Appendix 2: The Accident Compensation Corporation's approach to scheduled services

The Reduced Waiting Times for Public Hospital Elective Services: Government Strategy (the Strategy) does not apply to ACC. ACC's methods for managing scheduled services differ from those of the Ministry and DHBs because it has a different and specific role. Its role is to purchase treatment for people who have been injured by an accident covered by the Accident Compensation Act 2001 (the Act).

ACC's role is set out in the Act and supporting regulations. This Appendix gives general and summarised information about ACC's approach to scheduled services. The information that ACC provides to patients and health care providers uses terms that have a specific meaning. For ease of reading, we may use these terms differently or omit certain information. Patients and their health professionals should rely on information provided by ACC about their care and treatment.

Patients with injuries from accidents can be cared for by a GP, physiotherapist, specialist, or a public hospital when an injury is first sustained. Services are funded separately from scheduled services. ACC pays for more scheduled orthopaedic surgery than other types of surgery because it is commonly needed after an accident. ACC has started to introduce rehabilitation pathways for common types of injuries. These are equivalent to the care pathways that some DHBs use.

At an appropriate time, the specialist and patient may agree that scheduled surgery is in the patient's best interest and will apply to ACC to approve funding for a treatment plan using an application form devised for that purpose. ACC will approve the request for surgery, based on the information supplied, when:

• the treating surgeon can demonstrate a causal link between the injury and need for the proposed treatment;
• the treating surgeon is listed with ACC as accredited to work in the hospital where the surgery will occur; and
• the treating surgeon is approved to carry out the treatment.

After ACC has approved funding for a request for surgery, the surgeon is expected to provide treatment within the time frame that they proposed to ACC. Nearly all surgery is completed within three to nine months of its approval.

ACC has a review process²⁷ that patients can use after it has declined to fund a request for surgery. A private hospital or DHB may complete the patient's surgery before a review has been concluded. If directed by the review authority, ACC will retrospectively fund the surgery if the patient's appeal is successful. If unsuccessful, the DHB or patient has to fund the surgery. The patient can use their private health insurance and/or their own funds.

Surgeons can support a patient's appeal to ACC so that the patient can access entitlements they might be missing out on or that their insurance might not cover.

How ACC pays DHBs for scheduled surgery

DHBs choose whether to contract with ACC. DHBs have contracts with ACC and manage to an agreed budget for a financial year, and some DHBs sub-contract some of the ACC-funded and/or DHB-funded surgery to private hospitals. Some DHBs provide the surgery in private premises – they hire the facility and equipment but use their staff to perform the surgery.

Expenditure is relatively stable from year to year and relatively insignificant compared to Vote: Health funding. From 2006/07 to 2008/09, about half to two-thirds (11-14) of the then 21 DHBs had contracts with ACC, which were all worth less than $1 million annually.

DHBs can access "Regulation 18 funding" if they want to do more surgery for ACC.²⁸ DHBs may want to do more surgery because they want to earn more revenue. The amount of Regulation 18 funding that ACC paid to DHBs was about:

• $0.7 million in 2006/07;
• $0.6 million in 2007/08;
• $1.0 million in 2008/09; and
• $1.4 million in 2009/10.

The increase in the use of Regulation 18 funding in the last two years might be because some DHBs have improved their ability to identify which of their patients are eligible to have their surgery funded by ACC instead of Vote: Health.

Receiving surgery in public and private settings

Depending on where they live and the type of surgery they need, patients may be able to have their surgery at their Home DHB or at a private hospital.

Most surgery is completed in a private hospital because there is a high likelihood that the surgery will be completed in the preferred time frame. DHBs' ability to offer guaranteed admission and theatre time can be affected by higher than expected unscheduled admissions, workforce shortages, or industrial action, which do not trouble private hospitals to the same degree. Another factor influencing patients' decisions is that DHBs are seldom specific about how long patients will wait for surgery when an offer of treatment is first made.

Some DHBs work closely with the surgeons in their district to treat ACC-funded patients locally. This helps to ensure that there are enough surgeons to make a particular service clinically and financially viable for the DHB and the private hospital. An example is Wairarapa DHB, which works closely with the local small private hospital to help recruit and retain a skilled workforce, particularly for complicated shoulder surgery. This means that patients do not need to travel out of the district for surgery. Whanganui DHB manages a joint contract with its local private hospital for ACC-funded elective surgery. Patients can be treated in either hospital, depending on their individual risk factors or the availability of beds.

ACC's focus is to ensure access to a quality service, which is appropriate for the patient's clinical priority for treatment and effective rehabilitation. ACC does not direct in which facility the treatment is to be provided.

27: In May 2011, the Minister for ACC announced changes to the status of ACC's review body, Dispute Resolution Services Limited. It is to become an independent Crown entity on 1 July 2011.

28: Regulation 18 of the Injury Prevention, Rehabilitation, and Compensation (Liability to Pay or Contribute to Cost of Treatment) Regulations 2003.