Change through Continuity: A Quiet Revolution in Primary Health Care in New Zealand

By Ashton, Toni | Australian Health Review, November 2005 | Go to article overview

Change through Continuity: A Quiet Revolution in Primary Health Care in New Zealand


Ashton, Toni, Australian Health Review


IN A RECENTLY PUBLISHED paper entitled Continuity through change: the rhetoric and reality of health reform in New Zealand, I and my co-authors Nick Mays and Nancy Devlin pointed out that, in spite of a series of major health sector reforms during the 1990s and early 2000s, some key aspects of the system have endured.1 Moreover, many incremental changes to existing processes and systems that occurred during the reform period have, arguably, been more important to improving the functioning and performance of the system than the more high level (and more visible) structural changes.

Since that paper was written, many further changes have occurred in the organisation, funding and management of the New Zealand health system. However, in contrast to the 1990s, the focus now is on continuity and stability rather than on any need for further major change. Indeed, terms such as "reform" or "restructuring" have now all but vanished from any debate about health policy in New Zealand. Perhaps the reformers have learned that health system reform is akin to training for the Olympics. The whole process takes a fair bit of time and effort, and results are unlikely to be achieved in the short term. Further major reform is also not regarded as politically viable. As noted in an article in the New Zealand Herald just before the general election in September, there is "... considerable public sensitivity over any whiff of restructuring in health".2

Primary health care foundations revisited

It is therefore somewhat ironic that in the primary health sector some of the most profound changes are now in train since the foundations of the public health system were first laid in New Zealand in 1938. A brief historical journey is required to place the current changes into context. The aim of the first Labour government that was in power at that time was to introduce a wide range of health services free of charge for all New Zealanders, as part of a comprehensive revision and expansion of the welfare state. The proposed services included a range of health promotion programs as well as the more traditional curative services. The vision was to shift the focus away from treatment to prevention by emphasising public health and early intervention.3 However, the proposals for a primary health service that was fully funded by the government met with bitter opposition from the medical profession, causing a delay in implementation. Eventually the proposals were modified, and a compromise was reached in 1941. The result was that not only could general practitioners choose to be paid the subsidy on a fee-for-service basis rather than by capitation as favoured by the government, but they also retained the right to charge a nominal patient fee over and above this subsidy.

These arrangements for the funding of general practice remained largely unchanged for the next 60 years. Over time, the real value of the patient subsidy was inevitably eroded by inflation. However, subsequent governments were reluctant to increase the subsidy back up to its original level because they could never be sure that the additional funds would be passed on to patients in the form of reduced co-payments. GP subsidies were eventually targeted to the lower income bracket in an effort to ensure affordable access to those most in need. Even so, many who were entitled to the higher subsidies were not receiving them and, by the end of the 1990s, more than half of the population were paying the full cost of a visit to the GP (NZ$50 or more).

Primary Health Care Strategy 2001

In 2001, the Minister for Health announced plans for reorganising GP services and other primary health care through the Primary Health Care Strategy.4 The vision this time around is that "People will be part of local primary health services that improve their health, keep them well, are easy to get to and coordinate their ongoing care" 4 (page vii). This vision mirrors that held by the first Labour government 60 years ago, the aim once again being to shift the focus of primary health care away from treatment to prevention, from individual practitioners to teams of primary health providers, and from the health of individual patients to the health of communities. …

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