For the past three months the Herald has investigated if all New Zealanders are getting good healthcare when they really need it.
The Fair Care? series has revealed pressure points and outright failures, with causes ranging from a lack of skilled workers to poor planning. A summary of findings can be found below, with links to full reports.
Even the ambulance at the bottom of the cliff can be denied…
South Auckland has higher rates of often painful skin conditions because more residents live in poverty and overcrowded housing.
When doctors or other health services send patients with the most severe cases for specialist treatment a huge number are declined - more than half of children sent for care, and 42 per cent of adults.
Hundreds of cases are declined each year because of a lack of resources, the DHB has told the Health Minister David Clark, who has now asked for advice on the problem.
Postcode can determine healthcare - Auckland DHB declines fewer than one-in-10 patients.
Prevention efforts could actually make things worse…
One of the country's biggest health initiatives isn't picking up serious problems and could actually widen the rich-poor divide.
When every child in the country turns four they are offered a "before school check" (B4SC), to identify health, behavioural, social or developmental issues, such as a hearing problem.
However, serious concerns have come out of research involving schools in Auckland's Glen Innes, Pt England and Panmure.
Specialists and nurses checked new entrants, and found a large number of issues that hadn't been picked up by before school checks.
Russell Burt, study co-author and principal at Pt England School, said there had been a misunderstanding about what checks covered. For example, schools assumed eye testing was more comprehensive.
Burt said the most disadvantaged families - often Māori and Pacific - were more likely to say their child was okay, because their development was typical for the community.
"Middle classes and above tend to be far more in-advocacy for their children's needs - taking note of when other children walk, how early they are toilet trained, how well they speak - this view of developmental things being a competition."
Women are being left in limbo...
Counties Manukau DHB has been about seven gynaecology beds short for the past 12 months, a shortfall it says carries "very concerning" risk.
Women are waiting up to half a year for procedures to help rule out cancer. Dr Mark Arbuckle, a GP at Otara Family and Christian Health Centre, has patients caught up in the delays.
"Gynaecology is under huge pressure," he told the Herald. "We are having to try manage patients who should have had surgery. And the gynaecologist is saying, 'just keep a close eye on them, because we can't do it at the moment.'
"The real risk is that cancers are missed if these procedures are being delayed."
Overloaded emergency departments turn to the private sector…
Waitemata DHB, which runs Waitakere and North Shore hospitals, is handing out more than 1000 vouchers a month to people presenting at the ED, entitling them to free treatment at a nearby private clinic.
The cost last year averaged almost $100 a voucher.
The vouchers are given for specific conditions including bruising, sprains, minor wounds colds and other needs like repeat prescriptions and medical certificates.
More than 40 patients given a voucher have later been admitted to hospital, but the DHB says it has no record of "any adverse outcomes" as a result.
Patients can decline a voucher and get treatment at the ED. Half of North Shore patients and 15 per cent of West Auckland patients agree to take the voucher.
Lack of planning can have devastating results…
An 11-year-old girl slowly lost sight while languishing on a waiting list for follow-up treatment.
Keratoconus distorts sight as it thins the cornea, the tissue covering the eye. There's no cure, but it can be stopped in its tracks through a procedure called cross-linking.
A follow-up appointment was cancelled by Counties Manukau DHB and not rebooked, as it struggled with a huge backlog of cases.
Overdue cases were prioritised only by how long people had waited and the priority at the time of booking. Someone going blind didn't factor.
When she was eventually seen two years and nine months after the first specialist appointment her right eye had been so weakened as to be untreatable.
Booming demand for eye services is partly caused by a relatively new treatment for age-related wet macular degeneration, which about 200,000 Kiwis suffer from.
A decade or so ago there was no treatment, but now drugs such as Avastin, which are injected into the eye monthly, stop vision deteriorating.
About half the country's 20 DHBs had delays in eye treatment last year, partly because of the extra work caused by Avastin injections.
Spotlight on potential bias…
Extremely premature babies born close to death are less likely to receive a resuscitation attempt if they're Māori, Pacific or Indian - and a group of experts think racial bias could be a factor.
The divides were outlined in a report to Health Minister David Clark, by the Perinatal and Maternal Mortality Review Committee, a taxpayer-funded watchdog tasked with reviewing deaths of babies and mothers.
"Māori, Pacific and Indian live born babies were statistically significantly less likely to have an attempt at resuscitation," the committee stated.
"Institutional bias or implicit biases are likely to play at least some part."
Dr John Tait, chairman of the mortality review committee and chief medical officer at Wellington's Capital & Coast DHB, told the Herald no baby would not be resuscitated because of the colour of its skin.
Rather, bias could strike earlier in the chain of events and explain why more Māori, Pacific and Indian women have babies whose condition, such as birth weight, makes resuscitation less viable.
"Is enough effort going into Māori and Pasifika health to prevent them going into labour early? If people don't attend antenatal clinics, it may be they can't afford the bus ... should we be going to them?" Tait said.
"There's no deliberate bias. But there's that underlying bias for years that's led to poor Māori health outcomes, and poor Pasifika outcomes as well."
A DHB has taken a radical step to improve diversity…
All eligible Māori and Pacific job candidates are being automatically fast-tracked to the interview stage for openings at Auckland DHB.
The change has been made to try to increase workforce diversity, and has already resulted in more Māori and Pacific candidates being interviewed and hired.
Māori and Pacific candidates must still meet core criteria for a role to progress to interview. If not hired, managers must give specific feedback to HR, so the unsuccessful candidate can be coached to improve their chances next time.
The population Auckland DHB serves is more than 10 per cent Māori and about 14 per cent Pacific. Its workforce is 4 per cent Māori and 7 per cent Pacific.
When doctors don't believe you...
Stephanie Aston has been diagnosed with Ehlers-Danlos syndrome (EDS), a genetic connective tissue disorder that causes symptoms including spontaneous bleeding.
However, the 28-year-old says she can't easily access transfusions because some doctors believe she is deliberately bleeding herself to cause severe anaemia.
She believes their suspicions stem from a conflicting diagnosis of factitious disorder - previously called Munchausen syndrome - where a person makes up a physical or mental illness to get sympathy or special attention.
Aston is one of four women spoken to by the Herald who have formal diagnoses of EDS, but who have either been diagnosed with or suggested as having factitious disorder or personality disorder traits, which some doctors believe has hampered their ability to get treatment.
A big change to the Pharmac model is being considered...
Hundreds of people travelled to Parliament in October and presented a 32,000-signature petition calling for the funding of Ibrance, and another petition for breast cancer drug Kadcyla.
Petitioners have also called for an urgent select committee inquiry into how Pharmac operates, particularly around how quickly it assesses new drugs and Māori access to medicines.
In Opposition Labour pledged to investigate an early funding model to speed-up access to some drugs, and Clark has asked for advice from officials, which is yet to come back.
Pharmac chief executive Sarah Fitt has been critical of early access schemes, saying they could weaken the agency's considerable bargaining power.
Fitt has cited research that concluded early access schemes overseas could do more harm than good, because too many high-cost and ineffective drugs were funded.
Drug companies often claimed products were breakthroughs, she told the Herald, but studies later disproved that.
Krystal Hekau, who has advanced breast cancer but cannot afford Ibrance, travelled to Wellington to help present the petition, and said she was fighting for her kids, aged 3 and 5.
"For them to hopefully one day understand how much I tried. And how much of a fight I put up to be here for them."
It can pay to be pushy…
Hawera resident Darryn Sunnex was dismayed to be declined a specialist appointment to check a growth his GP thought could be cancerous.
The 54-year-old automotive service manager noticed a small bulge on the right side of his neck about a month ago. He went back to his GP after antibiotics did nothing and it grew rapidly.
His GP referred him to the DHB, expecting an MRI and needle biopsy to be booked. Eventually Taranaki DHB sent back a letter - he didn't meet the clinical threshold for a first appointment.
"You have a person dealing with possible cancer growth - shit scared, basically, as to what the hell is going to go on. You are scared. And the family are the same. We just want to know what it is," Sunnex said.
After the Herald inquiry the DHB contacted Sunnex and, he said, told him they hadn't realised the lump had grown substantially in size, and booked him to see a specialist.