What can we expect from our public health system?

You are ill and you turn to the health service. JAN CORBETT investigates what you can expect from it.

Through what has been the coldest winter in 30 years two topics have dominated the Herald's front pages. One has been the appalling weather. The other, which won't go away with the coming of spring, has been the deepening crisis in the public health system.

The reports began with the worldwide shortage of radiotherapists, leaving cancer patients having to suffer more radical surgery because of a delay in their treatment.

Then came:

* Ambulances circling Auckland because no accident and emergency department had room to take them. Severe respiratory illnesses and people not going to their GP first because of a variety of cultural and economic reasons.

* The nursing shortage, which has been building for some time, became front-page news when it forced hospitals, including Starship children's hospital, to cancel elective surgery.

* Government funding being so lean relative to the growth in demand that hospitals are threatening to either cut services to live within their budget, or run ever-larger deficits.

At the same time, it was revealed that the latest round of restructuring into district health boards will cost an extra $32 million. And all this just when nominations were being called for candidates for the boards - the structure that is supposed to put the public back into the decision- making in their health system.

But the long-term prognosis for the public health system goes beyond these issues. There is a widespread acceptance in the Western world that no centrally financed health system can meet the demand for ever-improving health technology and therefore public health services will always be limited. With that in mind we ask one simple question: What can the public expect from the public health system?

M ark Clatworthy is an orthopaedic surgeon who splits his working life between Middlemore Hospital and private practice. He says there are 2534 South Aucklanders waiting to see an orthopaedic surgeon, with 1043 waiting longer than six months.

They are graded on seriousness from one to three. "If you're a three, you're not going to be seen," says Clatworthy. Threes are people who might have bunions or knee pain. If you're a two, you'll be told you'll be seen within three to six months, but that might not happen if the volume of patients increases. "We've just sent a whole lot of twos back to their GP," he says.

Twos are people in moderate pain whose joints may be locking up from time to time.

The way Clatworthy sees it, you have to have 20 per cent worse pain this year to get surgery than you needed to have to get surgery last year. There is an inbuilt incentive for patients to inflate their symptoms.

He says the average wait for a hip replacement is 12 months, a knee replacement 16 months and for a foot problem you can wait four years. For the afflicted it means, he says, "a lot of time off work and not sleeping".

What frustrates Clatworthy is that this Government promised it would be different. Instead "we're doing worse under a Labour Government".

He expects that funding will increase next year, being election year. But people don't get sick to suit the vagaries of the election cycle.

If the public still believes it will get the treatment it needs from the public system, "then the public is being duped", says Clatworthy. Indeed, it is government policy that everyone referred from a GP to a hospital specialist will be seen within six months and that if they qualify for treatment they will get it within six months of that assessment. Qualifying for treatment means satisfying the levels of severity guidelines, which anyone can read on the Ministry of Health website, www.moh.govt.nz.

Every quarter, the ministry publishes an elective surgery report showing how well the system is working to meet those goals.

The data says that funding for elective surgery has steadily increased since 1995 to just over $500 million annually, albeit at times only with the help of one-off cash injections.

Over the same period there has been a steady rise in elective and acute surgery, to what will be just over 185,000 surgical procedures performed in the public health system this year.

The figures show steady increases in the number of people getting treatment, and steady decreases in how long they wait to get it.

More significantly, they show 24,430 people have been put on a list called active review - meaning they would benefit from surgery but there is no money for it, or they have to wait until their condition is more serious.

These people at least show up in the numbers.

Everyone agrees it is better they know whether they are going to get treatment or not and roughly when they might get it, as opposed to people such as Jean Billinge, who are left languishing in ignorance on the waiting list.

But what is not measured are those who see a hospital specialist and are told to come back later, or those whose conditions have no show of qualifying for publicly funded treatment and are sent back to their GPs.

Brenda Bromell, the ministry's project manager of elective services, says there are embryonic plans to collect information on this group. Until then, they remain statistically invisible.

B UT they are anything but invisible at medical centres like the one at the People's Centre in central Auckland.

Here beneficiaries and low-income earners line up to see a GP such as Dr Rebecca Potts. These are people with no hope of affording medical insurance, let alone $220 or so to see a specialist privately. The public health system is their only hope.

And in Potts' view that system is at best chaotic, at worst destitute.

She complains that what the hospitals will and won't do for her patients changes from day to day, week to week and from hospital to hospital.

Potts relates a litany of despair. She describes the patients with hernias - a protrusion of an organ or tissue through a weak area in the muscle - who have been told they will not get surgery. Some have had to give up work and live off sickness benefits.

Men are particularly susceptible to hernias. About 2 per cent will get one, usually in the groin. But women can also get them in the abdomen.

They can be debilitatingly painful but are unlikely to kill you, unless they strangulate.

Even the medical dictionary says early surgery is generally recommended, but that's unlikely to be made available in a public hospital. The best anyone can hope for is that when their hernia strangulates they will be rushed into accident and emergency.

Potts tells the story of a mother of three with a melanoma on her face so large it needed to be removed by a plastic surgeon. The woman waited so long to be seen at the hospital and was so desperate she went to a private specialist, knowing full well she would never be able to pay the bill.

And she describes another patient with suspected bowel cancer - one of the most curable cancers if found early - who waited more than a year for a colonoscopy to properly diagnose it. That person now has inoperable cancer.

"In Australia [where Potts is from] that would be absolutely suable."

Then there is the woman she sees who may have had a minor stroke, but needs a CT scan to be sure it is not a tumour. Auckland Hospital has written to her saying she is on a priority B list, "which means she'll never be seen".

Says Potts: "If there was a 1 per cent chance of having a brain tumour, wouldn't you want to know?"

On another level, Potts points out that teenagers of poor parents are now the only adolescents in New Zealand who have to suffer from disfiguring acne. Roaccutane, an effective drug against severe acne, is available only from a specialist. Potts says she has had six to seven acne referrals rejected, but she doesn't give up trying.

She is not afraid to "go into hassle mode", writing to the hospital and repeatedly phoning in attempts to get her patients treatment, even if it is just because she will not take no silently for conditions that matter. "I'm prepared not to refer people for varicose vein operations [which are no longer performed in the public system] but I refuse to conform to a system of not referring hernias, so we continue to hassle them."

I N many respects Rebecca Potts is rare as a GP, because she does seem to know what happens to her patients after they are referred to a hospital specialist. Many GPs do not.

Which is why hospitals now have newly appointed people who both field the hassling from the GPs and help the GPs to better understand what they can expect from the public system.

For Auckland Hospital that man is Dr Allan Pelkowitz.

In his eight years as a GP, Pelkowitz says, he had no idea what happened to patients he referred into the public system. "It was like throwing a stone out into the great unknown. Someone either threw it back, or it stayed there."

Pelkowitz says no health system is able to meet the demand for health services and all developed countries are constantly eyeing other countries' systems with envy. In the knowledge that not everyone is going to get treatment he considers his job is "to be honest and caring and say to people, there is a limit to what the public health system can do and we're trying to be fair".

What that means, for example, is that people with lower back pain will not get surgery in the public system. If you have cataracts that prevent you from driving, you can expect to be treated within six months. If they're not that bad you'll be told to wait and have it monitored. And yes, you can wait over a year for your orthopaedic surgery, if you're severe enough to qualify for it.

If you have diabetes, however, you will receive largely exemplary and timely treatment and monitoring. The same is true for breast cancer.

B UT what about Jean Billinge, the woman in our accompanying story?

Dr Warren Smith, the clinical director of Green Lane's adult cardiology unit, says he cannot say when she is likely to get surgery, but he hopes it will be within the next six to nine months. He agrees that she is "justified to say she's not getting a good service".

The truth is that acute patients keep piling in ahead of her, and because she has not had a heart attack and her angina settles down with medication, she is not considered acute enough. Her treatment "depends on the acute load not getting worse", he says.

It also depends on more nurses being found to staff the intensive care ward, where heart patients are sent after surgery.

Billinge represents what Smith now calls the second backlog. Last year Green Lane heart surgeons became so concerned about the 137 people waiting more than 12 months for heart surgery that they lobbied the Health Funding Authority for extra money, which was granted in two blocks.

The good news is that only 18 of those original 137 are still waiting for their operation. "But in the meantime," says Smith, "people who hadn't been waiting 12 months then are now the new backlog."

So where does this confused and ever-changing picture of the public health system leave people who might be wondering whether they can count on it, or need to find the money for medical insurance or, like Billinge, are thinking about mortgaging or selling the house for a $33,000 operation that could be done in the private system next week?

The paradox is that while the public system is failing to treat people who might die or who are suffering severe discomfort and mental torment while they wait, it excels beyond what the private system can offer when it comes to dealing with complex cases like complicated cancer surgery, organ transplants or saving lives when an operation has gone wrong. The best surgeons still spend some of their working life in the public system because this is where the challenging work still gets done.

It is also where much of the training gets done. Which is another thing you can expect from the public system when you live in the same town as a medical school. Your hospital will also be a teaching hospital, which means you might be treated by trainees.

C ANCER and thyroid surgeon Professor James Shaw sits in his fifth-floor office at Auckland Hospital dressed in blue surgical overalls. He also works privately but today is his day to operate in the public hospital and he is between procedures.

Ask him the central question and he reiterates what a number of specialists maintain: "If you're an average New Zealander and you have a major medical catastrophe, you're better off in the public system. If you need a difficult operation you may also be better off in public. But if you're reasonably fit and well and you have a common problem like breast or bowel cancer, melanoma, gallbladder trouble, a hernia or varicose veins, it would be handy to have access to the private system."

According to the health insurance industry, 20 years ago 11.9 per cent of medicine was privately funded, now 22.9 per cent is.

Says Shaw: "You don't see teachers in the public system much any more - even they've gone and got medical insurance."