Wait times for surgeries have long been a contentious issue. In part three of a five-part series, Natalie Akoorie examines the social and financial costs of a two-tier health system.
An American living in Wellington is so desperate to get treatment for a recurring sinus problem he's considering returning to the United States - a move which may put his 16-year marriage to a Kiwi at risk as his partner has to stay in New Zealand.
The man, who does not want to be named, said for the past six months he had only managed to sleep for three hours at a time before breathing difficulties forced him awake.
During that time he has been plagued by repeated sinus infections and multiple rounds of treatment with steroids and antibiotics.
"It's getting quite stressful. It just kind of drags on."
In 2010, the man used private health insurance to have surgery for a deviated septum (cartilage in the nose that separates the nostrils), but once he became a New Zealand citizen he dropped the insurance.
A follow-up surgery in the public health system never happened when the man gave up after waiting six hours at Hutt Hospital.
In the latest episode, the man said he had been offered antidepressants but declined them because he was not depressed.
"I just have anxiety because I'm not sleeping well and it's disrupting my life. I get these headaches bending over tying my shoes.
"[I'm] coughing and I get really bad headaches and pressure in my cheeks."
Public v private: Why are we waiting so long for surgery?
He had been waiting for a CT scan which this month showed cysts growing in his nasal cavity.
"I sent this information to the ENT [ear, nose and throat specialist] who has refused to see me.
"He told my GP to keep treating me with steroids, which will lead to thinning of my skin and weakening of my bones.
"They don't even know if the polyps/cysts are cancerous or not without doing a biopsy."
He said his GP recommended he go private and now he wishes he had kept his health insurance.
If the man paid out of his own pocket his first ENT appointment would be $343.
Scans would be an additional $500 and surgery to remove the cysts blocking his sinuses starts at $20,000.
So he is considering going home to the United States after a decade in New Zealand.
"I don't really want to do that. My home is here, my partner's here, my dog is here, my life is here. But what can I do?"
It could mean an end to his marriage because his partner cannot leave his recently widowed, elderly mother.
The man is also investigating the cost of the surgery in China and other countries.
Complementary, competition and the cost
There are those such as Middlemore Hospital surgeon Dr Andrew Connolly who argue private practice is complementary to the public system, but at what cost?
A 2005 Ministry of Health report to then-Health Minister Dame Annette King pointed out barriers to reducing inequalities arising from the conflict of interests in dual practice which affected those who had little option but to rely on the public system.
"As Māori and Pacific people are over-represented in the high-deprivation deciles, this affects these groups as well as other lower-income groups more than other New Zealanders."
Another disadvantage was the reduced time available for specialists to train junior doctors in the public system when they are off-site working in private practice.
In 2017 Waikato Hospital began a $2.4 million project to sort out its "spaghetti bowl" surgical system after the death of a baby during delivery because of a delayed caesarean section, as well as lobbying from doctors and spending $25m annually on outsourcing elective surgeries to private hospitals.
The project by Australian consultants Keezz was initiated after Waikato District Health Board (DHB) was put on notice by the Medical Council over the training of junior doctors in orthopaedics because of a serious imbalance in the types of surgeries they were learning.
Registrars were not performing enough elective surgeries to meet training requirements, putting the DHB at risk of losing accreditation in orthopaedics.
Public affairs executive director Lydia Aydon said so far the project had saved the DHB just under $10m each year in better managed surgeries.
The DHB's interim chief operating officer, Ron Dunham, said there had been some improvement in wait times although this varied across specialities.
"More efficient processing of acute presentations frees up capacity for planned procedures."
Not to mention a vast number of the electives shuffled into private hospitals are paid for with the public purse, through ACC.
The fact the public health sector was alone in allowing a key segment of its workforce to be engaged in private activity outside their public sector work had not gone unnoticed.
"Other sectors, such as telecommunications, and the New Zealand public service, do not allow employees to work for competing organisations, or in any capacity that may lead to a conflict of interests," the report to King stated.
At the opposite end of the debate was the notion private hospitals, where those surgeons in private practice operate, can help reduce ballooning waiting lists at public hospitals.
The year before the report to King, the Government announced an extra $70m in funding for orthopaedic surgeries.
King told the Herald : "In 2004 we arranged for orthopaedics to be done in private, paid at the cost it would be in the public, to reduce waiting lists for orthopaedics and cataracts.
"That was a definite decision made by the [then] Prime Minister [Helen Clark] and me to reduce the number of people waiting for orthopaedic surgery.
"The really interesting thing about it was we got the orthopaedic surgeons to agree they could not charge any more than it would have cost to have done it in the public health system."
At the time the Health Funds Association of New Zealand [HFANZ], said while $70m in four years seemed like a lot of money, anyone who thought it would provide more than a temporary respite to the fundamental and underlying problems faced by the public health system would be disappointed.
In April HFANZ chief executive Roger Styles said health insurers paid an unprecedented $1.322b in claims in the year to March, "reflecting the value of the private sector at a time surgeries in public hospitals have been cut and waiting lists grow due to ongoing industrial action".
Styles predicted elective surgery forecasts for the full 2018-19 year would miss their targets because, for the first year in more than a decade, volumes were down compared with the previous year.
An estimated 300,000 New Zealanders were waiting for elective surgery, according to a 2016 survey commissioned by HFANZ and the Private Surgical Hospitals Association,
although around 170,000 of them were not officially recognised as being on waiting lists.
Back in 2005, HFANZ said successive Governments had failed to admit the public sector did not have the capacity to provide emergency services and undertake the quantum of elective surgery required.
"By failing to face up to this fact, despite evidence to the contrary, the public are misled into thinking the public health system will be there for them when they need it."