A Review of the Elective Services Orthopaedic Major Joint and Ophthalmology Cataract


Report prepared for the Ministry of Health
Philip Gandar
Synergia Limited
7th July2008

Summary 3

Recommendations 6

1. Overall 6

2. Review specific procedure target service levels 7

3. Prioritisation 9

4. Capacity and productivity Development 10

5. Funding & monitoring 11

6. Learning & innovation 12

Purpose, scope and intent 14

Context 14

The structure of the initiatives 15

Review approach 16

Document Review 16

Service performance data analysis 16

Online survey 16

In-depth interviews 17

Analysis 17

Review findings 19

The process of implementation 19

Aim 1: Sustainable increases in service level 25

Aim 2: Treatment access based on need and ability to benefit 36

Aim 3: Dealing with people well 42

Aim 4: Improving capacity and productivity of public sector elective services 49

Aim 5: Developing our organisations’ capability to innovate and learn from others 62

Overall assessment of results 67

Lessons for the future 69

Appendix 1 Detail Survey Results 72

References 78

About the author:

Philip Gandar is a partner in Synergia, a health research, evaluation, strategy and service design company based in Auckland. He has extensive prior experience in the design and implementation of the electives services programme across New Zealand.


This report provides the results of a review of the Orthopaedic Initiative (OI) and the Cataract Initiative (CI) commissioned by the Ministry of Health in association with the New Zealand Orthopaedic Association (NZOA) and the Royal Australian and New Zealand College of Ophthalmologists (RANZCO).

The review provides both a retrospective view on the achievement of the initiatives, relative to their original intent, and a prospective view of key learnings and priorities for the future evolution of the initiatives.

Overall the two initiatives have successfully increased the level of service for people needing hip and knee replacements and cataract surgery. Since these procedures are highly effective in alleviating the burden of their respective underlying degenerative diseases this increase in access has restored functioning and wellbeing to thousands of New Zealanders who otherwise would not have had timely treatment. Earlier treatment has taken away years of disability burden and increased treatment levels have been effective in reducing disparities of access to treatment.

As often is the case, success can have its unintended consequences. For example before the initiatives commenced people needing joint replacements had inequitable access and higher levels of need than most other elective patients. That situation has been redressed but the increase in service level for specific conditions has created different inequities as some people, with other conditions and higher levels of need, remain untreated; firstly as a direct consequence of the focus on treating joint replacement or cataract patients and, secondly, through a more general effect of ‘crowding out’ other services drawing on the same limited hospital resources, e.g. specialist time or physical facilities.

Two key aims of the initiatives were to lift service levels and develop sustainable public sector capacity to efficiently deliver services. While the first has been achieved the sector as a whole has struggled to develop sustainable capacity. Although there are some outstanding and instructive examples of success in rethinking service models and creating innovative solutions to increase productivity and capacity, most District Health Boards (DHBs) have not succeeded in this requirement, and are stressed and struggling to deliver their increased service commitments.

A central finding of the review is that the failure to build sustainable capacity arises from limitations in how the sector collectively understands the role and function of elective services within the broader systems of health care. The tendency amongst hospital managers, funders and boards is to equate ‘elective’ with ‘discretionary’ or ‘optional’ and therefore give low priority to building elective capacity, relative to the competing demands of acute care or managing the rising burden of chronic diseases.

The challenge is to integrate the thinking, planning and funding of elective services within a broader context that includes long term conditions and acute demand management. Only by seeing electives as a critical part of our planned, proactive and managed response to health needs we will understand its function as something other than the ‘optional’ care provided after dealing with unplanned and unmanaged acute demand. Without this shift in collective thinking most DHBs are unlikely to create the sustainable, value focussed systems and capacity that will be required.

Shifting from the conceptual to the practical, the review believes that the initiatives’ most significant long term success will be seen in its supporting role in facilitating innovative DHBs and services to develop examples of new ways of thinking, planning and operating - a whole system/patient centred model that demonstrates a new level of effective, efficient, people centric care.

Within the body of this report the results and forward looking recommendations are summarised under the five broad aims of the initiatives:

  1. Sustainable increases in service level: Both initiatives have substantially reached the planned levels of intervention and have delivered the additional procedures without erosion of base volumes of joints or cataracts. Previous levels of variation in service provision across the country have been largely reduced. People needing joint replacement or cataracts are now generally able to access treatment with minimal waits. In some DHBs it is considered likely that the target service level is too high and may exceed the incidence rate of the underlying degenerative disease.

However this increased level of service has come at the cost of generating inequities of access for other, non-initiative procedures. Within the CI this is of particular concern for the ongoing care of chronic conditions - diabetes; age related macular degeneration and glaucoma that can cause permanent, irreversible vision loss in those of working age.

  1. Access based on need and benefit: The intention of the initiative was to ensure that there were consistent processes for clinical prioritisation and assessment across the country. This has been partially achieved with all services using recognised tools and improved linkages between assessed priority, treatment decisions and timeliness of treatment. However the service imbalances described above have generated deep concern from many clinicians that this undermines their ethical responsibilities and the principles of fairness which are core to elective care.
  2. Handling patients well: Handling patients well requires that their journey from referral, through assessment and treatment is timely, that they are kept informed of their plan of care, know if treatment is available and can depend on the commitments given by the service. As measured by the Elective Services Patient Flow Indicators (ESPIs) both services have achieved the standards of performance expected of them.
  3. Developing sustainable capacity: In this area there are some notable examples of success where changes to the model of care and service provision have increased productivity and developed sustainable capacity. However for the majority of DHBs, despite having made substantial efforts to improve processes and invest in capacity and achieve target volumes, their progress towards sustainability has been slow. Specific components of the initiatives designed to support productivity development, such as the Continuous Quality Improvement (CQI) facilitators and nurse scholarships, have overall been worthwhile investments although with large variation in scope and scale of impact. In retrospect the expectation that relatively limited initiatives could, by themselves, develop sustainable capacity in the face of competing demands for resources, complex interdependencies and constraints, seems unlikely. These issues require a level of strategic focus and investment across multiple fronts beyond that achieved by most DHBs to date.
  4. Developing a capability to innovate and learn: This area, central to any effort to develop sustainable systems, has been variable in its reach and impact across the country. However, on a positive note the experience of the last three years has generated a wealth of knowledge and experience across the country about what works. Where-as the challenge at the outset of the initiatives was to stimulate innovation and identify new ways of working the challenge for the next phase is to propagate and integrate the best of these innovations more broadly to improve the impact on the system as a whole.

A summary map of the recommendations of this review is shown in the diagram on the following page:

Synergia – OI-CI Review Page: 2

Figure 1: Overview of recommendations

Synergia – OI-CI Review Page: 2


1. Overall

1.1 Continue and extend the overall approach

The strategy of using high volume/high benefit procedures within a service to act as anchor points to target increased service levels has been successful and is worthwhile retaining within Orthopaedics and Ophthalmology as well as extending to other services as part of the wider Electives Initiative.

However the unintended consequences on other procedures that has been found in the both initiatives requires a different approach and should be minimised through an analysis of the mix of population health needs and targeting a more balanced service response (see recommendation 2 below).

1.1.1 Retain the structure of the initiatives for a further period of 3 years.

The first recommendation of this review is that the initiatives are maintained for a further 3 years in order to continue support for service level gains, prioritisation improvements and, in particular, facilitate continued productivity and capacity development.

1.1.2 Redesign the initiatives to reduce the level of unintended consequences and integrate with current policy frameworks

This review has demonstrated that the initiatives require redesign to reduce the level of unintended consequences and to bring the initiatives up to date with current policy frameworks. This should be done in consultation with the sector (see recommendations below).

1.1.3 Implement an alternative model for DHBs that demonstrate that they have established sustainable systems

This recommendation is proposed in order that the leading DHBs with sustainable systems of improved capacity are able to increase their flexibility for further development and innovation and reduce monitoring/compliance costs. Management of the achievement of standards and intervention goals could be done through normal processes of District Annual Plan development and monitoring.

1.2 Rethink the role and function of electives within the overall system of care

Running throughout this review is an underlying issue that the role and function of elective services within wider health services response is poorly conceptualised and understood. This results in conflicting priorities in funding, investment and operations thereby limiting the development of sustainable capacity and is contributing to the deep unease felt by some clinicians of an unbalanced and ethically problematic approach to care. By contrast, those DHBs that have clarity over the role and function of elective services have been successful in meeting the wider aims of these initiatives.

While warranting further discussion, beyond the scope of this review, we would make the following recommendations.

1.2.1 Establish a joint working party to review the role and function of electives within the wider systems of health care.

This recommendation requires a joint working party of DHBs, the Ministry and Colleges to rearticulate the priority, role and function of elective services within a population approach to health and develop a paper that will serve as a planning framework for district investment in sustainable service provision, productivity improvement and capacity/facilities planning.

The focus on waiting list management and service levels for specific procedures has tended to disconnect elective services from the macro prioritisation based on underlying population health needs that is the combined responsibility of DHBs and the Ministry. The OI and CI, with centrally prioritised and ring-fenced funding for specific procedures was required since prior patterns of local prioritisation undertaken by most DHBs had resulted in poor levels of access over many years. However the reasons for the different priorities have not been explicitly explored, debated or understood. The impact of this goal conflict is most clearly seen in the limited development of sustainable capacity and, we believe, will continue to limit the future success of this initiative and the broader electives funding package.

1.2.2. Adopt a whole system/patient journey approach as a formal part of electives strategy to achieve better health outcomes and increase efficiency

Current focus on specific elective procedures leads to the belief that health value is only created on the operating table, hence the capacity that matters is that clustered around that table; surgeons, anaesthetists, theatres etc.

However those DHBs that have been successful in the initiatives have taken a whole system/patient journey perspective and described a pathway of escalating planned care responses that start with advice to GP, deployment of functional support to help increase mobility, manage pain, and reduce the impact of excess weight. Further along the pathway, those with complex situations and multiple conditions gain access to more coordinated responses across the spectrum of need, managing CVD risk for example, rather than being seen as simply medically unfit for treatment. Post-surgery, the care journey includes rehabilitation, recovery and reintegration support.

In Canterbury DHB the use of a patient journey approach reduced demand on critical constrained workforce capacity and was achieved within existing resources. By contrast those DHBs that are procedurally focussed, and juggling capacity across electives and acutes, tend to see the solution as increasing capacity or recruiting more staff. While there are clearly situations where more staff are needed the rising scarcity of critical workforce means this is unlikely to be the solution by itself.

To date the OI and CI have promoted the use of whole system approaches such as patient journey analysis but only as tools. We recommend the lessons from leading DHBs are formally developed, adapted and adopted as part of a whole system/whole journey approaches to elective care within electives strategy to achieve better health outcomes and increase the overall efficiency of care delivery.

2. Review specific procedure target service levels

2.1 Establish national working groups within Orthopaedics and Ophthalmology (including clinicians, planners, funders and providers) to identify the desired mix, level and balance of service

The major unintended consequence of the initiatives is that the focus on specific procedures (particularly high visibility surgical procedures) has detracted from the mid level prioritisation structures that each service has developed to allocate resources across types of need and procedure.