Health Targets

Big improvements in access to surgery in Counties Manukau

Counties Manukau District Health Board has had a deliberate strategy to improve access to elective surgery through increased investment using benchmarking to the national intervention rates as a guide. As a result, Counties Manukau residents now have rates of publicly funded surgery similar to or higher than the New Zealand average for the first time. This document outlines in more detail the changes for Counties Manukau residents for elective surgery overall, and for specific surgical procedures.

Elective surgical procedures numbers have increased
There has been a significant increase in publicly funded elective surgical procedures for Counties Manukau residents over the past 10 years. For children (ages 0-14) the annual number of procedures climbed from about 1,600 in 1996/97 to 2,650 in 2005/06, a 65% increase. For adults (age 15+) the rise was from 5,000 in 1996/97 to 8,000 in 2005/06, a 60% increase.

Compared with New Zealand elective surgery rates, rates for Counties Manukau children were below the NZ average for the late 90s, then improved to exceed the national average for four years before dropping back to slightly below the NZ average in 2004/05 and 2005/06. In contrast, the adult rate was below the NZ average for the late 90s but for the past five years, the rates have been fluctuating around the NZ average. This is the first time Counties Manukau residents have had such access to publicly funded surgery.

Elective surgical procedures waiting times have decreased
The number of people waiting for an elective surgical procedure has dropped from about 8,000 in the 1990s to around 3,000 as at 30 June 2006. More importantly, the number waiting longer than 6 months has dropped from about 60% of surgical procedures performed to 18% as at 30 June 2006 (from 4,600 to 500 people). The average waiting time for elective surgical procedure was relatively stable at around 10 months in the 1990s, but dropped precipitously to under 4 months by 2006.

Significant system change was required
The Elective Services Booking System has been progressively implemented over the past 5 years by CMDHB. It required all patients to be assigned clinical priority scores, and implementation of the switch to a booking system from the old waiting list system (for CMDHB this occurred in 2002). This gave more certainty to the patient, along with more clearly demonstrated fairness - the neediest patients are scored highest and receive surgery ahead of those with low scores. This fundamental change required the removal from the waiting list of all those people assessed in the old system as being able to benefit from surgery but with a level of need too low to meet the new booking list criteria. The mechanism used was to refer these patients back to their general practitioner, leading to over 3,200 letters being sent to patients advising them of their removal from the waiting list between 2003 and 2006.

By the end of 2005/06 the booking system has been fully implemented at Counties Manukau, with patients being added to the booking list at a rate balanced by the patients being treated, ensuring the 6-month maximum is being largely adhered to. By June 2006 only 552 patients were waiting longer than 6 months, and this number has continued to fall. In parallel with this process, CMDHB invested in the Manukau Surgery Centre, purpose-built for elective surgery, allowing the separation of elective work from many of the demands of acute surgical work.

Elective surgery based on need
One of the key aims of the elective surgical reforms was to make the system fairer for patients – ensuring service was provided in proportion to need. One measure of that is the rates of surgery by ethnicity and deprivation group. In the past the Maori rate for elective surgery has been below the Other rate despite Maaori having higher rates of acute surgery. As the booking system has been implemented the gap has closed for Counties Manukau residents, such that by 2005/06, for the first time, the Maaori rate equalled the Other rate. The gap between Pacific peoples and Other has also reduced over time. Asian rates were consistently much lower than all other groups.

The public system has consistently had higher intervention rates for people living in areas of higher deprivation, a difference usually attributed to wealthier populations choosing to use private surgery options. This intervention rate difference has been maintained or become more pronounced over the past five years for most procedures. For three procedures, the deprivation difference has decreased – cholecystectomy, inguinal hernia repair and prostatectomy; mainly due to increases in publicly funded procedures rates for people living in low deprivation areas. This possibly signals some shift from private surgery, with the increasing certainty enabled by the booking system making the public system more attractive. In general, however, while cause and effect cannot be determined definitively, it appears likely that improvements in equity have taken place as a result of the new system’s implementation.

Surgical complexity has increased
Procedures can be assigned different weights depending upon the complexity of the procedure. The caseweighted adult elective discharge rate for Counties Manukau residents was above the NZ average in 2004/05 for the first time. The case-weighted child elective procedure rates for Counties Manukau have fluctuated around the NZ average since 1999.

The overall complexity of surgical procedures has increased by about 12% since 2000/01 for NZ and 20% for CMDHB. The increases in complexity are likely to be related to the new Clinical Priority Access Criteria (CPAC) scoring system ensuring treatment of the higher need and hence higher complexity cases first, and to the increased investment in major procedures like hip and knee joint replacement increasing average procedure complexity.

Private surgical data are limited and not current
Unfortunately little recent data were available to measure the effect of privately provided elective surgery, through either ACC purchasing, health insurance or self-funding. The most recent Counties Manukau data set is for 2001, and even that has little cover of the ENT, Ophthalmology or sterilisation areas. We have noted past private rates where possible – see notes on specific procedures in the table on page 7 of this report.

In 2001 the overall utilisation of privately funded surgery by CM residents was similar to the NZ average, but was less that of Waitemata and Auckland residents.

Other important points to note when interpreting data on privately funded surgical procedures are that ethnicity or socioeconomic status recording are somewhat limited; private surgery is likely to be for less serious conditions (does not have to meet any particular CPAC threshold) so the balancing of private and public is not necessarily comparing like with like; and data for private procedures is only required for private hospital inpatient cases. As various procedures become more ‘office-based’ (e.g. cataract surgery) rather than theatre-based so they disappear from the dataset.

Despite these data limitations it seems likely that the majority of private surgery over the 10-year period was performed in people with health insurance, Europeans and the least deprived. Private surgery is happening in those living in more deprived areas – this may be assisted by workplace and union medical insurance schemes, or the simple misclassification bias inherent in area-based socio-economic categorisations.

Specific procedures
Looking across the surgical procedures examined in this report, there has been a marked improvement in access to publicly funded surgery for Counties Manukau residents over the past 10 years. Most procedures have had increased intervention rates, improvements compared to the New Zealand average, and apparent improvements in equity, with Maori and people living in high deprivation areas seeing improved intervention rates. A summary of the progress made for each procedure is noted in the table on page 7 of this report.

Procedures that have shown the largest improvements in intervention rates are hip and knee joint replacements, cardiac procedures, and cataracts. The largest improvements in access for Maori are in those areas, and also cholecystectomy procedures. For people living in high deprivation areas the cardiac and orthopaedic rates showed improvements, and high rates were maintained in cataract surgery and provision of tubal ligations.

Some procedures showed little rate change or declined slightly – hysterectomy, prostatectomy, grommets and tonsillectomy/adenoidectomy. In each case there are either alternative treatments becoming available or re-evaluations of the effectiveness of the surgery in treating the underlying condition. Low intervention rates in these conditions may in fact be the prudent course, assuming there is good access to the alternate treatments. Access to urology and gynaecology services remain a concern for the DHB however.

Some procedures – cholecystectomy, inguinal hernia repair and prostatectomy – showed a reduction in the gap between those living in low deprivation areas and those living in high deprivation areas. In each case this has mainly been due to increases in procedure rates from people living in low deprivation areas, while those in poorer areas have largely maintained intervention rates. This possibly signals some shift from private surgery for the wealthier population, with the increasing certainty enabled by the booking system making the public system a more attractive option. While this may be seen by some as an unwanted byproduct of the Elective Booking System, one cannot argue with the basis of the system determining priority by need.

Download full report
View the full report - Counties Manukau District Health Board - Improving Access to Elective Surgery 1996/97 - 2005/06 (PDF, 563 KB)

Related information

In this section:
Improving Elective Services Target

In other sections in this website:
Elective Services section

Page last updated: 8 August 2007