We already know how to solve our elective surgery crisis, says New Zealand Orthopaedic Association president Peter Robertson. We just need to take action.
New Zealand is facing an elective surgery crisis – this isn’t news. The situation has been worsening for years and over successive governments. Now and again some money is lobbed in, enabling a small amount of catch-up – but this only addresses the symptoms, not the cause.
Behind the fight for health dollars and debates about funding formulas are tens of thousands of New Zealanders waiting in pain for surgery that could change their lives. They have effectively been “left on hold”. Delaying surgery risks turning potentially reversible illnesses or injuries into permanent disabilities, with huge implications on lifelong physical and mental wellbeing.
Covid-19 has made things worse. More than 10,000 patients across the country had their elective surgery cancelled during level four lockdown. Worldwide, it is estimated that more than 28 million elective surgeries could be cancelled or postponed in 2020.
In New Zealand, when surgery began again in June, district health boards faced an even larger than usual backlog. Recent Ministry of Health figures show that the average time patients spent on a waiting list in June 2019 was 67 days. A year later that had increased by 28 days to 95 days.
As part of the Covid fund, the government allocated additional funding to DHBs. This is welcomed of course – and we look forward to the money arriving – but it continues the approach of addressing the symptoms of the problem, not solving it. The money is being put into a health system with a finite number of orthopaedic surgeons and surgical teams, who are already working at full steam to handle urgent and emergency surgery, leaving little capacity for elective surgery.
What we need to “solve” is a population-based funding model that isn’t working for urgent and elective surgery; a resistance to working with those outside the public system; and a fragmented approach to workforce training, leaving us short of orthopaedic surgeons.
There are three ways to do this:
- Have more equitable funding of trauma care, with a greater percentage of funding going to DHBs with more complex cases
- Develop public-private partnerships, with private hospitals picking up the elective surgery cases that public hospitals lack the capacity to perform
- Have a long-term approach to the training of orthopaedic surgeons, to address shortages.
More equitable funding for trauma care
DHBs are significantly underfunded for urgent trauma cases. Directing more funding to these urgent cases will get them done more quickly, clearing the way for more elective orthopaedic surgery to be carried out. It’s pretty simple, really.
The current population-based funding model doesn’t work for today’s environment – where we have more complex, resource-intensive cases. The Ministry of Health receives a bulk funding amount from ACC for the coverage of acute services such as for injuries from accidents. However, funding for acute orthopaedic services does not follow the patient. This means DHBs that provide specialist orthopaedic services for complex cases are underfunded for these services.
There is a need to direct more ACC funding to all DHBs, and especially those that provide highly specialised orthopaedic services. Ring-fencing payment for acute cases would free-up funding for other services, including elective services.
We are currently in the ludicrous position of having surgical theatres in private hospitals available but unused. Private hospitals have capacity to pick up many of the elective surgery cases – orthopaedic and other – that public hospitals simply do not have the capacity to perform.
Some DHBs already have successful partnerships with private hospitals, but this is not widespread. However, such partnerships can work very well. For example, shortly after lockdown Canterbury DHB and Capital & Coast DHB worked with their respective local private hospitals to continue providing elective surgery.
Unfortunately, this partnership approach is uncommon; complex administration protocols make such partnerships difficult, as well as a lack of will on occasion. We need a national framework, mandated by government, that requires public-private partnerships to be put in place. Voluntary partnerships are not enough and will just increase inequitable access to elective surgery.
Long-term approach to training of orthopaedic surgeons
There is a shortage of orthopaedic surgeons and this will only get worse unless there is a change in the way training is funded. The expansion of joint replacement surgery alone is likely to require up to 80 additional surgeons in New Zealand by 2026. This surgical training requires seven years of time investment, so must be planned for well in advance.
We need a commitment across the sector for a long-term approach to training. DHBs need to focus on advance workforce planning so positions are available for orthopaedic surgeons once they are trained.
We know what needs to be done. It will take commitment, collaboration and time, but the benefits to New Zealanders will be huge. If Covid has shown us anything, it is that large- scale, spectacular change is possible – if the will is there.
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