Will we learn from history or repeat it? The new New Zealand health system

The big news in New Zealand healthcare since our last issue came out in March is the announcement of a new New Zealand health system.¹ The health system we live with today kicked off 30 years ago with then Health Minister, Hon. Simon Upton, releasing his Green and White Paper in 1991.² In British-based parliamentary systems Green Papers are discussion papers while White Papers are statements of policy, often before parliamentary debate. Upton’s paper was, and still is, memorable. It occurred in the context of general upheaval across a wide range of public services that were acknowledged as poorly fit for contemporary purposes. Then, as now, there was a collective sigh of relief that the old system was to be abandoned and a sense of excited anticipation that the new structures would deliver better healthcare for the people of New Zealand.

The Green part of Upton’s document provides a rationale for change that looks remarkably similar to problems in our health system today: inadequate services for Māori, low investment in public health, long waiting lists for essential hospital care, and low morale among health (meaning ‘hospital’) workers. Many of the proposed solutions were also remarkably similar: establishing separate Māori health and public health institutions, making hospitals more accountable for managing their waiting lists, and integrating primary and secondary care. Diametrically different was the intent to decentralise health service decision-making in 1991 rather than the centralisation intended in the 2022 new health system. Underpinning everything in 1991 was a dramatically different funding structure. Some of it happened, many things started and then stopped, some never happened.

During 30 years of health system tweaks and contortions aimed at creating a fit-for-purpose health system the values of this country have also changed. ‘Fairness’ was a strong social value in New Zealand in 1991 and politically interpreted in efforts to make sure everyone could access the same health services. Today, ‘equity’ trumps fairness. If we think of equity as access not to the same health services but to the same health outcomes, then an abundance of local research makes it obvious why changes are needed.

Our Guest editorialist writes of the critical role of the proposed new Māori Health Authority in restoring balance to the New Zealand health system, such that Māori can walk alongside other New Zealanders as equal partners.³ This is no more than was agreed in the Treaty between Māori and the British Crown in 1840 and intended by Upton in 1991, but has never happened despite formal agreement and good intentions. Te Karu draws on both research and her clinical experiences as a primary care pharmacist to explain why equity in health outcomes could not be achieved in the past nor presently. She also offers some solutions as to how to measure and achieve equity with respect to medicines. Hikaka et al.⁴ also write about medicines, mapping intended outcomes, requirements for change and outcome measures to Te Tiriti o Waitangi (Treaty of Waitangi) principles to inform both research processes and the research-based structure for pharmacist-facilitated medicines review that they are developing. All these authors represent an emerging generation of articulate bicultural New Zealanders who, in the end, I think may be responsible for lasting changes in this country because they can explain the sense of Māori approaches to health (and a wide range of other things) in language that monolingual (English speaking) New Zealanders can understand. Underpinned by research such as theirs, it is hard to see how a Māori Health Authority could justifiably be abandoned as it was in the past.

Providing more lessons from history, in this issue we have a Viewpoint paper mapping anthropometric changes to people in general, and Māori in particular, before and after Europeans populated this country, citing Cook’s diaries and other historical documents.⁵ Our other Viewpoint papers celebrate the internationality of this Journal’s readership. From Japan, Maki discusses the pros and cons of diagnosing mild dementia among very elderly people⁶ and we have updates on COVID-19 stories from South Korea and Italy.^7,8 In the early days of the Covid pandemic in 2020, the disease trajectory in South Korea was the same or better than New Zealand’s but has, in the authors’ views, now worsened because of lack of strict lockdown periods.⁷ Second and third pandemic waves have overcome early successes. In Italy, twice as many general practitioners (GPs) have died from Covid as other doctors: Nicoli et al. consider ethical issues related to how Italian GPs work.⁸

Research in this issue reflects cultural diversity locally and internationally. Cundy et al. conducted a classical piece of longitudinal general practice research in a Tongan medical centre.⁹ Their findings send a clear message that for Pasifika people it is critically important to check for symptoms of type 2 diabetes very early to avert long-term dire consequences (having retinopathy on diagnosis being a signal that it is too late). A Canadian group researching immigrant health found that mostly neither immigrants who are participants in research nor clinicians who care for them know the results of the research they contribute to.¹⁰ This is relevant internationally because informing participants of research findings shows respect for their contribution to research as altruistic human beings – not insensate ‘things’ to be studied.

From Australia we have a case report about an immigrant patient presenting repeatedly to his GP with persistent back and rib pain, being referred to different specialists and having a range of investigations.¹¹ Finally, someone asked the right question and found the patient had had a recent trip to India, prompting investigation that enabled definitive diagnosis and treatment. Our other case report is one for rural hospital generalist readers, reporting an unusually late-presenting postoperative complication.¹²

We also have three clinical and health services research papers from New Zealand authors. Ding discusses the views of GPs and hospital-based vascular specialists on the use of ankle brachial pressure in general practice.¹³ This procedure is usually done at vascular outpatient clinics but it can be done in primary care. Most interviewees favoured this as a special interest (GPSI) procedure rather than an expectation of every GP.

The problems and practices of a youth health clinic in Porirua are investigated in one report.¹⁴ Exemplifying some issues discussed in our Guest Editorial, although healthcare was free in this clinic for youth, they could do nothing about prescription charges. As these young people often had no money, they often did not fill prescriptions. Another research report found that an e-tool developed to help practices in the care of patients with sexually transmitted diseases (STIs) was used for only a minority of patients but if it was used, care was better managed and documented.¹⁵ Documentation is especially important for STI management because of the array of different people involved in the care of individual patients with these infections.

As always, we hope this issue holds plenty of interest for readers and we welcome your feedback.