The saga over Southern DHB’s poorly managed colonoscopy services takes another turn. David Williams reports
The Southern DHB can’t say with certainty how many people were declined colonoscopies before December last year, despite being required by the Ministry of Health to keep such data.
The DHB, which covers Otago and Southland, has been in the spotlight for its poorly managed colonoscopy service, which has led to some people dying prematurely of cancer. Last October, then health board chair Dave Cull apologised for “lapses and inadequacies”, after the latest of three external audits found more than half of 32 cases reviewed were inappropriately managed.
One of the report’s criticisms was patients who appeared to meet acceptance criteria were declined or delayed, while some of those accepted faced long waits. Early detection is key – if bowel cancer is caught early enough, nine of 10 people can be cured.
Newsroom asked Southern DHB to provide monthly referrals data since it joined the national bowel screening programme in April 2018. But chief executive Chris Fleming says: “We do not have accurate data for referrals accepted and declined specifically for colonoscopy prior to December 2020 due to the way the data has been captured.”
Fleming says that’s because, before last December, the way data is entered into its system didn’t allow for declines for colonoscopies to be “accurately identified” over and above declines for other gastroenterological appointments and procedures.
That might surprise the authors of the colonoscopy service’s last external audit, who reported annual decline data back to 2013. (The report said in 2019, the latest year reported, there were 326 referrals declined in 2019 and 1754 accepted – a decline rate of 15.7 percent.)
Sarah Dalton, executive director of the Association of Salaried Medical Specialists, says: “I’m just a little bit taken aback by what you’ve just told me about the DHB claiming they can’t provide data.”
The union has serious concerns about Southern DHB, she says. “The fact that despite a lot of ink being spilt on this it hasn’t resulted, we think, in positive action or, as you show, measurable difference.”
A 2019 Health Ministry report says all DHBs are required to monitor and report colonoscopy declines. The same document notes New Zealand has one of the highest rates of bowel cancer in the world, and it’s the second-biggest killer after lung cancer.
Newsroom asked Southern DHB if it had to provide decline data to the Ministry of Health.
“Without further investigation we cannot comment as to whether it was specifically requested prior to commencement of the Bowel Screening Programme,” Fleming says.
That’s an odd answer. It doesn’t explain the two-and-a-half-year gulf in data between April 2018, when the national screening programme started, and December last year, when colonoscopy decline numbers started to be kept in accordance with ministry policy.
The Ministry of Health ignores Newsroom’s questions, about whether it’s concerned about the DHB’s data gap.
Instead, in an emailed statement, Deborah Woodley, the deputy director-general of population health and prevention says Southern DHB will consider the latest declines data at an upcoming board meeting, “and the Ministry of Health will be following up with the DHB after that”.
Unbidden, Woodley then embarks on an explanation about Southern DHB’s referral process. The national criteria for colonoscopies is binary, the statement says – it either meets the criteria or does not. Any declined referrals are reviewed, after which they might be: accepted, referred for another “more appropriatet” test, referred to a clinic, asked for more information, declined with no further review.
Three months of data
What Southern DHB did provide in its Official Information Act response was three months of colonoscopy decline data from December 1.
On a straight comparison between cases accepted and declined, Otago’s decline rate was 17 percent, while Southland’s was 22.5 percent. Over the three months, the DHB declined 271 cases out of 1451, or 18.7 percent.
What that means is almost one in five patients referred for a colonoscopy, usually by a GP, was declined.
By Southern DHB’s own admission, that’s relatively high. Last November – at a time, remember, the DHB now says it didn’t have accurate data – concern was raised about the DHB’s 15 percent colonoscopy decline rate, when compared to about 3 percent in “most other DHBs”.
Fleming, the DHB boss, says the figures provided to Newsroom give an “absolute rate”.
He says a significant subset of declined patients are redirected to other, “more appropriate”, services, like gastroscopy, CT scan of the bowel, surgical outpatients or gastroenterology outpatients. Other patients are declined because of the inability of the patient to undergo colonoscopy, requests for further information, and a request for non-symptomatic colonoscopy that didn’t meet the criteria.
In the “most recent period” – which wasn’t specified – Fleming says the DHB’s decline rate for patients excluding those categories was 7.6 percent.
Critics of the service would say you can’t exclude those categories, however – not when a ruthless triaging regime in the past has meant people who needed colonoscopies didn’t get them, including those redirected to less effective procedures.
Given past mismanagement, there’s suspicion the overly stringent application of guidelines continues.
Canterbury Charity Hospital Trust chair Philip Bagshaw – a Christchurch surgeon who co-authored an audit of Southern DHB’s colonoscopy cases published in 2019 – says Southern DHB’s raw decline rate for colonoscopies is very high, and an indication that people who meet the guidelines for a colonoscopy are being rejected.
Bagshaw was lead author of a recent article in the NZ Medical Journal which questioned the ministry’s decision to allow Southern DHB to join the national screening programme.
He tells Newsroom: “If I was organising a system to decide whether a DHB is ready to start doing screening or not, the decline rate would be one of the benchmarking standards that you would want to use, because it would be an indication of just how many people are being turned away.
“Accepting that some should have been turned away, but if they’re regularly having a high decline, higher than everywhere else, but it’s supposed to be using the same sort of standards, then you would be worried, wouldn’t you?”
Bagshaw has called for a public inquiry into the DHB’s colonoscopy service – a call resisted, so far, by Health Minister Andrew Little.
“They are declining a lot of endoscopies,” Bagshaw says of Southern DHB, “and we are very concerned that quite a lot of these actually do have advanced malignant disease.”
The dearth of data also worries cancer care advocate Melissa Vining, of Winton, whose late husband Blair’s case made national news. Vining, who sits on the DHB’s endoscopy users group, told Newsroom she also wanted to know how many people are turning up at emergency departments with late-stage cancer.
In the same article, Andrew Connolly, the Crown-installed monitor and colorectal surgeon who chairs Southern DHB’s endoscopy oversight group, said symptomatic waiting times were very good.
Recommendations from the colonoscopy service’s last audit, by Auckland colorectal surgeon Professor Ian Bissett and Rutherford Clinic general manager Kate Broome, are being incorporated over time, Connolly says.
Signs of improvement, however slow, might be accepted at a well-functioning service, but there’s copious evidence of multiple historic problems, as well as ongoing ones. Earlier this month, the DHB’s executive director of specialist services Patrick Ng raised issues with a backlog of Southland patients, colonoscopy rooms sitting idle because of a lack of staff, and poor data reporting.
(Southern DHB, as a whole, is under severe strain with a “code black” for Dunedin Hospital beds in March, and an official request for private medical contractors to treat breast and prostate cancer patients to reduce its surging waiting list. All this while a new, $1.48 billion hospital is planned for Dunedin.)
The three external audits of Southern’s colonoscopy service were sparked by complaints from Southland surgeons who complained, over a number of years, their referrals were being declined when patients met the criteria. Expert reviews of cases agreed there had been wrongful rejections.
The Bissett/Broome audit said endoscopy capacity was “constrained”, putting “undue pressure” on those referring and triaging patients. The implication is there was pressure to decline patients, or delay access.
Delays can have severe consequences. The Bissett/Broome report, which reviewed 50 cases, said two patients who were delayed access to colonoscopy services were later diagnosed with “end-stage, inoperable disease”.
The report also noted unacceptably long delays which “suggest a service that is struggling to provide the colonoscopy volumes that are required to meet the population needs”.
That was nine months ago, but concerns remain. Bagshaw, the Christchurch surgeon, says there was evidence the service improved, for a while. “They are now slipping back into their old ways. And people are going without who should have an endoscopy.”