The row broke out after a September 5 letter, signed by 13 orthopaedic surgeons at Waikato Hospital, said the department no longer had faith in management, that Waikato Hospital was no longer a safe place to practise elective surgery and that to block doctors from patients was "immoral, unethical and dangerous".
"This directive from management is a cynical denial of our patients' rights to medical care they have been offered during their clinic visit, in order that management may continue to pretend that Waikato Hospital is achieving more than it is," the letter stated.
"This represents both a catastrophic failure of the current management structure and a bewildering departure from Waikato Hospital's stated aims of delivering 'People-centred care' in 2016."
The surgeons also argued that there was potential for legal ramifications.
Emails obtained by the Herald claimed the situation within the department was at breaking point, as senior managers pressured doctors to meet the Ministry of Health-imposed targets.
A breach of targets could have meant millions of dollars in lost funding but the letter shows the surgeons, including the department's clinical director, Stewart Hardy, refused to compromise patient safety and continued their responsibilities at the expense of the FSAs.
The chief medical officer, Dr Tom Watson, told Waikato Hospital DHB executive director of services Brett Paradine there was a "crisis within the service and, at some stage, you are going to have to make some difficult decisions about how you deploy the resource available to you to manage the crisis, which may mean postponing some elective surgery to facilitate FSAs".
One email, from former surgical services business manager Chris Clarke to Paradine, asked: "Are we proceeding with the elective list cancellation and putting [surgeon] Hamish [Deverall] in clinic? Hamish has indicated that if we cancel this surgery of this young girl to put him in clinic she runs a real risk of paralysis."
Paradine told the Herald there was pressure to provide a timely service to patients, not to meet health targets. He said no elective surgeries would be postponed if the patient was acutely ill and any postponements were approved by the surgeon.
He apologised for the postponement of the 22-year-old's surgery, saying the second time was because of the junior doctors' strike.
Paradine said management was aware of the short-staffing in the orthopaedic department which led to them being behind with the FSAs.
He said a specialist from Taranaki was brought in to help relieve the pressure.
At one stage the DHB investigated bringing a specialist over from Australia to help. In the end the DHB did not breach the target.
Paradine said two specialists had been recruited to fill vacancies in orthopaedics and would start in February and April, and the DHB had approval for a locum to fill a third vacancy, and for 12 extra theatre nurses.
Chief executive Nigel Murray said a commissioner had been appointed to investigate solutions and she had already filed an external review.
He strenuously denied allegations managers were manipulating patient waiting lists to meet health targets.
Association of Salaried Medical Specialists executive director Ian Powell said gaming the system by manipulating waiting lists was "completely plausible".
"We know this happens and I'm not talking specifically Waikato. No one will ever admit it.
"To some extent it's the fault of the targets being used by the Government and that's pretty messy."
Health Minister Jonathan Coleman said he had been assured there was no manipulation of the system at Waikato DHB. "The health targets are not just about numbers -- they are about delivering better, faster access to services.
"The target of patients seeing specialists within four months is all about getting better health outcomes for the patient."
Coleman said 3641 Waikato DHB patients received their First Specialist Assessment for orthopaedics in 2015/16 compared with 2758 in 2009/10, a 32 per cent increase.
Extracts from the letter and emails
Letter to Waikato Hospital surgical and critical care director Kevin Harris from 13 orthopaedic surgeons regarding suspension of patient follow up appointments dated September 5:
"We have to be able to continue the care we have instituted for our patients that we are already in a therapeutic relationship with and to block this is immoral, unethical and dangerous.
"Unfortunately, now that we are unable to trust Waikato Hospital's systems for ensuring appropriate follow-up is offered to our patients, Waikato Hospital is no longer a safe place to practice elective surgery."
Orthopaedic clinical director Stewart Hardy to executive director of Waikato Hospital services Brett Paradine in an email dated September 13:
"My other concern is that individual surgeons are now being approached to cancel their operating lists to do FSA [First Specialist Assessment] clinics.
"This is a short-sighted book-keeping exercise that will surely lead to a blow out in cases suddenly requiring surgery before they breach. At some point maybe we need to accept we are not staffed or resourced for the work we have, and this should be conveyed to the CEO and Ministry."
Extract of email from Brett Paradine to orthopaedic surgeons dated September 14:
"We'll still need to examine every possible option for different ways to get this month's outstanding FSAs done. Where we are today is that for want of around three days of FSA clinics we risk losing a minimum of $2.723 million of revenue. We just have to find a way to avoid that."
Email from former surgical services business manager Chris Clarke to Brett Paradine dated September 16:
"Are we proceeding with the elective list cancellation and putting [surgeon] Hamish [Deverall] in clinic? Hamish has indicated that if we cancel this surgery of this young girl, to put him in clinic she runs a real risk of paralysis."
