Forty years ago, when I first became Labour’s spokesman on health, I recall George Gair, the then Minister of Health, saying that if health spending continued to rise at the current rate there would come a time around 2030 where the entire national budget would be given over to health care. Scarcely surprising, when I think back: an ageing population, more and more sophisticated (and costly) drugs and interventions, and rising public expectations about what people were entitled to from the public purse. Like National ministers, I turned my mind in the early 1980s to structural reforms that could reduce costly overheads within the health system. I recall becoming convinced that combining regional departmental services with Hospital Boards and forming area health boards would significantly reduce budgets. I put this to the then Director General of Health when I became Minister in July 1984. A wise old dog, Dr Ron Barker looked at me and said – very properly – “Minister, while little bits can be saved around the edges by structural changes to the health services, they won’t make health care more accessible to people in remote areas, or to working folk, or to Maori or Pacific Islanders. They need easier access to primary health care - access to GPs. And you can’t deliver hospital care to people in remote parts without better transport and air services, and they are very expensive”.
Nearly forty years later Ron Barker’s wisdom still holds. As I watch the new Minister, Andrew Little, enthuse over his proposed structural reforms, I shake my head. All the wailings about a “fragmented service” have been heard before: a need for “better primary and community care, hospital and specialist services”, and these days, burble about Treaty obligations. However, no amount of structural reform will conjure up an ideal service. We’ve been there before: the old city and small-town hospitals were pulled into hospital boards in the 1950s, and then into area health boards in 1988, and then after Alan Gibbs’ report on hospital structures, a more centralized system in the 1990s where funding and purchasing of services were conducted by separate entities. By the time Helen Clark came to office in 1999 and gave us district health boards, health delivery to our citizens was much more efficiently delivered than it had been twenty years earlier. But costs kept on mounting steadily. And they will continue to do so despite Little’s structural changes. The new Public Health Agency sounds rather like a return to the 1990s. Whether the new Maori Health Authority makes much difference to Maori health outcomes remains to be seen. There is a great need for more Maori engagement with health care and the MHA needs to set targets for immunization, vaccination and smoking cessation so that the public can measure the effectiveness of this new structure.
Once more we are promised stronger primary health care to take the pressure off hospitals, more concentration on prevention in preference to treatment of health problems, and better management at the Ministry of Health that struggles to deliver assurances given by Dr Ashley Bloomfield. We’ve heard it all before too. I’ll believe the improvements when I see them. Incrementally, things have developed over the years since my extra government subsidies to GPs to make care more affordable for children, trade-union clinics for working folk, nurse practitioners, and then free immunization for the elderly, and now free Covid testing with immunization coming up. But in the end, much of it comes back to money. And while this government has been acting recklessly with the purse strings, that’s the only way they seem to know in a time of inflated expectations.
Money alone, however, cannot deliver better health care. New Zealand is seriously short of health care personnel: from specialist care, to nurses, to GPs, to paramedics. Our training systems are excellent, but too many graduates depart. Today we are heavily dependent on skilled immigrants in every nook and cranny of our health system. There is already a serious shortage of GPs, especially in the areas of greatest need outside the main centres. The last Minister of Health promised millions for mental health. How much of that has been delivered? To what effect? That is an area where the need for extra facilities and people to deliver the services has been unfulfilled for decades. Does this minister have any answers?
I believe that no amount of structural change will meet today’s challenges. Most of the fat has long since been squeezed out of the health system. Exponentially increasing demand for services is our principal problem. It’s high time we started to discuss a new way of incentivizing people to pay more attention to their personal health, and open up discussion on what can reasonably be expected from the public system. As well, everyone wants a better education system, more police, additional new social housing, and enhanced environmental and conservation policies. No country anywhere has managed to achieve all that while operating an open-ended entitlement to health care as well. Andrew Little’s structural shake-up, unfortunately, provides slender cause for optimism. Ron Barker could have told him that nearly four decades ago.