Summary of progress against the Strategy's main objectives

This is a summary of progress towards achieving the main objectives of the government strategy Reduced Waiting Times for Public Hospital Elective Services: Government Strategy (the Strategy). This summary highlights where further progress is needed. It is not a full summary of our report, and readers with more time should read the whole report.

The Strategy's main objectives are to ensure:

• that patients wait no more than six months for their first assessment with a specialist (first specialist assessment, or FSA);
• that all patients with a level of need that can be met within the resources (funding) available are provided with surgery within six months of assessment;
• a level of publicly funded service that ensures access to scheduled services before patients reach a state of unreasonable distress, ill health, and/or incapacity; and
• national equity of access to scheduled services, which means that patients with a similar level of health need and ability to benefit from treatment have similar access to scheduled services, regardless of where they live.

Waiting times for first specialist assessment and treatment

At the end of June 2003, there were 36,190 patients still waiting for an FSA or treatment that they should have received within six months. District health boards (DHBs) made relatively fast progress in reducing these numbers. By 30 June 2007, this figure was 7688. Since then, progress has slowed.

At the end of June 2010, there were 6821 patients who had not yet received scheduled services that they should have received within six months (see Figure 3). At the end of each month during 2009/10, between 3500 and 5500 patients had not received their FSA within six months, and between 2700 and 3600 had not been treated within six months (see paragraph 4.60).

Of the patients seen and treated in June 2010:

• 89% of surgical patients received an FSA within six months (see Figure 5);
• 93% of medical patients received an FSA within six months (see Figure 6);
• 89% of surgical patients were treated within six months (see paragraph 4.65 and Figure 7); and
• 95% of medical patients were treated within six months (see paragraph 4.65 and Figure 8).

From 2006 to 2010, most patients who received treatment in June of each year were treated within four months. By June 2010, fewer patients had waited longer than nine months before receiving treatment (see Figures 7 and 8).

The Strategy's implementation has provided increasing certainty that, as a group, patients who are offered scheduled services will receive them within six months. This is an improvement on the waiting list system and early booking systems that the Strategy replaced. That 89% to 95% of patients received scheduled services within six months is a good result compared to the past situation. However, under the Strategy, each individual patient is meant to wait no more than six months for an FSA or treatment. The results for June 2010 mean that 10% of patients did not receive scheduled services within six months.

DHBs need to improve their ability to match the number of patients accepted for scheduled services to their resources. We expect DHBs to achieve this by making scheduled services more effective and efficient (or by increasing resources used for scheduled services) rather than by raising the thresholds for access to scheduled services. In Part 4, we suggest some improvements that DHBs could make.

We consider that the public's perception of the DHBs' performance would be improved if DHBs took a different approach to publicly reporting on their progress. We consider that our approach in Figures 5-8 gives DHBs credit for good performance and shows where there are any emerging or increasing problems. For example, Figure 7 indicates that, from 2006 to 2010, fewer patients waited longer than nine months for treatment, but an increasing number were treated in six to nine months.

National equity of access to scheduled services

National equity of access to scheduled services means that patients with a similar level of need and ability to benefit from treatment will have similar access to scheduled services, regardless of where they live. Two sets of national tools were considered necessary to implement the Strategy – selection (sometimes called triaging) tools to decide which patients would get an FSA within six months and prioritisation tools to decide which patients had priority for treatment within six months.

Access to an FSA

We found that patients are selected for an FSA using three main methods. Two of these methods are likely to achieve consistency within the DHB even if selection tools are not used (see paragraphs 5.7-5.13).

National selection tools are needed to achieve consistency throughout the country. To the best of our knowledge, there are currently no such up-to-date tools (see paragraphs 5.14-5.17). This means that specialists are using local tools or outdated national tools, which may not produce the same scores for patients in similar circumstances. As a result, we consider that it is unlikely that patients seeking an FSA are selected consistently throughout the country.

Access to treatment

Under the Strategy, national prioritisation tools are meant to ensure that each patient's level of health need and ability to benefit from treatment is assessed consistently throughout the country. There are 30 currently available national prioritisation tools, but they do not apply to all patients who are prioritised for scheduled services. Some of these tools are not of good quality and may not meet the Strategy's objectives.

DHBs also use local tools. Each DHB's version of these tools may not produce the same or similar priority scores for patients in similar circumstances. This means that access by priority score cannot be used to fairly compare thresholds for access to treatment between DHBs. We are also aware of practices within DHBs that have not changed in any material way since the Strategy was introduced (see paragraphs 5.32-5.34).

We consider that not all patients are consistently prioritised for treatment (see paragraph 5.36 and Figure 10). Without consistency in priority scores, the objectives of prioritisation (such as applying standard processes, defining levels of need, and ensuring similar access between specialties or procedures) are simply not achievable.

Treating patients in priority order

Once patients are allocated a priority score, they should be treated in priority order. Figure 9 shows how this is done for cardiac surgery patients. The principle is the same for all patients waiting for scheduled treatment. Figure 9 demonstrates that there is no problem in quickly treating patients with low scores as long as patients with higher scores are treated within a suitable period.

To test whether DHBs apply this principle in practice, we compared the results in 2006 and 2010 for patients in one DHB who had received cardiac, general gynaecology, and hip and knee replacement surgery. We expected that the graphs for 2010 (see Figures 12, 14, and 16) would show the pattern of treatment set out in Figure 9, but over six months. General gynaecology surgery came the closest (see Figure 14), but some patients had waited much longer than other patients with similar scores.

We are particularly concerned that problems with treating adult cardiac surgery patients in priority order are longstanding (see paragraphs 5.40-5.42). We consider that DHBs need to address this problem as soon as possible.

Improving progress

Some DHBs told us that progress towards achieving national equity had been slow and needed to improve. They raised doubts about the commitment to prioritisation. We consider that there have been muddled responsibilities for the life cycle of the prioritisation tools, which may have contributed to slow progress in this area (see paragraphs 5.56-5.65).

We consider that the specialists' professional groups should be responsible for:

• preparing, introducing, and using national access criteria for FSAs;
• preparing, introducing, and using a full suite of national tools to prioritise patients for treatment;
• ensuring that these tools are able to:
  • produce scores that reflect a patient's need and ability to benefit from treatment relative to other patients; and
  • produce scores that have a matching clinically appropriate treatment period (see paragraph 5.26-5.28); and
• analysing and/or auditing the results that the national tools produce so as to improve them (see paragraphs 5.53-5.55).

Increasing the supply of scheduled services to prevent unreasonable distress

Under the Strategy, patients are meant to receive scheduled services before they reach a state of unreasonable distress, ill health, and/or incapacity.

Before the Strategy was introduced, DHBs were to reduce the backlogs of patients waiting for an FSA and/or treatment and add no new patients to these lists. The backlogs had more than halved by the time the Strategy was introduced. They were finally cleared in 2006. DHBs achieved this at the same time as trying to ensure that newly referred patients were seen and/or treated within six months.

The number of surgical operations decreased in 2001/02 and 2002/03 before slowly increasing up to 2005/06. Since 2006/07, the number of operations has increased more quickly – partly as a result of increased funding (see Figure 17).

We agree that more work is needed to know whether increased scheduled services have reduced unmet need (see paragraph 5.56). If we had been able to fairly compare the priority scores at which patients got access to scheduled services, we might have been able to examine this matter in more detail and draw conclusions. Until this is possible, it is difficult to know whether:

• the patients who needed treatment the most were treated, regardless of where they live;
• patients were able to receive surgery before suffering unreasonable distress, ill health, and/or incapacity; and
• increases in the provision of treatment had occurred in the specialties or procedures where it was needed the most, regardless of where patients live.

In the meantime, the Ministry of Health (the Ministry) is using other means, such as standardised intervention rates, to help scheduled services keep up with changes in population demographics and population growth, and to remedy inequitable access between DHBs (see paragraphs 6.9-6.11).

Improving service delivery

Setting priorities

We found that one DHB's progress in improving scheduled services stalled while it waited for its neighbouring DHB(s) to catch up. This can be a problem when DHBs share a patient's care (see Appendix 4). We also observed that clever ideas and improvements in one DHB had not been taken up by other DHBs. The reasons for this are not entirely clear. Differing priorities are a contributing factor, as are each DHB's capacity and capability. Sometimes, a single DHB has found it difficult to improve its systems and methods entirely on its own. More could be achieved if DHBs shared some of the workload and costs.

Therefore, we suggest that the Ministry and DHBs agree on a set of priorities for better managing scheduled services and implement them in a series of five-year plans. For example, regional booking systems are needed to:

• effectively manage the care of patients whose care is delivered by more than one DHB;
• help DHBs to improve inter-regional equity; and
• make the best use of theatre time and the specialist workforce.

Having agreed a set of priorities, the Ministry would be in a position to advise the Government on how any proposed changes to scheduled services would affect the agreed priorities.

Care pathways

Even when DHBs are able to provide all FSAs and treatment on time, the value of this to each patient is undermined if their care "from start to finish" is delayed by inefficient service delivery.

Figure 1 details our understanding of how a patient who needs surgery moves through the scheduled services system. Applying this generic approach to patients with specific health needs produces a care pathway. Appendix 5 provides an example of a care pathway for patients needing a hip or knee replacement.

Care pathways enable DHBs to "join the dots" by bringing together the decisions and activities that make up scheduled services. Care pathways outline the care that the patient should receive and when, which means that care pathways cross traditional boundaries between community and hospital care. Care pathways can help to make the best use of available resources.

A few DHBs have introduced, or are planning to introduce, care pathways for some or all medical and surgical specialties. There is a real risk that 20 DHBs could produce 20 different sets of care pathways (and so different standards of clinical practice) for the same set of conditions, which would not be desirable. DHBs are responsible for the quality of care that they deliver, and we expect them to want that care to be of a consistently high standard throughout the country. We also consider that such duplication would be a waste of public funds and scarce clinical resources.

Diagnostic tests

The Strategy discussed services to provide access to diagnostic tests in its description of problems with waiting lists for scheduled services. Getting access to a test at the right time is useful in determining whether or how quickly patients should be seen by a specialist or treated.¹ Protocols to implement care pathways would set out whether diagnostic tests could be requested by the GP directly or by the specialist after an FSA or virtual FSA.

We understand that improved access to diagnostic tests by GPs is being dealt with as part of the Better Sooner More Convenient initiative in primary health care. However, specialists also need timely access to diagnostic tests from their Home DHB and/or Treating DHBs. We consider that there is a risk that access to diagnostic test services will further fragment unless access criteria are based on patient need rather than who orders the test.

1: In December 2008, the Royal New Zealand College of General Practitioners estimated that one in five patients waiting for an FSA were waiting because they needed access to diagnostic tests. The patients may or may not have needed to have an FSA before receiving a diagnostic test.