The future of public healthcare is uncertain, Dr Dennis Pezaro writes.
I was saddened to read recently the concerns of David Young, a well-respected dermatologist, over the parlous state of specialist dermatology care in the South.
It reminded me of an old conversation with Tim Wallis, who was a very generous benefactor to our little rural health centre in Wānaka.
I was concerned that the base hospital at Dunedin seemed to be making ongoing and possibly unsustainable financial losses, but Tim was reassuring and held that public hospitals could not be allowed to fall into insolvency. Now, I wonder if that approach is still correct.
My dictionary defines insolvency as "a lack of financial resource", but bankruptcy is described as, "the inability to discharge all debts as they become due".
As the bulk of healthcare is a public service, the assets and debts take on different forms:
• Fiscal policy relates to government income and expenditure to build and operate the service;
• Specialist care comes via a wide range of highly trained health professionals working at many levels of increasingly complex care;
• Management is by those in charge of the business of hospitals, supplying services to people, traditionally called patients.
The recently redefined public health service, Public Health South, Te Whatu Ora (PHS) continues to repeat vague, aspirational future options, but mixed with planning uncertainties and slow progress, sometimes extending into indefinite rationing.
Modern healthcare is itself partly a victim of its own success. Lower mortality at both ends of life, together with a healthier lifestyle and modern technology, has greatly increased healthcare needs while, at the same time, allowing a greater range and complexity of interventions.
We can do more care for more people, but we cannot now afford to do all appropriate care for all eligible people.
A core of funded health services was considered in the 1990s, with an example working in Oregon, but it was rejected by the government of the day and the New Zealand public health service became the core.
Two changes were made which affected healthcare services.
• Waiting lists were reassessed to give increased priority to those with more severe disabilities, but lists became more congested when blocked by more urgent work. Qualifying scores seem to be increasing.
• The "user pays" philosophy entered healthcare via two separate initiatives — specialist outpatient clinic fees were tried but quickly abandoned. I understand that the cost of collection of the fees almost equalled the amount collected. Prescription charges have been much more successful, although they remain somewhat a political football, withdrawn by the last Labour government but recently reimposed.
The question of healthcare funding remains. The dominant funding stream comes from government.
Both present and recent political administrations have made praiseworthy efforts to assist those awaiting treatment, together with new funding for new treatments, but the calls for funding are almost limitless and the government is also the funder of last resort for many other major demands such as education, welfare, disaster management and recovery.
Health funding will continue to be a carefully considered political compromise.
Other sources of health funding include the possibility of specific taxation of consumer items known to be associated with increased morbidity and mortality — alcoholic beverages and nicotine products are the most common examples.
The government is conflicted on this issue because it earns large tax revenue from such sales but could legislate to impose a health-specific tax as well.
Some communities use a state lottery to fund health services, but that does not happen in New Zealand.
If the daily cost of inpatient care is to be kept free for New Zealanders then some other forms of funding are urgently needed.
Taxation is the most direct but politically sensitive.
Philanthropy works well but would be easily overwhelmed.
A review of accident compensation coverage for foreign tourists might be considered.
It would be possible to expand the user pays principle into many consumer items used in patient care such as intraocular lenses, heart stents and valves, pacemakers and replacement joints, which are all used solely for the benefit of a single patient who might contribute a portion of the cost to defray the cost of care.
But the hard truth is that if we fail to accept the societal responsibility to find more funding to make the health system work then two things are likely to happen: we shall see the prompt development of two-tier healthcare in New Zealand, with a large growth of insurance-based private healthcare, and for ordinary people, struggling to raise family, secure housing and pay rates and taxes, they will stare abjectly at the spun narrative of increased rationing and wonder if they see something closer to clinical bankruptcy.
• Dennis Pezaro is a retired Wānaka GP.
