“The health system remains under pressure.”
That was the stark warning from health officials that the health minister received every Friday for 10 weeks in a row earlier this year, according to a dozen briefings released to Newsroom under the Official Information Act.
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Weekly reports on the state of the health system were sent to Andrew Little, then Ayesha Verrall, warning about hundreds of ambulance hours lost to ramping, lengthy waits at emergency departments and unsafe staffing levels for more than a quarter of nursing shifts. The problems are systemic, touching nearly every part of the country frequently throughout the 12 weeks covered by the documents.
In Auckland, occupancy in the paediatric intensive care units rose above 100 percent in late January and early February. In Porirua and Kapiti, pharmacies had to reduce their hours in mid-February because of staff shortages. In early March, Whakatāne hospital averaged 100 to 119 percent occupancy and staff reported significant fatigue in the aftermath of the cyclone. A week later, Canterbury reported inpatient occupancy of 97 to 110 percent, prompting South Canterbury to redeploy an anaesthetic technician and theatre coordinator to help out.
Nationally, it took ambulances an average of 34 minutes to respond to a 111 call, and bed blockages at hospitals meant they waited for an average of 63 minutes to hand over patients to ward staff. In the final week of March, nearly 1000 crew hours were lost to ambulance ramping – a third above average.
Generally about seven in 10 visitors to emergency departments were admitted or discharged within six hours, but the data in the reports offers new insight into this crucial statistic. The weekly updates break down the emergency department stays by those who were eventually admitted and those who were discharged. For patients who actually needed further hospital-level care, only 53 percent were seen within six hours.
Wellington performed the worst, with three quarters of patients who were admitted regularly waiting more than six hours.
The figures provide a new look at the state of the health system as it struggled with abnormally high patient loads and staffing shortages. They cover the period from January 1 to April 2 and therefore don’t take into account additional demand that built up over winter.
Nonetheless, they tell a grim tale of a health system that was, as 10 of the 12 reports began, “under pressure”. The documents were obtained via an Official Information Act request in April to Health Minister Ayesha Verrall.
Newsroom’s request was initially extended and then refused by Verrall’s office in June, under provisions that allow the Government to withhold information containing “free and frank” views of officials and ministers. Newsroom complained to the Ombudsman, who began an investigation. Before that investigation could conclude, the documents were released in late August.
In an interview, Verrall disputed the reliability of some of the figures provided to her by Te Whatu Ora, but said they were still useful for displaying trends. Frontline doctors and nurses, however, told Newsroom the data confirmed what they were seeing with their own eyes.
Safe staffing
One of the metrics included in the weekly reports – except two from the first half of February – is safe staffing levels for nurses.
The technical term for the indicator is “shifts below target”. It displays the percentage of medical, surgical and assessment, treatment and rehab shifts where nursing staff were “significantly below the required level for the patient case mix”. This is determined by nurses assessing the needs of each patient on a shift and totalling those needs against the resources available.
Where the care hours required are at least 8.5 percent above the nursing capacity, the shift is below target. This translates to about 40 minutes of extra work per FTE.
On average, 27 percent of all shifts were below target over the period covered by the documents. It was worse for day shifts, where two in five were regularly understaffed.
In the early months of the year, it wasn’t uncommon for more than half of day shifts to be understaffed in Waitematā, Auckland, Counties Manukau, the Waikato, the Wairarapa, and Wellington.
Verrall told Newsroom this metric had issues.
“I’ve worked, before coming into politics, with health system data considerably. It was immediately apparent, those operational data sets have a lot of limitations,” she said.
“The percentage of nursing shifts covered had a very unusual pattern at the beginning of the year. It had a pattern where one district had really bad numbers across all shifts as well. Then I visited and spoke to the director of nursing and it didn’t add up. I then talked to officials and indeed there was a systemic error in how that district’s data was being presented.
“If you’re measuring the same way over time, then you can rely on those things for trends. Something getting worse could be a warning. But, would you say something recorded at 70 percent means in real life it’s exactly 70 percent? No.”
Kerri Nuku, the kaiwhakahaere (chief executive) of the New Zealand Nurses Organisation, said the data confirmed what nurses had been experiencing.
“It vindicates what the nurses have been saying, when Te Whatu Ora have failed to provide the evidence or data. It matches up with what our nurses have said and the reason why after every shift they come home exhausted,” she said.
“I had a couple of calls from really upset nurses and we spoke to them about your data. These women were in tears because it was an acknowledgement around how shocking it has been. And then they tell their story of how depleted their workforce is.”
It’s like the boiling frog, Nuku said.
“How long do you continue on before something breaks? It’s the quality of care that is impacted on. Nurses go home broken, that they haven’t been able to do what they’ve needed to do.”
In July, the Government estimated it was short of about 4800 nurses and announced a Health Workforce Plan to plug this and other gaps.
“We had 3000 nursing registrations in the last quarter that the Nursing Council reported on, so we’re getting absolutely huge growth now,” Verrall said.
The staffing levels metric has been enabled through the Care Capacity Demand Management (CCDM) system.
“It’s a system which allows nurses to say how much care the patient needs and how many patients there are and therefore how many nurses they need on a ward,” Verrall said.
“That’s really important for safe staffing levels and an area where we’ve been progressively rolling it out but it is not complete. In the last Budget, we recognised that that was identifying need for more staff than we presently recognise, so that’s why there was a commitment to 500 additional nursing positions to fill CCDM vacancies.”
Nuku agreed that training new nurses was critical, but that it was a long-term solution.
“Unfortunately, this is going to take a long time to rebuild because it’s taken a long time to erode the workforce. So we’ve got to look at initiatives that actively retain the nurses we’ve got,” she said.
Shane Reti, National’s health spokesperson, said Labour hadn’t done enough to ease immigration pathways for new nurses.
“The emergency department sector has been conveying to me for some time that they are in crisis with hugely problematic staff shortages. A significant factor was the delayed decision by the Labour Government to give nurses a Day 1 pathway to residency,” he said.
Emergency departments
The “Shorter Stays in Emergency Departments” metric has long been a fixture of health performance reporting. Under National, a target was set for 95 percent of visits to EDs to be resolved with either discharge or admittance within six hours.
Though Labour scrapped the target, the percentage of ED visits that last less than six hours is still regularly reported. These figures are available in Te Whatu Ora’s quarterly reports, although they were the subject of controversy in March.
The weekly reports contain SSED data which wasn’t affected by that March error, however. They also break down the stays by those who were eventually admitted or those who were discharged.
The rates for people discharged are significantly better than average. Nationally, 71 percent of stays were shorter than six hours, but this rose to 78 percent for those who were discharged. On the flip side, people who needed to be admitted to hospital had to wait longer, on average, because of bed blocking. Just 53 percent of these stays were shorter than six hours.
“We fully support the breakdown because it actually helps us determine where the accountability lies and where the problems lie,” Kate Allan, the chair of the New Zealand branch of the Australasian College of Emergency Medicine, told Newsroom.
“SSED makes it about the emergency department. It’s not – it’s about the system. Breaking it up into the admitted and discharged streams helps show how much of that issue was related to getting people through the system. Bed block is the problem and occupancy is the problem.”
That’s something Verrall agreed with.
“Emergency department nurses and physicians will quite rightly point out that it’s not fair that it’s called the SSED and that they feel a little bit targeted by that measure. Actually it is a measure of the entire system and hospital performance so that’s probably a fair criticism.”
A range of solutions for this are being trialled, including through the Government’s winter response plan. Allan said improving aged residential care resourcing so older patients with more complex needs can still be moved quickly through hospital to free up beds would be key, as would more resources for mental health patients, who often require long stays.
Over the period covered by the data, about one in five resourced ward beds were taken up by a patient with a length of stay longer than a week.
“Emergency Department wait times have consistently deteriorated under this Labour Government,” Reti said. “National will bring back lifesaving health targets, such as emergency department wait times, to focus the sector on a goal and improve health access for sick and injured New Zealanders.”
“There are mitigations that we’ve been pushing, including programmes having hospitals having really good internal leadership on their flow. Which is the sort of day-to-day, bread-and-butter, nursing management of, ‘We’ve got a patient who needs to go home, can we get them home, get the bed turned over and have someone come up from ED in a timely fashion?’” Verrall said.
In addition to overcrowded EDs, another symptom of bed block and hospital flow problems is ambulance ramping. The data shows ambulance crews lost an average of 815 hours to ramping outside EDs each week – the equivalent of more than 20 staff working 40-hour weeks. On average, ambulances waited 33 minutes to hand over patients once they arrived at hospital.
“When adjusted for average shift times and utilisation, ambulance capacity was reduced by 18 ambulance shifts per day between January and March this year due to ramping,” Damina Tomic, the deputy chief executive for clinical services at Hato Hone St John said.
“We work closely with hospital staff to optimise the process of transferring the care of patients and this may include establishing an ambulance waiting area within the ED, to safely offload appropriate patients from ambulances to an area managed jointly by our crews and Te Whatu Ora nursing staff and conducting a review of the highest priority patients waiting in an ambulance to get them into ED faster.”
Though the data obtained by Newsroom only covers January to March, Nuku and Allan said the situation would only have deteriorated since then. Verrall compared Newsroom’s data against more recent weekly reports and confirmed winter saw increased pressure on the health system.
“Winter is typically the busiest time for our health services and this winter was no different. Provisional data shows that hospitals experienced sustained pressures, due to high numbers of ED presentations, admissions, and levels of hospital occupancy,” she said.
Reti blamed Labour for the immense pressures on the health system.
“Labour has consistently denied there is a health system crisis under their watch. They are wrong. National has been raising concerns about the state of the health sector for years, and Labour have only reacted during an election year. This is not good enough and New Zealanders deserve better.”
Nursing staff shortages would have worsened in winter because some would be off sick, Nuku said.
“It would have been far worse over winter. It may well be plateauing off now, but when I say plateauing off I mean going back to the position that you’ve got the data on. There has been no significant [alleviation] that our members have noticed at all.”
Allan believes that though there is increased pressure in winter, that may no longer drop away come spring.
“My sense is that things have gotten much worse. There’s even debate whether the seasonal variation is really a thing any more. It’s just this increasing pressure that we’re experiencing,” she said.
“It will be interesting to see whether there is an ease going into the warmer months. We’re not expecting necessarily that that will be the case. It’s definitely the worst it’s ever been.”
The worst it’s ever been – but also, maybe, based on current trends, the best it will be for a long while?
“That would be a fair assumption.”
In other words, the health system remains under pressure.
