The main focus of the task force addressing hospital waiting times should be the development of a national strategy for the better long-term integration of public and private hospital sector capacity and resources
Comment: The relationship between the public and private hospital sectors has always been uneasy. Public hospitals have generally been viewed more positively, even if criticism of waiting times has been a constant feature, whereas private hospitals have been seen as the preserve of the wealthy or those with private health insurance. Surgeons move effortlessly between the two.
The uneasiness contributes to a governmental wariness about acknowledging what private hospitals do. The public system does not like to admit there are times when private surgical capacity is required to meet needs, as though that implies a criticism of the worth of the public hospital system.
I recall when I was associate health minister, seeking confirmation from the Capital and Coast District Health Board about the numbers of elective procedures being carried out by a local private hospital – which I already had – and being told there were none.
When I challenged that and produced the draft figures, the board admitted to me that the private hospital had been contracted to carry out those operations on the board’s behalf, so they were really “public” procedures, not private ones, hence their original statement. Such doublespeak has been symptomatic of the relationship between the public and private hospital sectors for years.
There are 36 private surgical hospitals in New Zealand and about 40 public hospitals. According to the New Zealand Private Surgical Hospitals Association, more than half of the country’s annual elective surgery is now carried out in private hospitals.
The 2020 Heather Simpson-led Health and Disability System Review recognised what many had been arguing for years that there needed to be rationalisation and “strategic collaboration” between the two sectors, enabling public hospitals to focus on more acute and complex cases, with a greater emphasis on the role of private hospitals to reduce waiting times.
The recent announcement by the minister of health of a new national focus on reducing hospital waiting times, and a task force to develop the strategy for doing so is the government’s first substantive response to this conclusion.
The minister has indicated he wants the task force to be bold in its thinking and explore all possible solutions, and “full use of all health resources, including those in the private sector”. Given the historical antipathy of Labour governments to the private hospital sector, this is potentially a significant change of focus.
However, the outcome in terms of better capacity utilisation of the private hospital sector may not be as comprehensive as the minister’s comments imply. The task force’s membership is very narrowly drawn. Seven of its 10 members come from district health boards, and there is no one on the task force from the private hospital sector.
It has been asked to report back by September on what can be done in the short-term to alleviate waiting times, and to produce a long-term plan. The latter becomes problematic, given the imminent disestablishment of DHBs, and uncertainty about what will replace them.
Neither is it clear which aspect of the problem is the minister’s primary focus. As has happened in other countries, waiting times have increased sharply over the past two years because of system delays brought about by the pandemic.
Dealing with these delays featured strongly in the minister’s speech announcing the task force. He noted three times as many people were waiting more than four months for treatment than at the time of Covid-19’s arrival in February 2020. His focus was on dealing with those numbers, but as GPs and others have pointed out, waiting times were a problem long before the pandemic.
No one will criticise the minister’s apparent determination to reduce waiting times. But some will note that, with numbers burgeoning, albeit because of the pandemic, it is very much in the government’s political interests to engineer some downward movement before next year’s election.
More so as it is likely by then the new health reforms will not have fully bedded in and will be having inevitable teething troubles. Good news on the waiting times front will be particularly welcome.
When the task force was announced, the eminent Wellington orthopaedic surgeon Professor Geoffrey Horne drew attention to the greater efficiency in the private hospital sector. Horne, who works across both sectors, observed: “The public sector is about half as efficient as the private sector at performing operative procedures. Generally speaking, the costing systems in the public sector are not very robust, whereas in the private sector every cent is accounted for.” He supported greater use of private surgical hospitals to reduce waiting times.
Within the numbers of public and private surgical hospitals, and staff, there is the capacity to deal effectively with the demand for elective surgery within what most people would consider a reasonable period.
The task force’s primary focus should be the development of a national strategy for the better long-term integration of public and private hospital sector capacity and resources to deliver the number of procedures required.
We cannot go on treating the private hospital sector as secondary to the public system, while relying on private hospitals to carry out more than half of all elective surgeries. Instead, we need to develop an approach that recognises private hospitals as the dominant providers of elective surgery, and funds and supports them accordingly so their existing capacity is fully realised.
This would leave public hospitals to focus on acute surgery and more complex medical needs and challenges.
The wariness and unease that has dominated the relationship to date needs to be replaced by a genuine partnership focused on achieving the best possible outcome for the patient. The task force has a unique opportunity to forge this new type of public-private partnership.
But whether they will be bold enough to do so, and the Labour government willing to accept such an approach, remain intriguing questions for the future.
As for the public, they just want to see a meaningful plan to permanently bring down waiting times.
