Part 1: Introduction

Progress in delivering publicly funded scheduled services to patients.

1.1
In this Part, we explain:

Our approach to this topic

1.2
In March 2000, the then Government released its strategy to reduce waiting times for scheduled services – Reduced Waiting Times for Public Hospital Elective Services: Government Strategy (the Strategy). The Strategy set out proposed improvements to booking systems of district health boards (DHBs) and their management of scheduled services. The Strategy introduced maximum waiting times (of six months each) for scheduled specialist advice and treatment. DHBs continue to implement the Strategy.

1.3
During 2009 and 2010, we sought to understand how the Strategy was being carried out and the progress that had been made towards the Strategy's objectives. We have broadly assessed the public health sector's progress in implementing the Strategy. We did not specifically audit the performance of any of the DHBs, the Ministry of Health (the Ministry), or the Accident Compensation Corporation (ACC).

1.4
Appendix 1 sets out more details about our methodology. We have not adjusted the statistics that we report to account for population growth. The terms used in this report are explained in a Glossary at the end.

What scheduled services are

1.5
Broadly, there are two types of scheduled services for medical and surgical conditions:

  • specialist advice; and
  • treatment.

1.6
Patients can receive their care entirely in the public or private sectors. Alternatively, they can move between the public and private systems to get these services. They can receive their specialist advice (and any related diagnostic tests) from the public system and be treated privately, or the reverse.

1.7
A patient's primary care professional, such as a general practitioner (GP), optometrist, or dentist, can seek specialist advice. In the private sector, patients are sometimes able to see specialists without a referral – for example, for dermatology services. Specialists in one branch of medicine can refer patients to specialists in another branch. Specialist advice can be delivered by telephone, electronically, or by letter and may or may not require the patient to attend an appointment with a specialist.

1.8
GPs can ask for specialist advice to:

  • reach or confirm a diagnosis;
  • get the patient access to a diagnostic test that the GP is not allowed to order; or
  • check that the current treatment regime is the best one for the patient.

1.9
GPs can also ask a specialist to take over the patient's care until the patient can be safely returned to the GP's care.

1.10
Treatment can be recommended or offered to a patient when a specialist considers that it would improve the patient's quality of life – by reducing pain or discomfort, improving independence, or increasing the patient's ability to engage in the activities of daily life – or life expectancy. Treatment can be provided to the patient in an out-patient, day stay, or in-patient setting. Examples of common scheduled treatments are operations or procedures to:

  • treat cataracts;
  • insert tubes, called grommets, to treat recurring ear infections;
  • replace hip and knee joints affected by arthritis;
  • remove gallbladders, prostates, and uteruses;
  • repair hernias;
  • repair or unblock damaged blood vessels or arteries; and
  • relieve angina by using a blood vessel from the patient's chest or leg to bypass clogged heart arteries.

1.11
We found some disagreement about the importance of scheduled services. Some specialists and DHB staff consider that scheduled services are those that DHBs provide only after they have assigned funds to all other services.

1.12
In part, the Strategy was introduced because of a concern that some operations were difficult to get in public hospitals. Patients in some parts of the country were waiting too long and were very unwell before they were treated. Therefore, the Strategy was prepared in a political and policy environment that considered that scheduled services were an integral part of our public health system.

1.13
DHBs have some discretion about the mix of scheduled services that they fund and/or provide. In other instances, the Ministry sets targets for DHBs to provide a certain number of some operations, such as cataract and hip and knee replacement operations. Currently, a Health Target monitors DHBs' combined progress against the number of surgical procedures they must provide during a financial year. Since 2008, DHBs have been expected to increase the number of patients receiving scheduled surgery each year by an average of 4000 operations nationally. Only surgical operations, excluding dental operations, count towards this Health Target. Information about the Health Targets is available from www.moh.govt.nz.

Why scheduled services are important to the public

1.14
Internationally, the public, politicians, health departments, and bodies such as the Organisation for Economic Co-operation and Development consider that long waiting lists for publicly funded scheduled services suggest that a health system is performing poorly.

1.15
Public and political interest in the availability of these services is persistent in our country. More often than not, the main public and political concern is about the availability of scheduled surgery. News media stories regularly highlight problems with patients' access to specialist advice or waiting times for surgery.

1.16
The systems to provide scheduled services are complex, and scheduled services are not isolated from other health and disability services. A "bottleneck" in one part of the system can affect the delivery of scheduled services or whether patients can get some services. For example, until patients receive certain diagnostic tests, it can be difficult to know whether they need unscheduled or scheduled services – or no services at all.

1.17
Evidence about the effect of waiting for scheduled services is limited. Research findings tend to conclude that serious, irreversible, or catastrophic effects of waiting are rare but can occur if surgery for life-threatening conditions is delayed for significant periods of time.

1.18
Some evidence exists of deterioration in health while waiting for treatment for some conditions. While waiting for scheduled services, some patients may need unscheduled services for an exacerbation of their problem or for a new problem, such as a heart attack. If their scheduled treatment is delayed for too long, patients might:

  • lose their jobs and need a sickness benefit;
  • need publicly or privately funded home support services, or extra support from family;
  • suffer from side effects from pain, limited mobility, or medication that, in turn, need treatment or make recovery from surgery more difficult; or
  • experience disrupted social relationships.

How much is spent on publicly funded scheduled services

1.19
We estimate that about $1.23 billion was spent on publicly funded scheduled services in 2009/10. This comprised about $1 billion from the Ministry to DHBs and about $234 million from ACC to DHBs and private hospitals or surgeons.

1.20
Funding for scheduled services makes up about 7.7% of the Ministry's total funding to DHBs.

1.21
ACC has contracts with private hospitals and DHBs to deliver scheduled surgery. In 2009/10, it spent about $195 million (83% of its total spending) on scheduled services delivered in the private sector and about $39 million (17% of its total spending) on scheduled services delivered by DHBs. We discuss ACC's overall approach to scheduled services in more detail in Appendix 2.

1.22
From 2005 to 2007, 30% of all scheduled services were privately funded. Most of these patients were low risk (see paragraph 3.25).

The cost of not providing scheduled services

1.23
It is difficult to quantify the cumulative cost of not providing effective and efficient scheduled services. Good information is sometimes available about the cost of some ineffective or inefficient scheduled services, the cost of delaying surgery for too long, or the cost to the country of not publicly funding some types of surgery. For example, studies have calculated the benefits of replacing hip and knee joints or performing cataract operations earlier in a person's life.2

1.24
However, that is only some of the information that DHBs need to consider when deciding what proportion of their funding to allocate for scheduled services. The New Zealand Public Health and Disability Act 2000 (the Act) requires each DHB to regularly investigate, assess, and monitor the health status of its resident population, any factors that the DHB considers may adversely affect the health status of that population, and the needs of that population for services (see section 23(1)g of the Act).

2: For example, Fielden, Jann M et al (2005), "Waiting for hip arthroplasty: economic costs and health outcomes", The Journal of Arthroplasty, Vol. 20, No. 8, page 990-997.

page top