The ‘postcode lottery' for hip and knee replacements is still strongly in force

RNZ News

04-08-2025

Lynette Wall
Photo:
RNZ / Cole Eastham-Farrelly
Lynette Wall is waiting to find out if she will get a knee replacement
Reforms were supposed to eliminate the 'postcode lottery' for healthcare. But new data shows access to care for people needing a hip or knee replacement still varies massively across the country.
Lynette Wall did not think her retirement would be like this. She dreamed of freedom, travel and ticking off her bucket list.
"I'm too scared to go anywhere," she says. She can't tackle the bucket list or do anything much, "apart from looking through a window".
Three months before she was due to retire, she discovered she had severe osteoarthritis in her knee. She now walks with a cane and takes a self-prescribed combination of panadol and ibuprofen each day to manage the pain.
Her world has shrunk. The long walks she loved are now short and full of fear her knee will either lock up, or give way. Social outings to places with stairs make her apprehensive, she sticks to territory she knows.
She suspects she needs a knee replacement, but has no idea when this might happen. She has not even had a first specialist appointment at Middlemore Hospital which would assess whether she can join the surgery waitlist.
A letter she received tells her the average wait time for the specialist appointment at Middlemore's Super Clinic is 47 weeks.
"I would like to stop things getting worse, I would like to stay out of a wheelchair if I can," Wall says.
Data obtained by RNZ shows that at the end of January 2025 Middlemore Hospital had 654 people on the waitlist for knee surgery - the biggest hospital waitlist in the country - with an average waiting time of 223 days.
While Wall's likely wait for surgery may seem long, she may be one of the lucky ones. She is more likely to get onto a surgery waitlist than people in places like Wairarapa, Taranaki or Southland, and her wait for surgery will likely be shorter.
If Wall lived in Invercargill, her time spent gazing out a window instead of enjoying life before she could get surgery would likely be three times as long - a whopping 721 days, despite a smaller waitlist of 190 according to the same data. A few hours drive north, at Christchurch Hospital, the average wait time for the very same surgery is 107 days, the lowest in the country.
New Zealanders needing hip or knee replacement surgery face a double-whammy postcode lottery. The bar to entering a waitlist differs across the country, as does the time it takes to get surgery once you are accepted to a waitlist.
Based on average wait times at the end of January, Southland hospital is the worst place to be if you need a knee replacement with 721 days, followed by Grey Hospital at 443 days. Christchurch hospital (107 days) is the only hospital meeting the target of treating patients on the knee surgery waitlist within four months.
Patients needing hip replacements can also face long waits. Grey Hospital on the South Island's west coast is the worst for hips. The shortest waiting time was 128 days for Hawke's Bay Hospital, but this still exceeds the target of four months. Southland's average wait for 2025 was missing from data supplied to RNZ, but in 2024 it was 454 days.
Average waiting times at different hospitals has changed over time, with some hospitals, such as Dunedin, experiencing several years with long wait times before improving.
While wait times tell one part of the persistent postcode lottery story for hip and knee surgery, it is not the only factor. Patients in some areas need to be in a far worse way to even make it onto a waiting list than patients in other parts of the country.
By the time many patients make it to Southland hospital's operating theatre for a hip replacement, their hip ball has practically imploded, according to Invercargill surgeon Chuck Luecker.
"The ball has gone from being round, to not just having spurs," Luecker says.
"Sometimes cysts form in the bone and sometimes you can collapse the wall of the cyst and the ball becomes deformed."
Leuker estimates 40 percent of the patients who make it to surgery fall into this category.
"They're not getting surgery in less than six months."
Patients in other locations get seen before they are in such a bad way. In Southland, patients have to have a score of 70 in a prioritisation tool to get surgery. In Canterbury, they only need a score of 50 and in Tairawhiti, just 20. People in Wairarapa have the toughest time making it onto a waiting list, with a score of 80 required.
Luecker says this postcode lottery of surgery comes down to Southland Hospital's capacity.
"According to the Ministry, you're not supposed to offer anybody surgery that you can't provide in a timely way."
Health New Zealand is working to standardise the bar to waitlist entry across the country. So far, this has been completed for cataract surgery but is yet to be put in place for orthopaedics such as hip and knee replacements. A
report
into the inequities in planned care published by the Office of the Auditor General noted standardising some treatments would incur additional costs for districts already under pressure.
Luecker believes a one-off population decline is behind the hospital's current predicament. The decline was incorrectly taken as a sign Southland's population would continue to fall and when a new hospital was built the number of beds was reduced from 198 to 166. Of those 166 beds, only 157 were fully staffed.
But, instead of decreasing, the population grew from 82,000 to 135,000.
The hospital opened in the middle of the ski and flu season and immediately elective surgeries were cancelled due to a lack of staffed beds, he says.
"We were turning away people who were truly disabled, out of work, on a cane or a crutch, and struggling."
Health New Zealand national chief medical officer Professor Dame Helen Stokes-Lampard says work is underway to standardise the score for acceptance onto waitlists across the country, but she says there are challenges to do this over 20 separate districts.
"In some areas it's workforce challenges," she says. This means more staff are needed to increase the number of surgeries which can be completed and lower the acceptance score. In other districts, the number of people already on the waiting list needs to be reduced before the score can be lowered. "In some areas there's been disagreement as to what the standard should be," she says.
Stokes-Lampard is unable to give a timeline for when entry criteria to surgical waitlists will be equitable no matter where someone lives. The current focus is on reducing the number of people waiting for surgery, and a funding boost to outsource procedures will tackle this, she says.
In the 2024/2025 financial year, 990 hip replacements and 1061 knee replacements were outsourced to the private sector.
Data at the end of January shows in total 4600 people were waiting on the public hospital lists for hip replacements and 3300 for knee replacements
There is concern the push to outsourcing could have perverse results long term.
"Outsourcing in the short term is undoubtedly very helpful for our waiting lists. In the longer term, you need to get the balance right of using the private sector so that you don't destabilise the public sector," she says. "That would be quite an own goal."
Patient Voice Aotearoa's Malcolm Muholland
Photo:
Matthew Rosenberg/LDR
Chair of advocacy group Patient Voice Aotearoa Malcolm Mulholland sees the sense in outsourcing elective procedures to private hospitals as a short term method to get through a backlog of surgeries, but he's against it as a long term plan.
"We're basically paying twice. We pay tax, it goes into the public health system. Then the government finds they have a shortage of workers, and therefore they contract out at a higher rate to the private sector."
A lack of staff is the biggest issue he sees, but says he is yet to see a workforce plan. Wages need to be increased to match other countries, such as Australia, to make New Zealand an attractive option.
He is against the idea of
10-year-long contracts
with the private sector.
"It's a move to privatisation," he says. "We're saying that no longer do we trust or have faith in the capability within the public health system, so rather than try and fix the public health system all we're going to do is outsource to private and they will charge a higher price."
Since Mulholland started advocating for patients, he says he's seen a little less of the postcode lottery, but it's not because things are improving. He believes access for people in all areas of the country is worse, with a widening divide between rural and urban access to help.
Photo:
RNZ / Cole Eastham-Farrelly
For Lynette Wall, who may be waiting months to find out if she is eligible for surgery, daily life consists of cautious shuffling around her home. She's determined to not need a wheelchair.
"I want to stay independent, not need home help, which would cost the government money."
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