Questions and answers – Planned Care services

Planned Care encompasses medical and surgical care, traditionally known as Elective or Arranged services that are delivered in hospitals for people who do not need to be treated right away. 

It also includes a range of treatments funded by DHBs that are delivered in primary and community settings.

If you need publicly funded Planned Care services you can expect:

• to receive information about your assessment and treatment options and whether or not they will be available to you
• that your level of need and ability to benefit will be assessed compared to other people
• to know in 15 calendar days or less whether you will receive assessment or treatment
• to receive care at the most appropriate time to ensure improved health and minimise ill-health, discomfort and distress.

The traditional model of admission into hospital for treatment is changing. 

Modern, safe treatment practices mean some people’s needs may now be met by day-surgery, less invasive surgery, or non-surgical techniques.

If you have a condition you think may require treatment you should first see your primary care provider such as your doctor, nurse practitioner, Māori health provider, optometrist or physiotherapist.

They will assess your condition and discuss the best option with you, including whether to refer you to a specialist.

You may be referred by your GP (or primary health provider) for specialist advice, further investigations or to be considered for specialist intervention. 

As part of this referral you may be asked to fill out an ‘Impact on Life Questionnaire’, to assess how much your condition impacts your day-to-day life.

If your GP (or primary health provider) refers you for specialist advice the specialist will review your referral and provide the requested advice, where appropriate.

If you are referred to a specialist at a public hospital for investigation or consideration for intervention or treatment, the local clinical staff will prioritise your referral for an FSA.

Your referral is prioritised against other referrals in your region.

If your referral meets the clinical threshold set for a First Specialist Appointment (FSA) you will be assessed by a specialist.

Sometimes this does not require a face-to face appointment.  The hospital should inform you and your primary care provider within 15 calendar days about whether or not you will receive an FSA. Your primary care provider will care for you while you are waiting to see the specialist.

If your condition gets worse during this time you should contact them.

The specialist will assess your condition and recommend the best option of care for you.

There are a number of possible outcomes depending on how urgent your condition is and what resources the Hospital has available.

• the specialist may arrange for more tests to be done before a decision is made
• you may be prescribed a course of medical treatment (eg, drugs) after which you may need to be reviewed again
• if surgery is seen as the best treatment option your priority score will be determined based on how urgently you need the surgery and how much you will benefit from it compared to other people
• the DHB will determine whether it can provide treatment, depending on your priority score and the available resources
• if the DHB can offer you the required intervention, treatment will be provided within a clinically appropriate timeframe based on your level of priority. This must be within 4 months of the date the offer to treat you was made
• if your condition is deemed not urgent enough to receive specialist care within 4 months, but it may get worse, you may be given the status of Active Review. This means the hospital must re-assess your condition at least every 6 months for up to 18 months. If your condition does not get any worse you will be discharged to your primary care provider with advice on what to do should your condition get worse
• in some cases a specialist may tell you that a service is not available even though you would benefit from it. This could happen if some Planned Care services have not been prioritised to be delivered in your DHB. If this happens, you and your primary care provider will be informed, and the best options of care will be discussed with you.

The specialist will assess your condition and recommend the best option of care for you.

There are a number of possible outcomes depending on how urgent your condition is and what resources the Hospital has available:

• the specialist may arrange for more tests to be done before a decision is made
• you may be prescribed a course of medical treatment (eg, drugs) after which you may need to be reviewed again
• if surgery is seen as the best treatment option your priority score will be determined based on how urgently you need the surgery and how much you will benefit from it compared to other people
• the DHB will determine whether it can provide treatment, depending on your priority score and the available resources
• if the DHB can offer you the required intervention, treatment will be provided within a clinically appropriate timeframe based on your level of priority. This must be within 4 months of the date the offer to treat you was made
• if your condition is deemed not urgent enough to receive specialist care within 4 months, but it may get worse, you may be given the status of Active Review. This means the hospital must re-assess your condition at least every 6 months for up to 18 months. If your condition does not get any worse you will be discharged to your primary care provider with advice on what to do should your condition get worse
• in some cases a specialist may tell you that a service is not available even though you would benefit from it. This could happen if some Planned Care services have not been prioritised to be delivered in your DHB. If this happens, you and your primary care provider will be informed, and the best options of care will be discussed with you.

Two important questions guide the specialist in making this decision:

1. How severely does your condition impact on your day-to-day life and, how much will you benefit from it compared to other people?
2. DHBs are expected to make use of nationally-recognised prioritisation tools to ensure the decision making process is fair and clear.

If the DHB confirms it can provide treatment, it must provide the treatment within four months of making the decision to treat. 

This could be sooner, depending on your level of priority.

If you are waiting for surgery and your condition suddenly gets worse, you may be admitted to hospital immediately (acutely) to receive an operation.

If the DHB confirms it can provide treatment, it should provide that treatment within 4 months.

However, if you are waiting for surgery and your condition suddenly gets worse, you may be admitted to hospital immediately (acutely) to receive an operation.

If at any time your condition gets worse you should see your GP (or primary care provider). They will ask the specialist to reassess you, which may mean your priority score for treatment changes.

New Zealand’s health system is funded by the taxpayer.

Accordingly, we make choices through our elected representatives about how much tax we pay, and how it is spent.

This determines the level of publicly funded treatment that can be provided. 

Demand for Planned Care services is increasing for a number of reasons, including the ageing of our population and new technologies that enable a larger number of procedures to be delivered.

DHB's have to balance their spending on Planned Care with other health priorities such as maternity services, cancer treatment, mental health services and accident and emergency care.

Often there simply aren’t enough resources to meet all of these demands.

Yes, both you and your GP (or primary care provider) will be told the results of any tests and what treatment options are available and most suitable for you.

If you don’t agree with a decision that you will not be given a publicly funded FSA or treatment, you should talk to your GP (or primary care provider).

They will explain why the decision has been made and what options are available to you.

These may include referral to a private specialist for assessment or treatment, or a clinical review of your condition, either by the original specialist or by another clinician (a ‘second opinion’).

You have the right to ask for a clinical review, but the original decision may still stand.

You should also check that all relevant information about your condition has been given to the specialist, including the impact your condition has on your life.

DHBs often have a process for addressing patient concerns – please visit your DHB’s website.

Often the letter you first receive says you will be seen within four months.

This doesn’t necessarily mean you will need to wait the full four months. Specialists will decide how soon you need to be seen, based on the information provided in your referral.

You can discuss your options with your GP (or primary care provider).

They will be able to tell you whether or not the recommended treatment is likely to be available from a public hospital or if it can be delivered elsewhere such as at a GP or community based clinic.

There are no additional costs to service users when they are receiving publicly funded services.

There may be a range of options and services available to you, depending on your circumstances.

The specialist may discuss these with you, and or your GP (or your primary care provider) and can advise on possible alternatives. These could include non-surgical treatments or ongoing care, or private treatment.

Other factors are also important to consider such as cost, how long you are prepared to wait, whether you have private health insurance and the level of expertise required.

No, you won’t automatically be transferred to another waiting list because hospitals operate within their own district and budgets.

One option is to stay on the waiting list where you lived before, until treatment becomes available. Any travel costs required (both before and after your operation) would be at your expense.

DHBs are required to meet their commitment to treat you even if you have moved out of their district – but you must make yourself available for appointments and follow up procedures.

Alternatively, you could get a new referral from your current specialist, or your GP (or primary care provider) in your new location. If you do this, you would be starting the process again from the beginning.

Even if you have seen a private specialist, your referral will be treated in the same way as everybody else’s.

If your priority score is high enough you will receive treatment from the public system.

You may be required to see a specialist at the public hospital to have your priority score determined or confirmed.

Under the Code of Health and Disability Services Consumers’ Rights, you have the right to be treated fairly, consistently, and to an appropriate standard.

If you feel you have been treated unfairly, or wish to make a complaint, you have rights under the Health and Disability Commissioner Act 1994.

Information about how to make a complaint is available on the Health and Health and Disability Commissioner’s website

You also have the right to have a support person or advocate help you whenever you are dealing with your DHB.

You have a number of obligations when seeking publicly funded treatment through your DHB. These obligations help keep things fair for others.

You must:

• confirm whether or not you are willing to have the treatment (with all its implications), so that your DHB can best use its resources
• carry out all instructions given to you to prepare you for treatment, so your treatment can proceed safely
• let your DHB or specialist know if your contact details change in any way, so they can contact you urgently if necessary
• give your DHB or specialist reasonable notice if you can’t keep your appointment, so it can be made available to another patient.

Valuable time and resources are wasted when DHBs can’t contact patients, or when patients don’t show up for appointments and treatments.

DHBs can’t always reschedule appointments at short notice, or ask others to take your place so the treatment slot may not be used.

This contributes significantly to waiting times.

Your GP (or primary care provider) should be the first person you talk to because they understand how the Planned Care system works.

For some things you will need to talk to your hospital.

They will have a customer liaison representative you can contact.