A copy of the briefing appears below.
Introduction
On behalf of our New Zealand Fellows and Trainees, the Royal Australasian College of Surgeons wishes to congratulate you on your new appointment as the Minister of Health. Over the next three years we look forward to working with you, the Government and the Ministry to ensure that New Zealanders have on-going access to high quality healthcare.
The aim of this document is to provide a brief overview of the Royal Australasian College of Surgeons (RACS) and the issues which we perceive to be of importance to the provision of quality surgical care in New Zealand. We outline below the issues and the actions that we believe need to be taken to address these.
About the Royal Australasian College of Surgeons
RACS was established in 1927 and is the leading advocate for surgical standards, professionalism and surgical education in New Zealand and Australia. RACS is a not-for-profit organisation representing more than 7,000 surgeons and 1,300 surgical trainees across nine surgical specialties: cardiothoracic surgery, general surgery, neurosurgery, orthopaedic surgery, otolaryngology head and neck surgery, paediatric surgery, plastic and reconstructive surgery, urology, and vascular surgery. Approximately 95 per cent of all surgeons practising in New Zealand and Australia are Fellows of this College (FRACS).
RACS is committed to ensuring the highest standard of safe and comprehensive surgical care for the communities it serves and, as part of this commitment, strives to take informed and principled positions on issues of public health relevant to surgery.
Issues for quality surgical care
Prioritisation of Elective Services
Ensuring that the New Zealand public has good access to assessment and elective surgery is a key issue for RACS. Public funds do not provide assessment and elective surgery for all who could benefit from it, so it is essential that the limited resources are effectively prioritised to maximise their benefit and equitable distribution.
National prioritisation and Clinical Priority Access Criteria for elective surgery have evolved considerably since their introduction and have potential to be useful tools for specialists to prioritise patients. It is important that prioritisation systems for both assessment and elective surgery continue to be developed, reviewed and adjusted as required to ensure their effectiveness.
Recommendations:
- That the Ministry of Health supports the ongoing development and improvement of Clinical Priority Access Criteria and national prioritisation systems for elective surgery across all surgical specialties.
- That the Ministry of Health continues to develop reporting systems and analysis of the data both from First Specialist Assessments (FSA) and elective prioritisation to determine unmet need (ie. patients who could benefit from an assessment and/or elective procedure, but are unable to receive this in the public system due to resource constraints).
Funding of elective surgery
The number of publicly funded elective procedures has increased in recent years but this has not kept up with the country's growing and aging population. While prioritisation is an effective means for extending current resources, on-going investment in personnel, infrastructure and facilities is needed to ensure that the surgical needs of the population can be adequately met. Methods to identify and address unmet also need to be improved. At present, there are many New Zealanders who are unable to access treatment that will resolve conditions that are affecting the quality of their personal and work lives.
Recommendations:
- That the Ministry of Health closely monitor and expand the collection of data to capture patients who either do not receive a FSA, or those who do not receive elective surgery when their FSA has identified this as the appropriate treatment.
- That the Ministry of Health continues to fund elective surgery to a level that minimises unmet need in the community.
- That the Ministry of Health continues to minimise the inequity between funding for accident related conditions and those caused by other health conditions.
Health workforce
The provision of quality healthcare in New Zealand is reliant on the on-going training of the health workforce. This training needs to meet the growth and changing requirements of New Zealand's population. A proportion of post-graduate training is funded by Health Workforce New Zealand (HWNZ) who allocates $180 million to District Health Boards, tertiary education providers, and other health organisations every year. HWNZ has recently announced that, pending approval from the Minister of Health, it will be gradually moving its investment approach to a sliding scale model whereby funding is open to contestable bidding every year, with $10 million available for 2018/2019.
RACS, along with many of the other medical colleges, have expressed to HWNZ concern that this proposed investment model will likely result in reduced vocational graduate numbers in some specialty areas where there is an ongoing or increasing need. The proposed contestable process will be resource intensive, costly to manage and have no surety of outcome. For training organisations that are not the trainees' employer, and particularly for those who have national programmes encompassing many DHBs, this process will be prohibitively complex.
Medical vocational training takes many years and the impact of disinvestment on the specialist workforce will not be immediately apparent. This is especially true in small specialties where a small decrease in training numbers will show a marked impact some years later. As many training schemes rely on complex infrastructure to function, reinstating these some years later following disinvestment will be very difficult.
Recommendations:
- That the Ministry of Health review the proposed HWNZ model for the funding of the New Zealand health workforce to ensure that there is continuing and adequate funding for the vocational training of surgeons into the future.
Registries/audits
Registries/audits are essential tools for the collection of data and understanding standards of care and outcome. They assist with determining what is usual and acceptable, can identify when results fall outside of these norms and the possible reasons for that. Registries/audits also allow for earlier and a more thorough evaluation of new techniques and devices when these are introduced.
An Ombudsman decision in 2016 recommended that the health sector should collect and report on relevant data relating to patient outcomes. For this data to be usefully reflective of surgical activity it is essential that it is provided within the appropriate context. The development of a range of robust Registries/audits is a central component of achieving this. There are some already in existence (eg. the Bi-National Breast Surgery Audit and the NZ National Joint Registry), but Registries/audits still need to be developed for many other procedures.
Recommendations:
- That the Ministry of Health works with relevant health organisations to develop and support Registries/Audits for a wide range of surgical procedures.
Māori health equity
There are significant discrepancies in health outcomes between Māori and non-Māori. Māori continue to have a greater incidence of conditions amenable to health care, have higher rates of acute admissions for surgery and have significantly higher perioperative mortality rates. Health inequity is further compounded by differential access to health services and treatment options, significantly worse outcomes following treatment, and under-representation in the health workforce. A purported equality approach to healthcare delivery has clearly not resulted in equal outcomes.
RACS has a Māori Health Action Plan that is committed to fulfilling its obligations under te Tiriti o Waitangi by addressing health inequity and improving Māori representation in the surgical workforce.
Recommendations:
- That the Ministry of Health work with the health sector to address health inequity and improve Māori representation in the health workforce.
- That the Ministry of Health supports research into improving Māori health outcomes.
Preventative health
RACS is committed to addressing potentially preventative health conditions that impact on the well-being of New Zealanders. Not only do issues such as alcohol-related harm and obesity contribute to the country's burden of disease, they also lead to co-morbidities which increase the risk associated with surgery.
Obesity
Obesity presents a significant problem for healthcare and is associated with a broad range of chronic medical conditions, mental health issues and premature mortality. Morbidly obese patients (BMI over 40) suffer disproportionately greater complications and morbidity when under-going surgery, including an increased risk of coma, stroke or acute kidney injury.
Nearly one third of New Zealand's adult population is now estimated to be obese with a further third overweight, making us the third most obese country in the OECD. RACS believes that a combination of preventative measures and an increase in the availability of treatment options for those already obese is the most effective way to address this growing issue.
Recommendations:
- That the Ministry of Health increases the availability of publically funded bariatric and associated surgery for the morbidly obese.
Alcohol related harm
Alcohol is the most commonly used recreational drug in New Zealand, yet is a causal factor in more than 200 diseases. Excessive alcohol consumption increases an individual's overall risk of developing many types of cancer, many of which then require surgical intervention. Surgeons are also frequently confronted with the secondary effects of alcohol consumption when treating patients with injuries from vehicle accidents, interpersonal violence and other accidental injury.
It is estimated that between 600 to 800 New Zealanders die each year from alcohol-related causes. Despite this knowledge, alcohol continues to maintain a strong presence in the New Zealand psyche due to its in-grained cultural status, availability, and high visibility. RACS endorses preventative and educational measures as well as restricting the availability of alcohol as the best way to reduce alcohol-related harm.
Recommendations:
- That the Ministry of Health investigate measures to reduce the availability of alcohol, including greater restrictions on trading hours, outlet density and the introduction of a volumetric tax on alcohol.
- That the Ministry of Health expand its public education to include the longer term impact of alcohol on individual health.
- That the Ministry of Health re-consider the Ministerial Forum on Alcohol Advertising and Sponsorship's recommendations regarding youth exposure to alcohol.
Trauma
RACS is a leading advocate for the prevention and management of trauma. This includes advocating on issues related to speed on our roads, firearm safety and the inappropriate use of quad bikes, particularly by children.
RACS considers that the greatest gains in the management of trauma come from creating efficient local trauma systems. To this end, RACS is undertaking a review of New Zealand's trauma systems in November 2017. This is based on the RACS Australasian Trauma Verification Programme and will review systems of trauma care from a national perspective. A Trauma system review is a consultative process involving a wide ranging system review across the country to assist in the development of an inclusive and effective trauma system within New Zealand.
The review will assist relevant agencies to assess and analyse the integrated trauma care provided throughout the country and provide a benchmark of the services against international standards.
Recommendations:
- That the Ministry of Health advocate strongly for road and firearm safety and the restriction of the use of quad bikes by children.
- That the Ministry of Health consider the findings from the RACS New Zealand Trauma Review; and assist hospitals to enact systems that will improve care.
Read the complete briefing at the link below.