Feature / A Rational Response?

To say I was surprised to see an advertisement promoting elective surgery would be a serious understatement. I had hoped to find some new ideas on the HFMA study tour of New Zealand, but not advertising for patients in the public non-paying sector.

New Zealand has waiting lists for non-urgent surgery. The maximum wait for a first specialist assessment (consultant appointment) is six months and then surgery has to be within six months of the assessment. Like the UK, the government is keen to ensure that these targets are met and improved upon and has provided initiative funding to treat additional patients.

However, the national maximum is just that. Most district health boards (DHBs) operate well within the maximum and, increasingly, waiting is not a factor. And so it was when we visited Counties Manukau District Health Board in South Auckland. There was a government waiting initiative for surgery running at the time and the health board’s waiting times were low – at three to four weeks. In fact, this was so low that to obtain the government funding, it needed more patients. So it advertised.

We might expect a different approach in the UK. But probably the most startling difference between the NHS and the New Zealand system is that rationing on the islands is explicit and accepted by the population.

When a patient is assessed for surgery, their clinical need is scored and only when the score is above a predetermined threshold is the patient put on the waiting list.

If the score does not reach the threshold, the patient is referred back to the GP for management. Thresholds can vary from DHB to DHB (a postcode lottery?), sometimes according to what a DHB can afford. This does provide some flexibility to achieve financial balance, but too great a disparity from neighbouring DHBs would not be acceptable.

Access to waiting lists is controlled by nationally consistent clinical assessment and prioritisation. This is described as ‘the process by which doctors decide from those patients who would benefit, which individuals should have priority for the available capacity of publicly funded services’. To do this the doctors use standard templates and scoring methodologies. A level of checking is undertaken to ensure that individual doctors are operating the system equitably and fairly.

The patient clinical assessment results in a score between 0 and 100. Generally, a score of below 40 indicates that the procedure is not likely to be clinically beneficial. The current threshold for orthopaedic major joints is around 60. When this system was first started, the equivalent orthopaedic threshold was 90, a level at which the patient is virtually immobile. So, over the past few years not only has the threshold reduced significantly, but the waiting time at Counties Manukau has also reduced to well within the maximum wait.

There is another important facet of the New Zealand system that influences waiting lists directly. Between 50% and 60% of elective surgery is carried out in the private sector. We visited a couple of private sector units and they appeared to be highly efficient, well organised with high patient throughput. Despite much higher doctors’ fees, they are able to operate at price levels that are about the same as the national tariff. About a third of the population is covered by health insurance. This extensive use of the private sector means that less than half of the patients that would go on the waiting lists in the UK do so in New Zealand.

In the UK, we still use the private sector much less, although our primary method for rationing is waiting lists. We have used targets, increased investment and additional capacity in the public and private sectors to improve access and reduce waiting times.

We spend about the same proportion of gross domestic product on healthcare in both countries, so how do we assess which approach has been more successful? From a financial viewpoint, the chequered history of NHS organisations and deficits over the past couple of years is a negative. We do not have the flexibility to defer patients to manage the financial position.

From the patient’s perspective, waiting times have reduced significantly in both countries. In the UK, however, we do not know what has happened to our thresholds for treatment. As waiting times reduce, we must be treating patients when they are healthier, but does this also mean the threshold has reduced? It is difficult for us to prove and quantify the improvement in quality as waiting times reduce.

It seems to me that the real advantage of the New Zealand system is the explicit acceptance of rationing based on consistent and equitable clinical assessment and prioritisation. The fact that rationing can also be based on affordability is an added bonus, particularly as it does not detract from the public’s view of a fair and equitable system.


New Zealand in profile

Despite its geographical distance from us, New Zealand shares many of the healthcare and health-related challenges facing the NHS, writes Mark Knight.

The census (2006) puts the overall population of New Zealand at just over 4 million – similar to that of Scotland. The country is made up of two islands and covers some 103,000 square miles. Compare this with the UK, where the land mass – smaller by some 7,000 square miles – has to accommodate a population approaching 61 million. In fact, New Zealand’s population is concentrated in specific areas with most people living on North Island and fewer than a million living on South Island.

New Zealand’s population is 78% white-European, 14% Maori, 5% Pacific, with the remainder made up of Indian, Chinese and other racial groups. Each group has its own unique issues. The white-European population is ageing, with conditions familiar in the UK such as heart disease. The incidence of diabetes, obesity and smoking related illnesses is generally higher within the Maori communities, whose populations tend to be younger and comprise larger families. As in the UK, diabetes is a real problem for the Indian community.

People live slightly longer than in the UK (New Zealand average 77.5 for men and 81.7 for women). However, the Maori life expectancy is a lot poorer. Whereas white-Europeans can live to 80 for men and 85 for women, the Maori equivalent is 69 for a man and 74 for a woman – an alarming difference in health outcomes and one that the New Zealand government takes very seriously.

Rurality is a massive issue for the New Zealand health system and particularly so in the South Island, where there are only 31,000 people in the West Coast region, an area about 350 miles long.

The New Zealand system is publicly funded in the main with a small amount coming from insurance. There is also a pretty unique accident compensation scheme. Overall control of the health budget is the responsibility of the health minister while the Ministry of Health monitors the healthcare system’s performance, enforces legislation and provides the national economic planning for the system.

Health delivery is devolved to 21 statutory district health boards (DHBs), which are responsible for primary, secondary and tertiary care in their patch – an arrangement similar to the Scottish single-system structure. These boards have detailed agreements over funding and performance with the ministry.

Primary care is similar to the UK, with the doctors self-employed and having lists of registered patients. Co-payment to see your doctor, however, is pretty universal in New Zealand. Most New Zealanders pay £20 to £25 per time (free for children under six and subsidised for elderly and unemployed).

In secondary care, the hospitals are run by the DHBs as part of the unified system. Like the UK, New Zealand has its own issues with waiting. In complete contrast to the UK, however, rationing is openly exercised, with individuals scored and told where they are placed on the list (see main article).

Phil Taylor, HFMA international officer, Andy Leary, immediate past chairman of the association and Mark Knight HFMA, chief executive, (all pictured left) attended an HFMA/ACCA study tour of the New Zealand health system in October. For details on HFMA bursaries to study aspects of international healthcare finance, contact [email protected]