Wait times for surgeries have long been a contentious issue. In this week-long series Natalie Akoorie examines the conflict faced by doctors working in public and private healthcare that some argue leads to longer waits.
When Kay Billman lost control of her bowels one morning she was grateful her husband of 25 years was not there to witness her humiliation.
At the time the 72-year-old could barely walk and was also "drugged up" on medication to combat debilitating pain.
Her life was spiralling downhill; she had not been able to function properly since injuring her back gardening the year before.
Yet she was not eligible for publicly-funded spinal surgery at Waikato Hospital because she did not meet the district health board's threshold for the $17,000 operation.
She could not afford to pay for the surgery at a private hospital and ACC would not cover it, later citing a pre-existing condition.
So Billman languished for 18 months, unable to sleep properly or maintain her home, worried she might become paralysed, reduced to crawling out of bed each morning in constant pain and fearful of going out in public in case she wet or soiled herself.
It was no way to live. But it's how New Zealand's public health system left her to exist.
It has been 80 years since that public health system began via the 1938 Social Security Act, an initiative of the first Labour government, developing as a dual system of public and private provision.
At the core of the Act was a free health system, with hospital and other health services universally available to all New Zealanders, though that has never fully eventuated.
In the mid-1990s a booking system was introduced to reduce waiting times for patients above the qualifying threshold for treatment.
Doctors nationally determined a points system to prioritise patients according to need and thresholds were set based on the number of operations the system could fund.
The target was to have 90 per cent of patients assessed by a specialist within two months of referral by their GP, what's now termed a First Specialist Assessment (FSA).
Patients who met the threshold for treatment would either receive it immediately or be given a date within six months.
Over time those targets changed and now sit at four months to FSA and four months for treatment.
Billman went though her First Specialist Assessment quickly and was admitted to a ward at Waikato Hospital in March 2016, one month after her injury, where she had an MRI scan.
It showed a spinal stenosis - a narrowing of the spinal canal which can result in a pinched spinal cord or surrounding nerves.
Billman claims a registrar told her she needed surgery to resolve the pain and bladder emptying problems she had endured.
The surgery was explained in detail, she signed consent forms, and her husband Eddie stayed in a motel. But on the morning of the surgery Billman was examined by the surgeon who said her symptoms could be managed by pain medication.
Waikato District Health Board said Billman was never on the list for surgery and with 45 points she did not meet the threshold of 80 for the operation.
She was sent home and eventually removed from the waiting list altogether.
While most patients accepted there will be a wait for surgery, those in pain or worsening conditions could be impacted by anxiety, an inability to work leading to lost income, lost independence and disability - with some no longer able to care for other family members.
When they did get surgery it could mean a longer recovery time in hospital through a deterioration in health and fitness while waiting and poorer overall health. In extreme cases, patients died.
Last year the Ministry of Health ended the public reporting of national health targets, removing improved access to elective surgery from interim targets altogether.
In the final publicly posted improved access results, from April to June 2017, the country's 20 DHBs had surpassed the planned total elective surgery discharges of 192,237 by 11,798.
It meant all but two DHBs, Auckland and Southern, had bettered the target of increasing their volume of elective surgery by 4000 more discharges for the year.
However there was no indication of whether an extra 4000 surgeries a year was enough to reduce waiting list times or threshold criteria, or if the figure was keeping up with an ageing and growing population.
And that figure included about 34,000 "arranged" surgical admissions that were not subject to the long waits because they happened within seven days of the decision to treat.
Drilling down further, the national comparison of DHB data, for February 2018, showed 2036 patients waited longer than four months for their First Specialist Assessment across 11 districts.
Fifteen DHBs then failed to treat 3140 patients who were given a commitment of treatment within the required timeframe.
Across surgical services for the same month, orthopaedics had the worst performance with 783 patients or 6.1 per cent waiting longer than four months for their FSA.
In the same speciality, 1315 patients did not receive treatment within the required timeframe.
In total, across all specialities including dental, ear, nose and throat, general surgery, gynaecology, ophthalmology, paediatric surgery, plastics, urology and vascular, 3123 patients were left waiting for treatment.
In a 2005 Ministry of Health report on the public-private interface prepared for then Health Minister Dame Annette King and released to the Herald under the Official Information Act, it pointed to evidence from New Zealand and overseas of a link between long public wait lists and specialists' dual practice.
The report, the most recent dealing directly with the "conflict of interest" specialists face when they work in the public and private sectors, presented three options to the Minister.
• Offering specialists in particular locations and specialities a contract to work exclusively in the public sector, possibly starting with a pilot;
• Requiring certain conditions to be met in the public sector in relation to waiting times before specialists could undertake private practice;
• Using different forms of remuneration and/or other changes to working conditions for specialists in the public sector to encourage reductions in public sector waiting times.
King declined the first option and agreed to the other two in May that year but the two-tier system has remained largely unchanged.
It is a system where patients who can afford to pay for their care or who have private insurance, receive faster care in nicer hospitals than those who cannot afford it.
Find out what happened to Billman in the next parts of the series.
• Part 1: Waiting times
• Part 2: The conflict of interest
• Part 3: Complementary, competition and the cost
• Part 4: Retention and remuneration
• Part 5: Overseas and the alternatives