Wait times for surgeries have long been a contentious issue. In the final part of this week-long series Natalie Akoorie looks at overseas examples and potential solutions.
Kay Billman waited 18 months for spinal surgery. In that time she was in debilitating pain with humiliating and worsening symptoms after an injury while gardening in February 2016.
After she was discharged without surgery from Waikato Hospital in March that year, Billman was offered an epidural steroid injection for her continuing back pain but, worried about the risks and told the effects would only last a month, she declined.
By the time she received a letter from Waikato DHB stating she would not be added to the waiting list because she was less severely affected than others requiring surgery, Billman had been in limbo for seven months.
"It just went on and on and on and it wasn't getting any better. It just got worse, the pain in my leg and I couldn't feel when I wanted to go to the toilet. It was dreadful."
The grandmother no longer did the things she loved including walking her dog, baking and gardening.
"Public hospitals have a set amount of funding for assessing and treating patients, and as a matter of fairness, we are obliged to endeavour to see those people with the greatest need first," the October 2016 letter said.
Billman did not meet the threshold for spinal surgery based on pain, mobility, assistance needed, consequences of delay and what benefit would be gained.
Two months later the Herald highlighted Billman's plight and a good Samaritan offered to pay for her to go private.
"I asked him why and he said, 'Hey it's Christmas, and I can.' But I didn't go ahead with that. I just didn't feel comfortable with it and I thought 'Why should a stranger have to pay for something like that?'."
Billman and her husband, originally from Auckland, had cancelled their medical insurance when they retired because the premiums became too expensive.
Instead Billman persevered with outpatient checks at Waikato Hospital, pain management and repeating her request for surgery.
"You do have to make an awful nuisance of yourself I'm afraid to say."
Finally Billman was referred to another spinal surgeon who put her on the waiting list.
Five months later, in August 2017, she underwent a lumbar decompression surgery which Billman said transformed her life.
Now she can do all the things healthy, able-bodied people take for granted, such as showering, cooking, cleaning her home, playing with her grandchildren and gardening.
"I can dance again."
Overseas and potential solutions
Several international studies on dual practice health systems show the higher the proportion of private activity, the longer the wait in the public system.
That's according to 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.
They included studies done in Australia, Canada and the United Kingdom in the 1990s and mid-2000s.
The Canadian study on wait times for cataract surgery found in 1998 the median waiting time for public sector patients was 10 weeks if their surgeon worked only in a public hospital, but 26 weeks if the surgeon also operated in private hospitals.
That was before a law banning or strongly discouraging private health insurance in many of Canada's provinces.
In British Columbia it has been the subject of a decade-long battle between doctors in private practice and the Government, that culminated in a trial in September 2016.
The law also required physicians to work solely for the public system or "opt-out" and practise privately.
But opponents, including Dr Brian Day of the Cambie Surgery Centre in Vancouver, said it prevented patients in the public health system receiving timely and sometimes medically necessary treatment because it was overloaded.
The trial is ongoing and scheduled to run until Septmeber this year.
In Britain, different governments had tried for three decades to clean up any conflicts of interest stemming from dual practice.
Prohibiting dual practice was recommended as a long-term objective by the UK Select Committee on Health in 2000.
"We believe it is indefensible that patients with similar clinical needs receive significantly different treatment purely because of their ability to pay," a summary said.
The latest UK effort was in 2016 when a review of conflicts of interest in the National Health System (NHS) proposed that senior staff declared their annual income from private work, in £50,000 brackets.
The move failed after it was rejected by doctors.
The main conflicts of interest, as outlined in the report to King, were:
• Specialists may gain a financial benefit if the waiting time goals of their employer are not met;
• They could use their position in a public hospital to access potential private patients to "feed" their private practice and private practice income;
• There is potential to manipulate waiting times or clinical criteria for public treatment, to maximise remuneration from private work - treating less urgent and more routine cases in private while still having access to more difficult and interesting cases in public.
In the report, solutions to removing or reducing the conflicts were presented. They included removing the conflict altogether by:
• Prohibiting private provision of services available in the public system [this was not recommended];
• Prohibiting dual practice as is done in Canada and at the time in Sweden, Luxembourg, Greece and Italy;
• Contracting specialists to work exclusively in public.
And reducing the conflict by:
• Enticing specialists to work exclusively in public with higher remuneration;
• Limiting private sector income;
• 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 agreed to investigating a requirement that certain conditions be met in the public sector in relation to waiting times before specialists can undertake private practice, and using different forms of remuneration to encourage reductions in public sector waiting times.
Minister of Health David Clark announced a wide-ranging Health and Disability System Review in March last year.
Led by Heather Simpson, former chief of staff to Helen Clark, the review is tasked with looking at the distribution of services, how financial resources could be altered to provide greater flexibility in allocation, reducing inequities and transparency.
In an online update the review team said Dr Lloyd McCann had presented to the New Zealand Private Surgical Hospitals' Association and heard about the range of different elective demand and supply models across the country.
"Particularly relevant was the critical role of workforce to enable new models of care and service delivery."
Clark said his priority was building a strong public health service.
"Where there are capacity constraints in the public health service, I am not opposed to the use of private providers to help speed up treatment.
"I expect that where DHBs contract out to private providers, they ensure this delivers good value for each health dollar."
He said there was work under way to improve planned care and DHB performance and he would have more to say on that later in the year.
"The Health and Disability System Review's terms of reference are deliberately broad, but include a focus on how we can optimise our health workforce."
An interim report is now due in August.