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It is now generally accepted that there is a large amount of unmet healthcare need in Aotearoa New Zealand. This unmet need often goes unrecognised and is not only due to inadequate accessibility to, and quality of, healthcare services but also to much wider problems of poverty, colonisation, racial discrimination and other aspects of socio-economic deprivation.[[1,2]] Regarding secondary elective healthcare, many younger people are unable to access care for non-life threatening problems such as groin hernias that affect their ability to work, and many older people cannot have care such as cataract surgery that allows them to function socially and independently.

As described in more detail elsewhere,[[3,4]] following the failed New Zealand Health Reforms of the 1990s, the Canterbury Charity Hospital Trust (CCHT) was formed in 2004. The objective of this charity was to meet some of the increases in this unmet healthcare need for the people of Canterbury District Health Board (CDHB) region. The vision of the CCHT was: (i) to provide free secondary elective healthcare for some of those who were refused care in the public health system, did not have medical insurance (personal or through the national Accident Compensation Corporation scheme) and could not afford private healthcare; (ii) for the care to be provided by a largely volunteer workforce; and (iii) for the charity to be funded solely by public charitable giving.[[5]] The objective and vision have not changed.

To meet the vision of the CCHT, an old family villa was purchased in the Bishopdale area of Christchurch in 2005 (Building One; Figure 1) and, with major funding from the Ron Ball Charitable Trust and public donations, converted into a modern day hospital, the Canterbury Charity Hospital (CCH), with facilities for contemporary medical, surgical and other health services. The clinical services provided by the CCH changed with time, in an attempt keep in step with the areas of clinical need that were not adequately addressed by the local public healthcare system. At the time of the Christchurch earthquakes, a large counselling service was started; in 2011 the adjacent property was purchased (Building Two; Figure 1) to accommodate the counselling and to allow the introduction of a dental and an endoscopy service.

Figure 1: Aerial photograph of Canterbury Charity Hospital Trust properties 2020

Corner of Harewood Road and Leacroft Street, Christchurch—CCHT properties encircled in red.
Building One (Ron Ball House, 349 Harewood Road)—Main operating theatre and recovery ward, clinical examination rooms and offices.
Building Two (Patsy Mauger House, 351 Harewood Road—Endoscopy unit, counselling rooms, lecture/staff room and offices.
Building Three (Warner Mauger House, 353 Harewood Road)—Twin oral surgery units, community room, and administration offices.
Buildings Four and Five (66b Leacroft Street and 355 Harwood Road)—both for future developments. The CCH has been well received by the general public. It has never been short of people willing to work in Medical, Nursing, Technical, Administrative and as other volunteers. These people have been managed and supported by a small skeleton staff of employees. It has never taken government contracts or been paid for any of its services. Generous funding has always come from the general public, local community groups and numerous individual philanthropic organisations and individuals.

METHODS

Chronology of main events

The main clinical planning, developments, structural and infrastructural changes, and fundraising events during the eight-year period from the beginning of 2013 to the end of 2020 are listed in the timeline (Table 1).

Between May and November 2016, the CCHT Board was increased from four to six members. From then, the board comprised: a general surgeon; an adolescent health physician; a lawyer; a businessperson; a retired anaesthetist; and a colorectal surgeon. CCHT has always had an independent Clinical Board, which has remained at arm’s length from the Trustee Board. Its membership remained diverse, consisting of: the CCHT executive officer; two GPs, a dentist; a retired anaesthetist; a clinical psychologist; a senior nurse; a Māori advisor and an Anglican vicar. It has given advice on clinical issues such as eligibility of patients for treatment, changes to service provision, research and credentialing approvals. Incident reporting and all complaints were also heard by the Clinical Board for both their advice and decisions.

View Tables 1 & 2.

Staff employee numbers changed very little (Table 2). Spontaneous volunteer workers came from a pool, which averaged about 280 people over the eight-year period. Their individual work commitments at CCH varied greatly. Some worked there every week and others only several times a year. The staff comprised: a full-time executive officer, and senior nurse; two part-time nurse specialists; and a part-time fundraising person.

The CCH facilities and services were extensively developed during the eight-year period to meet the changing and increasing unmet secondary elective healthcare need of the CDHB region (Table 1). In 2015, the operating theatre and post-operative recovery room in Building One were comprehensively upgraded and expanded. In 2016, an adjacent property (Building Four; Figure 1) was purchased for future development. Another adjacent property (Building Three; Figure 1) was purchased, extensively renovated and opened in 2017 with twin oral surgical units. Dental and oral surgery was then moved there from Building Two.

Finances

The part-time fundraiser and a small support committee of volunteers organised a programme of annual and special fundraising activities. These included: regular appeals in local media, sometimes enhanced by publicised visits to CCH by national and international celebrities; lectures to community groups; an annual dinner and other community events; donations from charitable trusts; and applications to philanthropic trusts. Other funding sources included bequests and returns from investments.

The influence of social media and the phasing out of cheques by the major banks, meant there were some changes in the sources of funding for the CCHT. However, much funding still came from middle-aged and elderly members of the community, and the rates of charitable donations did not change significantly. As a result of the CCHT Board, Management’s careful financial stewardship, and the relatively small staff budget, the average proportional expenditure over the eight-years period for patient treatment and running costs was 89% of budget, with only 7% for fundraising and 4% for fixed costs.

Relationships with local healthcare organisations

Based on CCHT’s general utilitarian philosophy and specific role to address as much of the unmet need as possible, it endeavoured to foster and strengthen working relationships with other local healthcare providers. To these ends, it had a Memorandum of Understanding with the CDHB since 2008. It also shared ownership of some surgical equipment as follows: orthopaedic equipment with Southern Cross Hospital; gynaecology equipment with Christchurch Women’s Hospital; and eye equipment with Christchurch Eye Surgery, Papanui.

RESULTS

Clinical throughput

The types of clinical services and the numbers of cases assessed and treated at CCH changed over the eight-year period (Table 3). The onsite services included: General Surgery, Audiology (facilities only provided by CCHT), Orthopaedics, Urology, Gynaecology & Family Planning, Dentistry, Oral Surgery, Vascular Surgery, Lower Gastrointestinal (GI) Endoscopy, Counselling and Dietician Services. The offsite services included Ophthalmic Surgery, and Dermatology. Dermatology open-day clinics were run on a Saturday in 2017, 2018 and 2019 at CCH. At these members of the public were able to have skin lesions assessed by specialist dermatologists and any suspicious lesions were automatically accepted for treatment by the CDHB. Unfortunately, COVID-19 restrictions prevented the possibility of holding such a clinic in 2020. View Table 3.

What services CCH offered at any particular time was largely dictated by changes made by the CDHB to which services it was providing, and by what workforce and physical resources were available to CCH to fill the emergent deficiencies. For example, CCH started an elective groin hernia repair service when it opened in 2007, as such surgery was not routinely offered by the CDHB. However, the CDHB then restarted doing such surgeries in late 2016, with many of the cases done under contracts with private healthcare providers, so CCH stopped providing this routine service.

Most patients were referred directly to CCH by their GPs when the service was not available through the CDHB. In these circumstances, GPs were usually advised to do so through their computerised patient management system (called Health Pathways by the CDHB). For some CCH clinical services, however, other specific referral processes were in place (vide infra).

Patient numbers and profiles

During the eight-year period (Table 3), there were 3,903 outpatient appointments and 11,752 interventions performed for patients (39.78% male, 57.36% female, 2.86% unspecified; mean age of 54.0 years, range <1–97 years; n=8,520). Ethnicity proportions were as follows: African 0.45%; Asian 3.10%; Australian 0.07%; NZ Māori 10.20%; Pākehā/NZ European 78.24%; Pasifika peoples 4.84%; South American 0.84%; Middle East 0.97%; Other 1.29%.

Clinical outcomes

CCH always invited all forms of, and routes for, comments about its clinical services. In particular, all patients were invited to take part in an anonymous satisfaction survey, but few took the opportunity to do so. The survey asked six questions on satisfaction with specific peri-consultation /interventional instances of care, and one question on overall satisfaction with patient experiences at CCH. Responses were registered on a five-point Likert scale of 1 (poor) to 5 (excellent). A random sample of 77 survey responses, taken from the period 2017 to 2020, showed scores of 4 and 5 by 11.36% and 88.20%, respectively for specific instances of care, and 3.90% and 96.10%, respectively for overall satisfaction (n=77). All significant issues raised in the surveys or by other routes were addressed immediately or, if necessary, brought to the attention of the Clinical Board.

During the eight-year period there were very few peri-procedural or 30-day complications. One operative case was terminated at the beginning of surgery because of a patient ventilatory problem—recovery was complete. Post-operatively, there was one wound infection (Grade II) and there were three cases with pain management issues (Grade I).[[8]]

Specific clinical services

Endoscopy Service

Since the CCH opened in 2007, local GPs referred cases of outlet-type rectal bleeding and other anorectal symptoms for management. In order to fully investigate these cases, a second operating theatre equipped for lower GI endoscopy was added in Building Two in July 2012, and has been mainly used for this purpose since then.

In May 2017, CCHT was approached by CDHB and requested, along with St Georges Hospital Christchurch, to help by providing a flexible sigmoidoscopy (FS) service for the management of patients less than 50 years of age with outlet-type rectal bleeding. The reasons for this request were: (i) emerging national and international data showing an appreciable increase in the incidence of colorectal cancer (CRC) in such young patients;[[9]] and (ii) CDHB did not have the capacity to investigate these patients with endoscopy.

The service was started at CCH in July 2017, and St Georges Hospital helped with provision of the service for the first 10 months. Patients were referred from the CDHB and from local GPs via Health Pathways. After a one-day bowel preparation, patients underwent un-sedated FS and were discharged immediately afterwards. By the end of 2020, 759 patients (381 male, 374 female, 4 not specified; mean age of 36.64 years, ranging 15–79 years) had a FS (32 at St Georges Hospital; 727 at CCH), performed by 15 volunteer endoscopists. Among the findings were eight patients with CRCs and 212 with colorectal polyps; 74 of the latter had tubular adenomas or serrated polyps and required appropriate follow-up. Were it not for this rectal bleeding service, diagnoses of some of these colorectal pathologies would have been unduly delayed with serious prognostic

Patients with CRC and serious colorectal pathology were referred back to CDHB; those with haemorrhoids and other benign causes for rectal bleeding were treated at CCH. In the absence of any relevant national or international guidelines, it was debatable which patients required a follow-up completion colonoscopy. Some local endoscopists thought the findings of advanced polyps or serrated lesions were necessary to merit such follow-up;[[10]] others thought the presence of any colorectal polyps was sufficient cause. To resolve this issue, advice was sought from a group of international experts. Recommendations for criteria for completion colonoscopy were formulated and published[[11]] and have since been implemented as the minimum required standards at CCH.

During the described eight-year period at CCH, a colonoscopy service was provided. This was for patients who had a previous FS at the CCH, with findings that indicated the need for completion colonoscopy, and those that had been declined by the CDHB for symptomatic investigation, as they did not meet the prioritisation threshold. Patients were referred on to CDHB after colonoscopy if: (i) their pathological findings indicated the need for inclusion in a regular surveillance programme; or (ii) there was significant pathology needing treatment beyond what CCH could offer, such as large lesions needing endoscopic mucosal resection or operative surgical treatment.  The quality of the colonoscopy service at CCH from 1 October 2016 to 31 September 2017 was independently audited. The findings were that this service was safe and complied with the accepted quality indicators.[[12]]

FS is a quick, relatively safe and economic investigation. It is, however, uncomfortable for some patients. For this reason, modifications were tried in pre-procedure patient information systems and intra-procedural processes, with the objective of improving the experience for everyone having lower GI endoscopies. The whole Endoscopy Unit was upgrade in 2020 to improve the patient facilities and to comply with new GESA guideline standard for endoscope cleaning and storage, which came into effect in February 2022.[[6]]

Dental and Oral Surgical Service

There was a high demand for the Dental Services provided at the CCH, with the number of people needing dental treatment increasing all the time. There are subsidies and grants available from Work and Income New Zealand (WINZ) for emergency care and relief of pain for low-income adults to allow them to be treated in the community by both private dentists and the Dental Department of Christchurch Hospital. However, this WINZ benefit did not cover the cost of routine dental care.  

Since June 2012, CCH has offered treatment for the WINZ beneficiaries who have been referred from local dentists and who might not have otherwise been able to access necessary dental care. These people could no longer be treated at the Dental Department of Christchurch Hospital for routine dental care because of changes to the criteria for admission. The treatment needed could be complex and difficult, and the patients themselves often presented with complicated medical, psychiatric and social issues. They were a vulnerable population group, with great needs for treatment that were financially out of their reach.

During the eight-year period, dental surgeons and assistants volunteered their time and expertise, providing a total of 3,833 dental treatments at an average of 2.5 service sessions a week. The dentists offered a single course of treatment for adult WINZ beneficiaries (who had exhausted their annual $300 WINZ dental grant) to get them “dentally fit”. Treatments offered included check-ups, cleans and periodontal treatment, extractions, root canal treatment on front teeth and fillings. Complex oral surgery extractions were done using intravenous sedation. More recently nitrous oxide sedation was introduced, making routine dentistry much easier for many of the patients who suffered from anxiety and had a deep fear of dental treatment. The efficiency of the dental service was significantly improved by the purchase and installation of an Orthopantomogram X-ray machine in March 2019.

Between 2013 and 2019, nine dental technicians from three companies staffed a denture clinic at CCH once a fortnight. Here, they provided full and partial dentures to those in need. The denture service was suspended in 2020 as a result of the COVID-19 pandemic.

Counselling—Terror attacks

Around the time of the Canterbury earthquakes on 22 February 2011, CCH started a free counselling service for self-referred people and those referred by healthcare, social and care workers. This service continued afterwards but slowly reduced with time in numbers of referrals.  As a consequence of the previously established local counselling networks and the nimble way CCHT was accustomed to reacting to change, in March 2019, following the terrorist attacks at the Christchurch mosques, the CCH was able to immediately ramp up its counselling service. This offered help to victims, their families and others who felt they needed support dealing with the mental and psychological impact of the shootings—it involved an extra 13 counsellors. While little is known about the effectiveness of therapeutic interventions in the recovery phase of disasters, it is recognised that, although immediate support is very important, it also allows for people experiencing more extreme reactions to be quickly identified, assessed and referred for further assistance as required.

There were 999 appointments for counselling between 15 March and September 2019. Most were terror- attack-related but, as all counselling records are strictly confidential, the total numbers of counselling sessions could not be classified by reason for referral, types of counselling received or of what methods were used.

Effect of COVID-19 pandemic

The COVID-19 pandemic started in New Zealand with the first case on 28 February 2020. The pandemic had a serious impact in reducing the volume of work that could be done at CCH during the extended periods during which the hospital was unable to open. At the time of the initial lockdown period on 15 March, CCHT management started consulting with CDHB and followed Ministry of Health (MoH) advice as indicated.

Discussions were held with CDHB. It was suggested that, if the pandemic accelerated rapidly, CCHT might be used as either a small isolation unit or as an overflow unit for cases needing ventilation. An assessment was made of the equipment and facilities at CCH, including the number of patient ventilators. A non-DHB hospitals COVID-19 reaction group was set up. This was coordinated by the CDHB and met on the internet (Zoom) most days of the week during the Level 4 lockdown to discuss plans, exchange ideas and update everyone with events. As the pandemic did not escalate, CCH remained in lockdown until MoH recommendations changed to Level 2 on 13 May 2020. Then CCH gradually returned to normal levels of clinical activity but implemented precautions as outlined by the MoH for general situations and by the Dental Council of New Zealand, in regard to Dental and Oral Surgery.

Clinical research

During the eight-year period, CCHT undertook and published some original clinical research. One important component was a research project to assess the efficacy of the counselling service offered to the Christchurch earthquake victims in 2011. During 2017–2020, a randomised sub-sample of 60 (15% male, 85% female; mean age of 53.67 years, SD=15.5, ranging 14–91 years) from the 858 patients who had attended the counselling service between 2011–2012, were contacted and interviewed to ascertain how helpful the counselling had been. The number of sessions attended ranged from 1–20 (mean=3.28) with anxiety, low mood, sleep disturbance, earthquake trauma, stress and difficulties coping as the main presenting problems. While a small number were dissatisfied with the number of sessions offered, and not having a choice in the gender of their counsellor, the large majority found the counselling very helpful.

The Short Form 36 Health survey (SF-36) was used to assess the patients’ psychological wellbeing at the time of interview.[[13]] Table 4 shows the CCH sub-sample SF-36 subscale scores were considerably lower than the SF-36 participant scores in the 2006/07 New Zealand Health Survey. This suggests the patients attending the CCH Counselling Service were significantly less well than the general population at the 95% confidence level. These findings are supported in the study by Spittlehouse et al (2014),[[14]] where it was found that 212 participants, aged between 45–54 years and living in post-earthquake Christchurch, also had significantly lower scores on the mental health and wellbeing scales of SF-36 compared to 2006/07 national data. View Table 4.

CCHT staff and volunteers undertook and published other clinical research including: a survey of outcomes for open mesh repair of inguinal hernia at CCH;[[16]] a pilot study of methods to assess unmet secondary healthcare need in New Zealand;[[17]] and a report on Southern DHB’s colonoscopy service.[[18]] They also published on a number of healthcare issues including: the importance of measuring unmet healthcare need;[[19,20]] variation in policies for management of inguinal hernias;[[21,22]] adequacy of public healthcare funding;[[23,23]] physician advocacy in the twenty-first century;[[25]] the code of rights and bowel cancer screening;[[26]] enhanced bowel screening by FS;[[27]] effects of Neoliberalism on healthcare;[[28]] towards a better world after COVID-19;[[29]] and adequacy of publicly funded colonoscopy services in New Zealand.[[30]]

CONCLUSIONS

It became clear at the time of the Health Reforms of the 1990s, that there was a large amount of chronic unmet need for secondary elective healthcare in Aotearoa New Zealand. This was estimated to be about 9% in the adult population,[[17,31]] and was undoubtedly higher in Māori and Pasifika communities, and those living in poverty. The CCHT has done extensive research on this subject and made numerous public calls for the quantity and nature of the unmet secondary elective healthcare need to be estimated repeatedly, independently and transparently, using validated population survey techniques.[[7,32]] However, until recently, successive governments and public health officials have shown little interest in measuring the size of this problem or doing anything substantial to address it. The CCHT was formed with the specific intent of offering as much help to as many of these people as possible to reduce their unmet healthcare needs.

During the eight-year history of the CCHT described in this article, secondary elective services provided by the CDHB changed periodically with time. The CCHT attempted to respond to these changes by trying to fill the moving gap between what the public and private healthcare systems provided. Although CCHT could never address all the unmet need, it was successful in providing quite large numbers of interventions across a diverse range of services, thanks to the unfailing generosity of the Canterbury public and the army of hospital volunteers that worked so tirelessly.

The main changes to the services offered by CCHT since the end of 2012 were: the sudden increased need for counselling after the Christchurch terror attacks; the expansion of the dental and oral surgery service; and the increased endoscopy service. Most of the other services remained largely unchanged but some, such as general surgery reduced as CDHB reintroduced some elective services. The largest overall influence on the activities of the CCHT was, however, the COVID-19 pandemic, which unfortunately led to periods of closure or reduced services.

One area of improvement was better cooperation between CCHT and CDHB. This was particularly evident in the direct patient referrals from the latter to the FS rectal bleeding service run by the former. There was also cooperation in the organisation of dermatology days by the two organisations. Many possibilities remain, however, for greater future cooperation between them, particularly regarding the use of CCHT facilities, for example, for elective day surgery for low-risk general surgery cases.

The large amount of unmet secondary elective healthcare is not only a Canterbury problem, but actually a national one. This is attested by the fact there has been an Auckland Regional Charity Hospital since 2009, and planning started for a Southland Charity Hospital in Invercargill in 2019. These developments resulted from the humanitarian actions of local communities reacting to the unmet healthcare need of their fellow citizens. It is earnestly to be hoped that present and future governments awaken to the fact that investment in health is not only a characteristic of a properly functioning society, but it has also been shown to be extremely economically advantageous.[[33]]  If they do not do so, the likely long-term consequence will be “a charity hospital in every town”.[[34]]

Summary

Abstract

Aim

To update activities of the Canterbury Charity Hospital (CCH) and its Trust over the eight-year period 2013 to end of 2020, following previous reports in 2010 and 2013.

Method

CCH continued to provide free secondary elective healthcare services to some patients in the Canterbury Distinct Health Board (CDHB) region who were unable to access healthcare they needed through public hospitals and were unable to pay for private care. CCH’s services were supplied by a large volunteer workforce, supported by a skeleton staff, and were financed solely by charitable giving. Changes occurred periodically in the quantity and nature of regional unmet healthcare need, largely due to changes in services provided by the CDHB. In order to accommodate these changes, major structural and infrastructural developments were necessitated at CCH.

Results

Many healthcare services at CCH remained the same as before this period but new changes occurred there as a result of: (i) establishment of a flexible sigmoidoscopy day clinic for the management of fresh rectal bleeding in those under 50 years of age; (ii) requirement for a sudden increase in counselling services immediately after the terror attacks at Christchurch mosques; (iii) expansion of the Dental and Oral Surgery Service; and (iv) interruption of CCH service provision by the COVID-19 pandemic.

Conclusion

CCH continued to fill some of the regional unmet elective healthcare need. This is, however, a national problem as attested by the presence of a charity hospital in Auckland and another being planned for Invercargill. Hopefully present and future governments will appreciate that free universal access to secondary elective healthcare is not only a humane imperative, but also a sound economic investment.

Author Information

Philip Bagshaw: Chair, Canterbury Charity Hospital Trust, Christchurch. Lynne Briggs: Associate Professor, School of Health Sciences and Social Work, Griffith University, Gold Coast Campus, Queensland, Australia. Susan Bagshaw: Trustee, Canterbury Charity Hospital Trust, Christchurch. Vivienne Levy: Dental Surgeon, Longhurst Dental Centre, Christchurch. Carl Shaw: Executive Officer, Canterbury Charity Hospital Trust, Christchurch. Averill Williamson: Nurse Coordinator, Canterbury Charity Hospital Trust, Christchurch. Anita Tuck: Clinical Nurse Specialist, Canterbury Charity Hospital Trust, Christchurch. Alice Brown: Clinical Nurse Specialist, Canterbury Charity Hospital Trust, Christchurch.

Acknowledgements

The authors wish to acknowledge the unfailing generosity of the people of Canterbury and the massive support of an army of volunteer workers.

Correspondence

Philip Bagshaw: Chair, Canterbury Charity Hospital Trust, Christchurch.

Correspondence Email

philipfbagshaw@gmail.com

Competing Interests

Nil.

1) National Conference. Creating Solutions Te Ara Whai Tika; A roadmap to health equity 2040. Association of Salaried Medical Specialists and the Canterbury Charity Hospital Trust. Report published 28[[th]] September 2021. Available at: https://issuu.com/associationofsalariedmedicalspecialists/docs/asms-creating-solutions-fa-web_-_final and at https://charityhospital.org.nz/wp-content/uploads/2021/09/Creating-Solutions-publication-FINAL.pdf    

2) Keene L, Dalton S. Closing the gaps: health equity by 2040. NZ Med J 2021;134(1543):12-8.

3) Bagshaw PF, Allardyce RA, Bagshaw SN, et al. Patients "falling through the cracks". The Canterbury Charity Hospital: initial progress report. N Z Med J. 2010;123(1320):58-66.

4) Bagshaw PF, Maimbo-M’siska M, Nicholls MG, et al. The Canterbury Charity Hospital: an update (2010-2012) and effects of the earthquakes. N Z Med J. 2013;126(1386):31-42.

5) Canterbury Charity Hospital Trust Enduring Vision Statement. Available at: https://charityhospital.org.nz/about-us/vision-statement/

6) GESA Clinical Practice Resources: Endoscopy – Standards for Endoscopic Facilities and Services. Available at: https://www.gesa.org.au/education/clinical-information/

7) Alternative Aotearoa Conference. Wellington. 25[[th]] July 2020. Available at: https://m.scoop.co.nz/stories/PO2008/S00171/alternative-aotearoa-final-report.htm  and at  https://chchpn.blogspot.com/?m=1  

8) Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250(2):187-96.

9) Gandhi J, Davidson C, Hall C, et al. Population-based study demonstrating an increase in colorectal cancer in young patients. Br J Surg. 2017 Jul;104(8):1063-8.

10) Atkin WS, Morson BC, Cuzick J. Long-term risk of colorectal cancer after excision of rectosigmoid adenomas. N Engl J Med. 1992;326(10):658-62.

11) Bagshaw PF, Cox B, Frizelle FA, Church JM. Guidelines for completion colonoscopy after polyps are found at flexible sigmoidoscopy for investigation of haemorrhoidal-type rectal bleeding. Letter. Gut 2 June 2020;0:1 doi:10.1136/gutjnl-2020-321655.

12) Lamba M, Ding S. Can colonoscopy at peripheral day hospitals meet internationally accepted quality and safety standards? N Z Med J. 2018;131(1484):26-9.

13) Ware JE, Jr, Kosinksi M, Bjorner JB, et al. (2007) User’s Manual for the SF-36v2 Health Survey, Lincoln, RI: QualityMetric Incorporated.

14) Spittlehouse JK, Joyce PR, Vierck E, et al. Ongoing adverse mental health impact of the earthquake sequence in Christchurch, New Zealand. Aust N Z J Psychiatry. 2014;48(8):756-63.

15) Frieling MA, Davis WR, Chiang G. The SF‐36v2 and SF‐12v2 health surveys in New Zealand: norms, scoring coefficients and cross‐country comparisons. Aust N Z J Public Health. 2013;37(1): 24-31.

16) Bagshaw P, Weller S, Shaw C, Frampton C. Open inguinal hernia repair using polypropylene mesh: A patient reported survey of long-term outcomes. J Curr Surg 2015;5(2-3):165-70.

17) Bagshaw P, Bagshaw S, Frampton C, et al. Pilot study of methods for assessing unmet secondary health care need in New Zealand. N Z Med J. 2017;130(1452):23-38.

18) Bagshaw P, Ding S. Assessment of diagnostic and treatment times for endoscopic cases for Southern District Health Board. 10[[th]] May 2019. Available at: https://www.southernhealth.nz/sites/default/files/2019-07/SDHB%20Endoscopy%20Cases%20Report%20Final%20-%20redacted.pdf.

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20) Bagshaw P, Hudson B. Unmet health-care need. J Prim Health Care. 2018;10(2):179-80.

21) Bagshaw PF. What should be the management policy for asymptomatic inguinal hernias? N Z Med J. 2015;128(1411);83-8.

22) Bagshaw P. A new report on the effects of a policy used to restrict access to elective inguinal hernia surgery. N Z Med J. 2018;131(1480):94-5.

23) Keene L, Bagshaw P, Nicholls G, et al. Funding New Zealand's public healthcare system: Time for an honest appraisal and public debate. N Z Med J. 2016;129(1436):10-20.

24) Bagshaw P. The clinical consequences of underfunding elective healthcare: A second red flag warning. N Z Med J. 2016;129(1440):135-6.

25) Bagshaw P, Barnett P. Physician advocacy in Western medicine: a twenty-first century challenge. N Z Med J. 2017;130(1466):83-9.

26) Cox B, Bagshaw P, Talbot A, Sneyd MJ. Code of Rights and bowel screening. N Z Med J. 2019;132(1497);78-9.

27) Cox B, Sneyd MJ, Hingston G, et al. Enhancing bowel screening: preventing colorectal cancer by flexible sigmoidoscopy in New Zealand. Public Health 2020;179:27-37.

28) Barnett P, Bagshaw P. Neoliberalism: what it is; how it affects health; and what to do about it. N Z Med J. 2020;133(1512):76-84.

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30) Bagshaw P, Cox B. Adequacy of publicly funded colonoscopy services in New Zealand. N Z Med J 2020;133(1526):7-11.

31) Health Funds Association of New Zealand and New Zealand Private Surgical Hospitals. Assessing the demand for elective surgery amongst New Zealanders. March 2016. Available at: https://img.scoop.co.nz/media/pdfs/1604/HFANZ_Unmet_Need_Infographic.pdf

32) Brown K. ‘Damning picture of unmet health need’. RNZHealth 24[[th]] March 2017. Available at: https://www.rnz.co.nz/news/national/327359/'damning-picture-of-unmet-health-need'

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It is now generally accepted that there is a large amount of unmet healthcare need in Aotearoa New Zealand. This unmet need often goes unrecognised and is not only due to inadequate accessibility to, and quality of, healthcare services but also to much wider problems of poverty, colonisation, racial discrimination and other aspects of socio-economic deprivation.[[1,2]] Regarding secondary elective healthcare, many younger people are unable to access care for non-life threatening problems such as groin hernias that affect their ability to work, and many older people cannot have care such as cataract surgery that allows them to function socially and independently.

As described in more detail elsewhere,[[3,4]] following the failed New Zealand Health Reforms of the 1990s, the Canterbury Charity Hospital Trust (CCHT) was formed in 2004. The objective of this charity was to meet some of the increases in this unmet healthcare need for the people of Canterbury District Health Board (CDHB) region. The vision of the CCHT was: (i) to provide free secondary elective healthcare for some of those who were refused care in the public health system, did not have medical insurance (personal or through the national Accident Compensation Corporation scheme) and could not afford private healthcare; (ii) for the care to be provided by a largely volunteer workforce; and (iii) for the charity to be funded solely by public charitable giving.[[5]] The objective and vision have not changed.

To meet the vision of the CCHT, an old family villa was purchased in the Bishopdale area of Christchurch in 2005 (Building One; Figure 1) and, with major funding from the Ron Ball Charitable Trust and public donations, converted into a modern day hospital, the Canterbury Charity Hospital (CCH), with facilities for contemporary medical, surgical and other health services. The clinical services provided by the CCH changed with time, in an attempt keep in step with the areas of clinical need that were not adequately addressed by the local public healthcare system. At the time of the Christchurch earthquakes, a large counselling service was started; in 2011 the adjacent property was purchased (Building Two; Figure 1) to accommodate the counselling and to allow the introduction of a dental and an endoscopy service.

Figure 1: Aerial photograph of Canterbury Charity Hospital Trust properties 2020

Corner of Harewood Road and Leacroft Street, Christchurch—CCHT properties encircled in red.
Building One (Ron Ball House, 349 Harewood Road)—Main operating theatre and recovery ward, clinical examination rooms and offices.
Building Two (Patsy Mauger House, 351 Harewood Road—Endoscopy unit, counselling rooms, lecture/staff room and offices.
Building Three (Warner Mauger House, 353 Harewood Road)—Twin oral surgery units, community room, and administration offices.
Buildings Four and Five (66b Leacroft Street and 355 Harwood Road)—both for future developments. The CCH has been well received by the general public. It has never been short of people willing to work in Medical, Nursing, Technical, Administrative and as other volunteers. These people have been managed and supported by a small skeleton staff of employees. It has never taken government contracts or been paid for any of its services. Generous funding has always come from the general public, local community groups and numerous individual philanthropic organisations and individuals.

METHODS

Chronology of main events

The main clinical planning, developments, structural and infrastructural changes, and fundraising events during the eight-year period from the beginning of 2013 to the end of 2020 are listed in the timeline (Table 1).

Between May and November 2016, the CCHT Board was increased from four to six members. From then, the board comprised: a general surgeon; an adolescent health physician; a lawyer; a businessperson; a retired anaesthetist; and a colorectal surgeon. CCHT has always had an independent Clinical Board, which has remained at arm’s length from the Trustee Board. Its membership remained diverse, consisting of: the CCHT executive officer; two GPs, a dentist; a retired anaesthetist; a clinical psychologist; a senior nurse; a Māori advisor and an Anglican vicar. It has given advice on clinical issues such as eligibility of patients for treatment, changes to service provision, research and credentialing approvals. Incident reporting and all complaints were also heard by the Clinical Board for both their advice and decisions.

View Tables 1 & 2.

Staff employee numbers changed very little (Table 2). Spontaneous volunteer workers came from a pool, which averaged about 280 people over the eight-year period. Their individual work commitments at CCH varied greatly. Some worked there every week and others only several times a year. The staff comprised: a full-time executive officer, and senior nurse; two part-time nurse specialists; and a part-time fundraising person.

The CCH facilities and services were extensively developed during the eight-year period to meet the changing and increasing unmet secondary elective healthcare need of the CDHB region (Table 1). In 2015, the operating theatre and post-operative recovery room in Building One were comprehensively upgraded and expanded. In 2016, an adjacent property (Building Four; Figure 1) was purchased for future development. Another adjacent property (Building Three; Figure 1) was purchased, extensively renovated and opened in 2017 with twin oral surgical units. Dental and oral surgery was then moved there from Building Two.

Finances

The part-time fundraiser and a small support committee of volunteers organised a programme of annual and special fundraising activities. These included: regular appeals in local media, sometimes enhanced by publicised visits to CCH by national and international celebrities; lectures to community groups; an annual dinner and other community events; donations from charitable trusts; and applications to philanthropic trusts. Other funding sources included bequests and returns from investments.

The influence of social media and the phasing out of cheques by the major banks, meant there were some changes in the sources of funding for the CCHT. However, much funding still came from middle-aged and elderly members of the community, and the rates of charitable donations did not change significantly. As a result of the CCHT Board, Management’s careful financial stewardship, and the relatively small staff budget, the average proportional expenditure over the eight-years period for patient treatment and running costs was 89% of budget, with only 7% for fundraising and 4% for fixed costs.

Relationships with local healthcare organisations

Based on CCHT’s general utilitarian philosophy and specific role to address as much of the unmet need as possible, it endeavoured to foster and strengthen working relationships with other local healthcare providers. To these ends, it had a Memorandum of Understanding with the CDHB since 2008. It also shared ownership of some surgical equipment as follows: orthopaedic equipment with Southern Cross Hospital; gynaecology equipment with Christchurch Women’s Hospital; and eye equipment with Christchurch Eye Surgery, Papanui.

RESULTS

Clinical throughput

The types of clinical services and the numbers of cases assessed and treated at CCH changed over the eight-year period (Table 3). The onsite services included: General Surgery, Audiology (facilities only provided by CCHT), Orthopaedics, Urology, Gynaecology & Family Planning, Dentistry, Oral Surgery, Vascular Surgery, Lower Gastrointestinal (GI) Endoscopy, Counselling and Dietician Services. The offsite services included Ophthalmic Surgery, and Dermatology. Dermatology open-day clinics were run on a Saturday in 2017, 2018 and 2019 at CCH. At these members of the public were able to have skin lesions assessed by specialist dermatologists and any suspicious lesions were automatically accepted for treatment by the CDHB. Unfortunately, COVID-19 restrictions prevented the possibility of holding such a clinic in 2020. View Table 3.

What services CCH offered at any particular time was largely dictated by changes made by the CDHB to which services it was providing, and by what workforce and physical resources were available to CCH to fill the emergent deficiencies. For example, CCH started an elective groin hernia repair service when it opened in 2007, as such surgery was not routinely offered by the CDHB. However, the CDHB then restarted doing such surgeries in late 2016, with many of the cases done under contracts with private healthcare providers, so CCH stopped providing this routine service.

Most patients were referred directly to CCH by their GPs when the service was not available through the CDHB. In these circumstances, GPs were usually advised to do so through their computerised patient management system (called Health Pathways by the CDHB). For some CCH clinical services, however, other specific referral processes were in place (vide infra).

Patient numbers and profiles

During the eight-year period (Table 3), there were 3,903 outpatient appointments and 11,752 interventions performed for patients (39.78% male, 57.36% female, 2.86% unspecified; mean age of 54.0 years, range <1–97 years; n=8,520). Ethnicity proportions were as follows: African 0.45%; Asian 3.10%; Australian 0.07%; NZ Māori 10.20%; Pākehā/NZ European 78.24%; Pasifika peoples 4.84%; South American 0.84%; Middle East 0.97%; Other 1.29%.

Clinical outcomes

CCH always invited all forms of, and routes for, comments about its clinical services. In particular, all patients were invited to take part in an anonymous satisfaction survey, but few took the opportunity to do so. The survey asked six questions on satisfaction with specific peri-consultation /interventional instances of care, and one question on overall satisfaction with patient experiences at CCH. Responses were registered on a five-point Likert scale of 1 (poor) to 5 (excellent). A random sample of 77 survey responses, taken from the period 2017 to 2020, showed scores of 4 and 5 by 11.36% and 88.20%, respectively for specific instances of care, and 3.90% and 96.10%, respectively for overall satisfaction (n=77). All significant issues raised in the surveys or by other routes were addressed immediately or, if necessary, brought to the attention of the Clinical Board.

During the eight-year period there were very few peri-procedural or 30-day complications. One operative case was terminated at the beginning of surgery because of a patient ventilatory problem—recovery was complete. Post-operatively, there was one wound infection (Grade II) and there were three cases with pain management issues (Grade I).[[8]]

Specific clinical services

Endoscopy Service

Since the CCH opened in 2007, local GPs referred cases of outlet-type rectal bleeding and other anorectal symptoms for management. In order to fully investigate these cases, a second operating theatre equipped for lower GI endoscopy was added in Building Two in July 2012, and has been mainly used for this purpose since then.

In May 2017, CCHT was approached by CDHB and requested, along with St Georges Hospital Christchurch, to help by providing a flexible sigmoidoscopy (FS) service for the management of patients less than 50 years of age with outlet-type rectal bleeding. The reasons for this request were: (i) emerging national and international data showing an appreciable increase in the incidence of colorectal cancer (CRC) in such young patients;[[9]] and (ii) CDHB did not have the capacity to investigate these patients with endoscopy.

The service was started at CCH in July 2017, and St Georges Hospital helped with provision of the service for the first 10 months. Patients were referred from the CDHB and from local GPs via Health Pathways. After a one-day bowel preparation, patients underwent un-sedated FS and were discharged immediately afterwards. By the end of 2020, 759 patients (381 male, 374 female, 4 not specified; mean age of 36.64 years, ranging 15–79 years) had a FS (32 at St Georges Hospital; 727 at CCH), performed by 15 volunteer endoscopists. Among the findings were eight patients with CRCs and 212 with colorectal polyps; 74 of the latter had tubular adenomas or serrated polyps and required appropriate follow-up. Were it not for this rectal bleeding service, diagnoses of some of these colorectal pathologies would have been unduly delayed with serious prognostic

Patients with CRC and serious colorectal pathology were referred back to CDHB; those with haemorrhoids and other benign causes for rectal bleeding were treated at CCH. In the absence of any relevant national or international guidelines, it was debatable which patients required a follow-up completion colonoscopy. Some local endoscopists thought the findings of advanced polyps or serrated lesions were necessary to merit such follow-up;[[10]] others thought the presence of any colorectal polyps was sufficient cause. To resolve this issue, advice was sought from a group of international experts. Recommendations for criteria for completion colonoscopy were formulated and published[[11]] and have since been implemented as the minimum required standards at CCH.

During the described eight-year period at CCH, a colonoscopy service was provided. This was for patients who had a previous FS at the CCH, with findings that indicated the need for completion colonoscopy, and those that had been declined by the CDHB for symptomatic investigation, as they did not meet the prioritisation threshold. Patients were referred on to CDHB after colonoscopy if: (i) their pathological findings indicated the need for inclusion in a regular surveillance programme; or (ii) there was significant pathology needing treatment beyond what CCH could offer, such as large lesions needing endoscopic mucosal resection or operative surgical treatment.  The quality of the colonoscopy service at CCH from 1 October 2016 to 31 September 2017 was independently audited. The findings were that this service was safe and complied with the accepted quality indicators.[[12]]

FS is a quick, relatively safe and economic investigation. It is, however, uncomfortable for some patients. For this reason, modifications were tried in pre-procedure patient information systems and intra-procedural processes, with the objective of improving the experience for everyone having lower GI endoscopies. The whole Endoscopy Unit was upgrade in 2020 to improve the patient facilities and to comply with new GESA guideline standard for endoscope cleaning and storage, which came into effect in February 2022.[[6]]

Dental and Oral Surgical Service

There was a high demand for the Dental Services provided at the CCH, with the number of people needing dental treatment increasing all the time. There are subsidies and grants available from Work and Income New Zealand (WINZ) for emergency care and relief of pain for low-income adults to allow them to be treated in the community by both private dentists and the Dental Department of Christchurch Hospital. However, this WINZ benefit did not cover the cost of routine dental care.  

Since June 2012, CCH has offered treatment for the WINZ beneficiaries who have been referred from local dentists and who might not have otherwise been able to access necessary dental care. These people could no longer be treated at the Dental Department of Christchurch Hospital for routine dental care because of changes to the criteria for admission. The treatment needed could be complex and difficult, and the patients themselves often presented with complicated medical, psychiatric and social issues. They were a vulnerable population group, with great needs for treatment that were financially out of their reach.

During the eight-year period, dental surgeons and assistants volunteered their time and expertise, providing a total of 3,833 dental treatments at an average of 2.5 service sessions a week. The dentists offered a single course of treatment for adult WINZ beneficiaries (who had exhausted their annual $300 WINZ dental grant) to get them “dentally fit”. Treatments offered included check-ups, cleans and periodontal treatment, extractions, root canal treatment on front teeth and fillings. Complex oral surgery extractions were done using intravenous sedation. More recently nitrous oxide sedation was introduced, making routine dentistry much easier for many of the patients who suffered from anxiety and had a deep fear of dental treatment. The efficiency of the dental service was significantly improved by the purchase and installation of an Orthopantomogram X-ray machine in March 2019.

Between 2013 and 2019, nine dental technicians from three companies staffed a denture clinic at CCH once a fortnight. Here, they provided full and partial dentures to those in need. The denture service was suspended in 2020 as a result of the COVID-19 pandemic.

Counselling—Terror attacks

Around the time of the Canterbury earthquakes on 22 February 2011, CCH started a free counselling service for self-referred people and those referred by healthcare, social and care workers. This service continued afterwards but slowly reduced with time in numbers of referrals.  As a consequence of the previously established local counselling networks and the nimble way CCHT was accustomed to reacting to change, in March 2019, following the terrorist attacks at the Christchurch mosques, the CCH was able to immediately ramp up its counselling service. This offered help to victims, their families and others who felt they needed support dealing with the mental and psychological impact of the shootings—it involved an extra 13 counsellors. While little is known about the effectiveness of therapeutic interventions in the recovery phase of disasters, it is recognised that, although immediate support is very important, it also allows for people experiencing more extreme reactions to be quickly identified, assessed and referred for further assistance as required.

There were 999 appointments for counselling between 15 March and September 2019. Most were terror- attack-related but, as all counselling records are strictly confidential, the total numbers of counselling sessions could not be classified by reason for referral, types of counselling received or of what methods were used.

Effect of COVID-19 pandemic

The COVID-19 pandemic started in New Zealand with the first case on 28 February 2020. The pandemic had a serious impact in reducing the volume of work that could be done at CCH during the extended periods during which the hospital was unable to open. At the time of the initial lockdown period on 15 March, CCHT management started consulting with CDHB and followed Ministry of Health (MoH) advice as indicated.

Discussions were held with CDHB. It was suggested that, if the pandemic accelerated rapidly, CCHT might be used as either a small isolation unit or as an overflow unit for cases needing ventilation. An assessment was made of the equipment and facilities at CCH, including the number of patient ventilators. A non-DHB hospitals COVID-19 reaction group was set up. This was coordinated by the CDHB and met on the internet (Zoom) most days of the week during the Level 4 lockdown to discuss plans, exchange ideas and update everyone with events. As the pandemic did not escalate, CCH remained in lockdown until MoH recommendations changed to Level 2 on 13 May 2020. Then CCH gradually returned to normal levels of clinical activity but implemented precautions as outlined by the MoH for general situations and by the Dental Council of New Zealand, in regard to Dental and Oral Surgery.

Clinical research

During the eight-year period, CCHT undertook and published some original clinical research. One important component was a research project to assess the efficacy of the counselling service offered to the Christchurch earthquake victims in 2011. During 2017–2020, a randomised sub-sample of 60 (15% male, 85% female; mean age of 53.67 years, SD=15.5, ranging 14–91 years) from the 858 patients who had attended the counselling service between 2011–2012, were contacted and interviewed to ascertain how helpful the counselling had been. The number of sessions attended ranged from 1–20 (mean=3.28) with anxiety, low mood, sleep disturbance, earthquake trauma, stress and difficulties coping as the main presenting problems. While a small number were dissatisfied with the number of sessions offered, and not having a choice in the gender of their counsellor, the large majority found the counselling very helpful.

The Short Form 36 Health survey (SF-36) was used to assess the patients’ psychological wellbeing at the time of interview.[[13]] Table 4 shows the CCH sub-sample SF-36 subscale scores were considerably lower than the SF-36 participant scores in the 2006/07 New Zealand Health Survey. This suggests the patients attending the CCH Counselling Service were significantly less well than the general population at the 95% confidence level. These findings are supported in the study by Spittlehouse et al (2014),[[14]] where it was found that 212 participants, aged between 45–54 years and living in post-earthquake Christchurch, also had significantly lower scores on the mental health and wellbeing scales of SF-36 compared to 2006/07 national data. View Table 4.

CCHT staff and volunteers undertook and published other clinical research including: a survey of outcomes for open mesh repair of inguinal hernia at CCH;[[16]] a pilot study of methods to assess unmet secondary healthcare need in New Zealand;[[17]] and a report on Southern DHB’s colonoscopy service.[[18]] They also published on a number of healthcare issues including: the importance of measuring unmet healthcare need;[[19,20]] variation in policies for management of inguinal hernias;[[21,22]] adequacy of public healthcare funding;[[23,23]] physician advocacy in the twenty-first century;[[25]] the code of rights and bowel cancer screening;[[26]] enhanced bowel screening by FS;[[27]] effects of Neoliberalism on healthcare;[[28]] towards a better world after COVID-19;[[29]] and adequacy of publicly funded colonoscopy services in New Zealand.[[30]]

CONCLUSIONS

It became clear at the time of the Health Reforms of the 1990s, that there was a large amount of chronic unmet need for secondary elective healthcare in Aotearoa New Zealand. This was estimated to be about 9% in the adult population,[[17,31]] and was undoubtedly higher in Māori and Pasifika communities, and those living in poverty. The CCHT has done extensive research on this subject and made numerous public calls for the quantity and nature of the unmet secondary elective healthcare need to be estimated repeatedly, independently and transparently, using validated population survey techniques.[[7,32]] However, until recently, successive governments and public health officials have shown little interest in measuring the size of this problem or doing anything substantial to address it. The CCHT was formed with the specific intent of offering as much help to as many of these people as possible to reduce their unmet healthcare needs.

During the eight-year history of the CCHT described in this article, secondary elective services provided by the CDHB changed periodically with time. The CCHT attempted to respond to these changes by trying to fill the moving gap between what the public and private healthcare systems provided. Although CCHT could never address all the unmet need, it was successful in providing quite large numbers of interventions across a diverse range of services, thanks to the unfailing generosity of the Canterbury public and the army of hospital volunteers that worked so tirelessly.

The main changes to the services offered by CCHT since the end of 2012 were: the sudden increased need for counselling after the Christchurch terror attacks; the expansion of the dental and oral surgery service; and the increased endoscopy service. Most of the other services remained largely unchanged but some, such as general surgery reduced as CDHB reintroduced some elective services. The largest overall influence on the activities of the CCHT was, however, the COVID-19 pandemic, which unfortunately led to periods of closure or reduced services.

One area of improvement was better cooperation between CCHT and CDHB. This was particularly evident in the direct patient referrals from the latter to the FS rectal bleeding service run by the former. There was also cooperation in the organisation of dermatology days by the two organisations. Many possibilities remain, however, for greater future cooperation between them, particularly regarding the use of CCHT facilities, for example, for elective day surgery for low-risk general surgery cases.

The large amount of unmet secondary elective healthcare is not only a Canterbury problem, but actually a national one. This is attested by the fact there has been an Auckland Regional Charity Hospital since 2009, and planning started for a Southland Charity Hospital in Invercargill in 2019. These developments resulted from the humanitarian actions of local communities reacting to the unmet healthcare need of their fellow citizens. It is earnestly to be hoped that present and future governments awaken to the fact that investment in health is not only a characteristic of a properly functioning society, but it has also been shown to be extremely economically advantageous.[[33]]  If they do not do so, the likely long-term consequence will be “a charity hospital in every town”.[[34]]

Summary

Abstract

Aim

To update activities of the Canterbury Charity Hospital (CCH) and its Trust over the eight-year period 2013 to end of 2020, following previous reports in 2010 and 2013.

Method

CCH continued to provide free secondary elective healthcare services to some patients in the Canterbury Distinct Health Board (CDHB) region who were unable to access healthcare they needed through public hospitals and were unable to pay for private care. CCH’s services were supplied by a large volunteer workforce, supported by a skeleton staff, and were financed solely by charitable giving. Changes occurred periodically in the quantity and nature of regional unmet healthcare need, largely due to changes in services provided by the CDHB. In order to accommodate these changes, major structural and infrastructural developments were necessitated at CCH.

Results

Many healthcare services at CCH remained the same as before this period but new changes occurred there as a result of: (i) establishment of a flexible sigmoidoscopy day clinic for the management of fresh rectal bleeding in those under 50 years of age; (ii) requirement for a sudden increase in counselling services immediately after the terror attacks at Christchurch mosques; (iii) expansion of the Dental and Oral Surgery Service; and (iv) interruption of CCH service provision by the COVID-19 pandemic.

Conclusion

CCH continued to fill some of the regional unmet elective healthcare need. This is, however, a national problem as attested by the presence of a charity hospital in Auckland and another being planned for Invercargill. Hopefully present and future governments will appreciate that free universal access to secondary elective healthcare is not only a humane imperative, but also a sound economic investment.

Author Information

Philip Bagshaw: Chair, Canterbury Charity Hospital Trust, Christchurch. Lynne Briggs: Associate Professor, School of Health Sciences and Social Work, Griffith University, Gold Coast Campus, Queensland, Australia. Susan Bagshaw: Trustee, Canterbury Charity Hospital Trust, Christchurch. Vivienne Levy: Dental Surgeon, Longhurst Dental Centre, Christchurch. Carl Shaw: Executive Officer, Canterbury Charity Hospital Trust, Christchurch. Averill Williamson: Nurse Coordinator, Canterbury Charity Hospital Trust, Christchurch. Anita Tuck: Clinical Nurse Specialist, Canterbury Charity Hospital Trust, Christchurch. Alice Brown: Clinical Nurse Specialist, Canterbury Charity Hospital Trust, Christchurch.

Acknowledgements

The authors wish to acknowledge the unfailing generosity of the people of Canterbury and the massive support of an army of volunteer workers.

Correspondence

Philip Bagshaw: Chair, Canterbury Charity Hospital Trust, Christchurch.

Correspondence Email

philipfbagshaw@gmail.com

Competing Interests

Nil.

1) National Conference. Creating Solutions Te Ara Whai Tika; A roadmap to health equity 2040. Association of Salaried Medical Specialists and the Canterbury Charity Hospital Trust. Report published 28[[th]] September 2021. Available at: https://issuu.com/associationofsalariedmedicalspecialists/docs/asms-creating-solutions-fa-web_-_final and at https://charityhospital.org.nz/wp-content/uploads/2021/09/Creating-Solutions-publication-FINAL.pdf    

2) Keene L, Dalton S. Closing the gaps: health equity by 2040. NZ Med J 2021;134(1543):12-8.

3) Bagshaw PF, Allardyce RA, Bagshaw SN, et al. Patients "falling through the cracks". The Canterbury Charity Hospital: initial progress report. N Z Med J. 2010;123(1320):58-66.

4) Bagshaw PF, Maimbo-M’siska M, Nicholls MG, et al. The Canterbury Charity Hospital: an update (2010-2012) and effects of the earthquakes. N Z Med J. 2013;126(1386):31-42.

5) Canterbury Charity Hospital Trust Enduring Vision Statement. Available at: https://charityhospital.org.nz/about-us/vision-statement/

6) GESA Clinical Practice Resources: Endoscopy – Standards for Endoscopic Facilities and Services. Available at: https://www.gesa.org.au/education/clinical-information/

7) Alternative Aotearoa Conference. Wellington. 25[[th]] July 2020. Available at: https://m.scoop.co.nz/stories/PO2008/S00171/alternative-aotearoa-final-report.htm  and at  https://chchpn.blogspot.com/?m=1  

8) Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250(2):187-96.

9) Gandhi J, Davidson C, Hall C, et al. Population-based study demonstrating an increase in colorectal cancer in young patients. Br J Surg. 2017 Jul;104(8):1063-8.

10) Atkin WS, Morson BC, Cuzick J. Long-term risk of colorectal cancer after excision of rectosigmoid adenomas. N Engl J Med. 1992;326(10):658-62.

11) Bagshaw PF, Cox B, Frizelle FA, Church JM. Guidelines for completion colonoscopy after polyps are found at flexible sigmoidoscopy for investigation of haemorrhoidal-type rectal bleeding. Letter. Gut 2 June 2020;0:1 doi:10.1136/gutjnl-2020-321655.

12) Lamba M, Ding S. Can colonoscopy at peripheral day hospitals meet internationally accepted quality and safety standards? N Z Med J. 2018;131(1484):26-9.

13) Ware JE, Jr, Kosinksi M, Bjorner JB, et al. (2007) User’s Manual for the SF-36v2 Health Survey, Lincoln, RI: QualityMetric Incorporated.

14) Spittlehouse JK, Joyce PR, Vierck E, et al. Ongoing adverse mental health impact of the earthquake sequence in Christchurch, New Zealand. Aust N Z J Psychiatry. 2014;48(8):756-63.

15) Frieling MA, Davis WR, Chiang G. The SF‐36v2 and SF‐12v2 health surveys in New Zealand: norms, scoring coefficients and cross‐country comparisons. Aust N Z J Public Health. 2013;37(1): 24-31.

16) Bagshaw P, Weller S, Shaw C, Frampton C. Open inguinal hernia repair using polypropylene mesh: A patient reported survey of long-term outcomes. J Curr Surg 2015;5(2-3):165-70.

17) Bagshaw P, Bagshaw S, Frampton C, et al. Pilot study of methods for assessing unmet secondary health care need in New Zealand. N Z Med J. 2017;130(1452):23-38.

18) Bagshaw P, Ding S. Assessment of diagnostic and treatment times for endoscopic cases for Southern District Health Board. 10[[th]] May 2019. Available at: https://www.southernhealth.nz/sites/default/files/2019-07/SDHB%20Endoscopy%20Cases%20Report%20Final%20-%20redacted.pdf.

19) Gauld R, Raymont A, Bagshaw PF, et al. The importance of measuring unmet healthcare needs. N Z Med J. 2014;127(1404):63-7.

20) Bagshaw P, Hudson B. Unmet health-care need. J Prim Health Care. 2018;10(2):179-80.

21) Bagshaw PF. What should be the management policy for asymptomatic inguinal hernias? N Z Med J. 2015;128(1411);83-8.

22) Bagshaw P. A new report on the effects of a policy used to restrict access to elective inguinal hernia surgery. N Z Med J. 2018;131(1480):94-5.

23) Keene L, Bagshaw P, Nicholls G, et al. Funding New Zealand's public healthcare system: Time for an honest appraisal and public debate. N Z Med J. 2016;129(1436):10-20.

24) Bagshaw P. The clinical consequences of underfunding elective healthcare: A second red flag warning. N Z Med J. 2016;129(1440):135-6.

25) Bagshaw P, Barnett P. Physician advocacy in Western medicine: a twenty-first century challenge. N Z Med J. 2017;130(1466):83-9.

26) Cox B, Bagshaw P, Talbot A, Sneyd MJ. Code of Rights and bowel screening. N Z Med J. 2019;132(1497);78-9.

27) Cox B, Sneyd MJ, Hingston G, et al. Enhancing bowel screening: preventing colorectal cancer by flexible sigmoidoscopy in New Zealand. Public Health 2020;179:27-37.

28) Barnett P, Bagshaw P. Neoliberalism: what it is; how it affects health; and what to do about it. N Z Med J. 2020;133(1512):76-84.

29) Bagshaw P, Bagshaw S. Towards a Better World after Covid-19. N Z Med J. 2020;133(1516):100-1.

30) Bagshaw P, Cox B. Adequacy of publicly funded colonoscopy services in New Zealand. N Z Med J 2020;133(1526):7-11.

31) Health Funds Association of New Zealand and New Zealand Private Surgical Hospitals. Assessing the demand for elective surgery amongst New Zealanders. March 2016. Available at: https://img.scoop.co.nz/media/pdfs/1604/HFANZ_Unmet_Need_Infographic.pdf

32) Brown K. ‘Damning picture of unmet health need’. RNZHealth 24[[th]] March 2017. Available at: https://www.rnz.co.nz/news/national/327359/'damning-picture-of-unmet-health-need'

33) Reeves A, Basu S, McKee M, at al. Does investment in the health sector promote or inhibit economic growth? Global Health. 2013 Sep 23;9:43. doi: 10.1186/1744-8603-9-43.

34) Nicholls MG, Frampton CM, Bagshaw PF. Resurrecting New Zealand's Public Health Care System or A Charity Hospital in Every Town? Intern Med J. 2020;50(7):883-6.

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It is now generally accepted that there is a large amount of unmet healthcare need in Aotearoa New Zealand. This unmet need often goes unrecognised and is not only due to inadequate accessibility to, and quality of, healthcare services but also to much wider problems of poverty, colonisation, racial discrimination and other aspects of socio-economic deprivation.[[1,2]] Regarding secondary elective healthcare, many younger people are unable to access care for non-life threatening problems such as groin hernias that affect their ability to work, and many older people cannot have care such as cataract surgery that allows them to function socially and independently.

As described in more detail elsewhere,[[3,4]] following the failed New Zealand Health Reforms of the 1990s, the Canterbury Charity Hospital Trust (CCHT) was formed in 2004. The objective of this charity was to meet some of the increases in this unmet healthcare need for the people of Canterbury District Health Board (CDHB) region. The vision of the CCHT was: (i) to provide free secondary elective healthcare for some of those who were refused care in the public health system, did not have medical insurance (personal or through the national Accident Compensation Corporation scheme) and could not afford private healthcare; (ii) for the care to be provided by a largely volunteer workforce; and (iii) for the charity to be funded solely by public charitable giving.[[5]] The objective and vision have not changed.

To meet the vision of the CCHT, an old family villa was purchased in the Bishopdale area of Christchurch in 2005 (Building One; Figure 1) and, with major funding from the Ron Ball Charitable Trust and public donations, converted into a modern day hospital, the Canterbury Charity Hospital (CCH), with facilities for contemporary medical, surgical and other health services. The clinical services provided by the CCH changed with time, in an attempt keep in step with the areas of clinical need that were not adequately addressed by the local public healthcare system. At the time of the Christchurch earthquakes, a large counselling service was started; in 2011 the adjacent property was purchased (Building Two; Figure 1) to accommodate the counselling and to allow the introduction of a dental and an endoscopy service.

Figure 1: Aerial photograph of Canterbury Charity Hospital Trust properties 2020

Corner of Harewood Road and Leacroft Street, Christchurch—CCHT properties encircled in red.
Building One (Ron Ball House, 349 Harewood Road)—Main operating theatre and recovery ward, clinical examination rooms and offices.
Building Two (Patsy Mauger House, 351 Harewood Road—Endoscopy unit, counselling rooms, lecture/staff room and offices.
Building Three (Warner Mauger House, 353 Harewood Road)—Twin oral surgery units, community room, and administration offices.
Buildings Four and Five (66b Leacroft Street and 355 Harwood Road)—both for future developments. The CCH has been well received by the general public. It has never been short of people willing to work in Medical, Nursing, Technical, Administrative and as other volunteers. These people have been managed and supported by a small skeleton staff of employees. It has never taken government contracts or been paid for any of its services. Generous funding has always come from the general public, local community groups and numerous individual philanthropic organisations and individuals.

METHODS

Chronology of main events

The main clinical planning, developments, structural and infrastructural changes, and fundraising events during the eight-year period from the beginning of 2013 to the end of 2020 are listed in the timeline (Table 1).

Between May and November 2016, the CCHT Board was increased from four to six members. From then, the board comprised: a general surgeon; an adolescent health physician; a lawyer; a businessperson; a retired anaesthetist; and a colorectal surgeon. CCHT has always had an independent Clinical Board, which has remained at arm’s length from the Trustee Board. Its membership remained diverse, consisting of: the CCHT executive officer; two GPs, a dentist; a retired anaesthetist; a clinical psychologist; a senior nurse; a Māori advisor and an Anglican vicar. It has given advice on clinical issues such as eligibility of patients for treatment, changes to service provision, research and credentialing approvals. Incident reporting and all complaints were also heard by the Clinical Board for both their advice and decisions.

View Tables 1 & 2.

Staff employee numbers changed very little (Table 2). Spontaneous volunteer workers came from a pool, which averaged about 280 people over the eight-year period. Their individual work commitments at CCH varied greatly. Some worked there every week and others only several times a year. The staff comprised: a full-time executive officer, and senior nurse; two part-time nurse specialists; and a part-time fundraising person.

The CCH facilities and services were extensively developed during the eight-year period to meet the changing and increasing unmet secondary elective healthcare need of the CDHB region (Table 1). In 2015, the operating theatre and post-operative recovery room in Building One were comprehensively upgraded and expanded. In 2016, an adjacent property (Building Four; Figure 1) was purchased for future development. Another adjacent property (Building Three; Figure 1) was purchased, extensively renovated and opened in 2017 with twin oral surgical units. Dental and oral surgery was then moved there from Building Two.

Finances

The part-time fundraiser and a small support committee of volunteers organised a programme of annual and special fundraising activities. These included: regular appeals in local media, sometimes enhanced by publicised visits to CCH by national and international celebrities; lectures to community groups; an annual dinner and other community events; donations from charitable trusts; and applications to philanthropic trusts. Other funding sources included bequests and returns from investments.

The influence of social media and the phasing out of cheques by the major banks, meant there were some changes in the sources of funding for the CCHT. However, much funding still came from middle-aged and elderly members of the community, and the rates of charitable donations did not change significantly. As a result of the CCHT Board, Management’s careful financial stewardship, and the relatively small staff budget, the average proportional expenditure over the eight-years period for patient treatment and running costs was 89% of budget, with only 7% for fundraising and 4% for fixed costs.

Relationships with local healthcare organisations

Based on CCHT’s general utilitarian philosophy and specific role to address as much of the unmet need as possible, it endeavoured to foster and strengthen working relationships with other local healthcare providers. To these ends, it had a Memorandum of Understanding with the CDHB since 2008. It also shared ownership of some surgical equipment as follows: orthopaedic equipment with Southern Cross Hospital; gynaecology equipment with Christchurch Women’s Hospital; and eye equipment with Christchurch Eye Surgery, Papanui.

RESULTS

Clinical throughput

The types of clinical services and the numbers of cases assessed and treated at CCH changed over the eight-year period (Table 3). The onsite services included: General Surgery, Audiology (facilities only provided by CCHT), Orthopaedics, Urology, Gynaecology & Family Planning, Dentistry, Oral Surgery, Vascular Surgery, Lower Gastrointestinal (GI) Endoscopy, Counselling and Dietician Services. The offsite services included Ophthalmic Surgery, and Dermatology. Dermatology open-day clinics were run on a Saturday in 2017, 2018 and 2019 at CCH. At these members of the public were able to have skin lesions assessed by specialist dermatologists and any suspicious lesions were automatically accepted for treatment by the CDHB. Unfortunately, COVID-19 restrictions prevented the possibility of holding such a clinic in 2020. View Table 3.

What services CCH offered at any particular time was largely dictated by changes made by the CDHB to which services it was providing, and by what workforce and physical resources were available to CCH to fill the emergent deficiencies. For example, CCH started an elective groin hernia repair service when it opened in 2007, as such surgery was not routinely offered by the CDHB. However, the CDHB then restarted doing such surgeries in late 2016, with many of the cases done under contracts with private healthcare providers, so CCH stopped providing this routine service.

Most patients were referred directly to CCH by their GPs when the service was not available through the CDHB. In these circumstances, GPs were usually advised to do so through their computerised patient management system (called Health Pathways by the CDHB). For some CCH clinical services, however, other specific referral processes were in place (vide infra).

Patient numbers and profiles

During the eight-year period (Table 3), there were 3,903 outpatient appointments and 11,752 interventions performed for patients (39.78% male, 57.36% female, 2.86% unspecified; mean age of 54.0 years, range <1–97 years; n=8,520). Ethnicity proportions were as follows: African 0.45%; Asian 3.10%; Australian 0.07%; NZ Māori 10.20%; Pākehā/NZ European 78.24%; Pasifika peoples 4.84%; South American 0.84%; Middle East 0.97%; Other 1.29%.

Clinical outcomes

CCH always invited all forms of, and routes for, comments about its clinical services. In particular, all patients were invited to take part in an anonymous satisfaction survey, but few took the opportunity to do so. The survey asked six questions on satisfaction with specific peri-consultation /interventional instances of care, and one question on overall satisfaction with patient experiences at CCH. Responses were registered on a five-point Likert scale of 1 (poor) to 5 (excellent). A random sample of 77 survey responses, taken from the period 2017 to 2020, showed scores of 4 and 5 by 11.36% and 88.20%, respectively for specific instances of care, and 3.90% and 96.10%, respectively for overall satisfaction (n=77). All significant issues raised in the surveys or by other routes were addressed immediately or, if necessary, brought to the attention of the Clinical Board.

During the eight-year period there were very few peri-procedural or 30-day complications. One operative case was terminated at the beginning of surgery because of a patient ventilatory problem—recovery was complete. Post-operatively, there was one wound infection (Grade II) and there were three cases with pain management issues (Grade I).[[8]]

Specific clinical services

Endoscopy Service

Since the CCH opened in 2007, local GPs referred cases of outlet-type rectal bleeding and other anorectal symptoms for management. In order to fully investigate these cases, a second operating theatre equipped for lower GI endoscopy was added in Building Two in July 2012, and has been mainly used for this purpose since then.

In May 2017, CCHT was approached by CDHB and requested, along with St Georges Hospital Christchurch, to help by providing a flexible sigmoidoscopy (FS) service for the management of patients less than 50 years of age with outlet-type rectal bleeding. The reasons for this request were: (i) emerging national and international data showing an appreciable increase in the incidence of colorectal cancer (CRC) in such young patients;[[9]] and (ii) CDHB did not have the capacity to investigate these patients with endoscopy.

The service was started at CCH in July 2017, and St Georges Hospital helped with provision of the service for the first 10 months. Patients were referred from the CDHB and from local GPs via Health Pathways. After a one-day bowel preparation, patients underwent un-sedated FS and were discharged immediately afterwards. By the end of 2020, 759 patients (381 male, 374 female, 4 not specified; mean age of 36.64 years, ranging 15–79 years) had a FS (32 at St Georges Hospital; 727 at CCH), performed by 15 volunteer endoscopists. Among the findings were eight patients with CRCs and 212 with colorectal polyps; 74 of the latter had tubular adenomas or serrated polyps and required appropriate follow-up. Were it not for this rectal bleeding service, diagnoses of some of these colorectal pathologies would have been unduly delayed with serious prognostic

Patients with CRC and serious colorectal pathology were referred back to CDHB; those with haemorrhoids and other benign causes for rectal bleeding were treated at CCH. In the absence of any relevant national or international guidelines, it was debatable which patients required a follow-up completion colonoscopy. Some local endoscopists thought the findings of advanced polyps or serrated lesions were necessary to merit such follow-up;[[10]] others thought the presence of any colorectal polyps was sufficient cause. To resolve this issue, advice was sought from a group of international experts. Recommendations for criteria for completion colonoscopy were formulated and published[[11]] and have since been implemented as the minimum required standards at CCH.

During the described eight-year period at CCH, a colonoscopy service was provided. This was for patients who had a previous FS at the CCH, with findings that indicated the need for completion colonoscopy, and those that had been declined by the CDHB for symptomatic investigation, as they did not meet the prioritisation threshold. Patients were referred on to CDHB after colonoscopy if: (i) their pathological findings indicated the need for inclusion in a regular surveillance programme; or (ii) there was significant pathology needing treatment beyond what CCH could offer, such as large lesions needing endoscopic mucosal resection or operative surgical treatment.  The quality of the colonoscopy service at CCH from 1 October 2016 to 31 September 2017 was independently audited. The findings were that this service was safe and complied with the accepted quality indicators.[[12]]

FS is a quick, relatively safe and economic investigation. It is, however, uncomfortable for some patients. For this reason, modifications were tried in pre-procedure patient information systems and intra-procedural processes, with the objective of improving the experience for everyone having lower GI endoscopies. The whole Endoscopy Unit was upgrade in 2020 to improve the patient facilities and to comply with new GESA guideline standard for endoscope cleaning and storage, which came into effect in February 2022.[[6]]

Dental and Oral Surgical Service

There was a high demand for the Dental Services provided at the CCH, with the number of people needing dental treatment increasing all the time. There are subsidies and grants available from Work and Income New Zealand (WINZ) for emergency care and relief of pain for low-income adults to allow them to be treated in the community by both private dentists and the Dental Department of Christchurch Hospital. However, this WINZ benefit did not cover the cost of routine dental care.  

Since June 2012, CCH has offered treatment for the WINZ beneficiaries who have been referred from local dentists and who might not have otherwise been able to access necessary dental care. These people could no longer be treated at the Dental Department of Christchurch Hospital for routine dental care because of changes to the criteria for admission. The treatment needed could be complex and difficult, and the patients themselves often presented with complicated medical, psychiatric and social issues. They were a vulnerable population group, with great needs for treatment that were financially out of their reach.

During the eight-year period, dental surgeons and assistants volunteered their time and expertise, providing a total of 3,833 dental treatments at an average of 2.5 service sessions a week. The dentists offered a single course of treatment for adult WINZ beneficiaries (who had exhausted their annual $300 WINZ dental grant) to get them “dentally fit”. Treatments offered included check-ups, cleans and periodontal treatment, extractions, root canal treatment on front teeth and fillings. Complex oral surgery extractions were done using intravenous sedation. More recently nitrous oxide sedation was introduced, making routine dentistry much easier for many of the patients who suffered from anxiety and had a deep fear of dental treatment. The efficiency of the dental service was significantly improved by the purchase and installation of an Orthopantomogram X-ray machine in March 2019.

Between 2013 and 2019, nine dental technicians from three companies staffed a denture clinic at CCH once a fortnight. Here, they provided full and partial dentures to those in need. The denture service was suspended in 2020 as a result of the COVID-19 pandemic.

Counselling—Terror attacks

Around the time of the Canterbury earthquakes on 22 February 2011, CCH started a free counselling service for self-referred people and those referred by healthcare, social and care workers. This service continued afterwards but slowly reduced with time in numbers of referrals.  As a consequence of the previously established local counselling networks and the nimble way CCHT was accustomed to reacting to change, in March 2019, following the terrorist attacks at the Christchurch mosques, the CCH was able to immediately ramp up its counselling service. This offered help to victims, their families and others who felt they needed support dealing with the mental and psychological impact of the shootings—it involved an extra 13 counsellors. While little is known about the effectiveness of therapeutic interventions in the recovery phase of disasters, it is recognised that, although immediate support is very important, it also allows for people experiencing more extreme reactions to be quickly identified, assessed and referred for further assistance as required.

There were 999 appointments for counselling between 15 March and September 2019. Most were terror- attack-related but, as all counselling records are strictly confidential, the total numbers of counselling sessions could not be classified by reason for referral, types of counselling received or of what methods were used.

Effect of COVID-19 pandemic

The COVID-19 pandemic started in New Zealand with the first case on 28 February 2020. The pandemic had a serious impact in reducing the volume of work that could be done at CCH during the extended periods during which the hospital was unable to open. At the time of the initial lockdown period on 15 March, CCHT management started consulting with CDHB and followed Ministry of Health (MoH) advice as indicated.

Discussions were held with CDHB. It was suggested that, if the pandemic accelerated rapidly, CCHT might be used as either a small isolation unit or as an overflow unit for cases needing ventilation. An assessment was made of the equipment and facilities at CCH, including the number of patient ventilators. A non-DHB hospitals COVID-19 reaction group was set up. This was coordinated by the CDHB and met on the internet (Zoom) most days of the week during the Level 4 lockdown to discuss plans, exchange ideas and update everyone with events. As the pandemic did not escalate, CCH remained in lockdown until MoH recommendations changed to Level 2 on 13 May 2020. Then CCH gradually returned to normal levels of clinical activity but implemented precautions as outlined by the MoH for general situations and by the Dental Council of New Zealand, in regard to Dental and Oral Surgery.

Clinical research

During the eight-year period, CCHT undertook and published some original clinical research. One important component was a research project to assess the efficacy of the counselling service offered to the Christchurch earthquake victims in 2011. During 2017–2020, a randomised sub-sample of 60 (15% male, 85% female; mean age of 53.67 years, SD=15.5, ranging 14–91 years) from the 858 patients who had attended the counselling service between 2011–2012, were contacted and interviewed to ascertain how helpful the counselling had been. The number of sessions attended ranged from 1–20 (mean=3.28) with anxiety, low mood, sleep disturbance, earthquake trauma, stress and difficulties coping as the main presenting problems. While a small number were dissatisfied with the number of sessions offered, and not having a choice in the gender of their counsellor, the large majority found the counselling very helpful.

The Short Form 36 Health survey (SF-36) was used to assess the patients’ psychological wellbeing at the time of interview.[[13]] Table 4 shows the CCH sub-sample SF-36 subscale scores were considerably lower than the SF-36 participant scores in the 2006/07 New Zealand Health Survey. This suggests the patients attending the CCH Counselling Service were significantly less well than the general population at the 95% confidence level. These findings are supported in the study by Spittlehouse et al (2014),[[14]] where it was found that 212 participants, aged between 45–54 years and living in post-earthquake Christchurch, also had significantly lower scores on the mental health and wellbeing scales of SF-36 compared to 2006/07 national data. View Table 4.

CCHT staff and volunteers undertook and published other clinical research including: a survey of outcomes for open mesh repair of inguinal hernia at CCH;[[16]] a pilot study of methods to assess unmet secondary healthcare need in New Zealand;[[17]] and a report on Southern DHB’s colonoscopy service.[[18]] They also published on a number of healthcare issues including: the importance of measuring unmet healthcare need;[[19,20]] variation in policies for management of inguinal hernias;[[21,22]] adequacy of public healthcare funding;[[23,23]] physician advocacy in the twenty-first century;[[25]] the code of rights and bowel cancer screening;[[26]] enhanced bowel screening by FS;[[27]] effects of Neoliberalism on healthcare;[[28]] towards a better world after COVID-19;[[29]] and adequacy of publicly funded colonoscopy services in New Zealand.[[30]]

CONCLUSIONS

It became clear at the time of the Health Reforms of the 1990s, that there was a large amount of chronic unmet need for secondary elective healthcare in Aotearoa New Zealand. This was estimated to be about 9% in the adult population,[[17,31]] and was undoubtedly higher in Māori and Pasifika communities, and those living in poverty. The CCHT has done extensive research on this subject and made numerous public calls for the quantity and nature of the unmet secondary elective healthcare need to be estimated repeatedly, independently and transparently, using validated population survey techniques.[[7,32]] However, until recently, successive governments and public health officials have shown little interest in measuring the size of this problem or doing anything substantial to address it. The CCHT was formed with the specific intent of offering as much help to as many of these people as possible to reduce their unmet healthcare needs.

During the eight-year history of the CCHT described in this article, secondary elective services provided by the CDHB changed periodically with time. The CCHT attempted to respond to these changes by trying to fill the moving gap between what the public and private healthcare systems provided. Although CCHT could never address all the unmet need, it was successful in providing quite large numbers of interventions across a diverse range of services, thanks to the unfailing generosity of the Canterbury public and the army of hospital volunteers that worked so tirelessly.

The main changes to the services offered by CCHT since the end of 2012 were: the sudden increased need for counselling after the Christchurch terror attacks; the expansion of the dental and oral surgery service; and the increased endoscopy service. Most of the other services remained largely unchanged but some, such as general surgery reduced as CDHB reintroduced some elective services. The largest overall influence on the activities of the CCHT was, however, the COVID-19 pandemic, which unfortunately led to periods of closure or reduced services.

One area of improvement was better cooperation between CCHT and CDHB. This was particularly evident in the direct patient referrals from the latter to the FS rectal bleeding service run by the former. There was also cooperation in the organisation of dermatology days by the two organisations. Many possibilities remain, however, for greater future cooperation between them, particularly regarding the use of CCHT facilities, for example, for elective day surgery for low-risk general surgery cases.

The large amount of unmet secondary elective healthcare is not only a Canterbury problem, but actually a national one. This is attested by the fact there has been an Auckland Regional Charity Hospital since 2009, and planning started for a Southland Charity Hospital in Invercargill in 2019. These developments resulted from the humanitarian actions of local communities reacting to the unmet healthcare need of their fellow citizens. It is earnestly to be hoped that present and future governments awaken to the fact that investment in health is not only a characteristic of a properly functioning society, but it has also been shown to be extremely economically advantageous.[[33]]  If they do not do so, the likely long-term consequence will be “a charity hospital in every town”.[[34]]

Summary

Abstract

Aim

To update activities of the Canterbury Charity Hospital (CCH) and its Trust over the eight-year period 2013 to end of 2020, following previous reports in 2010 and 2013.

Method

CCH continued to provide free secondary elective healthcare services to some patients in the Canterbury Distinct Health Board (CDHB) region who were unable to access healthcare they needed through public hospitals and were unable to pay for private care. CCH’s services were supplied by a large volunteer workforce, supported by a skeleton staff, and were financed solely by charitable giving. Changes occurred periodically in the quantity and nature of regional unmet healthcare need, largely due to changes in services provided by the CDHB. In order to accommodate these changes, major structural and infrastructural developments were necessitated at CCH.

Results

Many healthcare services at CCH remained the same as before this period but new changes occurred there as a result of: (i) establishment of a flexible sigmoidoscopy day clinic for the management of fresh rectal bleeding in those under 50 years of age; (ii) requirement for a sudden increase in counselling services immediately after the terror attacks at Christchurch mosques; (iii) expansion of the Dental and Oral Surgery Service; and (iv) interruption of CCH service provision by the COVID-19 pandemic.

Conclusion

CCH continued to fill some of the regional unmet elective healthcare need. This is, however, a national problem as attested by the presence of a charity hospital in Auckland and another being planned for Invercargill. Hopefully present and future governments will appreciate that free universal access to secondary elective healthcare is not only a humane imperative, but also a sound economic investment.

Author Information

Philip Bagshaw: Chair, Canterbury Charity Hospital Trust, Christchurch. Lynne Briggs: Associate Professor, School of Health Sciences and Social Work, Griffith University, Gold Coast Campus, Queensland, Australia. Susan Bagshaw: Trustee, Canterbury Charity Hospital Trust, Christchurch. Vivienne Levy: Dental Surgeon, Longhurst Dental Centre, Christchurch. Carl Shaw: Executive Officer, Canterbury Charity Hospital Trust, Christchurch. Averill Williamson: Nurse Coordinator, Canterbury Charity Hospital Trust, Christchurch. Anita Tuck: Clinical Nurse Specialist, Canterbury Charity Hospital Trust, Christchurch. Alice Brown: Clinical Nurse Specialist, Canterbury Charity Hospital Trust, Christchurch.

Acknowledgements

The authors wish to acknowledge the unfailing generosity of the people of Canterbury and the massive support of an army of volunteer workers.

Correspondence

Philip Bagshaw: Chair, Canterbury Charity Hospital Trust, Christchurch.

Correspondence Email

philipfbagshaw@gmail.com

Competing Interests

Nil.

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2) Keene L, Dalton S. Closing the gaps: health equity by 2040. NZ Med J 2021;134(1543):12-8.

3) Bagshaw PF, Allardyce RA, Bagshaw SN, et al. Patients "falling through the cracks". The Canterbury Charity Hospital: initial progress report. N Z Med J. 2010;123(1320):58-66.

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5) Canterbury Charity Hospital Trust Enduring Vision Statement. Available at: https://charityhospital.org.nz/about-us/vision-statement/

6) GESA Clinical Practice Resources: Endoscopy – Standards for Endoscopic Facilities and Services. Available at: https://www.gesa.org.au/education/clinical-information/

7) Alternative Aotearoa Conference. Wellington. 25[[th]] July 2020. Available at: https://m.scoop.co.nz/stories/PO2008/S00171/alternative-aotearoa-final-report.htm  and at  https://chchpn.blogspot.com/?m=1  

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11) Bagshaw PF, Cox B, Frizelle FA, Church JM. Guidelines for completion colonoscopy after polyps are found at flexible sigmoidoscopy for investigation of haemorrhoidal-type rectal bleeding. Letter. Gut 2 June 2020;0:1 doi:10.1136/gutjnl-2020-321655.

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