The value of being sensible, John Martin

New Zealand Health Policy: A Comparative Study
Robert Blank
Oxford University Press, $34.95,
ISBN 0 19 5583191

Whaiora: Maori Health Development 
Mason Durie
Oxford University Press, $32.95,
ISBN 0 19 5583167

Children’s Health, The Nation’s Wealth: A History of Children’s Health Camps
Margaret Tennant
Bridget Williams Books and Historical Branch, Department of Internal Affairs, $34.95,
ISBN 908912684

The health reforms outlined in Simon Upton’s 1991 “Green and White Paper” (Your Health and the Public Health) were a self‑confident attempt to bring rationality and political will to bear on what was seen as a recalcitrant health sector. After a decade of reports and incremental “tinkerings” a coherent and comprehensive restructuring was deemed to be necessary to deliver improved health outcomes and a return on the taxpayers’ large investment in the public health system. Measured by the values that informed them, the reforms must be judged a failure.

In the event there has not been the political will to implement the “grand design” of 1991: there are no alternative healthcare plans or list of “core” services; and the Public Health Commission has been abolished. And yet, despite these concessions to political reality, health issues continue to pose major electoral threats to the Government. Similarly, the improvements in productivity which were to flow from painful management changes have not demonstrably appeared ‑ at least in the currency of shorter waiting lists in which, unwisely, they were marketed. Nonetheless, there are widespread reports of low morale and disaffection among health professionals, dissatisfaction among those in need of care and alienation in communities who no longer feel a sense of ownership of “their” health system.

This may be a harsh judgment; more time, it will be said, is needed to make a fair assessment. But the time dimension of public policy is crucial in a democracy. The pain of radical transformation is immediate; the gain is for the longer term. How, therefore, in a democracy do the governors persuade the governed that they have struck a reasonable balance ‑ that the closure of wards now means a more effective service that can be sustained in future? Why, in particular, are governments all round the world finding it so hard to bring about changes in health policy (as with President Clinton’s reforms) or to gain acceptance for them (as in the United Kingdom or New Zealand)?

At one level, this is simply because health policy is very complex and multi‑faceted. It boils up in one pot a politically toxic brew of ethical, economic and managerial considerations. At another level ‑ that of specific health policies ‑ questions requiring hard analysis need to be asked. Were the issues adequately defined at the outset? Was it the policy response as designed that was at fault? Was the process of implementation badly managed? Did political will falter at the critical point (1993?)? Have the problems changed?

If you believe these are important questions you should welcome Robert Blank’s contribution to the very useful Oxford Readings in Politics (and, as I shall explain, for different reasons also the books by Mason Durie and Margaret Tennant). In the rather overheated atmosphere of health policy discussion I can think of no more prized epithet than “sensible”; and Blank’s is a very sensible book. Its focus is not principally on the current New Zealand reforms but it provides a context in which they can be intelligently discussed. Blank is a political scientist (at Canterbury University). He takes a comparative policy approach: he places the New Zealand situation alongside those of other countries and particularly those of the United States. The identification of differences and similarities is illuminating.

Blank, like most commentators on health policy, identifies three near‑universal trends: the ageing population; rapid advances in medical technology; and vastly‑expanded public expectations and demands “even though there is little corresponding public sympathy for raising taxes to pay for these positive rights” (p39). The ageing population is one of the clichés of social policy debate ‑ but it has important implications. In 1990 44% of the budget was spent on the 15% of the population that was over 60. Although in New Zealand the rate of growth of the elderly does not speed up until after 2005 we are already seeing an increase in the numbers of those over 80, by far the greater number of whom are women. Care and facilitating the quality of life for the elderly is, of course, not an issue for the health system alone; but the recent report by Richmond et al (Care for Older People in New Zealand, Core Services Committee, 1995) suggests that we cannot be complacent about our present arrangements.

“Globalisation” has long been a fact for the health service. Knowledge of developments in medical technology pass quickly over national boundaries. Pressures for the availability of new treatments and pharmaceuticals come first from professionals. They soon become entwined with claims of individual entitlement. Governments face public clamour for Solomon‑like reconciliation of priorities within capped budgets. And, as the case of Mr McKeown in Auckland earlier this year demonstrated, it is very difficult to “depoliticise” these decisions. What Blank calls the traditional “maximalist” approach ‑ marked by individual entitlements of citizens, the physician’s obligation of care and “the insulation” of individuals from costs (whether by the state or insurance schemes) ‑ ensures that governments will have to apply limits to the application of medical technologies.

Some form of rationing is inevitable, as is a high degree of government regulation. As Blank reminds us, even in the market‑oriented United States system the government meets over 40% of healthcare expenditure and in the words of a former Secretary of Health, Education and Welfare, is “a Dante’s hell of regulation and manipulation”. (p82) Of course, that is an invitation to those who worship the market to argue that the United States arrangements would be more efficient and effective if the competitive market were left to itself. This is a point to which I shall return, but there is a quick riposte, viz, all OECD countries continue to intervene in the health market because they are concerned with equity, fairness and justice as much as with efficiency and effectiveness.

In turn, it may be asked: how can notions of “justice” be incorporated in a health care system? Ronald Dworkin, discussing the ill‑fated Clinton health package (The New York Review of Books, 13 January 1994) contrasts what he calls the traditional “rescue” principle of justice in healthcare with the “prudent insurance” ideal of justice. The rescue principle has two connected parts: first, that, in Descartes’ words, life and health are chief among all goods; and that healthcare must be distributed on grounds of equality. Despite the inequalities elsewhere in society, healthcare should be available to all those who need it. Dworkin argues that this principle is of no practical utility in dealing with the real issues of public policy.

This view that “health” is something special, and immune from the considerations that influence the distribution of other goods in society hinders the development of a just and effective health policy. It did so in New Zealand in the mid‑1980s when many in the health service could see no reason why the reforming tides of Rogernomics should lap at their shores. If it did nothing else, the 1988 Gibbs report dispelled that illusion. (On the other hand, it built up false expectations of the efficiency gains that could be made if commercial structures and practices were transplanted into the health sector.) The acceptance that health is not “different” in a special sense enables us more easily to see that decisions about rationing resources have to be made. What is needed is both a philosophical basis upon which to design a rationing system; and then to construct arrangements that can command a reasonable measure of support in the community.

Dworkin helps me to come to grips with the place of “justice” in a health system. He provides a conceptual bridge between a regard for the principles of allocative efficiency and the ideas of justice which can so easily get lost in the market model. He does this by advancing, as an alternative to the “rescue” principle with its connotation of the “exclusiveness” of health, the “prudent insurance” model under which “we should allocate resources between health and other social needs and between different patients who each need treatment, by trying to imagine what healthcare would be like if it were left to a free and unsubsidised market”. (p22)

But Dworkin corrects the market for three deficiencies. First, he assumes that “the distribution of wealth and income is as fair as it possibly can be”. Second, “imagine that all the information that might be called state‑of‑the‑art knowledge about the value and cost and side‑effects of particular medical procedures … is generally known by the public at large”. And, third, “imagine that no‑one ‑ including insurance companies ‑ has any information available about how likely any particular person is to contract any particular disease or to suffer any particular kind of accident”. (p22)

Dworkin’s argument is that if we make the act of imagination he asks we can assume that the healthcare decisions made in this transformed community would be just decisions: “a just distribution is one that well‑informed people create for themselves by individual choices, provided that the economic system and the distribution of wealth in society in which these choices are made are themselves just”. (p23) On this basis we can think usefully about what prudence requires of the health system. Prudent people might be expected to “buy” access to primary healthcare (regular checkups), care for children, availability of accident and emergency services and so on. But they are unlikely to insure themselves so that “heroic and expensive treatment” which could prolong life for a few months would be provided.

Of course, New Zealand society is not a just society and we will continue to look to the political process to ensure that resources are allocated in accordance with something like Dworkin’s prudent insurance principle. What is required is both an acceptance of the essentially political nature of health and the provision of processes in which “the community” believes they have a continuing role. In my view one of the lessons to be learnt from the past five years is that you cannot depoliticise healthcare; the aim cannot be to take politics out of health, but rather to ensure that the inevitable political decisions (at all levels) are good political decisions built on good information and appropriate contributions from professionals, managers and the community.

In practice, having put aside the search for an explicit list of core services, this is the way the Core Services Committee in New Zealand has influenced discussion. Rationing, implicitly by health professionals and explicitly by administrative decision of providers, is over time becoming better informed. As Blank notes, “the vast majority of submissions [to the Core Services Committee] strongly called for a rebalancing of resources between primary and secondary care and between community‑based and institution‑based services”. (p104) I think, as does Blank, that discussion over the past 15 years at least, assisted by the greater transparency introduced into the debate by the Upton health reforms, is setting “the groundwork for fair and workable rationing approaches”. (p109) We are, however, far from having in place a management system that can translate something like the “prudent insurance” principle into operational decisions.

This is where Blank’s book is so helpful. He applies the frameworks of the comparative policy literature to classify types of healthcare system by state involvement, by funding arrangements (private/public) and by the ways they pay providers. He analyses the shifting goals of health policy (and the importance of being explicit) ‑ from the emphasis on equity of access and quality of care in the first two post-World War II decades to cost‑containment from the 1970s. Strategies for achieving this latter objective are reviewed supply‑ and demand‑side controls ‑ and the inevitability of rationing is recognised. Blank’s treatment of these basic issues is clear and inexorably draws the reader back to the importance of having political institutions in which societal choices can be adequately informed and determined.

A critical question for the designers of such political institutions concerns the role that citizens (differentiated from élites, whether political or technocratic) should play. Here, too, Blank has useful things to say. One of the fatal flaws perceived by those behind the 1991 reforms was the “dual accountability” of area health boards to their paymaster, the Minister of Health, on the one hand, and the local constituency on the other. In an action which even Mrs Thatcher in her heyday would not have been allowed to get away with, elected boards were removed at a stroke of the pen in the 1991 Budget, to be replaced first by appointed commissioners and now by a hierarchy of centrally‑appointed directors. At the time the demise of this element of local democracy in the health service was not widely lamented (certainly not in the metropolitan areas). Now, however, it seems to me that one of the most debilitating factors in New Zealand’s health system over the past five years has been the alienation of the decision-makers from “the public” ‑ realistically, not the mass public but, in political science terminology, the “attentive public”.

Blank succinctly sets out the considerations in democratic theory which suggest that we need once more to examine the mechanisms “through which interested members of the public can be informed and at the same time enjoy more than a token role in formulating policy choices”. (p23) Recent experience suggests that public relations‑type “selling” activities are, if anything, counter‑productive; and that boards of Crown Health Enterprises (CHES) which add to the medical élite a business élite do not have the confidence of the community. Indeed, it is not easy to define where “the community” or local voice, has a place in our current system. Regional Health Authorities (RHAS) are supposed to represent the interests of consumers, but four across the country hardly accords with any sense of community of which I am aware. CHES, for their part, are supposed to be “successful businesses” in a market dominated by the state’s funders, the RHAs. Some reintroduction of an elected local component (even if indirect through local authority representation) to CHE boards (or whatever may replace them after the next election) is, I believe, essential if there is to be the degree of public confidence in the health system. Without public confidence the “prudent insurance” decisions will be that much harder.

The other key area for political attention is the disintegration of the provision of health services. A structure which deconstructs the health system into a network of contracts between funders and providers competing on a level playing field has a beguiling attraction. It forces all concerned to clarify what they are attempting to achieve; it can encourage efficiency by the introduction of appropriate incentives and disincentives; and it may have seemed to offer protection for the system against the dreaded “capture” by interest groups including those most demoralised, doctors. Experience in the “old” health service offered support for all these aims. But the commercial production model of healthcare epitomised by the funder/provider split (cf, the turbulence in September around the New Zealand Archives) went too far. Many of the advantages of “managed competition” and indeed the techniques of contracting could be utilised in a much simpler structure under which funds were allocated directly from the centre (bulk funding?) to public authorities (hopefully, more than four but fewer than 23) which, taking into account the health status and needs of their area and the availability of alternatives, would make the decision whether to provide services themselves or to contract out. In short, do away with the RHAs and the extraordinary paraphernalia of contracts for every service.

The production model of healthcare is particularly ill-suited to cope with the caring services which are likely to make up an ever‑increasing proportion of health services. Integration and cooperation are the key requirements for good mental health services, adequate care for the elderly and for children.

Margaret Tennant’s very professional history of the health camp movement has important lessons. It illustrates sharply the difficulty of drawing boundaries around “health” as a policy area. Health camps were a response to the needs of society in 1919; their role has changed (sometimes too slowly) as those needs have changed and as New Zealand’s notion of the proper place of the child, the family and the state has changed.

This is also a case study in the evolution of the relationship between the voluntary sector and the state. There are now seven health camps through which pass more than 4000 children annually. Funding comes primarily from contracts with the RHAs but there is still a strong element of community support. Tennant concludes: “The future of children’s health camps as currently conceived is by no means secure. Their present dependence on not one but four main funding providers makes them vulnerable to a slow death through the gradual and uneven shaving of funds.” (p265)

One of the challenges for the health camps over the past decade has been to accommodate the place and aspirations of Maori. In this they are a microcosm of the health service as a whole. Mason Durie’s Whaiora is one further contribution, and an especially timely one, by Massey’s Professor of Maori Studies, who is also a consultant psychiatrist.

The subject of this book can be seen as part of the much wider whariki, or fabric, of Maori development generally. But its principal focus is on the many‑pronged initiatives of the last decade to improve the health of Maori. Some have had a considerable degree of official involvement at both national and local level but the outstanding characteristic has been the investment of Maori in their own programmes. “If there is a central theme, it is that Maori health cannot be separated from the historical and contemporary experience of Maori in Aotearoa/New Zealand.” (p7) There are chapters on traditional Maori approaches to health, the demographic and health status history of Maori, the contribution of such bodies as the Maori Women’s Welfare League, the implications of the Treaty of Waitangi, Maori in society and the promise and doubts of the health reforms. The closing note is optimistic: “Overall, Maori health, at least as measured by mortality rates, including infant mortality, is … better than it has ever been.” (p215) And there is “exuberant” Maori vitality. But the gaps between Maori and non‑Maori remain serious.

Mason Durie’s vision for the future is one which resonates beyond Maori: “We need to agree on public policies which can convey a sense of order in a changing environment and yet at the same time encourage whanau and communities to nurture each other.” (p216) In the recent words of a respected health professional, we need a “healing period” in which all the “stakeholders” in the health industry, while not forsaking their own interests, try to reach some common understanding of the issues discussed in these books and at least the direction of health policy. Ideological purity ‑ on the part of both economic rationalists and defenders of the welfare state ‑ as well as some of the tenets of the “professional tribes”, will need to be compromised. Unfashionable as it may be, only governments can provide the kind of leadership which will bring about pragmatic and incremental change. The alternative is another fundamental upheaval in a few years.

John Martin is senior lecturer in public policy at Victoria University of Wellington. He is a former Deputy DirectorGeneral of Health (Administration).

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Posted in Health, Non-fiction and Review
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