A suggestion to restrict emergency care to some has provoked an explosive reaction. David Williams reports
The evidence is all around.
Look at the lights that pop out of the ceiling in Whangārei Hospital’s intensive care unit. Or join the horror at an 84-year-old waiting 23 hours to be seen in Palmerston North’s overcrowded emergency department. Then there’s the 117 people in the Southern District Health Board area who have waited more than 600 days for surgery.
The already creaking health system, and hard-working staff and managers, are being pushed to breaking point by Covid-19.
A year ago, while announcing the creation of Health New Zealand and the Māori Health Authority, Health Minister Andrew Little said the current system no longer serves the country’s needs well.
“People are not getting the healthcare they need when they need it,” Little said, blaming people living longer and developing more complex health issues.
There are many arguments about how to fix it.
But a suggestion in an editorial in February’s edition of the NZ Medical Journal went to such extremes it’s being described as “disturbing” and “draconian”.
Breaking the taboo
“Is it acceptable to continue to have unrestricted access to a hospital or service that has exceeded sustainable working conditions?” asks Christchurch surgeon Saxon Connor in the editorial.
His taboo-breaking suggestion is to explicitly and systematically ration healthcare to some of the sickest people who turn up at emergency departments – or, in health parlance, rationing access to acute secondary care health services – to “save the Aotearoa health system”.
Connor, a hepato-pancreto-biliary surgeon, muses: “Is ‘cradle to the grave’ philosophy still appropriate, sustainable and affordable?” He also asks: “Is it morally and ethically acceptable for a generation of health privileged individuals to leave a legacy of financial debt and a decimated workforce in pursuit of delaying an inevitable death at any cost?”
A category of patients would not be admitted to hospital but “offered compassionate care at home or in residential care”. “How such an approach could translate across a whole spectrum of emergency specialties and disorders is unknown.”
A “Cullen fund” for health is suggested. Individuals “privileged enough” to live beyond the “agreed outcome” would pay for their healthcare.
Consensus on the approach could be found using citizen juries, and a “multi-criteria decision-analysis support tool” could prioritise patients using “individual weightings” and incorporating “stakeholder preferences”. “Unwanted variation” could be removed from clinical decision-making, and the frequency of “futile treatment” reduced.
Connor notes in-patient costs in the final year of life “are eight-times higher in comparison to costs for age-equivalent individuals who did not die in the same time-period”.
Active rationing could help society understand the health system’s limitations, he writes. “It would allow people to think ahead and potentially reconsider how they plan to use their wealth as they age.”
“A rationing of acute care is a draconian step of unthinkable consequence.” – Phil Bagshaw
Forceful letters in the latest edition of the Journal rail against Connor’s suggestions.
They’ve been compared with a United States-style system. Despite spending the highest amount of any country per capita on health, the US has 27.5 million people who, because they’re uninsured, have no access to publicly funded healthcare, and live in fear of falling sick.
Gil Barbezat, Emeritus Professor of Medicine at University of Otago, described the editorial’s theme as abhorrent and disturbing.
“The shoe needs to be designed to fit the foot, not the foot squeezed into whatever footwear is cobbled together by ad hoc assembly of readily available historic components.”
A letter from the Association of Salaried Medical Specialists (ASMS) says the country’s health spending, measured per capita or as a percentage of gross domestic product, is relatively low when ranked alongside comparable countries. Yet those countries – apart from the United States – have better health statistics, and stronger economies.
The lead authors of another rebuttal were Philip and Sue Bagshaw, founders of Canterbury’s charity hospital.
They said factors such as poverty, access to primary healthcare (GPs, pharmacies, dentists), inadequate housing, and poor diet, were a major cause of increased demand. Yet the lowest-decile groups, with the worst predeterminants of health, also had the poorest access to healthcare.
Phil Bagshaw told Newsroom that people had learnt to live with the rationing of planned, non-urgent procedures as a consequence of Rogernomics and the 1990s health reforms. Connor’s article basically advocated tearing up universal healthcare.
“A rationing of acute care is a draconian step of unthinkable consequence.”
In the same Journal issue, Bagshaw and seven authors provided an update on the charity hospital, which provides free services for those unable to pay for private care, or who have slipped through the cracks of the public system. That includes dentistry, counselling services after the 2019 terror attack, and endoscopy procedures for those aged under 50 with rectal bleeding.
Over eight years, there were 3903 outpatient appointments and 11,752 interventions.
Bagshaw says most people would be horrified by Connor’s rationing proposal. “History has shown that once you start rationing something, Governments will go on and on and on,” he says. “’Not on my watch’ would be my chief comment.”
(Connor didn’t respond to a request for comment. But in a response to the letters published in the NZMJ, he wrote: “Although many of the points are well made, none of the responding authors offer practical solutions to the issues those working at the coalface in secondary care are currently facing every day. Nor is it acknowledged that, like it or not, implicit rationing is a daily occurrence in the Aotearoa secondary health care system.”)
“If we’re serious about health as a public good then we are doing our modelling and our funding all wrong.” – Sarah Dalton
Dr Samantha Murton is president of the Royal New Zealand College of General Practitioners. She says hospitals will continue to be overwhelmed without greater investment in community care.
“Rationing at the point of contact with patients is probably unfair on the patient because they don’t know what services are available where. They can’t afford to go to the GP, or there’s no space at the GP.”
ASMS executive director Sarah Dalton says rationing access to hospital-level acute care is throwing in the towel, and a wider discussion is needed about appropriate funding, preventive approaches, and the social and commercial determinants of health. What would also help is a clearer picture of the health need, and how the system is functioning.
“If we’re serious about health as a public good then we are doing our modelling and our funding all wrong at the moment because people are not at the centre.
“And, yes, health can feel like a bottomless money pit in terms of cost, but I think all of the research says there are strong cost-benefit arguments for a whole bunch of things that we’re not even doing at the moment.”
Dalton picks out dentistry. If adults were subsidised to access dental care, at or above the rates of GP subsidy, “there’s a whole bunch of way more serious, way more expensive conditions, health conditions that would disappear”.
About 1.6 million New Zealanders avoid dental visits because of the cost. A story in March’s North & South magazine details how people with oral health issues are predisposed to chronic conditions like cardiovascular disease and cancers.
Dalton says: “The cost-benefit for pumping money into supporting people to access dentists, early and often, well-offsets the downstream effects.”
Connor’s right when he says even if a massive boost healthcare materialised tomorrow, services couldn’t be improved immediately because of staff shortages and poor infrastructure.
“So it’s gnarly, and it’s difficult,” Dalton says. “But I don’t think we should let shooting for perfection get in the way of doing better than we are now.”