whose treatment will need to be cancelled and re-booked may be from virtually any clinical area at the hospital, including those waiting for gall-bladder removal, vascular surgery, bladder treatment and neurosurgery.

Their waiting times may rise by a week or two, he says.

The plan also looks ahead: to the new hospital being built next to Auckland Hospital, and to the shedding of some of Waitemata's acute orthopaedic patients to North Shore Hospital.

But the Herald revealed last month that while the Auckland District Health Board's overall number of operating theatres will rise from 29 to 33 with the new hospital, this is four fewer than previously planned.

This disturbs Twaddle. Sage says the four "mothballed" theatres can be opened in future.

Twaddle says shedding some Waitemata patients will not help the delays because 40 per cent of his department's patients have suffered major trauma and 80 per cent of these are from outside the Auckland board's boundaries.

And he says the Government's so-called "roadside to bedside" initiative, a plan to centralise trauma treatment in several big hospitals, is likely to increase Auckland Hospital's complex trauma load by 300 per cent.

Health Minister Annette King was unavailable for comment yesterday. Her spokesman said she was satisfied the Auckland health board was dealing with the orthopaedic problems appropriately.

However, the delays at Auckland Hospital may be a surface complaint obscuring a deeper malaise in the health system.

For more than a year, the Auckland health board has been struggling with crippling deficits as it tries to comply with a Government demand to break even within three years. This financial year it has been told to reduce its losses to $61 million, from a predicted $86 million.

It and some other boards have signalled the possibility of cuts to health services, although Auckland last year abandoned an attempt to save $30 million over two years with a range of cuts.



Any proposed cuts to services would need to be subjected to public consultation and approved by Ms King - who would be risking political damage.

More likely the relentless pressure to save money will force a gradual erosion of services, leading to occasional outbursts from angry doctors, who have long claimed the right to criticise rationing of health services when it affects their patients. Bruce Twaddle's plea for action looks unlikely to be the last.

Feature: Our sick hospitals