Part 4: Giving patients certainty

Progress in delivering publicly funded scheduled services to patients.

4.1
In this Part, we discuss the Ministry's and DHBs' progress in carrying out overlapping actions relevant to two of the Strategy's sub-strategies – giving patients certainty and increasing public confidence. The actions to achieve these sub-strategies are to:

communicate the intent of the scheduled services policy to the public;
adhere to minimum standards in timeliness and patient information; and
communicate which scheduled services the public system provides.

4.2
In assessing progress on these matters, we discuss:

communicating the Strategy's aims to the public;
telling patients about thresholds for access to scheduled services;
telling patients about waiting times for FSAs or treatment;
how DHBs ensure that individual patients receive specific information about scheduled services;
the number of patients who do not receive an FSA or treatment within six months;
how long patients who received scheduled services in 2009/10 waited for FSA and treatment;
improving waiting times for FSAs and treatment;
publishing reports about actual waiting times;
whether hidden waiting lists exist; and
whether transaction costs in the scheduled services system have reduced.

Communicating the Strategy's aims to the public

4.3
The Strategy said that one of the most critical failings of the traditional waiting-list system was that it did not provide basic information to patients, such as the expected waiting time, options for care, and who was responsible for their care at the various stages of the process. This lack of information was considered to have contributed greatly to the perception of poor service from the public health system.

4.4
In response to these concerns, the Strategy set out specific commitments in a pledge to patients. They are that patients:

will know within 10 working days of the DHB receiving the referral whether they will receive access to specialist advice or treatment;
will be given an FSA within six months of their referral being accepted;
will receive treatment within six months of it being offered; and
in active review (see Appendix 7) can receive up to three six-monthly clinical assessments.

4.5
The Ministry monitors DHBs' performance using Elective Services Patient-flow Indicators (or ESPIs). Figure 4 and Appendix 6 provide more detail about each of the ESPIs. The Ministry can impose financial penalties on DHBs when they do not meet the requirements imposed by the ESPIs.

4.6
General information about scheduled services needs to be easy to find. It needs to be up to date if patients and GPs are to have confidence in it. The Ministry has issued a series of brochures outlining what the public can expect when seeking publicly funded scheduled services. The current brochure was released in 2008 and is called A Guide to Elective Services at Public Hospitals. It is available on the Ministry's website (www.moh.govt.nz/electiveservices) in seven languages: English, Chinese, Cook Islands Māori, Korean, Māori, Samoan, and Tongan.

4.7
The Ministry has information about scheduled services on two websites. One is www.electiveservices.govt.nz. The other information is found by going to www.moh.govt.nz, finding Health Topics A-Z, and selecting "elective services". The Ministry's websites contain useful information about the Strategy, define technical terms, and provide a lot of information about the data that the Ministry uses to monitor the flow of patients through the scheduled services system. The Strategy is available from the Ministry's web page for publications released in 2000.

4.8
Both of the Ministry's websites need to be visited to find all of the information that is available about scheduled services. Some information is duplicated on the sites. Some information at www.electiveservices.govt.nz is out of date, and the date that each page was last updated is not recorded. For example, the "Innovative Ideas" web page has not been added to since 2004. We encourage the Ministry to consider consolidating the two websites into one and keeping the information up to date.

4.9
We visited all the DHBs' websites on 14 May 2010. Nine of 20 DHBs provided general or customised information about scheduled services on their websites or linked to the Ministry's relevant web pages. They were Auckland, Bay of Plenty, Hawke's Bay, Hutt Valley, Lakes, MidCentral, Nelson Marlborough, Northland, and Taranaki DHBs.

4.10
We encourage all DHBs to make better use of existing information about scheduled services on the Ministry's website(s) by providing the relevant link(s) on their own websites. We suggest that all DHBs link to the Ministry's elective services website and publish an overview of how their DHB manages scheduled services.

4.11
In our view, DHBs should also briefly explain how they receive and manage referrals (such as by a central booking office or other means) and how patients can find out what is happening with their referral.

4.12
Anecdotally, we found that members of the public broadly know that:

a referral from their GP to a hospital to see a specialist does not mean they will always receive an appointment;
seeing a specialist is no guarantee of receiving publicly funded surgery; and
a promise of an appointment or treatment within six months is not a guarantee that either will occur within that period.

4.13
This indicates that members of the public understand that they are not entitled to scheduled services unless their health needs meet certain thresholds, even if they are not always happy about it. We found that people often distrusted their DHB's performance. They were not confident that they or a family member would be dealt with fairly or in a timely manner. We found that people tended to assume that scheduled services would not be available more than they assumed that they would be. As a result, people were anxious about how they would be dealt with if they needed scheduled services.

4.14
Some people told us they were frustrated that, when they visited a GP to discuss a problem, the first question asked of them when considering referral for specialist advice was often "Do you have health insurance?" Even if they had health insurance, they would incur some expenses because only some costs would be reimbursed. They may also need to get advance approval, which some people considered stressful. Some people we spoke to wanted GPs to give them the option of using publicly funded scheduled services first.

Telling patients about thresholds for access to scheduled services

4.15
Under the Strategy, patients are meant to know which scheduled services the public health system provides. In practical terms, this means that patients would know whether they meet a DHB's threshold for access to FSAs and treatment.

4.16
We consider that it is reasonable for DHBs to make this information available to patients through their GP or specialist. The referral guidelines are often technical documents that need to be interpreted by a health professional, which means that there is little value for patients in DHBs publishing the guidelines on their websites. Many DHBs have prepared these guidelines and might have involved GPs' representatives. We found that DHBs' practices vary. For example:

Some DHBs have prepared referral guidelines for some specialties and not others.
One DHB started to distribute referral guidelines to its GPs only in 2010.
One DHB does not distribute referral guidelines unless a GP asks for them. The GPs in this district need to know whether the specialists have updated the guidelines before they can ask for them.

4.17
Some DHBs told us that referral patterns do not necessarily change even when referral guidelines are updated. They said that sometimes GPs hold off making referrals or refer patients privately because they assume that access to a service is difficult. Or they make referrals when access has been reduced. Other DHBs tell us that GPs are more likely to make appropriate referrals when the DHB has distributed good quality referral guidelines that are easy for GPs to access and use and that are up to date. DHBs need to be consistent to retain GPs' confidence.

4.18
The way that the Strategy has been carried out means that the thresholds for scheduled services may need to alter in response to changes in DHBs' capacity and funding. DHBs risk becoming noncompliant with ESPI 3 if they change the thresholds too fast. DHBs also risk becoming noncompliant with ESPI 2 or ESPI 5 if they do not change their thresholds to respond to changes in capacity.

4.19
Overall, it appears that changes to thresholds in each specialty occur infrequently, maybe once or twice a year. This relatively slow pace of change means that the administrative and consultation costs of keeping the public or GPs up to date about the thresholds for access to each specialty should be relatively low. Nevertheless, few DHBs have this information on their websites (see paragraph 4.20), and some do not provide GPs with this information (see paragraph 4.16). We consider that up-to-date referral guidelines should include thresholds for access and routinely be made available to GPs.

Telling patients about waiting times for first specialist assessments or treatment

4.20
On 14 May 2010, we visited all DHBs' websites to find out what information they provided about estimated waiting times for FSAs and scheduled treatment. Five DHBs published information about waiting times for FSAs – they were Bay of Plenty, Counties Manukau, MidCentral, Southern, and Taranaki DHBs. Two DHBs published information about waiting times for scheduled surgery – they were Bay of Plenty and Hawke's Bay DHBs.

4.21
Most of the information was intended for GPs' use. As a result, the information was usually in technical language and placed on the web pages for primary care providers. We consider that this is reasonable (see paragraph 4.16).

Ensuring that patients receive specific information about scheduled services

4.22
Under the Strategy, patients are meant to receive information about whether they would receive publicly funded treatment, their maximum waiting time, their likely booking date, the date they would be next assessed or reviewed, their care or treatment options, who to contact if there was a problem, and whether they have joint care plans. We discuss each of these in turn.

4.23
Our comments are based on information from the Ministry and some of the DHBs we visited, but not from every specialty within those DHBs. We have no reason to believe that these specialties and DHBs are significantly different from any others.

4.24
The Ministry has produced and distributed Generic Requirements for Patient Letters, to help ensure that communication with patients complies with the Strategy. The Generic Requirements for Patient Letters sets out the minimum requirements for letters that are commonly sent to patients seeking or receiving scheduled services. These requirements are not always followed. We encourage DHBs to occasionally check that the standardised letters used in each specialty, and the letters sent to patients, comply with the Ministry's requirements.

Telling individual patients whether their referral has been accepted

4.25
Under the Strategy, patients are meant to know whether their referral has been accepted.

4.26
The Ministry told us that it last audited the letters that DHBs sent to patients in 2006, in part because some patients were told that their referral had been received but not whether it had been accepted. The Ministry considers that DHBs' practices improved after it released the generic requirements. We saw copies of letters that told patients their referral had been accepted.

Giving GPs advice when referrals are declined

4.27
In 2009, the report of a Ministerial Review Group said:

New Zealand has for a long time been open with the public and explained when specialist interventional needs cannot be met within existing capacity. This … increase[s] the responsibilities of primary care practitioners, who must support those patients who do not meet local access criteria. This is a further opportunity for closer hospital/primary linkages in developing good supportive information and care pathways for these patients in primary care. Initiatives already exist in this area, but should now be accelerated.⁶

4.28
DHBs are meant to provide GPs with management guidelines to support them to manage the patient's care and review or reassess their condition as appropriate.⁷ We are aware that DHBs return some referrals to GPs without providing advice to the GP about the patient's care. We did not audit the extent to which DHBs do not provide such advice, but our experience suggests that this is likely to occur in most DHBs. The likelihood that referrals will be returned without advice increases when any referral guidelines are not followed.

4.29
The methods that DHBs and specialties use to assess referrals for specialist advice and/or an FSA influence whether referrals are declined without advice (see paragraphs 5.7-5.13).

4.30
Even though advice specific to an individual patient may not be provided, some DHBs may refer GPs to generic or DHB-specific advice about the patient's condition that is provided on a website. For example:

Healthpoint at www.healthpoint.co.nz (used by Auckland, Capital and Coast, Counties Manukau, Northland, and Waitemata DHBs) has a website for the public's use and a secure website for the DHBs' and GPs' use.
Health Pathways at www.healthpathways.org.nz is a website specific to Canterbury DHB, which does not have a public component.
The New Zealand Guidelines Group publishes guidelines on its website (www.nzgg.org.nz) or, if appropriate, on a specific website, such as the Autism Spectrum Disorder website (www.asdguideline.com).

4.31
Methods such as these are replacing the guidelines for managing patients with low-priority common health conditions that were introduced in the early years of the Strategy's implementation. GPs and DHBs told us that the early guidelines were a useful and well-used resource. They are no longer available from the Ministry's website, because the Ministry considers that they may be out of date (see paragraph 5.15). The guidelines were introduced without any process or funding for keeping them up to date. We were told that there are no plans to update them. Partly because of this, the DHBs have to create their own guidance for specialists and GPs to use.

Knowing whether GPs have asked for specialist advice or an FSA

4.32
We expected that patients would not be scheduled for an FSA unless it was necessary. Sometimes, patients are scheduled for an FSA by mistake because it was not clear to the DHB that a GP meant to ask only for specialist advice or a virtual FSA. Unclear requests can delay matters for that individual patient but can also prevent other patients from accessing scheduled services.⁸

4.33
Northland DHB told other DHBs that it addressed this problem by introducing an electronic generic referral form for GPs to use. The new form makes GPs choose between referral for an FSA and referral for advice. Before the form was introduced, 75% of referrals had no clear reason for the referral. Half of the referrals did not include the results of diagnostic tests that would have influenced the decision to offer the patient an FSA. The DHB says that the new form has reduced the length of time it takes to accept or book patients for an FSA.

4.34
Northland DHB reported that the GPs using the system were pleased with it. It is easy to use, and the GPs are now able to send a much higher proportion of referrals to the DHB during the business day instead of after hours. By March 2011, 90% of GP referrals were electronic. The DHB considers that this high rate has been achieved because the health professionals who use the system were involved in its planning and development.

4.35
When access to health services is rationed, the systems that DHBs use to identify which referrals need a virtual FSA, an FSA, or other specialist advice must be effective and efficient. We understand that about 20% of the DHBs have, or are introducing, systems to identify the purpose of a referral so that it can be dealt with effectively and efficiently. (Northland's system was based on Hutt Valley DHB's earlier experience. Canterbury DHB started phasing in a separate electronic referral management system during 2010.) GPs told us they are pleased that virtual FSAs have improved access to specialist advice that might not otherwise have been available.

4.36
The benefits of a generic electronic referral form (or forms, if needed) do not appear to be in dispute. This approach can improve scheduled services' effectiveness and efficiency because it reduces the amount of wasted time and the likelihood that patients will be incorrectly denied access to scheduled services.

4.37
Given the obvious benefits reported by Northland DHB (and Hutt Valley DHB before it), we expect all DHBs to take steps to introduce such a system. These systems should be DHB-wide – that is, when DHBs have more than one hospital, the system should receive and respond to referrals using the same processes and criteria so that decisions about access are consistent throughout the DHB. This has not always been the case, and we know that one DHB is consolidating its booking systems.

4.38
Staff from other DHBs told us that they would like to introduce such a system. But they were daunted because they perceived that each DHB needed to separately prepare a business case and buy a suitable system.

4.39
We are concerned at the potential for unnecessarily duplicating the costs of creating and operating these systems. To reduce the total cost to the country, we expect most – if not all – of the DHBs to agree to jointly procure such a system and implement it within their districts.

Ensuring that individual patients with priority are given a commitment to treatment

4.40
Some patients' priority scores meet or exceed the DHBs' thresholds for treatment, but – for whatever reason – they are not given a commitment to treatment within six months. All patients with priority scores that meet or exceed the threshold are meant to be given a commitment to treatment. ESPI 3 monitors the number of these patients for surgical specialties only. We suggest that a more complete assessment would include medical patients.

4.41
Figure 2 shows results for ESPI 3 for the year ending 30 June 2010. All the DHBs had some patients awaiting treatment who should have been given a commitment to treatment within six months but were not.

Figure 2
DHBs' performance in giving certainty of treatment to patients who meet the threshold, for 2009/10

Patient-flow Indicator	Variation allowed	Results for 2009/10
ESPI 3 [Surgical] patients waiting without a commitment to treatment whose priorities are higher than the [DHB's minimum] treatment threshold.	The goal is to have no patients in this category. A small variation of 5% is allowed before a financial penalty is imposed.	All of the DHBs were within the compliance standard, but only two DHBs achieved the goal of having no patients waiting for a commitment. West Coast DHB achieved it in 11 months of the year and Tairawhiti in seven months. DHBs met the goal of no patients waiting without a commitment to treatment on 34 of 252 occasions (21 DHBs x 12 months), which is about 14% of the time. At the end of each month, the number of patients waiting without commitment to treatment ranged from 662 to 1093, and the average was 843.

Data extracted from the National Booking and Reporting System on 2 August 2010.

4.42
We are concerned that patients given priority scores high enough to qualify for treatment were not given a commitment to treatment within six months. We do not know whether these patients were told that they had qualified for treatment. We do not know how DHBs deal with these patients or why commitments were not given.

4.43
In our view, it is not fair – or in keeping with the Strategy – for DHBs to treat patients who have the same priority scores differently by offering to treat some and not others.

Telling patients about maximum waiting times for FSAs and treatment

4.44
DHBs are meant to tell patients that the maximum time they will wait for an FSA or for treatment is six months. We found that this routinely occurs.

Giving patients a likely date for an FSA or treatment

4.45
The Strategy intended that patients should be given information about a likely date for an FSA or treatment. DHBs have this information because they need it to manage their booking systems. We did not see any letters giving this information.

4.46
Some DHBs told patients who had been offered scheduled services but were not yet booked that surgery was available at a private hospital at a cost to the patient. The DHB asked the patient to tell the DHB if they chose to have surgery privately, so that their name could be removed from the DHB's treatment list. It is appropriate that DHBs tell patients that surgery may be available in the private sector. However, we are concerned that DHBs provided this information without also indicating when the DHB was likely to provide treatment.

Arranging a booking date for an FSA or treatment

4.47
A fundamental element of the Strategy is that patients will be booked for FSAs and treatment – and that this occurs, even when patients are booked at short notice.

4.48
When booking FSAs, instead of sending patients a date and time of the DHB's choosing, some services in some DHBs invite patients to book appointments for days and times that suit them. The problems that Hutt Valley DHB overcame by introducing such a system are documented in Targeting More Elective Operations.⁹ Other DHBs have had similar success. We consider that all DHBs should adopt or adapt these initiatives to make the best use of out-patient clinic sessions.

Telling untreated patients when they will be reassessed and who to contact if there are problems

4.49
Patients in active review (see Appendix 7) are to have their health status and priority score reassessed every six months. These patients could be assessed more frequently, but this is seldom necessary. We found that there was confusion about how active review should be used. This has resulted, in some instances, in the Strategy's principles and objectives being undermined. We discuss these issues in more detail in Appendix 7.

4.50
We found that patients were told who to contact if their condition worsened before their next assessment or appointment, or if there was a problem with their appointment for an FSA and/or treatment. Patients were also told who was responsible for their care while they were waiting for an FSA or treatment. This was usually their GP.

Preparing joint hospital and community care plans for patients

4.51
Under the Strategy, information given to patients is meant to be part of a clear, patient-centred care plan, which community and hospital providers will jointly maintain. The Strategy did not define a care plan, although it is clear that the premise was that a GP and specialist would work in a co-ordinated way to care for a patient.

4.52
We consider that information and responsibility for a patient's care is exchanged between community and hospital providers in a similar way to how a baton is passed between relay runners; two parties are involved, but only one is in charge at a time. As in a relay race, risk (in this case, to the patient's continuity of care) increases when the baton is passed from one party to the next.

4.53
In our view, effective co-ordination is more likely when community and hospital staff (in one or more DHBs) can care for patients using agreed care pathways or protocols and a single clinical record that can be shared – at least at a summary level – by all health professionals involved in caring for a patient.

4.54
One DHB told us that it was concerned about inconsistent sharing of information between multiple providers. We understand that other DHBs have this concern.

4.55
We have not recommended introducing integrated clinical records, because it is not within the scope of this report. Nevertheless, we want to register our concern that patient information is fragmented within DHBs and between DHBs. We consider that this situation unnecessarily increases the risk to patients' safety because relevant information is not always easily available.

The number of patients who do not receive a first specialist assessment or treatment within six months

4.56
From 2000, DHBs were to ensure that patients did not wait more than six months for an FSA or treatment. DHBs were to achieve this by introducing prioritisation and improving their planning.

4.57
The Ministry provided us with trend data about the numbers of patients who had waited longer than six months for treatment and FSAs from 2001 to 2010. The data is for 30 June each year.

4.58
Figure 3 shows that DHBs made good progress in reducing the numbers of patients waiting longer than six months for an FSA up to 30 June 2007. During this period, DHBs reduced or eliminated their residual waiting lists (see paragraph 6.5, which explains what these lists were). Initially, the numbers of patients waiting longer than six months for treatment increased because more patients were seen at an FSA, which increased the demand for treatment. Since 2007, the rate of improvement in providing treatment within six months has slowed.

Figure 3
Patients waiting more than six months for a first specialist assessment or surgery, at 30 June, from 2001 to 2010

All data is from the National Booking and Reporting System. The Ministry does not know whether the data is accurate because it is supplied as a summary.

4.59
There is little doubt that the Ministry's insistence on compliance with the ESPIs is partly responsible for the relatively sharp decrease in the numbers of patients waiting longer than six months between 2006 and 2007. These numbers have not grown even though DHBs increased the scheduled services provided from 2007 to 2010 (see Figure 17). But it is also clear that, despite improvements in ESPI compliance, further improvements have proved difficult.

4.60
We examined the ESPI results for 2009/10. Figure 4 reports these results and compares them with trends for June over five years. There is more variation from month to month than an annual snapshot shows. At the end of each month:

3500 to 5500 patients did not get their FSA within six months (compared with 3462 at 30 June 2010); and
2700 to 3600 patients were not treated within six months (compared with 3520 at 30 June 2010).

4.61
At the end of each month, 6200 to 9100 patients had waited longer than six months for a service that they were told to expect within six months. We discuss how long patients wait for treatment in paragraphs 4.63-4.66.

Figure 4
DHBs' performance each month against maximum waiting times, for 2009/10

Patient-flow Indicator	Percentage of patients who are made to wait more than six months	Results for 2009/10
ESPI 1 DHB services that appropriately acknowledge and process all patient referrals within 10 working days.	All DHBs must fully comply with this indicator. However, a small variation is allowed before DHBs attract a financial penalty.	All DHBs complied, except: Hawke's Bay DHB in July 2009, when five of its 17 services did not comply; and Southland DHB in June 2010, when one of its 26 services did not comply.
ESPI 2 Patients waiting longer than six months for their first specialist assessment.	From the August 2010 ESPI results, DHBs are allowed to keep up to 1.5% of patients waiting for an FSA waiting more than six months before attracting a financial penalty.* This means that smaller DHBs are allowed fewer patients waiting more than six months than larger DHBs. As DHBs' contracted number of FSAs increases, the number of patients making up the 1.5% also increases.	No DHB ensured that all patients saw a specialist within six months. The total number of patients not seen on time each month ranged from 5542 to 3462. The level of acceptable variation was exceeded nine times by seven DHBs: Auckland, Capital and Coast, Lakes, Southland, and Waitemata once each; and Tairawhiti and Wairarapa twice each.
ESPI 5 Patients given a commitment to treatment but not treated within six months.	From the August 2010 ESPI results, DHBs are allowed to keep up to 4% of patients waiting for treatment waiting more than six months before attracting a financial penalty.** This means that smaller DHBs are allowed to have fewer patients waiting than larger DHBs. As DHBs' targets for the number of patients to be treated increase, the number of patients who make up the 4% also increases.	None of the DHBs ensured that all patients were treated within six months. The total number of patients not seen on time each month ranged from 2763 to 3662. South Canterbury DHB exceeded the level of acceptable variation in two months.
ESPI 6 Patients in active review who have not received a clinical assessment within the last six months.	A larger variation (up to 15% of all patients in active review) is allowed before DHBs could attract a financial penalty.	Of the DHBs using active review, none of them ensured that all patients were assessed on time. The total number of patients not seen on time each month ranged from 177 to 297 and the average was about 216. The level of acceptable variation was exceeded in nine months by MidCentral Health DHB and in one month by Hutt Valley DHB.

Data is from the National Booking and Reporting System as at 31 July 2010.

* The calculation is "patients waiting more than six months" divided by "patients seen (from National Booking and Reporting System) in the previous 12 months".

** The calculation is "patients waiting more than six months" divided by "patients exited treated (from National Booking and Reporting System) in the previous 12 months".

4.62
The ESPIs are "patient flow" indicators, but they do not report patients' actual waiting times. Information about waiting times is collected but not publicly reported.

How long patients wait for a first specialist assessment

4.63
The Ministry's information about waiting times for an FSA is confined to whether FSAs are provided before or after six months. (More detailed data was collected from August 2000 to 1 July 2006. However, DHBs took different approaches to what they reported, which meant that the data could not be compared. The data is no longer collected.)

4.64
We report on a snapshot of DHBs' performance for the month of June from 2006 to 2010 in Figures 5 and 6. In June each year, most patients who attended an FSA received it within six months:

In 2006, the proportion of patients seen in June who were seen within six months was 78% for surgical patients and 82% for medical patients.
In 2010, the proportion of patients seen in June who were seen within six months was 89% for surgical patients and 93% for medical patients.
Since 2007, performance has stabilised at 87%-91% for surgical patients and 90%-93% for medical patients.

Figure 5
Number of patients receiving a surgical first specialist assessment within and after six months, for June, from 2006 to 2010

Data extracted from the National Booking and Reporting System on 29 March 2011. All patients had been given a commitment to services. We selected trend data for one month to ensure consistency from year to year. The pattern of service delivery changes throughout the year. However, whichever month is chosen, we expect the trends to be similar.

Figure 6
Number of patients receiving a medical first specialist assessment within and after six months, for June, from 2006 to 2010

How long patients wait for treatment

4.65
Information about actual waiting times for treatment is collected but not publicly reported. In Figures 7 and 8, we report on a snapshot of DHBs' performance for the month of June from 2006 to 2010. The number of patients who were treated increased during this period, and most patients were treated within four to six months:

From 2008 to 2010, 89% or 90% of surgical patients were treated within six months.
From June 2008, 95% or 96% of medical patients were treated within six months.¹⁰

4.66
The total number of patients who had waited longer than six months for treatment did not significantly change. However, the pattern of when patients were treated did change. By 2010, fewer patients had waited longer than nine months. An increasing number of surgical patients were treated in six to nine months, which DHBs need to address.

Figure 7
Time taken for all DHBs to treat patients waiting for surgery, for June, from 2006 to 2010

Data extracted from the National Booking and Reporting System on 31 July 2010. All patients had been given a commitment to treatment. We selected trend data for one month to ensure consistency from year to year. The pattern of service delivery changes throughout the year – for example, less surgery is generally done in January. However, whichever month is chosen, we expect the trends to be similar.

Figure 8
Time taken for all DHBs to treat patients waiting for medical procedures, for June, from 2006 to 2010

Improving waiting times for first specialist assessments and treatment

4.67
In March and July 2010, the Ministry wrote to DHBs asking them to reduce the number of people waiting more than six months for FSAs and treatment. From August 2010, the accepted maximum deviation from the commitment to provide scheduled services within six months was reduced from 2% to 1.5% for FSAs and from 5% to 4% for treatment. DHBs were not to comply with the new thresholds by removing patients from waiting lists after they had been offered scheduled services. The Ministry also told DHBs that further reductions could occur.

4.68
The Ministry made the change to manage the fact that, as the quantity of scheduled services increases, so too will the number of individual patients "allowed" to wait longer than six months. For example, if 110,000 patients were treated in a year and the maximum deviation was 5%, the number of patients "allowed" to wait longer than six months would be 5500. However, if the number of patients treated in a year increased to 140,000 and the maximum deviation remained at 5%, the number of patients "allowed" to wait longer than six months would be 6500.

Publishing reports about actual waiting times

4.69
ESPIs for patients waiting more than six months for an FSA or treatment are relatively easy to report in consolidated statistical tables for the 20 DHBs. The benefit of these reports is that they readily allow comparison between DHBs, which helps the Ministry to monitor an individual DHB's performance and to examine long-term trends. However, we consider that the ESPI tables have limited value in clearly communicating DHBs' overall performance to patients, GPs, and the public.

4.70
In paragraph 4.13, we commented that people seemed to distrust their DHB's performance. In our view, Figures 5-8 give a richer understanding of how well the DHBs are doing, despite giving trends for only one month of each year. We consider that the public's perception of DHBs' performance would improve if such reports were available. The reports give credit where it is due and also show where further improvement is needed.

4.71
Some DHBs and the Ministry have told us that they consider that they have done well to restrict the numbers of patients waiting longer than six months for scheduled services at the same time as increasing the quantity of scheduled services provided. Extra funding and the threat of financial penalties for non-compliance with ESPI requirements have helped with this.

4.72
We do not underestimate the efforts that DHBs have made in the last 10 years to remove the backlog of patients waiting for scheduled services (see Part 5) and to introduce and improve their booking systems. Nevertheless, six months – and not any longer period – is the maximum length of time that patients are meant to wait for scheduled services that they have been offered. Patients with high health needs and ability to benefit from treatment should not wait that long. They should be treated much more quickly.

4.73
Looking ahead to the next 10 years, we encourage the Ministry and DHBs to consider introducing methods of reporting on the total time taken for patients to progress through care pathways, instead of using only the "snapshot" approach of waiting times for specific events, such as an FSA and treatment. We anticipate that reports of this type would be confined to selected "key marker" pathways, such as pathways that all DHBs commonly provide or where there is concern about waiting times.

Do hidden waiting lists exist?

4.74
We sometimes discussed with DHBs and others whether DHBs have "hidden" waiting lists. This term is not defined, but we have heard it used when someone considers that the number of patients waiting more than six months for treatment may be larger than is reported to the Ministry in the National Booking and Reporting System. We did not find any evidence of "hidden" waiting lists.

Reducing transaction costs in the scheduled services system

4.75
Increased confidence in the booking system was expected to reduce transaction costs. The intention was that GPs would make just-in-time referrals rather than using multiple referrals, letters, and telephone calls to get patients timely access to scheduled services.

4.76
We consider that transaction costs for a patient who has a straightforward passage through the scheduled services system are less than they would have been under the former waiting list and booking systems.

4.77
However, we consider that transaction costs are unlikely to have reduced where:

DHBs have not released clear referral guidelines;
DHBs have not prepared and introduced care pathways that cross community and hospital boundaries; and
specialists and GPs are not frank with patients about the likelihood of the patient getting access to publicly funded treatment.

6: Ministerial Review Group (31 July 2009), Meeting the Challenge: Enhancing Sustainability and the Patient and Consumer Experience within the Current Legislative Framework for Health and Disability Services in New Zealand, Annex 2, page 11, www.beehive.govt.nz.

7: Ministry of Health (2010), 2010/11 Operational Policy Framework, page 69, paragraph 4.20.2.c, www.nsfl.health.govt.nz.

8: The elements of a good referral and booking process are set out in Making Our Hospitals Safer: Serious and Sentinel Events 2009/2010 (November 2010), which was published by the Health Quality and Safety Commission New Zealand.

9: The Ministry released this publication in March 2011. It is available from www.moh.govt.nz.

10: The data may overstate DHBs' performance because some patients whose treatment is postponed after they have been admitted to hospital may be re-entered into the National Booking and Reporting System as a new patient. By December 2010, all DHBs had made changes to prevent this occurring.

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