Waiting lists, budget blowouts, strikes and staff shortages ... the health sector seems constantly bedevilled. In our final look at Labour's pledges we ask if extra money has made a difference. By FRANCESCA MOLD.
Labour's 1999 Pledge 2:
Focus on patients not profit and cut waiting times for surgery.
No experienced politician would be stupid enough to hit the hustings with a promise to "fix" health.
But success at the polling booth can be measured by the ability to leave voters with that lingering impression.
Labour made two major health promises at the last election - to reduce waiting times and put patients before profit.
The party was up front about its plan to raise the personal tax rate for the highest earners to ensure it had enough money to achieve its goals.
At the start of the election campaign in 1999, Labour leader and soon-to-be Prime Minister Helen Clark claimed people had told her they did not mind paying more tax if it was spent on health and education.
The tax rise from 33c to 39c for those earning more than $60,000 in personal income brought in more than $1 billion extra for the new Government over the first two years.
In the 2000/01 financial year, the Government spent $74 million of the extra cash on boosting the number of operations in public hospitals. It was the first step towards reducing waiting lists.
The next year that extra funding was increased by a further $84 million to a total of $158 million of new money for elective surgery.
The National Government had proposed at least an extra $25 million for cutting waiting times if it was re-elected. The difference was that Labour put the money into the baseline of its health budget, so hospitals could be certain the money would continue.
Under National extra money had gone in as a one-off waiting times fund.
Finance Minister Michael Cullen does not believe Labour tried to give the impression it could mend all the problems in health.
"We were always clear that so-called fixing health is a very long term project indeed, in the sense that there is always pressure at the margins in terms of increased demand versus limited, capped, if you like, resources," he said.
"I don't think there should have been any misunderstanding about that."
A month before the election Annette King warned that waiting lists would not be reduced overnight. "We may not even achieve it in three years," she said.
The Government also refused to make promises about fixing health in the New Zealand health strategy that details priority areas for the future.
"It will never be possible for the Government to do everything for everybody. Choices have to be made in health," the report said.
Labour's choice was to attack waiting lists.
It wanted all patients who met clinical and funding criteria to get operations within six months. It also imposed a six-month maximum for those waiting for their first appointment with a specialist.
It is slowly delivering on these promises. But it is too early to tick them off as a success.
The residual waiting list has shrunk from more than 50,000 before the 1999 election to 14,109 in the latest figures.
Most of those still on the list are waiting for treatment for ear, nose and throat conditions, general surgery, gynaecological complaints, eye and orthopaedic operations.
There are questions about whether the statistics have been cooked because a new "active review" queue has been created.
It consists of 25,506 people who are close to qualifying for surgery and need to have their conditions monitored. They still have to queue, but the difference between active review and the residual list is that patients are not left to get bitter about their lack of treatment. Their cases are reviewed every six months. Patients feel reassured the system has not forgotten them.
There are 32,547 patients who have waited longer than six months for their first appointment with a specialist. But this is about 8000 less than before the election.
Figures for those waiting longer than 18 months have halved from 12,453 to 6253. Patients waiting more than six months for treatment have dropped from 35,473 to 16,902.
There are 3,419 people who have waited longer than two years for surgery, but that is down from 14,190 before the election.
"We have got waiting times down for the great majority of procedures. To that extent the changes have worked," says Cullen.
King is not completely satisfied with progress. She is concerned that district health boards do not seem to be able to make use of all the extra elective surgery money. The unused portion of funding is carried over each year.
"I never thought it would be done in the first year," says. "It had to happen over a number of years. Each report shows we are getting closer to it. But we've still got some way to go."
Funding for elective surgery has grown from about $350 million in 1995-96 to just over $500 million. On top of that, $200 million is spent each year on 50,000 acute operations.
Labour wants patients to get an operation before they reach a state of "unreasonable distress, ill health or incapacity" and it wants them treated in a similar manner no matter where they live.
Health officials have developed guidelines for each speciality to ensure patients are assessed using the same criteria in every region.
But there is a potential conflict with Labour's desire that everyone is treated equally.
King has announced an extra $410 million for primary health care over the next three years. Most will go to areas with deprived populations.
This means that poor, sick people in South Auckland are likely to pay less for a visit to the GP than those in the same situation on the North Shore.
King admits this is a potential problem, saying that in the short term the scheme will not treat all like individuals in the same way. But it is important the public see it as a step to a more equitable system, she says in a Cabinet paper.
A major blip in the largely smooth passage towards reduced waiting lists came in February last year. King, basing her statement on Ministry of Health advice, claimed 20,000 extra people had received treatment in just three months. It was a miracle 56 per cent reduction in the waiting list.
The fact another "active review" queue had been created, that some people may have simply been sent back to their GPs or taken off the list, was not made clear.
King apologised for misleading people and has instructed her officials to come up with improved information on waiting list figures that will be published every month on a website.
This will make it easier to measure the Government's progress in implementing its promise and the performance of hospitals.
While the management of waiting lists has largely run smoothly, the crisis over cancer patients forced to wait longer than recommended times for radiation therapy threatened to explode.
King says the radiation crisis and the Gisborne cervical screening scandal were the most difficult incidents she has dealt with as Health Minister. "It was heartbreaking. The feeling of impotence, that I couldn't sort of wave a wand to fix it," she said.
But the cancer crisis did not draw the expected criticism from the public because King was able to blame it on previous governments that had ignored warnings over radiation therapist shortages.
King says the Government dealt with the issue quickly. Radiation waiting times are gradually coming down, the Government and district health boards have paid for patients to fly to Australia for treatment, overseas therapists have been recruited and more New Zealanders are training.
Labour's second credit card pledge was to put people before profit. This is harder to measure.
Cullen suggests "somewhat tongue in cheek" that the Government has achieved the not-for-profit promise because district health boards are running big deficits.
These have been predicted to rise to about $220 million by the end of the financial year. Latest figures for the six months to December show a combined deficit of $90 million.
"Clearly we have to manage back those deficits," says Cullen. "The health boards very quickly got into the business of opening up the so-called second cheque book (deficit financing) and we have to manage our way out of that."
King says that at least every district health board is now a Crown entity and has the comfort of the Government behind it.
"We have not put pressure on them to make a profit," she says. "We want them to get the costs of their hospital arm under control but we haven't put pressure on them to do it this year. We've said over time you've got to work through that.
"I don't think the public are too focused on it (deficits) because we're talking at the end of the next three-year funding cycle of something like $10 billion being in health.
"And if you look at deficits that are anywhere from $20 million to $200 million, it's a minuscule part of the investment that goes into health."
Ian Powell, executive director of the Association of Salaried Medical Specialists, says bigger deficits are the result of the Government under-funding public hospitals.
In the last Budget, public hospitals received a revenue increase of 0.6 per cent, but the increase in the Consumer Price Index was 2.4 per cent, reports by Health and Treasury officials show.
Powell says deficits are preferable to the alternative of cutting the quality and range of patient services.
Health managers have warned that any new money the Government puts into health will be swallowed by the deficits.
They also face pressure to meet rising wage costs. The Canterbury health board settled a seven-month dispute with nurses with a 10 per cent rise over 22 months. It followed strikes, threats of hospital closures and warnings that patients could die.
King says there is an incentive for boards to find efficiencies and make savings because they get to keep the cash. So if they spend money on prevention, which reduces the number of people needing hospital care, they benefit.
She lists getting rid of the company-structured Crown Health Enterprises and moving away from the competitive, business-focused model to a co-operative system as a major achievement in putting people first.
Setting up the district health boards is expected to cost about $44 million in the four years to 2004.
The district health boards, with community representatives elected by the public, are a way to involve the public in running the health system, says King.
"The core components of the new system are based on people. We wanted to change the environment, the thinking and the direction we were heading. After two years, when you consider what we've done, it's been huge."
Although the public may not be able to explain how the Government has met that pledge, King believes they will be aware of the emphasis on rebuilding the public system and the new community input.
"Each of the achievements may not be burning in peoples' minds but it is the overall perception," she says.
Labour has already announced plans for future spending. It will put in an extra $400 million in each of the next three years. Each portion of the new money will be built into baselines so the amount spent will total $2.4 billion.
The spending was announced around the time the Government was warned half of district health boards were in danger of breaching loan agreements with banks.
National's Roger Sowry says the Government's new contribution is less than the last National Government spent.
Between 1996 and 1999, National increased operational spending by $1.26 billion (25 per cent). The Labour-led Government increase was $1.2 billion (21 per cent).
Of the new money, King has set aside $410 million for cutting the cost to patients of primary health care, beginning with the poor, children and the elderly. The Government wants to move to low-cost or free access to primary health care over the next eight to 10 years.
The portion of GP care and pharmaceuticals paid for in part-charges is about $465 million a year. The Government would have to cover this from taxes if it wants to deliver free primary care.
King says Labour will focus on the primary sector in its election campaign.
"I see that as being the real winner for New Zealand in terms of improving health," she says. "We have to focus on actioning key population health goals like diabetes, cancer, cardiac disease and immunisation."
Legislation to remove asset testing for long-stay elderly care is being drafted and is likely to be introduced to Parliament before the election.
But Cullen says it will not be passed into law until the Government's next term, if it is re-elected, because there is no room to finance it in this year's Budget. The cost has been estimated at $200 million.
King says the cost of removing asset testing and introducing a meningococcal vaccine, estimated at more than $100 million, will be paid from outside the $2.4 billion increase already announced.
Mindful of the cost, Cullen goes back to the question of whether health can be "fixed". He warns that the development of new drugs, new procedures and the ageing of the population place immense stress on the Government's capacity to meet people's expectations about the health system.
"It would be possible to spend a great deal of money in health and still there would be some demand at the margins that would not be met," he says.
"That reflects the fact that we still have a system which does not allow for an intelligent public debate about the connection between what people are prepared to pay for and what they get."
The message is that either people are satisfied with what they've got or they accept the need for paying higher taxes.
Cullen has done this once and is not prepared to do it again.
Feature: The $1 billion question
First steps on road to health
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