Health Denied

A recent study by Otago university has indicated that there has been an increase in the number of people over the age of 65 being readmitted to hospital or dying within one month of surgery. The study was done comparing the years 2001-2 and 2003-4. The usual expected comments come from the usual people. Grey power say that this “demonstrated the health sector’s increasing inability to care for patients, particularly the elderly”. 

“The aged-care political group says it may be because patients are discharged too early to clear beds or community care is poor.”

All of these suggestions are wrong. There is no evidence at all that hospitals are struggling to provide care, once patients are in hospital (they are struggling to provide a good outpatient and elective service). There is also no evidence at all that patients are being discharged “too early” (an entirely subjective assessment anyway) – in actual fact there are indications that the very elderly stay in hospital too long and are subject to catching pneumonias and resistant urine infections. Community care is not brilliant by any standards but is certainly normally adequate. There has also been no drop in the standard of community care that might explain the decrease in survival rates.

The real reason is quite simple – waiting lists.

To be sure, there is a gradual rise in the number of oldest old (people over the age of 80) which, inevitably, gives rise to post-operative complications, increased readmissions and increased mortality. But this rise has been partly ameliorated by improved surgical and diagnostic techniques. No, the real reason behind our worsening statistics for the elderly are our waiting lists. Simply put, our elderly are waiting too long to have their elective operations – this means that the operation either becomes more complex or more acute.

For example, let’s take a fit 78-year-old lady who needs a hip replacement – her mobility has become mildly restricted and she is in constant low-grade pain. She is not placed on the waiting list because her score is too low because she is mobile. She is classified non-urgent. 

A year later, she now needs a walker to get around, and has had several falls. She is reassessed by the orthopaedic surgeon and upgraded to urgent and placed on the waiting list. She will wait a further 18 months, becoming more frail and immobile until she falls and breaks her hip. The fracture is repaired by a partial hip replacement.

She now remains in a rehabilitation ward for four weeks because she is now so frail. Her family members are shocked at her deterioration and want her placed in a nursing home. It takes a further three weeks to arrange this. She never regains full mobility and succumbs to a pneumonia four months later.

The very act of scoring people to determine the need for an operation, actively biases the health system against fit, healthy people who need only a single intervention such as a hip or knee replacement, or a gall bladder or prostate operation. The system waits for people to become very debilitated or acutely ill before offering services. This ensures that the cost of those services is high and the outcome for patients is poorer than it need be. It is especially biased against the fit elderly who are likely to deteriorate far faster than the young.

This is the reason why the readmission rate and mortality rate for older people is increasing so rapidly. The waiting list system is actively selecting sicker and sicker patients. The number of these patients are inevitably increasing because no mildly sick patient is receiving surgery, only the severely ill. The only way to improve these statistics is to not to reduce waiting lists, but extend them to include the less ill (there is still, of course, an imperative to reduce the waiting times). This means that fitter elderly people will receive the full benefit of prompt surgery and maintain their health for far longer, at great saving both in health and disability dollars and social cost.

It has long been said that justice delayed is justice denied. In the world of hospital waiting lists, health delayed is, indeed, health denied.

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