Where you live — rather than how sick you are — is still a major factor in how quickly you get elective surgery — or whether you get it at all, according to a new report by the government watchdog.
The report, Providing equitable access to planned care, which has just been tabled in Parliament by the Auditor-General John Ryan, showed elective services in the public system were often “not equitable or timely”.
People with the same level of clinical need will qualify for treatment in some districts but not in others.
“As a result, a person’s ability to access treatment is, to a significant extent, determined by where they live,” the report noted.
“Some clinical staff we spoke with were of the view that a lack of capacity to provide treatment had led to some thresholds that no longer reflect clinical need.”
The Pae Ora (Healthy Futures) Act 2022 required Health New Zealand to ensure access to treatment (such as operations to remove cataracts or tonsils, joint replacements and hernia repairs) was based on people’s clinical need — not their background, circumstances, or where they live.
However, the audit found Māori, Pacific peoples, people with disabilities, those living in rural areas or in poverty had worse access to planned care.
Health NZ was gradually introducing nationally consistent thresholds for ranking access to planned care.
“It has introduced a national threshold for cataract treatment. Work is under way to align other thresholds for orthopaedics, otorhinolaryngology (ear, nose, and throat conditions), and cardiology,” the report said.
RNZ reported on Thursday about the long wait times for ear, nose and throat services in Tairāwhiti, which had less than a quarter of the specialist capacity needed.
Introducing a national threshold for cataract treatment had led to about 1800 people added to the waiting list in the Southern District and about 900 more people put on the waiting list in Counties Manukau, the new report found.
In orthopaedics, threshold “scores” for orthopaedic treatment range from 50 in Auckland and Canterbury to 80 in Wairarapa.
“This means that a person’s condition needs to be significantly worse in Wairarapa than Canterbury or Auckland to qualify for treatment.”
District-specific thresholds still in place were also “obscuring the extent of unmet need for treatment in some districts”.
“Significant work will be required to deal with the changes in demand that will result from the introduction of nationally consistent thresholds across all specialities.”
Faster treatment not same as ‘equitable’ treatment
The true level of unmet need was unknown, the report continued.
“One possible measure of unmet need is the number of people who are assessed by a specialist but do not meet the threshold for treatment.
“However, we also heard some clinicians will not refer a person for specialist assessment if they are considered unlikely to meet the treatment threshold.
“Media reports during our audit suggested that specialities in some districts were not accepting referrals because they did not have the resources and would be unable to meet target time frames for assessing or treating people.”
Meeting the government’s target for 95% of people receiving planned care treatment within four months by 2030 was going to require “significant improvement” the report said.
“During our audit, the latest available reporting (for October to December 2024) showed that about 59% of planned care patients received treatment within four months of being placed on a waiting list.
“The proportion of people receiving planned care treatment within four months has been in decline since 2017.”
However, the focus on improving wait times should go hand-in-hand with a focus on equitable access, the report urged.
“Equity also needs to be a central consideration in Health NZ’s work to improve timely provision of treatment. If this does not happen, there is a risk that strategies to improve timeliness could cause further inequities.”
Health was so interconnected, that too much focus in one area inevitably put pressure on the system elsewhere.
For instance, the number of patients waiting longer than one year for treatment was cut from more than 4000 in October 2023, to 1916 by July 2024, although it rose again to 2630 by December 2024.
However, in the same period, the waiting list for first specialist assessments nearly doubled, from 5000 to 9936, the auditors found.
Outsourcing could ‘exacerbate’ inequities
Health Minister Simeon Brown’s push for more outsourcing to private providers needed to be carefully managed so it did not lead to greater inequities, the Auditor-General said.
“Access to the private hospitals that provide outsourced treatment is not equally distributed across the country. This means that some districts can outsource patients more easily and at shorter notice than others.
“In addition, not all patients can be outsourced for treatment. The people selected for outsourcing to private facilities are generally determined to be non-complex patients.”
Māori and Pacific peoples and people living in socially deprived areas were also more likely to have complications, which would bar them from treatment in a private hospital.
“Health NZ needs to manage and monitor the outsourcing of treatment so that it does not compromise its focus on the treatment of patients in priority order or otherwise increase inequity in planned care.”
Auditor-General’s recommendations for Health NZ
- Prepare a plan with a clear timeline for introducing nationally consistent thresholds for planned care treatment
- Put in place actions to improve equity of access to treatment and that efforts to improve timeliness do not increase inequities
- Strengthen its knowledge of equitable access to treatment by looking at unmet need and other information gaps
- Enable clear public reporting of how long people waiting for treatment, variations in access and how HNZ will improve equity of access.
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