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The story of the Aotearoa New Zealand health system is one of early optimism, some success and then disappointment at the failure of the public sector to respond to the needs of the community. Health and healthcare are very complicated, and we now understand the important links between health needs and other aspects of wellbeing.

The early story

In 1938, we led the world with the Social Security Act, which formed the basis of the first Labour government’s welfare programme. This was expected to introduce a national health service, with universal access to healthcare. However, from its origins it inherited two deficiencies: (i) partially private primary healthcare; and (ii) a Western-style system that did not address the needs of tangata whenua and other marginalised groups.

In Aotearoa New Zealand, with increasing prosperity in the first half of the 20th century, heavy investment in health meant that, despite underserving some groups and embedding health inequities, we climbed high among international health rankings. The economy then stagnated and, with soaring oil prices and high inflation starting in the 1970s, the downward trend in health investment began. From the late 1980s, successive governments introduced neoliberal policies that established destructive, managerialist processes and austerity budgeting.[[1]]

The Health Reforms in the 1990s (Health and Disability Services Act, 1993), created a pseudo-market for health services, attempting to use competition to drive efficiencies, and to use reduced funding as an incentive to ration services. Over the decade, a range of explicit rationing efforts were tried without success.[[2]] For example, part charges in hospitals in 1991 were abandoned in the face of public ridicule. The efforts of the Core Services Committee in 1992 to create a list of which services would be provided were similarly discarded.[[3]] The use of clinical guidelines as a method of healthcare rationing also proved impractical, so more devious methods were tried. For example, the National Waiting Time Project in 1998 used softer, more sanitised language: rationing was called prioritisation; waiting lists were referred to as waiting times; but no mention was made of the large numbers of patients who did not qualify for treatment under the newly introduced points scoring systems.[[4]] In this way, it was said, the public were slowly adjusting to the notion that rationing of healthcare was inevitable.[[5]] However, the process of denying patients the treatment they needed was referred to in health management documents by the harsh metaphor of “steps you can take to alter the trajectory of demand”.[[6]]

Under the neoliberal philosophy, austerity budgeting was applied to many aspects of healthcare.[[7]] Many of the most senior nurses at Christchurch Hospital were made redundant or were redeployed. This resulted in unsafe ward environments that led to a series of unnecessary patient deaths, culminating in the first major inquiry by the Health and Disability Commissioner, and what became widely known as the Stent Report of 1998.[[8]] This marked a minor win in a battle against the neoliberal reforms but did not seriously weaken the dominance of this philosophy within the Government.

It became ever more obvious to healthcare professionals that unmet need for both primary and secondary healthcare was growing; increasingly they had to inform patients that needed treatment that they would not qualify for inclusion on waiting lists. However, the health professionals’ own representative bodies were unable to effectively highlight and counter these growing problems.[[9]]

Enter the charity hospitals

The growing frustration at the lack of progress with these problems led, in 2004, to the formation of the Canterbury Charity Hospital Trust (CCHT).[[10]]

The aims of the Trust were to provide a dedicated day hospital to meet as much unmet secondary elective healthcare need (USEHN) as possible; to be exclusively funded by public, charitable giving, and to be largely staffed by volunteers. It was followed by the opening of the Auckland Charity Hospital (ARCH) in 2009.[[11]] This was organised differently, using downtime in existing private hospitals. However, both have provided purely reactive services by trying to fill the ever-changing gaps, where public hospitals do not provide some necessary secondary elective services. Some gaps, such as inadequate dental and women’s health services, have remained and have grown in size. Other gaps have come and gone over the years. For example, some district health boards (DHBs) prematurely restricted or stopped elective groin hernia surgery when early research initially indicated that it was safe to leave hernias until they became symptomatic.[[12]] However, with longer follow-up, research showed this policy increased the serious morbidity and mortality rates,[[13]] and so elective herniorrhaphy was reinstated by DHBs.

The CCHT has been able to react quickly to sudden changes in unmet needs, and it was able to set up counselling services within days of the Canterbury earthquakes and terror attacks.[[14,15]] It has been very well supported by the public, but also occasionally criticised as letting government off the hook. This criticism has been countered with the information that, without it, tens of thousands of patients would have gone without needed treatment, and that it is a sure reminder of the existence of USEHN.

Measuring unmet need

The lack of knowledge of the existence of USEHN by many people, and the absence of knowledge of its quantity and nature by everyone, led CCHT to assert the importance of regular independent measurement of USEHN by using population surveys. The resulting data would inform the public and the Government of the size and nature of unmet need, and also inform health planners of the effects of policy changes.[[16]] The NZ Health Survey has been measuring and reporting on unmet primary healthcare need for years, but it has never assessed USEHN.[[17]]

In 2015/16, CCHT brought together a national expert panel and, with financial support from other organisations, completed the first small population survey of USEHN in Auckland and Christchurch. This showed that around 9% of adults had an USEHN, for which they could not get treatment in the public healthcare system and could not afford private care.[[18]] It did not include those under 18 years old and also probably underestimated the unmet need for the most disadvantaged people, who are known to respond less frequently to such surveys. The private health sector did small internet-only surveys of USEHN in 2013 and 2016 with similar results.[[19]]

Having tested the methodology for measuring USEHN, CCHT’s expert group convinced two Ministers of Health of the desirability of having survey questions on the topic regularly included in the NZ Health Survey. Both Ministers instructed the Ministry of Health (MoH) to include such questions, but on each occasion the MoH avoided the task. It appears that the MoH did not want USEHN regularly and independently measured, even though this has been done in many very large surveys in Europe, North America and elsewhere.[[20]] Our expert group went on to make two applications to the Health Research Council for support for a comprehensive national population survey of USEHN, using well established procedures, but both were turned down for funding.

Where to next?

Recent governments may have pursued somewhat less overt neoliberal health policies but nevertheless the USEHN has continued to grow: the wealth gap has also become very large.[[21]] Māori, Pasifika, and those in poverty still have deplorable disadvantages in health and wellbeing, with unacceptably high rates of some chronic diseases, and with poor health intervention rates, treatment outcomes, and life expectancy.[[22]] These appalling statistics are due partly to poor access to health services but also to disadvantageous socio-economic determinants of health (poor nutrition, inadequate housing, insecure employment, inadequate welfare benefits).[[23]]

What are the answers to these problems with health and wellbeing? Firstly, the charity hospital movement is growing; a third is being built in Invercargill,[[24]] others are being considered or planned elsewhere, and a national association has been formed. They, along with many other not-for-profit charities, are doing good work to help fill some of the health and welfare gaps,[[25]] but their efforts cannot keep pace with the levels of unmet need. Current health restructuring might eventually bring some benefits; we must be optimistic that Te Whatu Ora/Health NZ and Te Aka Whai Ora/Māori Health Authority will work together to provide the leadership to reduce inequity.[[26]]

Second, if we believe in universal access to healthcare, with equity of outcome for all citizens, major policy shifts are needed. We must expunge the remaining remnants of neoliberal philosophy and policies, and reject more rationing of healthcare and welfare services. We need to acknowledge the results of massive international studies showing: (i) that widening income gaps are associated with larger health and social problems;[[27]] and (ii) that large financial dividends are achievable by moving from austerity to investment policies in health, education and welfare.[[28,29]]

Third, investment should be in human, physical and financial resources. We need to increase the numbers training as health professionals, and improve salaries and working conditions in order to retain trained and experienced staff.[[30,31]] Cultural differences need to be viewed as blessings and treasured, with stronger affirmative policies to train a more culturally representative health workforce.

Fourth, armed with better information about unmet health needs from regular national population surveys, a policy of proportionate universalism should be used to address inequities and lift standards of health and healthcare for all citizens.[[32–34]] This policy combines features of both targeting and universalism. Targeting ensures that extra resources go to the areas of greatest need, with the aim of achieving equal outcomes, while universalism directs resources for the welfare of all citizens, so that general standards are raised.

Significance of charity hospitals

Charity hospitals are important because they demonstrate every day the reality of unmet need and have worked to mitigate its impacts. The limited research available confirms this, but the reluctance of government to invest in research into unmet need is a clear failure of responsibility. Charity hospitals, with their professional and community commitment, are evidence of social capital of which we can be proud, but they are also symbols of the shame we all share in the inadequacy in our political decision-making.[[35]]

The longer we leave the current deplorable situation, the harder it will be to get us on a satisfactory track to improvement.

We need a better national story, with a sincere hope for a health and welfare system of which we can all be justly proud.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Philip Bagshaw: Chair, Canterbury Charity Hospital Trust, New Zealand. Pauline Barnett: School of Health Sciences, University of Canterbury, New Zealand. Susan Bagshaw: Trustee, Canterbury Charity Hospital Trust, New Zealand.

Acknowledgements

Correspondence

Philip Bagshaw: Chair, Canterbury Charity Hospital Trust, New Zealand.

Correspondence Email

p.s.bagshaw@gmail.com

Competing Interests

Nil.

1) Roper BS. Prosperity for All?: economic, social and political change in New Zealand since 1935. Southbank, Vic: Thomson/Dunmore Press, 2005.

2) Dew K, Cumming J, McLeod D, et al. Explicit rationing of elective services: implementing the New Zealand reforms. Health Policy. 2005 Sep 28;74(1):1-12. doi: 10.1016/j.healthpol.2004.12.011.

3) Campbell AV. Defining core health services: the New Zealand experience. Bioethics. 1995 Jul;9(3-4):252-8. doi: 10.1111/j.1467-8519.1995.tb00359.x.

4) Gauld R, Derrett S. Solving the surgical waiting list problem? New Zealand's 'booking system'. Int J Health Plann Manage. 2000 Oct-Dec;15(4):259-72. doi: 10.1002/hpm.596.

5) Feek CM, McKean W, Henneveld L, et al. Experience with rationing health care in New Zealand. BMJ. 1999 May 15;318(7194):1346-8. doi: 10.1136/bmj.318.7194.1346.

6) Timmins N, Ham C. The quest for integrated health and social care: A case study in Canterbury, New Zealand. The King’s Fund, 2013. [Accessed at: https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/quest-integrated-care-new-zealand-timmins-ham-sept13.pdf].

7) Barnett P, Bagshaw P. Neoliberalism: what it is, how it affects health and what to do about it. N Z Med J. 2020 Apr 3;133(1512):76-84.

8) Canterbury Health Limited: A Report by the Health and Disability Commissioner. April 1998. [Accessed at: https://www.hdc.org.nz/decisions/search-decisions/1998/report-on-canterbury-health-limited/].

9) Bagshaw P, Barnett P. Physician advocacy in Western medicine: a 21st century challenge. N Z Med J. 2017 Dec 1;130(1466):83-9.

10) Bagshaw PF, Allardyce RA, Bagshaw SN, et al. Patients "falling through the cracks". The Canterbury Charity Hospital: initial progress report. N Z Med J. 2010 Aug 13;123(1320):58-66.

11) Auckland Charity Hospital (ARCH). [Assessed at: https://www.healthpoint.co.nz/private/general-surgery/aotearoa-charity-hospital-arch/#:~:text=The%20Aotearoa%20Charity%20Hospital%20Trust,support%20necessary%20for%20private%20treatment.].

12) Bagshaw PF. What should be the management policy for asymptomatic inguinal hernias? N Z Med J. 2015 Mar 27;128(1411):83-8.

13) British Hernia Society. A dangerous waiting game? A review of patient access to inguinal hernia surgery in England. June 2018. [Accessed at: http://allcatsrgrey.org.uk/wp/download/commissioning/RCS-BHS-Hernia-Report-June-2018.pdf].

14) Bagshaw PF, Maimbo-M'siska M, Nicholls MG, et al. The Canterbury Charity Hospital: an update (2010-2012) and effects of the earthquakes. N Z Med J. 2013 Nov 22;126(1386):31-42.

15) Bagshaw P, Briggs L, Bagshaw S, et al. Update on Canterbury Charity Hospital Trust activities 2013 to end of 2020: adapting to changing unmet secondary elective healthcare need. N Z Med J. 2022 Apr 1;135:37-48.

16) Gauld R, Raymont A, Bagshaw PF, et al. The importance of measuring unmet healthcare needs. N Z Med J. 2014 Oct 17;127(1404):63-7.

17) The New Zealand Health Survey. Ministry of Health. Manatu Hauora. [Accessed at: https://www.health.govt.nz/nz-health-statistics/national-collections-and-surveys/surveys/new-zealand-health-survey].

18) Bagshaw P, Bagshaw S, Frampton C, et al. Pilot study of methods for assessing unmet secondary health care need in New Zealand. N Z Med J. 2017 Mar 24;130(1452):23-38.

19) Health Funds Association of New Zealand and Private Surgical Hospitals Association Inc. Assessing the demand for elective surgery amongst New Zealanders. September 2013. [Accessed at: https://www.scoop.co.nz/stories/GE1312/S00039/280000-new-zealanders-wait-for-public-surgery.htm and February 2016 https://www.scoop.co.nz/stories/PO1607/S00306/insurance-can-help-meet-surgical-shortfall-hfanz.htm].

20) Health at a Glance 2021. OECD Indicators. OECD Publications, Paris. [Accessed at: https://www.oecd-ilibrary.org/docserver/ae3016b9-en.pdf?expires=1660098988&id=id&accname=guest&checksum=003F35E0397A75315110E464A648F1A2].

21) Rashbrooke M. Too much Money: How wealth disparities are unbalancing Aotearoa New Zealand. 2021 Bridget Williams Books Ltd PO Box 12474 Wellington 6144, New Zealand.

22) Ministry of Health. Manatu Hauora. Health statistics and data sets: Statistical publications and data sets on a variety of health topics. [Accessed at: https://www.health.govt.nz/nz-health-statistics/health-statistics-and-data-sets].

23) Creating Solutions. Te Ata Whai Tika: A roadmap to health equity 2040. [Accessed at: https://issuu.com/associationofsalariedmedicalspecialists/docs/asms-creating-solutions-fa-web_-_final].

24) Southland Charity Hospital. [Accessed at: https://www.southlandcharityhospital.org/].

25) Chive 2021: Health and Wellbeing Charities New Zealand. [Accessed at: https://www.chivecharities.nz/charity-type/health-and-well-being].

26) Te Whatu Ora/Health New Zealand – Te Aka Whai Ora/Māori Health Authority. Update on the National Operating Model and High-Level Structure. [Accessed at: https://www.tewhatuora.govt.nz/assets/Uploads/Update-on-the-National-Operating-Model-and-High-Level-Structure.pdf].

27) Wilkinson R, Pickett K. The Spirit Level: Why equality is better for everyone. 2010 Penguin Books Ltd, 80 Strand, London WC2R ORL, England.

28) Reeves A, Basu S, McKee M, et al. Does investment in the health sector promote or inhibit economic growth? Global Health. 2013 Sep 23;9:43. doi: 10.1186/1744-8603-9-43.

29) Stuckler D, Basu S. The Body Economic: Eight experiments in economic recovery, from Iceland to Greece. 2013 Penguin Books Ltd, 80 Strand, London WC2R ORL, England.

30) Health Workforce Advisory Board. Annual Report to the Minister of Health. November 2020. [Accessed at: https://www.health.govt.nz/system/files/documents/publications/health-workforce-advisory-board-annual-report-11nov2020.pdf].

31) Why health workers are striking and leaving for better pay overseas. Vandhna Bhan. NZ TV1 News 16[[th]] May 2022. [Accessed at: https://www.1news.co.nz/2022/05/16/why-health-workers-are-striking-and-leaving-for-better-pay-overseas/].

32) Marmot M. Fair Societies, Healthy Lives. The Marmot Review Post-2010. [Accessed at: https://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review/fair-society-healthy-lives-full-report-pdf.pdf].

33) Carey G, Crammond B, De Leeuw E. Towards health equity: a framework for the application of proportionate universalism. Int J Equity Health. 2015 Sep 15;14:81. doi: 10.1186/s12939-015-0207-6.

34) Francis-Oliviero F, Cambon L, Wittwer J, et al. Theoretical and practical challenges of proportionate universalism: a review. Rev Panam Salud Publica. 2020 Oct 15;44:e110. doi: 10.26633/RPSP.2020.

35) Nicholls MG, Frampton CM, Bagshaw PF. Resurrecting New Zealand's public healthcare system or a charity hospital in every town? Intern Med J. 2020 Jul;50(7):883-6. doi: 10.1111/imj.14903.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

The story of the Aotearoa New Zealand health system is one of early optimism, some success and then disappointment at the failure of the public sector to respond to the needs of the community. Health and healthcare are very complicated, and we now understand the important links between health needs and other aspects of wellbeing.

The early story

In 1938, we led the world with the Social Security Act, which formed the basis of the first Labour government’s welfare programme. This was expected to introduce a national health service, with universal access to healthcare. However, from its origins it inherited two deficiencies: (i) partially private primary healthcare; and (ii) a Western-style system that did not address the needs of tangata whenua and other marginalised groups.

In Aotearoa New Zealand, with increasing prosperity in the first half of the 20th century, heavy investment in health meant that, despite underserving some groups and embedding health inequities, we climbed high among international health rankings. The economy then stagnated and, with soaring oil prices and high inflation starting in the 1970s, the downward trend in health investment began. From the late 1980s, successive governments introduced neoliberal policies that established destructive, managerialist processes and austerity budgeting.[[1]]

The Health Reforms in the 1990s (Health and Disability Services Act, 1993), created a pseudo-market for health services, attempting to use competition to drive efficiencies, and to use reduced funding as an incentive to ration services. Over the decade, a range of explicit rationing efforts were tried without success.[[2]] For example, part charges in hospitals in 1991 were abandoned in the face of public ridicule. The efforts of the Core Services Committee in 1992 to create a list of which services would be provided were similarly discarded.[[3]] The use of clinical guidelines as a method of healthcare rationing also proved impractical, so more devious methods were tried. For example, the National Waiting Time Project in 1998 used softer, more sanitised language: rationing was called prioritisation; waiting lists were referred to as waiting times; but no mention was made of the large numbers of patients who did not qualify for treatment under the newly introduced points scoring systems.[[4]] In this way, it was said, the public were slowly adjusting to the notion that rationing of healthcare was inevitable.[[5]] However, the process of denying patients the treatment they needed was referred to in health management documents by the harsh metaphor of “steps you can take to alter the trajectory of demand”.[[6]]

Under the neoliberal philosophy, austerity budgeting was applied to many aspects of healthcare.[[7]] Many of the most senior nurses at Christchurch Hospital were made redundant or were redeployed. This resulted in unsafe ward environments that led to a series of unnecessary patient deaths, culminating in the first major inquiry by the Health and Disability Commissioner, and what became widely known as the Stent Report of 1998.[[8]] This marked a minor win in a battle against the neoliberal reforms but did not seriously weaken the dominance of this philosophy within the Government.

It became ever more obvious to healthcare professionals that unmet need for both primary and secondary healthcare was growing; increasingly they had to inform patients that needed treatment that they would not qualify for inclusion on waiting lists. However, the health professionals’ own representative bodies were unable to effectively highlight and counter these growing problems.[[9]]

Enter the charity hospitals

The growing frustration at the lack of progress with these problems led, in 2004, to the formation of the Canterbury Charity Hospital Trust (CCHT).[[10]]

The aims of the Trust were to provide a dedicated day hospital to meet as much unmet secondary elective healthcare need (USEHN) as possible; to be exclusively funded by public, charitable giving, and to be largely staffed by volunteers. It was followed by the opening of the Auckland Charity Hospital (ARCH) in 2009.[[11]] This was organised differently, using downtime in existing private hospitals. However, both have provided purely reactive services by trying to fill the ever-changing gaps, where public hospitals do not provide some necessary secondary elective services. Some gaps, such as inadequate dental and women’s health services, have remained and have grown in size. Other gaps have come and gone over the years. For example, some district health boards (DHBs) prematurely restricted or stopped elective groin hernia surgery when early research initially indicated that it was safe to leave hernias until they became symptomatic.[[12]] However, with longer follow-up, research showed this policy increased the serious morbidity and mortality rates,[[13]] and so elective herniorrhaphy was reinstated by DHBs.

The CCHT has been able to react quickly to sudden changes in unmet needs, and it was able to set up counselling services within days of the Canterbury earthquakes and terror attacks.[[14,15]] It has been very well supported by the public, but also occasionally criticised as letting government off the hook. This criticism has been countered with the information that, without it, tens of thousands of patients would have gone without needed treatment, and that it is a sure reminder of the existence of USEHN.

Measuring unmet need

The lack of knowledge of the existence of USEHN by many people, and the absence of knowledge of its quantity and nature by everyone, led CCHT to assert the importance of regular independent measurement of USEHN by using population surveys. The resulting data would inform the public and the Government of the size and nature of unmet need, and also inform health planners of the effects of policy changes.[[16]] The NZ Health Survey has been measuring and reporting on unmet primary healthcare need for years, but it has never assessed USEHN.[[17]]

In 2015/16, CCHT brought together a national expert panel and, with financial support from other organisations, completed the first small population survey of USEHN in Auckland and Christchurch. This showed that around 9% of adults had an USEHN, for which they could not get treatment in the public healthcare system and could not afford private care.[[18]] It did not include those under 18 years old and also probably underestimated the unmet need for the most disadvantaged people, who are known to respond less frequently to such surveys. The private health sector did small internet-only surveys of USEHN in 2013 and 2016 with similar results.[[19]]

Having tested the methodology for measuring USEHN, CCHT’s expert group convinced two Ministers of Health of the desirability of having survey questions on the topic regularly included in the NZ Health Survey. Both Ministers instructed the Ministry of Health (MoH) to include such questions, but on each occasion the MoH avoided the task. It appears that the MoH did not want USEHN regularly and independently measured, even though this has been done in many very large surveys in Europe, North America and elsewhere.[[20]] Our expert group went on to make two applications to the Health Research Council for support for a comprehensive national population survey of USEHN, using well established procedures, but both were turned down for funding.

Where to next?

Recent governments may have pursued somewhat less overt neoliberal health policies but nevertheless the USEHN has continued to grow: the wealth gap has also become very large.[[21]] Māori, Pasifika, and those in poverty still have deplorable disadvantages in health and wellbeing, with unacceptably high rates of some chronic diseases, and with poor health intervention rates, treatment outcomes, and life expectancy.[[22]] These appalling statistics are due partly to poor access to health services but also to disadvantageous socio-economic determinants of health (poor nutrition, inadequate housing, insecure employment, inadequate welfare benefits).[[23]]

What are the answers to these problems with health and wellbeing? Firstly, the charity hospital movement is growing; a third is being built in Invercargill,[[24]] others are being considered or planned elsewhere, and a national association has been formed. They, along with many other not-for-profit charities, are doing good work to help fill some of the health and welfare gaps,[[25]] but their efforts cannot keep pace with the levels of unmet need. Current health restructuring might eventually bring some benefits; we must be optimistic that Te Whatu Ora/Health NZ and Te Aka Whai Ora/Māori Health Authority will work together to provide the leadership to reduce inequity.[[26]]

Second, if we believe in universal access to healthcare, with equity of outcome for all citizens, major policy shifts are needed. We must expunge the remaining remnants of neoliberal philosophy and policies, and reject more rationing of healthcare and welfare services. We need to acknowledge the results of massive international studies showing: (i) that widening income gaps are associated with larger health and social problems;[[27]] and (ii) that large financial dividends are achievable by moving from austerity to investment policies in health, education and welfare.[[28,29]]

Third, investment should be in human, physical and financial resources. We need to increase the numbers training as health professionals, and improve salaries and working conditions in order to retain trained and experienced staff.[[30,31]] Cultural differences need to be viewed as blessings and treasured, with stronger affirmative policies to train a more culturally representative health workforce.

Fourth, armed with better information about unmet health needs from regular national population surveys, a policy of proportionate universalism should be used to address inequities and lift standards of health and healthcare for all citizens.[[32–34]] This policy combines features of both targeting and universalism. Targeting ensures that extra resources go to the areas of greatest need, with the aim of achieving equal outcomes, while universalism directs resources for the welfare of all citizens, so that general standards are raised.

Significance of charity hospitals

Charity hospitals are important because they demonstrate every day the reality of unmet need and have worked to mitigate its impacts. The limited research available confirms this, but the reluctance of government to invest in research into unmet need is a clear failure of responsibility. Charity hospitals, with their professional and community commitment, are evidence of social capital of which we can be proud, but they are also symbols of the shame we all share in the inadequacy in our political decision-making.[[35]]

The longer we leave the current deplorable situation, the harder it will be to get us on a satisfactory track to improvement.

We need a better national story, with a sincere hope for a health and welfare system of which we can all be justly proud.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Philip Bagshaw: Chair, Canterbury Charity Hospital Trust, New Zealand. Pauline Barnett: School of Health Sciences, University of Canterbury, New Zealand. Susan Bagshaw: Trustee, Canterbury Charity Hospital Trust, New Zealand.

Acknowledgements

Correspondence

Philip Bagshaw: Chair, Canterbury Charity Hospital Trust, New Zealand.

Correspondence Email

p.s.bagshaw@gmail.com

Competing Interests

Nil.

1) Roper BS. Prosperity for All?: economic, social and political change in New Zealand since 1935. Southbank, Vic: Thomson/Dunmore Press, 2005.

2) Dew K, Cumming J, McLeod D, et al. Explicit rationing of elective services: implementing the New Zealand reforms. Health Policy. 2005 Sep 28;74(1):1-12. doi: 10.1016/j.healthpol.2004.12.011.

3) Campbell AV. Defining core health services: the New Zealand experience. Bioethics. 1995 Jul;9(3-4):252-8. doi: 10.1111/j.1467-8519.1995.tb00359.x.

4) Gauld R, Derrett S. Solving the surgical waiting list problem? New Zealand's 'booking system'. Int J Health Plann Manage. 2000 Oct-Dec;15(4):259-72. doi: 10.1002/hpm.596.

5) Feek CM, McKean W, Henneveld L, et al. Experience with rationing health care in New Zealand. BMJ. 1999 May 15;318(7194):1346-8. doi: 10.1136/bmj.318.7194.1346.

6) Timmins N, Ham C. The quest for integrated health and social care: A case study in Canterbury, New Zealand. The King’s Fund, 2013. [Accessed at: https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/quest-integrated-care-new-zealand-timmins-ham-sept13.pdf].

7) Barnett P, Bagshaw P. Neoliberalism: what it is, how it affects health and what to do about it. N Z Med J. 2020 Apr 3;133(1512):76-84.

8) Canterbury Health Limited: A Report by the Health and Disability Commissioner. April 1998. [Accessed at: https://www.hdc.org.nz/decisions/search-decisions/1998/report-on-canterbury-health-limited/].

9) Bagshaw P, Barnett P. Physician advocacy in Western medicine: a 21st century challenge. N Z Med J. 2017 Dec 1;130(1466):83-9.

10) Bagshaw PF, Allardyce RA, Bagshaw SN, et al. Patients "falling through the cracks". The Canterbury Charity Hospital: initial progress report. N Z Med J. 2010 Aug 13;123(1320):58-66.

11) Auckland Charity Hospital (ARCH). [Assessed at: https://www.healthpoint.co.nz/private/general-surgery/aotearoa-charity-hospital-arch/#:~:text=The%20Aotearoa%20Charity%20Hospital%20Trust,support%20necessary%20for%20private%20treatment.].

12) Bagshaw PF. What should be the management policy for asymptomatic inguinal hernias? N Z Med J. 2015 Mar 27;128(1411):83-8.

13) British Hernia Society. A dangerous waiting game? A review of patient access to inguinal hernia surgery in England. June 2018. [Accessed at: http://allcatsrgrey.org.uk/wp/download/commissioning/RCS-BHS-Hernia-Report-June-2018.pdf].

14) Bagshaw PF, Maimbo-M'siska M, Nicholls MG, et al. The Canterbury Charity Hospital: an update (2010-2012) and effects of the earthquakes. N Z Med J. 2013 Nov 22;126(1386):31-42.

15) Bagshaw P, Briggs L, Bagshaw S, et al. Update on Canterbury Charity Hospital Trust activities 2013 to end of 2020: adapting to changing unmet secondary elective healthcare need. N Z Med J. 2022 Apr 1;135:37-48.

16) Gauld R, Raymont A, Bagshaw PF, et al. The importance of measuring unmet healthcare needs. N Z Med J. 2014 Oct 17;127(1404):63-7.

17) The New Zealand Health Survey. Ministry of Health. Manatu Hauora. [Accessed at: https://www.health.govt.nz/nz-health-statistics/national-collections-and-surveys/surveys/new-zealand-health-survey].

18) Bagshaw P, Bagshaw S, Frampton C, et al. Pilot study of methods for assessing unmet secondary health care need in New Zealand. N Z Med J. 2017 Mar 24;130(1452):23-38.

19) Health Funds Association of New Zealand and Private Surgical Hospitals Association Inc. Assessing the demand for elective surgery amongst New Zealanders. September 2013. [Accessed at: https://www.scoop.co.nz/stories/GE1312/S00039/280000-new-zealanders-wait-for-public-surgery.htm and February 2016 https://www.scoop.co.nz/stories/PO1607/S00306/insurance-can-help-meet-surgical-shortfall-hfanz.htm].

20) Health at a Glance 2021. OECD Indicators. OECD Publications, Paris. [Accessed at: https://www.oecd-ilibrary.org/docserver/ae3016b9-en.pdf?expires=1660098988&id=id&accname=guest&checksum=003F35E0397A75315110E464A648F1A2].

21) Rashbrooke M. Too much Money: How wealth disparities are unbalancing Aotearoa New Zealand. 2021 Bridget Williams Books Ltd PO Box 12474 Wellington 6144, New Zealand.

22) Ministry of Health. Manatu Hauora. Health statistics and data sets: Statistical publications and data sets on a variety of health topics. [Accessed at: https://www.health.govt.nz/nz-health-statistics/health-statistics-and-data-sets].

23) Creating Solutions. Te Ata Whai Tika: A roadmap to health equity 2040. [Accessed at: https://issuu.com/associationofsalariedmedicalspecialists/docs/asms-creating-solutions-fa-web_-_final].

24) Southland Charity Hospital. [Accessed at: https://www.southlandcharityhospital.org/].

25) Chive 2021: Health and Wellbeing Charities New Zealand. [Accessed at: https://www.chivecharities.nz/charity-type/health-and-well-being].

26) Te Whatu Ora/Health New Zealand – Te Aka Whai Ora/Māori Health Authority. Update on the National Operating Model and High-Level Structure. [Accessed at: https://www.tewhatuora.govt.nz/assets/Uploads/Update-on-the-National-Operating-Model-and-High-Level-Structure.pdf].

27) Wilkinson R, Pickett K. The Spirit Level: Why equality is better for everyone. 2010 Penguin Books Ltd, 80 Strand, London WC2R ORL, England.

28) Reeves A, Basu S, McKee M, et al. Does investment in the health sector promote or inhibit economic growth? Global Health. 2013 Sep 23;9:43. doi: 10.1186/1744-8603-9-43.

29) Stuckler D, Basu S. The Body Economic: Eight experiments in economic recovery, from Iceland to Greece. 2013 Penguin Books Ltd, 80 Strand, London WC2R ORL, England.

30) Health Workforce Advisory Board. Annual Report to the Minister of Health. November 2020. [Accessed at: https://www.health.govt.nz/system/files/documents/publications/health-workforce-advisory-board-annual-report-11nov2020.pdf].

31) Why health workers are striking and leaving for better pay overseas. Vandhna Bhan. NZ TV1 News 16[[th]] May 2022. [Accessed at: https://www.1news.co.nz/2022/05/16/why-health-workers-are-striking-and-leaving-for-better-pay-overseas/].

32) Marmot M. Fair Societies, Healthy Lives. The Marmot Review Post-2010. [Accessed at: https://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review/fair-society-healthy-lives-full-report-pdf.pdf].

33) Carey G, Crammond B, De Leeuw E. Towards health equity: a framework for the application of proportionate universalism. Int J Equity Health. 2015 Sep 15;14:81. doi: 10.1186/s12939-015-0207-6.

34) Francis-Oliviero F, Cambon L, Wittwer J, et al. Theoretical and practical challenges of proportionate universalism: a review. Rev Panam Salud Publica. 2020 Oct 15;44:e110. doi: 10.26633/RPSP.2020.

35) Nicholls MG, Frampton CM, Bagshaw PF. Resurrecting New Zealand's public healthcare system or a charity hospital in every town? Intern Med J. 2020 Jul;50(7):883-6. doi: 10.1111/imj.14903.

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The story of the Aotearoa New Zealand health system is one of early optimism, some success and then disappointment at the failure of the public sector to respond to the needs of the community. Health and healthcare are very complicated, and we now understand the important links between health needs and other aspects of wellbeing.

The early story

In 1938, we led the world with the Social Security Act, which formed the basis of the first Labour government’s welfare programme. This was expected to introduce a national health service, with universal access to healthcare. However, from its origins it inherited two deficiencies: (i) partially private primary healthcare; and (ii) a Western-style system that did not address the needs of tangata whenua and other marginalised groups.

In Aotearoa New Zealand, with increasing prosperity in the first half of the 20th century, heavy investment in health meant that, despite underserving some groups and embedding health inequities, we climbed high among international health rankings. The economy then stagnated and, with soaring oil prices and high inflation starting in the 1970s, the downward trend in health investment began. From the late 1980s, successive governments introduced neoliberal policies that established destructive, managerialist processes and austerity budgeting.[[1]]

The Health Reforms in the 1990s (Health and Disability Services Act, 1993), created a pseudo-market for health services, attempting to use competition to drive efficiencies, and to use reduced funding as an incentive to ration services. Over the decade, a range of explicit rationing efforts were tried without success.[[2]] For example, part charges in hospitals in 1991 were abandoned in the face of public ridicule. The efforts of the Core Services Committee in 1992 to create a list of which services would be provided were similarly discarded.[[3]] The use of clinical guidelines as a method of healthcare rationing also proved impractical, so more devious methods were tried. For example, the National Waiting Time Project in 1998 used softer, more sanitised language: rationing was called prioritisation; waiting lists were referred to as waiting times; but no mention was made of the large numbers of patients who did not qualify for treatment under the newly introduced points scoring systems.[[4]] In this way, it was said, the public were slowly adjusting to the notion that rationing of healthcare was inevitable.[[5]] However, the process of denying patients the treatment they needed was referred to in health management documents by the harsh metaphor of “steps you can take to alter the trajectory of demand”.[[6]]

Under the neoliberal philosophy, austerity budgeting was applied to many aspects of healthcare.[[7]] Many of the most senior nurses at Christchurch Hospital were made redundant or were redeployed. This resulted in unsafe ward environments that led to a series of unnecessary patient deaths, culminating in the first major inquiry by the Health and Disability Commissioner, and what became widely known as the Stent Report of 1998.[[8]] This marked a minor win in a battle against the neoliberal reforms but did not seriously weaken the dominance of this philosophy within the Government.

It became ever more obvious to healthcare professionals that unmet need for both primary and secondary healthcare was growing; increasingly they had to inform patients that needed treatment that they would not qualify for inclusion on waiting lists. However, the health professionals’ own representative bodies were unable to effectively highlight and counter these growing problems.[[9]]

Enter the charity hospitals

The growing frustration at the lack of progress with these problems led, in 2004, to the formation of the Canterbury Charity Hospital Trust (CCHT).[[10]]

The aims of the Trust were to provide a dedicated day hospital to meet as much unmet secondary elective healthcare need (USEHN) as possible; to be exclusively funded by public, charitable giving, and to be largely staffed by volunteers. It was followed by the opening of the Auckland Charity Hospital (ARCH) in 2009.[[11]] This was organised differently, using downtime in existing private hospitals. However, both have provided purely reactive services by trying to fill the ever-changing gaps, where public hospitals do not provide some necessary secondary elective services. Some gaps, such as inadequate dental and women’s health services, have remained and have grown in size. Other gaps have come and gone over the years. For example, some district health boards (DHBs) prematurely restricted or stopped elective groin hernia surgery when early research initially indicated that it was safe to leave hernias until they became symptomatic.[[12]] However, with longer follow-up, research showed this policy increased the serious morbidity and mortality rates,[[13]] and so elective herniorrhaphy was reinstated by DHBs.

The CCHT has been able to react quickly to sudden changes in unmet needs, and it was able to set up counselling services within days of the Canterbury earthquakes and terror attacks.[[14,15]] It has been very well supported by the public, but also occasionally criticised as letting government off the hook. This criticism has been countered with the information that, without it, tens of thousands of patients would have gone without needed treatment, and that it is a sure reminder of the existence of USEHN.

Measuring unmet need

The lack of knowledge of the existence of USEHN by many people, and the absence of knowledge of its quantity and nature by everyone, led CCHT to assert the importance of regular independent measurement of USEHN by using population surveys. The resulting data would inform the public and the Government of the size and nature of unmet need, and also inform health planners of the effects of policy changes.[[16]] The NZ Health Survey has been measuring and reporting on unmet primary healthcare need for years, but it has never assessed USEHN.[[17]]

In 2015/16, CCHT brought together a national expert panel and, with financial support from other organisations, completed the first small population survey of USEHN in Auckland and Christchurch. This showed that around 9% of adults had an USEHN, for which they could not get treatment in the public healthcare system and could not afford private care.[[18]] It did not include those under 18 years old and also probably underestimated the unmet need for the most disadvantaged people, who are known to respond less frequently to such surveys. The private health sector did small internet-only surveys of USEHN in 2013 and 2016 with similar results.[[19]]

Having tested the methodology for measuring USEHN, CCHT’s expert group convinced two Ministers of Health of the desirability of having survey questions on the topic regularly included in the NZ Health Survey. Both Ministers instructed the Ministry of Health (MoH) to include such questions, but on each occasion the MoH avoided the task. It appears that the MoH did not want USEHN regularly and independently measured, even though this has been done in many very large surveys in Europe, North America and elsewhere.[[20]] Our expert group went on to make two applications to the Health Research Council for support for a comprehensive national population survey of USEHN, using well established procedures, but both were turned down for funding.

Where to next?

Recent governments may have pursued somewhat less overt neoliberal health policies but nevertheless the USEHN has continued to grow: the wealth gap has also become very large.[[21]] Māori, Pasifika, and those in poverty still have deplorable disadvantages in health and wellbeing, with unacceptably high rates of some chronic diseases, and with poor health intervention rates, treatment outcomes, and life expectancy.[[22]] These appalling statistics are due partly to poor access to health services but also to disadvantageous socio-economic determinants of health (poor nutrition, inadequate housing, insecure employment, inadequate welfare benefits).[[23]]

What are the answers to these problems with health and wellbeing? Firstly, the charity hospital movement is growing; a third is being built in Invercargill,[[24]] others are being considered or planned elsewhere, and a national association has been formed. They, along with many other not-for-profit charities, are doing good work to help fill some of the health and welfare gaps,[[25]] but their efforts cannot keep pace with the levels of unmet need. Current health restructuring might eventually bring some benefits; we must be optimistic that Te Whatu Ora/Health NZ and Te Aka Whai Ora/Māori Health Authority will work together to provide the leadership to reduce inequity.[[26]]

Second, if we believe in universal access to healthcare, with equity of outcome for all citizens, major policy shifts are needed. We must expunge the remaining remnants of neoliberal philosophy and policies, and reject more rationing of healthcare and welfare services. We need to acknowledge the results of massive international studies showing: (i) that widening income gaps are associated with larger health and social problems;[[27]] and (ii) that large financial dividends are achievable by moving from austerity to investment policies in health, education and welfare.[[28,29]]

Third, investment should be in human, physical and financial resources. We need to increase the numbers training as health professionals, and improve salaries and working conditions in order to retain trained and experienced staff.[[30,31]] Cultural differences need to be viewed as blessings and treasured, with stronger affirmative policies to train a more culturally representative health workforce.

Fourth, armed with better information about unmet health needs from regular national population surveys, a policy of proportionate universalism should be used to address inequities and lift standards of health and healthcare for all citizens.[[32–34]] This policy combines features of both targeting and universalism. Targeting ensures that extra resources go to the areas of greatest need, with the aim of achieving equal outcomes, while universalism directs resources for the welfare of all citizens, so that general standards are raised.

Significance of charity hospitals

Charity hospitals are important because they demonstrate every day the reality of unmet need and have worked to mitigate its impacts. The limited research available confirms this, but the reluctance of government to invest in research into unmet need is a clear failure of responsibility. Charity hospitals, with their professional and community commitment, are evidence of social capital of which we can be proud, but they are also symbols of the shame we all share in the inadequacy in our political decision-making.[[35]]

The longer we leave the current deplorable situation, the harder it will be to get us on a satisfactory track to improvement.

We need a better national story, with a sincere hope for a health and welfare system of which we can all be justly proud.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Philip Bagshaw: Chair, Canterbury Charity Hospital Trust, New Zealand. Pauline Barnett: School of Health Sciences, University of Canterbury, New Zealand. Susan Bagshaw: Trustee, Canterbury Charity Hospital Trust, New Zealand.

Acknowledgements

Correspondence

Philip Bagshaw: Chair, Canterbury Charity Hospital Trust, New Zealand.

Correspondence Email

p.s.bagshaw@gmail.com

Competing Interests

Nil.

1) Roper BS. Prosperity for All?: economic, social and political change in New Zealand since 1935. Southbank, Vic: Thomson/Dunmore Press, 2005.

2) Dew K, Cumming J, McLeod D, et al. Explicit rationing of elective services: implementing the New Zealand reforms. Health Policy. 2005 Sep 28;74(1):1-12. doi: 10.1016/j.healthpol.2004.12.011.

3) Campbell AV. Defining core health services: the New Zealand experience. Bioethics. 1995 Jul;9(3-4):252-8. doi: 10.1111/j.1467-8519.1995.tb00359.x.

4) Gauld R, Derrett S. Solving the surgical waiting list problem? New Zealand's 'booking system'. Int J Health Plann Manage. 2000 Oct-Dec;15(4):259-72. doi: 10.1002/hpm.596.

5) Feek CM, McKean W, Henneveld L, et al. Experience with rationing health care in New Zealand. BMJ. 1999 May 15;318(7194):1346-8. doi: 10.1136/bmj.318.7194.1346.

6) Timmins N, Ham C. The quest for integrated health and social care: A case study in Canterbury, New Zealand. The King’s Fund, 2013. [Accessed at: https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/quest-integrated-care-new-zealand-timmins-ham-sept13.pdf].

7) Barnett P, Bagshaw P. Neoliberalism: what it is, how it affects health and what to do about it. N Z Med J. 2020 Apr 3;133(1512):76-84.

8) Canterbury Health Limited: A Report by the Health and Disability Commissioner. April 1998. [Accessed at: https://www.hdc.org.nz/decisions/search-decisions/1998/report-on-canterbury-health-limited/].

9) Bagshaw P, Barnett P. Physician advocacy in Western medicine: a 21st century challenge. N Z Med J. 2017 Dec 1;130(1466):83-9.

10) Bagshaw PF, Allardyce RA, Bagshaw SN, et al. Patients "falling through the cracks". The Canterbury Charity Hospital: initial progress report. N Z Med J. 2010 Aug 13;123(1320):58-66.

11) Auckland Charity Hospital (ARCH). [Assessed at: https://www.healthpoint.co.nz/private/general-surgery/aotearoa-charity-hospital-arch/#:~:text=The%20Aotearoa%20Charity%20Hospital%20Trust,support%20necessary%20for%20private%20treatment.].

12) Bagshaw PF. What should be the management policy for asymptomatic inguinal hernias? N Z Med J. 2015 Mar 27;128(1411):83-8.

13) British Hernia Society. A dangerous waiting game? A review of patient access to inguinal hernia surgery in England. June 2018. [Accessed at: http://allcatsrgrey.org.uk/wp/download/commissioning/RCS-BHS-Hernia-Report-June-2018.pdf].

14) Bagshaw PF, Maimbo-M'siska M, Nicholls MG, et al. The Canterbury Charity Hospital: an update (2010-2012) and effects of the earthquakes. N Z Med J. 2013 Nov 22;126(1386):31-42.

15) Bagshaw P, Briggs L, Bagshaw S, et al. Update on Canterbury Charity Hospital Trust activities 2013 to end of 2020: adapting to changing unmet secondary elective healthcare need. N Z Med J. 2022 Apr 1;135:37-48.

16) Gauld R, Raymont A, Bagshaw PF, et al. The importance of measuring unmet healthcare needs. N Z Med J. 2014 Oct 17;127(1404):63-7.

17) The New Zealand Health Survey. Ministry of Health. Manatu Hauora. [Accessed at: https://www.health.govt.nz/nz-health-statistics/national-collections-and-surveys/surveys/new-zealand-health-survey].

18) Bagshaw P, Bagshaw S, Frampton C, et al. Pilot study of methods for assessing unmet secondary health care need in New Zealand. N Z Med J. 2017 Mar 24;130(1452):23-38.

19) Health Funds Association of New Zealand and Private Surgical Hospitals Association Inc. Assessing the demand for elective surgery amongst New Zealanders. September 2013. [Accessed at: https://www.scoop.co.nz/stories/GE1312/S00039/280000-new-zealanders-wait-for-public-surgery.htm and February 2016 https://www.scoop.co.nz/stories/PO1607/S00306/insurance-can-help-meet-surgical-shortfall-hfanz.htm].

20) Health at a Glance 2021. OECD Indicators. OECD Publications, Paris. [Accessed at: https://www.oecd-ilibrary.org/docserver/ae3016b9-en.pdf?expires=1660098988&id=id&accname=guest&checksum=003F35E0397A75315110E464A648F1A2].

21) Rashbrooke M. Too much Money: How wealth disparities are unbalancing Aotearoa New Zealand. 2021 Bridget Williams Books Ltd PO Box 12474 Wellington 6144, New Zealand.

22) Ministry of Health. Manatu Hauora. Health statistics and data sets: Statistical publications and data sets on a variety of health topics. [Accessed at: https://www.health.govt.nz/nz-health-statistics/health-statistics-and-data-sets].

23) Creating Solutions. Te Ata Whai Tika: A roadmap to health equity 2040. [Accessed at: https://issuu.com/associationofsalariedmedicalspecialists/docs/asms-creating-solutions-fa-web_-_final].

24) Southland Charity Hospital. [Accessed at: https://www.southlandcharityhospital.org/].

25) Chive 2021: Health and Wellbeing Charities New Zealand. [Accessed at: https://www.chivecharities.nz/charity-type/health-and-well-being].

26) Te Whatu Ora/Health New Zealand – Te Aka Whai Ora/Māori Health Authority. Update on the National Operating Model and High-Level Structure. [Accessed at: https://www.tewhatuora.govt.nz/assets/Uploads/Update-on-the-National-Operating-Model-and-High-Level-Structure.pdf].

27) Wilkinson R, Pickett K. The Spirit Level: Why equality is better for everyone. 2010 Penguin Books Ltd, 80 Strand, London WC2R ORL, England.

28) Reeves A, Basu S, McKee M, et al. Does investment in the health sector promote or inhibit economic growth? Global Health. 2013 Sep 23;9:43. doi: 10.1186/1744-8603-9-43.

29) Stuckler D, Basu S. The Body Economic: Eight experiments in economic recovery, from Iceland to Greece. 2013 Penguin Books Ltd, 80 Strand, London WC2R ORL, England.

30) Health Workforce Advisory Board. Annual Report to the Minister of Health. November 2020. [Accessed at: https://www.health.govt.nz/system/files/documents/publications/health-workforce-advisory-board-annual-report-11nov2020.pdf].

31) Why health workers are striking and leaving for better pay overseas. Vandhna Bhan. NZ TV1 News 16[[th]] May 2022. [Accessed at: https://www.1news.co.nz/2022/05/16/why-health-workers-are-striking-and-leaving-for-better-pay-overseas/].

32) Marmot M. Fair Societies, Healthy Lives. The Marmot Review Post-2010. [Accessed at: https://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review/fair-society-healthy-lives-full-report-pdf.pdf].

33) Carey G, Crammond B, De Leeuw E. Towards health equity: a framework for the application of proportionate universalism. Int J Equity Health. 2015 Sep 15;14:81. doi: 10.1186/s12939-015-0207-6.

34) Francis-Oliviero F, Cambon L, Wittwer J, et al. Theoretical and practical challenges of proportionate universalism: a review. Rev Panam Salud Publica. 2020 Oct 15;44:e110. doi: 10.26633/RPSP.2020.

35) Nicholls MG, Frampton CM, Bagshaw PF. Resurrecting New Zealand's public healthcare system or a charity hospital in every town? Intern Med J. 2020 Jul;50(7):883-6. doi: 10.1111/imj.14903.

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