CA Daverick: Equity Adjuster Tool - Fair Go or Vote Catcher?

Once again, the Control Freak Labour/Green/Te Pati Maori government has seen fit to interfere in the health sector on the basis of “we know best.”

The issue is so-called “equity of access” and there is a view that the health system does not adequately address all the issues in deciding an individual’s place on a surgical waiting list.

Before the introduction of the Equity Adjuster Tool, surgical specialties had their own scoring system which was based on clinical need.

Put simply, the more seriously sick you were, the more rapidly progressive your condition, the greater the impact it would have on your survival and quality of life, the more urgently you received treatment. This is clinical need.

Additional factors now have to be taken into account and these are:

The time an individual has already waited for treatment;

An individual’s location - someone who lives further away from the hospital ends up with a better “points score” than someone who lives close by;

Deprivation status - someone who is poorer goes up the queue;

Ethnicity - if you’re Māori or Pasifika, you get a bigger points score so move up the waiting list.

There has been criticism of the ethnicity criterion on the basis that this determines eligibility for treatment on the basis of race. The justification for the ethnicity criterion encompasses the terms poorer outcomes and racism, institutional or otherwise. These poorer outcomes, apparently, are a failure of the current health system. However, no evidence has been produced to support this assertion and there is plenty of commentary pointing out that poorer outcomes are due to many factors external to the “bottom of the cliff” health system. This government cannot produce a definition of racism so quite what is meant by “institutional racism” remains a mystery.

All of the factors require careful consideration. Clinical need is a given – serious illness, rapid progression, impact on survival and quality of life necessitates more urgent treatment. Surely, nobody can argue with that.

What about the other factors? “The time an individual has already waited for treatment” – what does that mean? Treatment for what? And at what point does the clock start on the waiting time, and who decides that? Currently, referrals for a specialist opinion are triaged. A large number of referrals are declined on the basis that they do not meet the “threshold” for being seen. Does the clock start from the date of the initial, declined referral? Now, clearly, most declined referrals are for conditions which do not necessitate an urgent assessment. Assuming the individual’s condition does not change, is it now considered that subsequent referral and acceptance of the need for a specialist assessment means that the individual is moved up the surgical waiting list because they have already “waited for treatment”? If so, it needs to be borne in mind that this will be treatment for a minor condition and it will push someone with a more serious condition back down the waiting list. But it is not quite as simple as that. Not only are referrals triaged but the placement of an individual on the surgical waiting list is also subject to restriction. The surgeon may tell you that you need a procedure and do the paperwork to place your name on the surgical waiting list. Subsequently you may receive a letter from the hospital indicating that you have once again “not met the threshold” and therefore, despite the surgical advice you have received, you are not on the waiting list. Does the clock start then?

But let’s assume that you have made it onto the surgical waiting list. You have been given a date for your surgery. For whatever reason it does not go ahead on that date. There may be events in your personal life such as the development of another medical condition, a bereavement, or you may have to move because of your job or for other reasons and end up in another hospital’s catchment area, which can result in the whole process starting again. The hospital may cancel the proposed date of your surgery. Does the clock start at any of these times? If the hospital cancels the date of your surgery my experience has been that every effort is made to treat the individual as expeditiously as possible after that cancellation date. Similarly an individual who moves to another hospital catchment area is generally dealt with reasonably expeditiously if already on a waiting list. This is common sense and it doesn’t require formalisation. The time an individual has waited for treatment is likely to result in a large and foggy grey area, subject to dispute, complaint and argument. It should not be a scoring criterion.

“Location” is another difficult area. Are we talking about physical location, i.e., distance from the hospital or we talking about travelling time? If you live in Auckland you may be quite close to the hospital but it might take you a long time to get there, particularly at certain times of the day. And why on earth is distance from the point of treatment considered to affect an individual’s position on a waiting list? And who decides what that distance will be? What is the reason for this? An individual who lives a long way from point of treatment might want to talk to their employer about the amount of time they will require to be away from work, to possibly check into a nearby motel or stay with a friend or relative the day before an appointment is due, but why should it have any impact on the position on the waiting list?

“Deprivation status” also requires some careful thought. We have known for a long time that serious illness is more prevalent amongst the lower socio-economic groups. It was not by accident that many of the great teaching hospitals were located in poor areas. The effects of deprivation are reflected in clinical need. But there is an additional reason for being concerned about this. Your socio-economic status may determine how readily you can access publicly funded treatment. Let’s take it to an extreme. Supposing both the referral and subsequent placement on a surgical waiting list required you to submit your last year’s tax return for all of the people living in your household. You receive a letter from the hospital telling you that you are deemed to be too well off to qualify for publicly funded treatment. The translation - you’re not getting publicly funded treatment, you are well enough off to use the private sector. Ordinarily this proposition would be considered to be the ravings of a lunatic, but with this government? Already the wealthy have been forced to reveal very detailed information to the IRD so that the government could launch a propaganda campaign about our “unfair tax system.” Whilst the proposition above is going too far, “deprivation status” does suggest that socio-economic standing may disadvantage people who pay a substantial amount of tax and who find a service they expect to be able to access becomes further remote. There is no justification for determining a place on the waiting list on the basis of “deprivation status” when the effects of deprivation are reflected in clinical need.

Finally, ethnicity. It has all been said. It is totally unacceptable to determine an individual’s priority for treatment on the basis of ethnicity. The government has been unable to define racism but it has certainly provided an excellent example.

No information has been provided about how the different sections of the Equity Adjuster Tool are scored. One would hope that clinical need is weighted heavily and that the other factors attract a much lower score. The government needs to be upfront about this. Details about how exactly the system works in practice, other than just the statement that ethnicity is only one of five factors, needs to be provided. The major focus has centred around ethnicity so the question is what is the weighting of the ethnicity factor compared to the other four factors?

Notwithstanding, the Equity Adjuster Tool should be headed for the round filing cabinet ASAP.

C A Daverick is a retired doctor with extensive public and private practice experience.