After two years of constant pain and immobility, a 73-year-old man from Whangārei can finally walk again.

Jack, who does not want to be identified, was one of many Northlanders to endure an
extraordinarily long wait for hip replacement surgery.

A parliamentary question to Health Minister Andrew Little revealed 266 Northlanders have been on the waitlist for orthopaedic surgery for more than a year, as of June 2022.

The waitlist is the second-longest in the country, behind the Southern region (411 patients) and ahead of Waitematā (253).

The shortest wait lists are in Capital and Coast with two, Whanganui with four, and Counties Manukau with 12 patients.

Jack waited 21 months until he finally ended up on the operation table five weeks ago.

“I’m walking perfectly normal again. I am brilliant, it is just wonderful.”

Before the hip replacement, Jack was trapped at home. Sitting in a car for too long was far too painful, and driving himself wasn’t an option due to the number of painkillers he took.

His daily dose contained 400 milligrams of tramadol, 20mg morphine, eight paracetamol pills, 150mg pregabalin and 50mg amitriptaline, which impacted his cognitive abilities.

Now, he doesn’t need any pain relief. Jack is astounded at the difference the operation made in his life.

“The surgeon apologised for the delay and said there was very little joint left, and he understood why I was throwing morphine down my mouth.

“He said it wasn’t fair and it wasn’t right.”

Orthopaedics is the worst affected specialty in Northland. Ophthalmology (eye-related health care), as well as gynaecology, also looks at a huge backlog.

Te Whatu Ora – Te Tai Tokerau, formerly the Northland District Health Board, was asked along with all local health authorities to actively tackle the surgery backlog by Minister Little’s planned care taskforce, set up in May.

All regions were given until yesterday to book surgery appointments for patients waiting more than a year – even if those surgeries are still months out.

The directive affects 643 Northlanders as of July 31 and another 816 people awaiting an initial specialist appointment.

Whangārei-based MP Reti says “it doesn’t make sense” that Northland is worse off than other regions of similar size.

“This is a health system in crisis and the [Government] needs to acknowledge it.”

Why is Northland performing so badly?

The long wait list for surgeries, particularly in orthopaedics, boils down to several reasons.

Mark McGinley, Te Whatu Ora – Te Tai Tokerau general manager for surgical and support services, says historically the biggest constraint was the theatre capacity at Whangārei Hospital. For over 30 years, the number of operating theatres hadn’t increased.

“In recent years the growth in acute surgery resulted in elective or planned operating being reallocated to accommodate this growth,” McGinley said.

“Additional theatres were opened at Whangārei Hospital in July 2021; however, capacity has been constrained due to impacts from Covid-19 and other inpatient capacity pressures.”

Northland’s rapidly growing population is another complicating factor. Government funding for health is based on Statistics New Zealand’s Census data, but both McGinley and Whangārei general practitioner Dr Tim Cunningham says the number of people living in Northland exceeds their forecast.

“The poor orthopaedic situation is worse in Northland,” Cunningham said.

“We have a much higher percentage of elderly who require a lot more of the major joint replacement surgeries. Elderly patients create a much bigger demand for orthopaedics.”

Increasing obesity rates that are often connected to high BMIs could also fuel the demand for joint replacements, Cunningham suggested.

He said the situation is a lot worse than 25 years ago when he started working as a GP in New Zealand.

“The patients are a lot more disabled before getting surgery, and the waiting lists do not reflect need.”

One of the consequences is that there is “a significant number of patients on very powerful opiates like morphine and methadone while they wait for surgery”, Cunningham says – just like Whangārei man Jack was.

Opiates increase fall risks, confusion, tiredness, nausea and constipation.

“Opiates like morphine and methadone are far from ideal, but they end up being our only way to help with the severe pain that is unbearable for these patients waiting for orthopaedic surgery,” Cunningham said.

“GPs don’t refer a lot of patients who need surgery because they will be deemed not to meet the threshold to be seen in clinic, and the referral letters are just sent back.”

Northland’s orthopaedic workload is currently managed by nine orthopaedic senior medical officers and one orthopaedic fellow.

“This headcount contributes 8.23 FTE [full-time equivalent positions] and 1.15 FTE respectively, noting the FTE relates to all duties including elective operating, acute operating, and on-call,” McGinley said.

How can we get more Northlanders on the operating table?

Reti says “most of the health crisis comes down to the workforce”, and that by adjusting immigration regulations, the Government “could solve this in a blink”.

Meanwhile, GPs like Cunningham feel like they have run out of options to help those patients waiting for surgery.

“GPs are really stressed in Northland over this – sending updated letters recording patient’s deteriorating health is all we can do.

“Moving to a different part of the country like Auckland or Nelson can get you surgery much quicker.”

The planned care taskforce has so far not allocated any additional resources to Northland despite its demands to get more people into surgery.

Te Whatu Ora – Health NZ frequently says the health reform means that patients could be sent across regions to receive care if the hospital in their home region doesn’t have capacity.

Te Whatu Ora told the Advocate that associated travel costs would most likely fall back on patients.

“In some circumstances travel assistance may be available to support patients travelling for specialist treatment or appointments outside of their area. For example, this may be connected to organ donation or a specialist disability service,” a spokesperson said.

Northland’s health authority is working with other nearby hospitals to provide relief for waiting patients.

“We continue to work closely with our Northern region colleagues. They have recently provided support to conduct a range of virtual reviews of long-waiting patients,” McGinley said.

Co-operation with private health providers “to utilise any additional or marginal capacity that they have available” is also ongoing.

The New Zealand Orthopaedic Association has suggested a public-private partnership that could see 200 surgeons adding one public surgery a month to their private lists for the next 10 months at a cost of between $80m and $100m.

Te Whatu Ora has not yet committed to such a partnership.