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Frustrated with "patchy progress" in cardiac surgery, senior official Michael Hundleby wrote to the board in July saying despite "numerous reassurances", it was not getting on top of the cardiac list.
"The cardiac surgery waiting list has not been below the maximum expectations since July 2016 and there continues to be an unacceptable number of patients waiting beyond clinically appropriate timeframes."
Later that month, the situation became a national news story when Mosgiel man Merv Telfer went public saying his urgent heart operation had been postponed six times. The family of Dunedin man Owen Glover spoke out later that month, saying their father died in 2016 after his heart operation was postponed four times. In another July letter, Mr Hundleby outlined several areas of concern, including a failure to make progress in ophthalmology and urology.
"Your recovery plan for ophthalmology services has been further delayed from September to November, which extends well past your original timeframe of June 2017."
The ministry considered imposing a $13.7 million penalty for failing to meet elective surgery targets.
"To enable a speedy recovery we have decided not to apply a funding penalty in 2016-17."
Mr Fleming replied, saying the new intensive care unit to be commissioned in 2018 would help the cardiac situation but until then it was a ‘‘costly’’ problem.
"Southern DHB has budgeted for some outsourcing of cardiac services, however we do not have adequate financial resources in place to simply utilise other capacity as and when required."
Mr Fleming blamed doctors for the poor elective performance, saying they promised too many operations, making it hard to hit targets.
"We ... face a huge challenge where, culturally, certain specialties have consistently failed to accept that the [elective targets] process is non-negotiable.
"Southern DHB has lurched from crisis to crisis on electives over an extended period ... The history of this organisation has seen that every time we tip over the edge we simply purchase our way out of the problem. This results in rewarding the very behaviours we are trying to eradicate."
When contacted, Mr Fleming stood by his comments some doctors promised too much.
"Long-standing government policy requires us to firstly only accept the patients we have the ability to see within four months and then once seen only accept them for surgery if we equally can commit to seeing them within a further four-month period.
"It is easy to advocate for one service, however we need to engage in discussion across our community about ... priorities."