Derry Seddon: Doctors fail to offer solutions

The proposed strike action by hospital junior staff and the difficulties experienced by district health boards over passing on the decrease in GP fees are current problems in our healthcare system.

The causes are not new. They are not peculiar to any one government or political party, although the Herald's June 1 editorial left the impression that Labour's efforts to reduce fees paid by patients in primary care were the only ones to fail.

All parties have attempted changes in healthcare, ranging from the steady increase in spending from the 50s to the 80s and the "competition will fix all" of the 90s to the present.

What is consistent over those years is the apparent inability of the medical profession, through its various structures, to put forward testable solutions, in medical education and training, or the provision and funding of services.

This is disheartening as there are models of how to do things better.

In medical education and training there seems to be a perverse clinging to old ways. The medical schools are following the 1906 model (yes, the Flexner reforms of 100 years ago) with only minor changes.

Add to this in the 1950s, a compulsory year of hospital service for all graduates before full registration - not related to what is their intended branch of medicine - and you can see the underlying cause of the unrest and dissatisfaction of junior doctors. This indentured situation has been pointed out as a stress point in New Zealand since 1985.

The recent defence of paying a fee for service and the principle of a "right" to set whatever fees are appropriate has a long history dating back to the late 1930s. Nowhere is this service defined, in terms of time, content or appropriateness.

This last quality is part of the problem in definition. The provision of medical services differs across age groups, populations, social and physical structure, education, genetics and culture of the target population.

The formation of PHOs (primary health organisations) that service a defined population is an important advance because this will enable solutions that fit. It also assists a team approach and, at last, provides a structure where the population becomes part of that team.

Using the team structure in primary care allows for more efficient and effective services tailored for existing problems. This model has been tested in New Zealand, but not in all primary care situations.

The trial of team care and population-based funding in Tauranga primary care in the 1980s was studied over five years. Results showed no decline in health parameters while there was a marked decrease in the costs of referrals, pharmaceuticals and in hospital admissions, X rays and laboratory tests. An independent assessment of patient satisfaction showed increasing ratings over the trial.

The New Zealand situation is amazing in its inability to change. The leadership from the medical profession is reactionary, some would say stubborn.

Take fee for service. This is defended as if it is holy writ. Never has the service been defined, as it has in other countries such as Canada and Germany. There, a discussion can be held. Here, statements abound as would fit religious debate.

Discussion in the media follows a pattern of highlighting a crisis, extracting comment from spokespeople who present their line, with only very occasionally a wide health-sector perspective. There is room for the media to take a wider and continuing approach.

The public, through its organisations and interest groups, the politicians and the professions should look at what can be tried and measured and continue this over the years - as people and society change and new knowledge becomes available.

Whatever is done must be evaluated, not just as one project but in a continuing manner. Without this there is no ethical defence of any system - just blind belief.

New Zealand deserves better.

* Derry Seddon of Tauranga is a retired GP and health services researcher.