It is common for doctors in our public hospitals to also work in the private sector, creating a conflict for the doctors involved. Here is a typical example of how our public and private health sectors interact.

‘Jennifer’ was advised she would need back surgery. Because there was a lot of pain and a risk of paralysis, the doctor advised the operation should be performed soon. However, she would have to wait up to eight months for treatment in the public system.

On the other hand, if she had private health insurance, or could pay about $50,000 from her own pocket, she could receive an operation within two weeks in a private hospital. Long waits for public treatment clearly increase demand in the private sector. What would happen if we got rid of long waits?

Reducing the public hospital wait for Jennifer to something like the 2-4 weeks on offer privately would mean a large drop in demand in the private sector. Because doctors are generally paid a much higher rate when they work in the private sector than they earn in public hospitals, doctors with dual practices would suffer a drop in income.

This conflict has long been recognised in the UK health system, and efforts have been made to address it. Meanwhile the issue barely gets a mention here.

Operations such as hip and knee replacements, the back surgery Jennifer needs, replacing a heart valve, and cardiac bypass surgery, are classed as elective. This doesn’t mean unnecessary or optional, it simply means the service is provided seven or more days after the decision to proceed with treatment.

The current maximum waiting times for these procedures are four months to be assessed by a specialist after a patient is referred by their GP and a further four months to be treated following assessment.

However, even these modest targets are proving too difficult for some district health boards.

For example, the Ministry of Health’s website showed that in February this year Auckland Orthopaedics had required 42 per cent of patients to wait longer than four months from assessment to treatment and at Hutt Valley Ophthalmology, 14 per cent of patients had waited longer than four months to be assessed by a specialist, while 12 per cent of patients had waited longer than four months from assessment to treatment.

Whether led by National or Labour, reducing waiting times has been a priority for successive governments for the past 22 years. Before then, we had waiting lists that some people stayed on for years, many never receiving surgery.

The change from waiting lists to booking systems in the mid-1990s signalled a serious intention to do better for public patients. Waiting times would be reduced and patients would have the certainty of an actual booked appointment time.

Points systems and qualifying thresholds for treatment were introduced to make the system fair and transparent. They would also give governments a sound basis for investing more money to lower the thresholds and get more people treated.

As part of this push, the Government invested $260 million to clear the large backlogs of patients on waiting lists. Later, a central pool of funding for extra electives (above what DHBs were already delivering) was set up. This pool has increased from $132m in 2007/08 to $364m in the current year.

But despite it being a priority, and very significant financial investment, we have yet to achieve what was envisaged 22 years ago.

What needs to happen?

Waiting several months for treatment causes an unacceptable level of pain, disability, anxiety and disruption to the lives of the people affected. This situation won’t improve without making changes. To make a start, one of our larger DHBs should take the lead by offering a new contract to doctors in one specialty (e.g. cardiothoracic) to work exclusively in the public sector.

The contract would include milestones to cut the current maximum waits in half and provide patients with the earliest possible booked appointment times.

Funding would be provided to the DHB to pay more to doctors willing to give up their private practices.

Next, the DHB managers and clinical staff would make the changes they need to run a more efficient service. This could mean greater separation of elective and urgent cases so that fewer electives are ‘bumped’. It could also mean nurses and other staff being employed more flexibly (e.g. as surgical assistants) to release surgeons to perform more operations.

Can we afford it?

The cost of paying more to some doctors needs to be compared with the high costs in the present system – the costs for patients waiting for treatment, the extra money that governments keep investing in electives, costs to people who take out private insurance to avoid long waits, large co-payments for insured people, and costs for those who pay for private treatment out of their own pockets.

With the system under review, the time is right to start talking about the elephant in the waiting room – dual-practice specialists.

Kathy Spencer was a deputy director-general in the Ministry of Health, a general manager in ACC and a manager in the Treasury. She has also worked as a senior adviser to a Minister of Health and a Minister of Revenue.

Source: NZ Herald


  1. This is a classic misconception by the public and managers who are not exposed to the daily struggle of looking after patients in the public health system, that specialists working more hours in the public sector equals more surgery. Also, doctors are always easy targets for managers, for ALL public health issues, as demonstrated by Kathy. First of all, our public healthcare is second to none. If someone has a desperate need for surgery, they will have access to surgery within 8 months of GP referral. This compares to 2-4 years in Australia and Canada. The only countries in Europe that perform better are the ones with compulsory health insurance schemes (not a bad idea!). Secondly the rate limiting step is theatre space, theatre staff, clinic space, etc. I work as a surgeon in a hospital where surgeons are forced to retire from public as there is no room for them to operate and there is no government funding to pay their salary. I have many colleagues who can’t find a job in NZ public sector in the first place. Like I said, doctors in public sector is not the elephant in the room.

    **It is highly concerning to hear that the system is under review without appropriate consultation involving people who actually look after patients.

  2. I read this as code for saying that the ASMS has not been asked to be part of the review. Well, no interest group has been asked, and I’m not sure that it would be wise to run a review that way. Let’s wait to see what process the review follows. I for one would hope that groups representing key parts of the workforce are consulted, but not that the review should do everything that a particular group might want. There are conflicitng interests in health and the Review will have an interesting job balancing them.

  3. As a nurse who often works in public hospitals, we frequently struggle to provide beds for patients who urgently need them, and have patients waiting for long-term care beds who are too dependent to be sent home. Which beds will the extra surgical patients have? I have also worked in various countries around the world and have always found the same thing; the limiting factor on the number of elective cases treated is not the surgeon to do the operation, it’s the ward space and nursing staff to provide the aftercare. Yet most countries have significantly reduced the number of hospital beds available over the last forty years, despite rising populations. The greater availability of keyhole procedures has reduced the length of stay in hospital for many but is not suitable for all operations. My local DHB has tackled this bed shortage by contracting patients out to private hospitals, which seems to work well, as long as their surgeons work in both sectors. The other thing to consider is that contracting surgeons only for public hospitals would deny their skills to elective ACC patients, and could result in some opting for private practice over public health if put to a choice.


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