Source: Radio New Zealand
A computer illustration of a person with foot pain. KATERYNA KON/SCIENCE PHOTO LIBRARY
Rheumatologists in some regions are turning down about half the specialist referrals they receive from GPs in order to provide adequate treatment for their existing patients.
However, they say even with restricting “in-flow” in that way, wait times for first specialist appointments – and critical follow-up appointments – continue to grow.
Anna*, a fit and healthy 27-year-old, started feeling unusually fatigued in August last year.
“I work quite a high-stress job and I study, so I initially thought, ‘It’s burnout’. But then the fatigue continued and I then noticed swelling and stiffness and odd things I had never experienced before.”
Her GP immediately suspected rheumatoid arthritis and referred her to the rheumatology service in Auckland – and kept updating that referral as Anna’s symptoms worsened.
Accepted best practice is for rheumatoid arthritis patients to be seen within three weeks – she waited six months.
At her appointment in February (five days before she left Auckland for a job in another city), she was prescribed a drug to suppress symptoms.
Unfortunately, she suffered a bad reaction.
“The medication caused extreme nausea, it would last for five days. I had quite a bit of my hair fall out. I was always sick, and then I began to develop a dry cough. It suppressed my symptoms but the cons definitely outweighed the pros.”
Her new GP made an urgent referral to the local rheumatology service – but it was another three months before she was seen.
“I honestly at this point think that if I did not have a severe reaction that I probably would not have got in to see him as quickly as I did.”
Anna has seen a specialist twice more this year, and undergone multiple tests but is still waiting for a definitive diagnosis.
She has had to quit her “dream job”.
“There were days that I could not walk around, I could not get up out of bed on my own, I couldn’t stand up on my own,
“I needed help just to do the basic things, like brush my teeth.”
The best advice she has had on how to manage symptoms and live her life has come from Arthritis New Zealand’s online support group, she said.
“Sometimes you get lucky – like I got lucky – and you have really great GPs who advocate for you, who help you, who take what you need to the rheumatologist and say ‘You have to see this person’.
“But if you don’t have a good GP that’s just not going to happen for you.”
Patients waiting longer than ‘target
In April – the most recent month for which data is available – 281 patients had waited longer than four months for a first appointment with rheumatology: more than 14 percent of patients are waiting too long.
It varies dramatically nationwide, from less than 2 percent in some centres, to nearly half of all patients in Nelson-Marlborough and Northland.
Long-time Waikato Hospital rheumatologist Alan Doube said there was usually “no quick fix” for rheumatology patients; they needed long-term follow up.
Waikato “accumulates” another 300 patients every year.
“So over 10 years that’s an extra 3000 patients. And unless the facility expands to facilitate that, you get to a crunch point.”
As of April, Waikato had 46 patients who had waited longer than four months for a first specialist appointment (FSA) – more than one in five.
However, Doube said many others did not even get on the waiting list because the service was already stretched.
“Currently we decline about 50 percent.”
Sometimes, specialists could advise GPs on how to manage those patients, Doube said.
“But even then we still can’t see the 10,000 patients [on their books] in the way that they need to be seen over time. So the model that’s been put forward to us doesn’t help us – the focus on FSA.
“You can either see those FSA or you can see the follow-ups. But you can’t do both.”
Osteoarthritis can occur in a number of joints, and mobility can be impaired when it occurs in the hips, knees and ankles. Wikimedia Commons / Milorad Dimic MD CC BY-SA 3.0
Poor access to specialist and medicines
Rheumatology Association spokesperson Hugh de Latour said there had been a huge surge in rheumatology referrals post-Covid – but New Zealand also had much fewer specialists per capita compared with other developed countries.
“So even with our select grading, our timeliness to see patients is less than ideal.”
In his region, Waitematā, routine follow-ups were “six months overdue”.
Arthritis alone cost the country millions in terms of lost productivity but inflammatory disease generally was not really prioritised, de Latour said.
“New Zealand is well behind compared to any other country both in terms of what we have and the threshold you must get to in order to actually qualify for it.”
The quicker patients were seen by a specialist, the more effective their treatment and management of their condition, he said.
New medicines available could completely alter the outlook for people with symptoms of inflammatory disease.
“But no-one is really going to get upset if someone’s rheumatoid arthritis didn’t get seen within three weeks, which is our target.
“If you get rheumatoid, you should be seen within three weeks.”
De Latour said in recent years New Zealand had lost most of its newly qualified rheumatologists to jobs in Australia.
The Royal College of Physicians recommends 1.16 full time equivalent (FTE) rheumatologists per 100,000 people in the public sector.
A 2019 paper found none of the 20 district health boards met the guideline in the public sector, and only four areas reached this level when private FTE were included.
Arthritis NZ estimates the specialist workforce would need to increase by 13 FTE rheumatologists to achieve the guideline.
It has recommended greater efforts to recruit and train specialist nurses to support rheumatologists in their practice.
Health NZ responds
In a written response to RNZ’s questions, Health NZ’s national chief medical officer Dame Helen Stokes-Lampard said there were “a range of challenges related to workforce shortages in healthcare”.
“The Health New Zealand Workforce Plan has a series of workstreams that are considering total workforce numbers, as well as newer ways of working to optimise the efficiency of all our existing healthcare professionals and support their wellbeing.
“Discussions are under way to see how we can reduce rheumatologist workloads.”
*Name changed for privacy reasons.
– Published by EveningReport.nz and AsiaPacificReport.nz, see: MIL OSI in partnership with Radio New Zealand
