Poor fall through the cracks

When it comes to health, New Zealand has a two-tiered system.

When the public system cannot meet their needs, there are those who can afford to, or have health insurance, to go private and those who can’t.

For the people who have no choice, getting rejected from the public system means pain, it means pills and it means waiting. ‘‘It is misery. It is inability to work. It is inability to lead a good life,’’ says Professor Robin Gauld, a health systems expert at Otago University. ‘‘We have very serious issues with equity in New Zealand because of the twotiered nature of the system.’’

Access to public treatment is rationed for a reason: resources are finite. In Budget 2019, the Government set aside

$19.8 billion for health, including

$13.9b for district health boards (DHBs). There are also workforce and physical constraints – hospitals have a limited number of operating theatres and beds, and there are only so many specialists.

To get treatment in the public system, patients are usually referred by their family doctor.

A specialist assesses the referral and determines if they should get a first specialist assessment, where it is determined if and what treatment is required. If a patient would benefit from treatment, their priority score is worked out and if they meet the threshold they go on a waitlist.

If they are accepted, Ministry of Health guidelines require

DHBs to give people a first specialist assessment within four months. September reporting figures show that, across the 20 DHBs, 11,035 people had been waiting longer than that. If they are accepted for treatment, the guidelines require DHBs to provide it within four months. The September reporting shows 7312 people had been waiting longer.

For some people, waiting in agony is too much.

‘‘I decided that financial pain was easier to deal with than physical pain,’’ Christchurch woman Susan Wauchop told The

Press earlier this year.

The 74-year-old had her left hip joint replaced in September, paying about $22,000 to have the procedure done in a private hospital. While it cost her a significant chunk of her retirement savings, Wauchop said it was worth it. Before surgery she could barely walk and had not been sleeping. ‘‘This has been my year of pain.’’

Wauchop said the public health system did an amazing job but she believed it was not funded adequately for a growing and ageing population, meaning people were missing out or managing severe pain waiting for surgery.

Waiting too long for treatment can have serious consequences.

Christchurch man Graham Kingswell developed a serious condition while waiting for spine surgery, resulting in a permanent loss of bowel and bladder control. The 75-year-old was put on a wait list for spinal decompression surgery in April

2018 and waited 175 days for treatment. The day before surgery, Kingswell collapsed at home, paralysed from the waist down. ‘‘My quality of life, it was stuffed. And it is still not that bloody handsome, either,’’ he told The Press earlier this year.

DHBs carried out 199,080 elective surgeries in 2018-19, according to ministry figures.

While the care provided by hospitals is generally excellent, thousands of people are not getting in the door each year.

In 2018, ministry data shows there were 773,323 referrals for first specialist assessments across all 20 DHBs. Of these,

78,993 referrals were declined. The ministry stresses the data is under development but it gives some picture of the number of people missing out. Other studies have put the overall rate of unmet need much higher.

Gauld says: ‘‘It is like saying to people: sorry we don’t have enough classrooms ... These kids here, they can come in, those ones can’t. If you want to, you can go and pay privately but otherwise you have got to wait.’’

These delays and access issues are often highlighted by the health insurance industry.

On its website, industry group Health Funds Association says delays accessing non-urgent treatment are likely to get worse over the coming decade as demand for healthcare rises faster than the ability to fund it through taxes. ‘‘This means New Zealanders will have to pay for their own non-urgent healthcare costs or wait longer for treatment in the public system.’’

Recent figures show

1.4 million people have health insurance.

In Christchurch, people who fall between the cracks of the public and private system can try to access care through the Canterbury Charity Hospital.

Its founder, Dr Phil Bagshaw, has long advocated for comprehensive reporting on the level of unmet need for hospitallevel care. He was one of the authors of a pilot study, published in 2017, which found

9 per cent of respondents had an unmet secondary healthcare need that had been identified by a doctor or other health professional in the past five years. Using that 9 per cent rate, the Association of Salaried Medical Specialists estimated there could be as many as 430,000 children and adults with an unmet need for hospital care.

Bagshaw believes there needs to be regular, population-level surveys of unmet need to assess how the health system is performing. ‘‘If you want to know how well your health system is functioning, rather than measuring what you do, we should be measuring what we ought to be doing,’’ he says.

As well as the personal cost to people who can’t access care, Bagshaw says there is an economic cost. People who are unwell often can’t work, and deferring surgery can result in costly complications and longer recovery times. He believes the current model of funding is austerity-based, when it should be viewed as an investment.

‘‘It would be a sea change ... if you start thinking about investing in health as opposed to thinking of it as a cost and a burden,’’ he says. ‘‘If you think of it as an investment, not only do you make a whole lot of people more productive and happier, you start to save some money.’’

‘‘This has been my year of pain.’’

Susan Wauchop