The great debate: New Zealand health system--world leader?
Article Type: Conference notes
Subject: Medical care, Cost of (Analysis)
Medical care, Cost of (Conferences, meetings and seminars)
Medical personnel (Conferences, meetings and seminars)
Health care reform (Conferences, meetings and seminars)
Pub Date: 10/01/2010
Publication: Name: Kai Tiaki: Nursing New Zealand Publisher: New Zealand Nurses' Organisation Audience: Trade Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2010 New Zealand Nurses' Organisation ISSN: 1173-2032
Issue: Date: Oct, 2010 Source Volume: 16 Source Issue: 9
Topic: Event Code: 970 Government domestic functions
Product: Product Code: 8010000 Medical Personnel NAICS Code: 62 Health Care and Social Assistance
Geographic: Geographic Scope: New Zealand Geographic Name: New Zealand Geographic Code: 8NEWZ New Zealand
Accession Number: 241179364

Conference delegates do not believe New Zealand's health system is a world leader. The overwhelming number of delegates supported the negative team in the second-day debate at conference.

The three-member winning team consisted of economist and philanthropist Gareth Morgan, Pacific health adviser at Hurt Valley District Health Board (DHB) Siloma Masina, and head of Massey University's school of public health and former Children's Commissioner Cindy Kiro. The affirmative team was led by director of the Safe Staffing Healthy Workplaces Unit Jane lawless, supported by health, education and research consultant Chris Walsh and former government statistician Len Cook.

Resilient and adaptive

Opening the debate, lawless said New Zealand's health care system was a remarkably resilient and adaptive entity. "We are a world leader in the compromises implicit in health care, in resilience and in doggedly delivering on care."

Despite repeated system reform and huge shifts in where and by whom services were provided, the health system had continued to make progress and staff continued to be creative and to get the job done.

Conceding there were "hot spots" where access was an issue, lawless said generally "we cut our cloth very well.... We don't have to be the best at everything but we are very good at compromise and, God help us, we are very good at adapting to the vagaries of the political will."

The cost of the health system was escalating and one of the major drivers was the public's expectations of a universal health system, which meant an "all-you-can-eat system", Morgan said. "There is an expectation that whatever affliction you suffer, it will be fixed. That is not the case. Very rich New Zealanders are not turning to the New Zealand system for care.... We are completely fooling ourselves if we think our system is the best in the world. It runs on peanuts and there is no doubt the productivity within the supply system is to be applauded. Clinicians do a lot better than elsewhere but that doesn't make it the best system in the world."

Other drivers of escalating costs were the aging population, new technology, new treatments and the spread of chronic disease. "We are the third worst in the Organisation of Economic Co-operation and Development (OECD) for obesity; deaths from cancer and heart disease are higher than the OECD average. We are already in a situation where health needs are unmet and the system is in huge need of reform. Who gets treatment first if there is not enough money to treat? The squeaky wheel. And who gets the most treatment?--squeaky old whities. That's a dereliction of duty in terms of providing care to those who need it most," Morgan said.

Referring to [Labour Government Health Minister] Arnold Nordmeyer's fight to establish New Zealand's health system in the 1940s, Cook said its present cost was not a particular concern and it cost significantly less than most other countries. "Pharmac means we have the lowest drug costs of any OECD country. We have a Health and Disability Commissioner, a girl baby born today has a 50 percent chance of living to 90, 92 percent of GPs have access to top class technology and we have one of the most effective primary health care systems in the world."

Cost was not the only measure; quality, scope and access were also important. "On the degree of equity New Zealand's system is at the top of the world," he said.

But a serious concern was that politicians were not up to our health system. "Ministers of Health's use of structuring and restructuring as instruments of change reflects their inexperience."

New Zealand's health system had plummeted from first to fifth in internal rankings of seven Commonwealth countries, Masina told delegates. This fall was mostly to do with the cost of doctors' visits, filling prescriptions, management of chronic illnesses and the fact New Zealanders were the most likely to get an infection when in hospital.

New Zealand faced a health workforce crisis with skilled practitioners going overseas because the system didn't recognise their value; the Ministry of Health was one of the worst performing government departments; nurses were resigning due to horrific workloads; and some DHBs had waiting lists of more than six months for cancer-detecting colonoscopies. "The high quality of doctors and nurses is the only thing holding the health system together," she said to applause.

"How can we as nurses support a system that focuses on bangs for bucks and ignores the human cost? The system does not support families struggling to make ends meet," Masina said.

The final speaker for the affirmative, Walsh, told delegates that when she trained Bonanza was the best thing on television and chlorpromazine was the drug of choice at Oakley Hospital where she trained.

Giving an "insider's perspective", Walsh praised the talents and diversity of the nursing and midwifery workforces and said New Zealand's nursing leadership had led the world, as New Zealand was the first country to regulate the profession. The current nursing workforce was able to adapt to constant change, was the backbone of the health system, its human face, provided stability and nurses were highly trusted.

Walsh said a life threatening cancer diagnosis meant she had to rely on a clinical nurse specialist for support and guidance. "She was skilled, compassionate, creative and responsive. Behind every health encounter is a nurse or midwife, able to adapt to suit new demands and continue to provide safe care. New Zealand nurses are sought after world wide."

New Zealand was also a world leader in the development, growth and progress of cultural safety as a way of addressing inequalities in Maori health and that was unique on the international stage, she said.

The New Zealand health system is bereft of original ideas and courage to fulfil the changes needed to have a system blind to issues of social class, colour and creed, according to Kiro. "In fact it perpetuates inequities and unfairness. Money is spent at the wrong end of life. In one DHB, 80 percent of the budget is spent on the last six months of life."


Health spending should be at the other end of life. Referring to a number of reports, Kiro said they overwhelmingly confirmed that the best return and the most moral investment was funding mothers and children in early life. " Kiro, quoting the book, The Spirit level." Why equal societies almost always do better, said inequality hurt everyone through higher crime, shorter lives and ill health, drove a wedge between people, corroded trust and increased anxiety. "Social justice is a matter of life and death. We spend $9 billion on health but do we get what we deserve? We are spending far more but we are not getting far move back in terms of health outcomes."

Inequities were most striking between Maori and non-Maori. There were significant differences in life expectancy, diseases and levels of care. Maori were less likely to be offered the use of pharmaceuticals and laboratory services. During the 2000s there was a reduction in inequalities but there was now evidence suggesting they were trending upwards again, Kiro said.

'Deep and difficult' questions

"If we are going to substantially improve the health of New Zealand we have to ask deep and difficult questions: why do we allow a health system that allows and Facilitates inequality, that invests in the wrong end of life and that perpetuates a significant burden of illness and pain in most vulnerable populations?" she asked. In rebuttal of the affirmative team's arguments, Masina said DHBs were stretching the health dollars "until we can't see the serial numbers"; that in many cases people were living longer because their families were looking after them; and that New Zealand nurses were high quality but heading overseas because they were undervalued and underpaid here.

In her rebuttal of the negative team's arguments, Walsh said New Zealand was doing very well in maintaining integrity in the health system. "Nurses are not responsible for social justice--they work with what's available and do their best for patients. They are distressed if they can't do that."

Kiro, in her rebuttal, said what was needed in the debate were facts not "an appeal to the nostalgia and emotional connectedness you feel as health professionals". She did not dispute that nurses were the glue that held the health system together "but that's not what we are debating. We are debating whether New Zealand's health system is a world leader and the overwhelming evidence is that it is not. Nurses are worth their weight in gold but are all those efforts creating a world-leading health system? No."

In his rebuttal, Cook said one of the key elements in any debate on the health system was the need for constructive debate but "we are not very good at discussing the hard issues".

The primary health care strategy was a very effective strategy to mitigate inequities in health, he said. Referring to inequities for Maori, Cook said that in Nordmeyer's time up to 70 percent of Maori men died before retirement age. "There's been a huge shift and there's a huge way to go, but the health system has demonstrated its capacity to change."

In his summing up, Morgan said the health system should bejudged on outputs not inputs. "There are pockets of excellence but they don't make the world's best health system. It punches above its weight but that doesn't make it the world's best health system. A major concern is the political micromanagement in our health system." An example was the Government's decision, once elected, to fund the breast cancer drug herceptin for 12 months, which he said was disgusting. "I thought John Key's mother, wife or sister must have been at the centre of that decision ... We need an evidence-based system for allocating health dollars and that allocation should be led by health professionals not politicians, and it should be transparent."

Morgan said a well-informed patient required 40 percent less treatment. "A well-informed public will make very rational decisions; an ill-informed public cannot do that."

Far too much was spent on trying to cure old age--"there's a lot of us and we have a lot of votes." Morgan joked about bringing in a maximum voting age. He also referred to "two New Zealands" in terms of health care and the blight of health conditions he witnessed in South Auckland "that were just obscene" In her summing up, lawless she said the negative team had cherry picked statistics and taken an inward-looking approach to the health system. "We should not look inwards but outwards. We are productive, efficient, cost effective and balanced. With some exceptions, all our patients do exceptionally well. We are not an utter failure. I want my children to be born, live and die in this health system. We are exceptional and we should celebrate our successes and our excellence," she concluded.

But her call to celebrate did not secure victory. When chair Ross Wilson asked the audience to judge, there was a muted response to the affirmative team and an overwhelming endorsement of the negative view.
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