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Booking Systems for Elective Services in New Zealand: Literature scan to identify any ethical issues of national significance

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... Disparities exist between Māori or Pacific people and New Zealand Europeans in different aspects of surgical care, including delay to treatment. 7,8 The third aspect of inequity refers to surgical conditions allocated different priority scores. There needs to be an unbiased assessment conducted between different conditions depending on their need and ability to benefit. ...
... Patients were assigned a category of urgent, semi-urgent or routine then placed on a waiting list and given a general indication of the duration of wait. 10 Throughout the 1990s, the increasing need for publically funded services prompted the government to remove waiting lists and improve its distribution of funding through the creation of the booking system. 8,11 Patients were prioritised based on predetermined criteria known as clinical priority assessment criteria (CPAC). 10 However, multiple tools, with varying degrees of resemblance to national CPAC, were developed by individual hospital district health boards (DHBs) throughout New Zealand. ...
... 10 However, multiple tools, with varying degrees of resemblance to national CPAC, were developed by individual hospital district health boards (DHBs) throughout New Zealand. 8 Despite some similarities, these tools lacked national consistency in criteria, were not validated, were often mathematically flawed and did not reflect clinical judgement. [12][13][14][15] For example, several systems were based on expert clinicians directly J o u r n a l P r e -p r o o f specifying point values for categories within criteria without this being mathematically derived. ...
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Patients waitlisted for elective general surgery in New Zealand used to be prioritised by multiple tools that were inconsistent, did not reflect clinical judgement and were not validated. We describe the development and implementation of a national prioritisation tool for elective general surgery in New Zealand, which could be applicable to other OECD countries. The tool aims to achieve equity of access, transparency, reliability and should be aligned with clinical judgement. The General Surgery Prioritisation Tool Working Group commenced development of a prioritisation tool in 2014 which showed strong correlation with clinical judgement (r = 0.89), excellent test-retest reliability (r = 0.98) and significantly lower variability (p < 0.001). Preliminary findings showed no significant difference in scores attributable to age, gender or ethnicity. General Surgeons were in favour of the tool criteria and agreed on the importance of prioritisation; however a minority opposed its introduction. Health organisations and general practitioner groups were in favour, however, along with many surgeons, expressed apprehensions regarding subjectivity, manipulation, equity of access and degree of benefit. Despite reservations, the majority of stakeholders were supportive and through collaboration between clinicians and the government, the tool was implemented in 2018 in New Zealand. Overall, the prioritisation tool is a reliable method of assessing priority, demonstrating transparency and reflecting clinical judgement, with equity of access to be further assessed by evaluation in clinical practice.
... Also, patients with private health insurance may receive an appointment privately with a surgical consultant quicker than a noninsured patient, and thereby reduce the time to surgery. Research suggests that Māori and Pacific people with cardiac conditions receive a surgical consultation when their condition is more serious compared to non-Māori and non-Pacific people (Derret, 2005). ...
... Access to elective services is based on assessment of the patient's need and ability to benefit (Cumming, 2013). In New Zealand, the booking system refers to the entire medical pathway from an initial consultation with a GP (Derret, 2005) to a patient's confirmed surgical date. The system was developed from the 1990s onwards because of major concerns over the management of waiting lists and long waiting times for surgery. ...
... In the case of consultations where surgical treatment is an option, patients are provided a score based on the CPAC (Derret, 2005;MOH, 2013g). Once a CPAC assessment has been conducted a patient may be booked for surgery. ...
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New Zealand has a predominantly tax-funded health system, providing universal coverage. The population enjoys high health status overall, but with significant inequalities in Māori and Pacific health. Since the 1980s, there have been five major health system reforms. Currently, a central Ministry of Health (MOH) oversees the health system, while 20 District Health Boards are responsible for planning and funding health services for their geographical areas. There are no user charges for inpatient or outpatient services in publicly owned hospitals. Primary health care (PHC) is provided through Primary Health Organisations (presently 36) that receive capitation funding for their enrolled populations, and work with general practices and other providers to deliver comprehensive PHC in the community. Patients may pay user fees for PHC services, although most children under six years of age pay no fees. The Pharmaceutical Management Agency (PHARMAC) manages the New Zealand Pharmaceutical Schedule and negotiates the purchase of drugs from suppliers, successfully controlling supply-side expenditure. A recently reformed National Health Committee is now responsible for strengthening assessment of new technologies and services to promote the delivery of a cost-effective mix of services in New Zealand. The Accident Compensation Corporation (ACC) is a comprehensive, social insurance, no-fault, personal injury scheme which funds treatment, rehabilitation and compensation for people who are injured in New Zealand. It sits alongside the tax-funded health system, and can fund a wider range of services, raising concerns over equity of access between those whose health condition is due to illness and those receiving services because of accidents. Current challenges for the health system include reducing inequalities in health, managing noncommunicable diseases and chronic conditions, reducing waiting times, improving productivity, and ensuring greater integration and coordination of services within and between primary and secondary care, and intersectorally with other social services.
... The New Zealand total joint arthroplasty (TJA) registry has been collecting postoperative PROs since its inception in 1998. 83 Some Clinical Priority Assessment Criteria (CPAC) tools were developed to manage waiting lists and assess priority for surgery in NZ. 84,85 Some CPAC tools, such as one for cataract surgery, included patient-reported data (e.g. items concerning the patient's condition and its effect on their function) and could be considered to be PROMs. ...
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