Appendix 7: Different understandings about active review

"Active review" is a category of patients within the National Booking and Reporting System. Patients in active review do not have enough priority to receive a commitment from the DHB for treatment, but there is a realistic probability that their condition will worsen to reach the threshold for treatment within two years. These are the patients who would next receive treatment if DHBs' capacity increased, which would mean that the threshold for treatment would be lowered.

We have found that DHBs – and specialties or service groups within DHBs – are not using active review as they are meant to. We consider that there is confusion about how active review should be used. In some instances, this has undermined the Strategy's principles and objectives.

Given the Ministry's definition of active review, in our view, it follows that there would always be a small number of patients in active review. However, some DHBs do not use active review. In other DHBs, only some specialties use active review.

Preventing misuse of active review

Some DHBs said that they wanted to prevent active review from being misused, so they have banned its use rather than manage its use responsibly. We consider that this may disadvantage some patients who may be more effectively and efficiently cared for specialists than GPs.

Lack of capacity in secondary care

Sometimes a DHB does not have the capacity to regularly review patients, so active review is not used in some specialties. Instead, the patient is returned to GP care and potential re-referral at a later date.

Shifting costs from secondary care to primary care

To manage their budgets and scheduled services effectively, some hospital managers prefer to shift the cost of reviewing patients to their (or the referring) DHB's primary care budget. Patients are returned to GP care and potential re-referral at a later date. When we asked, these managers did not know whether this practice was more or less effective or efficient for the patient or for the DHB overall.

When patients can be adequately managed in the community, they should be, and this is consistent with the Strategy's objectives. However, the main motivation for having GPs manage patients should not be to shift costs between different parts of a DHB's budget.

Managing compliance with Elective Services Patient-flow Indicators

Some DHBs put patients into active review even though they have no intention of reviewing them in six months – instead, they intend to treat them within six months. Putting patients in active review – when they should be given certainty of treatment within six months – gives the DHB up to 12 months to treat the patient instead of six months.

The logic behind this practice is that DHBs risk financial penalties when they exceed the Ministry's limits on the number of patients they are allowed to keep waiting for more than six months. One method of reducing this risk is to commit to treat only those patients who the DHB can treat within five or five-and-a-half months, instead of six. The DHB may hold the additional month's or half-month's worth of patients in active review as insurance against interruptions to service delivery that could affect compliance with ESPI 5. To some degree, the Ministry can use ESPI 3 to monitor whether DHBs are doing this. This practice clearly benefits the DHBs that use it. However, it does not meet the Strategy's requirement that patients be given certainty of treatment.

There are different perspectives on this practice. Some people consider that DHBs are manipulating the system, and others consider that DHBs' actions are a reasonable response to reduce financial risk. One DHB considers that active review was created for just this purpose, which surprised us. The DHB told us that one of the improvements in the last 10 years has been "the active review buffer [that] actively manages patients … [with the greatest need] and also offers booking flexibility". Patients with the greatest need should not be in active review – they should be treated as soon as possible and within six months.

Patients who are not medically ready for treatment

Some DHBs use active review to hold patients who are not yet ready for surgery – because they need to lose weight, bring their blood pressure under better control, or have a dental check before cardiac surgery. This is not the purpose of active review. DHBs need to use other methods to manage these patients.

Patients with no realistic chance of receiving publicly funded treatment

Active review is also used to hold patients who have no realistic chance of receiving publicly funded treatment within the next year. The extent to which this occurs has reduced since 2000 for various reasons, but we have been told that it still occurs.

Some specialists may wrongly put patients into active review instead of referring them back to their GPs because they hope that the DHB will be able to offer them treatment within six months by the time the patient is next reviewed. We consider that this is unlikely unless more resources become available or the DHB creates opportunities to treat more patients within the resources available by making significant efficiencies in the way that it delivers scheduled services. It is more likely that patients will be returned to their GPs' care after they have had the maximum three reviews that they are allowed.

Specialists who place patients in active review for the wrong reasons are more likely to be deferring the day when the patient is told that scheduled services are not available to them. The public health system needs patients to be responsible for their own health. A paternalistic approach, which may be kindly meant, is not helpful (even in the short term). It is not consistent with the Strategy's focus on providing patients with clarity and certainty.

It is also not in keeping with many patients' expectations that they will be dealt with fairly. The reluctance to give patients certainty denies patients the opportunity to make timely decisions about their own needs, means, and requirements for care. The specialist who incorrectly leads a patient to believe that they will receive publicly funded treatment by being in active review potentially stops the patient from actively seeking other available care. The specialist – and maybe the DHB – may also be at risk of breaching patients' rights, which are set out in the Code of Health and Disability Services Consumers' Rights.²⁹

The New Zealand Medical Association's Code of Ethics (2008) sets out the role of doctors in prioritising care. One of the four clauses on this topic (clause 65) states that:

Patients must be able to trust their doctor to deal with their needs fairly and honestly. Doctors should, within reason, provide adequate information to their patients about their assessment and available treatments, including those not readily available.

29: Health and Disability Commissioner, The Code of Health and Disability Services Consumers' Rights, www.hdc.org.nz.