One of the Labour Party's most effective advertisements of the 1972 Election Campaign was on the Health Service, showing a young family with a sick child trying to contact a doctor. The caption underneath was the answerphone's reply: 'The doctor is unavailable ...' Recent ads. showing the genial face of Tom McGuigan have asked: 'How long have you had to wait for a doctor?' Bob Tizard's Budget this year (p22) stated: 'When the Government took office in 1972, it inherited health services which had been allowed to run down in earlier years... the whole structure of health care was in need of an overhaul'.

These ideas are pushed hard in the Government's recent White Paper entitled. 'A Health Service for New Zealand', which Bob Tizard has described as 'a comprehensive review of all aspects of health care', while various other people (eg. the National Party and various doctors) have attacked the plan on grounds ranging from 'creeping socialism' to 'interfering with the relationship between the patient and the doctor'.

As far as most of the public is concerned, however, the White Paper is a bit of a non-starter. Despite various plans for feedback, there has not been much discussion or comment, possibly because most people (quite sensibly) don't feel like wading through 180 pages of turgid prose and another 110 of statistics and tables (including a 35 page comparison of the Hospital Acts of 1885, 1909, 1926 and 1957). And that's one of the bad things about this White Paper — its very difficult to read. 620 paragraphs wind their way backwards and forwards, often recovering ground (see later on private health proposals), nearly always in an uninteresting style.

History of NZ Health

The first seven chapters of the book, paragraphs 1 through to 208, give a general history of the development of NZ's health service. It's an interesting history, basically cuting on the chaotic and rather disjoined health system NZ has insisted on developing.

Our story starts with the early provision of health care facilities, especially 'lunatic asylums' and health legislation (eg. vaccination against smallpox) by the state. The Hospitals and Charitable Institutions Act of 1885 provided the first attempt to rationalise what was happening, and provide guidelines for government subsidies for public hospital fund raising. The stress in this period, one the Paper contends still exists in private health care, is a curative rather than a preventive medicine. At this stage, one starts to suspect where the accent of the Government's thinking is — on administration.

Moving through various insufficient attemps at reforming the Public Health and Hospitals set up we arrive at the fifth summary, chapter on Towards Social Security' which is probably the best of the book, giving a summary of the creep of 'creeping socialism' up to 1938. The 1938 Social Security Act is then looked at, and the retreat from principles of free State medicine is detailed: 'Eventually the Government compromised in order to get some scheme working' (p48) due to the intransigence of the medical profession. This group comes for quite a bit of criticism. 'Social security failed to produce an integrated health service because it left such a large amount of health care in the hands of private practitioners and private hospitals.' (p50.1). The development of private hospitals and practices since 1938, especially marked under the Holland and Holyoake administrations is considered. The great rationale for this was that each bed subsidised in private hospitals was one less for the public sector to provide. The White Paper often makes the point that in fact this is not fully true — the one more bed made available is essentially a bed for the wealthy (and those who are members of medical insurance groups, which often comes to the same thing). Lower class people miss out. There are other considerations — as the 1972 Royal Commission on Social Security noted, the existence of [unclear: com] petition with the public sector [unclear: means] 'there must be a consequent drain [unclear: of] personnel (and resources) from the [unclear: p] hospitals.' The growth of medical [unclear: in] urance is seen in itself as a sign of [unclear: di] satisfaction with the Public Health [unclear: Se] vice. The historical section is closed with a long and boring chapter on hospital financing.

Diagram 1. Proposed New Health Administration Set-Up.

Changes

Chapters VIII (The Need for Change) and IX (Principles for [unclear: Chang] cover a broad area of principles in [unclear: w] detail. Some comments are very [unclear: pen] tive: 'the fragmented pattern of health care delivery means that NZ lacks a national health service', 'middle class areas tend to be relatively over [unclear: provide] with general practitioners, while [unclear: some] other areas are often characterised [unclear: by] a shortage', 'in certain areas, it is [unclear: ai] impossible to secure the services of [unclear: a] general practitioner, even in an [unclear: emer] the low state of public specialist [unclear: serv] and of public health programmes. [unclear: 'pa] chial planning', 'the absence of [unclear: co-op] ated planning', and 'administrative [unclear: con] fusion' add to the sorry picture.

To attack these problems, the [unclear: gov] ernment proposes three principles:-that the community has a [unclear: responsible] for health care, that the [unclear: administration] should be connected with sources of [unclear: a] ce, that health services should be [unclear: ade] tered to 'be capable of meeting the [unclear: d] needs of the community'. From [unclear: here] in the emphasis is very clearly on [unclear: adr] tration and reorganisation. The [unclear: prop] plan is in diagram 1.

This diagram is reasonably [unclear: sim] to understand — or at least it seems [unclear: t] way. It must be more complicated [unclear: f] thought, because it takes six chapters 272 paragraphs and 72 pages to [unclear: des] it. Admittedly I got bored half-way and started skipping things, but most the details seemed 1 trivial and 2 [unclear: bor] and 3 missing major points. The [unclear: g] drift of the proposals is greater [unclear: Gover] ment control over what happens to [unclear: c] (in this order) value for money and [unclear: r] ional planning approach to health [unclear: care]

One could spend a lot of [unclear: time] criticising the details of the [unclear: proposals] such as the lack of scope for medical staff representatives on the various Health authority committees, but [unclear: me] of these areas will undoubtedly be page 9 covered by the groups concerned in their submissions. As far as the general public is concerned probably the most important sector is the provision of general practitioners, and the relationships between private and public health care.

Public Versus Private Health Care

On page 119 the reader finds 'Methods of Remuneration' — or 'Who pays for the doctor?' There are six alternatives: totally private practice; the present system (i.e. fee for service) with or without patient contributions; a contract scheme (where each GP would 'contract' with the RHA for a list of patients — which would seem to present problems if you want to change doctors) with or without charges to patients; and a salary system, giving free medical services and set salaries for doctors, regardless of services. While there are plans for all shades of opinion to be heard, the Government's thinking is obviously on a contract system which seems too restrictive to me, the salary idea being far better. It is a large issue though, which can't really be gone into here.

It would appear from all these kites flying in the wind that Labour is sort of committed to reviewing private hospitals, but the entire atmosphere is such a tenuous, almost nebulous one, that pretty well anything could happen.

What is Left Out

There is nothing in the proposals worth criticising half as much as that left out. After stating, 'staff are the most most important single resource in the health service' (p169), the bureaucracy machine ignores this point almost completely. The issues of training of doctors (what about a [unclear: third] medical school, or rapidly expanding one of the present ones?), the complex and controversial nature of nursing training (seen by many as archaic, patronising and degrading), and the general question of working conditions are scarcely touched on. We noted above the lack of room on RHA's for staff representatives — a lack that must surely be rectified. There have been complaints from staff organisations about lack of appreciation of their efforts by health authorities — the White Paper mentions nothing of these. There is a strong case for the idea that many medical staff prefer private hospitals because of the less bureaucratic atmosphere — again no response from the White Paper.

There is a strong belief in NZ that private hospitals are more efficient (in terms of providing care per dollar) than are private ones. While the social implications of private hospitals (many favouring the rich) must be borne in mind mind, if this belief is correct, it poses various questions that should be faced up to. Especially necessary is an investigation of why public hospitals are inefficient — an investigation that is surely vital before any nationalisation of the private hospitals takes place. Such an investigation, sadly, has no place in the White Paper.

And what of medical innovation such as the Remuera Abortion Clinic? One suspects that these will become engulfed by the deadening bureaucracy envisaged by the likes of Dr. Wall. And how about the abysmal medical services in Porirua? When he suggestes rationalisation of hospital boards, does the Minister overlook the dearth of services supplied by the mammoth Wellington Hospital Board here?

Conclusion

Health services must serve the people — there can be little justification for them if they cannot. Proposals for reform, for rebuilding the Health services in this country, are beneficial insofar as they improve the services people get — and that is the only criteria they can be judged upon. Bureaucracy for bureaucracy's sake when Peoples' lives are at stake is crass and callous stupidity. Yet that is what the White Paper comes close to at times. There is a commendable set of principles outlined: that people should have health services by right, not by money; and that the private sector should not be able to divert resources from the public sector to serve a wealthy elite, leaving the poor with a deprived service. There is a welcome desire to restructure services to ensure they are less chaotic than at present, and an attempt to integrate all aspects of health care — educative, preventive and curative. All this is good.

However, there is a disturbing stress in the White Paper on organisation, on the methods of structuring things and not enough on how the men and women in the medical service can improve their own conditions and the standard of community service. Much of the White Paper is good, but insofar as it continues the present pattern of ordinary people having little control over their health service provided by upper-middle class doctors and public servants, there is still a long way to go.