Wellington doctors told to stop referring women to specialists unless their condition is urgent

Wellington Regional Hospital's Women's Health Service is under so much pressure, it has told GPs to stop referring patients unless they suspect cancer or something equally urgent.

Specialists and family doctors say this is becoming common practice across many departments, as hospital services nationwide become increasingly overwhelmed.

For nearly three months and 11 weeks, the only women who have seen a gynaecologist in the public system in Wellington have been those with suspected cancer, extreme pelvic pain requiring hospitalisation, new cases of faecal incontinence after giving birth, or another serious condition from a very short list.

A letter from Wellington's Women's Health Service sent to every GP in the region in July said due to junior doctor vacancies, it was "again facing significant demand" beyond its capacity to offer care in a timely fashion and was "again restricting referrals to URGENT ONLY".

For six months last year - between March and August - gynaecology was also limited to "urgent" cases only.

No one from Wellington Regional Hospital was available for interview. However, in a written statement to RNZ, acting director for hospital and specialist services Jamie Duncan said the department was experiencing significant demand, partly due to four junior doctor vacancies.

"We appreciate the impact that delays in first specialist appointments have on patients, and our focus is on those referrals that need to be seen within two weeks. We are taking a number of steps to manage the backlog."

That included re-triaging patients already booked for urgent referrals, extra clinics as staffing allowed, pausing follow-up appointments and using GPs to provide some services.

A new clinic started this week, allowing some patients to be seen and treated in the same appointment.

Porirua GP Dr Bryan Betty said even before the official word on gynaecology, he and his colleagues had noticed a big upswing in patients turned down for assessments across all departments.

Some patients got through that hurdle only to be turned down for treatment, like one of his patients who needed a hip replacement.

"The specialist said, 'Yes, she needs surgery,' and she certainly does. Then the letter came back from the hospital saying, 'We don't have capacity to carry that surgery out'.

"I've just referred her back in, and she's gone to the bottom of the waiting list to see the specialist again. So there's a bit of a round-robin going on with this stuff at the moment."

Betty, who chaired General Practice New Zealand, said there were thousands of patients and their doctors stuck in this pointless holding pattern, which cost patients in terms of time and money and piled more work on GPs, filling in the same forms for the same patients again and again.

"Why [do] they need to go back to see a specialist again when they've already been assessed for surgery... I'm puzzled. They should just go on the waiting list."

Tauranga doctor Luke Bradford, medical director of the College of GPs, said hospital services often resorted to restricting or halting new referrals as a way of managing waiting lists.

Sometimes they issued an advisory, such as Capital and Coast had done with gynaecology. Sometimes the threshold just moved up a notch.

"But what it does of course is manage the waiting list - it doesn't manage the underlying condition, which is still present. It's just saying, 'Don't tell us about it for now, otherwise the list won't get any shorter'."

Auckland gynaecologist Gillian Gibson, president-elect of the College of Obstetricians and Gynaecologists, said services nationwide were struggling to treat so-called "benign" conditions, ie. anything that was not cancer.

"Women requiring cancer care or who have suspicion for cancer are definitely having priority, which you can't argue with.

"But what it means is that because of constraints on services, benign gynaecology (non-cancer) services are very much restricted. And benign doesn't mean they're not extremely distressing and disabling conditions."

Women suffering pelvic pain, incontinence, endometriosis, infertility and other problems were left in limbo, she said.

Moreover, 'women's health' - like every other surgical speciality - was having to compete for theatre space and resources.

Gibson, based in Auckland, said the new Pae Ora Healthy Futures legislation included a women's health strategy for the first time - but it must be resourced.

"What's needed is a national strategy to ensure resources are shared equitably."

Dermatology was another speciality with huge regional inequities going back decades. Middlemore Hospital specialist Paul Jarrett, spokesperson for the Dermatological Society, said some districts had no public dermatology service at all.

"The ideal ratio is one dermatologist per 80,000 head of population. Our best estimate is that currently New Zealand only has about one public dermatologist to 250,000 people, and that is not enough.

"The services that exist struggle to meet demand, and where there are insufficient staff numbers, those services quickly become overwhelmed and that leads to burnout.

"I suspect this is a microcosm of the wider difficulties facing the public health system at present."

Many patients suffering serious inflammatory conditions like eczema received no treatment until they ended up in hospital, with a massive infection for instance, which was hugely expensive to treat, he said.

"It is very stressful and deeply uncomfortable for every specialist when we can't provide the level of care that the community deserve."

The Association of Salaried Medical Specialists, in the midst of a pay dispute with Te Whatu Ora and ongoing strike action, said the shortfall of 1700 consultants was leading to burnout, piling more pressure on those who remained.

'They know they won't be seen'

Meanwhile, GPs say no one knew the true level of unmet need: the children who cannot hear because they need grommets, the people giving up work because they require cataract operations and the elderly ending up in care while waiting for hip replacements.

Bradford said GPs had "long argued" there was no visibility in the system of these patients.

"This is because of those people who aren't being added to waiting lists because of the shift in criteria, or who aren't even being referred by GPs because they know they won't be seen."

Betty said patients who were assessed as needing a procedure should go on the waiting list "no matter how long it is".

"We need to be transparent about this."