Road to recovery

HOT SEAT: Nelson Marlborough District Health Board chief Chris Fleming, who admits they took their eye off the ball.
HOT SEAT: Nelson Marlborough District Health Board chief Chris Fleming, who admits they took their eye off the ball.

Nelson Marlborough District Health Board had the worst performance of all 20 district health boards on elective surgery. Heather Simpson finds out how the board is turning around its fortunes to hit Ministry of Health targets.

Nelson Marlborough District Health Board has recovered from a slow start and is on target to meet Ministry of Health goals on elective surgery.

By the end of this month it hopes to have had delivered more than 6100 life-changing surgeries to patients.

Elective surgeries are medical or surgical services for people who do not need to be treated right away.

It has been a recovery of houdini proportions for the board that had under-delivered on targets since July last year.

Between July and September 2013 it was ranked second to last of the 20 district health boards for meeting elective surgery and between October and December last year it was the worst performing district health board, when it met 94 per cent of its target.

Board chief executive Chris Fleming admitted they had "taken their eye off the ball".

To address its under-delivery of elective surgeries, the board was placed under intensive monitoring by the National Health Board.

It began daily monitoring of elective discharge volumes, introduced more services at Wairau Hospital in Blenheim and additional surgery sessions on Saturday mornings when staff were available.

Board general manager of clinical services Peter Bramley said a combination of staff illness and unexpected events contributed to the poor performance.

Within the four-surgeon ENT department, one surgeon went on maternity leave and another broke their arm in a mountainbike accident and a locum cancelled their contract at short notice. An anesthetist who was unwell further compounded matters.

The board were put under further pressure in January when the Ministry of Health said it wanted them to complete an additional 86 elective surgeries.

As part of a recovery plan the board outsourced the additional electives to Blenheim's Churchill Private Hospital Trust and Nelson's Manuka Street Hospital. The board used extra funding from the ministry for ear, nose and throat surgery, general surgery, orthopaedics and eye surgery.

Bramley said by the end of April they were only four discharges behind the year-end target of 6029 surgeries. At the board's monthly meeting last week, he estimated they would be 20 discharges behind target by the end of May.

Bramley said staff had been under intense pressure but they had been responsive, helping to pull the board back.

Fleming said achieving the ministry target of 6115 surgeries by June 30 "would be tight" but they were confident it was possible.

"There has been significant progress over the last couple of months. That has come at a cost to staff in relation to workload expectations. The challenge for 2014-15 is to have scheduled surgery that doesn't put pressure on staff."

The pressure remains. By January 2015 a patient must wait no longer than four months for a first specialist visit and to be waitlisted for surgery.

"There is a lot of misinformation about the shifting from five months to four months, like there was when moving from six months to five months," Fleming said.

"Often the suggestion is that tightening the target will reduce access. Indeed, the transition of moving from five months to four months poses two options: increase production to clear the hump that is generated to reduce the waiting times, or tighten access for a period of time to allow the hump to be addressed.

"The reality is our approach will be a mix of both."

To cut waiting times, the board is using Blenheim's Churchill Private Hospital Trust to complete orthopaedic surgery on six or seven long-wait patients before the end of this month.

Arthritis New Zealand's chief executive Sandra Kirby said osteoarthritis patients failing to meet the threshold for orthopaedic surgery and facing lengthy wait times for operations was one of the most common complaints to Arthritis New Zealand.

Marlborough has the highest number of over-65s per capita in New Zealand and the ageing population meant the current system would struggle to meet demand, Kirby said.

The board's threshold for hip and knee elective surgery has risen since June 2012. That year patients needed to score 74 points or more to go on to receive their procedures. In that November, the threshold was raised to 83 points and remains at that level.

"To qualify for joint replacement surgery your arthritis needs to be so bad it impacts your daily life," Kirby said. "A common side effect is the pain is so bad that it keeps you awake. Every movement feels like having broken glass between your bones. For many people, a short walk to the letterbox becomes hard.

"We have heard of people who can't dress themselves because they are in so much pain. They are being told nothing can be done until they qualify for surgery."

Kirby said those who didn't meet the threshold were sent back to their GPs for "GP care".

She knew a patient who waited at least 12 months for surgery.

"It becomes a painful waiting game. The difficulty is a huge number of people feel they are wasting their lives. We have people in Nelson and Marlborough in their 50s who have had to give up work because they have used up all their sick leave. They still can't get surgery."

Kirby said it was hard to accurately tell how many people are in the same predicament because there are no records kept.

The ministry take note of how many people leave or are expelled from its booking system, but not why.

Those who are taken off the list involuntarily are filed under the same category as patients who change their minds about surgery, switch to private providers or are judged medically unfit to proceed. With that in mind, the raw figures are high. A total of 1573 or nearly a quarter of Nelson and Marlborough patients entered into the national booking system were taken out of the system without surgery during 2011-12. During the previous two years it was even higher at 29 per cent. The national average has sat at 21 per cent or less between 2007-08 and 2011-12.

Blenheim GP and Nelson Marlborough District Health Board clinical director Ros Gellatly said in the past patients may have been referred earlier "to get onto the list" and expected to wait until their name came up.

"People would simply be added to a waiting list and they would languish until their name rose up the list; in some instances this could be years, Gellatly said.

"The problem with the old method for managing waiting lists was that often no-one would be managing the patient's condition effectively as the GP had referred the patient and the patient was simply languishing on a list somewhere."

Gellatly said the push for hospitals to be more efficient means patients will only get onto a waiting list if their surgery can be done in four-five months after seeing the orthopaedic surgeon.

It resulted in patients being given more certainty about when their surgery will be, she said.

"In the current system the GP and the patient know they have to manage the condition and seek re-referral if the situation gets worse."

Gellatly said patients and GPs were frustrated about gaps in services to help manage hip and knee osteoarthritis.

In response, Nelson Marlborough District Health Board is one of 18 DHBs working together with the ministry electives team on an enhanced recovery after surgery programme which starts with education about osteoarthritis, self-management tips and readiness for surgery before referral is done.

Green Party health spokesman Kevin Hague said he believed it was likely that a large number of people met the criteria for surgery and had been assessed as such, but had been ejected from the waiting list.

"What that allows the Government to do is say, ‘Well, there's been a reduced number of people who are waiting for surgery.' But it has no data at all about the remainder," Hague said.

"This is part of the game with elective surgery: Make it look like the Government has done a lot because there's more money going in, more surgery, and apparently fewer people booked in for surgery, but that's the missing part of the puzzle there."

The Marlborough Express