Former Southern Region medical officer of health Peter Hinds shares thoughts on issues facing the public health service.
Recently we had an extraordinary demonstration of strength of support to keep our neurosurgical service in Dunedin.
This is written to suggest that we must continue to be vigilant to preserve our public health system, which is the legacy of the struggle and vision in our past.
When Britain brought in its National Health Service after World War 2, the minister of health with Welsh grandiloquence maintained it gave them the "moral leadership of the world".
In fact, New Zealand had passed its Social Security Act in 1938, followed by the introduction of our health service later.
In the United States after a century of trying, healthcare reform has only just become law in "a call of history"; but it is still uncertain.
A legal challenge is coming from the half of America apparently not concerned about the health needs of their 30 million poor.
The insurance lobby can become very powerful.
Our major problem is the cost.
We just cannot afford the latest medicines and equipment - much of it of doubtful benefit and safety.
So we need to appreciate that we have an organisation at national level that assesses scientific evidence both to protect us and to set priorities. It cannot be a free-for-all for drug companies.
Keeping our expectations and demands realistic would help us to feel less aggrieved and to spend less on private insurance, alternative therapists and advertised remedies "proven by clinical trial".
A major and growing cost is in the care of the elderly.
There needs to be increasing attention to mobility, diet, social activity and measures to prevent accidents, particularly in the home.
Primary Health Organisations were formed with the view to encouraging this attention and other protective measures in general practice, with particular care for the young and the elderly.
Can general practices take on more of the load?
The hope was that this might be helped by forming the Primary Health Organisations.
But the GPs' reduced charge for the elderly is still a barrier to their attending when they should, especially for follow-ups.
Patients then leave things too late or go to the hospital emergency department. GPs set their own additional charges which vary, and at least one practice, the Servants in Princes St, is run by volunteers and makes no charges to patients so as to cater for the less well off.
Patients should shop around to find the practice that best suits their needs; not just in cost, but for other services, such as hours available, home visiting, help with transport and emergencies.
This was offered by the Mornington PHO and Health Centre from its own surgery and by its own doctors, who would be familiar to the patients and have access to their clinical files.
The southern PHOs have now been disbanded with the forming of just one PHO covering Otago and Southland.
It is hoped this new structure can carry on the better features of some of its predecessors.
Emergency care is provided for the rest of Dunedin from the privately run Urgent Doctors and Accident Centre across the road from the hospital, which must result in making it more impersonal and expensive.
It does not cover between 11.30pm and 8am, when the hospital emergency department staff have to take over.
But some non-urgent patients also go to this hospital department mainly, it seems, because it is free.
They must clog up this department's own emergency work and be a real hindrance to staff attending the really ill.
Could GPs take on more emergencies in their surgeries and more home visiting?
Is the drift to the private sector helpful?
Aside from the organisational problems of waiting and of choice, there is nothing inherently less expensive or better about private practice - mostly the same clinicians appear in public and private hats.
Hospital accommodation and service is much the same with only minor, rather social, differences.
And, in fact, in more serious clinical developments, patients are transferred from private to public hospitals.
Insurance companies assert they are taking the pressure off public facilities; but this is simplistic, and costs are just transferred.
Some difficulties are inevitable if the public-private boundaries are obscure.
The sharing of a good after-hours service in general practice; the running of extra operating sessions at weekends to catch up on waiting lists; the use of the Mercy Hospital for the same reason; and a claim that senior doctors at the Lakes District Hospital felt betrayed by the plans for its development may have resulted.
In the hospital service with very variable work demands, it must be a nightmare to try to juggle strict limitations to hours worked, weekend rates, overtime, time off, with fatigue and danger to patients.
But fanned by vitriolic advocates, striking seems to have started: junior doctors are concerned about their pay and hours of work.
In the past it resulted in their getting utopian conditions which were impossible to accommodate without severe distortions, particularly with seniors who held the responsibility for their patients.
The juniors must realise these have to be gradually corrected at a time of severe shortages.
Our administrators need to be commended in their difficult task of trying to make ends meet.
They are often thought of as bureaucrats denying people who "do the work" what they want.
One difficulty has always been the vying for authority between managers and operational staff, instead of working in a co-operative way to see to it that those in the field get what is available, without too much paperwork.
The recent admirable response to the Christchurch earthquake did not take place without considerable careful planning, preparation and action by bureaucrats first.
Praise be for good co-operative administration.
Can the Government itself make it easier for health boards to keep within their budgets to provide a good service?
It could heed the advice of the Law Commission on alcohol to cut down on the huge costs of alcohol-related diseases, accidents, deaths and social disruption to the community, and to the hospitals and their emergency services.
It has been adequately shown without need for further study that the most effective measure is by increasing the cost of alcoholic drinks and limiting access to cheap liquor.
One might wonder whether boards can make clear the anomaly of trying to keep within their budgets while the Government continues to neglect taking effective measures to relieve them of this unnecessary load.
