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Dr Muriel Newman

Questions of Governance

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1 April 07

Questions of Governance

A Newman Weekly reader, Martin Visser, recently sent me a copy of a letter he had written to the Minister of Health on 28 November 2006 about the way his brother was being treated by the health system. In his letter he stated:

“My brother Anton Visser who lives at 228 Ormond Road Gisborne, was diagnosed with prostate cancer in 2003. I have been informed that in spite of numerous referrals and follow up phone calls by his GP Anton is still waiting 3 years later to see a urologist… his prostate cancer, while left untreated is now in an advanced state with a PSA reading of around 100”.

By December 5th, Anton had fallen and broken his arm in two places. Two days later a scan revealed his bones were riddled with cancer, and by the 12th his PSA level had risen to 340. On December 26th, Anton died.

Family and friends are understandably outraged. They believe the way that the government and the District Health Board failed Anton is appalling. They would like to see some accountability. At the very least they ask for honesty – if the government system cannot cope, then patients should be advised to seek health care elsewhere instead of leaving them in limbo thinking that help is just around the corner.

What is so tragic about Anton’s case is that with medical evidence showing that early detection of prostate cancer can save up to 90% of lives, if a national screening programme for prostate cancer had been in place – similar to the breast screening programme for women – his cancer would probably have been detected years earlier and could have been treated. A few years ago I presented a petition to Parliament calling for a prostate-screening programme (to view the submission, click here). While the Select Committee has not yet reported back on their findings, the Ministry of Health website states that they “do not recommend routine screening of men without symptoms for prostate cancer in New Zealand”.

The Prostate Cancer Foundation have challenged this advice, since prostate cancer often show no symptoms at all until it is well advanced, which is why several countries including the USA and Germany have routine PSA screening.

At the very least, a “warrant of fitness” health check for 50-year-old men (a comprehensive check-up being promoted by men’s health groups which would include a prostate cancer PSA test) should be introduced. That check-up would give GPs an opportunity to alert their male patients to key medical risks that they face as they grow older, as well as advising them on healthy living strategies.

Anton’s tragic case puts a human face to New Zealand’s health crisis and raises serious questions about systemic management failure. His death was preventable – he died because he was denied access to specialist care. But his death should not be in vain. It should shame the government into action so that others do not have to suffer what he did.

Bronwyn Howell, a lecturer in Corporate Management at Victoria University and Research Associate for the NZ Institute for the Study of Competition and Regulation is this week’s NZ Centre for Political Debate Guest Commentator. She has serious concerns about the efficacy of our health system’s governance arrangements and in an article “Governments, Governance and Trust: unpacking the fiduciary duties of NZ healthcare quangos” Bronwyn writes: “The health care governance systems and processes concerning over 20% of government expenditure appear to defy most rational principles of sound governance design. Ultimately, responsibility for this shortcoming lies at the feet of the politicians who have established these systems and the ministerial officials who advise them and carry out the disbursement processes. Questions need to be asked about what will be done to redress the problem”. (To read the article click )

Just this week the New Zealand Medical Association claimed that patient care was being compromised by a grave shortage of trained doctors and specialists in at least three District Health Boards – Southland, Wanganui and Wellington’s Capital Coast Health – with the Wanganui Health Board accused of “never-ending failure” during a Parliamentary Select Committee hearing. Meanwhile, health unions are warning that the health system will be “bogged down in industrial strife by the middle of the year”, further compromising the delivery of critical health care in New Zealand.

But it isn’t just the health boards and hospitals that are coming under pressure. In an excellent article “Why the Sick Will Pay More”, written by Bronwyn Howell for the NZCPD last year, she warned how Labour’s callous culling of hospital waiting lists would force the cost of the care of the patients who had been dumped to pass from the government onto GPs and their sick patients.

Under Labour’s new Primary Health Organisation (PHO) ‘capitation’ strategy, doctors in General Practice no longer receive a fee-for-service from their patients. Instead, the PHO pays them a fixed fee for each patient on their books, and they receive a price-regulated ‘top-up’ from patients who visit. That means that any GP unlucky enough to have large numbers of very sick patients – who should be in hospital but have been dumped from the waiting lists – who need frequent medical care, will be unable to recoup their costs.

In her article, Bronwyn explained it in this way: “Under the fee-for-service payment policy, GPs would have been indifferent to the effects of [the waiting-list cull] policies as full remuneration would have been received for each additional visit made, from a combination of government subsidy and patient payment. Under capitation, however, GPs must incur the additional costs of providing consultations that they would not have been required to make, had hospital treatment been provided, yet they receive no additional government funding for these additional consultations” (to read the full article, click here).

The cost pressure on doctors in General Practice has been further exacerbated by the generous pay increases that the government recently awarded nurses. With wages making up some 70% of the cost of running a medical practice and pay rises for nurses amounting to 20% last year and 17% this year (when the costs of an extra week’s paid holiday is factored in) the cost escalation in many GP practices is now extreme. It is little wonder that the number of GPs continues to fall.

Yet none of this has been recognised by the government, which contracted LECG Consultancy to set the level of fee increases deemed to be acceptable under their PHO price-regulation policy. As one irate GP put it: In the 2005/06 year, the LECG Report says a 2.1% increase in fees is reasonable. Yet General Practice wages bill increased by 20% not including other practice costs. In the 2006/07 year, the LECG Report says a 5.3% wage increase is reasonable, yet general Practices face wage increases of 17% not including other practice costs. This LECG Report is very seriously flawed. The data does not in any way represent what is going on in General Practices around this country!”

Under the surface of New Zealand’s health system, big trouble is brewing. The concept of a universal health insurance for every New Zealand citizen is looking more attractive by the day!

The poll this week asks: Do you support the concept of a warrant of fitness health check for men? I would also like to invite anyone with a health horror story they would like to share to submit the details. Take part in poll

Reader’s comments will be posted on the NZCPD Forum page click to view .