By Robin Gauld*
As New Zealand’s COVID cases rose in 2021, we were warned the virus would put significant pressure on our health system. But, in reality, New Zealand’s medical system has been struggling for a long time.
Over and over again, the media have put the spotlight on the struggling health-care system and the impact these issues have on individual patients and their families as well as, of course, staff.
In some situations, waiting list delays, stretched services and overworked staff have resulted in serious outcomes, including death. For New Zealanders who are missing out on treatment, or facing years-long delays, the insufficient care can cause significant stress and inhibit their ability to contribute to our economy and society.
For others, our struggling public health system can take a financial toll, by forcing people to gather all the money they can to pursue treatment in the private sector.
The long wait
Recently, the media focus has turned to New Zealand’s worsening access to non-urgent surgery.
As of last October, 30,000 people were waiting longer than four months for surgery, up from 27,500 in May when the Planned Care Taskforce was formed to cut national surgical waiting times.
At the same time, a further 38,000 New Zealanders had been waiting longer than the four-month target for being seen by a specialist for an initial assessment, up from 35,000 in May.
On the upside, there had been a reduction from 5,500 to 3,500 in those waiting over a year for surgery.
‘Worst ever’ hospital wait lists climbs to 67,000 https://t.co/hXGeUE5sWc pic.twitter.com/2RJcYrgJj0
— nzherald (@nzherald) January 28, 2023
The enduring postcode lottery
The data highlighted major differences in access and care by region – the so-called “postcode lottery”.
The situation is unacceptable and was never anticipated or expected in a country with universal access as a fundamental guiding principle for health care. This principle means everyone should be treated in a timely manner without any barrier to or inequality in access.
These rising waiting lists, lengthy emergency department waiting times and uneven access can’t be blamed on COVID-19 alone. The pandemic has simply added to the pressures and revealed more starkly the multiple cracks in our health system.
A history of pressures
The issues across our health system are long-standing and attempts over the past three decades to resolve the fundamental issues have had mixed results.
In the early 1990s, the government set up the Committee on Core Health Services. The goal of the committee was to ensure patients with non-urgent needs were treated in order of priority. Assessment involved scoring patients based on need. The committee also aimed to eradicate the postcode lottery.
Since then, subsequent governments have made significant changes to the health system, including introducing district health boards (DHBs) in 2001 and then the dismantling of these boards with the creation of Te Whatu Ora in 2022.
While there have been periodic improvements to the system with these changes, the basic problems recently highlighted by the media have persisted thanks to a constant and reactive game of catch-up.
Underlying problems
To be clear, the professionals providing care in New Zealand are outstanding and superbly trained. They work within a context, however, that persistently lets them down and is deeply stressful for all.
The basic issue is lack of long-range planning or solid investment in health care, affecting the entire public health-care system and all who rely on it.
Planning is usually reactive rather than establishing a solid foundation for the future.
Investments in hospitals and workforce are largely within a short-term framing, dictated by funding availability and yesterday’s needs. This means facilities are often inadequate and workforce shortages are ongoing. Hospital staff have been regularly asked to reduce expenditure to prevent budget blowouts.
It is also no secret that New Zealand is historically heavily reliant on foreign-born-and-trained health professionals.
There is no specialised long-range health planning group working in government; we badly need one, with deep expertise and connections to global networks.
The postcode lottery of NZ's cancer treatment helps determine who lives and dies - cartoon by @domesticanimal in Stuff newspapers today about inequities in the health system: pic.twitter.com/WKNbv1BHF7
— Bryce Edwards (@bryce_edwards) August 1, 2019
System-wide solutions
There is also a historic lack of focus on system-wide solutions. We should be looking at how we use all resources in the health system – public and private – to collectively deliver on needs.
Moving to a system-wide approach would have wide-ranging implications, from how we fund health care through to health professional training.
This could mean lifting the lid on health professional regulation and allowing different professionals to take on work that is currently limited to specialists, for example.
General practice also needs strengthening within the health system, along with hospitalists – specialists trained in hospital general practice.
Finally, there is a pressing need to embrace “operational excellence”, a set of practices aimed at systematically improving the quality and organisation of services. If anything, New Zealand’s health system and services currently exhibit the direct opposite of operational excellence.
The health reforms under way, led by Te Whatu Ora, offer the opportunity to address our health-care system’s key weaknesses by embracing long-range planning and operational excellence. Let’s hope we achieve this for the sake of our patients, health professionals and future generations.
*Robin Gauld, Pro-Vice-Chancellor and Dean, University of Otago. This article is republished from The Conversation under a Creative Commons license. Read the original article.
32 Comments
The reduction in those waiting for surgery over a year is misleading. The elective operating around NZ has been decimated due to Covid 19. Waiting lists have undergone re-prioritisation (removed and regraded), in addition to many other manipulations. Middlemore for example barely recovered from White Island in terms of elective back log before Covid 19 hit. Now there is a staffing crisis reducing theatre capacity.
Key senior theatre staff have left for Australia in numbers we have not seen before. Hospitals by their nature are in urban areas of high population density where housing costs are higher. A nurse's salary is simply not enough to allow home ownership in NZ after the Covid surge so they are leaving. Low pay and poor immigration settings have hamstrung the hospitals.
Things will get much worse before they improve due to the inertia in training or importing people in the numbers we require. Areas that are just horrific to work in (ED) are worst hit. The reports you read do not do the current situation justice.
I hate the word 'holistic', but it is the approach to the health crisis that is needed.
First, primary health care needs to be free for everyone: that means free GP visits as well as free prescriptions. Means testing does not cut it, because means testing is just another barrier for the poor, though intended to exclude the 'undeserving'.
Second, state hospital staffing will only be improved when the Government pays internationally competitive salaries to all health workers in the state service, and is willing to foster sufficient places for trainee doctors, nurses, and other health workers in New Zealand tertiary institutions, instead of prioritising revenue from overseas students.
Third, the cost of living in New Zealand must be made affordable to keep health workers from fleeing to Australia.
The 'holistic' part is that all this can only be accomplished by increased taxation; and that taxation must be a land tax to depress the cost of housing, for health workers and for everyone else.
Seems to be advocating for more centralization and oversight. If the trading is good like you say (I believe that is the case) then maybe we just need to get those professionals out where they are needed
Bigger expensive overhauls are not necessarily better just look at the think big.
Relatively simple, but definitely not cheap.
There's around 100k staff working in Te Whatu Ora alone. That would be an annual extra billion to add another 10k to their salaries, plus maybe 20 billion capital to address the most pressing issues with the infrastructure to provide functional spaces for health care. And another 1 billion annually to keep up with ongoing renewals.
I mean.. if it means drastically improved access to medical services and medicines for my family and I, I'll pay the extra tax.
But I want that to be an option we actually get to choose. Not political bickering that maintains a veneer of action while everything unwinds no matter who is in charge.
This will go against the grain of most comments here, but I have never encountered undue delays in ED, seeing a GP or getting to see a specialist. I can't recall any of my family or friends having anything bad to say about the level of care received, in fact quite the opposite. None of us are in the big cities though.
You mean predominantly the most severely disabled people who cannot get hired even if they apply to hundreds of jobs they are skilled and experienced in. Yep lets bring up that unlike the pension benefits which are non means tested and increase regularly there have been severe cuts to income support for disabled and they are on jobseeker even though many need daily support carers for basic needs which are mostly unfunded. Many severely disabled get no income support; predominantly women who are then forced into abusive relationships because they need to survive. Lets have a frank discussion about the kind of people who abuse disabled folk and just for you I will not reference and link your ethics to the attitudes of the 1930s, 1940s, 1950s 1960s,1970s where NZ imprisoned, tortured, and raped disabled kiwis, especially kids. Most did not survive to ever live in a home freely. Seems you lucked out winning physical lotto. Entitled much? Your disabled peers mostly died before retirement age and never got the opportunity for employment income. You could have been them, you are just lucky.
If they have FASD or TBI then they are equally disabled and even more likely to not receive adequate care and treatment as neurological conditions that require private specialist diagnosis and treatment (as the public system does not provide this). You cannot tell just be looking and for many people with FASD their ability to make decisions is even more impaired than those with severe autism. However I knew several disabled guys though and the only option for meals on wheels when they could not access a kitchen to cook (including no accessible stove) was takeaways. Many areas did not have St Barnabas and they were too young to get support from Age Concern. In fact for many families with disabilities in unsuitable unsafe housing they are often denied the support and access to cook. They cut disability funding for meal prep to many disabled people so it is cold raw meat & uncooked food from a packet or takeaways. On any given day cooked food is better than none.
It's also going to keep getting worse when there is no foresight on prevention through healthy diet and healthy lifestyle. People haven't deliberately gone down a less active lifestyle and less healthy diet. It's what is there in front of them and where more and more time is spend working and getting to and from work, there is less motivation to keep on top of both.
The hospital service is screwed. The % of the population that would aspire to be working in that setting given how badly it's seen to be declining must be constantly shrinking.
Nothing new. Well covered already but ignored....like everything that matters in NZ -
Health Cheque, Gareth Morgan Geoff Simmons - Shop Online for Books in New Zealand (fishpond.co.nz)
The problem is not the health system. The problem is peoples 'health' or lack of it. We are a country full of lazy obese diabetics, living on a western world diet devoid of nutrition and loaded with preservatives, dyes, toxic 'vegetable oils', refined sugar and sprayed by lord knows how many chemicals. Not much in a grocery store anyone should consume. Corporations have dealt the people this hand, with cheap, toxic, sugary commodities, wrapped in plastic. Yum.
Yes indeed. To be fair the people are very much deceived when it comes to nutrition. The nutritional value of fruit and vegetables is overstated and the value of meat, especially beef and lamb is understated. The harm that high sugar foods cause is barely comprehended by most people who continue to fear consuming nature's super food: grass fed red meat.
Exactly, health stars are meaningless. Cricket protein versus biscuits often don't fair much better either with biscuits able to game the health star rating. I remember speaking with one of NZs leading canned food companies and they could not guarantee the actual nutritional ratings were even close to the label and the variability between batches was so high they were constantly glad not many people knew & just trusted the labels. The company gamed the system with a high amount of carbs and sugar through the health star system (they kept the salt, fats &protein down but increased the sugar content to a huge degree in comparison to core nutritional ingredients). The health star system was always broken but with NZs failing numeracy rates I don't think many would read and process the back label with amounts per serving and % of total.
One cereal brand proudly advertised added iron... what they missed saying and could be tested with magnet was tiny iron filings mixed in. It was hilarious (still safe to consume). However there are many others that when it comes to meat vs processed food we have a lot more problems with highly processed highly sugared food, that contain several plant and other additives toxic to many people. Even the added plant fiber products are high risk and can cause severe gut bleeding, allergic reactions, irritable bowel and trigger a flare of autoimmune symptoms which then will have severe long term effects.
The ingredients list is critical to many and a detailed in depth understanding of harmful plant species which can kill people that are added to foods regularly. E.g. Even Inulin/chicory can kill as many people in NZ are highly allergic to it. But it is treated as a health supplement being added to many so called "healthy" processed products. With no standards for advertising for allergies and harmful additives it can do a lot of damage to those who are already medically vulnerable.
Hence starting from plain vegetables you know are safe for you is good but only if you have the ability to prepare, cook them into the finished components yourself (e.g. stocks, sauces, stirfrys, crackers, salads, sandwiches etc). Otherwise you can be in a worse state relying on processed precooked foods and easy to eat foods. Hence we need more medical funding to provide for those who physically cannot cook like disabled and elderly who if left to fend for themselves end up with worse health conditions and needing more hospital time (which often they may never need if they could have and afford the basics of living). We do not currently fund meal prep for most disabled people who need that support.
A perverse inventive is that there's much more profit to be made from maintaining a somewhat unwell population than prevention and cure.
They're trialling some health coaches with public funding at my GP including support for people who want to take prophylactic measures such as sleep, getting the right nutrient mix, physical exercise and mental and emotional support to keep them in optimum health for as long as possible.
The rub is that the public system doesn't see a direct return (less health interventions required so less $ needed) on that kind of investment for years, sometimes decades
Did you know untreated immune, thyroid and hormone conditions lead to obesity even with starvation level diets. We actually have a high incidence of untreated medical conditions that lead to more people becoming disabled because they have not had necessary joint operations, or the specialist referral go through so they can get accurate treatment & specialist medication. We barely even have the GPs to even see the patients with those serious conditions that often require surgery just to give them a repeat prescription (there is not even the time for assessment and follow ups to see the referral got through). You cannot tell just by looking at people what their medical condition is... even PCOS can be difficult (in some women they have balding but then I knew a ex stripper with it and they could access early specialist treatment overseas in Australia and China so no huge weight gain, no surgery needed, no balding). Access to timely specialist medical treatment pays a big part in preventing conditions getting so bad that obesity as a symptom is unavoidable.
Also Protip the most deadly eating disorder is anorexia as far more people die young in their twenties from being too thin than those who are obese. Obese people normally live much longer lives, (often reaching retirement) and decades longer than those obsessed with looking thin and exercise addiction (more likely to cause organ damage and bone issues). Maybe we should look into support for the high risk conditions before symptoms get bad perhaps.
Yes it is tragic for you that people live longer than you deem they should be allowed.
Joint operations are needed because of our arthritic diet. Preservatives, sugar, refined flour all very detrimental to our joints. Immune, thyroid and hormone conditions are created by a bad diet. You will never become obese eating only 'real food', not the sugary, preservative laden, refined flour commodities the western world consume. Ever see an obese tribesman?
If you only consume real food, starvation level diets are not needed.
"Immune, thyroid and hormone conditions are created by a bad diet" factually scientifically wrong. It is ludicrous you think this when many are GENETIC conditions, conditions caused by VIRUSES, and conditions from which environmental exposure cause poisoning such as in their place of work or in their home residential area. You are literally wrong when you think "real" food does not kill people when we have direct evidence it has killed more people than thyroid, immune and hormone conditions combined. It is also completely hilarious you do not know that obesity is often from eating "real" food as well. Do you really think overeating carb heavy vegetables and fruit does not cause weight gain. How bad is the NZ education system now that the complete lack of knowledge in nutritional content, metabolism and energy values can be peddled without question. This is Idiocracy the movie levels of sad. But as Hanlon's razor states it is not malice causing you to peddle these falsehoods to others and cause ongoing medical neglect and fraud. Protip Paleo diets DO NOT prevent or cure autoimmune diseases. Try being a type 1 diabetic going insulin free and over eating tons of "real" food and see how long it takes before a diabetic coma... oh wait we don't need you to test that we have literally millions in case evidence on it. Truly I wish you the best in learning about the nutritional and chemical contents of the food you eat and a clue is: all foods and plants are made up from chemicals, learn about them and how they affect your body. I doubt you could actually love fossils if you do not know key information about them across species. Perhaps you think they heal your chakra.
Do you really think overeating carb heavy vegetables and fruit does not cause weight gain.
Carb heavy vegetables and fruit are essentially human creations and should not be considered to be "real food". All vegetables and fruits contain toxic chemicals that have been reduced through processing and selective breeding to make them somewhat edible and to increase their sugar content.
Wow just levels of lack of basic education about plants and science wow. This is really sad. It is however a symptom of wider misinformation campaigns in NZ but it takes next level maliciousness to promote this harmful fraud to others and refusal to learn the basics about the plants and food you eat and effects on wider public. Yes NZs education system is worse than sitting a kid in front of a internet blog but you were not meant to be peddling the misinformation to others. It goes against basics in ethics. ALL food can cause weight gain, they all convey energy. There is no special class of "real" food that does not because that would exclude every single consumable item that does not cause you to throw up most your stomach contents. Protip those who lose weight fast without surgical intervention are affected by conditions caused by eating disorders, and severely ill medical conditions. Here is another clue those with eating disorders are often the most ill and die young. Many children suffer because of the physical malnourishment "real" food fad eating disorders cause.
I truly hope you have the time to learn about the chemical constituents of the food you eat everyday. Even a basic class in biology of plants and the evolution of the human gut would do wonders. Or perhaps study the psychology of why people are so easily tricked into eating disorders and fad diet campaigns; why even though we know and have evidence they are not cures why people still get fooled, frequently because they are so desperate for a simple answer and so vulnerable to corrupt practices. I have seen friends and family die through these campaigns. It is sad and tragic because like many corrupt practices it is a level of psychopathic control to ensure these diet fads are convincing to vulnerable people, especially those with disabilities, especially those who could live decades more if only they had adequate medical intervention. They died young; like most similar kiwis tricked by these fads they do die younger than most of their peers (of that sadly we have too much evidence).
We welcome your comments below. If you are not already registered, please register to comment.
Remember we welcome robust, respectful and insightful debate. We don't welcome abusive or defamatory comments and will de-register those repeatedly making such comments. Our current comment policy is here.