Standard of urology services 17HDC02066
Source: Health and Disability Commissioner
Health and Disability Commissioner Anthony Hill today released a report finding Southern District Health Board in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures relating to the standard of its urology services.
Mr Hill initiated an investigation of the DHB’s urology service, in which he addressed four individual cases. In each case he found the DHB to have breached the Code. He said there had been lengthy delays in the assessment and treatment of patients, and consequently a substantial clinical risk.
For one man, the time taken for him to receive treatment was almost double the target timeframe, which was compounded by a failure to keep him informed about a likely date for his surgery.
Another man had an unacceptable delay in receiving treatment. He was graded as priority 3 (expected to be seen within six weeks), but he was not seen until over five months after his initial referral. It was then a further seven weeks until his biopsy was performed, even though the booking form was marked urgent, with multiple circles and a star to emphasise the urgency.
A third patient, who was triaged "to be seen within 6 weeks", was offered a first specialist appointment more than four months after he was referred by a GP. Subsequently, the appointment was brought forward after his GP made a further referral noting the "high suspicion of cancer". In this case the Commissioner was also concerned about the DHB’s communication with the man, in particular regarding information about managing his anticoagulation medication.
The fourth patient was booked for a flexible cystoscopy, an examination of the bladder using a fibre-optic tube. This was not performed until after a gynaecologist made an "urgent referral" six months later. In this case, the DHB was also found in breach of the Code for failures relating to its response when the woman complained.
Looking across the four cases, Mr Hill found there had been little planning for urology services in light of changing demographics, and referrals exceeded the DHB’s capacity. The DHB did not have an effective system for managing patients who were waiting for urology services, and clinicians and the public came to expect delays, which became normalised.
"These are issues of central importance for all DHBS, and can have severe consequences for patients if not recognised and acted on. In this case, Southern DHB’s inadequate response failed each of the patients discussed in this report," Mr Hill said.
"Many patients waited with no treatment and no information about when they would be treated.
"It is essential that providers assess, plan, adapt, and respond effectively to the foreseeable effects that changing demographics in their population will have on systems and demand."
"In the context of constrained resources, appropriate waiting list and appointment management systems are vital to managing risk. Having mechanisms to monitor wait times and make these transparent to both the public and to referrers is essential. Organisations also need to consider initiatives such as different models of care to reduce the gap between capacity and demand."
The investigation also found that relationships within the DHB had become strained, and there was a lack of willingness to work together to find solutions. Mr Hill said the report highlighted the importance of collaborative and mutually accountable relationships between management and clinicians.
He acknowledged the work undertaken by the DHB in the last two years to address the challenges faced by its urology service and said HDC would continue to monitor progress.
Following his investigation Mr Hill made a number of recommendations to the DHB, including that it apologise to the four patients. He also recommended:
- An independent evaluation of the systems currently in place to prioritise urology patients
- Audits of the management of urology service referrals
- A review of mechanisms for monitoring wait times and making this information transparent
- A report to HDC on steps to build capacity of the department
- Making clinical staff routinely available to urology patients by telephone
- Arranging ongoing shared learning, including with other DHBs, in response to this case
- Regular credentialing for the urology service and its facilities
- Regular updates to HDC on implementation of recommendations from a separate external review
- A review of the DHB’s complaints management processes
He also recommended that the Ministry of Health consider a national discussion of urology service priorities and reporting of overdue urology appointment statistics.
The full report for case 17HDC02066 is available on the HDC website.