Appendix 3: Changes in health care and society that increase demand for scheduled services

Progress in delivering publicly funded scheduled services to patients.

Expecting all new treatments to be available throughout the country may place a strain on publicly funded health services. When they are first introduced, new treatments and techniques commonly cost more than the treatments they replace. Sometimes, more staff are needed to deliver the new treatment and maintain new equipment.

Some procedures and surgery can become cheaper when performed as day-cases instead of bringing patients into hospital to stay overnight. These opportunities tend to be taken up cautiously because of fears that the quality of care could decrease. By the time the cost to treat an individual patient is reduced, more people want the treatment, which means that the total cost to the public health system may not decrease.

Figure 18 gives examples of improvements in health care that increased the demand for, and cost of, scheduled services and improved people's quality of life and/or the length of their life.

Figure 18
Examples of advances in health care that have increased the demand for scheduled services

Health condition Brief description of changes
Heart disease Since the 1960s, a range of new treatments has been introduced to care for patients with heart disease, such as angioplasty and heart valve surgery. Over time, when the whole-of-life costs and benefits are considered, the techniques have become more effective and more cost-effective compared to traditional conservative techniques.

The overall cost of treatment has risen as the population ages and expects more aggressive management of heart disease with better outcomes.
Gallbladder disease These days, surgeons commonly remove gallbladders using a laparoscopic (or keyhole) technique instead of traditional abdominal surgery. The patient recovers more quickly from the laparoscopic technique (which has fewer adverse side effects, such as infection) and is discharged from hospital sooner.

However, more expensive equipment (with cameras and screens) is needed to perform laparoscopic procedures. Sometimes, operating theatres may need to be larger to accommodate the extra equipment used in this and other laparoscopic procedures, so that staff can work safely.

Nevertheless, this is another example where there are better patient outcomes and reduced overall costs. This means that more people can safely have this surgery instead of having their condition managed conservatively.
Wet macular degeneration Wet macular degeneration is an eye condition caused by the growth of abnormal blood vessels, which can leak. The leaks cause the retina to lift away from the eye wall, causing swelling and decreased central vision. Until recently, there was no treatment for this condition, which affects relatively few people.

A treatment is now available, and success depends on prompt intervention. A drug can be injected into the back of the eye, and these injections are delivered six-weekly in an operating theatre and involve follow-up visits to hospital after each treatment.

Although fewer people are affected, providing this treatment reduces costs elsewhere in the health and disability system, the non-government organisation sector, and the welfare system that would be incurred if the patient lost their sight.

How changes in health care affect how scheduled services are accounted for

As medical knowledge becomes more reliable and codified, the places where scheduled services are provided can change because it is possible for a wider group of health professionals to provide high quality and safe scheduled services. Some scheduled services move from hospital to primary care, but the reverse can also occur if high-cost technology is needed to treat conditions that were previously untreatable. New methods of caring for patients can increase timely access to scheduled services, but can cause problems in accounting for this care.

Traditionally, health services have accounted for improvements by counting the number of patients:

  • seen at a first specialist assessment rather than the number of patients who got access to specialist advice; and
  • operated on rather than the number of patients who did not need surgery because effective non-surgical care had been provided.

These statistics can be used to produce standardised intervention rates for different population sizes. Intervention rates can be used to assess whether access to scheduled services is adequate. However, the intervention rate will be low for conditions that have been prevented by good public health and primary health care, or are well managed in primary health care. Therefore, a comprehensive knowledge of a DHB's population is needed before assuming that a low intervention rate indicates poor access to scheduled services. Also, the smaller the size of the population, the less likely it is that the standardised intervention rate will be reliable because the number of patients in each age group will be too small to produce statistically reliable results.

Sometimes, an assumption exists that the number of patients who are seen and treated should automatically keep up with population growth. Whether this is a useful measure depends on whether treatment methods have changed and whether the demographics of the population have changed. In this situation, a national standardised intervention rate would be more useful.

In contrast to most other countries, New Zealand's booking system could produce good information about whether the supply of scheduled services is meeting the needs of the population. This is because there is the potential to quantify the level of unmet need by measuring the gap – if any – between the threshold at which most people consider that patients should be treated and the threshold at which most patients receive publicly funded treatment.

The age profile of patients receiving scheduled services

In the past, a patient's older age might have restricted their access to surgery. Nowadays, a patient's frailty has more bearing on the assessment of their ability to benefit from treatment than their age.

We asked the Ministry to produce a report for us to show the ages of patients receiving scheduled surgery from 2005/06 to 2009/10. Figure 19 shows the ages of patients who received scheduled surgery in five-year age groups in each of these years. The data shows that the number of patients receiving surgery were stable or increased in most age groups and, from the age of 60 years, the number of patients receiving surgery increased faster than in younger age groups.

Figure 19
Number of patients receiving scheduled surgery, in five-year age bands, from 2005/06 to 2009/10

Number of patients receiving scheduled surgery, in fi ve-year age bands, from 2005/06 to 2009/10.

Data was extracted from the National Minimum Data Set on 31 August 2010. This is a dynamic data set, which means that the same information request may produce different results when data is extracted on different days. The data does not include patients who received scheduled medical or dental services or patients whose care was funded by ACC.

The effect of better management of long-term conditions

There is a view that better management of long-term conditions will lead to lower levels of unscheduled use of services and that this will release resources for scheduled services.

Others consider that this is not necessarily the case. They say that increased investment in primary health care and prevention may:

  • alter the purpose and timing of specialist assessment for a patient's condition;
  • delay, rather than prevent, a patient's need for scheduled surgery, which means that the person is older when they are treated; and
  • mean that patients live to an older age, which means that they live long enough to experience other health problems and may then need scheduled services.

Information and communication technologies

Improvements in information and communication technologies offer benefits for health care, but these projects can be difficult to introduce effectively and efficiently. They also need capital investment at the beginning, training for staff, and ongoing maintenance. Nevertheless, some DHBs have successfully introduced such technologies to improve the management of scheduled services.

Making faster progress in areas such as introducing telemedicine, electronic referrals from GPs to specialists or between specialists, and electronic clinical records has been complicated in most countries. In our country, factors complicating progress are the DHBs independently choosing products that may not easily communicate with each other, DHBs' priorities and financial position, and privacy concerns.

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