Reviewing health services, Ben Gray

Health where it hurts: The story of the Newtown Health Service
Don Matheson (ed),
Newtown Union Health Service, Wellington, 1992, $15

Health reforms: A second opinion, 
Lyndon Keene (ed),
Wellington Health Action Committee, 1992, $10

Core Services 1993/94: The First Report of the National Advisory Committee on Core Health and Disability Support Services

We are in the midst of the most significant reform of our health services since 1938. The current Minister of Health has devised a grand plan for the running of health services, and is in the process of implementing it against a background of major opposition from many sectors of the community.

Health care is an emotional issue, at times a matter of life and death. Unfortunately emotional responses will not devise the best health care system. Much of the public debate has been more based on emotion and ideology than rationality. The Minister believes in market mechanisms to deliver a good system, but initial changes, such as user part charges in hospitals, have been abysmal failures. Some of those who oppose the reforms propound the view that the current system is fine and don’t tinker, just provide the money necessary to run it. One of the problems is that these views tend to be held as a matter of belief rather than being backed up by sound information. The books under review go some way to providing the sort of information required to debate these issues sensibly.

The Newtown Union Health Service (NUHS) is a pilot primary health care scheme. Since it began in May 1987, it has modelled a different method of delivering health care from that offered in most general practices in New Zealand. This 70-page book describes the achievements of NUHS in clear prose and complementary photographs and diagrams. The book documents NUHS’s particular focus on clinical care, health service delivery, and information-gathering and audit.

The clinical care the service provides is clearly up with the best (a 90% immunisation rate at two years is excellent), despite the well-documented fact that they service a high-risk population. Of the practice population, 41% are new migrants, including people from the Pacific, Cambodia, Vietnam and Iraq. The majority of their Pakeha patients are chronic psychiatric patients.

NUHS is run with significant community involvement, and is therefore able to respond to community needs. This is not a feature of most general practices. All health workers are employees of the service. This diminishes the traditional doctor dominance and enables much more effective teamwork. There is significant emphasis on health education. From the outset, NUHS has had excellent record keeping and audit of performance. Without this such a concise book could not have been written. I doubt whether many other practices in the country could describe what they do so accurately.

This book describes a model of how primary care can be provided in New Zealand, that explicitly caters for a large group of people who are rarely well serviced in traditional general practices, because of problems with access and finance. It highlights many of the issues at the forefront of the current debate on health reforms: Is community involvement necessary to provide good health care? Does a fee for service private enterprise service cater for all needs? What role should nurses have in primary health care? Should doctors determine the priorities for primary health care expenditure? Many of these issues have parallels in the secondary care sector. Any reform that ignores the lessons that NUHS has learnt proceeds at its peril.

Health Reforms: a second opinion accurately describes itself as a ‘Comprehensive critique by leading commentators’. It consists of 31 one-page articles by a wide and distinguished array of commentators. The critique is developed under four headings: The context and direction of change; Key elements in the new health system; Impact on health care consumers; and, Impact on providers and the health system. It concludes with a succinct description of the desired health system, those features of the re-organisation that are potentially worthwhile, and key steps that must be taken in changing the content of the current reforms.

The first startling thing about this publication is the breadth of opposition represented by the contributors. If nothing else, this demonstrates that the Minister has totally failed to take the public along with him in the proposed reforms. Consultation has been slight and unheeded, and an important group of the major contributors to a debate on health reforms have found it necessary to publish their own critique in the hope of mustering public opinion because the Minister has clearly ignored them.

I am unconvinced by the commentators who attack the reforms on ideological grounds saying that market and business have nothing to do with health care. For a large proportion of the population, general practitioners provide good primary care, working as small businesses. That said, the arguments in this book against market forces in the provision of hospital care in New Zealand are unassailable.

Add to this the contributions outlining the failure to provide for adequate services for people with disabilities and mental illness, the failure of the new targeting of assistance in primary care, the inequity of the new system, and the scepticism of the representatives of all the major health workers.

The most important point made is that health services are extremely important and provision of quality cost-effective service is something that New Zealand is doing pretty well at, on an international basis. Any change of the system should be by evolution, not revolution, with careful monitoring of the changes to ensure that they achieve the goals intended. This is essential reading for anyone interested in the provision of health care in New Zealand.

The Core Services Committee is an independent committee appointed by government, set up ‘to advise government on what health services and disability support services the Government should ensure are purchased with due respect to its limited financial means in order that people have access to effective services on fair terms’.

There is some measure of truth to the Minister’s claim that the Government spends $5.6 billion on health and disability support services, but does not have a clear idea of what it is buying with that money. The Minister has stated that initially the Core will consist of those services currently provided.

For its first report the Committee has done a stock-take of the services purchased by government. In particular, it has looked at equity of access to those services starting from the premise that if a service is available with public funding to one person then it should be available to all. This has thrown up some major discrepancies. Roughly the same number of cataract operations per head of population are performed in Northland as are performed in Auckland. Only one third of the Auckland operations are done at the public hospital, virtually all the Northland operations are done at the public hospital. Auckland has a GP/ patient ratio of 1:1230, Taranaki has 1:1850, and yet Aucklanders average a subsidy of $65 each per year, while those in Taranaki only average $50. In other words Taranaki people have poorer access and less government subsidy than Aucklanders.

The report contains a series of recommendations to RHAs on what areas of care they feel should receive particular emphasis. Importantly the committee report each year and will provide a mechanism whereby an assessment will be made by an independent body on whether RHAs are purchasing appropriate health services.

The establishment of the Core Services Committee is one part of the reforms that deserves strong support. It has approached its task in a pragmatic and helpful way, and will provide some information on which to judge government’s performance in the provision of health care.


Ben Gray is a medical practitioner who recently moved from Waitara to Wellington.



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