Prioritizing patients for the NZ Ministry of Health
Public health systems worldwide have limited funding (typically, from taxes or social insurance). Inevitably, therefore, they are constrained with respect to the health services they are able to provide to patients.
Consequently, tough decisions about which patients are offered elective or “planned” (i.e. non-urgent) services, such as hip replacements, cataract surgery, etc, have to be made on a daily basis.
In New Zealand, since 2004, prioritization systems consisting of explicit criteria and weights for ranking patients have been created for more than 20 elective services by the Ministry of Health and clinicians using 1000minds.
1000minds also built the online platform for implementing these prioritization systems across the country’s hospitals, known as the National Prioritization Web Service.
20+ patient prioritization systems created using 1000minds
500+ clinicians involved in creating the systems
10,000+ patient interactions per month, National Prioritization Web Service
New Zealand’s Ministry of Health, which administers the country’s health system, needs to ensure that patients are prioritized for access to elective (non-urgent) services consistently, fairly and transparently.
Since 2004, the Ministry, working with groups of clinicians, has used 1000minds to create patient prioritization systems for use across the country.
About New Zealand’s Ministry of Health
New Zealand’s health system is a predominantly public system funded from taxes and with a relatively small private sector. The system is managed and overseen by the Ministry of Health.
Other agencies with an interest in patient prioritization include clinical professional organizations (e.g. Cardiac Society of Australia and NZ), the National Ethics Advisory Committee, the Medical Council, the Health and Disability Commission and the Human Rights Commission.
The challenge
NZ’s health system, like all health systems in the world, is resource constrained. There is insufficient capacity to be able to provide elective, or non-urgent, services to everyone who could potentially benefit from them.
Therefore, inevitably, patients have to be prioritized via waiting lists.
But how do you decide who gets treated (and who doesn’t), and in what order they appear on the waiting list?
And how do you ensure that these important decisions are made consistently, fairly and transparently?
These fundamental questions have challenged NZ’s public health system since its inception more than 80 years ago. These challenges are not unique to NZ – all countries face them.
Back in the 1990s, before NZ’s surgery waiting lists were overhauled, they were criticized for being “a diverse mix of patient cases – placed and kept on the list for a number of different reasons, and with no agreed criteria for admission to the list” (G Fraser et al 1993).
The old prioritization system was also grossly unfair. One cardiologist put it like this: “Manipulation by referring doctors, friends in high places, MP letters, or just persistent nagging, and just slight exaggeration of symptoms, is rampant, and the poor benign patient simply sits on the list and is leap frogged” (D Hadorn & A Holmes 1997).
As well as the negative effects on people’s health and the overall unfairness of the system, the political pressure on the Ministry of Health and the government to fix the prioritization system was immense.
The solution
A new approach to prioritizing patients for elective services was developed in NZ based on the application of explicit criteria and weights reflecting each patient’s need for treatment and capacity to benefit – known as Clinical Priority Access Criteria or CPACs, or more simply as “points systems”.
Participants’ preferences with respect to the relative importance of the criteria were elicited and quantified by 1000minds asking them a series of simple trade-off questions.
Since 2004, 1000minds has been used by the Ministry of Health and groups of clinicians, with the endorsement of their professional organizations, including Māori representation, to determine valid and reliable criteria and weights for prioritizing patients for the 21 specialties listed in Table 1 below, and more systems will be developed in the future.
The first prioritization system created in 2004 using 1000minds was for coronary artery bypass graft (CABG) surgery. In a Ministry of Health-led collaboration with the NZ Region of the Cardiac Society of Australia and NZ, an expert group of cardiologists and cardiac surgeons spread throughout the country used 1000minds to work together (via the Internet).
Over time, a process for creating prioritization systems fully supported by 1000minds has been developed and refined.
Also, in early 2020, a system for prioritizing Covid-19 patients for intensive care was quickly built (in less than a week) as SARS-CoV-2 entered the country.
This world-leading body of work has been overseen and positively reviewed at various points by the National Ethics Advisory Committee, the Medical Council, the Health and Disability Commission and the Human Rights Commission.
Table 1: Patient prioritization systems for 21 specialities
Coronary Artery Bypass Graft
Aortic regurgitation
Mitral regurgitation
Triscuspid regurgitation
Aortic stenosis
Mitral stenosis
Cardiac – other
Genetic referral
Bariatric
General surgery
Skin lesions
Cataract surgery
Non-cataract Ophthalmology
Orthopedic surgery
Pediatric orthopedics
ORL, head and neck
Skin lesions
Assisted reproductive technology
General gynecology
Sterilization
Plastics Hand and Upper Limb
Skin Lesions
Sterilization
General urology
The results
The Ministry of Health, as well as patients and clinicians, can have more confidence in the patient prioritization decisions made using the prioritization systems created using 1000minds.
These systems are systematic, transparent and evidence-based, and they differentiate between patients fairly, consistent with established ethical principles.
In addition, surveys of the clinicians involved in creating the systems revealed high levels of satisfaction with 1000minds software and the PAPRIKA method for determining the weights on the criteria.
1000minds also developed the online platform for implementing prioritization systems across NZ’s hospitals, known as the National Prioritization Web Service. The service is used by the Ministry of Health and clinical directors and clinicians in hospitals, and is accessed by other information systems.
Conclusion
In public health systems, it’s inevitable that demand for elective (non-urgent) health services will exceed their supply. And so some way of prioritizing patients for access to treatment is essential.
The prioritization systems built for NZ by the Ministry of Health and clinicians using 1000minds ensure more equitable access and better patient outcomes overall.
These important contributions have been recognized in several awards for health-sector innovation and impact.
Inspired by NZ’s success with 1000minds, the approach summarized above, supported by 1000minds, has also been implemented in Canada, under the leadership of the Western Canada Waiting List Project.
This large body of work, spanning 20 years in NZ and Canada, is documented in more than a dozen peer-reviewed publications, as below.
The approach, supported by 1000minds, was also used for prioritizing social services, including health care, for “people in need” in the UK.
Peer-reviewed publications
About the use of 1000minds to create patient prioritization systems.
P Hansen, A Hendry, R Naden, F Ombler & R Stewart (2012), “A new process for creating points systems for prioritising patients for elective health services”, Clinical Governance: An International Journal 17, 200-9
A Fitzgerald, C De Coster, S McMillan et al (2011), “Relative urgency for referral from primary care to rheumatologists: The priority referral score”, Arthritis Care & Research 63, 231-39
G Srikumar, T Eglinton & A MacCormick (2020), “Development of the general surgery prioritisation tool implemented in New Zealand in 2018”, Health Policy 124, 1043-49
Another 10+ peer-reviewed articles are available.
References
G Fraser, P Alley & T Morris (1993), Waiting Lists and Waiting Times: Their Nature and Management, National Advisory Committee on Core Health and Disability Support Services, Wellington.
D Hadorn & A Holmes (1997) “The New Zealand priority criteria project. Part 2: Coronary artery bypass graft surgery”, BMJ 314, 135-8.
