Are People Safe in our Health System?
Facing up to the reality of medical harm in Aotearoa New Zealand
17 October 2023
The four co-founders of the Health Consumer Advocacy Alliance have all experienced significant harm in our health system. Every day we are in touch with New Zealanders from all walks of life who have also been harmed when seeking treatment. Although we focus on two case studies in this discussion document, there is ongoing and repeated harm inflicted upon many New Zealanders across the health system in many disciplines. This must stop. You can read our report on the reporting of medical harm and treatment injury in iur health system here...
- This report is not just about data and statistics, and clinical responses. It is about humanising the harm. People are not just numbers. You cannot – and should not – separate the human factor from the cold, hard data. Behind every number is a person.
- What do medically harmed New Zealanders wish for the most?
- The most common answer is they want acknowledgement, and for no one else to experience the same trauma, the same harm, and the loss that they have experienced. Their biggest hope is for meaningful change; and to not feel like a lost statistic.
- It is one thing to be able to detect harm in our health sector, but responsible health authorities must also take swift action when serious issues have been identified. Responsible health entities should be doing everything possible to ensure that medical harm is stopped. This is why Risk of Harm (ROH) and Severity Assessment Code (SAC) reporting is so important. It acknowledges the significance of harm and demonstrates the need for safer practice.
- Too many people have been harmed or have died due to intractable systemic failures that have not been properly addressed for decades. Robust harm reporting systems ensure that patients are kept safe. However, there is no evidence at all that patient harm is being identified and successfully monitored, with explicit action taken to stop harm when it occurs and to prevent further harm. While some medical harm is being reported there is no consistency in what is being reported, and these reports seem to disappear into the ether, with no transparency regarding follow-up and action. This is exacerbated by a failure of all health entities to identify and track practitioners who are repeat offenders in causing harm to multiple patients. No-one in Aotearoa New Zealand is competently tracking individual practitioner harm.
- Multiple health entities talk about working together to make improvements to our harm reporting systems; however, actions to date fall well short of what needs to be done to ensure the public are safe. Incredibly, there is no one with the legislative mandate or enforcement power over the private health sector; there is no doubt that this is perilous. How, in 2023, can this still be a problem? Our health system is meant to protect us but, upon delving into our harm reporting systems, we found the exact opposite – our health system is actually enabling this harm. Not one health entity can confidently say they are doing a good job of protecting our people. Where is the scrutiny, where is the accountability, where is the transparency?
- New Zealanders need to know that our health entities will act and do whatever they need to do to ensure we are safe in the hands of our health professionals. Cherry picking individual health issues to focus on without enacting transformative change across the entire system, is just tinkering around the edges; the flaws go beyond individual health issues. Fix the systems, scrutinise the selected measures of reporting, and we can address multiple health issues. We don’t need more talk; we need action! We need patient safety to be taken more seriously.
- The impact of unsafe care cannot be underestimated, it affects all New Zealanders receiving and providing treatment in Aotearoa.
- This discussion document asks our health agencies to consider ‘how can we collectively make the change that is needed, work together, take shared responsibility and ownership to proactively prevent harm?’