Whether on or off a waiting list, the pain remains

Since 2009, the country's district health boards have managed to increase the number of elective surgical operations each year by about 8000, which is double the target increase set by the Ministry of Health.

Now, more than 158,000 such procedures are now carried out annually, compared with fewer than 120,000 in 2007-08. However, with an ageing population, the demand for elective surgery - hip and knee operations, for example - is ever-increasing.

It is no secret that much of this need is simply not met. Health officials like to indulge in a kind of upbeat jargon which accentuates the positive, so they will willingly talk and write reports about "maximising scarce resources" or "improving the flow of patients to enhance quality of care". At the heart of their valiant efforts, however, lies an unpalatable truth. This country is, to put it plainly, rationing the provision of essential healthcare.

This rationing is here to stay. It would be nice to think that a developed country could meet all the health needs of all its citizens, but we probably do not have the resources. That is not just a question of funding; in the public sector, at least, there is not the capacity in our hospitals to do all the operations that doctors and surgeons might want to do. Much of the improvement in recent years has been achieved by making those hospitals more efficient.

The health sector used to have waiting lists for surgery. They now have waiting times, which are being reduced from five months to four months. What that means is that people on a list for an operation can expect it to be done within that timeframe. The reduction of the waiting times looks, on the face of it, like a victory, and that makes the Government look good.

However, the system masks significant, but unknown, levels of unmet need. Research results published in the New Zealand Medical Journal show that 36 per cent of more than 1200 hip and knee patients in Northland and Hawke's Bay referred for a publicly-funded operation by their surgeons were rejected because they did not meet the "financial threshold". Many were in severe pain and significantly disabled.

The authors caution that the study was based on a small sample size in only two hospitals, but it is a fair assumption that possibly a third of people needing an operation nationwide don't even make it on to the waiting lists. These people are - as far as the system is concerned - out of sight and thus out of mind, at least for now. The Ministry of Health started measuring unmet surgical need for the first time in July, but says results are not yet available.

Many people who don't meet criteria for a publicly-funded operation can elect to have it done in a private hospital, but this is obviously expensive. About 30 per cent of New Zealanders have health insurance, but this drops to below 25 per cent for the over-65s, an age when premiums start to become prohibitively expensive, yet also the age when people are more likely to need the operations.

It would help if more of the public-sector patients could be diverted into the private hospitals, where theatres are available and surgeons are willing to do the work.

However, this would involve putting taxpayers' resources into the private system - essentially promoting a mixed private and public health system, which is politically fraught.

Likewise, incentives or subsidies to help people maintain their private health insurance for longer, perhaps through tax breaks, would also involve spending public money on the private health sector, with the perception that this could undermine the public hospitals.

But if our health system as a whole is to become ever more efficient, the capacity in private hospitals should not be ignored.

The Press