Despite a public apology and promises to do better, it’s still better to live in Dunedin than Invercargill when it comes to colonoscopies. David Williams reports
On its face, the Southern District Health Board is improving its much-maligned colonoscopy service.
Demand for the procedure, the primary method for diagnosing bowel cancer in a timely way, has increased since the national screening programme started. Southern DHB joined in April 2018 – controversially, as it turns out, with three external reviews painting a terrible picture of delays and wrongful rejections of colonoscopy referrals which, in some cases, led to people dying of cancer before they should have.
The latest internal DHB report on the service, tendered at a health board committee meeting earlier this month, talks of “good performance”. Executive director of specialist services Patrick Ng said average wait times for urgent or semi-urgent cases were within the respective national targets in Dunedin and Invercargill.
But several red flags emerge even in the official narrative.
One is meeting Southland’s “surveillance” scoping targets – for seeing lower-risk patients who are often returning to be sure pre-cancerous polyps haven’t come back. The latest figures show 181 patients in Southland, and just 10 in Dunedin, have waited longer than 120 days for the procedure.
Southland’s ability to meet the non-urgent work dropped in March, from 72 percent to 45 percent. The gastroenterology department’s Dunedin-based clinical leader Jason Hill has decreed Southland patients should be offered a “scope” in Dunedin to be seen more quickly. The backlog should be cleared by September.
The situation might raise alarm bells in the far south. The recent external reviews were sparked by complaints from Southland surgeons who, for years, complained to DHB management about cases being declined when criteria were met, and specialist referrals being overridden, leading to “missed cancers”.
A big problem now is how often the colonoscopy rooms lie empty.
Ng’s report said Dunedin’s “green room”, one of two dedicated scoping rooms, was only used 27 percent in April, compared to the blue room’s 74 percent. Invercargill’s suite was used 53 percent of the available time.
The gastroenterology department needs more nurses – but a hiring decision “will need to be considered within the context of our overall budget priorities”, Ng writes.
Given the bewildering array of percentages and target figures, the last problem highlighted by Ng is perhaps the most concerning – that the data reporting isn’t up to scratch. There’s an issue with surveillance scoping reporting which can skew waiting times, and its patient administration system can’t accurately report instances of colonoscopy referrals being declined.
Fundamentally, then, there’s not a fully accurate picture of how the service is performing. And this is seven months after an apology for “lapses and inadequacies” from the then DHB chairman Dave Cull (who died of pancreatic cancer last month), following a damning audit which found half of 32 cases were inappropriately managed, with delays leading to an “extensive impact” on nine patients.
“I personally don’t trust the data because I don’t think all the pieces are there to make a fair assessment.” – Melissa Vining
Cancer care advocate Melissa Vining, of Winton, whose late husband Blair’s case made national headlines, sits on the endoscopy users group. (Colonoscopy is a type of endoscopy, as it involves an endoscope.)
The couple’s advocacy was influential in the Government decision to create a national Cancer Control Agency, and Melissa has been instrumental in the construction of a charity hospital in Invercargill.
She tells Newsroom it’s essential the DHB provide data for decline rates, and the people turning up at emergency departments (ED) with late-stage cancer.
“Those two pieces of information are what would give me comfort that we’re doing a good job. Yes, the numbers have definitely improved in terms of what’s being presented to us, but I think the transparency comes from knowing how many physical humans are being declined and how many are presenting at ED where they’ve had a referral or previous symptoms and not been picked up.”
Vining believes Andrew Connolly, the Crown-installed monitor and colorectal surgeon who chairs Southern DHB’s endoscopy oversight group, is making a difference. But she adds: “I personally don’t trust the data because I don’t think all the pieces are there to make a fair assessment.”
Connolly mounts a stern defence of the gastroenterology service. (The DHB declined an interview, but provided written responses to Newsroom’s questions.)
Symptomatic waiting times are very good, he says.
Recommendations from the last audit of colonoscopy patients, undertaken by Professor Ian Bissett and Kate Broome, are, “over time”, being incorporated into “the services quality improvement processes”.
Those recommendations include attempts to address inter-professional tensions, something characterised by a previous audit as “inter-service warfare”. A “process review” for all suspected cancer patients following colonoscopy is underway.
There’s a telling gap, however, when it comes to decline rates. Connolly says the endoscopy oversight group has made significant progress “but would like more detail from automatically generated data”. No figures were provided.
Where details get difficult, there’s repetition of what the “DHB reports”.
Asked whether the colonoscopy data reporting is accurate, Connolly says: “The DHB reports there is significant complexity with the reporting of colonoscopies due to the multiple clinical indication and pathways different patients follow.” It’s still relying on time-consuming manual data entry, but its IT team is working on an automated system. The DHB “rightly believes it is important to take the time to get this right”, Connolly says.
Newsroom has been told by multiple sources that specialist referrals for colonoscopies have been declined this year.
“The DHB reports it has been unable to corroborate this claim,” Connolly says. A “small number” of referrals made by junior medical staff on behalf of a GI specialist were declined, but the issue was fixed.
Is there an extra list of colonoscopy patients, known as “diagnostic planned and staged”, to effectively mask the true number? “The DHB reports”, Connolly says, this list (containing 76 patients in April, compared to four in the urgent list and 171 non-urgent) is not for symptomatic indications, but patients still need to be waitlisted and scheduled.
Examples include cases where the timing of an operation and colonoscopy have to be coordinated. “This is no different to other DHBs,” he says.
Why is Southland lagging in surveillance scoping, when it was meant to be the focus of improvements after the Bissett/Broome report? “The DHB reports good progress continues to be made.”
The most bullish part of Connolly’s emailed statement covers the ability of the gastroenterology department to cope with both the diagnostic service (symptomatic patients) and screening.
“Yes, Southern DHB was in a fit state to commence the national bowel screening programme in 2018 and this has been highly successful in the region.”
Introducing the programme was the result of years of planning and preparation, he says, and its implementation “always has to balance the risks and benefits to participants and the wider community”.
The programme’s “success”, and a higher than expected positivity rate, meant more colonoscopies and surveillance procedures were required. “Once this was realised, additional resource was provided.”
As a result of screening, 243 bowel cancers were detected, and 2333 colonoscopies performed. Roughly a third of those detected had stage one cancers, meaning 90 people had a 90 percent chance of a five-year survival rate, he says. “Only 11 percent of patients diagnosed with bowel cancer on the symptomatic lists had stage one cancer diagnosed.” (Critics might say that could be because of delayed diagnoses.)
Deborah Woodley, the Ministry of Health deputy director general of population health and prevention, says the bowel screening governance group made the right decision to authorise Southern DHB’s inclusion, based on its “comprehensive” and “robust” readiness assessment.
“Sometimes, after a DHB goes live, issues escalate. This does not mean that the ministry’s decision was incorrect, but that anticipated actions do not eventuate or are unsuccessful. The ministry works with the DHB to seek resolutions to these issues.”
These rosy views jar with the findings of external reviews, however.
The Bissett/Broome audit suggested Southern DHB’s service “is inadequate for the population served”. Another audit, by Christchurch surgeon Phil Bagshaw and gastroenterologist Dr Steven Ding said, according to Dunedin staff, “access to colonoscopy services has declined since the national bowel screening programme started”.
There’s evidence the programme wasn’t working. Southland nurse Veronica Corbin was refused a colonoscopy, despite a referral from her specialist Murray Pfeifer.
The respected Invercargill surgeon, who retired in December, also went to the media to advocate for a procedure for symptomatic Winton man Jason Mitchell.
Pfeifer told Newsroom the results of the screening programme – the high uptake and pick-up of cancers and pre-malignant conditions – was great news. But the screening further impaired what was already a poor diagnostic service. “The ethics of that are questionable,” he says.
“The longer the delay to diagnosis, the more advanced the condition, and the worse the outcomes.”
Continued trouble with colonoscopy services comes as the Southern DHB is under severe strain.
Last week, it issued a request to private medical contractors to bid for the treatment of up to 200 patients with breast and prostate cancer to reduce its surging waiting list. University of Otago health academic Robin Gauld told the Otago Daily Times it was an “abject failure and people have suffered and died as a result”.
In March, Dunedin Hospital reached capacity and declared a “code black”. At one point, 18 people had to remain in the emergency department while waiting for a bed in a ward.
Meanwhile, a report released earlier this month said half of senior doctors are experiencing high levels of burnout, and the worst DHB is Southern.
Bagshaw, the Christchurch surgeon, was lead author of a recent NZ Medical Journal article which questioned the wisdom of approving Southern DHB to join the national screening programme. It noted the DHB didn’t reveal to the ministry it wasn’t fully assessing patients “in a clinically timely manner”, and the clinical lead of the national bowel screening programme wanted an assurance from the SDHB – that didn’t appear to be forthcoming – that “symptomatic patients will not be disadvantaged in any way”.
The ministry’s assessment of DHBs to join the programme is flawed, Bagshaw says, and the DHB fudged its figures to make its service look better than it was. He’s raised his concerns with Health Minister Andrew Little, and is calling for a public inquiry.
Little, however, says “based on the reports I have read” the process for bringing Southern DHB into the programme was thorough, and the authorisation decision proper.
“Wait times for colonoscopies for symptomatic people are greater than the national average but not at a level that causes me undue concern. Wait times for surveillance are significantly greater than the national average.”
The ministry is providing “active input” to help the DHB make “necessary improvements”, Little says.
Can Little expect a straight answer from the ministry, though? “That would be asking them to be their own judge and jury wouldn’t it?” Bagshaw says.
And how is it that seven months after a grovelling public apology, the decline rates of a beleaguered system aren’t being made public? This is a requirement by the Health Ministry, as is an assurance the screening programme doesn’t harm symptomatic patients.
The Health Ministry’s data give Southern DHB a mixed report card.
The latest colonoscopy wait time indicator shows Canterbury was the worst DHB in March for scoping urgent patients within 14 days – at 64 percent, compared to Southern’s 90 percent. Southern was over 90 percent for scoping non-urgent patients within 42 days – while many DHBs (Bay of Plenty, Canterbury, Hutt Valley, MidCentral, Northland, Taranaki, Waitemata) were under 50 percent.
Surveillance colonoscopies, however, which have an 84-day target, are a problem. Southern sits at 47 percent, though that’s better than Bay of Plenty (18 percent), MidCentral (10 percent), Nelson Marlborough (33 percent), Northland (35 percent), and Waitemata (36 percent).
Those rates don’t seem good enough for a country with one of the highest rates of bowel cancer in the world. (Otago and Southland’s rates are among the highest in the country.) Access to publicly funded gastroenterology services is important, especially for those who can’t afford private treatment.
When a DHB’s colonoscopy service falls down, as external reports suggest happened at Southern DHB, public officials should be held accountable.
Vining applauds former Southern DHB chair Cull who apologised for a failure that didn’t happen on his watch, and installed an outsider, Connolly, as a Mr Fixit. But she’s scathing of those who were in charge – she names chief executive Chris Fleming, chief medical officer Nigel Millar, gastroenterology department service manager Simon Donlevy, and the unit’s clinical director Jason Hill.
“While the same people are in charge without taking any accountability, and especially seeing as they can’t even pull together transparent data, I still don’t feel restful about it.”
Past behaviour is probably a good indication of future behaviour, Vining says.