Anatomy of a health crisis

Aotearoa New Zealand’s public healthcare services are increasingly unable to meet the population’s health need, be it in hospital and specialist services, mental health and addiction (MHA) or primary and community care. These findings are traversed in a new report, Anatomy of a Health Crisis, produced by Toi Mata Hauora, the Association of Salaried Medical Specialists (ASMS),¹ using official data to assess the condition of Aotearoa New Zealand’s public hospital services.

Almost 1.3 million people attended public emergency departments (EDs) in 2022/2023—an increase of 22.5% since 2013/2014, while the population grew by 16%. Compounding the ED pressures, the number of immediately or potentially life-threatening events (triage levels 1–3) is growing at a much higher rate (51.1%) than less-serious events.²

Triage levels 1–3 made up just over half of total ED presentations in 2013/2014. By 2022/2023 they amounted to almost two-thirds of total presentations.

Acute inpatient discharges increased by 24% between 2014 and 2023 (28% when adjusted for complexity), while non-acute discharges decreased by 1% (-3% when adjusted for complexity).²

These trends indicate publicly provided “elective” services are being displaced by a combination of budget constraints and the rising number of complex acute cases. The widening gap between population growth rates and public hospital discharge rates will be contributing to growing unmet need for elective treatments and, for those who can afford it, growing use of private healthcare.

Rising unmet need is also evident for mental health and addiction (MHA) services. The proportion of adults reporting high and very high levels of psychological distress skyrocketed by 72.5% between 2016/2017 and 2022/2023.³ Meanwhile, the number of clients accessing MHA services increased by 10.4% from 2016/2017 and 2021/2022, while the workforce grew by just 5% from 2017/2018 to 2021/2022.^4–6

MHA vacancy rates have more than doubled between 2018 and 2022, and nearly 20% of psychiatrist positions were vacant in 2022. Unpublished Te Whatu Ora – Health New Zealand forecasts of public and private employment for psychiatrists show a decline per capita to 2033, while unpublished Medical Council of New Zealand data show a shift towards private employment.^7,8

The shift towards more private sector employment is also evident across the spectrum of specialties, with several recent ASMS surveys of its 6,500 members indicating low job satisfaction and poor working conditions, as well as an ageing workforce, as key drivers behind medical specialists either moving away from the public health system or leaving medicine entirely.^9,10

The shift to private practice has significant implications for the provision of planned care, on top of an already-chronically understaffed Senior Medical Officer (SMO) workforce. Based on a national survey of clinical directors accounting for access, quality, safety and unmet need, Aotearoa New Zealand has a shortfall of approximately 1,140 public hospital SMO FTEs.¹¹

The shortages mean access to hospital specialists across many specialties is declining. Te Whatu Ora – Health New Zealand data show more than 68,000 patients were waiting more than 4 months for a first specialist assessment as of December 2023. That’s a 55% increase in 12 months and almost a six-fold increase since (pre-COVID) September 2019.¹²

Further, the number of patients who are deemed unwell enough to exceed “clinical” thresholds and given a commitment to treatment but don’t receive it within 4 months increased six-fold between July 2019 and September 2023—from 4,685 reported by the Planned Care taskforce, to 29,266 reported by Te Whatu Ora – Health New Zealand.^13,14

As access to hospital specialists declines, growing numbers of patients are left in limbo under the care of their GPs, adding further to the pressures on access to primary care services, and risks patients’ condition deteriorating and quality of life worsening.^15–17

The extent to which Aotearoa New Zealand’s primary healthcare sector is under unsustainable strain is starkly illustrated when unmet need data from the European Commission’s Eurostat survey and the New Zealand Health Survey (NZHS) are compared.¹⁸

The 2023 Eurostat survey found self-reported unmet need for GP or hospital specialist care due to wait time, cost or travel distance ranged from less than 1% of the adult population in eight countries, including the Netherlands, Germany and Switzerland, to 12.9% in Estonia.

In Aotearoa New Zealand, self-reported unmet need over a 12-month period for GP services alone due to these three criteria was estimated by the NZHS as 34.3% of the adult population. In addition, limited official data show an estimated 5.1% adult unmet need over 12 months for a hospital specialist.^3,12–14

The economic costs of unmet health need, whether it is for primary care, community care, hospital care or combinations of these, are unknown. For successive governments, such matters have remained largely out of sight and out of mind. What is clear is that the broader economic costs of ill health are large. Costs outside of the health system were conservatively estimated by Treasury in 2010 to be between 2.7% and 7.6% of GDP (about $10 billion to $30 billion today). At the upper end of the scale, that is well over the annual Vote Health budget.¹⁹

It is increasingly recognised that to assess the efficacy of a country’s health system—and have a better understanding of investment needs—you need to know how many people have a need for health treatment that is not being met. Hence a resolution adopted by the Seventy-sixth World Health Assembly in 2023 requested the World Health Organization’s (WHO) director general review the importance and feasibility of using unmet need for health services as an additional indicator to monitor universal health coverage nationally and globally.^20,21

Similar calls have been made locally to monitor how well our public health system is serving the population.^22,23 The information presented in the ASMS report indicates Aotearoa New Zealand’s unmet health need is far more serious than comparable countries and warrants urgent investigation to produce a strong evidence base for eliminating inequitable barriers to access, unmet need and informing decisions on health service investment. Chronic workforce shortages, long waiting lists and cost-barriers to healthcare won’t be fixed until governments widen the policy lens on health and recognise that investing in wellbeing is also an investment in the economy.