Book Review - Health Cheque: The Truth we should all know about New Zealand's Public Health System
Issue 30, April 2010
Authors: Gareth Morgan & Geoff Simmons
Publisher: Public Interest Publishing, 2009
Reviewer: John Kleinsman
The question of health care affordability is topical again.
In late February 2010 it emerged that Otago and Southland seniors are to lose home support "in a bid to save money." That same week the Southern District Health Board (DHB) also spoke of the need to reduce the number of elderly people in residential care. The Board Chair, only too aware of the political sensibilities surrounding the topic, described this move as based "on need rather than entitlement." Meanwhile the DHB General Manager of Funding was more candid, admitting that their aim was to reduce the number of beds. Then, in March, a group of concerned doctors raised questions about Pharmac's decision not to fund expensive "up-to-the-minute modern drugs"; the New Zealand Medical Association chairman was quoted as saying that while Pharmac is seen as successfully cutting costs, many professionals believed the agency was a barrier to high-quality care.
Morgan and Simmons give a frank assessment of the challenges facing our health system, citing "many good reasons to expect healthcare spending to continue to rise at the same rate it has in the past and faster than our income growth." As well as an ageing population, these reasons include technology changes, rising salaries and chronic health problems due to unhealthy modern living. Interestingly, for them the "crucial issue" is our increasing expectations as incomes rise. Their description of the dilemma is blunt: "Most of us labour under a delusion now if we think that our system can afford anything we want in the way of medical treatment ... To imagine that it will keep pace of [sic] our expectations in the future is just plain nuts."
A particular feature of the book is the way in which graphs, statistics and figures are used to present key information in an accessible way. The answer, we are told, is not just more money. The authors estimate that even if we could afford it, doubling our present health budget would lead to only a 30% increase in the number of operations and perhaps an additional two years of average life expectancy from 79.6 years to around 82 years! "Incredibly, we could as a nation get the same health benefits at very little cost if everyone stopped smoking, exercised and improved their diet." Thus, they argue, something has gone wrong with the logic behind our spending.
There are other serious issues too. In 2007 UNICEF rated New Zealand amongst the worst of the developed nations for child health with below average rates of immunisation and a death rate amongst young people from accidents and injuries three times higher than Sweden. Maori and Pacific Islanders, in particular, are living shorter lives, reflecting the fact that the answers lie not just in the health-care system; there are many other things, especially poverty and unemployment, that impact on health.
There are no shortage of suggestions in this book as to how to move forward, articulated in the common sense style Morgan is known for. If we can't afford to fund everything then we need to somehow prioritise. While New Zealand prioritises treatment pretty well, we would do better if "the sensible system we have" was used more widely and consistently. Too often it's the squeaky wheel that gets the oil; those able to advocate for themselves are at an unfair advantage. There are other suggestions: the health system needs to be de-politicised; doctors need to work together more; close small hospitals; stop the two timing between the private and public systems; there are many foreign doctors in New Zealand driving taxis; close to one third of all New Zealand doctors are practising overseas or no longer practising after ten years.
The authors are also controversial, suggesting that the pendulum of health care may have swung too far in the direction of the elderly: "Rather than throwing ever more money at old white people – where the marginal returns swiftly diminish – the numbers of Maori who would benefit from relatively simpler investments in public health would be greater per dollar spent."
The analysis offered deserves to be taken seriously given that the book is based on the views of health professionals. Morgan and Simmons have fearlessly grabbed the bull by the horns – and it is no ordinary bull but an elephant bull; the elephant in the (hospital and GP waiting) room that all of us, and especially politicians, have preferred to ignore.
While not everyone may agree with the analysis and/or suggestions offered, or enjoy the style of writing, there is no doubting the importance of clearly and unflinchingly stating the issues. The contribution of this book will be immense for steering the conversation about health care funding going along a more fruitful path; one that side-steps the over-politicised "vote-grabbing" rhetoric that too often characterises healthcare debates in New Zealand in favour of a debate that focuses the questions back onto the systemic and personal implications of a more communal and justice based approach.
Indeed, part of the value of the book for me is the way it has challenged me to think more carefully about my own expectations regarding quality of life, particularly at the end of life. In a society where demand exceeds the ability to provide, the question inevitably arises as to what we are prepared to sacrifice for the common good. This puts a new spin on an old debate previously dominated by the language of personal rights and personal choice. To paraphrase American ethicist John Kavanaugh, I think this book provides an opportunity to lance the boil of self-interest that appears within the body politic and New Zealand society in general.