Unmet need 'a national disgrace'

'BURIED PROBLEM': Professor and surgeon Philip Bagshaw, founder of the Canterbury Charity Hospital.
'BURIED PROBLEM': Professor and surgeon Philip Bagshaw, founder of the Canterbury Charity Hospital.

You have to be in more pain to access the publicly-funded operating table now than ever before.

Patients in need of surgery are ranked by their pain and assigned a number - they only make it on to the waiting list if their number is high enough to meet five different criteria thresholds.

These thresholds are getting further out of reach every year, despite the Government pushing more money into elective surgery, clinicians and experts say.

This is because the demand for healthcare is limitless and the ability to pay for it is not.

Millions of dollars go into elective surgery annually - for example $110m of new money will go toward electives over the next four years - but, at the same time, our levels of unmet need are growing.

The gap between the patients who meet the clinical threshold for surgery, but fall short of our hospitals' financial threshold is widening, New Zealand Medical Association (NZMA) chairman Dr Mark Peterson says.

This is heartbreaking for the patients and frustrating for the surgeons who believe they need an operation and the GPs they are sent back to for pain management until their situation worsens, he says.

"Patients are being assessed by clinicians and told that in an ideal world they would have this procedure in the next few months, but as the hospital doesn't have the capacity to do that they no longer meet the criteria," he says.

"This is certainly something all doctors are struggling with and more importantly it's a serious problem for our patients."

Unmet need is "what I get the most flak about in my position", Peterson, who is also chief medical officer of primary care at Hawkes Bay DHB, says.

"This is the one thing that my colleagues always say, ‘what are you doing about it?'. I have certainly taken the opportunity of telling the minister this is the most difficult part of my role," he says.

Over the past five years, the number of Kiwi patients receiving elective surgery has increased by 40,000.

Health Minister Tony Ryall has previously said more people are getting treated at rates faster than population growth "so we will be addressing levels of unmet need".

However, Peterson says despite the significant increase in elective surgeries, "to say there is no unmet need out there is to avoid the issue".

"There is always going to be a gap between what we can do and what we would like to be able to do, but our view is that gap is getting too wide now."

There is no way to prove Peterson's fears as levels of unmet need have never been measured in New Zealand.

The Government only counts the number of people who get an operation each year, it does not count the number of people turned away.

University of Otago health policy expert Professor Robin Gauld says government approaches toward unmet need have been "overriding" the issue.

District health boards (DHBs) are in an unenviable position over the debate because, he says, "they are answerable to the Government first and foremost, yet they are also responsible for providing services to the public".

"They really should be telling both sides of the story."

With increasing public awareness of the concept, next month the Ministry of Health (MOH) will start measuring unmet need for the first time, the ministry's DHB elective performance manager Clare Perry says.

The new national patient flow collection programme will capture the outcome of the referral process - "that is not just referrals accepted but also those declined".

"This will assist in being able to better understand variation across the country in referred unmet demand," she says.

Last year, the Health Funds Association of New Zealand, in conjunction with the New Zealand Private Surgical Hospital Associations, conducted a survey of unmet need that found 170,000 Kiwis are turned down from the waiting list every year.

It reported 280,000 Kiwis met the clinical threshold for elective surgery, but only 110,000 were placed on the list.

Only time will tell if the MOH find similar figures.

Need is a pivotal concept within health systems that drives Government policy and decision-making.

In an era of limited financial resources, increasing pressures from an ageing population and costly advancements in technology, need is used to prioritise resource allocation and redefine public health goals.

However, the concept of unmet need has been a fairly recent introduction into the international health sector lexicon, according to American researchers.

The concept has only really come to light in New Zealand in recent years as well.

Canterbury Charity Hospital founder and surgeon Dr Philip Bagshaw says to fully understand the unmet need debate, it is important to think about all that has changed since the health reforms of the 1990s.

Before the new waiting system was introduced, patients who needed surgery were just placed on a list.

The list was long, it would take patients years to get to the top and it did not guarantee certainty of care.

However, Bagshaw argues, the levels of unmet need were not hidden back then because the waiting list was a piece of public information.

"There was always pressure on the politicians to try harder to get the list down and they decided they didn't like that millstone around their neck, so they got rid of it," he says.

The national waiting time project was introduced in 1998 to provide patients certainty of care.

This project resulted in the then Labour Government dumping 25,000 Kiwis off the waiting list and setting up a six-month time limit for DHBs to provide surgery or treatment to patients.

Later this year, that six-month time frame will be cut to four months.

An unintended consequence of shortening the time frame for surgery is that it lifts the threshold to access it.

This has led to some GPs allegedly "gaming" the system to get their patients on the list.

In a report to the National Ethics Advisory Committee in 2005, researchers found some GPs were "coaching their patients to lie and exaggerate conditions to gain priority for surgery".

It also said "patients affected by increasing thresholds experience harm through a lack of certainty about the provision of surgery, negative health effects resulting from untreated health problems and even a sense of ‘being uncared for'," however, the researchers said, these issues were also experienced under the former system.

The most signficant difference, Bagshaw says, is the politicians that introduced the new system said they were bringing "transparency, honesty and equity - but all three were lies".

"It brought in obfuscation, dishonesty and inequity. They created a self-fulfilling prophecy and then patted themselves on the back and said they did a good job. However, I think all they have done is a very good job of hiding the problem."

Bagshaw says the new waiting time project was "deliberately misleading the public" because it sounded as though all the people who needed surgery would get it within a set time frame.

"What they don't say is large numbers of people won't get on the list at all. It is all very clever stuff."

Governments have succeeded in concealing the unmet need problem for so long by "presenting things with massive amounts of spin", he says.

"We are drowning in a sea of spin. People have heard the spin from so many politicians over the years they have just resigned themselves to the fact that they won't get treated in the public system."

Last year, the Canterbury Charity Hospital, one of only two in New Zealand, completed almost 1400 operations or treatments on patients who were not in enough pain to access the public system.

Every year its number of operations and number of patients in need goes up - exposing just the tip of the iceberg when it comes to unmet need, Bagshaw says.

"The $64,000 question is: Why hasn't the public protested about this and why aren't the doctors protesting about it?

"Why is everyone so accepting of this buried problem? It's a national disgrace."


A patient in need of elective surgery or treatment is referred to a hospital outpatient clinic through a letter from their GP.

Based on the letter, a clinician at the hospital decides whether the patient meets the first criteria to have a specialist assessment with a surgeon.

If so, the patient is then assessed by a surgeon, asked a list of questions relating to their pain and scored using set criteria.

If their score is high enough, the patient moves on to the next stage and are tested against the treatment threshold, dependent on the district health boards (DHBs) funding allowances for elective surgery.

If they pass this stage, the patient then must meet the commitment threshold, which is when a DHB guarantees they can provide surgery to the patient within the Government-set timeframe of five months (soon to be dropped to four months).

Only then are they placed on the waiting list.

If the patient doesn't meet any one of the criteria thresholds along the way, they are sent back to their GP for ongoing pain management until their condition worsens and they try again. 

The Press