Sickly system has all the ailments of Britain's model

New Zealand is often held up as the model state-run health system. But the reality is rather different, with people dying while waiting for surgery.

One complaint dominates debate about New Zealand's health system - long surgical waiting lists. Like the NHS, with which the New Zealand system has much in common, there are great difficulties in obtaining hospital treatment for the country's 3.8 million population, despite its higher proportionate spending.

One complaint dominates debate about New Zealand's health system - long surgical waiting lists. Like the NHS, with which the New Zealand system has much in common, there are great difficulties in obtaining hospital treatment for the country's 3.8 million population, despite its higher proportionate spending.

It is common for orthopaedic patients such as Jethro Rae (see case history) to wait up to 18 months. Some heart bypass patients have waited 15 months - others have died in the queue.

Many of those languishing on waiting lists are elderly people waiting for hip replacements or cataract surgery, children needing tonsillectomies and grommet procedures and the poor who can't afford health insurance or the option of paying for a private operation.

An extra $74m (£23.5m) a year is being thrown at elective surgery, in the hope of clearing surgical backlogs and slashing waiting times to a maximum of six months. The new money will raise total spending on elective surgery to $390m a year.

Health care has been in a state of constant reform in New Zealand, lurching from the political right's philosophy of corporatisation and competition to the new centre-left LabourAlliance government's promise to put people above profit by tackling surgical waiting times, a seriously deficient mental health service and improving the poor health status of Maori.

The reforms have followed a similar pattern to those in the UK, with the introduction of market forces and competition in the early Nineties to increase the efficiency of the system. There were also tentative moves towards explicit rationing with the establishment of a core services committee to determine which services should receive public funds, but those did not lead to clear-cut decisions.

In 1996 a new government decided to change direction, abandoning the emphasis on competition, much as the Labour government did a year later in Britain. A revolutionary surgical waiting system in 1998 was touted as the solution to long waits but health experts agree it has not worked.

Under that system, patients' eligibility for operations was ranked on a points basis, with funding determining the cut-off. But the main problem was that funding has never been enough to match the level of illness and disability doctors or patients believed deserved treatment.

Money dedicated to clearing backlogs of elective surgery patients has disappeared into the abyss of an increasing demand for acute surgery, not covered in tight funding contracts with the Government.

The booking system has put doctors and funders at loggerheads, and infuriated patients who had to be told the reason they were not getting the operation they desperately needed was financial rather than clinical. The prolonged period of restructuring and reform of New Zealand's health services is not over. The new LabourAlliance government is doing some tweaking of its own.

It proposes giving doctors and hospital specialists more power, relying on their judgement to decide whether patients are in need of an operation, rather than measuring their need on a points system.

Important changes are also being made to primary health care, where there is a chorus of complaints from GPs about the increasing burden of red tape, long hours and declining incomes. "I feel dispirited, disillusioned, undervalued, and I certainly don't drive a new car," said Dr Lannes Johnson, an Auckland GP. "I have the bank manager on my back most of the time."

About 85 per cent of the GPs operate under the fee-for-service scheme.The rest work under a capitation system, bulk-funded for consultations, prescriptions and diagnostic costs of patients enrolled with their practice.

There are no rules for what must be done with savings made by bulk-funded GP groups, but the policy has been that leftover cash mis spent on health care, say, preventive programmes such as immunisation or diabetes checks.

The Government wants doctors required to join primary care organisations, bulk-funded by the Government, using a population-based formula of race, age, health status and socio-economic factors.

Patients will be "strongly encouraged" to sign up with one GP or primary care organisation. The Government hopes that the move to bulk-funding will help it to control spending better on GP patient care and allow it eventually to increase subsidies from 35 per cent to 85. This is estimated to cost the Government an extra $350m and would see patient user charges drop to between $10 and $2.

A similar strong focus on curbing New Zealand's prescription costs has worked well in the past six years, with Pharmac - the Government's pharmaceutical purchasing agency - saving $257m by driving hard bargains for generic drugs. Doctors fear people will choose a subsidised drug rathern than one carrying big user-charges, even though the latter is better for their illness.

So far, the new policy has been supported by health professionals and the public. Although weary of restructuring, New Zealanders appear to believe it is not yet time to give up the notion of a decent public health system.