Most people waiting for osteoarthritis care never get it – it’s time to try a different approach

Hospital waiting lists have been a perpetual problem,^1–4 but the ‘extra’ money thrown at it intermittently has barely kept pace with population growth.⁵ Now we have another waiting list crunch, exacerbated by the COVID pandemic. In the 2 years since February 2020, the number of people waiting longer than 4 months for treatment has more than trebled. The government, recognising the growing problem and the opportunity to find different approaches to the problem, has commissioned a new task force and charged Health New Zealand and the Māori Health Authority with implementing new processes.⁶

A large proportion of the surgical waiting lists for elective procedures are musculoskeletal related problems, which are among the greatest cost category to the public health system and the largest health burden to the people of Aotearoa New Zealand.⁷ Osteoarthritis is a significant driver of this; the prevalence of hip and knee osteoarthritis continues to grow and will continue due to our ageing population, reduced physical activity levels, growing social inequities, and increasing obesity.⁸

The wait for osteoarthritis care does not start when someone is referred for an orthopaedic assessment. Joint replacement surgery is only appropriate for severe osteoarthritis with late-stage joint changes and is required by less than 20% of people with hip or knee osteoarthritis. Although joint replacement is highly cost-effective and can be life-changing for well-selected patients, it does not help most people with knee osteoarthritis because most people do not need surgery.⁹ This means that even when surgery is received, it happens after most of the personal, whānau, community, employment, societal, and economic impacts of osteoarthritis have already occurred. Put more simply, people wait for decades before (if ever) the system offers any help. There is a virtual absence of publicly funded care for most people who have osteoarthritis.

The solutions to the growing need for osteoarthritis care do not lie in hospitals. While acknowledging that a sustainable, upstream approach to health requires action at the social, economic and environmental origins of health problems, not just the symptoms or the treatment, the healthcare system must delivery more efficient access to appropriate care. The barriers are manifold. There is considerable inequity in access to care and outcomes, with research showing that Māori are less likely to be referred for surgical care, and receive lower than expected levels of care than non-Māori. Many GPs do not refer people they think may benefit from specialist care because of the current waitlist and approaches to prioritisation¹⁰ – and because the health system measures wait times by those who make the waitlist, the volume of patients referred by the GP for a first specialist appointment and declined is not known. Targeted programmes delivered by allied health have been shown to reduce that unmet need dramatically.¹¹ However publicly funded physiotherapy, occupational therapy, dietitian support and other allied health professional care are not available in primary care settings.

Core osteoarthritis care appropriate for all people with the condition is delivered in the community by primary health care professionals.¹² This care includes education and support to empower self-management, supervised exercise programmes, and behaviour change to support health through increased physical activity, weight loss, and improved nutrition. These approaches are primarily delivered by allied health professionals. A shift to more pro-active, person-centred, multi-disciplinary approaches supporting existing primary care teams, including expertise from allied health, has great potential to close the equity gaps in both access and outcomes.

There is strong evidence that providing comprehensive and coordinated care to people with osteoarthritis results in some patients choosing to delay or avoid joint replacement surgery surgery.^13–16 Care provided by allied health professionals in primary and community care is highly cost-effective.^17,18 Providing this care in the early stages of osteoarthritis represents an opportunity to improve the quality of life of all those who live with osteoarthritis, reduce the considerable burden of osteoarthritis on society and the economy, and prevent many people from being referred to a hospital specialist in the first place.

Te Manatū Hauora acknowledged musculoskeletal disorders as a priority in 2015 and commissioned the Mobility Action Programme to pilot new models of care delivered primarily by allied health professional teams,¹⁹ but to date has not acted on the positive evaluation of that initiative to provide more timely access to planned care.²⁰ Recent announcement of the inclusion of expanded primary care teams as part of Health NZ locality plans is heartening, provided such services are truly integrated and funded more comprehensively than current primary care models so that services can have minimal barriers to access, but there seems to be a disconnect between that thinking and the apparent standpoint of this new task force.

We applaud Te Minita Hauora for setting up a task force to tackle hospital waiting lists, but are perplexed by the absence of experts from allied health professions and of those involved with research including osteoarthritis research. That both the Minister and the Taskforce chair, Counties Manukau DHB chief medical officer and surgeon Andrew Connolly, cited examples where provision of physiotherapy resulted in reduced need for major surgeries^5,21 makes this omission all the more perplexing.

This is a serious omission – we are concerned the taskforce lacks the range of perspectives necessary to consider the heart of the problem, recognise the opportunities, and propose real solutions. The Health Minister acknowledges that if we approach this problem the same way we always have, we’ll always have the same problem.⁵ For osteoarthritis, delays related to COVID-19 disruption have simply compounded what was already a growing problem.⁷ If joint replacement is our only solution to this problem, we will never keep up.

Aotearoa New Zealand needs a coordinated system-wide approach to osteoarthritis.²² This approach should focus on prevention and the provision of equitable planned care, early. This would reduce hospital waiting lists and improve the lives of the many other New Zealanders who never have the opportunity to wait for hospital care. Additional benefits of delivering care to all people with osteoarthritis include the economic, productivity and mental health benefits of maintaining workforce and community participation, gaining collateral benefits of increased activity and improved nutrition, economic and productivity benefits, and reducing collateral harms (mental health, physical health, medication adverse effects).^17,23,24 This solution will not be adequately considered without people at the table who understand the opportunity.

If the government is truly serious about finding different approaches to reducing waiting lists, allied health must be at the table at every level of system reform.

No data beyond the referenced sources cited were used to generate the contents of this paper.

The authors declare no conflicts of interest. JHA DO’B BH and BD are members of Osteoarthritis Aotearoa New Zealand (https://events.otago.ac.nz/2021-osteoarthritis-basecamp/about). RK and BD are members of the Editorial Advisory Board of the Journal of Primary Health Care.

This article did not receive any specific funding. JHA is supported in part by the Health Research Council of New Zealand.