Uncovering some assumptions

Health Care Analysis, Vol. 4, No. 2, June 1996, pp. 134-136

Download entire feature, pp. 130-145

Brian Martin and Glenn Mitchell

Department of Science and Technology Studies
University of Wollongong, NSW 2522, Australia

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Paul East's speech 'Debunking the myths and restoring reality' [this issue, pp. 130-133] is, at the most obvious level, an attempt to defend the New Zealand government's health policies. It addresses a series of alleged 'myths' about public health services, answering each one with figures and arguments. Needless to say, some of these defences could be and have been themselves criticised. Challenging myths may be catching. It's interesting to note the NSW Minister for Health, Dr Andrew Refshauge, has recently decided to debunk some 'myths' about the NSW health system.

The Minister says that he invites a debate, but this seems to be only a rhetorical claim. Nowhere in the speech does he set out the procedure for a debate, nor the social values that might be subject to dispute, nor the constituencies that would be involved. This is not too surprising if the speech is taken primarily as a defence of policy rather than as a part of an attempt at dialogue or policy development.

Whether the speech is interpreted as a defence or as part of a dialogue, there is more insight to be gained by examining what is not said and by exposing the assumptions underlying it. The basic framework is essentially the economically rational allocation of medical services to people in need, with the constraints being finances and limits to flexibility in the mode of delivery. The assumed institutional structure is community, regional and central health facilities. The assumed goal is equal service to the entire population, at as high a quality as possible within constraints. Within the framework, the Minister's case is entirely logical, even if facts and conclusions may be disputed. But the framework of rational allocation of resources provided by health professionals has its own blind spots. In order to highlight these, it is worthwhile looking at issues and perspectives.

* The speech contains no mention of any fundamental inequities that might occur within the financial and flexibility constraints. For example, there is no mention of gender, ethnic or class issues. There can be unequal needs and/or demands for health care due to systematic discrimination, stereotypes, self-perceptions and different material conditions. Thus the system may be rational in its own terms while tolerating, perpetuating or aggravating social inequalities that are linked to health outcomes. While the Minister admits that the government has identified funding variations in the North and South Islands which it is addressing 'through its move to equity', this may not be the health system's only inequity. If 'an increasing range of home based services' and the growth of smaller hospitals to meet the needs of regions do not include policies or strategies for minority groups such as indigenous New Zealanders or women, then the 'funding bump from south to north' will indeed be 'like a thin snake swallowing an egg' - but an egg of inequity.

* The Minister assumes that health care is a professional service that is provided only as needed. He makes no mention of the power of the medical profession or pressures for high-tech medical intervention. Overservicing may occur for a number of reasons - patient demand, fee-for-service payments, promotion of medical technology by its manufacturers, prevention against legal action - none of which can be addressed with the framework of rational allocation, since the framework does not provide any scrutiny of decisions by professional providers.

* There is no mention of alternative strategies for health improvement. These include:

- provision of greater economic security, which is associated with improved health;

- promotion of better diet and exercise, not just through appeals to individuals but also by subsidies for or taxes on relevant foods, provision of cycle paths and removal of subsidies for cars;

- investigation and promotion of alternatives to medical intervention, such as nutritional and other non-medical ways of dealing with health problems;

- more vigorous efforts against smoking;

- efforts to reduce industrial accidents and hazards;

- promotion of alternatives to the car, itself one of the major technological hazards of our time.

Needless to say, many of these measures are highly controversial. They challenge business as usual in various ways. Some of them, such as taxes on 'unhealthy foods,' are a challenge to what seems to be consumer choice, namely the unfettered operation of the market. In the case of industrial accidents, the challenge is to the setting of corporate priorities by employers. In the case of the car, the challenge is to the lack of a fair market, namely lack of a 'balanced playing field' in transport alternatives, given the massive subsidies for the car that remain standard practice. Whatever the pluses and minuses of these alternatives, the point is that most of them are rarely even considered as part of health policy, which is usually restricted, as in the Minister's speech, to provision of health services.

* The Minister's speech assumes that health services are provided from outside the community. There is no examination of how community-based learning and practice could be used to improve health. This could involve not just first aid training but also developing local skills in stress management, awareness of warning signs, community plans for diet and exercise, local programmes to deal with problems with drugs (both legal and illegal, medical and recreational), promotion of sports less likely to cause injury, neighbourly support for people in emotional need and many other possibilities. Initiatives in many such areas do exist. The point is that within the framework of rational allocation of professionally provided health services, these possibilities are almost invisible. The strategy of systematically developing the capacities of communities to improve their own health and reduce dependence on professionals is not taken up.

* The Minister's speech contains much irony and many contradictions. In Myth Five, the Minister talks about 'rationing', 'choices', and the reality of finite resources - the same words and phrases used in the critical analyses of the health system. In Myth Three however, the Minister asserts that managers and administrators have little say in the process of resource allocation and decision-making - that this is the domain of doctors and nurses.

In Myth Eight, the Minister talks about the need for doctors/nurses/managers to work together, yet in earlier answers he implies that these operate independently of each other and suggests no need for co-operation.

In Myth Nine, he addresses the issue of money, arguing that this is not the appropriate benchmark by which to judge the health system. Yet in the earlier Myth Three, the Minister refers to a contract between RHAs and public hosptials, a financial contract which sets the number of operations which can be performed at any one time according to the amount of money contained in the relevant contract.

Finally, while the Minister calls for a vigorous debate, he directs the reader to take away certain 'facts' which are inviolable - hardly the basis for an effective debate.

In short, the Minister's speech reflects a standard professional-bureaucratic model of health care. It is an immense challenge to move out of this framework, which has an enormous institutional momentum as well as a hold on many people's thinking. It is especially difficult for a politician to open the door for consideration of fundamental alternatives in health, since this means both challenging vested medical interests and stepping on toes in other ministries, as well as coming under attack by political opponents.

There is much of the popular television series 'Yes Minister' in this document. It has the appearance of laying self-constructed myths to rest and defending changes to the New Zealand health system. But that is only the image. The real purpose of the speech is to defend the present and in doing so, the Minister has denied the system and its principal players the opportunity to go beyond the present system and develop new approaches, new methods, new ways of engaging with the maintenance of good health and addressing ill health.

The Minister's vision for the New Zealand health system is flawed. He is concerned only with the resolution of 'ill-health' - there is little or examination of what constitutes good health and how this can be maintained. And the Minister has overlooked his strongest constituency in his quest for a vigorous debate - doctors and nurses - who witness bad medical practice and who have many ideas on how to improve or change the health system, and policy makers who are sometimes reluctantly enrolled in the development and implementation of 'bad' policy.

There is no reference in the Minister's speech to the contribution these players could make. If there were no restrictions on doctors, nurses and policy makers in the public health system to engage in public commentaries, both the debate and health services would be significantly advantaged.