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New Zealand Department of Health LIBRARY Box 5013 Wellington

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H. 23

A HEALTH SERVICE FOR NEW ZEALAND

Presented to the House of Representatives by Leave

BY AUTHORITY: A. R. SHEARER, GOVERNMENT PRINTER, WELLINGTON, NEW ZEALAND-1974 Price $1.95 LIBRARY DEPARTMENT OF HEALT WELLJNGTON -

CONTENTS

CHAPTER MA II PAGES Principles of the World Health Organisation 5 Introduction 7-9

I The Hybrid System 1-19 10-14

II The Search for Uniformity 15-19 20-34 III Multiplying by Fission 35-46 20-23

IV The Period of Reform, 1909-28 47-79 24-34

V Towards Social Security . 80-112 35-46

VI The Dual System 113-153 47-59

VII Give and Take 154-208 60-74 VIII The Need for Change 209-235 75-82 IX Principles for Change 236-3l4 83-107 X The Scope of the Health Service 315-381 108-125 XI Establishing Regional Health Authorities 382-419 126-133 XII Managing the Regional Health Service 420-485 134-153 XIII The Future of Central Control 486-528 154-168 XIV Staffing the Health Service 529-557 169-174 XV Funding the Health Service.. 558-587 175-182 XVI Transitional Arrangements 588-617 183-191

XVII Conclusion 618-620 192

APPENDICES I Sources of Hospital Board Income, 1885-1957 193-197 II The Distribution of Powers, Functions, and Responsibilities under Hospitals Legislation 198-241 III Hospital Districts in New Zealand, 1885-1974 242-243 IV Commission to Inquire into and Report upon Proposals to Amend the Hospitals and Charit- able Institutions Act 1909, 1921 244-247 V Health Services Organisation, 1922-1974 248-259 VI Dr Macgregors Views on Hospital and Charitable Aid Services in New Zealand, 1898 260-270 VII Social Security Health Benefits 271 VIII The Consultative Committee on Hospital Reform, 1953 .. .. 272-274 IX Voluntary Agencies 275-276 X Hospital Board Representation and Election Results, 1971 .. 277-291 XI Health Service Personnel 292-304 XII Health Service Finance, 1974-75 305 3

FIGURES APPEARING IN THE TEXT

PAGES, I Suggested RegionalHeaith- Authorities •...... 93-94 II Functional IntegratiorI of the Health Service.. 97 III Extent; of Provision of Specialist Services in Different Types of Hospitals 104 Organisation of the New Zealand Health Servie 107 Management of a Regional Health Service ,136

:v1 Proposed Organisation Striiciire of the Nev Zealand Health Authority 162 Scheniati Representation of Interaction btween - BureãUx of the New Zealand Health Authority . VIII Flow. Ptocess Chart: Health Service Reorganisa-.. -,. tion ...... •... ------J1Al:....L.. 41. • .i : 1!

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4- PRINCIPLES OF THE WORLD HEALTH ORGANISATION CONSTITUTION

Health is a state of complete physical, mental and social well- being and not merely the absence of disease or infirmity. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition. The health of all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest co-operation of individuals and States. The achievement of any State in the promotion and protection of health is of value to all. Unequal development in different countries in the promotion of health and control of disease, especially communicable disease, is a common danger. Healthy development of the child is of basic importance; the ability to live harmoniously in a changing total environment is essential to such development. The extension to all peoples of the benefits of medical, psycho- logical and related knowledge is essential to the fullest attainment of health. Informed opinion and active co-operation on the part ofthepublic are of the utmost importance in the improvement of the health of the people. Governments have a responsibility for the health of their people which can be fulfilled only by the provision of adequate health and social measures.

(A INTRODUCTION It is appropriate that the Governments White Paper on the reorganisation of health services should be prefaced by the principles of the World Health Organisation (WHO). These principles display clearly the attitudes to health which have developed during the twentieth century. Concepts of an earlier age which concentrated on the treatment of disease have now been widened to emphasise the promotion of good health by all the means at our disposal. Such changing attitudes have arisen from a number of factors. While environmental problems still remain an important area of activity in the health service, they are different from those which faced society at the beginning of this century. Improvements in the environment, however, along with preventive measures and including the control of the perinatal mortality rate, have been largely responsible for improvements in the health status of the community in New Zealand. The success of environmental and preventive measures has also meant that many of the infectious diseases have been conquered. Diphtheria, poliomyelitis, typhoid, and many other diseases have almost been banished. The young now have a much greater chance of growing into old age, and this has changed the incidence and, therefore, the spectrum of disease. Nevertheless, preventive medicine is still the major area on which to base our efforts Infectious diseases will only be kept at bay by constant vigilance. Many of todays causes of death and disability —transport, industrial, home and recreational accidents; poisoning; lung cancer; chronic obstructive lung disease; heart disease; suicide, and cirrhosis of the liver—are all subject to some measure of prevention. In the past 25 years there has been a vast change in medical technology. Sophisticated methods of diagnosis and treatment have replaced the simple methods of the 1930s. The age of the general practitioner who did a modicum of surgery and obstetrics, often in his surgery or in the patients home, has passed. The isolation Of settlements in the past led to a widespread dispersal of health services and facilities. Because of modern transport services and communications networks, most skilled activities can now be concentrated in hospitals, where they can be carried out largely by specialists, in conditions designed to provide greatest safety for the patient. Highly specialised techniques and equipment require highly skilled staff and efficient use of resources. Much of advanced modern medical technology must be located in regional centres to ensure economic usage of skilled staff. Care however, cannot begin and end at the door of the hospital, but must provide for people in the environment in which they live and work. The community orientation of health services demands a j community based service. It is here that the general practitioner, responsible forcontinuing medical care of the patient, is so valuable. The concentration of specialised treatment techniques in the hospital service does not mean that the general practitioner should be divorced from these skilled activities. With earlier discharge from hospital and continuing care in the home, the general practitioner should have a much closer liaison with hospital services. At the same time, improved medical techniques and increasingly effective medication have made it possible for the general practitioner to handle much more work in the home than previously, and will enable him to play an increasing role in community health services. Primary health .care, or general practitioner services as it is more commonly known, is in the front line of continuing health care and the development of a comprehensive health service. The Govern- ments proposals on this subject are presented as a series of alternatives. The selection of one or more systems for integrating primary health-care will be made in the light of response from the broadest possible cross section of opinion expressed on the subject. The health service of the future must provide a structure within which all aspects of health care can be woven together It must bring together the full range of primary health care;. specialist diagnostic, therapeutic and rehabilitative services; and preventive services. Integration of these various facets of the health service will not immediately solve service problems, but will provide an effective means by which they may be tackled. The New Zealand :Health Service will require its own organisational structure. Provision is made for operational management and future planning to proceed together at both the national. and regional levels.. S A New Zealand Health Authority will be responsible for planning the strategy ófhealth cares determining national priorities, and laying down guidelines on policies needed to achieve planned targets, as well as invoking statutory responsibilities in certain critical • areas of tiational and international health. In this way good management principles will enable the taxpayer to get the best possible value for his contribution towards the cost of maintaining the service. Fourteen Regional Health Authorities will be concerned with tactical planning to ensure that policies . are implemented iii the manner which best serves the population of the region. They will have .authority to achieve this. . The health needs of the community have changed enormously in the last 30 years, and they will change again. The new organisation mst5 be . sensitive to change . and -be. capable of responding. to 8 varying needs. Changing the organisational structure will not necessarily make a better health service, but it will make it possible for a better health service to grow. A health service is about people, patients, and staff, and it is these Who will spell its success or failure The staff of the health services need not approach this major reorganisation with foreboding. Qn the. contrary, they w.11F take.--part in. an exciting :.development aridt can eñterthe -ne :heaith career ervice with the assurance that reorganisatio±i Will tiot be to their disadvantage The Government recognises that integration will be more easily attained by staff who recogmse in its common career service, extending through all levels and spheres of actiyity, the potential of a: first-class health service ofwhich they, and the community they serve,. can be proud.. , . ,•. . The WHO .principle states, informed opinion and active co operation on the , prt of the public,are of the utmost importance iiii the .irnprovemen of. the health of the people". To. This .end,the Government continues to invite submissions, on. any aspect of the health service. The development of views and proposals contained in this document has taken account. of submissions already made on the subject of administrative reform. Constructive. comment on proposals in the White Paper is invited. The proposed reforms should be seen in perspective For this reaon they are set out against the background of health services administration as it has developed in this country This historical perspective reveals the need for, and basis of the reorganisation The retrospect? should be studied as closely as the prospect so that the new, service may avoid the pitfalls of the past.ast The foundations of the reorganised health service should provide for proper emphasis upon the promotion of good health They should also make it possible for New Zealanders to be asiirèd , of thë .right:to the bet pdssible health servicesniade available Without ecOnomic barrier and accoFding tb their .needs...... It is tithefór ..change t not change to a rigid and ptedetermined pattern, because. every organisation shàuld capable of meeting the demands of changing needs Yet there comes a tiem when needs1 change to Such-ii-degree that the.organisation itself must be re-formecP if it is to fulfil fts purpose. The GOierrirneht fliml believes that thel right time is now. .

Minister of Health

9 I. THE HYBRID SYSTEM

1. "The system of Government hospitals as adopted in many Provinces of New Zealand, is bad in principle. It has a detrimental influence on the public mind. It tends to destroy that benevolent and self-reliant feeling which has ennobled the character of the British; it warps the best desires of the disposition, and tends to a despicable dependence upon the Government for aid to the sick and afflicted, which the generous instincts, when cultivated, invariably awards.. . This quotation, from a New Zealand newspaper of 1864, makes it clear that in some circles, the provision of hospital services by the generous for the impoverished was regarded as a voluntary public duty. But the newspapers comments came too late to reverse a hybrid system of hospital organisation dating back to the first decade of colonisation in New Zealand.

Voluntary Hospitals 2. The beginnings of New Zealands health services are to be found in the great development of hospitals in eighteenth-century England. The revival of charity led to the institution of "voluntary hospitals" for the poor, which were endowed by a wealthy benefactor or by philanthropic subscribers. For the payment of an annual fee, subscribers were entitled to nominate patients for admission to their hospital. Services were rendered gratis by honorary medical staff, for whom appointment represented professional distinction as well as social favour. 3. Voluntary hospitals were general hospitals which denied admission to classes of patients considered to be economic or therapeutic risks because of possible long stay or mortality. While the voluntary hospital movement did reach some of the "outcast" patient groups (as shown by the establishment of lying-in hospitals, lunatic asylums, foundling hospitals, fever hospitals, and homes for the incurable), the burden of caring for the medical needs of the poor generally fell upon officially organised charity.

Infirmaries 4. The State entered the field of hospital services in England as a repercussion of the Reformation. In the process of secularisation, a group of London hospitals known as the Royal Hospitals was transferred to civic control. In the seventeenth century State naval and military hospitals were founded. The State also accepted responsibility for the medical needs of the poor.

LL 5. The English Poor Law was consolidated in 1601, and adopted three divisions of poor persons. The able-bodied poor were those unable to find work; the idle poor represented those unwilling to work; and the impotent poor those unable to work by reason of age, infirmity, or illness. While Elizabethan legislation intended to make the basis of State aid "outdoor relief" in cash or kind, the eighteenth . century gradually saw the rise of "indoor relief" as an adjunct to the outdoor system. After 1723 it was permissible to build workhouses to provide indoor relief and to refuse relief to those who would not enter. 6. Until the late eighteenth century, the Poor Law remained a locally organised charity service based on the parish. Church- wardens and annually elected lay overseers were empowered to levy a poor rate to meet the costs of services. In part, costs could be recovered by the labour of recipients. Local organisation led to considerable diversity of services. In some places a parish might have a workhouse for the able-bodied poor, a house of correction for the idle poor, and an almshouse or infirmary for the impotent poor. Elsewhere, all three indoor services would be provided in the one institution. The infirmary was the second ancestor of New Zealands hospital service. 7. The Poor Law was revised in 1834 chiefly to slash Poor Law expenditure, the new legislation clearly distinguishing between the deserving and the undeserving poor. Indoor relief was accelerated and the principle of less eligibility was adopted. By rendering the condition of recipients lower than that of the humblest independent worker, it was hoped to deter malingerers from applying for relief. To ensure that even then spartan conditions would not be better than those enjoyed by independent workers, rigid institutional discipline, segregation of the sexes, punctuality and the requirement that patients should assist in the wards or workhouse, became hallmarks of nineteenth-century charity. The residue of therapeutic problems—the aged, the sick, the insane, and the orphaned—were classified much better after 1834 when the parish unit was absorbed in the administrative "union", which allowed for improved classification of inmates as well as a degree of uniformity impossible under parish organisation. Poor Law administration also became more centralised. 8. The provision of hospitals—be they infirmaries or voluntary hospitals—was justified on the grounds of economy and control of the social problem of the poor. In the eighteenth century it was said to be cheaper to meet the medical needs of the poor in institutions than in their own homes. Wealthier persons tended to remain at home when ill, seeking relief from a variety of persons possessing

11 (A medical knowledge or folklore, including physicians, surgeons, apothecaries, barbers, and quacks. Following the adoption of the principle of less eligibility, infirmary treatment became subject to the same stigma of pauperisation which the workhouse gave. 9. The industrial revolution prompted a fresh examination of health service organisation in England in the early part of the nineteenth century. Towns and cities were scarcely equipped to deal with the health hazards posed by overpopulation, as only in isolated instances had proper organisation for sanitation and other preventive services been made. Pandemic waves of cholera which swept through the overcrowded urban areas in the 1830s spurred on public health reform. The first effective step in this direction was the establishment of nearly 1,200 Local Boards of Health between 1831– 34. A Central Board of Health also existed during that time. More effective machinery awaited the agitation of public health pioneers during the following decade, as a result of which the Public Health Act 1848 was passed. State Health Services in New Zealand 10. The absence of a sizable class of wealthy philanthropists in the first years of colonisation lead to the general failure of early endeavours to establish voluntary type hospitals in New Zealand.2 The absence of a rich class, the scattered nature of the early settlements, and the general tendency on the part of the colonists to leave things to be done by the Government led to early State intervention in health and hospital matters. 11. From 1841 onwards, civil servants designated as Colonial Surgeons or Health Officers were appointed to each principal settlement. These men were appointed to meet the medical needs of the imprisoned, the insane, the impoverished, and the indigenous Imperial armed forces resident in New Zealand had their own medical officers. 12. The nucleus of the national hospital system followed Governor Greys native policy. He hoped to offer Maoris the fruits of Pakeha civilisation—health, education, and prosperity. Following discussions about native susceptibility to European illness, Grey promoted the establishment of four modest colonial hospitals at Auckland, Wellington, Wanganui, and New Plymouth. 13. Colonial hospitals were run as State concerns, financed by land endowments and various current revenues.4 Because they were State financed, the State assumed the traditional right of the voluntary hospital subscriber to nominate patients for treatment. Maoris were admitted free, but some attempt was made to collect fees from indigent Europeans, who were admitted under an order

1.2 from the C1onia1 Secretary. It is tempting to call these institutions public hospitals. True, they were public in that they were provided by the State, but their purpose must not be overlooked. By restricting European admissions to the indigent, the State merely followed the English custom of organising State hospital services on the basis of economic need rather than of social equality. 14. In marked distinction from the hospital organisation based on need, the Lunatics Ordinance 1846 envisaged a public colonial lunatic asylum for all social classes 5 The Ordinance did not follow the traditional differentiation according to pauper lunatics and private psychiatric patients which had only just been removed in England. It is possible to question the unique nature of the universal principle of admission applied to psychiatric hospital services from 1846. True to the oscillation of the psychiatric institution between the general hospital and the gaol, admission was still made after due official process (similar to the Colonial Secretarys approval of admissions to State hospitals). 15. Following the promulgation of the Constitution of 1852, 1. Colonial hospitals were transferred to, provincial governments. Provincial Executive Councils, which were to be known as "Boards of Commissioners", were given control of hospital and other public reserves6. Hospitals, and later lunatic asylums when they were established, were administered as medical departments of the provincial governments. 16. As was inevitable with the development of a State-run medical service for the poor, some features of its English counter- part appeared. New Zealand never officially adopted the Poor Law, but charitable aid or outdoor relief gradually became a function of hospital services throughout the country. The State still considered and approved applications for admission to hospitals except for emergency admissions which could be authorised by medical officers. 17. The role of voluntary charity was not entirely forsaken during the provincial period (1854-76). Benevolent societies were established in various centres to organise services for various groups whose needs were not met by the State social services. Pioneer initiative and pragmatism led to the development of subscription hospitals in new areas, particularly on the goldfields. For example, the Thames Goldfield Hospital rules of 1874 reiterated the familiar method of admission by a subscribers ticket except for accident cases7. The contributions of subscribers attracted Government subsidy and gave donors a say in hospital administration along the lines of the English voluntary hospital system. Even in those provinces with provincial hospital services, local public control was considered 13 to stimulate voluntary contributions and reduce provincial expenditure. 8 In some cases, the demand for local public control arose from a belief that provincial supervision was lax or its administration ineffective. 9 - - 18. By the end of the provincial period a number of forms of hospital management had been adopted in New Zealand. Some hospitals -were still officially run, either directly by the provincial governments or by their nominees. The voluntary hospital principle survived in a number. of towns, while in others hospital admini stration was entrusted to the representatives of local authorities. Combinations of methods were not uncommon. Lunatic, asylums Were run directly by the various provincial administrations. 19. Comprehensive public health legislation was also passed towards the end of the provincial era. The Public Health Act 1872 established a Central Board of Health in each province, and each local authority could become the Local. Board of Health for its territory. The legislation was spurred on, it has been suggested, by the population increase which followed the gold rushes, and perhaps by the threat of smallpox.° Before this date, various pieces of legislation. were passed to deal with quarantine, contagious diseases, and public vaccination. -

REFERENCES Southland Times, 16 May 1864. See for example, W. E. Henley, "The Early History of Auckland, Hospital" in N.Z. Med..Jnl, 1970, LXXI, 455, p. 201; W. B. Sutch, Poverty and Progress in New Zealand, Wellington, 1961, pp. 48-50; and D. M. Wilson, A Hundred Tears of Healing, Wellington, 1948, pp. 15-16. Wellington Independent, 29 April 1846. 4Great Britain Parliamentary Papers, 1847/337; J. Rutherford, Sir George Grey, K.C.B. 1842-1898, A Study in Colonial Government, London, 1961, pp. 77, 98. 6Lunatics Ordinance 1846, s. 4. 6Public Reserves Act 1854, ss. 1, 6. 7Rules of the Thames Goldfield Hospital, Thames, 1874. 8 Wellington Acts and Proceedings, 1854, I, p. 1; Otago Hospitals Ordinance 1862; Southland Votes and Proceedings, 1865, Appendix, p. 91; Hawkes Bay Acts and Proceedings, 1870, Council Paper XVIII; Auckland Acts and Proceedings, 1870, XXVI, pp. 130-1; and Otago Votes and Proceedings, 1873, XXXII, p. 81. °Nelson Votes and Proceedings, 1858, V, Report, p. 3, Otago Votes and Proceedings, 1863, - XVIII, p. 4; Auckland Acts and Proceedings, 1870, XXVI, pp. 130-1; Wellington Acts and Proceedings, 1874, XXVII, C-10, p. 1. °F. S. Maclean, Challenge for Health, Wellington, 1964, p. 12.

14 II. THE SEARCH FOR UNIFORMITY

20. The reorganisation of hospital services which followed the abolition of the provinces had to take account of the interwoven character of charity, local management, and State provision. These three factors dominated the various attempts to find a uniform system of local hospital administration until 1885. The method of financing hospital services necessarily, affected their management. This fact was quickly learned in Wellington: Management by committees elected by subscribers has much to recommend it, but it also has the drawback that the expenditure of public funds is placed in the hands of irresponsible bodies who, in many cases, expend it in needless quantities, get into debt and then bring pressure to bear upon the Government to obtain funds for their relief." 1 21. Lack of public enthusiasm for psychiatric services by the 1870s put them in a similar position to prisons. Consequently, all provincial lunatic asylums (being institutions which functioned independently of hospitals or prisons) were financed and administered as provincial departments. Direct Government control was continued beyond 1876. Because of their curious position between institutions for healing and punishment, the mental hospitals were to create another precedent in the health services. The Lunatic Asylums Department was the first social service department to be established and its organisation served as a model for the Departments of Hospitals and Charitable Institutions (1880), and Prisons (1881).

The Inspectorate 22. In 1876 the Government appointed an Inspector of Lunatic Asylums as permanent head of the new department. His powers were: "to see that the various provisions of the law with reference to lunatics and Lunatic Asylums in the colony are carried out, and to report from time to time upon the state of the several Lunatic Asylums and the inmates thereof, and to render all assistance in his power to the Government in initiating and carrying out such measures as may from time to time be found necessary to promote the care and proper treatment and supervision of lunatics." 23. Two attempts to adopt a similar system of inspection for hospitals in 1877 and 1879 failed. In February 1880, however, the inspectorate of lunatic asylums was extended to involve hospitals and charitable institutions .3 Records do not indicate the powers of

15 the Inspector, although they ultimately coincided with those of lunatic asylums. In both cases, the Governor appointed the Inspector, who might visit institutions without notice whenever he thought fit. Penalties could be imposed for obstructing him. He-was. also obliged to report bri his inspections andofficial investigations; By implication of being the Inspector of Asylums, the central inspectorate of hospital services was entrusted to a medically qualified person who could not practise hi profession while holding -office. It was quite clearly the intention to subordinate the, hospitals inspectorate to that of lunatic asylums because, while the office was combined, each of its incum- bents was appointed because of his service in mental hospitals. The inspectorate was not divided until 1907.

Hospital Finance 24: The establishment of the Hospitals and Charitable Department no doubt reflected the quest for a more stable basis for hospital administration in the first post-provincial decade. The Financial Arrangements Act 1876 empowered the central government to finance hospitals by deducting the necessary funds from subsidies paid to local b6dies. 5 These arrangements were continued in 1878, but the concept of local control was furthered—the central govern7 ment would subsidise at the rate of £1 for !J l contributions of local, bodies and voluntary subscriptions where a hospital was locally. controlled.° The Act of 1878 was as close as any government came to achieving uniformity in the hospital system based on the. principles of local, finance (plus Government assistance) and local control, Nevertheless, various pieces of legislation based primarily on experience in Otago were introduced to Parliament. 25. An abortive Bill of 1877 attempted to relate, local control to voluntary cóntributions. Fifty or more annual subscribers to an institution could apply for registration as an incorporated body and elect their own board of management, while the Government would operate institutions not included in the above set-up.7 26. The following year another Bill was prepared which would have left responsibility for hospitals with local authorities while the Government would have subsidised subscriptions and local body contributions at the rate of Cl : Cl. It was also intended that local bodies should apportion the amount of their contributions. Clyde and Cromwell Borough Councils attempted to implement the scheme.8 A similar effort in Westland was less successful. 27. The principle of local control was also envisaged in a Bill of 1879 which proposed Hospital Boards elected by contributory local bodies (e.g., borough and county councils and road boards). Boards would be given "exclusive management and control" over

16 all institutions in their districts.9 The Bill lapsed with, the fall of Greys Ministry, but -the ensuing Government also made two bids to. pass hospitals. legislation.,0

The Hospitals and Charitable Institutions Act 1885 28. In terms of hospital management, the period 1877-1885 was to be described as a "hybrid, system" by Vogel who designed yet another Hospitals and Charitable Institutions Bill in 1885.. This measure was passed by Parliament and laid the foundations for present hospital administration. 29. The Bill owes much to the influence of Dr G. W. Grab ham, whose appointment as Inspector of Asylums and Hospitals followed Skaes dismissal in 1881. Grabham disliked the irregular and capricious distribution of hospitals throughout the country, for which he blamed parochial rivalry." A firm believer in local management and voluntary and local finance, Grabhams views were welcomed by the Stout-Vogel Ministry, anxious to be rid of an economic burden. In the 3 years preceding the introduction of the 1885 Bill, the Government was providing nearly three-quarters of the funds needed to run hospital services. The role of charity was still significant and accounted for 13.2 percent of hospital income. Nevertheless, Grabham observed that the absence of a subsidy system had in many places allowed voluntary contributions to drop away •to nothing. The Inspector noted that so long as central funds were used to finance local concerns, so there would be -extravagant expenditure ill befitting a country in the middle of a depression." In the same way, he emphasised that the. State should be concerned only with care for the deserving poor, and was alarmed at the degree for which failure to collect fees for treatment threatened to pauperise the nation.14 (Details of hospital income are set out in appendix I.) 30. On the basis of Grabhams views, new hospitals legislation was submitted to Parliament in June 1885. Vogel based the Bill on three principles: . 30.1. That committees of hospital management. should be essentially local and made amenable to public opinion by, being elected. -30.2. That expenditure should be somewhat localised. 30.3. That central government should meet a reasonable proportion of the expenditure, but should not be looked upon as the last resort of local boards. 15 31. The lines of administrative control of hospitals were clearly, intended to follow, finance to its sources. A large section of the Bill therefore dealt with "separate institutions" to be financed from, 17 charity. Subscribers could apply for incorporation where 100 or more annual 5s. subscribers whose total contributions exceeded L100 were found. They could elect trustees who were to hold all the powers of a Hospital Board over the internal management of the separate institution. 16 32. For services not covered by separate institutions, the State would provide a subsidy on local contributions and charity. Hospital income was to be derived from the following sources, and matched by central government subsidy, as shown by figures in parentheses. 32.1. Rents and profits of land and endowments. 32.2. Rents and profits of land and endowments set apart for the benefit of particular institutions. 32.3. Voluntary contributions, including donations (l (and later Ll 4s. Od.) for IJl). 32.4. Bequests (lOs. for every Cl with a maximum subsidy of /J500 per bequest). 32.5. Grants from contributory local authorities in a Hospital Boards area. (/Jl per 1Jl. Originally the Government had sought a rate of lOs. for Cl.) 32.6. Subsidies from the Consolidated Fund. 32.7. Funds derived from other sources under the Act or other Acts. The bulk of this income would derive from patients fees. 17 / 33. Quite clearly, the Government intended hospital income to be of local origin supplemented from central sources. For this I reason, the Governments watchdog on the system would be the ( inspectorate, whose powers were merely of advice and report. With very few restraints, authority was to be exercised through Hospital Boards, whose functions under the 1885 Act and subsequent legislation are set Out fully in appendix II. Boards could open and close institutions at will, and could regulate the admission of patients and inmates to their institutions. Hospital Boards could demand contributions from territorial local authorities which, in turn, could levy a rate for hospital and charitable aid purposes. No central control of expenditure, loans or staff appointments was contained in the Act of 1885. Local control was assured by the provision for Boards to comprise members elected annually by respective local authorities or groups of local authorities. 18 34. Separate institutions could select whatever patients they wished. Hospital Boards could regulate the types of patients to be / admitted to their institutions. Thus the Christchurch Hospital in 1885 denied admission to insane persons, maternity cases, and 19 I persons suffering from infectious diseases. Such instances were no jdoubt common, so the State found itself having to operate its own 18 institutions for these residual cases. Lunatic asylums were the obvious and major example, although there were others. In 1903 the Public Health Department opened the Waikato Sanatorium for consumptives at Cambridge, and encouraged Hospital Boards to build their own annexes for tuberculosis cases. 20 In 1905 the State opened its own St Helens Maternity Hospitals. Another example of State operation was the Rotorua Sanatorium, which was run by the Hospitals Department after 1891. However, the unique nature of Rotorua municipal administration may have played a part in the move to place the sanatorium under State control.

REFERENCES

"Unsigned memorandum to Colonial Secretary, IA 1, L.77/3324, n.d. [1877]. Appendix to the Journals of the House of Representatives [A.7.H.R.] 1876, H-4c, p. 4. See also W. A. Brunton, "If Cows Could Fly" in Australian and New Zealand Journal of Psychiatry, 1972, 1, pp. 46-51. New Zealand Gazette, 1880, I, p. 264. 4Lunatics Act 1882, ss. 128-9, 131-2, 135, 143; Hospitals and Charitable Institutions Act 1885, ss. 93-5. "Financial Arrangements Act 1876, ss. 4 (5), 13. 617inancial Arrangements Act 1878, ss. 5-6, 8.. New Zealand Parliamentary Debates [N.Z.P.D.], 1877, 24, pp. 73-4. A.J.H.R., 1878, H-31, pp. 1-2; Appendix to the Journals of the Legislative Council, 1878, No. 20, pp. 12-16. Hospitals and Charitable Institutions Bill 1879, ss. 6-8, 35, 42 (7). "Hospitals and Charitable Institutions Bills 1880, 1881. "N.Z.P.D., 1885, 51, p. 102. 12A.J.H.R., 1883, H-3a, p. i. "A.J.H.R., 1885, H-18, p. 2. 34A.J.H.R., 1883, H-3a, p. ii. 15X.Z.P.D., 1885, 51, p. 101. "Hospitals and Charitable Institutions Act 1885, ss. 38, 42-3, 48, 56. For a full discussion of the hospital system between 1877-92, see M. F. Chilton, The Genesis of the Welfare State, Unpublished M.A. Thesis, University of Canterbury, 1968. Hospitals and Charitable Institutions Act 1885, s. 14; Hospitals and Charitable Institutions Act 1885 Amendment Act 1886, ss. II, 22. "Hospitals and Charitable Institutions Act 1885, s. 7. Rules and Regulations of Christchurch Hospital, Christchurch, 1885. °A.J.H.R., 1903, H-3 1, p. 16, and 1904, 11-31, p. viii.

19 III. MULTIPLYING BY FISSION / 35. The fragmented pattern of health care and administration f was accompanied by a shattering of the areas of administration. Geographic isolation and the remoteness of authority, from the I earliest days of settlement, inevitably led to pressures for local government. Where the provinces did not work, a multiplicity of local authorities arose under the guise of borough and county councils, road boards, and the like. The same shattering effect was to be observed in hospital administration. Chaos in Hospital Administration 36. Vogels original Bill of 1885 divided the country into 12 hospital districts, based on a rationalisation of the provinces, which the rampant parochialism of the day turned into 28. Details of the fragmentation are given in appendix III, although it does not convey the reality of the administrative confusion. By 1908 hospital services in New Zealand were provided by 27 separate institutions, 13 Hospital Boards, and 23 Hospital and Charitable Aid Boards, as well as institutions run by the Public Health, Lunatic Asylums, and Hospitals Departments. In Wellington, for example, the Hospital Board found the money by levying local authorities for the Welling- ton Hospital. But the Wellington Hospital Trustees were a separate institution controlling the Hospital which had power to requisition upon the Hospital Board for grants. Then the Wellington-Wairarapa United Charitable Aid Board levied local authorities for charitable aid in the Wellington-Wairarapa districts. In turn, this United Board was requisitioned upon by the Wellington Benevolent Institution which controlled the Ohiro Home and outdoor relief in Wellington. Even then, hospital services were not complete, for the Lunatic Asylums Department ran two institutions in the Wellington area, and the Hospitals Department the St Helens Hospital. Chaos in Public Health Administration 37. If hospital administration was confusing enough, that of public health was even more complex. 38. Following the abolition of the provinces, new public health legislation was required. The Public Health Act 1876 retained many features of its predecessor of 1872. The features of that Act were suitably adapted to suit new central-local government relationships. Local authorities continued to act as Local Boards of Health and

20 could appoint officers, including surveyors and inspectors of nuisances.2 However, the appointment of a medical officer of health was not made mandatory. 39. The provincial Central Boards of Health were superseded by one Central Board for the whole Colony. This was generally superior to the various Local Boards in that the latter were required to report to the Central Board of Health and to publish and execute any of its regulations. 3 The Central Board of Health was to consist of four to seven members, presided over by the Colonial Secretary. The Inspector of Lunatic Asylums and Hospitals was always a member. After an enthusiastic burst of activity, by 1881 the Central Board of Health had settled for a life of inertia, sitting only when necessary, and never taking the initiative in public health matters. The Government apparently recognised the Boards weakness and by-passed it on several occasions, even before the bubonic plague scare of 1900. 40. The Central Board of Health was given few powers over local authorities because: "To give a nominated. Board bureaucratic authority to compel the execution of its regulations by these elected Boards would be open to very grave objection."5 Local Boards of Health were given a considerable degree of control over sanitation, infectious diseases, nuisances, offensive trades, and food hygiene. 6 The multiplication of local authorities meant that, by 1900, public health responsibilities rested with 86 counties, 98 boroughs, 218 road boards, and a sprinkling of town boards.7 41. The diffusion of agencies involved in public health and hospital care was not only a thorn in the side of central administrators but also proved detrimental to the effective delivery of health care. An early Hospitals Department report spoke of: "Multitudes of municipalities multiplying by fission like so many bacteria in a good fat infusion. . . . We are almost in a state of administrative paralysis from the impossibility of organically co-ordinating their functions; worse still, but which is never heard of, a very large part of the real administration of the country is carried on by their officers, who are miserably underpaid because of their multitude, and whose efficiency is in proportion to their pay. . ." 8 42. The inspectorate of Dr D. Macgregor (1886-1906) was marked by the way in which the Lunatic Asylums Department became centralised and authoritarian under his direction. Hospital reform was more difficult, but Macgregor pressed for radical reorganisation of local government and a reduction in the number of hospital and charitable aid authorities to "about twenty strong boards". 9 He regarded parochialism as the curse of the hospital service:

21 "In all our centres of any size this pressure creates a demand for hospitals, in order that an existing doctor may be retained or a new one induced to settle. The usual procedure is: The doctor suggests to some of his influential friends that a district is entitled to a hospital quite as much as such-and-such a place. The local editor is enlisted, letters appear in the paper, some active and ambitious member of the local body sees possibilities in the movement. He heads a deputation to ihe Minister. Nobody counts the cost. I have resisted to the utmost in such cases, but always in vain. At this moment claims on claims are being urged, and all the obstruction naturally falls on me. . . . If things go on as they have been doing, I see nothing for it but that the practice of medicine be taken bodily over by the Government." 10

The Public Health Act 1900 43. The public health law was quite inadequate to meet the needs of a crisis in 1900 when bubonic plague threatened to sweep through the country. The crisis prompted Dr Macgregor to move successfully the most Important resolutions in the history of the 24-year-old Central Board of Health: "(1) That the functions of the Central Board of Health as defined by the [Public Health] Act of 1876 have until now remained practically in abeyance, so that there has been no attempt at such control as is provided for in section 11; "(2) That the time has come when the whole relations between the Central Board and the local boards be reconsidered, a Department of Public Health armed with the powers of the Central Board should be established, and systematic inspection should be carried out by an officer properly qualified by special expert training in modern sanitary science; "(3) That the powers of this officer should be carefully defined in relation to the necessary control of all the operations of the local boards."" 44. When Parliament met in June 1900, the first piece of legislation to be considered concerned bubonic plague prevention. The Bill was rushed through all of its stages in 2 days. The Act gave extreme powers to the central authority. Subject to notification of infected areas, the Governor could assume all powers of Local Boards of Health or other local authorities to deal with, the plague. In addition, he was given full and absolute power to enforce any other hygenic measures required to control the plague or cure infected persons. Such actions could not be challenged in courts of law. 12 Such extreme powers were only granted on a temporary basis, while the Government prepared permanent legislation. 45. The revised Public Health Act scrapped the outmoded, administrative machinery of 1876 which was quite inadequate to deal with the feared epidemic. The following comments made upon the Bills introduction showed how unsatisfactory the devolution of public health responsibilities had been:

22 "Under the law as it stands there is a Central Board of Health, that is absolutely powerless for the purpose of carrying on the functions it was intended to discharge when the Board was created under the present Public Health Act. . . . As it stands at the present time, there is divided authority. . . . The Local Board of Health is invariably the Borough Council; and if the Health Officer considers it necessary for the material well-being of the people that something should be done, he is at once confronted by the fact that the Local Board of Health, which is the municipal body, has pressure brought to bear upon its members from the ratepayers, with the result that undesirable and insanitary buildings cannot be removed, or objectionable nuisances dealt with. Local pressure is brought to bear upon the municipal body, and a state of affairs is allowed to continue which is not conducive to the health or well-being of the people. . . . In any reform of the health laws of the country, it ought to be one of the first essentials that it should remove from the local public bodies the duties now devolving upon them, which is never, or hardly ever, carried out." 13 46. The Public Health Act 1900 therefore began a trend towards centralised health administration. The general administration of the Act was entrusted to a Department of Public Health under the control of a Minister of the Crown. (New Zealand is the first Commonwealth country which took such a step.) The Department was to be headed by a full-time Chief Health Officer who was required to be a medical practitioner, having special knowledge of "sanitary and bacteriological science". Like him, the full-time District Health Officers were also required to have such training. Six districts were initially established—Auckland, Hawkes Bay (and Easi Coast), Wellington, Westland (and Nelson-Marlborough), Canterbury, and Otago.

REFERENCES

1A..H.R., 1908, H-22, pp. 57-8. Public Health Act 1876, ss. 14-15. ibid., s. 18. F. S. Maclean, op. Cit., pp. 115, 117, 119. X.Z.P.D., 1876, 21, p. 502. 6F. S. Maclean, op. cit., pp. 12, 421-6. A.J.H.R., 1960, 1-18, pp. 103-4. 84..J.H.R., 1889, H-3, p. 4. A.y.H.R., 1892, H-3, p. 2. cf. A.J.H.R., 1895, H-22, p. 1; 1897, H-22, p. 2; 1906, H-22, p. 2. Macgregor included his proposal for 20 Hospital Boards in the draft Hospitals and Charitable Institutions Bill 1906. Details are contained in appendix III. 10A.J.H.R., 1898, H-22, p. 6. 11F. S. Maclean, Op. Cit., p. 118. 112 Bubonic Plague Prevention Act 1900, ss. 2-5. 18X.Z.P.D., 1900, 113, pp. 190-1. 14Public Health Act 1900, ss. 6-7, 9; A.J.H.R., 1901, H-31, p. 1.

:4 IV THE PERIOD OF REFORM, 1909-28 A Healthy Marriage 47. Officers of the. newly founded department shared the dis- satisfaction of the Hospitals Department about the proliferation of local bodies. Those were said to multiply in the "spirit of Little Pedlington"—increasing universally as the size of the community diminishes. Perhaps this accounted for the friendship and courtship which sprang up between the two departments. The Chief Health Officer may well have been Macgregors spokesman when he said in1903: "The whole question of hospital-administration requires reconsideration Greater powers should unquestionably be., given to the Inspector-General, and Tam pleased .to see that the trend of opinion is in that direction. That the Government, required as it is by statute to provide half of the total expenditure on hospitals, should have absolutely no say in the spending of the money is ridiculous, and tends to extravagance."2 48. The courtship between the two departments led to engagement and eventually to marriage. Responsibility for maintaining ii- fectious diseases hospitals was transferred from the numerous local authorities to Hospital Boards. At the same time, District Health Officers were given the same powers as Inspectors of Hospitals. Public Health Department involvement in -hospital matters did not end there. The Department was responsible for inspecting private hospitals until 1906, when this was more properly entrusted to the Hospitals Department. 4 After Macgregors death in late 1906, the departments he had headed for 20 years were split into a Mental Hospitals Department and a Hospitals Department. The latter was entrusted to Dr T. H. A. Valintine, whose service had been iii the Public Health Department. Upon the departure of the Chief Health Officer in 1909, Valintine was appointed Chief Health Officer and Inspector-General of Hospitals thus uniting the two departments. The Mental Hospitals Department was left outside this arrangement and had a separate existence for 40 years. 49. In addition to their supervisory and inspectorial functions over local authorities, the Hospitals and Public Health Depart- ments acquired activities of their own. As nursing became more of a respectable profession, the Asylums and Hospitals Department established an assistant inspectorate. In 1895 Macgregor felt "driven" by some recent political and social developments to advise the appointment of Mrs Grace Neill to this office. Mrs Neill

24 had fornierlybeen with the Labour Department, but was a trained nurse. 5 Under her direction, State registration was extended to nurses (1901) and midwives (1904) as, it had formerly been granted to doctors (1867) and dentists (1880). Mrs Neill was also responsible for the institution of the Department-run St Helens Hospitals in 1905. After 1906, the Hospitals Department undertook the registration of private hospitals, many of which were small maternity homes. 50. The Public Health Departments functions were also accumu- lated in its early years. The establishment of the Waikato Sanatorium has been referred to earlier. In addition, the Department ran the national pathology laboratory, and after 1907, supervised food and drugs legislation. In 1911 the Department became responsible for the Maori Health Service.

Functional Self-Sufficiency 51. Valintine tried to pursue the alliance of preventive health and curative services at the local level after it had been secured in his Department. His views on the functional components of an ideal hospital district were set out in 1910 6 51. 1. The base hospital was to . be regarded as the centre of preventive and curative medicine in the district. It would ideally be staffed by a Resident Medical Officer and Assistant Medical Officers (one of whom would be a skilled bacteriologist). Nursing services would be headed by a Matron-in-Chief. Both the Resident Medical Officer and the Matron-in-Chief would exercise general control over the other institutions of the district, the . Resident Medical Officer advising his Board, in addition to his administrative duties, on public health matters. 51.2. Valintine also envisaged Hospital Boards acting as local authorities for public health purposes where the local authorities consented. This would help to link: preventive and curative components of the health :srvice. The base hospital would operate various specialised services for the district, including an outpatient department for those unable to pay a private doctor, a tuberculosis dispensary or outpatient preventive service, and a psychiatric ward for cases of incipient insanity. ShOuld sufficient land be available at the base hospital site, an infectious diseases hospital for the treatment of persons - who could not be treated at home would also be provided. . . .51.3. A maternity ward would be attached to all hospitals, except where a St Helens;: Hospital or other hospital provision already existed......

25 51.4. A tuberculosis sanatorium would be provided in larger hospital districts, and consumptives placed under a resident medical officers care. 51.5. An old peoples home would be available for the indigent and situated on a farm capable of producing food for inmates and patients. The home would be placed under a trained nurses control, and might have attached to it a chronic ward or hospital for incurable patients. 52. Such hospital districts were clearly intended to be functionally self-sufficient. Provision would be made for all types of patients including those patients (e.g., maternity, psychiatric, venereal, and consumptive) which Boards had hitherto shunned. The effective coverage of the district would not only be met by institutional and charitable aid services alone, but also by promoting the work of district nurses, whose duties embraced a degree of social work. District nurses were: 52.1. To call in medical aid if they thought such were required, and faithfully to follow out the doctors orders. 52.2. To acquaint the doctor of the daily condition, pulse, tem- perature., etc., of each patient so that he could know if another visit were needed. 52.3. To render first aid in case of accident, and to accompany the patients to hospital. 52.4. To be local supervisors of untrained midwives and see that they kept their kits clean. 52.5. To advise Hospital Boards of the circumstances of applicants for charitable relief. 52.6. To attend emergency maternity cases. 52.7. To advise mothers on baby-feeding and general sanitation.7

Hospital Reform, 1909 53. With the breakaway of so many hospital districts which were unable to. provide more than a cottage hospital service, some provision was needed to keep abreast of trends in health services. As communications improved (the North Island main trunk railway was completed in 1908), so the need for some rationalisation of services became obvious in order to take account of the rise of the nursing profession, the dispensary movement and technical advances - in medicine and surgery. Valintine was as deeply committed as Macgregor to the idea of a reduced number of hospital districts. He immediately pressed on with the task of hospital reform be- queathed by Macgregor. What might be termed Macgregors epilogue was the draft of a new. Hospitals and Charitable Institutions Bill dated 1906, which was presented for consideration by the first

26 conference of Hospital and Charitable Aid Boards in 1908. After this conference, the Bill was redrafted before its passage through Parliament in 1909. 54. Like its predeccessor of 1885, the Hospitals and Charitable Institutions Bill of 1909 unsuccessfully tried to secure a number of hospital districts which would be functionally self-sufficient by the standards of the day. The association of public health and charitable aid with hospital based functions in 1909 showed how much further health and welfare activities were understood by then. 55. The new Act of 1909 was more successful in the way it applied the principle that lines of administrative control of hospital matters should follow finance to its sources. Consequently, the number of separate institutions was drastically reduced by scrapping the autonomy of all those which relied upon Hospital Board finance. Only three hospitals survived as separate institutions, although a number of charitable institutions remained. 8 56. It will be recalled that the 1885 Act envisaged a tripartite source of hospital income derived from Government funds, local body rates, and voluntary contributions. The declining importance of the voluntary factor was recognised over the years, and offset to some extent by the rising proportion of income derived from patients fees. Before the 1885 Act, patients fees accounted for only 6.5 percent of hospital income, but in the quinquennium 1901/05 had doubled to 13.7 percent. Details are shown in appendix I. 57. The Departments pressure to make Boards collect fees was one aspect of its continual battle to make the autonomous Hospital Boards stop wasteful expenditure of public money. With central government providing about 10 percent more hospital funds than local authorities, the time was ripe to try to curb prospective areas of extravagance when the Act was revised in 1909. This was achieved principally by replacing the Ll per £1 flat rate subsidy on local body levies by a sliding scale of subsidies. Subsidies were based on the rateable value per head of population in a hospital district, together with the rate of levy per head of population. Thus, if the rateable value per head was under J100 and the rate of levy per head was less than 2s., subsidy was paid at the rate of 24s. 3d. The revised subsidy system was therefore designed to give a higher rate of subsidy to a poor district with low rateable values per head than a rich district whose high rateable value pre-supposed a lesser number of poor people to be provided for. if such a rich district proved to be extravagant and levied a high rate, it received a still lower subsidy. (Subsidy rates paid on bequests and voluntary donations were not altered.) The new subsidy scheme provided a nation wide average subsidy rate of /jl for Cl. 27 :58. The h6v financial. itiuktiiie was Tnót. eipected là. change the ositidi whereby half the. hàspital maintenance costs were met by central funds. At any rate, more money was derived from taxation than from rates.. For this reason, ,a theasure of central control,-.of Hospital and Charitable Aid Boards followed in 1909. By contrast; the legislation of 1885 hardly .mentionccl either the Department or the Minister: ,, • : 59.iIt will! be seen from appendix IF that the Ministers pbwes were considerably-, broadened in 1909. Capital . works which. cost more tha!J250, required his approval and 1.his consent was , required befoi .a Hospital,,BQard, could close an institution or sell its lands. The Minister, given power .to approve lylaws. In addition,. HQspitai ;Bpards .were , obliged , to seek Minsterial ,pprovahbefore, proceeding. -kraise:lpans.. In , the.area,of ,staffing, Boards had notir , the, ;Minister ftheir intention .to appoint principal. staffi The ultimate weapon in the .Gdvernments: armoury , was to withhold subsidies or to direct the Inspector-General to rectifr, .any, short- coñiñgt B6afdi dpeiise. L... £ Pjll" ) I P, i I I I :6Q. The powers of the , Department, were, not, ..widened greatly: The,Inspector-Oenerals., power to ..authorise the admission of infectious,- disease. cases was :extended .to include 1other diseases, but- exercise:of the power was qualifiedby. making it dependent, Upon ,he a..vailability: of adequateaccommàdatjon. After .1920, the Departmei could set minimum medical and nursing staff establishments Even so,, departmental .. controls , werelimited as .was ated in 10:

The Department1. does .not.administer Hospitals, bpi inspects ,them., Its powers of, control are ,limited, to thàse . .,. which enable, the Departnent before g1vmg its approval, to thoroughly consider plans of prdpoied büildings,and alsd tc prevent the establishment of ulmecessar)i or- ;,uAwitable , Institutions.. .When Once an institution-,is established, however, the Department possesses but little actual power, though -Section 77 of the Act gives certain penalising powers.1Subsidy, • however, has never. yet beenwithheld, -in fact it would be ,difficult "to doso, as if it were withheld it would mean, that the Board was short of funds and would levy its requirements the following year, receiving • subtidytheteon : atitomaticàlly. ...The Departrhents T.powets are rather in the direction of moral suasion and there is seldom a questiou of any. importance where.theDepartrnents requirements have not. in the6.1 long.,run been given effect td."i o , , ( ; . Th, , intrusion of central agencies .upon.their, autoi ny was bitterJy , resented 1by Hospital Boards in;spite of the fact, that, it. reflected, more fairly.the 1principle of control, following the source of fina.nce.. For-,this. reasons the, local .contributioh,whether by rtes, fees, or,, donation :,was.gien. much better recognition. in 1O9. . I i. :62bThe ginàl.AtpFovided fort Boards toomprise nominated members of contril5utoiy cIoCãl authoritiés ..:In a hospital1stiict:

28 Representation was to .be in proportion to the amount ontributed. The Actof 1909 replaced the nomination system by one of election except for filling casual vacancies. .Board members, were to be chosen directly by the electors of the .contributory, local authorities.,,, On. the basis of the relative populations and relative values of the rateable property in the contributory districts. An attempt to widen the electorate from that of rate-payers to the. Parliamentary franchise failed 11 Popular control of hospital srvices was extended still further in 1909 To involve the best and interested persons in hospital management, it ,was intendd tht every institution should be directly managed by a committee nominated by the Board While these committees were to" remain subordinate to the Bord, they could tinclude persons who were not Board nembrs, as could committees of inquiry AA , 63. The complicated sliding scale on local leviès introduced.in. 1909 soon. .pfoved to be workable. Its effectiveness ,, depended. upon, a statiohary population, and valuation. Inflation during the First World War played hav6c)with the system, so that the average subsidy rate fell steadily and by 1921 had reached the stage.wheré,,, instead of a Cl for Cl subsidy, the Government was providing 6hl14s. 6d. of its sharàfLiThe diffeieilcehàd t6be riade upby thd ratepaier 12 1920 the system needed major reform A nuthber cif propositiOns was thèxi thrash6do6t,i1 Of whIàh !âdherèd ththW eablisf1edprinciple that the iet cot Of the public , hospital ericè shOuld.be carried è4iâlly b local leviesãnd State finãn&.

Tile HosjitdsCl oi niii ission, 19211 F. . . 64. The financial pob1mwrredá refe to a Hospitals Commission set up. in 192lA number of:long standihg .prOblerns s .lso studied .by the Cothmision;:inchidiiighbspita1 representation : and .ai reduction A the :iithnber ofdithicts. Neithttof ihese traditional. quibbles ofthe central authrities: was ially .set•tled in theirfavOüi as is shown in appendix IV. However,iirprciementsin th subsidy. system, modelled along lines suggested by the Hospitals Commission, were introduced in 1923. The new scale varied the jate of Subsidy from 14s. to a maximum of 1,6s. Od..perjJl.with an assured national average f 11 for (J1 A higher subsidy was paid in those districts where the Boards levy was relatively high in relation to the rateable capita,, value Conversely, a lower, subsidy was paid where the levy was relatively low 13 (A .; .. .Al1...A ..A ... ;.,•.... ..I .,... .1

The InflueiizaConinission .,. ., -. 5 .Tiië infuenza..pandemicstruck NewZealarid at afirne When the Departments resources :wcir6a1readystretched-; to .thd :1iiit

29 because of the Great War. The nations unsatisfactory handling of the pandemic prompted the establishment of a Commission of Inquiry in 1919. The Commission was required to include for consideration the responsibilities and administrative relationships of the Department and local authorities in so far as they affected the public health. 66. The Commission was critical of the Departments tardiness in dealing with the emergency, even when due allowance was made for under-staffing. It also thought that the Departments medical officers spent too much time in administrative work for which they were not trained, which prevented them from fulfilling the professional aspects of their job. However, the Commission was even more critical of public health legislation, which was said to have been hastily prepared and which had failed to define the powers and responsibilities of the various agencies and persons. The Commission noted that there was "extreme complexity and diffuse- ness in this department of law, making it most difficult for any but specialists to have a knowledge of the requirements and obligations of the various statutes". 14 67. It was natural, therefore, that the Commission should recommend a consolidation and simplification of public health legislation. 15 Apart from large towns and cities, it was hoped to make the Department responsible for the administration of public health services through smaller health districts and improved staffing. Some recommendations also looked towards co-ordinated activities both within New Zealand and abroad and a tightening up on sanitation in slum areas and ports of entry. 68. The report of the Commission came too late to allow for immediate preparation of legislation, yet the Departments own recognition of the "chaotic condition" of public health administration, along with the Commissions mandate, warranted top priority for reform in 1920.16

The Health Act 1920 69. Responsibility for public health services was to be shared between a recast Department, a Board of Health, and territorial local authorities. The new Act reflected current thinking. The Department adopted the principle that "where local bodies are doing everything they can, leave them alone unless they ask for help; but the central Department must have mandatory powers in cases of neglect". 17 This was in line with a philosophy expressed as early as 1907, when the Department had overcome the major public health scares of the turn of the century: 30 "The public has come to look upon the Departments officers as the final court of appeal on all otherwise unsolvable matters of sanitation. Not now do we direct—we are consulted." 18 70. The reorganisation of 1920 showed up the Departments reluctance to wield the sweeping powers over local authorities it was given in 1900. Instead, many of these powers were given to the Board of Health, which had been revived in 1918, although initially in an advisory capacity. 19 "In order to strengthen the hands of the Minister and to avoid the charge of placing too much power in the hands of a "bureaucrat" [the Chief Health Officer] a Health Board is set-up which can deal with all matters wherein mandatory powers are given to the Health Department over local authorities. "This Board can itself exercise certain mandatory powers, but anything approaching interference with the principles of local government has to be referred to the Minister and is the subject of an Order in Council." 2 0 71. Under these circumstances, the relationship of the revamped Health Department to local authorities was largely of an advisory and supervisory nature, although reserve powers could be exercised when necessary. In certain cases authorities could make arrangements with the Department which would then undertake the authoritys powers and duties regarding sanitation. The Health Department retained responsibility for areas such as quarantine, epidemic control, purity of food, hospital inspections, and school medical services. QD2. Reorganisation of the Health Department not only followed from public health emergency, but also from various contemporary health needs. For this reason the word "public" was dropped from the Departments title and its internal structure modelled along British and American lines, where "divisions" of public and general health warranting special attention were given administrative entity. Some divisions—Public Hygiene, Hospitals, Nursing, and Maori Hygiene—were areas in which the Public Health Depart- ment was already interested. Others stemmed from an awakening need for child care: Child Welfare, School Hygiene, and Dental Hygiene Divisions. The full organisational structure is shown in appendix V. 73. Each of these new divisions reflected a concern for child health manifest from the early years of the century. The Child Welfare Division was placed under the control of Dr (later Sir) Truby King, formerly Medical Superintendent of Seacliff (psychiatric) Hospital. Arising from a hope that mental illness might be short-circuited by the adoption of proper physiological principles in child rearing, King instituted various feeding programmes at 31 Séaéiiffin,the early years of this .cëñtury,. In 1907, King established the Royal New Zealand Society for the Health of Women and Children, more generally known, as the Plurket Society. Its services played no small part in reducing infant mortality, and the Society rapidly became one of the major vpluntiry agenciesin health care. 74. A school medical service had, been suggested in 1904, but it was not until 1913 that a scheme was put into effect under the control of the Education Department. The transfer of the service to the Health Department reflected its expansion by the employment of school nurses, and also showed the awareness in the minds of its administrators that: . . . "AS most of the defects and poor health in school-children are due to causes operating in the pre-ichool period, nosystem_which concerns • itself only with ,children of • school age can effectively deal with the problems of child-health.. . . In the building of:a childs physique the first six years are of much greater importance than those of the school- going. period. The effect of errors of nutrition: in these earlier years can never in later life be wholly .remedied."22 75. The poor ..ñental heakh of recruits to the armed services during World War I drew attention to a hitherto neglected area of the public health. In 1919 a school dental service was started under he auspices of the Education Department, thus showing the priority accorded to early dental care When the service was transferred to the Health Department a year later the way was set for training school dental nurses. This began in 1921. 23 76. It is possible to find other reasons for the growing concern for .child health Seddon, writing from the viewpoint of imperial unity and defence, hadbeen med by the decliningalar birthrate New in Zealand "In the younger colonies of the Empire population is essential and if increased from British stock the self governing colonies will still further strengthen and buttress out great Empire In British interests it is clearly undesirable that the colOnies should be °popnlated by: the inferior surplus of people of older and alien countries.1124 Prgrammes to :ctffY the" situation- involved the- in the registration of midwives Some midwives were authorised to tend The poor at public expense. The establishment of St Helens Hospitals ensured the efficient training of midwives and the provision (if proper :maternity care for the. wives of working , .,class persons. Seddons programme also envisaged .State foundling hospitals and ,creches, but these failed to, eventuate. 2.5 77; The focus of child welfare activities was eventually the School Hygiene Division, which maintained contacts with State and private \ efforts to imprdve childrens health. Such measures later. included \ schemes for free milk and apples in sbOols, instituted iii 1937 and

32 1941 respectively, and since abandoned. The Division of School Hygiene also kept abreast of developments in health camps, whose on in may be attributed to an enterprising school medical officer. 78 An early feature of Health Department organisation was the method of meeting new needs in the health services by according them divisional status, and the disestablishment of such divisions when their work no longer warranted such status. Thus the Child Welfare Divisions responsibilities were shared between the maternity hospitals inspectorate and School Hygiene Division when Sir Truby King became Inspector-General of Mental Hospitals in 1924. The Food and Drugs Division was also short-lived. In due course the Maori Hygiene Division was abolished. But new divisions arose. Continued concern about the "white plague" led to the formation of a Tuberculosis Division in 1942. Specific health service needs also predetermined the formation and dismantling of other divisions, dealing with physical medicine, industrial hygiene or occupational health (both formed in 1947), and health education and maternal welfare/maternal welfare and private hospitals. These developments will be discussed later in terms of the altered functions of the Department of Health, but are shown in appendix V. The Mental Hospitals Department 79. Reorganisation of the Health Department undoubtedly spurred on the restructuring of the Mental Hospitals Department in 1928. That Department was always too small to allow for the establishment of divisions, hut, in a bid for status, its permanent head was given the designation Director-General. (The designation Director-General of Health for the permanent head of the Depart- ment of Health had been adopted in 1920 as a more appropriate and less cumbersome title than Chief Health Officer and Inspector- General of Hospitals.)

REFERENCES

1A.J.H.R., 1902, H-31, p. 31. A.J.H.R., 1903,431, p. iii. Public Health Amendment Act 1903, ss. 4, 12. 4A.J.H.R., 1904, H-31, p. xiii, and 1907, H-31, p. 24. See also Private Hospitals Act 1906. Inspector-General/Minister, 4 April 1895, L.95/1001, H.45/14. A.J.H.R., 1910, H-22, pp. 7-8, and Inspector-General, Draft Speech notes [?], n.d. [c. 1911], H.170/3 (12345). A.J.H.R., 1909, H-22, p. 6. 8Charleston, Oamaru and Mercury Bay Hospitals. The Jubilee Institute for the Blind, Wellington Convalescent Hospital, St. Andrews Orphanage (Nelson), Hawkes Bay Childrens Home and services provided by the Wellington Society for Relief of the Aged Needy, Wellington Ladies Christian Association, and Reefton Ladies Benevolent Society were recognised as separate charitable institutions under the 1909 Act. Hospitals and Charitable Institutions Act 1909, Fourth Schedule. 33 °Rep1ies to questions asked by Mr Hanify for the information of the Hon. J Huxham, Secretary for Public Instruction, Brisbane, 12 April 1920, H. 170/3 (12345). "X.Z.P.D., 1909, 147, p. 525 et seq., pp. 757-8. 12A.J.H.R., 1921, H-31a, p. 9, 13Hospitals and Charitable Institutions Amendment Act 1923, Schedule. 14A.J.H.R., 1919, H-31a, pp. 27-8, 35-6. °ibid., pp. 41-2. 16Chief Health Officer/Minister, 5 May 1920, H.166/8 (13607). 17Chief Health Officer/Town Clerk, Dunedin, 17 May 1920, H.166/8 (13540). 18A.J.H.R., 1907, H-31, p. ii. °Public Health Amendment Act 1918, ss. 2-3. The Board could report on methods or developments in the public health which it thought desirable to introduce to New Zealand; any matters concerning medical services, instruction in health matters, amendments to the law, Department-local body relations, training the health professions or any other public health matter referred to it by the Minister. "Chief Health Officer/Minister, n.d. [September 1920?], H.166/8 (13607). °For a survey of the early growth of the Plunket Society, see Royal New Zealand Society for the Health of Women and Children (Inc.), Thirteenth Report of Central Council, Dunedin, 1930, pp. 3-24. "Report of 1919 in A.J.H.R., 1921, H-31, p. 30. A more comprehensive account of the growth of the school medical service is contained in A.J.H.R., 1939, H-31, pp. 33-6. "For a comprehensive account of the development of the service, see J. L. Saunders, The New Zealand School Dental Service, Its Initiation and Development, 1920-1960, Wellington, 1963. 24R. J. Seddon, Child-life Preservation, Wellington, 1904. The Premiers obsession with the alien question is exemplified by the stern immigration legislation passed during his premiership, and in the exclusion of aliens from receiving pensions. "ibid., pp. 1-2.

34 V. TOWARDS SOCIAL SECURITY

80. Social services may be classified broadly into those which provide material advancement to citizens, or "self-help" services, and services enabling a measure of self support. "Self-support" services include those which are curative in purpose. 81. State involvement in the provision of "self-help" social services in New Zealand stretches back to the 1860s. State Post Office Savings Banks were first opened in 1867, followed by the Government Life Insurance Office in 1869. In 1872 the Public Trust Office was established. The emergence of State immigration schemes, free public education, and perpetual leases were other examples of State action of the "self-help" type of social service. 82. What William Pember Reeves described as a traditional New Zealand attitude of "colonial governmentalism" 1, or leaving things to be done by the State, the Victorian intellectual response to social change, and a pragmatic approach to the adversity of the long depression set the tone for social legislation of the Liberals. Leases in perpetuity of State land (1892) and the provision of cheap loans to settlers (1894), which were extended to workers in 1906, were in the self-help mould. New Government departments were needed to cope with the new policies, so the Agriculture Department was founded in 1892, and the Advances to Settlers Office in 1894.2 Reevess package of labour legislation necessitated administration through a Labour Department and Arbitration Court founded in 1892 and 1894 respectively. Government services were expanded with the foundation of the State Fire Insurance Office (1903) and the National Provident Fund in 1907. - 83. Various aspects of preventive health could also be placed among self-help social services. Child health services were to some extent a concomitant of free State education. The Vaccination Act 1863 authorised the vaccination against smallpox of all children within 6 months of birth. The role of the State in this programme is not altogether clear and neither is the question of cost. These matters received attention in a revised Act of 1871. By that time the compulsory requirement had become unpopular and the 1863 Act difficult to enforce. The Vaccination Act 1871 provided for the appointment of public vaccinators who were to obtain a sufficient supply of lymph from the Colonial Secretary. The compulsory element was retained by requiring pupils of State schools to be vaccinated. Vaccination was to be free to the pupil and to the 35 2 family as public vaccinators were prohibited from charging fees .3 The variety of State activities which followed widespread public concern for infant and child welfare in the early years of this century has been discussed earlier. 84. The self-help tradition must also include Sir Harry Atkinsons proposal for a national insurance scheme submitted to Parliament in 1882. His plan was intended to replace private saving by national, co-operative, and compulsory insurance. Perturbed at the rising expenditure on hospitals and charitable aid, he feared the spectre of "no greater curse" on New Zealand than the full force of the English Poor Law. Institutional treatment for paupers, he argued, could only be seen as a temporary palliative, so his scheme proposed sickness benefits, widows benefits and orphans benefit, and superannuation. Only the State could step in when private charity was harmlessly ineffective: "I entirely disagree with writers . . . who would confine the functions of Government simply to police duties. I would ask, what is the meaning of civilization but combination; and what is the meaning of a State but that we all band together to do certain things and to promote certain ends that we desire? In this country the Govern- ment has already done many things which fifty years ago the greatest Radical would probably have declared quite beyond the functions of Government. We have State railways, State telegraph, State post office savings-banks, and last, though not least, State education, all of which in their turn have been declared entirely beyond the proper functions of Government, and ruinous to the independence of the people who adopt them."4

Something for the Poor 85. Atkinsons far-sighted proposal was rejected on the grounds that it would sap the independence of persons relieved and jeopar- dise Christian concern for ones brothers. Apprehensions such as these delayed the translation of hospitals from a self-support to a self-help social service. This transformation awaited the spread of the notion of egalitarianism into the area of curative medicine. While voluntary contributions remained an influential factor in hospital finance, so the idea of reserving hospital care for the poor lingered on. Administrators versed in the ways of the Poor Law also resisted any encroachment into hospital services by the idea that it was the right of any person to receive medical treatment in a public hospital. Macgregors domination of the hospitals scene for two decades proved to have a retarding influence. 86. Macgregor feared that ladling out the soup of charitable aid and hospital care could only reverse social Darwinism, and breed a class of social undesirables for whose control discipline and eugenics 36 would be needed. Publicly provided charitable aid would have to be doled out with scruple and diffidence if wholesale pauperisation of the people was to be avoided. Macgregor had mulled upon such ideas from as early as 1876, and they were repeatedly aired in his annual reports. His reiteration of the points once again in 1898, in a style both rhetorical and fascinating is lengthy but most inter- esting. Appropriate extracts are therefore set out in appendix VI. 87. When provision for charitable aid services was tacked on to hospitals legislation, there could be no doubt that the system was meant for the poor. It is still possible to turn up vestiges of legal expression in current legislation which relate to the Poor Law function of hospital services. Enshrined in the present Hospitals Act is the duty of Hospital Boards to provide for "destitute persons". Boards can still make payments of outdoor relief or charitable aid. While the latter words disappeared from the title of Boards many years ago, the function did not. In a similar way Boards must still meet the cost of funeral expenses of the destitute. Boards may still make bylaws for the "order, discipline, decency, and cleanliness" of inmates.5 These quaint priorities have remained unaltered since 1885. The laws of settlement were laid to rest as recently as 1947.6 88. Macgregor tended towards the view that State sponsored charity should be given more in the spirit of Blakes cold and usurious hand than St. Pauls charity suffereth long, and is kind. This fitted in well with the distinction carefully drawn between the deserving and undeserving poor. The grant of State-provided old age pensions retained the delineation, since it was considered equitable that beneficiaries should be "deserving persons who during the prime of life have helped to bear the public burdens of the colony by the payment of taxes, and to open up its resources by their labour and skills". "Deserving" was then defined in order to preclude, for example, persons who had been imprisoned for 4 months during the previous 12 years, or for 5 years in the previous 25 years, or those who had deserted their spouse and children for 6 months or more. To qualify claimants had to be of good moral character and to have led a sober and reputable life. A residential qualification was added and a strict means test imposed .7 89. The universal principle was crippled by the means test which was applied to the old age and other pensions. Seddons ultimate plan would have included a contributory security scheme for the better-off, the old age pension scheme for the deserving poor, and charitable aid for the rest of the community." The means test followed extensions of State-funded pensions to widows (1911), Maori War veterans (1912), and a family allowance payable to the third and subsequent children of a family (1926).

37 The ifiegitimate Transformation 90. The role of the lunatic asylum in the growth of rightful access to health care was mentioned in para. 14. In 1912 psychiatric services advanced this concept a step further when legislation was passed to enable a widows pension to be paid to the wife of a psychiatric patient whose husband had been certified incurable for 12 months. Three years later the provision was expanded to allow these wives such pensions irrespective of the length of time their husbands were likely to be in a mental hospital. These developments were the first form of State monetary recognition of general disability. (The inception of a Gold Miners Relief Fund in 1910 to support injured miners or the families of miners killed or injured met specific occupational disability and was not therefore of general significance.9) General disability was later recognised by the payment of an influenza epidemic allowance to widows in 1918-19 and in pensions for the blind in 1924. 91. Macgregor fought a rearguard action against the pressures of egalitarianism and State socialism in so far as they affected the hospital system. By the end of his career he could no longer keep hospital doors shut. The lamentation of Dr Duncan Macgregor was that "the Hospital is turned illegitimately into a benefit club for the neighbourhood."° 92. What caused this illegitimate transformation? Macgregor readily admitted the part played by friendly societies: "The lodge system is so prevalent that in nearly every community a very large proportion of even well-to-do people are members for the sake, among other objects, of getting medical attendance cheap; and several of the largest societies admit honorary members, who join merely for the sake of getting medical attendance at lodge rates. The result is that the doctor has so few paying patients that he must either leave or get a State subsidy. Every effort is made accordingly to found a hospital, not because it is really wanted, but because the residents cannot get a medical man to settle without some guarantee, which is thus thrown largely on the State. A good many of our hospitals exist for the simple reason that, as things are, it is the only way of getting a doctor to stay." By 1938 it was estimated that friendly society members and dependants amounted to one-fifth of the population. 12 Undoubtedly, friendly societies attracted such wide membership, as their benefits included a sickness benefit, death benefit, and enabled members and their families to obtain, for the payment of a small premium, free medical services and pharmaceutical prescriptions. In due course other benefits were introduced to help meet hospital expenses. 93. The role of friendly societies is seen in the legislative provision enabling a Hospital Board to make contracts for payment

38 to it for the care of patients. Friendly societies were not the only organisations covered by this provision, as industrial workers were sometimes provided with sickness benefits. 13 Such developments undermined the nature of the general hospital as a service for the poor. Macgregors disappointment at these trends can again be noted from appendix VI. 94. Increasing use of general hospital services was also brought about by a fundamental change of social attitudes. In years gone by, hospitals had been institutions of despair, rather than of hope. Social prejudice against admission to hospital was two-fold—the risk of entering a terminal institution and the slur of appearing to receive public charity. For these reasons people who could afford it were treated in their homes or in private nursing homes. The sophistication of medical and surgical techniques and hospital equipment (particularly during and after the Great War) made entry to hospital not only necessary for adequate treatment but socially desirable. This idea was strengthened during the influenza pandemic of 1918-19 when a legal provision introduced in 1903 enabled the Public Health Department to direct a Hospital Board to receive any person suffering from an infectious disease. The wide use of this power during the epidemic strengthened the idea that public hospitals should be open to receive emergency cases. 95. Dr Valintine took a more realistic view of the situation than his predecessor, and in 1912 he reported that: "There is a tendency on the part of all classes of the community to take advantage of our hospitals, and this tendency is rapidly growing. There is no longer that repugnance, either on account of fear, ignorance, or pride, to enter a public hospital that was so noticeable a decade or so ago. We seldom hear nowadays of "butcher-shops" or "experiments"; nor, on the other hand, do we notice that independence or pride that prevented many a sick person from seeking relief in a public institution through fear of being considered by his neighbours as "on the rates".1114 In the previous year the Governor, Lord Islington, who was a man of wide experience in hospital matters, had supported the general principle that "medical service should be to-day accessible to all classes of the community"? 96. The matter was thrown into clear relief following the passage in 1914 of a resolution by such a body as the New Zealand Farmers Union which sought legislative amendment in order that: ". . . All persons if they desire can claim admission by right to the publich [sic] Hospitals during time of illness and so do away with the stigma of being accused of receiving charity even when they pay the fees charged by the Board."

WE On that occasion, the Department concluded: ". . . The law at present is that any person is entitled to admission to a Public Hospital provided he undertakes to pay certain fees not exceeding the cost of maintenance. . . The whole question seems to be whether it would be inconsistent with the Act that a bylaw should be made, prohibiting persons above a certain income from using the hospital or in any way restricting the right of persons to admission. I [Chief Clerk] dont think such provision has ever been inserted in a bylaw, and, therefore, if a person undertakes to pay the fees as laid down in the bylaws he could not be excluded. 97. By 1915 the Hawkes Bay Hospital Board had allowed patients of any status to be admitted to its hospitals subject to the availability of accommodation. Local doctors thereupon threatened to withdraw their honorary services, but the Ministers intervention postponed the matter until the War was over.17 98. The question of admissibility was well publicised in the post- war period. The British Medical Association, in recognising the need for better medical care for those able to pay for public hospital services, recommended the adoption of what was termed the Toronto Scheme whose salient points included: 98.1. Provision of a building in or near the grounds of a general hospital where private patients could be treated. 98.2. Patients in such a building would be charged maintenance fees in accordance with the room provided for them, and its location, aspect, etc. 98.3. Patients should be able to select their own doctor. 98.4. Fees paid for nursing attendance would be on the private hospital scale. 98.5. The fees to be paid to the doctor would be a matter between him and his patients. 98.6. Profits arising from such a venture would. be used in the finance of the general hospital.8 99. The suggestion that the public hospitals should make the necessary provision for the class of paying patient says much about what the British Medical Association called the "imperfect arrangements dependent on the enterprise of private hospitals." 9 Having only limited resources, private hospitals were in many cases only small nursing homes (although a large proportion were maternity homes) unable to provide the sophisticated equipment already installed in public institutions. 100. Consequently, the suggestion of paying wards in public hospitals became a recurrent theme in hospital circles during the 1920s. It was recommended by the Hospitals Commission (1921) and two visitors to New Zealand from the American College of Surgeons, Dr F. H. Martin, its Director-General, and Dr M. T. 40 MacEachern, the Director of Hospital Activities .2 0 Finally in 1930, a conference between the British Medical Association, the Hospital Boards Association, and the Health Department produced 10 definitive principles for the regulation of hospital admissions: "(1) That all members of the community requiring treatment in hospital be eligible for admission to public hospitals. "(2) That patients in public hospitals who need, because of the nature of their illness, accommodation other than in the larger wards shall be provided for by an adequate number of one- to four-bedded wards. "(3) That patients voluntarily availing themselves of such special accommodation shall pay the full cost of maintenance, including overhead expenses, provided that no distinction is made in the case of patients unable to pay. "(4) That the medical attendance on patients be in the hands of a visiting staff; with the assistance of a requisite number of resident medical officers. "(5) That each Hospital Board must determine the number of the visiting staff, but it be recommended that in arriving at a decision the Board shall, consistent with the convenience and smooth running of the institution, appoint as many of the medical practitioners residing in the district as possible. "(6) Subject to the approval of the Board, that the right of attending their own patients admitted under resolution (3) be extended to all practitioners except such as may for special reasons be deemed unsuitable. "(7) That in making appointments to the visiting staff and in determining the suitability or otherwise of practitioners for the privilege of attendance on patients the Hospital Board should be guided by the advice of a special consultative body, or, in the case of the smaller hospital districts, by the advice of the Director-General of Health. "(8) That such special consultative body comprise the consulting stafi if any, of the hospital, or in other cases should comprise the senior members of the medical profession of the district, selected by the Hospital Board with the approval of the Director-General. "(9) Patients unable to pay the ordinary hospital fees shall be attended by the visiting medical staff in an honorary capacity. "(10) Patients entering the hospital able to pay for medical attendance in addition to maintenance fees shall make their own terms with their medical attendant, who will be responsible for collection of his own fees."21 101. The issue of public hospital care was raised by the celebrated Bryce case in 1923. The daughter of a former Hospital Board member named Bryce was advised to undergo surgery. Bryce could afford private treatment, but had believed that no one should be denied medical treatment in a public hospital, if accommodation was available, merely because they could pay for private treatment. Seeking a medical certificate for her admission from an honorary surgeon, Bryce was refused on the grounds of ability to

41 pay. Eventually, the family doctor agreed to issue a certificate but, once admitted, the girl came under the care of the honorary surgeon who had previously declined to admit her. He now refused to operate, so the girl was discharged. Bryce sought a public inquiry, and eventually secured one in September 1924. The Commissioner endorsed the views of the Hospitals Commission, and confirmed the trend that hospitals should be open for all, since they were maintained by local rates and general taxes which were paid by all classes in the community. The Commissioner did suggest that adequate and reasonable fees cover the whole cost of treatment for those able to afford them .21 102. As the use of hospital services became accepted as the right of all citizens, so some of the traditional aspects of hospital administration began to change. As early as November 1919 the Depart- ment unofficially referred to "Hospital Boards" and in the following year the words "charitable aid" were deleted altogether from the designation of Hospital Boards .23 Aware of the undesirable conno- tations of the deleted words, the Health Department was inclined to suggest that Boards substitute the term "financial , assistance" to be administered through "Social Welfare Committees".24 Wide- spread unemployment during the great depression led to a conference of the Unemployment Board and Hospital Boards in July 1932. As a result the relief activity of Hospital Boards was further reduced. The Unemployment Board then assumed total responsibility for relief to able bodied men while Hospital Boards cared only for those who were unfit for work or fit for light work in towns .21 103. By the 1930s, therefore, the public hospital service had reached the stage where it could possibly be classed with other self- help State social services. Only the abolition of maintenance charges in public and mental hospitals would make hospital care as freely available to all citizens as State education. Like Government mental hospitals, by the 1930s public hospital services were available to all, subject to the payment of maintenance charges. 104. The "hospitalisation" process apparent in the bid to trans- form the character of lunatic asylums subjected them to the same pressures as general hospitals. The New Zealand mental hospital had never been intended for the poor, and alipatients therefore shared the same living accommodation and food. State psychiatric hospitals never faced much competition from the private sector, the only private psychiatric hospital having been established in 1882. This provided mainly for a patient intake from higher socio-economic groups. By the end of the last century, State mental hospital admissions showed a greater use by persons of the upper and middle classes and, consequently, lunacy gradually became mental illness.

42 New nomenclature under the Mental Defectives Act 1911 provided legal confirmation that the traditional and relatively simple role of lunatic asylum was not meeting the needs of the psychiatric service. "Mental hospital" and "inmate" therefore replaced "lunatic" and "asylum" in an attempt to restore the acute treatment function of institutions upon the hospital model. The same trend was apparent in the growth of a parallel nursing service to general nursing programmes, and the gradual substitution of the term "attendant" by "nurse". The recognition of "shell shock" as a legitimate psychiatric condition during the First World War tended to confirm a growing awareness that mental illness was not a disease of the lower social classes alone. The area of the new madness was veiled behind references to the "borderland", "nerves" and "neurasthenia". Treatment for such cases required "half-way houses". From 1906 a variety of peripheral services was tacked on to existing institutions so as to cater for the mentally ill of superior social classes. Fees were charged on a scale similar to that of public hospitals. Even so, in the egalitarian spirit of the mental hospital, patients, whatever their social background, were treated with uniformity and conformity.

Social Security 105. The eventual shape of New Zealands State health service owes much to the influence of Dr D. G. McMillan, M.P. As a general practitioner in Kurow, he had adapted the English National Health Insurance Scheme of 1911 to meet local needs .26 Dr McMillans success then prompted him to advocate a national health programme with free health and hospital services for all and financial security against invalidity, old age, and death .21 McMillans proposals were adopted by the Labour Party in its 1935 Manifesto. 106. In its first term of office the Savage Ministry appointed three committees on the subject. In 1936 two committees con- currently investigated various aspects of the proposed scheme. McMillan chaired the Parliamentary Select Committee while more precise details were entrusted to an inter-departmental committee.28 107. A further committee (the National Health and Super- annuation Committee) was set up in 1938 to examine the Govern- ments proposals, which had largely been the outcome of the McMillan Committees recommendations. The policies of the Government as set out in 1938 were to establish: "(a) A universal general practitioner service free to all members of the community requiring medical attention. "(b) Free hospital or sanatorium treatment for all. 43 "(c) Free mental hospital care and treatment for the mentally afflicted. • "(d) Free medicines. "(e) Free maternity treatment, including the cost of máintenânce in a maternity home." These services were intended to be supplemented when organisation and finance permitted by special services—anaesthetic, laboratory, radiology, specialist, consultant, massage and physiotherapy, transport to and from hospital, and dental and .optical benefits. When the required staff were trained, the Government Also hoped to institute a free home-nursing and domçstic help service. Health education programmes would be extended .29 108. Social security benefits proposed by the Government would have affected the health context in the following ways: 108.1. It was proposed that a Sickness Benefit of appropriate amounts be paid to men and women during periods when they were prevented from earning a livelihood because of sickness and accident. Payment would be made through friendly societies where applicable. 108.2. A disability benefit would also be made available to persons who otherwise would not qualify for invalidity, sickness benefit, or State Superannuation, but whose physical or mental disablement otherwise prevented them from earning a livelihood. • 108.3. Invalidity pensions which had been introduced in 1936 and miners phthisis benefits would be increased. 109. The concept of a free State health service met with initial resistance from some quarters. As early as March 1936 the New Zealand Branch of the British Medical Association (B.M.A.) intimated that while it was not prepared to actively advocate national health insurance, it would accept and co-operate with such a venture provided that:• "(1) Better medical service than at present exists is ensured for those unable to obtain it for themselves; "(2) The standards, status, and interests of the medical profession are adequately safeguarded"3° 110. By 1938 the attitudes of both the Government and the medical profession had hardened, especially after the Parliamentary Select Committee of that year seemed only to rubber stamp the Governments views. To some extent professional reaction was brought about by confusion and misunderstanding on both sides3 but even so it would appear that the profession was at the least conservative. The. B.M.A. proposed to divide the population into 44 four socio-economic groups. The lowest group and the unemployed would make no contribution and receive a complete medical service from the State. The middle groups would make some contribution and derive some benefits. Those in the top class would make contributions, but would obtain no benefits .32 The B.M.A. therefore offered five objections to the Governments proposed scheme. In the first place it considered that there was no need for a universal service while many people were able to pay for their own doctor and preferred to do so. The Association also contended that the growth of friendly societies and the public hospital system made a universal scheme unnecessary. It was also argued that the Governments proposals would lead to a deterioration in the standards of medical service and create social distinctions. From the professional point of view, social security could embarrass the commitment of doctors .33

111. At the same time the Government was adamant that the health services should be finally transformed into a self-help type of State social service. That view is contained in two paragraphs of the National Health and Superannuation Committees report: "We believe that the medical scheme should develop along the lines of our education system—be freely available to all whatever their rank, station, or income. If there are people in the community who prefer to make other arrangements for themselves—as there are in the educational world—they are entirely free to do so. . . . From our knowledge of the trend in respect of social legislation it is beyond dispute that the citizens of this country have a fixed determination to provide as far as is reasonably possible for those who are unable to support themselves. . . . It is quite clear to the Committee that public opinion in the Dominion requires that the normal Christian attitude of life of helping those in need, whatever the cause of their need, should be carried on into the community life, enabling the joint resources of the people to be applied for assisting in banishing distress and want. 134

112. The year of decision was 1938. Well aware that it possessed a Parliamentary mandate, the Government pressed on with the introduction of social security. The National Health and Super- annuation Committee was appointed on 9 March 1938 and presented its report 2 months later. Notwithstanding opposition from the press to the Committees recommeiidations, the Government hurriedly translated them into legislative form. The Social Security Bill was presented to Parliament on 1 August and passed into law on 14 September. Parliament adjourned 2 days later and the country went to the polls on 15 October. The Act came into force on 1 April 1939.

45 REFERENCES J. B. Condliffe, New Zealand in the Making, Wellington, 1959, p. 183. 2Similar in function to the modern State Advances Corporation. 3VaccinatiOn Act 1863, s. 3; Vaccination Act 1871, ss. 4-5, 8, 14; F. S. Maclean, op. cit., p.240. 4N.Z.P.D., 1882, 42, p. 188. °Hospitals Act 1957, ss. 4 (1) (c), 54 (1) (b), 76, 81, 93 (1) (f). 6Hospitals and Charitable Institutions Amendment Act 1947, s. 5 (1). 701d Age Pensions Act 1898, Preamble, s. 8. Asians and aliens were excluded nevertheless. 8See J. Drummond, The Life and Work of R. J. Seddon, Christchurch, 1907, p. 331; and Social Security Department, The Growth and Development of Social Security in New Zealand, Wellington, 1950, pp. 22-24. °The Relief Fund was the forerunner of the payment of pensions to miners suffering from phthisis in 1915. This development is discussed in Social Security Department, op. cit., p. 27. °A.J.H.R., 1906, H-22, p. 1. cf. A.J.H.R., 1897, H-22, p. 2. "A.J.H.R., 1890, H-1 1, p. 2. 12A.J.H.R., 1938, 1-6, p. 6. 13See, for example, Southland Hospital Board, History of the Southland Hospitals and Boards, 1861-1968, Invercargill, 1968, p. 12. 14AJ.H.R., 1912, H-3 1, p. II. 15A.J.H.R., 1911, H-31, p. 160. "Provincial Secretary, New Zealand Farmers Union, Southland District/Minister, 4 June 1914, and Chief Clerk/Chief Health Officer, 11 June 1914, H. 50/3 (1). 17J . P. S. Jamieson, "The New Zealand Hospital System" in N.Z. Med. ml. 1934, XXXIII, p. 265. "New Zealand Branch of the British Medical Association, Interim Report of Committee on National Medical Service, Wellington, 1920, pp. 3-4.. 119ibid., p. 3. 25A. R. Falconer, "Hospital Administration in New Zealand" in Bulletin of the Hospital Boards Association of New Zealand, 1926, I, 4, p. 24, and M. T. MacEachern (Typescript), Report on the Hospital System of the Dominion of New Zealand, 1927, pp. 271-2. sA.J.H.R., 1930, H-31, p. 29. 25J. P. S. Jamieson, op. cit., pp. 265-66. 23Hospitals and Charitable Institutions Amendment Act 1920 (No. 2), s. 4; Secretary! Accountant and Chief Clerk, 7 November 1919, H.50/3 (2). 24DirectorGenera1/Circular to Hospital Boards, 6 June 1921, H.50/3/3. 25Social Security Department, op. cit., p. 32. 56J. A. Campbell, The Political Origins of the Social Security Act of 1938, Unpublished M.A. Thesis, Victoria University of Wellington, 1964, pp. 37-8. 57D. G. McMillan, A National Health Service; The New Zealand of Tomorrow, Wellington, 1934. 28Representing the Public Service Commissioner, Treasury, Government Life Insurance and State Fire Insurance Offices, Government Statistician, National Provident Fund and the Health, Labour, Pensions and Friendly Societies Departments. Representatives of the Select Committee and the Cabinet were also members of the Inter- Departmental Committee which comprised 24 members. The Mental Hospitals Department was not included. 59A.J.H.R., 1938, 1-6, pp. 2-3. 50J. B. Lovell-Smith, The New Zealand Doctor and the Welfare State, Auckland, 1966, p. 43. 51ibid, p. 49. 5A.J.H.R., 1938, 1-6, p. 6. Compare with the National Partys proposal to provide a free health service to that section of the community unable to provide such a service for itself. W. D. McIntyre and W. J. Gardner (ed.), Speeches and Documents on New Zealand History, Oxford, 1971, p. 326. 33A.J.H.R., 1938, 1-6, pp. 5-6. 34ibid., pp. 7, 11.

46 VI. THE DUAL SYSTEM 113. The Social Security Act 1938 was much more than a consolidation of pensions legislation with provision for a free State health service. As one historian has put it "New Zealands social security system was shaped by the ideal of equality; it made men more free. Only a fortunate country could have afforded it, but it was not merely a by-product of reviving prosperity. It was created by the general will—a will which had sought expression from the earliest days; which had been inspired, in the colonial cradle, by the humanitarianism of the missionaries and by the utilitarian creed, the greatest good of the greatest number Welfare—insulation--meant the State. Perhaps that is the most striking feature of New Zealands history. From the beginning the settlers have sought to achieve their aspirations through the medium of government activity. Farmers governments or workers governments alike have extended their sphere of action. Slumps and wars alike have led to further centralization of power." 114. The Government intended to make a comprehensive State health service available free of charge to its citizens. An alternative for those desiring it (as with education) was envisaged, under which "partial relief from personal liability for care received in private hospitals" would be granted .2 The concept of a truly integrated State health service was never realised and social security perpetuated the dual systems of doctors and hospitals, and of public and private services. This state of affairs and its inherent difficulties were recognised by the Royal Commission appointed to study social security 31 years after its introduction: "Without discussing the desirability or otherwise of our system as it has developed, we feel entitled to make two observations: first, the pragmatic approach which New Zealand has followed here, as in so many other fields, has allowed a dual system to develop—State and private side by side. . "Our second observation is that monetary benefits do not make a health service. Improved services will not come from them alone if, for example, staff and facilities are scarce. Indeed, higher benefits may increase demand and intensify present shortages, and thus cut down services to parts of the community. 13 115. The dual system continued in part because of the Govern- ments plan to phase in the various health benefits. Between policy formulation and implementation, political realities and changes in the health services necessitated some accommodation of the private sector in a way not envisaged in the original plan. This point is best illustrated by the course of events surrounding the General Medical Services Benefit. 47 "Private" Practice 116. The staggered introduction of the promised health benefits, as shown in appendix VII, portrays the underlying tension between the Government and the organised medical profession. The wrangles over the Social Security Bill were only round one of the argument. Sparring continued over the introduction of Maternity Benefits. No arguments were attached to the idea of free mental hospital treatment because it was considered to be a minor matter. Its significance has therefore been overlooked. Free State mental hospital treatment was the first aspect of social security health care to be introduced. While various other hospital-based services became freely available by 1941, their relationship to general medical care had not been determined. Few doctors took up the opportunity to become, salaried rural or hospital medical staff, or to register for payment under an annual capitation system. Instead, the organised medical profession rallied its members in forceful opposition to any hint of the "socialisation" of doctors. 117. The medical professions basic grounds for negotiation had been set out in 1936: "I. Maintaining and strengthening the confidential basis between the family doctor and his patients and fostering satisfactory relationship between the general practitioner, specialist, consultant and hospital. "2. The statutory right of every registered medical practitioner to undertake national health insurance service. "3. Adequate remuneration to ensure the best quality of service. "4. Free choice as between doctor and patient. "5a. Adequate representation of the medical profession on both central and local administration. "5b. The constitution of a statutory local medical committee in each insurance area recognised as representative of the medical profession of the area. "6. The administration of the medical benefits should be separated from the administration of the cash benefits, the medical benefits to be administered by a body specially constituted for the purpose, on which the profession should be adequately represented. "7. Professional discipline to be maintained by tribunals, professional in constitution as in the British system. "8. Income limit to be fixed for those eligible. "9. Hospital benefits if included to apply in approved private hospitals as well as in public hospitals. "10. A central medical authority to be set up by the profession to adjust the inter-relation of specialist and general practitioner services.114 118. Eventually the Government compromised in order to get some scheme working. Free primary medical care was thereby transformed into substantially free care. When the General Medical Service Benefit was introduced the doctors standard fee was in the

48 order of lOs. 6d. The State paid 7s. 6d. towards a consultation fee, and doctors were allowed to charge a token fee for service. The patient contributed 3s. Od. or about one-third of the total.5 Doctors received about two-thirds of their income from the State but continued to assert their professional independence of State control under the name of "private" practice. 119. Even though a substantial part of the general practitioners income has been derived from State funds, the lines of administrative control never followed finance to the source. The Royal Com- mission on Social Security emphasised that point in attempting to redress the effects of inflation which had upset the position pertaining in 1941. While recognising variation in the fees for service between doctor and doctor and district and district, an overall decline had taken place in the G.M.S. Benefit so that by 1970, the benefit represented only one-third of the total fee for service. The Royal Commission commented: "We are satisfied that if the benefit is to be increased to the amounts we suggest [$1.25 Standard Benefit; $2.00 Special Group Benefit] the Government must take up a more important role in relation to medical charges than it has in the past. The States right, in a State- supported community health scheme, to participate in the fixing of fees charged by doctors and to supervise the fees charged seems to us undeniable. Indeed, if the State does not do these things, we think that the subsidisation of a fee-for-service system operated in the context of private practice is difficult to justify.116 In short, the Royal Commission was suggesting a review of the question of "whether the State should contract with the patient or the doctor". Since the settlement of 1941, the question had been answered largely in the doctors favour. 120. Presumably in order to secure the professions agreement to a suitable scheme with minimal interference, no machinery was established to safeguard the patients interests. In fact the only such concession in the Social Security Amendment Act 1941 was a provision which forbade doctors to sue for fees. An unscrupulous patient could therefore claim that the G.M.S. Benefit represented the total fee for service, and he could ignore the doctors additional charge with impunity. 121. This concession was short-lived. Following professional pressure for an expert investigation of the general medical services in 1947, the Minister of Health appointed a committee of departmental and B.M.A. representatives chaired by Mr T. P. (later Mr Justice) Cleary. The committee was generally to examine the provisions of the Social Security Act 1938 affecting the services and administration of medical practitioners, and to advise alterations necessary to give effect to the Governments policy of making available "adequate and proper medical services (general and specialist) free or substantially free of cost."8 122. As a general principle, the Cleary Committee suggested that "steps should be taken to place upon the profession itself as a body a large degree of responsibility for the ethical behaviour of its members and for the general quality of all medical services afforded in relation to benefits". The application of this principle meant that doctors would have more autonomy from the State. For example, the doctors right to recover fees would be, and was actually restored, while the patient was to be given 1 month in which to refer any complaint about the account to a "Local Investigating Committee". These committees would be empowered to say whether the charges were fair and reasonable having regard to the practice of the profession and the circumstances of the case. If they were found to be excessive the committees could determine an appropriate reduction.° 123. The effectiveness of local investigating committees (known as Divisional Disciplinary Committees), which were established in 1949, was noted by the Royal Commission on Social Security: Apart from this cumbersome and inadequate procedure (which it seems is rarely used), a patient has no opportunity to have the reasonableness of his account independently assessed. "Moreover, the Department of Health does not concern itself with the amount charged over and above the benefit. It sees its responsibilities as limited to the payment of the benefit. . "Provision was made for the Minister of Health to refer complaints to the Medical Practitioners Disciplinary Committee. These provisions are no doubt adequate to deal with the more serious aspects of alleged default or neglect by medical practitioners in providing professional services, but . they seem quite inappropriate in the area of fees and benefits."10 124. The matter of independent assessment was foreseen by the Cleary Committee in its recommendation that local investigating committees consist of the Medical Officer of Health and representatives of the local branch of the Medical Association. 11 However, as enacted in 1949 and subsequently, Divisional Disciplinary Commit- tees did not include the Medical Officer of Health as a statutory member. At the national level, the Medical Practitioners Disciplinary Committee comprises four representatives of the Association and one nominee of the Minister of Health "to safeguard the interests of any practitioner who might currently not be a member of the Association 1.12 The Medical Council deals with more serious charges relating to "disgraceful conduct in a professional respect."2 125. Social security failed to produce an integrated health service because it left such a large amount of health care in the

50 hands of private practitioners and private hospitals. In practice this has led to confusion in the direction of policy and compromise between the public and private sectors. 126. The Social Security Act 1938 enabled the Minister to make special arrangements with doctors working in isolated areas and those working under special conditions" which were intended to apply to developing suburban centres as well as the more remote.5 S In the past special areas have been staffed largely by directing bursars, but it has been the Departments policy to close down special areas whenever this is feasible. Over the years several have been converted to ordinary "private" practice. Nineteen special areas remain, and to help staff them in 1968 a medical practitioners assisted passage scheme was initiated to recruit suitable doctors from Britain for bonded service in designated rural areas. 127. Inducements to "private" practice in rural areas known as rural (private) practice bonuses were introduced the following year. Within a short space of time further incentives in the way of practice nurse subsidies, subsidies on locums and incentives for post-graduate study leave were introduced. /ZAnother problem is that of health centres versus group practice. Health centres had been advocated in the 1940s by the late Sir Douglas Robb and others as a means of removing the im- passe between "private" practice and the States health service.16 Although the concept failed to take hold among doctors at that time, it has been revived more recently. Provision for the establishment of health centres was written into the Hospitals Act 1957 by way of amendment in 1970. Any Hospital Board may, with the prior consent of the Minister, establish and maintain health centres at which medical, obstetric, dental, nursing, pharmaceutical, and other health services may be provided. 129. The legislation allowing for health centres to be established aroused the medical professions concern. Following representations to the Minister, a Health Centres Advisory Committee was set up in 1971. The Committees report has done much to dispel the initial apprehensions of the medical profession to the point that health centres now exist at Mosgiel and Mangere. Plans are well advanced for health centres in a number of other places. There is now considerable interest in the concept, especially among younger doctors. 130. The Departments proposals, for health centres have been paralleled by the offer of group practice loans. In a group practice, a number of general practitioners have their surgeries in the one building, share facilities and expenses, arrange a round-the- clock cover for their patients, and meet together to discuss clinical 51 problems. In spite of the similarities with health centres, group practices do not usually incorporate the same wide range of health professions. Believing in the need for greater partnership among doctors and for all-day coverage for patients, the Government introduced loan finance for group practices in August 1970.

"Private" Hospitals I 131. Confusion about the direction of primary medical care has its parallel in the area of private hospital services. At the outset it is necessary to acknowledge the general confusion which exists for many people by the unfortunate grouping of private (or profit- making) hospitals with those operated by trusts or religious and welfare organisations as part of their social services. The means of Government finance which has been provided to hospitals of either category has varied from time to time, and in accordance with recognised health trends, for example, the care of the aged. 132. Lack of interest on the part of nurses who ran them and the enforcement of higher standards, particularly in private maternity hospitals took their toll of private hospitals following the advent of social security. In 1939, 2,765 private hospital beds accounted for 22.1 percent of all hospital beds, excluding psychiatric beds. Ten years later there were 2,488 beds, just under 15 percent of the total.17 In the post-war shortage of hospital accommodation, some had been taken over by Hospital Boards, 18 but others just closed. The situation began to change when the Government introduced a maintenance subsidy scheme on the basis of need for private hospitals in 1950. The Government endorsed the policy in March 1952 on the grounds that "every private hospital bed is one less bed which the Government has to pay for and maintain". This step was taken to prevent the closure of private hospitals only," and should not be confused with the capital subsidy scheme introduced in April 1950 to enable religious and welfare organisations to establish homes and hospitals for old people. A number of these agencies then had to apply for registration as private hospitals in order to receive the daily hospital patient benefit and maintenance subsidy. 133. In October 1952 the Government approved a policy of granting loans for establishing new private hospitals and extending existing ones. Loans were to be administered through the State Advances Corporation and granted subject to the need for an institution and providing that more beds were built. Audited annual accounts and balance sheets of assisted hospitals were to be forwarded to the Department of Health. At the same time, the Government exempted private hospital fees .from price control.20

52 134. To put private hospitals "on a sound business basis, keep them in existence and encourage. the opening of additional units", procedures were later revised .2 The subsidy scheme was abolished, but hospital benefits were increased. Fees remained free from price control and a suspensory loan scheme was introduced to fund capital developments, which was modified in 1956. Soon afterwards, the Minister described the new development: "Government policy in regard to private hospitals has been a very successful one. Following on the Committee of Inquiry set up in 1950 various steps have been taken, at first somewhat cautious, but culminating eventually in the present increased benefit and the introduction of a suspensory loan scheme. The increase in benefits and the loan provisions have resulted in a much brighter outlook for this very important service. . . . This, in addition to saving a decadent and dissatisfied service and turning it into a happy satisfied and more efficient one, performs a very useful State function in providing one- seventh of our total hospital beds and are today adding beds at a greater rate than public hospitals. 1122 135. These policies were continued because: "If new private hospital beds are not established to help meet growing demands, the full responsibility of providing the beds devolves. on the hospital board and the total cost has to be met eventually from Government funds; In addition to the eventual capital savings, the Government also saves a considerable part of the maintenance costs of the beds to the extent of some several hundreds of pounds per day per annum." 136. In line with the increased accommodation in private hospitals, a Division of Private and Maternity Hospitals had a short existence after 1952. The revised Hospitals Act of 1957 made provision and maintenance of private hospital services a function of the Minister. 137. The private hospital loan system inevitably brought a degree of departmental control. Applications were examined by the Department of Health and if the work was considered necessary, plans were then submitted to the Hospital Works Committee and thence to the Minister of Health for approval. Cabinet authority was required for works in excess of £50,000. The Cabinet Works Committee approved an annual programme of private hospital works as part of the overall hospital works programme. In 1961 it was suggested that, to determine hospital needs, private hospitals might be required to furnish statistics about patients in the same way as public hospitals. As a first step in this direction information was obtained about disease classification and age groups of patients in public and private hospitals. Since 1966 the Director-General of Health has been empowered to obtain from

53 private hospitals medical information for statistical or research purposes .24 Even so, they retained a good measure of independence as was clearly shown in 1960: "By the very nature of the type of administration adopted for private hospitals in New Zealand there is a minimum of official interference, and although subsidised by the Government they remain fundamentally independent of Government control and are, in fact, private hospitals in the true sense of the word. Some inspection is, of course, necessary, but this is in the interests of the licensees, managers, and the Department alike since all are concerned with ensuring a satisfactory standard of accommodation and patient care. 1121 138. The position of private hospitals has been maintained by liberalising capital finance and by periodic increases in the hospital benefit. The Social Security Act 1938 entitled private hospitals to claim payment of a hospital benefit at "the same amount as would have been payable in respect of that treatment if it had been afforded by a Hospital Board. 112 However, various increases in the rate of private hospital benefit to take account of inflationary trends after 1950 led to a modification of the legislation. Since 1964 the hospital benefit has been paid at "such amount as may be prescribed. 1121

139. The development of private hospital services has proceeded virtually unchecked. In numerical terms alone, since the overall decline in the proportion of private to total hospital beds was arrested between 1956-61, that proportion has steadily grown. Two main factors account for this growth. Since 1938 the role of private hospitals has been considered only twice—in 1953 and 1971. All Governments since 1938 have accepted the compatibility of a dual system. The dual system has also been nurtured by the growth of private health insurance. 140. The Consultative Committee on Hospital Reform (Barrow- dough Committee) justified more liberal financial support for private hospitals because the State saves a great deal of money whenever a patient elects to go into a private hospital rather than into a public hospital. In addition, private hospital patients paid at least as much in social security charge and income tax as did public hospital patients. The Committee therefore thought it fair and reasonable to allow the former patient to receive out of the public fund to which he had contributed, something more nearly approaching what is received by the latter. Also: "The private hospital patient has a strong moral claim to much more liberal treatment than he now receives. If he got even only half what is expended on the public hospital patient it would assist him to pay more adequate fees for his accommodation in a private institution." 8 54 • 141. That was in 1953. In November 1971 the Board of Health, at the Ministers request, set up a committee to investigate the current policy on private hospitals. However, that committees report noted: "Prima facie the terms of reference presuppose the continuation of private hospitals as such, and the task set the committee was to redefine the part they should play in the overall development of total S health services. . . . The committee considers that it was not within its terms of reference to have regard to policy matters involved in the consideration of a wholly State hospital system vis-a-vis the present dual system. 1121 142. The orders of reference of the Board of Health Committee on Private Hospitals and the Royal Commissions on Social Security and Hospital and Related Services were not designed to explore the relationship of State and private health services. The Royal Com- mission on Social Security commented on this as follows: "The question of how far we should inquire into the health aspects of social security caused us a great deal of difficulty because the health benefits specified in our Warrant cannot be thoroughly examined in isolation from the general aims and organisation of the delivery of medical services to the community. . . . Thus we are not concerned with the design of our health services or their efficiency; for example, whether we should have both public and private hospitals, both salaried medical practitioners and doctors in private practice entitled to charge their patients fees, or whether the quality of the overall delivery of medical and health services is high or low. . . . In short we must accept the existing system under which our health and medical services are supplied. 1130 143. The role of private hospitals is therefore theoretically the same as that implied by the Nordmeyer Committee in 1938 and quoted in para. ill above. Successive Governments have upheld this principle. Perhaps the latest affirmation was made by the Board of Health Committee on Private Hospitals, which saw "no reason why those who wish to should not be able to be treated in private, and not be compelled to go into the public sector.""

144. The establishment of private hospital beds is thus dependent upon public desire for alternative care. The Board of Health Com- mittee thought 20 percent a realistic component, because that 20 percent is a reasonable approximation of what the private sector contributes to the total of general hospital beds." In other words, the status quo has been endorsed as an expression of need providing that those who wish to be treated in a public hospital should not, because of the waiting time involved, be compelled to pay to enter private hospital. It is only by substantially reducing this waiting time that true freedom of choice will be given.

55 145. This comment suggests that current demand for private hospital beds is inflated and does not reflect true need or, rather, true freedom of choice. Assessments of need are entirely a matter of value judgment as ultimately the question of provision of hospital beds—both public and private—devolves upon a consideration of what can be afforded. The Royal Commission on Social Security said: "Given limited community resources, there is an inherent danger that enhancement of the private sector may enable it to claim too great a share of these resources and so weaken the State sector that it cannot operate as it was intended to. The result could well be that an adequate health service could not be available to all who need it, but only to those who could afford it. 1133

Private Health Insurance 146. In a country where the provision of free health and hospital care by the State has been generally accepted as part of the national heritage, enhancement of private services has sometimes been interpreted as a deterioration of the public sector. The supposedly complementary relationship is thereby transformed into a competitive one. This danger was clearly recognised by the Royal Com- mission on Social Security in its concern about the growth of private health insurance. "The upward surge of private medical-care insurance stemmed from several factors, in particular that some people prefer to be cared for in a private hospital rather than a public hospital; some non- urgent surgery can be done in private hospitals more quickly and more conveniently for the patient than it can in public hospitals where there are waiting lists for such operations. . . . It is also understandable that the preference for private hospitals would also appeal to members of the medical profession who would find work in private hospitals more congenial or remunerative or who would be able to treat their patients in private hospitals but could not do so in public hospitals. . . . If even more people did in fact insure they could only be accommodated and have surgery on demand if there were more private hospitals, staffed with more nurses, and offering facilities for treatment and operations to more specialties. But all of these—hospitals, nurses, surgeons—are already scarce. Finance would no doubt be forthcoming for certain private hospitals, and it is possible that some doctors might be attracted from overseas, and some ex-nurses back into the profession by more lucrative conditions. But there must be a consequent drain of personnel from the public hospitals. "The public health and medical services would still have to cater for those who could not or would not insure; for those excluded from the private schemes, such as the old and the bad health risks; and for those who needed the extremely sophisticated or intensive care which only the most elaborately equipped public hospitals can give. Public hospitals would probably have to do this with depleted medical and nursing staffs, and perhaps with depleted financial resources if the health 56 vote had to carry half, and indeed more than half, the cost of maintenance, surgery, and treatment in private hospitals. "As we see it, the result could only be that the public medical and health service would become less adequate, and as it did so, more and more people would feel bound to insure thus aggravating an imbalance between State and private medical care facilities .1134 147. Over 300,000 New Zealanders, or about 10 percent of the S population are covered by private health insurance schemes of one sort or another. Membership has grown greatly since premiums for health insurance were made tax deductible in 1967. Of the various groups involved, the Southern Cross Medical Care Society is the oldest and largest. It was founded in 1961, and recently merged with the Manchester Unity Friendly Societys scheme. 148. Critics of the dual system have pointed out that further concessions to the private health sector would j eopardise the linchpin of the social security health scheme—that a medical service should be free and readily available to all on the basis of need rather than on ability to pay. It may be timely to return to the basis of the social security health service as laid down in the report of the National Health Insurance Investigation Committee of 1937: "Self-respecting, freedom-loving New Zealanders will never respect or tolerate a service which gives one type of service to the poor and another type to the well-to-do. Any scheme which savours of a poor man service, of charity, which divides the people into two groups, those able to pay private fees and those unable to do so, which differentiates in the mind of the doctor either consciously or unconsciously between patients, would be foreign to the ideals and aspirations of the government in particular and the people of New Zealand in general.1135

A Divided Health Service 149. Instead of bringing together the various components of the health service, social security, by its staggered extension of benefits, has created its own patchwork system of administration. Various benefits are administered within the Department of Health by several divisions. Under the Social Security Act 1964, the Minister of Health may "appoint such Committees or advisory bodies as he considers necessary" to advise on the fixing of terms and conditions for the availability of health benefits, or for any other purpose in connection with the administration of social security health benefits. The Act further provides that any professional association may be recognised by the Minister as an advisory committee, providing that its representatives have a majority of members on the committee .36 Advisory committees have been set up for medical services, laboratory services, radiological services,

57 pharmaceutical benefits, and dental benefits. Two negotiating committees have also been formed to deal with benefits available under the social security scheme. 150. The disjointed nature of social security administration is compounded by the fact that, theoretically, the strands are tied together by the Board of Health. This body is constituted, not under the Social Security Act, but under the Health Act 1956. The Board of Health may make recommendations upon any matter referred to it by the Minister of Health, and particularly "the adoption of a general health policy", and the relationship of hospitals and social security health benefits to the general health policy." 151. No general health policy has ever been requested or issued. The work of the Board of Health is therefore largely fragmented into a series of committees, some of whose work relates to that of committees established under social security legislation. There is certainly a great deal of common interest. Three examples may be cited. In 1961 the Board of Health established a Dental Health Committee to make recommendations upon a general dental health policy, the operation of social security dental benefits and their relationship to the general dental health policy, and the relative function of State and private organisations. In 1970 a Clinical and Public Health Laboratory Services Committee was formed to make recommendations on public hospital, private pathology, university, special unit and national reference laboratories and matters relating to their services .38 Reference should again be made to the Board of Health Committee on Private Hospitals. 152. To complicate the issue still further, both the Hospitals and Health Acts provide for advisory or technical committees to be appointed by the Minister and to make recommendations to him. These committees are really the health equivalent of the committees which may be set up under the Social Security Act. J 153. Had primary care services been integrated in a better manner, social security might have brought some sense of unity to the tripartite administration of the health service among the Department of Health, Hospital Boards, and territorial local authorities. Instead of unification, social security created its own administrative machinery, and by provoking an unfortunate distinction between public and private health services, has further divided the functioning and administration of the health service. How inappropriate these divisions will be for the future was hinted at by the Department of Health in 1969: "In the past there has been a tendency to divide medical care into watertight compartments—general practice; hospital care for the physically ill; hospital care for the mentally ill; and preventive medicine. 58 We must now realise that hospital care of the patient and the overall organisation of medical care should be such that the transition into hospital and out again is smooth and continuous, In New Zealand there has been a growing recognition of the need for a closer link between the work of the general and psychiatric hospitals and that of the general practitioner, and for fuller co-operation between Hospital Board extramural services and services provided by public health and S mental health personnel. 1139 The statement was as much an epilogue as a prophecy.

REFERENCES K. Sinclair, A History of New Zealand, London, 1969, pp. 271, 276. 2AJ.H.R., 1938, 176, p. 7. 8A.7.H.R., 1972, 14-53, p. 395. 4J. B. Lovell-Smith, op. cit., p. 44. 5A.J.H.R., 1972, H-53, pp. 402-3. °ibid., p. 415. 7J. B. Lovell-Smith, op. cit., p. 203. SA.J.H.R., 1948, H-31b, p. 2. ibid., p. 3. 10A.J.H.R., 1972, H-53, pp. 415-6. "A..7.H.R., 1948, H-31b, p. 13. "Medical Association of New Zealand, Annual Handbook 1971172, p. 24. "Medical Practitioners Act 1968, s. 55. "Social Security Act 1938, s. 82. 115J. B. Lovell-Smith, op. cit., pp.. 128-30. 6See A. Bush, H. Gaudin, J. M. Cole, S. Morris, B. MacKenzie, E. Hughes and D. Robb, A National Health Service, Wellington, 1943. 17 A.J.H.R., 1950, H-31, pp. 38-9. For the number of private hospital beds and the rates of daily benefit payable to patients in private hospitals under social security, see Board of Health Committee on Private Hospitals, Private Hospitals in New Zealand, Wellington, 1973, pp. 16,30-1. "A.J.H.R., 1946, H-31, p. 12. "Cabinet Paper [C.P.] 10 October 1952, H.6/43 (26991). "Secretary, Cabinet/Minister, 3 November 1952, H.6/43 (26991); C.P. (52)71210. "C.P. (54)/528. "Minister/Cabinet Memorandum, 18 October 1956, H.6/43 (26991). "C.P. (58)/152. 24A.J.H.R., 1961, H-31, p. 38 and 1962, H-31, p. 36; Hospitals Amendment Act 1966, s. 139A. "A.J.H.R., 1960, H-31, p. 48. "Social Security Act 1938, s. 93(a). 27Social Security Act 1964, s. 102. "Consultative Committee on Hospital Reform, Report, Wellington, 1953, p. 30. "Board of Health Committee on Private Hospitals, op. cit., pp. 11-2. °A.J.H.R., 1972, H-53, pp. 3,392. "Board of Health Committee on Private Hospitals, op. cit., p. 16. "ibid., p. 20. SA.J.H.R., 1972, H-53, p. 395. 84ibid., pp. 396-7. "Quoted in J. B. Lovell-Smith, op. cit., p. 59. "Social Security Act 1964, s. 121. 37Health Act 1956, s. 14. "Board of Health, Resolutions and Decisions of the Board of Health, 1957-1967, Wellington, 1968, p. 53; Board of Health, Committee Reports, 1971, Wellington, 1972, p. 9. "Department of Health, A Review of Hospital and Related Services, Wellington, 1969, p. 60

13] VII. GIVE AND TAKE

Reorganising Hospital Finance 154. The advent of social security health benefits accelerated a major reconstruction of hospital finance because, by making it easier for people to secure hospital treatment, services had to be expanded. This ultimately wrecked the long established principle that local and central funds should be applied equally to the maintenance of public hospitals. 155. Soon after hospital inpatient and out-patient benefits were introduced, Hospital Boards became pre- occupied with the increasing liability of loan and capital costs. By 1943 this trend had reached the stage where the idea had been accepted that the Government should assume more responsibility for capital works, providing that proposed works and plans were approved in Wellington. The bed occupancy I problem faced by Hospital Boards was solved by increasing the daily inpatient hospital benefit from 6s. to 9s. as from 1 April 1943. Three more years elapsed before major reforms were announced to relieve ratepayers of the burden of mounting hospital costs. 156. Stabilising the hospital rate in 1946 was the first nail in the coffin of a local hospital system. The Finance Act 1946 pegged the rate of levy to d. per Ll of rateable capital value in a hospital district, or an amount equal to one half of the net estimated expenditure of the Hospital Board, whichever was the lesser amount. This ensured that the minimum rate of subsidies on levies was l for Cl with no fixed maximum. The Government subsidy represented the difference between the net estimated expenditure and the levy.2 157. Even though the amount contributed from levies increased because of land revaluation, Hospital Board expenditure during the post-war boom threw a massive burden on the State.. As a proportion of levies and subsidies, levies dropped from 48.6 percent in 1940 to 21.7 percent 10 years later. This prompted the Government to decide to abolish the local rate altogether, and in 1951 legislation was passed which enabled the levy to be reduced by --1-d. each year until it was phased out altogether in 1957. 158. When the Government assumed more financial responsibility for Hospital Board activities, local autonomy was weakened: "The ever-increasing responsibility of the State . . . has not been overlooked, and . . . from time to time the State has recognised that responsibility. Already there is little that a Hospital Board can do and little that it can spend without the sanction in some form or other of the Minister of Health as the representative of the State."3 The comment was made in 1953, but suggestions to t)iis effect could have been made at any time from 1909. Some reference to the restraints imposed in 1909 upon Hospital Board autonomy has been made in para. 59. For the first time, Hospital Board estimates required approval by the Minister who could order them to be amended. That power was exercised on a few occasions when a Hospital Board declined to accept a recommendation. from the Department to adjust its budget or to increase the amount of estimated receipts. 159. By 1948 considerable limitations had been imposed on Hospital Board expenditure, and some measure of standardisation of remuneration had been obtained for a wide range of occupational gro within the hospital service .4 1-60. Control of expenditure was only one aspect of a trend to(Ss more involvement by central agencies in the affairs of Hospital Boards. Over the years from 1909, both the Minister of Health and the Director-General had been given more say about the provision of services by Boards. The permanent head was empowered to instruct Boards to provide for maternity cases and ambulance services. He could also determine the numbers of doctors, nurses, midwives, and dental staff to be employed by Boards. Medical staff appointments required Ministerial approval. After 1940, Boards were obliged to furnish the Director-General with any information he sought. In addition to his control over expenditure and a broad range of staff appointments, the Minister could also direct a Hospital Board to provide X-ray, vaccination, and laboratory services, and to make provision for treating tuberculosis patients. It should be also noted that from 1951 the Minister could delegate any of his powers to the Director-General.5 161. Various procedures of central origin were also introduced so as to reduce the number of hospital districts. Amending legislation of 1932 provided for the appointment of a commission under the Commissions of Inquiry Act 1908 to inquire into and report upon, inter alia, whether two or more contiguous districts should be combined. Should a commission so recommend, as was the case with the Thames, Waihi, and Coromandel Hospital Boards (1937) and Southland and Wallace Hospital Boards (1938) union could be effected by Order in Council .6 After 1944, union could follow an Order in Council issued merely on the grounds that "it appears to be expedient". In such a case the Order did not need to follow a Commission of Inquiry or a Boards "suicide" resolution. Union 61 could also follow upon the recommendation of the Local Government Commission which was established in 1946. This provision was availed of to amalgamate the six Hospital Boards in Northland in 1950.

The Consultative Committee on Hospital Reform 162. Once the course towards the abolition of hospital rating had been set, the whole future of the public hospital system needed to be examined, particularly in the light of the financial burden which would be thrown upon the State. The Government of the day set up a consultative committee chaired by Mr H. E. (later Sir Harold) Barrowclough in 1953. The Committees order of reference and principal recommendations are set out in appendix VIII. 163. The Barrowclough Committee frankly condemned the contemporary hospital system as "a relic of conditions which existed as long ago as 1885 or even earlier." 9 Furthermore, it endorsed the trend away from local finance. As the State alone was henceforth to meet virtually the entire cost of public hospital services, so its agent, the Minister of Health, should be regarded as head of the service. This streamlining would avoid the chaos of: A system under which, to begin with, each Hospital Board was made solely and primarily responsible for the control and management of its various institutions and forthe provision of hospital services in its district; but engrafted on that is a series of legislative provisions which limit, check, control, and co-ordinate the powers of boards by requiring them to seek the Ministers approval for most of what they propose to do and compelling them to do some things which they may not propose to do. With one hand the Legislature has given wide powers of discretion to a Board, with the other it limits and even takes away those powers and controls and places them in the hands of the Minister or of the Director-General of Health."° 164. Administrative responsibility was to be shared by a partnership between the Minister and Department of Health, five Regional Hospital Authorities and a diminished number of Hospital Boards. Regionalisation was not advocated just to remove some of the burdens of the Division of Hospitals. Nevertheless, the Com- mittee felt that some of its work could be handed to regional authorities, including surveys of hospital requirements and future developments; the introduction of an accurate costing system; the institution of medical "audits" of various aspects of hospital activities; research; and periodic hospital inspections. Regional authorities could therefore help make up for the remoteness of the Department. They would also play a worth-while role in co-ordinating research, specialist services, and education within the region."

62 165. The Committees report emphasised that regional authorities would not be charged with the duty of providing hospitals and hospital services. These functions would belong to elected Hospital Boards as before. However, in the case of the Hospital Boards in the regional centres, it was considered that a proportion of members should be appointed by the Minister having regard for their expertise in hospital administration. University centres having medical schools should have the right to appoint an additional member .12 These views confirmed the Committees belief that: The old basis of representation [population and rateable value] has become an anachronism. . . . What is wanted is a workable body of competent administrators who collectively possess an intimate and personal knowledge of all parts of the Boards district. 1113 166. The Consultative Committees findings were a valid attempt to untangle some of the extremely involved and confused interrelationships of Hospital Boards with the Department and to bring together the administration of treatment and preventive health services. The Consultative Committee considered that some measure of co-ordination might be assured by the attendance of the local Medical Officer of Health at Hospital Board meetings.14

Legislative Revision, 1956-7 167. Revision of the Health and Hospitals Acts proceeded apace in the 1950s with minimal attention to the possible integration of preventive and treatment services.

Health Act 1956 168. The new Health Act 1956 did not alter significantly the relationship of the Department and territorial local authorities; nor did it alter the relative functions of each in any major way.15 This means that since 1920, there has been no major overhaul of the public health duties and powers of these agencies, particularly with regard to environmental health services. However, under the legislation of 1920, the Board of Health had been given mandatory powers over territorial local authorities. While these powers were retained in 1956, the insertion of a "principal function" effectively transformed the nature of the Board of Health from an executive agency to an advisory one. Reference has already been made to the advisory function of the Board of Health in para. 150, in respect of the relationship of social security benefits to a general health policy. The general health policy was also to include advice about the promotion of health, the prevention of disease and disability, the adequate and effective treatment of disease, and the proportion of resources to be allocated to these activities. The Board was also 63 authorised to make recommendations on the co-ordination of the work of local authorities and voluntary agencies involved in the area of public health, along with the activities of the Department of Health. 169. Although no general policy has been issued to date the Board of Health has issued reports on a diverse series of topics, these reports having, in the main, been the work of expert committees.° Hospitals Act 1957 170. Revision of the Hospitals Act 1926 was necessitated by the Governments wish to establish a new basis for hospital administration before hospital rates were eliminated on 31 March 1957. Logically, when the system of local hospital finance collap- sed, the basis for locally elected Hospital Boards could no longer have been regarded as tenable, and hospital services should therefore have been administered through some form of State agency. The State, in providing the funds, should have been given the management, because control of hospital services has traditionally followed finance. It will be recalled that the application of this principle in earlier times led to the removal of independence of separate institutions and their absorption into Hospital Board services. Instead of abolishing Hospital Boards, or reconstituting them to meet the new financial arrangements, the new Hospitals Act simply subjected the Hospital Boards to further restraint. The traditional means of central control, by requiring Ministerial approval to Hospital Board plans and policies, was strengthened by enabling the Minister to issue directions to Boards. The full range of Ministerial responsibilities and powers is set out in appendix II. Ministerial control is supplemented by two agencies, the Hospitals Advisory Council and Hospital Works Committee. 173. The Hospital Works Committee had been formed in 1954 upon the recommendation of the Consultative Committee. Con- cerned with the orderly programming of capital expenditure to all Hospital Boards on the same lines as the Government works programme, the Hospital Works Committee, in the first instance, considers an overall national annual programme of capital works under way in planning stages and proposed for the future. Detailed examination of the programme of each hospital district then follows. The Committee then relates requests for new hospitals and extensions with the actual needs of the districts, and is advised by the Depart- ments Management Services Research Unit. Standard building plans involve detailed reviews by. architects and engineers, of the Ministry of Works and Development, who provide technical and 64 economic advice On all proposals for capital works. In reality, a Hospital Board submits a hospital development plan showing existing and proposed buildings. This plan is examined by Hospitals Division staff; and, if agreed to, is submitted for the approval of the Hospital Works Committee. The Board then states its case for proceeding with the project. If the Committee agrees to the pro- position it recommends that the Minister should approve the plan in principle. Consultation between the Committee, Board, and Hospitals Division continues during the preparation of sketch plans and the call for and acceptance of tenders. In addition to Hospital Board projects, the Hospital Works Committee deals with the purchase and sale of land, subsidies for old peoples homes (through religious bodies, etc.), loans for private hospitals, building proposals for the remaining departmental hospital (Lake Alice), and loans raised by Hospital Boards. 174. The Hospitals Advisory Council was intended to play an important advisory and leadership role in hospital services. The Council has been used chiefly for advising the Minister on matters of contention between the Department and local interests, such as the closure of institutions, or amalgamation of Hospital Boards, and associated issues. Its general responsibility to tender advice on matters relating to the provision, control, and management of Hospital Board institutions and services, has been used less frequently. It is therefore possible to compare the buffer-like role of the Hospitals Advisory Council with that of the Board of Health in the relationship between central and local authorities. 175. Radical revision of the basis of hospital administration was justified in 1957 because the Hospital Board system then prevailing was no longer applicable to the principles upon which it had been founded. Local bodies responsible for locally raised funds were no longer relevant once central government decided to provide all the funds. (The only element of local finance left after 1957 was the power of a Hospital Board to raise loans, providing that they were approved centrally. Even so, the Crown guaranteed repayment.17) The failure to apply firmly the principle of associating administrative control with the source of finance, has led to further limitations upon Hospital Board autonomy in the years since 1957.

Inroads Upon Financial Autonomy 176. When Hospital Boards were no longer restricted by having to provide part of the finance themselves, their expenditure escalated. This continued until June 1966 when Boards were advised that because the need to keep total Government expenditure within reasonable limits the total amount available from the Vote Hospitals

65 for 1966-67 had been set at $88.7 million. As this sum represented about .2 percent less than total Hospital Board estimates they were asked to scrutinise their estimates so as to reduce maintenance expenditure by some 0.2 percent. On the whole little was saved, and Hospital Boards overspent their grants by some $2 million. On 10 February 1967, therefore, the Prime Minister announced that maintenance expenditure by Hospital Boards for the 1967-68 financial year would be subject to much firmer control. Hospital Boards would be required to work strictly within allocations approved by the Government, rather than to receive grants which were based on Board estimates of expenditure. In 1968 provision for fixed allocations for maintenance grants was written into the Hospitals Act. 177. Initial allocations were based on maintenance expenditure for 1966-67 less interest on loans, estimated arrears resulting from the ruling rates survey, reductions for high-cost Boards, and additions for low-cost Boards and where there had been significant population increases. Whether a Board was given a high- or low-cost rating depended on the cost per head of geographical population based on such variables as operating expenditure and the economic effect of private health services. The basis was calculated from statistics on variable factors taken over a 7-year period. 178. Initial allocations were prepared in haste, and, admittedly, in administering rough justice, some resentment was caused among Hospital Boards. Reductions in the grants made to some Boards who had underspent their allocations in 1967-68 continue to cause grievance, particularly since this underspending took place at the Governments behest. 179. To bring about a fairer system in reaching decisions on the allocation for 1968-69, the services of selected Hospital Board personnel were therefore used. In August 1968 the Minister approved the establishment of the Allocations Committee comprising one nominee of the Hospital Boards Association, four from the Hospital Officers Association, two from the Medical Superinten- dents Association, and five departmental representatives. This Com- mittee constantly improved in the light of experience the basis for allocating available funds, particularly for meeting the problems of the growth of population and hospital services, commissioning new buildings and rewarding efficiency. 180. The introduction of fixed allocations met with a good measure of success. No Board has consistently overspent its allocation and, there have been comparatively few cases of overexpenditure. Government approval has allowed some Boards to spend in advance a substantially increased allocation for growth for the ensuing year.

go 181. Culpability in such instances of overexpenditure could be met in extreme cases by invoking the section of the Act enabling a Hospital Board to be replaced by a commission. Since 1970, however, attention has focussed on another method of ensuring financial responsibility, culminating in 1973 with legislation rendering members of a Hospital Board personally liable for overexpenditure S incurred without due regard (not "reckless disregard" as originally proposed) for the need to live within fixed allocations.

Inroads Upon Hospital Board Election 182. The new system of hospital finance introduced in 1957 would have given reasonable grounds for reforming the composition of Hospital Boards. At the time, there was some public alarm at the prospect of a bureaucratic takeover of the Boards in which Board members would be reduced to cipher-men carrying out orders from Wellington. It was a false alarm. The Minister took pains to assure Hospital Boards that they would remain "the trusted agents of Government in the domestic administration of hospitals."18 The Government therefore made no endeavour to modify the electoral system along lines suggested by the Barrow- dough Committee. Nevertheless, inroads have been made into this system. 183. In certain "vacuum-like" situations the Crown has always had power to appoint members of a Hospital Board or persons acting as a Hospital Board. For example, upon the constitution of a new hospital district, the Governor-General has the power to appoint a Board until an election can be held, and to fill extraordinary vacancies. In default of an election, or if insufficient members are returned at an election, the Governor-General may appoint the required number of persons as members of the Board. If a Hospital Board has failed to perform its duty a Commission of Management may be appointed by the Minister to act instead of the Board until the next election.9 184. Inroads upon the elective principle have also been made when hospital districts have been reorganised. Upon the merger of the Marlborough and Picton Hospital Boards in 1930 provision was made for a local committee of management for the Picton Hospital. The committee was to have certain members appointed by the Marlborough Hospital Board, others appointed by the Minister to represent territorial local authorities, and the remainder elected .20 Provision for nomination by territorial local authorities was continued at the time the six Hospital Boards in Northland were amalgamated. The same principle was applied during the

67 3 amalgamation of the Taranaki and West Coast Hospital Boards and when the Wairoa Hospital Board decided to unite with the Hawkes Bay Hospital Board.2 185. Until 1971 legislation allowed only for appointment to Hospital Committees of Management in reconstituted areas by way of nomination by the territorial local authorities, or by guber- natorial appointment. The elective principle was retained only in so far as the member or members of the new Hospital Board represented the constituent district covered by the old Board. However an amendment passed in 1971 allowed for the election of Committee members in the same way as Hospital Boards .12 To date this has not been acted on. 186. Only one Hospital Board is directly affected by a nominated element. Following a recommendation by Professor R. V. Christie, who saw the lack of communication between the Otago University Medical School and Otago Hospital Board as an impediment to efficient decisions on issues affecting the Medical School, the Hospitals Advisory Council supported the submission of both the University and Hospital Board for university representation. Accordingly, an amendment passed in 1968 provided for an additional five members to be appointed by the Governor-General on the nomination of the Otago University Council. These additional members have all the rights of the elected members .21

Amalgamation 187. Another weakness of the 1957 Act was its failure to rationalise the number of hospital districts. Functional self-sufficiency was a principle underlying the development of hospital administration in New Zealand. A considerable number of smaller Hospital Boards were unable to meet all the reasonable hospital needs in their districts, and had to rely on base hospitals in provincial or metro- politan centres for specialist services. While a degree of dependence upon these centres has been reached in order to make the best use and most economic distribution of scarce and expensive specialist services, territorial amalgamation did not follow. 188. The number of Hospital Boards in 1957 was 37, or 14 more than the Barrowclough Committee had envisaged. This number remained constant for nearly a decade until, following a recommendation of the Public Expenditure Committee in 1963, Hospital Boards in the West Coast and Taranaki were regrouped. When there were 31 Hospital Boards the Government stated that further amalgamations would follow. This issue was prominent among principles proposed by the Department in A Review of Hospital and 68 Related Services which noted that 11 Hospital Boards existed to serve less than 1 percent of the population. These Boards were said to be incapable of providing a comprehensive range of patient services without a disproportionate allocation of public funds.24 189. In November 1970 a number of smaller Hospital Boards was approached about reorganisation proposals. The Depart- S ments case for amalgamation was argued in the following terms: "(1) All residents will have equal rights of access to specialist and other services. They should not be dependent upon the growth of neighbouring boards. "(2) Extension of services in specialties such as pathology, obstetrics, cardiology, anaesthesia, etc., could more easily be arranged. "(3) Better planning and rationalisation of ancillary hospital services, such as laboratory, pathology, sterilisation, laundry, etc. "(4) A better climate will be created for recruitment and retention of staff, more opportunities for professional contacts, the assurance of continuity of sufficient clinical work and better training and refresher opportunity. "(5) With a larger pool of staff better provision can be made to cover emergency conditions. "(6) A larger unit can make more economic use of highly expensive equipment and scarce highly trained specialist staff, both medical and non-medical. "(7) Expensive specialised equipment could be justified for one large board which could not be justified for any one individual hospital. "(8) A larger administrative unit is better able through its large organisation and volume of work to facilitate specialisation and more expert knowledge in the secretarial, accounting, stores, medical records and other fields. "(9) Savings are possible in capital investment through smaller stocks, reducing potential loss through deterioration and obsolescence. "25 190. Of the nine Hospital Boards approached only Wairoa was prepared to accept amalgamation unconditionally. Five flatly rejected any such notion. Although the Wairoa Board was merged with the Hawkes Bay Hospital Board in March 1971 the Govern- ment agreed not to press amalgamation in areas where it was resisted. 191. Recommendations for amalgamation have recently been expressed by two inquiries into medical and administrative matters of the Opotiki Hospital Board. Acting upon these views a new hospital district covering the Opotiki and Bay of Plenty areas was created in November 1974. 192. It is apparent that the formation of a reasonable number of viable hospital districts which can be functionally self-contained has been a matter of concern for many years. In 1906 the call was for "about twenty" strong Hospital Boards--a number in vogue as late as 1972! Streamlining the Department 193. Amalgamation of Hospital Boards has been accepted by the Department in recent years only as a means to an end and this was clearly stated in submissions to the Royal Commission on State Services more than a decade ago: "The long term policy is for the development of regional health authorities combining the operational functions of the present Hospital Boards, which in reconstituted form would take over the administration of departmental mental hospitals, and possibly district health office functions. This is considered to be a logical evolution and sound administration, and would provide both for integration of preventive and curative health services and devolution of power from central Government to local authorities." 26 Since that time the policy has developed in an effort to unite all aspects of health care under single administration. For example, the 1972 annual report of the Department of Health recognised the need to integrate community medicine, clinical services, general practice and hospital work much more effectively. Under strong regional agencies the Department considered that the current emphasis on "delegation downwards controlled by accountability upwards" could be continued. 194. The Departments reconsideration of its role in the even- tuality of a reorganised hospital service has also been clarified. The 1972 report also referred to the need— "To equip the department so that it can effectively discharge responsibility for the direction of policy and determination of priorities, having regard to advice from appropriate sources, and for general financial control, the allocation of financial resources, and the evaluation and surveillance of the efficiency of management. 1,27 Again this move was foreshadowed in submissions made to the Royal Commission on State Services, and reflected the Departments bid to untangle the extremely involved and confused interrelationship of the Department with Hospital Boards. 195. Historically speaking, of course, the principal relationship had been one of inspection and advice to ensure that the standards of Hospital Board institutions, services, and administration were satisfactory. The emergence of a more distinctly national hospital service led to the adoption of various financial, planning, and staff responsibilities in Wellington. The confused pattern of relationships was not helped by the arrival of the Hospitals Advisory Council and Hospital Works Committee on the scene. Naturally enough, the changed emphasis on Hospital Board autonomy has caused growing pains not only in the Department but among Hospital Boards which have thereby incurred responsibilities for which they may

70 have felt themselves inadequately prepared. However unwise earlier policies may have been, a distinct relationship afforded a relative degree of security to inspector and inspected. 196. Departmental evolution has also caused problems, especially the ambivalence of the traditional executive role in public health and the supervisory nature of its role regarding hospital services. • Superimposed on this were a host of ad hoc functions acquired by the Department over the years. At the risk of tedium some of these activities should be listed. 197. The Departments involvement with professional registration began with general nurses and midwives at the turn of the century and was later extended to other groups including plumbers and gasfitters (1912), masseurs (1920), opticians (1928), dentists (1936), psychiatric nurses (1945), occupational therapists and drainlayers (1948), physiotherapists (1949), and dietitians (1950). The Depart- ment became closely concerned with the day-to-day administrative activities of a number of statutory councils and boards handling professional registration, and the stage was reached where their activities to some extent became intermingled with departmental functions. 198. Related to professional registration was the matter of training which was in some cases undertaken by the Department. Professional groups in this category included health inspectors, midwives, and school dental nurses. Special nurse training in functional nervous disorders and industrial nursing was given under departmental auspices. The Mental Hospitals Department and its successor, the Mental Health Division, trained psychiatric and psychopaedic nurses and occupational therapists. 199. The Health Department had also dabbled in direct hospital administration from the time it ran the Rotorua Sanatorium. Its tuberculosis sanatoria were handed over to Hospital Board control, but the Department always ran some St Helens Hospitals. For a while the Department controlled former Defence Department hospitals. Two of these it kept—Queen Mary Hospital at Hanmer Springs and Queen Elizabeth Hospital, Rotorua. Psychiatric and psychopaedic hospitals became Health Department institutions in 1947 after amalgamation with the former Mental Hospitals Department. 200. Direct administration of these institutions could be justified on the grounds of national importance in the same way as certain research became a departmental matter. The Medical Research Council originated from a departmental committee set up in 1938. In the following year the Director-General of Health recommended 71 the establishment of a public health institute to undertake medical research, the training of health personnel, and routine work associated with such matters as industrial hygiene and epidemiology. 201. World War II delayed the foundation of the institute whose laboratories opened in 1954. Until 1956 the main activities of the National Health Institute, as it is now known, were the establishment of reference laboratories in connection with various diseases and the introduction of specialised techniques in microbiology and virology. The Institute also became a base for the secretarial work required by the Medical Laboratory Technologists Board whose examinations were conducted on the premises. 202. The post-war period saw an expansion of reference and research agencies controlled by the Department. In 1949 the Medical Statistics Branch of the Census and Statistics Department was transferred to the Health Department. What is now known as the National Radiation Laboratory developed from co-operative enterprise between the Department and the British Empire Cancer Campaign Society. The Societys physical laboratory passed to the Departments control in 1951. Acquisition has continued as shown by the foundation of an Operational Research Unit (now the Management Services and Research Unit) in 1962, the National Audiology. Centre (1964), and the Design and Evaluation Unit (1971). 203. The full extent of the Departments commitment to these ad hoc activities was not really appreciated until 1961-62 when submissions were made to the Royal Commission of Inquiry into State Services. Item 2 of the Commissions order of reference called for a study of "any major functions that should be redistributed among Departments and Government agencies, or that should be transferred to or from any new or existing agency or body". Although it did not feel competent to judge the Departments proposals for decentralisation the Royal Commission supported the idea of future consideration by appropriate agencies. As a result many of these departmental functions have been transferred to other bodies. 204. Recent years have seen the formation of independent councils and boards to handle the registration and discipline of professional groups including dental technicians, laboratory technicians, and nurses. As could be expected departmental representation and influence on these bodies is minimal. 205. In line with the policy of decentralisation, agreements were reached with the Auckland and Wellington Hospital Boards to take over the St Helens Hospitals in their districts from 1 April 72 1966. Agreement also allowed for the transfer of Queen Elizabeth Hospital, Rotorua, from the Departments administration to the Waikato Hospital Board from 1 October 1968. 206. Negotiations for the transfer of psychiatric and psychopaedic hospitals proved to be much more complex. The Mental Health Act 1969 paved the way for the integration of general and psychia- S atric hospital services. Traditional separatist attitudes proved an obstacle to integration at first, but eventually negotiations enabled a smooth transition of mental hospital administration from the Department to Hospital Boards to be attained on 1 April 1972. Uncertainty about the fate of Queen Mary Hospital delayed its transfer to the North Canterbury Hospital Board by 6 months. Lake Alice Hospital, Marton, is now the only remaining departmental hospital. The Next Step 207. The uneasiness brought about by the administrative changes discussed in this chapter, the pressures for organisational change arising from modern attitudes to medical care, along with public criticism of the deficiencies of the New Zealand health services, combined to produce two inquiries into various aspects of the health service. The Royal Commission on Social Security (1969-72) studied some of the health components of the social security scheme. Arising from a dispute at Oakley Hospital, the Government of the day set up a Royal Commission on Hospital and Related Services in 1972. This body was disbanded in February 1973. 208. Like its predecessor, this Government also recognises that the health service needs thorough overhaul. The institutions devised to meet the health needs of years gone by may no longer be appropriate for the future organisation of the health service. It is therefore important to set out at length the need for a complete reorganisation of the health service, and to reiterate those historic principles upon which the reorganisation will be based.

REFERENCES Director-General/Minister, 17 May 1943, H.52/43 (26665). Finance Act (No. 2)1946, s. 15. Consultative Committee on Hospital Reform, op. cit., p. 6. 4See Hospital Expenditure Regulations 1948 and Hospital Employment Regulations 1948 and Amendments. 5Hospitals Amendment Act 1951, s. 7. °Hospitals and Charitable Institutions Amendment Act 1932, ss. 2-7. 7Statutes Amendment Act 1944, s. 31. Finance Act (No. 3)1946, s. 40. Consultative Committee on Hospital Reform, op. cit., p. 4. °ibid., p. 7. "ibid., pp. 11, 15-16. "ibid., pp. 16, 18-20. 73 3ibid., p. 19. °ibid., p. 21. 15For a list of territorial local authority health functions under current legislation, see Board of Health, Health Responsibilities of Local Government, Wellington, 1971. 16For a list of Board of Health publications, see Department of Health, Functions and Responsibilities, Wellington, 1973, pp. 61-2. 117Hospitals Act 1957, s. 87 (4). 118See for example editorials in Auckland Star, 10 July 1957; Press, 9 July 1957; Ye Awamutu Courier, 8 July 1957; Southland Times, 10 July 1957; Waikato Times, 8July 1957; Greymouth Evening Star, 22 July 1957; and Northern Advocate, 11 July 1957. The Ministers assurance is contained in Health and Service, February 1957, p. 27. 19Hospitals Act 1957, ss. 18 (7), 32, 36 (3), 84. "Hospitals and Charitable Institutions Amendment Act 1929, s. 2. cf. Hospitals Act 1957, Sixth Schedule. The old basis was changed in 1966, when the Ministerial appointments were dropped, the committee comprising only nominated and elected members. Hospitals Amendment Act 1966, s. 20 (1)—(2). 1See Statutory Regulations (S.R.) 1967/144; 1967/177; 1968/130; 1968/131; 1971/177. For general regulations concerning committees of management, see S.R. 1959/130; 1967/144; and 1967/227. 22Hospitals Act 1957, s. 58 (3); Hospitals Amendment Act 1971, s. 3. 23Hospitals Amendment Act 1968, s. 3 (1). 4Department of Health, A Review of Hospital and Related Services, Wellington, 1969, p. 25. 25e.g., Director, Hospitals Division/Chairman, Waiapu Hospital Board, 25 November 1970, H. 53/74. Submission by the Department of Health on Items (1) and (2) of the Terms of Reference of the Royal Commission on the New Zealand State Services, 1961, p. 4. 27A.J.H.R., 1972, H-31, p. 124.

74 VIII. THE NEED FOR CHANGE 209. New Zealand could not now claim its former international leadership in the provision of health care. Hard though it may ID be to accept, New Zealand has never attained a national health service, although such a service is often quoted. Nearly a decade ago, the countrys health services were criticised in these terms: "Although such descriptions as socialised medicine [or] the Welfare State are often used in referring to New Zealand, these terms do not apply to the provision of medical care in that country. There is a lack of coordination, organisation, and planning which one would not expect to find in a country as socially advanced, or in any country for which a highly organised system of medical care is claimed." 210. In short, the fragmented pattern of health care delivery means that New Zealand lacks a national health service. 211. The patient might recognise the problem in terms of an apparent shortage of doctors or undue delay before he can be admitted to a public hospital. Frustrated by these shortcomings, he may feel obliged to make his own arrangements for private treatment, and be left complaining about the shortcomings, in spite of its technological excellence, of the public system for which he pays. Primary Health Care 212. At present, there is, on average, one active general practitioner for every 2,400 people in New Zealand. Whether there are sufficient general practitioners is a matter for debate. More important than the overall population/doctor ratio is the fact that there are areas where this ratio is 50 percent above or below the national average. In recent years financial inducements have helped to redress the imbalance between urban and rural areas in this respect. However, the problem has not been solved entirely. There- remains the intra-urban maldistribution, where well established,, middle-class areas tend to be relatively overprovided with general practitioners, while some other areas are often characterised by a shortage of general practitioners. Some more effective means of overcoming this maldistribution needs to be found. 213. General practitioners in New Zealand are, rightly, extremely conscious of the nature of the doctor-patient relationship, and have strenuously resisted any administrative development which, in their view, would constitute a threat to that relationship. However, when concern for the individual patient is pursued in isolation from the

75 development of a good primary health care service for the comr munity, there can result the anomalous situation where general practitioners are dedicated to the ideal of giving the best possible care to their patients, while the news media and the public believe that the health service is, in many instances, inadequate. Provided that the individual has been accepted as a patient, his care will normally be excellent, but being ill does not automatically qualify the individual as a patient. With disturbing frequency incidents are reported which suggest that, in certain areas, it is almost impossible to secure the services of a general practitioner, even in an emergency. 214. The vast majority of New Zealand general practitioners are bound by self-imposed ethical standards, and accept the responsibility to provide continuing care for their patients. Even though they may not accept that group practice or health centre practice have organisational advantages, many practitioners ensure that their patients are "covered" for emergency calls outside surgery hours. Unfortunately a small minority of general practitioners are either unable or unwilling to make such arrangements, and those of their patients requiring urgent attention during the night and at weekends are obliged to try to make their own arrangements with other general practitioners or attend the nearest hospital accident and emergency department. 215. Failure to provide continuing care has given rise to complaints about deficient service and produced a recurrent ready- made formula to overcome the problem—more doctors. Such a solution would still not overcome the fundamental problem of the lack of a formal responsibility by the general practitioner to provide initial or continuing primary care to particular patients. Since there are a few practitioners who are apparently not swayed by ethical considerations, some method of ensuring that they provide the service obtainable from the majority of their colleagues must be sought. 216. Mechanisms established to overcome these difficulties of general medical service provision must not interfere with the clinical autonomy of the general practitioner in treating his patients, nor with the freedom of mutual choice between patient and doctor.

Specialist Services 217. The patient is also likely to encounter difficulty in gaining access to public hospital treatment, particularly if his condition requires minor surgery or long-stay geriatric care. There are two main areas of delay: that which occurs between referral by the general practitioner and consultation with the specialist at a public

76 hospital Outpatient clinic, and that which occurs between specialist consultation and admission for investigation or treatment. While, in many instances, these delays may indicate that resources provided are inadequate, it must not be assumed that this is the universal cause of delay. The efficiency of the use of existing resources must also be considered. 218. Misinterpretation of the length of waiting time by the S hospital authorities and the public generally may prompt an undue demand for more hospital beds—a "solution" which does not prompt due consideration of the need for improved planning or efficient use of existing resources. It is at present impossible to say whether or not the hospital services are efficiently managed because there is a lack of clearly defined management objectives; and insufficient factual or statistical information is collected to permit the efficiency of management to be assessed. In the future a greater emphasis must be given to the collection and collation of factual information. This will enable long-term regional and national policies for health care to be developed and will also permit their implementation to be continually assessed and reviewed. 19. As long as extensive waiting lists continue and public hospital treatment is not universally available within a reasonable period, other than for emergency cases for other patients whose need is considered as urgent, more and more people will feel obliged to accept private specialist and hospital care with or without taking out voluntary health insurance. A dual system of care will thereby be perpetuated, with substantially preferential treatment being given to those who can afford to pay for it privately. Those who can not afford the cost or who are excluded from voluntary health insurance programmes because of age, psychiatric illness, chronic or congenital disease or illness , 2 must wait their turn for access to public hospitals. The needs of these excluded groups are often the most pressing. 220. At different times and for various reasons the private hospital system has sought and obtained considerable injections of Government finance for maintenance and development, while they have remained functionally independent of the public system. Private hospitals do not accept any directions as to the type of patient they admit, nor have their programmes been adequately co-ordinated with overall health care programmes for particular groups of patients. 221. The pressure caused by public hospital shortcomings has led to the rapid growth of voluntary health insurance and altered the use and scope of private hospitals and health facilities, and has also changed their role from that suggested in 1938 (see para. 111). If private hospitals are to continue to receive substantial support from State finance, as at present, it is inevitable that their role and place in the health service and their relationship to the comprehensive public sector should be reconsidered and redefined. In so doing it may become necessary to differentiate between those private facilities which are run for profit, and those administered by religious, welfare, or non-profit trust organisations as part of their social service. Voluntary Services 222. Many services which are now regarded as integral parts of the organisation of health care in New Zealand owe their initial development to voluntary organisations and societies. In their efforts to provide continuing services, some voluntary organisations have, unfortunately, encountered problems of manageability. Such organisations, with extended regional or national commitments, have been obliged to turn to the State for the financial support required to maintain or develop their programmes. It is incongruous that while the necessity for the services provided by these organisations is acknowledged to the extent that financial support is granted, the State has been reluctant to assume responsibility for their provision in a co-ordinated and uniform manner. The situation has been compounded by the insistence of some voluntary agencies on complete independence which sometimes manifests itself in the form of opposition to any form of service co-ordination. As a consequence, the service provided in such fields as infant welfare, the care of the mentally and physically handicapped, and the accommodation of the aged is characterised primarily by its variability. Where the service exists it is usually excellent, but there are too many situations where no service is provided. 223. Even where voluntary agencies are able to provide such major services successfully, there is frequently a lack of effective co-ordination not only with other voluntary agencies, but also with other components of the health service, particularly primary medical care and the specialist services. As a result the organisation of facilities and services for particular patient groups is often fragmented. At best there may be duplication of effort; at worst, the separate agencies involved may strive to attain conflicting objectives. To overcome this very real problem, it is necessary to define the relationship between statutory and voluntary agencies in the health service so that planning for future development may take account of the contribution of voluntary agencies. The definition should not be left to chance or personal contact, but should be made as part of the overall strategy for health care.

78 Health Education 224. The increasing sophistication of health care technology gives added emphasis to the need, which exists in any organised system of health care, for programmes of health education based on the use of techniques of demonstrable efficacy. In addition to the scientific use of the communications media, there is a need for more extensive use of the educational opportunities afforded by the normal personal contact between members of the public and general practitioners, specialists, and other health professionals. Such programmes are necessary not only to promote a positive attitude towards the maintenance of high standards of health, but also to ensure that the resources of the health service are properly used by the public. Traditional health promotion programmes must be matched by education of the patient so as to limit unnecessary demands on and for health care services. Twenty years ago a WHO expert committee said that health education should have, as one of its aims, that of enabling the patient to make intelligent use of health care services.- It is thus appropriate to recall some comments about the publics attitude to medical care made in the Review of Hospital and Related Services: "Due to expanded means of mass communication and rising standards of education, the public are becoming increasingly exposed to information and viewpoints of very variable quality on a wide range of medical topics. . . . Patients and relatives know sufficient of the mysteries and superficial science of medicine to assume a more informed interest in their maladies. They, not unnaturally, seek explanation. This requires a different relationship between doctor and patient, and between the hospital as a whole and the public it serves. . With hospitals now financed wholly from the public purse, the patients approach to many aspects of hospital care is properly that of the owner-occupier."4 225. A special health information programme on the use of services is an overdue necessity. The public should be better informed, for example, of when it is necessary and when it is unnecessary to consult a doctor or to expect a prescription. The patient and taxpayers rights to free public hospital care and specialist consultations at public hospital outpatient clinics should also be publicised. Because there is a lack of information about the scope and working of public hospital services, too many patients feel con- strained to seek and pay for private treatment unnecessarily.

Administrative Confusion 226. Service defects and problems indicated in this chapter have arisen • from the fragmented delivery and organisation of health

79 care. The existent administrative machinery is outmoded and ill- equipped to produce a functionally integrated New Zealand health service. 227. The confused inter-relationships and responsibilities of the Department of Health, Hospital Boards, territorial local authorities, private health services, and voluntary organisations are relics of years gone by. They do not follow the realities imposed by technological advances, progress in medical science or a centrally financed health service. 228. The retention of locally elected Hospital Boards after the abolition of hospital rates has produced a most remarkable anomaly in the organisation of health care. All finance now required to run and develop the hospital service is derived from the Treasury with the exception of capital loans, and even these are serviced and paid back by the State. Allocation of working funds is the responsibility of the Minister of Health. Yet the residual influence of former hospital financial arrangements leaves the curious and unjustifiable notion that, because Hospital Boards still happen to be locally elected, their members may consider themselves solely and directly accountable to their local electorate. Some overlook the fact that the source of their finance imparts an additional responsibility through the Minister of Health and Parliament to the general electorate. The Parochial Outlook 229. A local perspective can also limit service developments. While all Hospital Boards can demonstrate a record of substantial achievement, priorities for service development have differed widely, as is evident, for example, in the varying pattern of provision of rehabilitation and extramural services and consultative outpatient clinics. By organising hospital services locally, there is no guarantee that the services provided in a particular locality fit into a broad nationwide scheme for health service development, so as to avoid, the local deficiencies in individual services which can arise as a result of unco-ordinated planning. This becomes even more apparent when the health activities of territorial local authorities are examined. 230. Perhaps less obvious to the citizen, but of great importance to the public health are environmental health services, organised to prevent and control the spread of communicable disease and other hazards to health by attending to such basic public health requirements as food standards, waste disposal, sanitation, good housing, and safe water supplies. Constant vigilance is required to ensure that an area is kept free from physical, chemical, and biological

80 hazards to health. An adequate standard of housing, public buildings, work places, and recreational facilities is also required. Local authorities and their health inspectors have played an important part in the environmental health field; but in general, the ultimate responsibility rests with the Medical Officer of Health and his team of medical officers, inspectors of health, public health nurses, health education officers, and other staff experienced in the environmental S health field. At national level the Medical Officer of Health also has available a wide range of expertise, including health and chemical engineers and other scientific officers and services. 231. The diversity of administrative practices and standards of inspection among the many territorial local authorities has created a number of problems. A health inspector may combine his health functions with service as a building inspector, noxious weeds inspector, or dangerous goods inspector. The general inspectorial role then becomes more important than the health purpose. In some areas, adequate environmental health surveillance has been handicapped because of parochial political procedure. 232. Environmental health services constitute a significant part of public health activities, but their administration under territorial local authorities has tended to separate them from mainstream health services. A greater degree of co-ordination and uniformity is badly needed.

The Absence of Co-ordinated Planning 233. Future arrangements for the health services must ensure that the management implications of a centrally financed national health service are clearly laid down. It is axiomatic that the management lines of responsibility and accountability must follow the lines of financial control to the ultimate source of finance. This does not mean that the administrative authorities concerned with providing health care should lose the close contact with the communities they serve, nor that the services provided should be developed without consideration of the manifest needs of those communities. Rather, while members of future administrative health authorities will still need to be drawn from the communities they serve and to be accessible to the people of those communities, the authorities must be so constituted as to be responsive to national objectives in service provision and development, and to act within a framework of national health policy. 234. Without national health policy guidelines there is a danger that planning will proceed in response to parochial pressure or exigencies of the moment. This, in turn, may lead to the inequitable distribution of facilities and services in which areas of 81 real need go unrecognised or neglected. The issue of guidelines and national policies is clearly a responsibility of the Minister and his Department. At the moment, the Department has no specific statutory authority for health service planning on a national scale. This, perhaps, is understandable, given the evolution of the Department to date and its involvement in the details of administration of the various components of the health service. It will be recalled that since 1962 the Department has sought to free itself from administrative detail so as to devote a great deal more time to formulating broad policy. Only in a limited number of areas of health care provision and development has the Department so far published firm policy guidelines; and, even in these areas, policy has developed largely in response to problems of the moment and not as part of a broad strategy for health care. The consequent effect has been a large number of small-scale endeavours, of immediate but short-term benefit, some of which have conflicting objectives. The Department of Health must be restructured to facilitate the planning and development of a functionally integrated health service, and to enable a greater concentration on national advisory services, which, to conserve resources of manpower and expertise, must be the direct responsibility of a Government ministry. 235. The administrative structures now in use throughout health services were devised to meet the immediate needs and problems of yesteryear. They do not take account of the present realities of responsibility, accountability, and management, and are not geared towards the administration of a national health service. To provide the sort of administration now needed in the health service, radical overhaul is necessary.

REFERENCES 1 G. M. Emery, "New Zealand Medical Care" in Medical Care, September 1966, 4, 3, p. 169. For a discussion of voluntary health insurance in New Zealand, see "Private Medical Insurance" in Consumer Review, February 1974, pp. 10-19. World Health Organisation, First Report of the Expert Committee on Health Education of the Public, Technical Report Series, No. 89, Geneva, 1954, p. 6, Department of Health, A Review of Hospital and Related Services in New Zealand, Welling- ton, 1969, pp. 59-60.

82 IX. PRINCIPLES FOR CHANGE

236. One of the unfortunate repercussions of the present fragmented system of health service administration has been an undue financial and administrative concentration upon the institutions and services for treating illness. This long standing historical CA4 emphasis in the health services cannot be changed overnight. Nevertheless, the Government believes that fundamental overhaul of the administrative structure is essential in order to bring into a single health service the full range of primary health care, specialist diagnostic, therapeutic and rehabilitation services and environmental health services. It is only by this means that the promotion of good health as distinct from the treatment of ill health will receive its rightful emphasis. 237. The reorganisation is also designed to fulfil the Govern- ments pledge to make health care available to thecitizen by right.) Complaints about the maldistribution of and limiEed accessibility to, health services must continue so long as their administration is divided in the present manner. Reorganisation is intended to bring the services closer to the whole community in terms of time, place, and people) 238. The need for change is apparent to those who suffer, whether physically or administratively, because of shortcomings of the present system of health service administration. This, in turn, stems in large part from fragmented organisation of health services in the past. These historical aspects and the proposals need to be considered together to obtain a clear appreciation of the need and basis for reform. At first sight the proposals for reorganising health service administration may seem to be radical. This is true. They are radical because they are based on certain principles rooted deep in the tradition of health services administration in this country. There are three such principles: 238.1. That the community, acting through the State, has a responsibility to provide for the health needs of its members. 238.2. That the lines of administrative control of health services should follow finance to its source. 238.3. That health services should be organised on a basis so that their administrative districts should be capable of meeting the health needs of the community.

83 239. Three further principles reflect the evolutionary needs of the health services to date: 239.1. That the various components of the health service should be functionally integrated. 239.2 That the future development of the health service should be rationally planned. 239.3. That there should be a national health service. Each of these principles is discussed below. Community Responsibility for Health 240. Community responsibility for health care of the citizen has been a continual theme in the development of health services in this country. Government involvement, whether direct or through statutory agencies, was gradually widened until community res- sponsibility reached a high-water mark in the concept of the comprehensive State health service proposed in 1938. The envisaged scheme, had it succeeded, would have removed from the individual the worry of financial responsibility for medical care. Since 1938, in spite of widespread public enthusiasm for the concepts of community responsibility for and egalitarian access to the health service, the residual influence and eventual renaissance of health services outside of the public sector have undermined community responsibility by creating a situation of potential competition between the public and "private" health services. 241. If it can be accepted that sound health is a fundamental human right, then health services are a social service, and not a marketable product. Self-reliance finds its highest expression in community responsibility. This inevitably leads to national responsibility for the provision of health services. Splintering of this responsibility by private services therefore threatens to destroy an achievement of social progress in New Zealand. It is morally indefensible that the individuals access to services, which should be freely available by right, may be facilitated or obstructed according to his ability to pay. It is a responsibility of the State to provide a high standard of health care, available to all on an equitable basis. 242. Acceptance of every individuals equal right to continual and comprehensive health care without economic barriers has been tacit rather than explicit. This has left little scope for redress when a health service has been denied to a patient or when it has been I granted only after an unreasonable length of time. 243. Full acceptance of the notion of community responsibility for the citizens health care entails an obligation upon the State to - place the individuals right to health care upon a statutory basis 84 rather than leave it to convention. Adequate mechanisms for dealing with complaints about the health service provided by the State also need to he established. Control and the Source of Finance 244. The hospital service in New Zealand was organised on the basis and application of the idea that local administrative control S should follow a local source of finance. The inception of social security health benefits and the abolition of hospital rates have made general taxation the ultimate source of health service finance. Under the circumstances, it is anachronistic to think that responsibility for the service should remain a local one. 245. General taxation and community responsibility combined ,- necessitate a national approach to the service. Some comments of the Barrowclough Committee on this subject are particularly apt: "It would be surprising if a system if administrative control of hospital services .which was adequate and satisfactory when hospitals were largely financed out of rates could be found to be equally adequate and satisfactory when those hospitals are entirely financed by the State. If the State is to provide the finances it must assume an increasing responsibility for the quality and nature of the services to be provided. It is not only a matter of checking expenditure, it is also a matter of determining, defining, and co-ordinating the quality of those services. . . . The assumption by the State of full responsibility for the cost of hospital services carries with it an even greater responsibility to supervise and control not only the expenditure on those services, but also to prescribe, define, and control their nature and quality." What constituted organisational reality in 1953 holds true for 1974 and the future. 246. It has sometimes been argued that community responsibility should find expression through the formation of a politically independent national health corporation. This could only be considered if the corporation were given responsibility for finding its own funds. In the meantime, sources of funds other than general taxation are unlikely to arise. The alternative of management by corporation would also be quite alien to the traditional pattern of health service administration in New Zealand. The Minister of Health 247. Community responsibility for the health service finds expression through established constitutional procedures. The Government of the day is the trustee of community responsibility, and is accountable to the community through Parliament. The Minister of Health is responsible to Parliament for the department of state and statutory agencies under his control. 85 248. It is logical to regard the Minister of Health as the person. to whom the health service will be directly accountable. The Minister will be responsible for establishing, maintaining, and. developing, on behalf of the Government, a comprehensive health. service to be made available with no economic barrier to all citizens.. 249. Certain broad powers are needed to enable the Minister to give effect to this responsibility. He must be able to delegate powers,. and issue directions on plans, policies, and priorities for the health service. He must also have the power to inquire into defects in the health service, or cause these to be investigated. 250. In seeking to fulfil his responsibilities, the Minister will need to rely upon the advice of others, both at the central and national. levels. Some of these persons will be appointed by him. The New Zealand Health Authority 251. In constitutional terms, a department of state assists the Minister in his public and official duties by tendering advice and implementing Government policy. This latter function is most important, since the funds appropriated through Parliament for a government activity are disbursed through a department of state. 252. It is neither feasible nor desirable to administer the entire health service from Wellington. The actual health service should be- provided, operated, and administered by some form of regional agency involving people from the region who have a clear appre-- ciation of regional health needs. Another type of agency—a national health authority—is then required to plan for, supervise, and co-- ordinate the development of regional activities, and to ensure that.. money is spent wisely and in accordance with national policy. 253. The Department of Health, which will itself be reorganised and be redesignated the New Zealand Health Authority (N.Z.HA.),, because of its national perspective, is best suited to fulfil this role... To achieve appropriate perspective, greater prominence must be- given to the present Departments supervisory and planning functions. Those operational activities which are not required for the maintenance of national standards must be relinquished by the N.Z.H.A. Involvement with minutiae, which until now has taken too large a part in the Departments oversight of Hospital Board activities, must also be reviewed. Regional Health Authorities 254. The N.Z.H.A.s supervision of regional activities is not- intended to create a bureaucratic paradise. The future regional.- agencies, which the Government proposes will be known as Regional-

86 Health Authorities (R.H.A.s), will be charged with the responsibility of promoting the health of the community in a region, and providing, maintaining, and developing a comprehensive health service incorporating primary health care; specialist diagnostic, therapeutic and rehabilitative services; and environmental health services in accordance with national guidelines. 255. The rate of change within the health service is such that S inflexibility or overstandardisation of development is undesirable. It is equally important not to stifle freedom to diversify activities within a service by the imposition of one currently fashionable form of service provision. In other words, while the N.Z.H.A. will be expected to define the services to be provided by R.H.A.s and to define the levels of provision, R.H.A.s should consider the best way of providing the service. The method of providing service will to some extent be influenced by the resources and demographic characteristics of a region, as well as the professional views of those in charge of a service. 256. In a system where lines of administrative control follow finance to its source, it would be improper to speak of regional autonomy. R.H.A.s will exercise powers delegated by the central agencies. At the same time, delegation must be matched by accountability to those agencies from which the power is delegated. The delegation of authority still entrusts ultimate responsibility with the delegating agency, to whom the authority may revert at any time. Further information about the extent of powers to be delegated is contained in subsequent chapters. 257. The principle of community responsibility for health care has considerable implications for the relationship of the national health service to voluntary organisations working in the health field, and to private health services.

Voluntary Organisations 258. The voluntary spirit has been a strong force in shaping the health services in New Zealand. Hospital administration has its origins, at least in part, in Voluntary initiative. So, too, have many services provided for infant welfare, the physically and mentally handicapped, and the care of the aged. 259. The range of services, as indeed the number of voluntary organisations, is extensive. A number of national voluntary organisations working in the field of health care are affiliated to the New Zealand Federation of Voluntary Welfare Organisations. A more compehensive list of national voluntary organisations

87 appendix IX. The extent of local voluntary agencies can be gauged from a perusal of the directories of social service agencies published for some New Zealand cities.3 260. Nine major activities have been suggested as ways in which national voluntary agencies can support national health programmes. These include: 260.1. Demonstrating and pioneering new ideas, including research. 260.2. Health education of the public. 260.3. Training health workers. 260.4. Assisting the Government in planning national health programmes, including the identification of health problems. 260.5. Providing health services to individuals. 260.6. Assisting the Government to evaluate national health programmes. 260.7. Influencing health legislation and the formulation of health policy. 260.8. Providing financial aid to others. 260.9. Stimulating community participation in health programmes.3 261. Voluntary organisations in New Zealand have generally arisen to meet a need or plug a gap in the network of State provided health services. Having pioneered a new service and demonstrated the practicability and value of it, voluntary agencies have sometimes found themselves trapped by the financial burden of providing the service, the cost of which has exceeded funds raised from charitable sources. Appeals to the State for financial assistance, whether by grant or subsidy, have often been favourably received, particularly for those from voluntary agencies whose activities have become integrally woven into the fabric of New Zealand society. 262. An undue preoccupation with financial responsibilities for maintaining a service may prove deleterious to the freedom of a voluntary agency to pioneer further and alternative patterns of care for the group of persons with which they work. A number of voluntary organisations are now very largely dependent upon the State for financial aid for maintaining and expanding their services. The financial predicament therefore calls into question the whole relationship of statutory and voluntary enterprise.

88 263. In attempting to define the relationship between State and voluntary agencies, it is important to recognise the fact that voluntary action has been an important stimulus to social progress. It is also important to ensure that voluntary action which springs from social concern or social conscience should not be stifled. Voluntary organisations have three vital functions to perform in a welfare state: 263.1. To harness the goodwill, abilities, and time of people in the community, and to channel these towards socially desirable goals. 263.2. To provide resources and facilities for small-scale experiments. They enjoy more flexibility than statutory agencies in this regard. 263.3 To stimulate statutory agencies to adopt alternative patterns of service provision, and to represent the community in ensuring that standards are maintained. 264. At the same time, it needs to be appreciated that the State, acting on behalf of the community, has the ultimate responsibility for the health and well-being of all citizens, and for distributing equitably the resources available for health care. The maintenance of standards and of a uniform level of accessibility to health care is also the States function. This means that the States responsibility is paramount. 265. If the above is borne in mind, it is clear that the relationship of voluntary and statutory agencies has not been adequately defined since the State accepted the notion of community responsibility for health care in 1938. An effort was made to establish a relationship by the Consultative Committee on Infant and Pre-school Health Services (1959) which was chaired by Mr Justice (later Sir George) Finlay. The Committees report noted: "It is impossible to escape the conviction that the responsibility of the Government is primary, general and comprehensive. . . . The responsibility of the Government in respect of such matters is, we conclude, basic and unlimited and, in any ultimate sense, inalienable: inalienable in that to whatever agency and to whatever extent the Government may delegate the performance of any part of its duty, the Government remains responsible for the final result. The only limiting factor is economy, for no Government can give a better service than it can afford. . "A voluntary society operating in the field has no inherent responsibility. Its responsibility is measureable solely by the extent and nature of the function it chooses from time to time to perform. Unlike a Government which, whilst it remains the Government, cannot escape its responsibility, a voluntary society can retire from activity to any extent it chooses. 89 "Such then are the relative responsibilities as we see them. It remains only to postulate that financial responsibility in such matters as we are concerned with is proportionate with the measure of relative responsibility. If this be so (as we believe it to be) then two consequences follow: the first that the financial responsibility . . . is wholly the responsibility of the Government: the second, that only to the extent to which a voluntary society is relieving the Government of that responsibility is it entitled to financial aid from the Government. "In this latter relation, it seems proper to say that the extent to which a voluntary society affords relief to a government depends upon the nature of the service it renders and the quality and extent of that service. Such then, is the touchstone by which, in our view, the obligation of the Government to give and the right of a voluntary society to seek financial assistance from the Government must be judged."4 266. The lack of a formal relationship between statutory and voluntary agencies can have unfortunate repercussions for the health service. Areas of service overlap or even duplication may arise from the absence of co-ordination. In extreme cases, an element of competition may even be present. A further problem arises from the want of co-ordination. While many voluntary organisations continue to receive substantial financial support from the State, they may unwittingly inhibit universal access to their services by imposing unduly restrictive standards for admission. Statutory agencies are then left with the problems of residual care. 267. A uniform level of accessibility can only be attained when the community, through the State, accepts responsibility for the provision of the service. To the extent that a voluntary agency relieves the State of a health service provision, it is essential, in the interests of the people being cared for, that its work be integrated with the fabric of national health care. In some areas of voluntary service, State responsibility could be for the direct provision and financing of the service, which would leave the voluntary agency free to pioneer new developments. As an alternative, the State could enter into a contract with a voluntary agency, by which the voluntary agency provided the service. This would provide financial security for the agency while at the same time allowing the State to develop a more effective partnership with the voluntary organisations in determining the nature and level of provision of services, and in integrating them with other health services.

Private Health Services 268. It is quite erroneous to speak of "private" health services in New Zealand at present. The term "State subsidised" might more accurately represent the status of the so-called private services, -which include general practitioner, medical and other specialist, hospital laboratory and radiological services, and nursing bureaux. 269. Consideration of the future of these components of the health service provision must be seen against the Governments responsibility to provide a comprehensive health service for all citizens • irrespective of ability to pay. In accepting this obligation, the Government has pledged to improve progressively the public sector of the health service. 270. In the long-term view, the progressive improvement of State health services will restore true freedom of choice for patients. The Government believes that the true role of the private sector :is to meet the medical needs of those citizens who freely and voluntarily elect not to use State provided health services and are •prepared to meet the full cost of private services. Should they wish to meet this expense by private insurance, they should be free to do so. When it has been established that patients seeking private treatment do so from freedom of choice, and not in an effort to circum- vent the difficulties of the public system, the real need for private health services will be more properly determined.

Functional Self-sufficiency 271. An historic principle underlying the organisation of health services in New Zealand has been that the territorial limits of a health or hospital district should enable the district to operate its health care programmes without recourse to assistance from outside the district. 272. The principle has been broken more than it has been honoured, particularly in the hospital service. It is true, nevertheless, that the continuing efforts of central agencies over many years, to secure some rationalisation of hospital administration based on functionally self-sufficient districts, have met with some success. For virtually half a century the pattern of fragmented hospital administration has been checked and slowly reversed. Appendix III shows that the last time a hospital district was carved from that of another Hospital Board was in 1925. During the past 20 or so years, the trend towards amalgamation of Hospital Boards has accelerated. However, as was shown in para. 188, about one-third of Hospital Boards are still incapable of providing a full general hospital service to their districts. 273. What is true of the hospital service is even truer of environmental health services, scattered among so many territorial local authorities. Some rationalisation of local government activities 91 will be achieved by current and pending legislation, but this is unlikely to affect the environmental health services to the desired extent. Health Regions 274. The regional approach to health service administration will restore the concept of functional self-sufficiency. The regional approach is necessary because of the complexity of medical tech- • nology which can be expected to continue to draw specialist services and sophisticated facilities to those cities which are regional focal points. Improved communications will facilitate the process as well as developing a regional consciousness among the population. 275. Suggested regional health boundaries, prepared in the light of service requirements and demographic and geographical factors, are set out in figure I. These are: 275.1. Northland. 275.2. Auckland. 275.3. South Auckland. 275.4. Waikato. 275.5. Bay of Plenty. 275.6. East Coast. 275.7. Taranaki. 275.8. Rangitikei. 275.9. Wellington-Wairarapa. 275.10. Nelson-Marlborough. 275.11. Canterbury-Westland. 275.12. Mackenzie. 275.13. Otago. 275.14. Southland.

Health Districts 276. Within health regions, each of whose pojulations will be at least 100,000, there will be districts. Health districts, which should Pot be confused with the present administrative units of the Depart- ment of Health, refer to the natural grouping of people in an area which is part of a region. It is difficult to fix criteria which can be applied to the definition or size of a district, except that its principal centre will invariably have a general hospital with departments of general medicine, including paediatrics, and geriatrics, general surgery, orthopaedic surgery, obstetrics and gynaecology. It will also be desirable for public health services to work on a district basis.

Figure 1: Suggested Regional Health Authorities

2 NORTHLAND 3 4 I Mangonul 2 Whangaron 6 3 Hokianga 4 Boy Of Islands 5 5 Hobson 6 Whangarel 7 7 Otaitsatea AUCKLAND SOUTH AUCKLAND •• 2 1 Franklin 1 Rodney 2 2 Woiheke 2 Waitemata • • 3 3 Coromandel 3 Great Barrier Island 4 Thames 1 Touranga 1 4 5 Hauraki Plains 2 Rotorua 6 Ohinemuri 3 Taupo 6 4 Whakatane WAIKATO 5 Opotiki 2 1 Raglan BAY OF PLENTY 2 Waikato 1 3 Pinko 4 4Waipa6 5 Otorohanga 2 6 Matamata 4 7 Waitomo 7 2 8 Taumarunui - - 3 TARANAKI 3 8 4 1 Taranaki EAST COAST 2 Inglewood j 2 3 Clifton 5 4 Stratford 6 1 5 1 Walapu 5 Egmont 8 2 Waikohu 6 Eltham 9 3Cook 2 3 7 Waimate West 4 Wairoa 6 8 Hawera RANGITIKEI 5 5 Hawkels Boy 9 Patea 1 Waimarino 6 7 8 6 Waipowa 2 Waitotara7 11 7 Waipukurau 3 Wanganui 9 8 12 8 Patangota 4 Rongitikei 13 5 Kiwitea 10 1 14 6 Pohangina 7 Oroua 2 WELLINGTON 8 Koiranga . 3 WAIRARAPA 9 Manawatu 5 - I Eketahuna 10 Horowhenua 2 Masterton 11 Oannervike 3 Wairarapo South 12 Woodville 4 Featherston 13 PahiatuaSHutt 14 Akitlo

Figure I: Suggested Regional Health Authorities

S 2. I4 2c3i() 2 NELSON - MARLBOROUGH 5 5 3 1 Golden Bay 2 Waimea 3 Marlborough 6 4 Awatere 7 5 Kaikoura 8 10 CANTERBURY - WESTLAND 121 Buller 14 15 2 lnangahua .16 3 Grey /2 18 19 17 4 Westland 5 Amen 3 6 Cheviot MACKENZIE 7 Waipora I Ashburton 8 Malvern 2 Mackenzie 9 Oxford 3 Strathollan 10 Ashley 4 Waimate 11 Rangiora 5 Waitaki 12 Eyre 13 Waimoiri 14 Paparua 15 Heathcote 16 Mount Herbert 17 Alcoroa 18 Ellesmere 19 Wciirewa 2 - OTAGO 2Or2O Chatham Islands 1 Lake 2 Vincent 3 Maniototo 4 Wail,emo 5 Waikouoitj 6 Taieri SOUTHLAND 7 Tuapeka 8 Bruce WA I Fiord dp 2 Wallace 9 Clutha 3 Southland 4 Stewart Island

94 277. Some of the suggested regions will already constitute what is effectively a district, and it would be pointless to break these down into artificial units. In other regions there may be several districts.

Local Government Commission 278.The regional reorganisation of the health services is part of the Governments plan to improve local government, which now involves more than 250 territorial local authorities and about 1600 ad hoc authorities. The 29 Hospital Boards are included in the latter figure. The Government intends that the total reorganisation of local government and health services will proceed apace. The Local Government Commission will be empowered to prepare schemes for the creation of local government regions by the end of 1979. At the same time, the Commission will review the provisional regional health boundaries in the light of demographic and geographical considerations to ensure the compatability of the boundaries of health regions and local government regions. The Local Government Commission will also consider appeals against inclusion of communities in particular regions. 279. Regional health services will be functionally self-sufficient to the point of meeting the health needs of regional populations, with the exception of some highly sophisticated specialist services which cannot be justified on a regional basis. Otherwise a full range of primary health care, specialist diagnostic, therapeutic, and rehabilitative services and environmental health services will be provided.

Functional Integration 280. It is not by accident that medical services in New Zealand are currently divided into three main branches—primary health care, the hospital and specialist services, and public health. The separation of these services reflects the development of British medicine, which has been inherited in this country. For many years, however, it has been recognised that this organisational pattern is outdated, and that the rigid compartmentalisation of medical services in this way may obstruct the effective care of individual . patients and the resolution of medico-social problems. Accordingly, some form of reorganisation is necessary to bring together the three branches of the medical services. 281. In endeavouring to achieve this, it is possible to conceive of local or regional authorities which would assume responsibility for the operation of the existing three branches in a particular locality. Such a process of administrative unification might represent a step forward in many instances. However, the perpetuation of a tripartite medical service within the organisational structure Of the new authorities could well achieve less, overall, than is at present possible in a few localities where there are already effective working relationships between general practitioners, the hospitals, and the public health authorities. . 282. Since the primary object of any reorganisation should improve the standard of service provided for patients, it is necessary to consider the way in which the whole of the health services might be reconstructed to improve the care of people. In this context, it is necessary to think of functional integration rather than administrative unification. 283. Functional integration is the bringing together of the various components of the health service. The concept can be approached in terms of the health care needs of the population and the specialised staff and facilities required to meet these needs through health care activities. The interaction of health care needs, personnel and facilities is dynamic, because of the continual realignment of the places and disciplines required to meet health needs in the wake of medical progress. Figure II shows the effect and scope of functional integration in the health service, and also serves to demonstrate that the existing tripartite division of service provision is inappropriate. 284. Functional integration is a challenge imposed by the changing nature of medicine. A Scottish report makes this point well.: "The nature of medicine today increasingly gives rise to the need to see the arrangements for health care as a single system. . . . The strength of the total system depends on its parts and each part should reinforce and strengthen the others, in order that each may achieve the most effective discharge of its own particular responsibilities. An equilibrium of strength and resources through the system will produce the best results. Imbalance in resources and planning support can dis- tort the functioning of the whole system and lead to an unsatisfactory distribution of work. The future of general practice and hospital work can no longer he effectively considered in isolation from each other. The essential role of community medicine is not in separation from the clinical services, but in unity with them to plan and assess services for the populations they serve. There are not three or more separate medical professions each going its own way; there is one profession discharging a range of responsibilities." 285. The concept of functional integration is not new to New Zealand. It was recognised in the Hospital and Charitable Institu- tions Act 1909 which adopted as a general principle that the authority responsible for the accommodation of the sick should also be responsible for controlling the influences likely to cause or spread sickness. U

Figure II: THE FUNCTIONAL INTEGRATION OF HEALTH CARE HEALTH CARE AREAS OF HEALTH CARE ACTIVITY PROFESSIONAL DISCIPLINES PRIMARY HEALTH CARE SPECIALIST CARE COMMUNITY HEALTH MEDICAL - GENERAL General Practice Community Health Education of (Solo or Group Hospital Patients Practice, or Health Care Immunisation and Centre Based) Vaccination - - SPECIALIST Outpatient Clinics Specialist Health Education at Health Centres Diagnostic of Patients where population and Thera- is-sufficiently large puetic services - COMMUNITY Public Health Clinics Hospital Environmental I Hygiene at Health Centres Administration Immunisation and and-Epidemiology Vaccination Community Health Education Community Epidemiology NURSING Domiciliary Nursing Hospital Nursing Public Health Nursing ANCILLARY Physiotherapists, Hospital Public Health PROFESSIONAL Social Workers, etc. Diagnostic, Laboratory Services AND TECHNICAL working in Health Therapeutic, and Centre Teams Rehabilitative Radiological and Services Pathological support for general practice 286. Farsighted though this was, functional integration of environmental health surveillance and hospital medicine was only shortlived. Since then functionalintegrationhas been the unfortunate victim of misinterpretation. Too often the term has been considered a synonym for Hospital Board amalgamation. It has also been fashionable to limit the idea to a devolution of functions of the Department of Health to Hospital Boards and territorial local authorities. 287. Either of these misinterpretations, while facilitating a degree of co-ordination within the, health service, is too narrow a view for application in the future. For the purposes of the reorganisation of the health services, functional integration will bring together primary health care, hospital and specialist care and community care services. The interlocking nature and interdependence of these services as thy exist at present will be recongised by the creation of a single health service. The absence from this scheme of certain legitimate aspects of health care, such as dental and optical services, is admitted. At some future time these will be accorded their rightful place within the national health service. In spite of this handicap, the drawing together of primary, specialist, and community health services will mark a major step forward in health progress in New Zealand.

Health Service Planning 288. Throughout this document recurring reference is made to the management and development of health services. The choice of this terminology is far from fortuitous, since it is believed that the management and the development of health services. are inextricably interrelated. No administrator can manage services effectively without considering the future developments which will be necessary; and no planner can be effective unless he has immediate experience of services management. Operational management and planning must therefore proceed together and be directed by the same officers, under the control and supervision of the same authorities. • 289. These activities at a regional level do not conflict with the intended role of the Minister and the N.Z.H.A. in the national planning and provision of health services. While the N.Z.H.A. will be concerned with the strategy of health care, determining national priorities and policy guidelines, R.H.A.s will be concerned with tactics, ensuring that policies are implemented in the manner which best serves the population of the regions.

98 290. The fact that regional services will be developed in accordance with national policy guidelines does not imply that there will be an undue uniformity in the nature of the services provided. The formulation of national policies will ensure realisation of the principles of equitable distribution of resources, and should guarantee a greater uniformity of access to services. However, the continuing development of health services, and their ability to meet changing medical needs, are dependent upon initiating new and diverse types of service. Given the level of service provision which will be determined by the policy guidelines, R.H.A.s will be encouraged to initiate and critically evaluate new methods of providing and operating necessary services. The success of such experiments may well serve to indicate the lines along which future policy should be guided. 291. Planning of health services in a rational and co-ordinated manner will be a new venture in New Zealand and at the outset the officers of R.H.A.s will probably find this the most taxing of their responsibilities. There may be some who believe that the extensive programme of hospital planning undertaken in recent years has produced a cadre of officers well equipped to undertake this work. Unfortunately such optimism is unfounded. 292. Although there are officers skilled in the design planning of major institutions, it is one of the sad realities of hospital planning in New Zealand that there are very few instances where the size, siting, and content of a new building have been the result of detailed consideration of the services manifestly needed by the community. At a time when other countries seek to expand outpatient services and day treatment to keep patients out of hospital; or develop such facilities as radiology departments, laboratories and operating theatres to expedite diagnosis and treatment, often without the need for admission; or provide extramural and rehabilitative services to allow effective care of patients in their environment, many New Zealand Hospital Boards still think in terms of the number of beds as the determining factor in hospital planning. In some instances, the content and operation of the hospital are subsidiary issues, for consideration after questions of size and architectural concept have been resolved. 293. In short, while Hospital Boards and their officers have considerable experience in design planning, very few of them have given sufficient thought to rational service planning. For the future, all health services will need to be planned as a whole in each region and district, taking account of the extent to which they function in institutions or within the community; assessing, the

4 manpower requirements for all health related professions; ensuring that necessary supporting services can be provided; and, finally, giving consideration to the accommodation and equipment which may be needed. It must be remembered that there are many instances where highly effective services are operated from modest accommodation; there are also a few instances where impressive examples of architecture are an embarrassment because they fail to provide effective services. 294. Reference has been made to the necessity to plan health services to meet the needs of the community. While identification of the community to be served is a relatively simple matter, definition of its needs is far from simple. In this context, a distinction must be drawn between need and demand. The former is generally considered to be the judgment of the medical profession on the requirement for medical care; the latter is a reflection of the communitys attitude towards illness and may be greater or lesser than the medical judgment. 295. In a strict sense comprehensive planning to meet community need is an impossible task, since it involves, inter alia, the quantification of manifest and presymptomatic illness, and the prevalence of predisposing and causative factors, followed by assessment of the nature and amount of health care resources required to deal with these. The first part of the exercise would represent a monumental task, the results of which would be unlikely to justify the resources expended. The second is a matter of professional value judgment, subject to so many variables that total objectivity is impossible. 296. However, demonstration that purism is not feasible does not vitiate the principle. There are many situations where services are inadequate to meet manifest needs. The obvious shortages of primary health care services in some areas, the delays in effecting specialist outpatient consultations, the differences in infant mortality rates between Polynesian and European communities, are all instances where manifest needs are not fulfilled. The 30,000 patients now on hospital admission waiting lists, having been seen by specialists who consider that they "need" to be admitted, are indicators of areas of specialist services requiring urgent development. 297. In planning services to overcome such areas of need, the interrelationship between management and development is again encountered. How far these needs are not met because services are inadequate or because management is defective is, at present, largely unknown. The available factual and statistical information relating to service management is insufficient to permit such a judgment. For the future, health service information systems will 100 need to be developed in order to provide, for each area of service activity, management data indicating the resources available, the demands made on those resources, and the way in which services are used to meet the needs of the community. As this is a problem of national proportions, the N.Z.H.A. must assume responsibility for developing these health information systems. 298. Similarly, the N.Z.H.A. will need to adopt a more positive position in defining health policy and providing guidance on service development than the Department has hitherto. For the formulation of policy the Minister and the N.Z.H.A. will need to take account of the availability of resources as well as the desirability of achieving certain objectives; the policies must be practicable. This will only be possible where there is effective and continuing communication between the N.Z.H.A. and the regions, so that regional planning may be responsive to national priorities, while the N.Z.H.A. remains aware of operational feasibilities at regional level.

299. An essential part of the guidance material prepared by the N.Z.H.A. will be "norms" for service planning. Given that there is a limit to the financial, manpower and material resources which can be made available for maintaining and developing health services, and that these resources should be equitably distributed, the judicious application of normative standards, related to the population to be served, is unavoidable. While the tentative use of norms in respect of the provision of hospital beds has operated in New Zealand for many years, it has often been in a negative context, to restrain potentially exuberant development proposals. A change in emphasis, to the use of norms as objectives for positive development, will be required in future. The application of normative standards throughout the field of health service manpower is also necessary, and will require extensive research and development studies by the N.Z.H.A.

300. In accepting that these standards will be prepared and applied, it should be borne in mind that these are not "magic numbers" which determine arbitrary standards of perfection. These • norms should be viewed as a mechanism whereby equitable distribution of available resources may be achieved. Where it can be demonstrated that there are special considerations, it may be necessary to depart from accepted normative standards. Standards will also require periodiceriodi review and modification in the light of changing resource availability, service needs, and national priority. Too frequent modification, however, will not be feasible if these standards are to constitute the basis of service development plans. 101 301. While normative standards will play an important part in the future planning of the health services, the fact that their application to service management is considered to be quite inappropriate requires explicit statement. There are very few accepted standards of excellence in health service management, particularly in those areas where care of patients is amenable to quantitative assessment. Certainly the elimination of protracted delays in effecting medical consultation or hospital admission are desirable objectives to pursue, but these are absolute standards rather than working norms. Attempts to contrive normative standards for application throughout the field of service management would betray a complete lack of understanding of the methods of operation of health services. This does not imply that a laissez-faire attitude will prevail in service management. As with service planning and development, the efficiency of service management will be subject to continuing critical scrutiny. However, assessments of management efficiency in particular instances must be based on comparisons drawn against similar situations elsewhere, rather than against normative standards.

A Hospital Plan 302. A substantial volume of active planning in the health services in this country has been concerned with the hospital service. Within this the intended shift of emphasis from design planning to service planning necessitates a reconsideration of the nature and distribution of hospital services to ensure that services are provided effectively to meet community needs without undue extravagance in the use of limited resources. 303. Many hospitals in New Zealand were built long before contemporary concepts of hospital service provision were formulated; and the rate of growth of some cities during the last 20 years has far outstripped the pace of development of hospital services. Thus most of the larger cities, particularly in the North Island, have levels of provision of public hospital services appreciably lower than in the remainder of the country. Efforts to redress this imbalance will require high priority in the national plans for service development. Again, the "single-specialty" hospitals, such as psychiatric and maternity hospitals, although they have fulfilled a vital purpose in the provision and development of specialist services, h ave certain well-documented shortcomings which preclude their future development. It is now accepted that all specialist services should co-exist in the same institutions. A disturbing tendency in the recent development of our hospitals has been the endeavour to segregate "acute" from "chronic" services in separated institutions. While this may serve the interests of the so-called "acute" specialties,

102 by expediting the capital developments they require, it is not in the interest of provision of comprehensive and integrated care for all patients. One of the first steps in the integration of health services must be the removal of artificial and unproductive distinctions of this nature. 304. In those centres which serve a geographically large and sparsely populated hinterland, there has developed the concept of the "base" hospital. This concept has been of value in that it has led to the concentration of the resources required to provide a fairly comprehensive range of specialist services, and has served to restrict parochial influences which tend to dilute available resources. With the reorganisation of the service, however, this concept can not be extended. Very few of the new health regions will be geographically appropriate for a "regional base hospital" to be feasible, and the pattern of hospital services provided throughout the regions requires some consideration. 305. The question whether or not a hospital is provided in a particular locality must always be determined by the size of the population to be served. There is a threshold in population size below which there are insufficient people to generate a case-load which will keep a specialist fully occupied. The threshold varies with clinical specialities in that, for instance, general surgeons and general physicians serve much smaller populations than derma- tologists or thoracic surgeons. The question of geography also affects this issue, in that some small but remote communities often enjoy levels of specialist service, provision which could not be justified if they were nearer to a major centre of population. In this context it is significant that, as transport and communications have improved, a number of the smaller hospitals have curtailed or lost the range of specialist services which they previously provided. 306. It is suggested that future hospital services be provided by three types of institution: 306.1. Base hospitals. 306.2. Satellite hospitals. 306.3. Community hospitals. As will be seen, this proposal is, in many instances, no more than a formal rationalisation of that which already exists. The specialist service activities undertaken in each of these three types of hospital are suggested in figure III. 307. Base hospitals would provide inpatient and outpatient services in a comprehensive range of clinical specialties, usually serving a population in excess of 60,000. In regions where populations are scattered it may be feasible to consider providing base

10191

FIGURE III: EXTENT OF PROVISION OF SPECIALIST SERVICES IN DIFFERENT TYPES OF HOSPITALS

Specialist Services Base Hospitals Satellite Hospitals Community Hospitals General medicine, paediatric medicine, general Full range of services in all Full range of services in all Convalescent beds in all hospitals; surgery, orthopaedic surgery, gynaecology hospitals hospitals consultative outpatient clinics in selected hospitals Geriatrics Full range of services in all Long-stay beds in all hospitals; Long-stay beds in all hospitals hospitals outpatient clinics, rehabilitative services, and day care at selected hospitals Obstetrics Full range of services in all General practitioner beds in General practitioner beds in all hospitals all hospitals; specialist services hospitals in selected hospitals Mental illness (adults), E.N.T. surgery, Full range of services in all Outpatient clinics at selected ophthalmology, urology hospitals hospitais Mental illness (children), mental handicap, Full range of services at selected chest diseases, physical medicine, derma- hospitals in all regions; out- tology, venereology, paediatric surgery, patient clinics at all hospitals dental surgery and orthodontics Cardiology, neurology, nephrology, endocrin- Full range of services at selected ology, rheumatology, plastic surgery, "national" centres; out- neurosurgery, cardio-thoracic surgery, patient clinics at selected radiotherapy hospitals in all regions Accident and emergency services, intensive At all hospitals At selected hospitals care (general, coronary, neonatal)

)

0 hospitals to serve 40,000 people, but populations smaller than this are unable to support the range of services which would normally be provided in a base hospital. In major urban areas it will be appropriate to provide a number of base hospitals, so that the population served by each rarely exceeds 120,000 unless high-density commercial or residential development leads to greater concentrations of population within distances of; say, 10 miles. 308. Satellite hospitals would provide inpatient care in a smaller range of specialties, as well as outpatient services in a fairly full range of specialties, some of the latter being provided by visiting specialists from the associated base hospital. Satellite hospitals would serve populations in excess of 25,000, although, again, geographic isolation may warrant provision for populations as small as 10,000 people, provided arrangements can be made with the base hospital to ensure continued specialist staffing. As will be apparent, satellite hospitals will require strong service links with the base hospitals. They will normally be a feature of outlying towns and will rarely be provided in large urban areas. 309. While the larger health districts within the intended regional organisation may contain more than one base hospital, the smallest districts will have at least a satellite hospital. Existing "single- specialty" hospitals should be regarded, for purposes of service organisation, as "satellite units" of base hospitals. 310. Community hospitals will be provided in isolated, outlying centres, serving populations of 4,000 or more. These hospitals will be staffed by the local general practitioners and will contain small numbers of beds for the medical treatment of patients whose admissions are necessitated as much by social as by medical considerations; they will provide beds for general practitioner obstetrics; for the convalescent care of local residents who have had surgical operations at base or satellite hospitals; and beds for the nursing care of long-stay geriatric patients from the locality. Generally, the total number of beds will rarely exceed 40. They will have no laboratories, but will act as collecting points for specimens to be dealt with at the nearest base hospital; and they will have radiological equipment of limited . capability, so that X-rays of chest and extremities can be undertaken by nursing staff or visiting radiographers. In addition, specialist outpatient clinics in medicine, surgery, paediatrics, ortho- paedics, and gynaecology should be provided, given that the catchment population is large enough to generate a sufficient case-load to warrant clinics being held frequently. 311. R.H.A.s will need to have regard for changing population size and structure, and where appropriate, provide for the establishment of additional hospitals, the reclassification or closure of others. 105 The proposal that some small maternity units be .developed as community hospitals will require appropriate amendment to the Obstetrical Regulations 1963. A New Zealand Health Service 312. The comprehensive New Zealand Health Service is perhaps not so much a separate principle upon which to base reform as a summation of all the other stated principles. The establishment of a health service which is comprehensive in scope and available without economic barrier to all citizens by right will be the major attainment of State involvement in New Zealand health services, which stretches back nearly 130 years. The New Zealand Health Service will also be the foundation for the delivery and organisation of health care for the future. 313. The health service will be an administrative entity. To be fully effective it must not be based on regional authorities alone, with the central agency as a department of state standing aloof from the rest of the service. The achievement of a New Zealand Health Service in an administrative sense will only eventuate when the central agency is brought into and seen as an integral part of the service. 314. Following the layout in figure IV, the organisation of the health service can be considered in terms of health care programmes, or operational services; regional structures, and national organisation. The ensuing three chapters will deal with these subjects in that order.

REFERENCES 1 Report of the Consultative Committee on Hospital Reform, Wellington, 1953, pp. 5-6. 2 See New Zealand Social Worker, February 1972, 8, 1, p. 61. T. R. Hood, R. E. Morgan, and C. Teasdale, The Role of National Voluntary Health Organizations in Supporting National Health Objectives, Washington D.C., 1973, p. 19. Report of the Consultative Committee on Infant and Pre-School Health Services, Wellington, 1960, pp. 27-28. Scottish Home and Health Department, Doctors in an Integrated Health Service, Edin- burgh, 1971, p. 1.

106 U Figure IV: Organisation of the New Zealand Health Service

RESPONSIBILITY FOR SERVICE PROVISION PEOPLE - - - -, CONSULTATIVE AND ADVISORY LINKS PRIMARY I COMMUNITY1 CARE I I HOSPITALS I HEALTH] - CHANNELS FOR I I I COMPLAINTS OPERATIONAL SERVICES LH I I

I DISTRICT MANAGEMENT GROUPS - - - -I I I .1 .1 CONTRACTING REGIONAL COMPLAINTS PARTIES COMMISSIONERS

VOLUNTARY -I REGIONAL HEALTH AUTHORITIES I AGENCIES ---I i I REGIONAL OFFICER COUNCIL OF / SECRETARIAT, I I LIAISON GROUPS CHAIRMEN REGISTRATION L___..1 OF HEALTH I PROFESSIONS I E11 N.Z. HEALTH AUTHORITY MINISTER OFit1/ HE HEALTH SERVICES 1TMAN -- ADVISORY COUNCIL I F PARLIAMENT X. THE SCOPE OF THE HEALTH SERVICE 315. To consider this subject properly it is necessary to define both the inherent functions of the service and the external boundaries of the area of responsibility of the health services.

Functions of the Health Service 316. The functions of a comprehensive health service will include: 316.1. Promotion of a safe and healthy environment. 316.2. Promotion of the physical and mental health of the population. 316.3. Promotion of patterns of personal behaviour which are conducive to physical and mental health. 316.4. Prevention of disease. 316.5. Provision for the early ascertainment of remediable or palliable disease and disability within the community. 316.6. Provision for the prompt and effective investigation, diagnosis, and treatment of disease; injury, and disability. 316.7. Promotion of the greatest capacity for independence and self-care among those with continuing disabilities, by development of maximum physical and intellectual potential. 316.8. Provision of effective supporting services for those with continuing disabilities.

The Boundaries of Health Care 317. As will be apparent, a number of these functions extend beyond the fields of activity of the statutory and voluntary health care agencies into the provinces of other statutory and voluntary agencies Issues relating to the environment such as water supplies, sewage and refuse disposal, pollution control, and housing standards, are of concern to territorial local authorities and other local bodies. Various welfare agencies, both statutory and voluntary, are involved in the continuing care of infants and young children, the elderly, the mentally ill and subnormal, and those who suffer chronic physical disabilities. Formal liaison between the health services, and education authorities is necessary in training the mentally subnormal and the physically handicapped, to secure the continuing education of children admitted to hospital, 108 and in relation to the training of health service staffs. A number of statutory and working relationships exist between the Depart- ments of Health and Justice in order to deal properly with those persons finding themselves in conflict with the law who may have a psychiatric disability that must be taken into account. • 318. Thus, while this paper must endeavour to define and clarify the boundaries between the areas of responsibility of the health services and other agencies, it is also necessary to consider the type of liaison which will be necessary to ensure effective operation of services in those areas where there must be an interface between health and other social services.

The Environment 319. In pursuing the "promotion of a safe and healthy environment", there are three levels at which the health services must be actively involved. These are: 319.1. The provision of advice to the Government, to enable national health policies relating to the environment to be formulated; 319.2. The provision of guidance and, if necessary, the application of pressure to ensure that local authorities concerned with sanitary engineering and other aspects of environmental control act effectively; and 319.3. The provision of operational services at regional level, linked with national advisory services and reference laboratories, which will enable potentially harmful agents throughout the environment to be monitored. 320. While the N.Z.H.A. must always be responsive to the Government of the day, and must act upon Government decisions, there are issues relating to health policy which must remain unaffected by political exigency and should be amenable to the formulation of consistent long-term policies; the effect of the environment upon health is one such issue. In the operation of the services which seek to ensure the safety of air, water, and food, the control of physical, chemical, and biological hazards, and the control of communicable diseases, the future New Zealand . and Regional Health Authorities will need to maintain the independence of action currently provided by the statutory powers vested in the Director-General of Health, Medical Officers of Health, and their staff. 321. R.H.A.s will be responsible for the environmental health services for the regions and will employ the health inspectors and inspectors of health at present working for local authorities and the Department of Health. This unification of the health 109 inspection and licensing services will lead to more uniform performance and standards under the direct leadership of an appropriately qualified medical officer—who will be a specialist in community medicine. The future health inspectors will have a wider range of responsibilities and, in consultation with the local authorities, be distributed throughout the region in much the same places as at present. This is a reversal of the present policy whereby local authorities have been encouraged to employ their own health inspectors, but it is more appropriate in a unified health service to place the full responsibility with R.H.A.s Continuing liaison will be necessary between R.H.A.s and those local or regional authorities charged with responsibility for sanitary engineering under local government legislation. 322. For the same reason, institution of legal proceedings in relation to environmental health will become primarily the responsibility of R.H.A.s. Welfare 323. In those areas where the activities of health and welfare agencies impinge upon each other, it is very difficult to define clear-cut boundaries some instances of overlap and parallel working being inevitable and sometimes desirable. Two aspects requiring particular consideration are that: 323.1. Each of the components of service provision for the groups involved is clearly seen to be the responsibility of one or other of the government agencies concerned with health and welfare; and 323.2. Health and welfare agencies should not be so inter- dependent that the deficiencies of one may obstruct the effective activities of others. 324. Thus, in the field of geriatric care, it would be appropriate for R.H.A.s to be vested with advisory direction and surveillance of all institutions providing nursing care or supervised accommodation for the elderly for which public funds are provided. By associating such institutions with regional specialist geriatric services, the provision of adequate amounts of accommodation and satisfactory care could be achieved with greater certainty. 325. The situation which prevails with the care of the mentally ill and mentally subnormal is similar. A recent survey of such patients currently accommodated in hospitals indicates that 26 percent of mentally ill and 14.5 percent of mentally subnormal patients could be more appropriately cared for by means other than large institutions. Where they are clearly a health service responsibility the provision of these alternative facilities will, in future, 110 be undertaken by the R.H.A.s, acting on the basis of policy guidelines laid down by the N.Z.H.A. Where they are not a health service responsibility they will be provided by other Government agencies. 326. Again, the health service will assume a greater responsibility for providing aids and services for the continuing care of the physically handicapped. Thus far, the relationships between the Departments of Health and Social Welfare, and the several voluntary agencies concerned in this field, have not enabled the provision of aids and services for the disabled on an equitable and just basis. For the future, where specialist opinion avers the need for aids which enable the physically handicapped or disabled of any age to sustain a greater degree of independence, it will be a responsibility of R.H.A.s to provide these aids and services. The health service will benefit from such a move since it will minimise the dependence of the disabled or handicapped, particularly upon the institutional health services. Justice 327. Working relationships between the health service and the Department of Justice are unlikely to be substantially affected by the intended reorganisation, as the existing responsibilities of Hospital Boards and their officers will be assumed by the R.H.A.s. However, special consideration will have to be given to the future of Lake Alice Hospital. 328. Lake Alice Hospital is the sole institution remaining under the control of the Department of Health. It was retained under departmental control at the time other psychiatric and psychopaedic hospitals were transferred to Hospital Board administration because of the importance and complexity of the national role of the security unit which is housed there. Lake Alice Hospital is not concerned exclusively with patients who have criminal records. The National Security Unit provides for those who need to be nursed in maximum security conditions because of their mental state. 329. The future of working relationships between the health and penal services and the future of Lake Alice Hospital could be . affected in a major way by decisions in the penal field. If the psychiatric service needs of the penal service were provided from within the penal service itself there would be some reduction in the demand for admission to Lake Alice Hospital; the need for continuing professional contact between health and penal service staffs would assume much greater importance. 330. For the foreseeable future the administration of Lake Alice Hospital will be a direct responsibility of the N.Z.H.A. 111 Education and Training 331. Smooth and effective liaison between the health services and the education authorities is evolving in three quite distinct areas of activity—the continuing education of children in hospital, the training of psychopaedic patients, and the basic training of nursing and paramedical staffs. It is intended that these joint endeavours should continue and grow, unaffected by health service reorganisation. Developments in the education of health professionals require special mention. In particular there is a need to improve the education of nurses. 332. The Government has agreed that the tutorial skills of educational institutions should be used wherever possible. Already they are providing basic education for occupational therapists, physiotherapists, chiropodists, pharmacists, medical laboratory technicians, inspectors of health, health education officers, and others. In addition, demonstration programmes for student nurses have been introduced in some centres and have yet to be evaluated. Wherever the training is provided it is fundamental to ensure that the type of training meets the needs of a functionally integrated health service. In other words, the health service must be actually involved, in consultation with the education service, in determining the scope and quality of education to be provided. It is then for the education service, again in consultation with the health service, to develop courses that will satisfy this requirement. 333. The education and training needs of the voluntary organisations must not be overlooked. The Government intends that steps already taken towards providing for these needs should be expanded and developed in consultation with the voluntary organisations concerned. 334. The location of a significant part of curricular activities in an educational setting does not obviate the need for the involvement of the health services. Students, as well as their academic and tutorial staff, must gain practical experience in the health services, without disrupting the operation of these services. Conditions regarding the right of access to the health services need to be carefully negotiated, along with the need to obtain satisfactory guarantees about ethical questions such as confidentiality or negligence. In the long-term view, the projected manpower requirements of the health service must be determined by the N.Z.H.A. Regard must be had to the ability of education agencies to produce sufficient numbers of students and graduates for the smooth development of health care programmes. Planning must also take account of the ability of the health service to absorb graduates. 112 335. The principal direct involvement of the Department of Health in the education and training of health professions lies in its administration of the School for Advanced Nursing Studies, Wellington, with its associated special programme for students sponsored by the South-east Asian Regional Office of the World Health Organisation, and Schools for Dental Nurses at Auckland, Wellington, and Christchurch. The four schools still administered by the Department of Health will be progressively moved to the control of appropriate educational agencies. As with •other professions where training takes place in an educational setting and practical experience is gained in service, arrangements will be made to meet the requirements of students of the four schools for practical experience.

Liaison Arrangements 336. In parallel with the main responsibilities of the proposed three levels of health service administration, there will be a need for liaison between the health services and other statutory and voluntary agencies at national, regional, and district levels. 337. At national level, there will be joint working parties comprising officers of the N.Z.H.A. and officers of other Government agencies and representatives of appropriate voluntary organisations. Each of these joint working parties will be concerned with formulating and developing policy relating to those areas where health services impinge upon the activities of other agencies concerned with the environment, welfare, justice, or education. Inasmuch as the policy promulgated by these working parties is accepted by the N.Z.H.A. and, thereby, the R.H.A.s, it is expected that local offices, agencies, and branches of the other participating groups will be equally bound by it. 338. Within each health region, there will be a need for regular formal liaison with agencies and authorities concerned with the environment, welfare, and education. For the most part these liaison groups will be concerned with administrative and financial • matters at regional and local level. However, when issues cannot be resolved, or national policy appears to require modification, it may be necessary to refer matters to the appropriate national working party for consideration. 339. At operational level, reorganisation of the health service is intended to facilitate the delivery of care by affording an approach to health care which integrates the activities of the manifold agencies involved in the delivery of health services. It is hoped that this approach may be extended so as to enable 113 RM

the establishment of multi-disciplinary teams dealing compre- hensively with the care of the elderly, the mentally ill and mentally subnormal, the physically handicapped, expectant and nursing mothers, and infants and young children.

Operational Services 340. Having briefly considered the boundaries of health care, and the liaison mechanisms necessary to reach those boundaries, it is necessary to examine the future scope of the health services themselves and the opportunities which the reorganisation will afford to improve the services available to individuals and the community at large. 341. It is improbable that the reform of health service organisation and administration will have any immediate effect on operational services as they affect the individual and the community. Indeed, the process of reorganisation should not be attended by any disruption or interference in the provision and operation of health services. One of the first duties of those involved in service administration during and after reorganisation must be to ensure a smooth transition, which minimises any potential untoward effects of the administrative changes. 342. However, as will be seen, sweeping and substantial administrative and organisational changes are intended. During the months which follow the implementation of these changes it is hoped that the new structure and organisation will enable an accelerating rate of change in the nature of the operational services. Some of the desired changes have been touched upon in chapter IX, in the context of functional integration; the succeeding paragraphs of this chapter deal, in greater detail, with other areas of change which are considered to be necessary.

Primary Health Care 343. At the outset it is necessary to acknowledge the apprehension which has been expressed by some members of the medical profession about the possible future of primary health care. Because of this, the Government affirms that the reorganisation of the health service will not have any effect, either immediate or remote, upon the existing clinical autonomy of the general practitioner. Further, while it is hoped that the current trends towards group practice and health centre practice will continue, no administrative measures will be instituted which seek to coerce general practitioners into such arrangements.

114 344. In looking to the development of primary medical care after the reorganisation, the Government accepts the general principles laid down in a report published by the World Health. Organisation, which emphasises the need for the general practitioner to cover the following areas of health care: 1. The Provision of Comprehensive and Continuing Care—To provide comprehensiveand continuing medical care, the general practitioner must be able and ready to act as adviser to the individual and his family. He must also be aware of the possibilities offered by the preventive and curative services, and be prepared to use them for his patients benefit. "2. The Provision of Front-line Medical Care—The general practitioner must be prepared to assume responsibility for dealing with a large proportion of the diseases and problems that he en- counters. The detailed content and nature of his work must depend on prevailing needs and circumstances, on the customs of the community and his profession, and on the system of medical care.. "3. Personal Care—The general practitioner, like every good physician,, must treat patients as individuals rather than as cases. His past knowledge of the patient, his family, and his environment, should enable him to provide personal and individual care. "4. Family Care—The general practitioner responsible for the care of the individual must have a sound working knowledge of his family background, so as to be able to take into consideration the effect of the family on the individual as well as that of the individual on the family. "5. Community Care—The general practitioner has certain important responsibilities to the community in which he works. He must be familiar with, and pay due attention to, the social factors, affecting the health of the individuals in his care, as well as the influence on the community of the health of the individual and his family. He must be prepared, by personal action, to influence the living and working conditions of the community with the aim of improving its health. "6. Educational Function—In all his contacts with his patients, with other medical, health, and social workers, and with representatives, of the community, the general practitioner should be alive to any opportunity to teach and guide them in matters relating to the health of the community. 112 345. Before these ideals can be brought to full fruition in New Zealand, a number of crucial issues need to be faced and resolved. These include: 345. 1. the pattern of services provided; 345.2. the remuneration of general practitioners; and 345.3. the necessary organisational framework of primary health care. 346. While the response to partnership has grown rapidly in recent,years, a substantial proportion of New Zealand practitioners, still cleave to traditional practice organisation. Even though

115 general practitioners deal with a wider spectrum of morbidity than specialists, more than half of them prefer to work alone or with only a nurse in support. Hospital specialists, on the other hand, function most effectively as leaders of a clinical team of junior medical staff; nursing staff; and other professional and technical staffs. Much of the responsibility for day-to-day care of patients can be delegated to the other members of the team. 347. General practitioners have tended to support the inter- doctor relationship of group practice rather than explore the possibilities of extending inter-professional relationships in health centres. The foundation President of the New Zealand College of General Practitioners has stated that "in group practice you can retain the doctor-family relationship. In health centres this would be in jeopardy. 13 On the other hand the Chairman of the Medical Association of New Zealand recently told the newly formed College: "It is absolutely essential if we are to maintain our sanity and a semblance of service that greater use be made of our paramedical staff, especially trained nurses." 4 Depersonalisation arising from particular working methods should be recognised as a problem to be avoided in whatever form of general practice is undertaken. 348. At the same time, integration as it affects primary medical care, must also be considered. While diagnostic and therapeutic activities are the most significant aspects of clinical care, in an integrated service primary medical care would also embrace and supplement much of the preventive medicine currently undertaken by public health services and such agencies as the Plunket Society. Immunisation and vaccination programmes, supervision of the health and development of infants and young children, the care of the disabled, the elderly, and patients especially prone to particular illnesses, with the preparation and maintenance of "at risk" registers, are likely to be most effective if based on the primary health care team in active association with staff concerned with community health. Much of this sort of work could be delegated to other non-medical staff, if group practice and the health centre pattern of primary care were more widespread. 349. Working relationships between the primary care team and the hospital also require attention. While there is a distinction between primary and specialist care, the hospital must be regarded as part of the facilities for community health care. If there is to be continuity of care for the patient by the general practitioner, he should be able to follow up his patient in hospital. The hospital should also move towards primary medical care by making its diagnostic and rehabilitative services more generally available 116 to the general practitioners, thus serving the patients interests by removing the expense of private investigations. 350. Community hospitals (as defined in paragraph 310) will be fostered in outlying and isolated communities. Medical care in these hospitals can be provided by general practitioners for medical cases, particularly those whose admission is necessitated by social considerations. Minor operative procedures which do not require the strict aseptic discipline of the operating theatre, obstetric patients in whom the need for specialist care is not immediately apparent, routine convalescent patients transferred from base hospitals, and geriatric patients in need of intermittent or long-term hospital care are all suitable for care in community hospitals under the supervision of general practitioners. 351. The financial and organisational aspects of primary health care need to be considered together, because of the effects that each have on the other. The standards of care provided for individual patients by New Zealand general practitioners will, for the most part, bear favourable comparison with such standards in any other developed country. However, the same cannot be said of the current distribution of general practitioners, or the ease of access to general medical services. Problems in these areas are, in no small measure, related to the methods of remuneration of general practitioners and to their perception of their position as "free entrepreneurs", able to practice where and when they will. The Fee for Service 352. The determination of some general practitioners to ask for the "fee for service" as the only mode of remuneration appears illogical in view of the fact that they accept other modes of remuneration. Some authorities, indeed, accept an exactly opposite view. In a report on general practice in New Zealand in 1971, Professor P. S. Byrne of the Department of General Practice, University of Manchester, and now President of the Royal College of General Practitioners, asked of the fee for service: "This is a symbol of freedom—of independence. . . . The fee per . item of service is in New Zealand some 30 years old and appears to be the major barrier to improvement and progress in the delivery of health care in the community. Is it so sacred, so inviolate, so necessary that it should be permitted to make difficult the use of the practice nurse, training for general practice, continuing education for general practitioners, pensions for general practitioners, good preventive and interventive care, the creation of a cadre of general practitioner teachers? For indeed it makes difficult all these things. . . ." 353. The method of remuneration most prevailent in New Zealand general practice is that whereby general practitioners claim 117 on behalf of the patient for each item .of service, a fee under the General Medical Services Benefit Scheme. In addition they may also charge patients such additional fees as are considered commensurate with the service given. Further fees may be paid by Government agencies for particular types of service. Under the fee for service system, the State currently meets approximately one-third of the cost of primary medical care. 354. Dealing as it does with items of service undertaken by the general practitioner, this method of remuneration tends to discourage services which do not involve the practitioner personally, together with any activities by the practitioner which are not strictly medical services; further, it tends to encourage an approach to primary health care which is episodic and disjunct, rather than continuous and holistic. 355. The consequences which may be inferred are that the fee for service may contribute to: 355.1. a willingness to deal with episodes of illness as they arise, rather than a desire actively to promote health; 355.2. a reluctance to adopt an active role in those preventive and supportive components of primary health care which are currently undertaken by such voluntary agencies as the Plunket Society; 355.3. a waste of medical manpower as a result of the inherent disincentive readily to delegate some items of service to be carried out by nursing and paramedical staffs; 355.4. an insufficiency of formal teaching, and clinical and operational research in general practice; 355.5. inadequate participation in continuing post-graduate medical education by general practitioners; and 355.6. a failure to participate in the institutional care of their patients on a wide scale. 356. In arguments which seek to justify the preservation of the general practitioners right to charge the patient "a fee commensurate with the service given" as the only method of payment, it is often forgotten that practitioners accept other forms of remuneration which do not entail payment of any fees by patients. These may take the form • of fixed fees, in the case of the Maternity Benefit and Immunisation Benefit; "commensurate" fees paid by the Accident Compensation Commission; or salaries, as are paid to general practitioners working in the special areas or to those who have part-time hospital commitments..

ll Methods of Remuneration • 357. In considering the question of how general practitioners could be remunerated, it would appear that there are six broad possibilities, ranging from a system where the State meets none of the cost, to three where the State bears the entire cost. These are: 357.1. Private Practice—Where general practitioners operate in a situation of completely "free enterprise", practising where they will and charging such fees as they consider appropriate. There is no involvement of government, agencies in the distribution of practices, and no contribution from State funds to the remuneration of the general practitioners. 357.2. The Present System—State subsidised fee for service with charges as described in para. 353. 357.3. Contract with Charges—Where general practitioners would enter into contract with R.H.A.s, to provide continuing care for a "list" of patients maintained by the R.H.A An annual "retaining" fee, proportionate to the size of the list, would be paid, with supplementary payments for patients under 15 and over 64 years of age. Additional fees would be paid by the R.H.A. for such services as obstetric care and immunisations; and for attending to patients between 5 p.m. and 8 a.m. on weekdays, or throughout the weekend and on statutory holidays. In addition, a fixed "token" charge (say, 50c) would be paid by the patient for services rendered between 8 a.m. and 5 p.m. on weekdays; this charge would be doubled for services outside these hours. (Patients who were under 15 or over 64 years of age, or permanently disabled, or pregnant, would be exempt from these payments.) 357.4. State Funded Fee for Service Without Charges—As for para. 357.2 without a charge to the patient. V 357.5. Contract Scheme—Identical with the Contract with Charges, except that no token fee would be payable by the patient, but the annual retaining fee would be set at an appropriately higher level. 357.6. Salaried Service—Where general practitioners would receive a fixed salary and would be employees of the R.H.A.s on a similar basis to the specialist staffs employed in hospitals. The patient would also receive general medical services free of charge. Practices would be controlled by the State, and vacancies filled by advertise- ment in the same way as for the public hospital , service. This is not an exhaustive list; there may be other possibilities and combinations which could be used. 119 358. It is acknowledged that proposals to alter the methods of remuneration of general practitioners will provoke debate. Never- theless there is evidence that a number of general practitioners, would be prepared to consider changes from the present system. The Government wishes to hear all shades of opinion both from the medical profession and from the public at large before it makes any decision on this matter. It should be clearly understood that adoption of either of the contract schemes or State funded fee for service would not preclude additional work in private practice, as described in para. 357.1 above. The same could apply within limits to be defined to practitioners in a salaried service. 359. While a substantial amount of the present income of general practitioners is derived from State funds, and there is the probability that the proportion of income so derived will increase,. the present system requires only minimal accountability by the general practitioner for this use of public finance. Beyond ethical considerations the general practitioner has no responsibility to provide initial or continuing primary care to particular patients. In consequence patients who are unable to obtain the services of a general practitioner, whether because of the level of provision of general medical services in their locality or because of the working methods of general practitioners, have no effective means of redress. The advent of contractual arrangements between practitioners and R.H.A.s entailing the registration of patients with particular practices, would enable a better provision of service to be guaranteed and would allow R.H.A.s and the N.Z.H.A. to deal more rationally with problems of service development. 360. The potential benefits accruing from such service contracts, would not be of advantage solely to individual patients and the community. The general practitioners themselves would have much to gain that is not available under a fee for service arrangement. As their part of the contract, R.H.A.s and the N.Z.H.A. would: 360.1. pursue the eventual determination of the size of contract practices within reasonable limits as, assessed by an acceptable and independent medical practice board; 360.2. guarantee total emoluments which would, from the outset, provide levels of income at least comparable with normal earnings under current methods of remunera - tion, which would be subject to regular review; 360.3. ensure that provision will be made for the general. practitioner to have time to take part in continuing: medical education; .

120 360.4. provide a graded system of payment which will reward participation in continuing medical education, and working in designated areas; 360.5. provide adequate overseas or local study awards as is done in the hospital service; 360.6. facilitate participation by contracting doctors in the institutional care of patients; 360.7. gradually introduce a scheme whereby the professional services of a wide range of health professional staff are available free of charge to general practitioners under contract to the R.H.A.s; 360.8. make provision for general practitioners to join a superannuation scheme; 360.9. provide for consultation with general practitioners in the management of the health services. 361. Again, the Government is anxious to hear all shades of opinion in this matter. For the many general practitioners, already providing high standards of service (as opposed to high standards of care for individual patients), the envisaged contractual arrangements would entail only insignificant changes in working methods. It is not intended that the contract schemes should interfere with the right of mutual choice of doctor and patient. Specialist Services 362. As has been indicated, it is not expected that the administrative changes inherent in the health service reorganisation will have any immediate effect upon the day-to-day workings of the specialist services. However, a primary object of the reorganisation is to modify the administrative structure so as to enhance the standards of delivery of health care. The future provision and development of specialist services will benefit from the organisational changes. 363. It is the Governments intention that specialist services will develop in such a manner as to permit the eventual fulfilment of two main objectives. These are: . 363.1. the better integration of specialist services with each other, wherever appropriate, and with the other health services provided for the community; and 363.2. the development of public hospital services to the extent that they are capable of providing the specialist care required by the community. 364. The intention to integrate specialist services with each other should not be construed as a desire to reverse the evolution of the various clinical specialties which have grown out of the main-

121 streams of medicine and surgery as a result of the progress of medical science. On the contrary, it must be acknowledged that the traditional "general" physician or surgeon, endeavouring to encompass the whole field of medicine or surgery, is no longer appropriate; and high standards of specialist care are now associated with increasing depth of knowledge in progressively narrowing fields. 365. However, there is an international trend towards elimination of the three centuries old dichotomy between medicine and surgery in situations where sub-specialties of these two main disciplines are concerned with the same organic systems. Thus physicians and surgeons have come together in units dealing with gastro-enterology, with neurology and neurosurgery, with chest diseases, cardiology, and cardio-thoracic surgery, and with nephrology and urology. Such developments are already well established in a number of centres in New Zealand. Further developments of this nature, which serve to enhance standards of specialist care, will be actively fostered. 366. Other opportunities exist for collaboration between different specialties, particularly in determining the most appropriate means of assessing and treating patients, rather than diseases of organs. Examples include collaboration between geriatric physicians and psychiatrists in the care of the elderly patients with transient or permanent mental illness; between geriatric physicians and orthopaedic surgeons, in dealing with orthopaedic problems of the elderly; and between psychiatrists and paediatricians, in the assessment of mentally subnormal children. 367. Wherever the multidisciplinary approach to patient care is appropriate, it is to the advantage of the patient and the clinical team if the general practitioner can be actively involved. It is considered desirable that all possible links between specialist services and primary care should be strengthened. Reference has already been made to the possibility of involving primary care with the institutional setting, both in community hospitals and base hospitals. The traffic should also flow in the opposite direction, with specialists being encouraged to hold outpatient clinics in community hospitals and health centres wherever the population served is sufficiently large to generate a case-load which justifies the expense of sending a specialist. 368. The Governments intention to improve the standard of provision of public hospital services has already been declared and given wide publicity, particularly in relation to the problems of outpatient clinics and admission waiting lists. It seems probable that, in some areas, deficiencies in public hospital services lead to the situation where many people feel obliged to seek private medical

122 care. This is true not only of specialist outpatient consultations and inpatient care involving investigations, treatment, and surgical operations; it also applies to such diagnostic services as radiology and pathology. 369. It must be acknowledged that, these deficiencies cannot be remedied in a few months or even a few years. In many instances, these shortcomings are attributable to the fact that the services which now exist were not planned to meet the needs of the communities now served by the hospitals concerned. With the integration of the health services, a greater degree of co-ordinated service planning and development will be possible. The development of information systems will enable more accurate assessment of the standards of service management. 370. As progress is made in improving the public hospital services, the Government will give further consideration to the future of the various forms of financial support and subsidy which have enabled private health services to flourish in New Zealand.

Community Health 371. Those aspects of public health practice and preventive medicine which are currently the province of the district offices of the Department of Health will pass to R.H.A.s, together with an unequivocal responsibility for surveillance of factors in the environment affecting health. 372. With the transfer of these public health activities, specialist services provided by Hospital Boards, and responsibility for primary health care and the services of voluntary agencies, it will become possible to view the scope of the service in terms of community health. 373. Reorganisation will place upon R.H.A.s responsibility for the provision, control and co-ordination of a comprehensive range of services which contribute to the health of the community including those services of voluntary agencies which draw heavily on public funds. 374. A new activity, which must be considered as part of the community health services, will be the formulation and development of national and regional plans for health care extending ahead for up to 10 years, as a series of "rolling programmes". Essential to the preparation and updating of these programmes will be the work of the medical administrators in the service. It is thus necessary to give some consideration to the training and methods of work of medical administrators.

123 375. The health of the community is not an exclusive medical responsibility, although the co-ordination of the component parts and planning for the development of the total health service should be tasks of the medical administrator, or, as he will be designated in the reorganised health service, the community physician. 376. At present there are two distinct groups of medical administrators in New Zealand—those whose background is primarily based in the public health service, and those whose background is based in the hospital service. The former group have had post-graduate training leading to the Diploma in Public Health, and, for the most part, pursue their careers in the Department of Health, either in its district offices as Medical Officers of Health, or at its head office. The latter group have had post-graduate training in clinical specialties, particularly surgery, and have usually worked as hospital specialists before taking up an administrative career as Medical Superintendents. Both groups of medical administrators are represented among the Departments head office staff. 377. Perhaps the greatest problem in medical administration in New Zealand is that only a handful of medical administrators have a practical understanding of both of these fields of work. In some centres the Medical Officer of Health has been accorded honorary status on the specialist staff of the hospital; and efforts have been made to establish joint appointments of Deputy Medical Superintendent/Deputy Medical Officer of Health. While such developments are encouraging they are not widespread, and there is inadequate professional contact and understanding between the two groups of medical administrators. Both groups are concerned with communities and the services which must he provided for them, rather than with the person-to-person, doctor-patient relationship of clinical practice; but, too often, this is all they have in common. 378. Maintenance of the divided system of medical administration is totally inimical to the principle of functional integration in health services. The reorganisation will aggravate the long- standing need for a cadre of medical administrators with a common background and training based on epidemiology and biostatistics, behavioural sciences as applied to medicine, medical sociology, and management theory. Only when this need is met will it he realistic to think in terms of the "specialists in community medicine" essential to the future management and development of the health services. 379. Specialists in community medicine will be expected to investigate and assess the needs of their communities (whether district, regional, or national) so that priorities for the promotion

124

of health, the prevention of disease, and the provision of medical care can be established. Community medicine specialists will also be concerned with the co-ordination of medical expertise in their communities so that policies which are in accord with medical needs of the population can be prepared and presented to decision-making bodies. 380. In dealing with matters which call for immediate and direct action to protect the public health, especially the control of communicable diseases, the statutory authority currently vested in the Medical Officers of Health will pass to Regional Community Physicians, together with the right of direct access to the permanent head of the N.Z.H.A. In these matters the authority of the permanent head, and of the Regional Community Physicians acting as his agent, must transcend the powers of the R.H.A.s. 381. Future medical administrators will need to be well informed on all matters affecting or likely to affect the health of their communities. They need to collect and collate information about the community they serve, in terms of its demography, geography and environment, socio-economic and industrial features, and transport and communication systems; and the relevance of these to health trends, morbidity, and mortality. This knowledge also needs to cover social and welfare services in the widest sense of the term, including labour and housing services. The information so gained must be interpreted. The medical administrator, in conjunction with those operating services, must therefore evaluate and review existing health services. Deficiencies must be rectified and new programmes devised to meet health problems. Evaluation is only part of the planning process in which medical administrators have a vital role to play. From their study of health information and from a review of services provided, community physicians will be in the best position to advise their controlling body of the priorities and programmes needed for regional health services, and the degree of emphasis needed for various programmes. Community physicians will have a co-ordinating and advisory role in relation to general practitioners and specialists and play a major role in the functional integration of services. The emergence of a corps of appropriately qualified community I physicians is thus essential to the reorganisation and integration of the health service. REFERENCES I. J. Jeffery andJ. M. Booth, Survey of Patients in Psychiatric Hospitals, Special Report to be published by the Department of Health, 1975. World Health Organization, General Practice, Technical Report Series, No. 267, Geneva, 1964, pp. 5-6. Dominion, 21 January 1974. 4Christchurch Star, 7 February 1974. P. S. Byrne, "General Practice in New Zealand", in New Zealand Medical Journal, March 1972, p. 165. 125 XI. ESTABLISHING REGIONAL HEALTH AUTHORITIES

Electing Members of R.H,A.s 382. The Governments proposals include provision for the election of seven members of each R.H.A., and the appointment of six others. Each R.H.A. will consist of 13 members. The ratio should give a workable size of membership while allowing adequate representation for electoral purposes. Obviously too large a membership will make an authority unwieldy. 383. R.H.A.s will not be revamped Hospital Boards, and it would be wrong to carry forward the constitution and organisation of these agencies into the area of regional organisation of total health care. Administration and responsibility for what is now a multi-million dollar State financed industry require wise manage- mentas much as social concern. It is doubtful if the present system of electing Hospital Board members meets this requirement. 384. In spite of the general failure of the electoral system in Hospital Board matters, the Government intends that a majority of members of R.H.A.s should continue to be elected by popular franchise because they are needed to represent community interests. 385. Public apathy is a well known and widespread problem of local body elections. Hospital Board elections share this lack of enthusiasm. In fact, the Departments annual report noted that the very first Hospital Board elections in 1909 raised "so little interest". This same situation prevails today, as was clearly apparent from an analysis of 1971 returns sent by territorial local authorities to the Department of Health. 386. Lack of interest in registration seems to be the first weakness of the electoral system. While the extent of this is hard to gauge, one county clerk with more than 7,000 registered electors noted that "residential people are always dilatory". He estimated the true number of electors in his county to be nearer 10,000. 387. The general lack of interest in Hospital Board affairs can next be seen when nominations are called for. Tables in appendix X show the very high proportion of districts in which no election was held because the number of nominations did not exceed the number of vacancies. No election was held in 57.5 percent of districts. This figure includes the very small number of districts (1.3 percent)

126 where insufficient nominations were obtained, and the Governor- General appointed the requisite number of "qualified" persons as members of the Hospital Boards concerned. 388. These facts alone give serious concern about the democratic process, but voting figures show that the problem is even more serious. Total possible votes have been calculated from the total electoral registrations in a district multiplied by the number of candidates required for the districts representation on the Hospital Board. Against this figure is set the total number of valid votes cast, by which means informal votes have been excluded. 389. In these calculations, it is recognised that there may be a margin of error caused by inaccurate numbers on the rolls. One town clerk considered that the amount of "dead wood" on a roll could probably be assessed as 10 percent of the total. 390. From the analysis of electoral returns only 36.2 percent of possible votes were cast for all Hospital Boards. This low figure takes account of areas where no elections were held, or voters were dissatisfied with some or all of the candidates, or did not bother to vote at all. As was mentioned earlier, informal votes have been excluded. 391. While the proportion of districts where no election was held may be regarded as a vote of confidence in the status quo, the Government does not share this view. Rather, it regards such widespread apathy as a vote of no confidence in the method of selecting the best directors. 392. In spite of the excellent service which has been given over the years by a number of outstanding people, the conclusions which can be drawn from the Hospital Board election results mean we should question whether the present system does in fact encourage enough of the right people to offer themselves for election. The Government fully appreciates the argument that publicly elected members enjoy the confidence of the people and the electoral system theoretically enables a good cross-section of the community to assume responsibility for hospital matters. Yet the shortcomings of the electoral system must not be ignored. Qualities now needed to run the health services—for Hospital Boards are no longer Poor Law guardians—are much different from the times when humanitarianism was linked with a hospital rate. 393. In part the circumscription of Hospital Board autonomy in recent times is an indication of the management needs in that area. The electoral system was calculated to protect ratepayers interests in the administration of what was still a charitable service largely financed from hospital rates. Control was initially coincident with the sources of finance.

127 394. This is no longer true. As the taxpayers interests and not those of the ratepayers now need protection, the Government should have more say in determining priorities in the health service. The altered financial basis also means that the hospital service is no longer a local one but part of the national service. It follows that the taxpayers interests should be safeguarded by the Minister of Health as agent of the State, or else he should depute that responsibility upon his nominees. If such persons are selected primarily for their known wisdom, judgment, and experience,, the taxpayers interests should be looked after much better than at present because of the increased efficiency which should result.

Appointed Members 395. The increasing complexity of health care, of which hospital services are only a part, requires that the common-sense views of elected members should be supplemented by expert opinion. Valuable though the contribution of academics and doctors is, and this is something which needs to be safeguarded in the new system, other disciplines and callings can play a part in the efficient administration of health services. The present system ignores the counsel of health professions, in and economic experts, and voluntary agencies in hospital administration. Now that all aspects of the health services are to be united, a fresh approach to directorship is timely. The proposed reorganisation will give Regional Health Authorities much greater freedom for initiative and planning than Hospital Boards enjoy, providing this is matched by responsibility. The Government has no wish to impose further restraints on Hospital Boards, of which the personal liability clause of the Hospitals Amendment Act 1973 is the latest example, but feels it has no alternative when undesirable trends of financial caretaking are a possibility. Similarly, where delegation has been extended, particularly in staffing areas, the present elected Hospital Boards have tended to refer uncomfortable issues to central authorities for decision. A greater acceptance of responsibility is required. 396. Basically, two methods of obtaining members other than by election could be used. Consideration was given to the possibility of enabling interested parties or professions to nominate members, as is already the case with the Board of Health and Hospitals Advisory Council. This method has distinct disadvantages. Nomination tends to strengthen sectional interests and lead to claims for inclusion by various professional organisations by virtue of their role in the health services. It is clearly

128 impossible to accede to all these requests. Besides, nomination restricts the availability or "catchment" of members to certain groups. Selection should be made from the widest possible range of expertise available in the community. In addition, if organisations were given the power to nominate members, officers of these organisations could be overloaded because of their membership of other statutory agencies. 397. At first reading, membership by appointment would seem to be surrounded by equal hazards. Political appointments have always been controversial in New Zealand, and the suggestion that some members of R.H.A.s be appointed by the Minister of Health will invite criticism. Nevertheless, the Government believes that a healthy balance between the voice of the public and administrative efficiency can be best achieved by this means. 398. Triennial election for R.H.A.s will coincide with those for other local authorities. When the results are known, the Minister will appoint the remaining members of the Authorities on the basis of their known relevant wisdom, judgment and experience. In this way, a choice may be made from the widest possible range of expertise available in the region. Appointment also allows for administrative flexibility, enabling a balance in members qualities to be achieved, and functional aspects to be emphasised when necessary. 399. The Government is confident that the foregoing proposals for elected and appointed membership will involve the right people in the important areas of decision-making for health. A careful balance will be arranged among citizen-consumer interests, professional involvement where appropriate, and relevant experts which will give R.H.A.s the best form of guidance in developing services. 400. The argument might be raised that a hybrid arrangement of appointed and elected members would automatically divide a health authority, and that elected members, feeling outweighed by the expertise of appointees, would lose interest. The Government does not share this view, being confident that adoption of the new system will help to revitalise public interest in health matters. Chairmen 401. The chairman of a R.H.A. will have not only a procedural role but must also be the co-ordinator and leader of all functions of the Authority. He will be regarded as the spokesman of the Authority when necessary, so will naturally be involved in presenting five- and 10-year regional health plans before these are incorporated into national plans. The chairmen will possibly need to devote

129 considerably more time to R.H.A. matters than will ordinary members, and the added duties imposed upon chairmen warrant special attention. 402. It is unfortunate that some Hospital Boards choose a chairman on the grounds of seniority rather than any ability he may have as leader of a multi-million dollar enterprise. To meet this requirement, the chairmen of R.H.A.s will be chosen by the Minister from among the members, and designated chairman in the warrant of appointment. 403. Chairmen will probably need to devote up to half of their working time to R.H.A. matters and the need for an improved method of remunerating them is readily apparent. This will be determined with regard to the extent of the regions over which they preside and the scope of their responsibilities, but in all cases will allow for the payment of a significant honorarium.

Disqualification and Retirement of Members 404. For some time, the Government has been concerned about the possibility of a conflict of interest arising for persons working in both private and public health services. This conflict of interest can lead to undesirable and even unethical practices. An element of competition between public and private health services already exists. The situation where persons having an interest in private health seivices are also placed in the invidious position of having responsibility for the public sector should be avoided. It would he undesirable if they were seen as being able to influence decisions which could undermine the public health and hospital service. Constitutional proposals will ensure that, people are not placed in such a position. 405. Membership of R.H.A.s will not be open to persons having vested interests in those aspects of the health service duplicated in the private sector, including private hospitals, private laboratories or private health insurance schemes. With this exception anyone will be eligible to stand for election or for appointment as a member of the health authority in his or her region. 406. The Government believes that the reduced status of Hospital Board membership may have been caused in part by the lack of competition for seats. Such a situation is obviously not helpful to the injection of new ideas at the top level. The R.H.A.s will in this regard set a precedent for local government in New Zealand. Provision will be made for the rotational retirement of all members with a limit to the period during which they might serve without a break of at least one term. The period proposed will be at the completion of three terms (9 years) of membership. Provision will also 130 be made for the retirement of R.H.A. members at the conclusion of the term during which they attain the age of 70 years. The retirement provisions will be binding on both appointed and elected members.

Electoral Representation 407. The electoral representation provisions for Hospital Boards should not be carried forward into the future. Since the earliest days of colonial government in New Zealand, local administrative units became smaller as smaller communities of interest demanded a measure of local autonomy. Early hospitals legislation accepted this trend by allowing counties, boroughs and town districts, a say in hospital matters. The proliferation of such territorial local authorities was probably a reasonable indication of communities of interest in Victorian times. Hospital Board representation was and has always been apportioned among these local authorities. 408. Before hospital rating was abolished in 1957 the Governor- General in Council apportioned representation on the basis of rateable property in a local authoritys district, and upon the relative populations in each local authority. Provisions for combined representation met the case of smaller local authorities. 409. The Hospitals Act 1957 abolished the criterion of rateable property. Relative populations within a hospital district and-"such other considerations" as the Governor-General thinks necessary are, now the criteria. Representation can be affected by such con, siderations as the presence of a subsidiary hospital in a constituent district, the relative size of constituent districts, and communications difficulties. For , practical purposes though, population is still the chief determinant. 410. Because "relative population" has always been a factorin setting representation on Hospital Boards, nineteenth century political realities have survived into the late twentieth . century. Hospital Board scene. The effects of these and future: trends are: shown in appendix X, although two , extreme cases could draw attention to the problem; The Maniototo Hospital Boards 8-members administer a 33-bed hospital. Each member of that Board represents 342 residents. If the present apportionment and size of membership are allowed to continue, by 1991 Maniototo Hospital Board will have one member for approximately 325 persons. By Way of contrast, each of the 13 Auckland Hospital Board members represents more than 53,000. people. By 1991, it is likely to be more than 94,000.

131 5 411. The present position of representation based primarily on relative populations is clearly inequitable and was challenged by the 1953 Consultative Committee in these words: "The nature of the problems facing a modern Hospital Board is such that in our view no very great weight should now be attached to mere population figures in deciding what the membership of Boards should be. We think that the foremost consideration is the desirability of ensuring representation of all the areas in a Boards district . . . It might have been different when hospitals were largely maintained by local rates, but under modern conditions the old basis of representation has become an anachronism and we see no advantage in continuing it. What is wanted is a workable body of competent administrators who collectively possess an intimate and personal knowledge of all parts of the Boards district. 12 412. The present position has two further defects. The population criterion has tended to outweigh the concept of communities of interest. At present the Department reviews representation every 3 years, and the revised basis is referred to territorial local authorities for comment. This method can lead to local authorities scrambling for increased or separate representation. 413. Final proposals for the reform of electoral representation must await the definition of districts by the Local Government Commission. Some general comments about the future pattern of representation can nevertheless be made. Within a R.H.A.s boundaries, in some cases, there may be two or more local government regions. In cases such as these, R.H.A. membership will be apportioned among the local government regions because these constitute clearly defined communities of interest. Where the boundaries of the R.H.A. are identical with those of the local government region, voting will take place on a regional basis. Health districts will otherwise be equated with local government districts wherever possible. 414. In all cases the breakdown into regions and districts for electoral purposes should avoid large numbers and/or combinations of districts. Representation by seven elected members will then be apportioned for each R.H.A. among the districts on the recommendation of the Local Government Commission. After the initial elections each R.H.A. will be able to decide for itself the allocation of representation among the districts.

Orientation for Members 415. Assistance will be given to all R.H.A. members by brief familiarisation programmes to be conducted nationally and regionally by the N.Z.H.A. in conjunction with R.H.A.s. The aim of 132 these programmes will be to guide new members on their role in health services administration and to enable them to gain an appreciation of regional health services. 416. The need to acquaint members of local authorities with some kind of knowledge of the expectations and limitations of their functionhas been raised in the United Kingdom by the Committee on the Management of Local Government (1967), which stated: "The question of the possible decline in the quality of members is less important than the ability of members to understand scientific and technical developments of the present age. We see in this a danger of a widening gulf between the expertise of the professional officers andthe limitations of the lay-man; this leads to an excessive preoccupation of the member with the more simple things which he does understand than with developments in which he is .uninitiated. Training of members will not give them professional expertise; if well done it can help to give an understanding- and appreciation of scientific and technical developments which form the basis of policy decisions. Local authorities should regard it as their responsibility to ensure that their members are well informed on scientific and technical developments and on research into social problems as well as having an understanding of government and management."3 417. Further discussion of orientation.- courses for members would lead to an examination of the functions and role of members of R.H.A.s. These are appropriate subjects for inclusion, in the next chapter. 418. It may be considered that the constitutional proposals contained in this chapter have dealt in considerable detail with an analysis of Hospital Board constitutional arrangements. This is necessary to obtain a full understanding of plans for the future. While the suggested pattern of administration of R.H.A.s main- tains some links with the method of selecting Hospital Board. members, nevertheless, all members will in future be accountable to the general electorate through the Minister of Health. 419. The proposals contained in this. chapter are designed to secure the best directors, for regional health services. - The Government believes that it is not only necessary, but logical, to -turn to appointment as another means of securing the best people for this important task, as well as retaining the system of elected membership.

.REFERENCES Aj.H.R., 1910, H-22, p. 6. Consultative Committee on Hospital Reform, op. cit., Wellington, 1953, P. 19. 3Committee on the Management of Local Government, Management of Local Government, London, 1967, Vol. I, p. 146. -

133 XII. MANAGING THE REGIONAL HEALTH SERVICE 420. The •three primary responsibilities with which R.H.A.s I will be charged will be: 420.1. the management and operation of health services in the region; 420.2. the planning, provision, and development of primary health care, specialist diagnostic, therapeutic and rehabilitative services, and community health services in the region in accordance with the health needs of the population and national policy guidelines; and 420.3. co-ordination with other statutory and voluntary agencies which are outside the field of health but whose activities impinge on the operation of health services in the region.

The Role of R.H.A. Members 421. The complexity of operating and developing a comprehensive health service in each region is such that the respective roles of members and officers of R.H.A.s should be clearly established at the outset. Members must maintain a general and corporate oversight of regional policies and programmes, while delegating major responsibility to appropriate professional administrators for the efficient operational management and planning of the regional health service in accordance with national policy guide- J1ines. . . 422. Members must not be diverted into administrative work that is the task of professional officers. Such diversion has been a tendency among Hospital Boards, and was criticised by the Public. Expenditure Committee in 1973: "One aspect of hospital boards administration that the committee became increasingly aware of was the practice of most boards to act as their own chief executive, a task for which they were, in most cases,. not suited. That is, they received reports from heads of various departments before making a decision, resulting in their being swamped with a formidable weight of printed matter . . . The committee accordingly recommends that the administrative structure of hospital boards be reviewed with a view to increasing its efficiency and easing the burden on the individual hospital board members." . . . 423. Because of the limited time they will be able to devote to regional health matters, members can be expected to confine their 134 discussions to major issues confronting regional health services, and where necessary, to adjudicate upon policies, priorities, plans, and standards of service within the region. Members will need continually to appraise health needs of the region to ensure that these will be met by plans and programmes. Members may require investigations and reviews of health services to be undertaken and may consequently approve policies to correct deficiencies. 424. The Government considers that this approach to top management will be facilitated by the appointment of selected chairmen, whose role has been discussed in paragraphs 401-403 of the preceding chapter. Standard procedures for the conduct of affairs of R.H.A.s will be prepared and promulgated as part of the consultative process before reorganisation. 425. To enable them to fulfil their responsibilities, members must ensure that they are properly advised and presented with information by competent professional administrators whom they have appointed. (By way of contrast, appointments to principal linical positions should be made upon the advice of committees which can gauge the professional merits of applicants, and ad hoc committees will be established in each region.) Regional and District Management 426. The Government envisages that the fulfilment of the responsibilities of R.H.A.s set out in para. 420.1 will be entrusted to two separate groups of professional managers. First, day-to-day management and operation of health services must be organised at district level, and the Government therefore intends toestabIish District Management Groups which will be responsible collectively to the R.H.A. for the efficient running of the health service. Because of the geography of New Zealand, in very few regions will the community of interest enable the day-to-day management of the health service to take place from a central point. While the planning of the total health service must proceed from a regional perspective, the management must in many cases be delegated to appropriate district officers. Second, the co- ordination and planning of health services throughout each region, together with the operation of services provided on a regional basis, will be entrusted to a Regional Group of Officers. The organisation of regional health management is shown in figure V. District Management Groups 427. All of the health services in a district must be co-ordinated and managed as a single unit, and the Government proposes that

135 Figure V: Management of a Regional Health Service

I REGIONAL HEALTH AUTHORITY I

REGIONAL GROUP OF OFFICERS

REGIONAL REGIONAL [REGIONAL - COMMUNITY NURSING ADMINISTRATION MANAGERIAL PHYSICIAN OFFICER I OFFICER RELATIONSHIP MONITORING AND CO-ORDINATING RELATIONSHIP I REGIONAL TECHNICAL & REPRESENTATIVE I I I SPECIALIST RELATIONSHIP [SERVICES

4 • DISTRICT DISTRICT DISTRICT COMMUNITY NURSING ADMINISTRATION PHYSICIAN • OFFICER OFFICER DISTRICT MANAGEMENT GROUP -

I -

DISTRICT HEALTH SERVICES OPERATIONAL SERVICES - ADVISORY COUNCIL fl District Management Groups will be charged with ensuring the / optimal use of resources. They will also provide a forum for assessing health needs in the district, and for finding the best means of implementing and applying regional health plans and policies to the district situation. This will inevitably lead to discussions with regional officers about priorities and programmes in the district, and may lead to new forms of service provision being implemented in districts, depending upon the professional views of clinicians and the existence of national guidelines on service provision. However, District Management Groups will be directly, accountable to the R.H.A. and will therefore have the right of direct access to that body. They will not be accountable to R;H.A.s through the Regional Group of Officers, but will be required to report regularly to the R.H.A. on health services, and to show the way in which programmes are meeting identified health needs in the district. 428. District Management Groups will comprise the District Community Physician (D.C.P.), District Nursing Officer (D.N.O.),. and District Administration Officer (D.A.O.). Much of the work of the individual members will consist of administrative duties inherent in the day-to-day running of the service and the supervision of their staffs. However, in its collective responsibility to the R.H.A., the District Management Group will be held accountable for the fulfilment of a series of specified objectives in service management and the optimal use of health service resources in the district. 429. These objectives will be agreed between the Districi Management Group and the R.H.A. on an annual basis, and will be set out as the management plan for the year. The objectives will be stated in quantitative terms, and will relate to specific aspects of service operation and resource utilisation. While each years objectives should represent an improvement in: performance over those set for the preceding year, all objectives should be accepted as feasible by both the R.H.A. and District Management Group. For this reason the objectives will require detailed discussion between members and officers of the R.H.A. and the District Management Group, taking account of the performance of the District Management Gr9up in fulfilling the

previous years objectives. V

District Community Physician 430. Administrative reform will bring together into one service medical administrators now working in the public health services and those, in the hospital , service. The, D.C.P. will be concerned 137 with assessing community needs, evaluating the effectiveness of services, guiding specialist staffs, and managing preventive health services. He will differ from his clinical colleagues in that while they will usually attend to the needs of individual patients, he must consider the needs of the entire community. 431. From his interpretation of information, and from the over- view which he has of both hospital and community services, the D.C.P. will be able to suggest to his colleagues ways of improving and integrating district health services. The D.C.P.s knowledge of epidemiology and management skills will greatly help clinicians to improve the effectiveness of their health care services. Information available to the D.C.P., as well as his special skills, will enable him to co-operate with local schemes for medical audit where this is sought by the medical staff. 432. It would be easy to fall into the trap of assuming that the D.C.P. is a dual purpose Medical Officer of Health and medical superintendent with managerial responsibility for clinical specialties under him. This misinterpretation must be firmly resisted, because it would interfere with the clinical autonomy of specialists in either primary health or specialist care. 433. Functional integration, the successful implementation of alternative methods of service provision, and the improvement of service performance will depend upon the ability of individual D.C.P.s to establish good working relationships with their professional peers of other specialties. Similarly, clinicians should recognise the role of the community physician because of the different perspective he can bring to the operation of health care services for the benefit of individual patients and the community. Health districts will be small enough to allow D.C.P.s to foster good working relationships with individual practitioners, whether general or specialist, and to be familiar with their views and needs. It follows that D.C.P.s should regularly participate in clinical meetings of general practitioners and specialists, and keep them informed in matters of service management and development. 434. The D.C.P. will inherit many of the preventive health services and requisite statutory powers of the Medical Officer of Health. Services co-ordinated and supervised by the D.C.P. and his staff will include: 434. 1. Disease control; 434.2. Food safety and hygiene; 434.3. Quarantine and port health; 434.4. Public health aspects of environmental services, e.g., town planning, air and noise pollution control; 138 434.5. Occupational health and environmental conditions at places of work; 434.6. Health education; 434.7. Family planning; 434.8. Maternal and child health care; 434.9. Vaccination and immunisation; 434.10 Toxicology and poisons control; and 434.11. Civil defence. 435. While the health inspection and associated licensing functions of territorial local authorities will move to R.H.A. control, the relationship of health to local government agencies will not cease. D.C.P.s will need to maintain a close link with regional or local government authorities in connection with the provision of environmental health engineering works and their supervision from a public health point of view. Their "watch" is the more necessary in order to check outbreaks of communicable disease. In many instances it is expected that this surveillance of the environment will be maintained by health inspectors as at present, but they will be accountable to the D.C.P. In the event of civil emergency or, upon an outbreak of communicable disease, the D.C.P., like the present Medical Officer of Health, will be authorised by the R.C.P. to exercise the wide powers already existing under public health law. 436. In summary, then, the D.C.P. will have the following functions: 436.1. the preparation and development of information services in the district which will enable health service requirements to be identified, and service performance to be critically evaluated. 436.2. the co-ordination of operational services by advising and guiding his professional colleagues on the more efficient use of resources, including the organisation of staff and location of services -as they affect individual health services. .436.3. the organisation of preventive medical services in the district, assisted , where appropriate by health inspectors, • health education officers, public health nurses, general practitioners and laboratory staff, and other staff.

District Nursing Officer . 437. Reorganisation of the health services provides an opportunity to unite the various elements of the nursing profession. The present division of the profession into public health nurses, general and specialist hospital nurses, district nurses, practice nurses, community nurses, and occupational health nurses, to name 139 but .a few categories, is. largely historic. However, , nurses, perhaps more than any other health profession, have been longer acclimatised to the need for community as well as institutional based programmes. Current professional thinking tends towards the view that nursing should be recognised organisationally as a unified service wherever it is delivered: "Nursing should be viewed as one unified profession, integrated within the health services, rather than as several branches as at ( present. Every effort should be made to eliminate artificial barriers which exist in varying degrees between different groups of nurses. "People need a comprehensive health service. There should be a much greater shift of emphasis away from sickness and hospital care to health and care in the community. This will require extension of the nursing component of community health services of all kinds to further decrease the need for additional expensive hospital services and to help conserve the time of doctors working in the community. 112 438. Unlike doctors, nurses have always been organised in a hierarchical structure. The head of the nursing service has been accountable both managerially and professionally for her sub- ordinates. The view that the nurse should remain as the handmaid of the doctor has perpetuated unduly the accountability of the nursing profession to the medical profession in both the public health and hospital services. 439. It may be considered that, in the present climate of professional activity in New Zealand, the inclusion of nurses in the management structure in their own right would be premature. In spite of the upheaval and redefinition of nursing roles which is taking place at present, two factors have to be considered. The continuing care of patients (particularly those in hospitals) is dependent upon the nurses observations, interpretation, and reports on the patients condition, and institution of necessary action in the event of crisis and is undertaken in many cases without any question of need for medical supervision. It must also be recalled that nurses constitute by far the largest single professional group in the "treatment" category of personnel. On 1 April 1974, Hospital Boards reported that they employed a total of 1,859 (whole-time equivalents) doctors, 4,788 other treatment staff, but a total of 20,621 in the nursing group. Further information about staff is given in appendix XI. 440. The Government proposes that all nursing services will be unified at district level, and that these services will be under the professional and managerial control of a District Nursing Officer. His or her responsibilities will be: . 440. 1. To manage an efficient and integrated community and hospital nursing service within the district; 140 440.2. To review and report regularly on nursing services, the assessment of needs and problems, and to assist Staff to understand objectives and policies; 440.3. To advise the District Management Group of nursing implications in service management and development, and of problems within the nursing service; and to co-ordinate nursing services within other health services; 440.4. To implement all relevant legislation and regional policies relating to nursing services. 441. The report of the Board of Health Committee on Nursing Services, which was quoted earlier, envisages the division of nursing services into hospital and community health aspects, under the professional head of the nursing service. The . Committees proposals were prepared without knowledge of the Governments intentions on the reorganisation of the health service. It would appear that the Committees recommendations in this regard, if implemented, would contradict the Governments desire to integrate nursing services at district level. A more appropriate basis, which would remove many of the distinctions between hospital and community, would be organisation along functional lines, for example, medical and surgical nursing, psychiatric nursing, and so forth. Functional organisation need not necessarily follow organilation upon the basis of registrable qualifications. Details of this organisation would need to be determined in the course of preparation for the transfer of all nursing services to the control of R.H.A.s.

District Administration Officer 442. The relationship between medical administrators and general administrators should be a complementary, not a competitive, relationship. The shortage of medical administrators is such that their talents and energies should not be dissipated upon administrative tasks for which the general or nursing administrator is better suited. Medical training is required for medical administration, which includes the assessment of health service requirements, organisation and planning of medical services, collection and collation of information for the proper planning and best use of resources, and for informing the R.H.A., the medical profession, other professions, and the public about health services .443. The general administrator will contribute to the overall management process by his ability to understand and elucidate the,. objectives of those more directly involved in the provision of health care programmes. The. D.A.O.s detachment from the clinical side of activities will enable him to co-ordinate the operation of the i4l District Management Group and its activities by ensuring that appropriate matters are discussed, and decisions reached and implemented. He will also be in the best position to advise fellow members of the administrative, financial, and capital impact of various policies, programmes, and alternatives; and to remind them of the administrative and financial limits imposed on districts by national and regional guidelines. 444: All health services in the district will need to call upon the administrative support services which will be managed by the D.A.O. He will be accountable to the R.H.A. for the day-to-day control of administrative and financial services. He will be responsible for the maintenance and upkeep of property in the district, and of "hotel" services provided in institutions. These will include laundry, catering, domestic, and transport services. As head of administrative services, he will be responsible for the storage, control, and issue of supplies; the maintenance of records; some staff recruitment and discipline; financial and budgetary control, including internal audit schemes and accounting systems; and public relations programmes. Heads of Paramedical Professions 445. Heads of paramedical and technical professions should normally be accountable for the maintenance of professional standards to the medical director of the service in which they are engaged; and to the D.C.P. for the day-to-day administration and use of resources in their departments. In such services as radiology and pathology this can usually be achieved; however, in services such as dietetics and social work it can rarely be achieved, and staffs in these paramedical disciplines may need to be accountable professionally and administratively to the D.C.P. It is important that operational programmes and management of the total health service at district level should take account of the needs of these disciplines and services. Consensus Management 446. The dominant characteristic of the health services, which must determine the methods of management (as opposed to administration) is the complexity of the services. This, together with the diversity of the skills of the staff employed, renders unrealistic the concept that a single officer might control and direct service management and development in any region or district. For example, if any one of the district officers were to be regarded as the "chief executive", he would require the authority to direct and control the activities of all health service employees in his district, including administrative staff, nursing and paramedical staffs,

142 technical staff; and specialist staff. As a corollary he would also be ultimately responsible for the work of these staffs and would have to account for any shortcomings in the standards of; say, laundry services, financial accounts, recruitment and training of nurses, or the specialist medical care of patients. 447. It would be undesirable and contentious for any single officer to be given such a range of authority and responsibility. Despite some erroneous current perceptions, no administrative officer in any of the present components of the health services has such a comprehensive range Of responsibilities. Individual officers may have powers of direction over a limited hierarchy of staff in a particular field, as in the case of the Medical Officer of Health, or the Matron- in-Chief of a Hospital Board. On the other hand, specialists in the hospital field are free from any form of direction; at best, they are open to persuasion in such matters as the use which they make of various resources. 448. In suggesting a pattern of operational management appropriate for the reorganised health service, it is thus necessary to think in terms of a multi-disciplinary approach, where a team, each member of which represents a substantial group of senior staff, or controls the day-to-day administration of a substantial area of the service, has corporate responsibility for the management and development of the entire service. This pattern of management, which is formally recognised in many areas of complex industrial and commercial enterprise, and which is already practised, albeit unconsciously, within the health services has the following features: 448.1. Each member of the team is of equal status, and has equal opportunity to contribute to the teams deli- berations. 448.2. Decisions are reached by consensus, so that all members of the team are committed to the decisions. Where the team is unable to achieve consensus, the issue will need to be resolved by the body to which the team is accountable. • 448.3. The team must have a set of clearly defined objectives to work towards in exercising its management functions. 448.4. Leadership is not predetermined, but will be assumed by the best suited individual; so that the leadership of the team , may vary according to the issue under con- sideraticin. 449. The Government considers that only by the adoption of this style of management, with free and active participation of all team 143 members on an equal basis, will the health service management and development undertaken by groups of officers at regional and district level become fully effective.

District Health Services Advisory Councils• 450. Most of the decisions which determine the use of health service resources are made by professional staff actually engaged in delivering and providing health care programmes. It is essential, therefore, to provide a consultative and advisory mechanism which will allow senior members of the health professions and those charged with the management of health services at district level to exchange views. To achieve this aim, the Government proposes to establish District Health Services Advisory Councils. In broad terms, their functions will be: 450.1. To provide a formal channel for presentation to the District Management Group of the views of health service professional staff on matters within their particular sphere of service involvement. 450.2. To afford a means whereby the District Management Group may obtain the views of the health professionals about developments in health services locally, and clarify with health professions, issues of national and regional policy concerning health service management and development. 451. To meet these purposes, it would be necessary for the District Management Group to have the right to convene a meeting of the Council. 452. However desirable it may be to have the Councils fully representative of all health professions, this would be unwieldy. The Government- therefore proposes that the District Health Services Advisory Councils should be composed of a core of representatives from those disciplines with the broadest involvement in delivering and providing health service programmes. In these terms, representatives of general , practitioners, whole-time senior medical staff, part-time specialists, medical staff in training, dentists, and nurses would have places on the Councils.. Members of the District Management Group should be present and be entitled to speak at meetings of the councils, but not to take any other part in proceedings. In addition, Councils will have power to co-opt members of other professions and to set up sub-committees where these• are found to be necessary for--the effective operation of the Councils-functions.,

1-447 453. Further details of the advisory mechanism, for example,. the method of representation or possible sub-committees, will need to be worked out in consultations preceding reorganisation. Regional Group of Officers 454. In the same way that the day-to-day management of regional health services will be undertaken by a collegiate group of officers. in each district operating by consensus, so the remaining function of R.H.A.s referred to in paragraph 420.2 will be shared among a group of officers. The Regional Group of Officers will consist of a Regional Community Physician (R.C.P.), Regional Nursing Officer. (R.N.O.), and Regional Administration Officer (R.A.O.). 455. In single district regions, the Regional Group of Officers will need to work at two levels. First, in relation to operational management and short-term service development, where the Regional Group of Officers will function in the same way as a District Management Group; and second, in relation to long-term planning and the administration of regional services. Planning the Regional Health Service 456. R.H.A.s will be required to publish comprehensive 5- and 10-year plans for the health service in the regions. 457. The Regional Group of Officers will be the chief planning officers of the R.H.A. and each will make a significant contribution to the preparation of these plans. Each officer will have responsibility for ensuring the implementation of national policies and regional plans relating to his sphere of professional activities. In . addition, the Regional Group of Officers will be the principal advisers to the R.H.A. Inasmuch as the R.H.A. is charged with the, responsibility for long-term planning, this activity will occupy much of the time of R.H.A.• members; however, the detail of planning and the drafting of regional programmes should be the exclusive responsibility of the regional officers. This will entail: 457. 1. an accurate assessment of the existing situation; 457.2. the definition of the means, recommended to improve • efficiency in the working of the sector;- - 457.3. an estimate of staff needs, category by category, together with an indication of the facilities needed for staff training; 457.4. the costing of the -various activities, project by project, taking into account and listing separately: - . (a) capital expenditure, (buildings, vehicles, and equip- - ment);. - (b) recurrent expenditure on personnel and materials; 145 457. 5. a description of the expected results, in terms as concrete as possible; 457.6. as accurate as possible an estimate of the expected economic effects; and 457.7. recommendations for activities in other sectors.3 458. The nature of the health services required will be specified by the R.C.P. These must be matched against the administrative, manpower, capital, and financial consequences of service planning. The regional 5- and 10-year programmes must not only indicate the means whereby planning objectives are to be fulfilled but must also define the consequences for existing facilities and services. 459. His epidemiological and statistical training will enable the Regional Community Physician to take account of vital statistics and to trace the aetiology of particular diseases prevalent in communities, thus to identify the health service requirements of the regional population. From statistical returns, reports, and other information obtained from a variety of sources, including general practitioners, specialist health services, voluntary agencies, statutory registers, the N.Z.H.A.s statistical and information services, national guidelines, and consumer reaction, the R.C.P. will be able to set objectives for health care planning. He will be expected to take the initiative in suggesting to fellow officers how various health needs can be met, where and by what means health services should be provided, and the medical and paramedical manpower required to run them. This process will include suggestions regarding the distribution of preventive, primary health care and specialist services throughout the region. 460. Current distinctions between institutional and community care impede the integration of the health services.-Although made with reference to the organisation of a mental health service, the following extract from the Review of Hospitals and Related Services has general applicability throughout the health services: "Traditional boundaries as between hospital and community or hospital and hospital either have to be very extensively modified or (entirely abolished if a mental health service is to be seen in functional, / rather than in architectural terms. Correlation of services in the community with services provided in hospital is essential. It cannot be too often reiterated that the hospital and community components / are inter-related aspects of a total health service. They are not alter- / native types of service. It follows that professional staff in all f categories should desirably have some links with both elements of the health service to which they belong."4 461. The breakdown of barriers between the hospital and the community depends in large part upon the development of supportive relationships which extend through both community care 146 and institutional care. Nursingservices, like general practitioner services, do much to facilitate this. The proposed functional organisation of nursing services in districts (see paragraph 441) will also promote functional integration. 462. The successful implementation of health service plans considered by the Regional Group of Officers will be affected by the R.N.O.sanalysis of the capacity of the nursing forces to staff many of the services, and to be equipped by education to cope with specific regional health problems. The R.N.O. must assess future manpower requirements for nursing services. 463. The Regional Community Physician and the Regional Nursing Officer should be guided on the means of providing specialist services by their professional colleagues working in these areas. Where appropriate, multidisciplinary health service planning teams should be established. 464. Support services outside the clinical field will be the responsibility of the Regional Administration Officer. Service planning must be weighed against the likely effects upon manpower recruitment, retention, and education; hotel services, supply services, and capital development required in the region. The R.A.O. will ensure that account is taken of the need for additional transport, stores, and office and other accommodation precipitated by health service plans. One of his primary responsibilities will be the co-ordination of all of the activities of his regional officer colleagues and external contractors, which lead to the fruition of the service plans. This will also involve such considerations as acquiring land and other property, and the engagement or commissioning of contracting firms. 465. The R.A.O. will also control regional budgets and expenditure and will advise the Regional Group of Officers about the sums likely to be available for health services in the region. All health service planning must eventually be quantified in terms of money and adjusted according to the funds likely to be allocated. Financial planning should be such as to allow for an equitable distribution offunds among districts in the region; and to guarantee the main tenance of essential services despite possible adverse financial circumstances. 466. Regional health plans, although containing objectives and forecasts of development for 5 and 10 years ahead, will also be presented as annual programmes for each service. Afie consideration and-approvalJy the .LH.A., and. the incprporation of ffi. 1gt5ffa1 plan within a national health plan, the R.H.A. shoulddiegate full authority •t6fliRegional Group of Officers and the District Management Groups to implement those parts of the plans with which they are concerned.

147:. Regional Specialist and Technical Services 467. Some services administered on a regional basis, such as geriatrics, psychiatry, and the school dental service, together with those dental services provided under contract or dental benefit schemes, will require supervision by officers who may have a combined clinical and administrative role. These officers will not be part of the Regional Group of Officers, but may from time to time require direct access in an advisory capacity to the R.H.A. 468. General areas of responsibility of the District Management Groups and the Regional Group of Officers have already been described. In addition to their activities in major planning, the Regional Group of Officers will also be concerned with services provided on a regional basis. These will include staff training and education, supplies and purchasing, the administration of contracts and liaison with officers of the N.Z.H.A. in provision of management services such as organisation and method study, computer technology, operational research, medical records, and statistical studies. Monitoring and Controlling the Regional Health Service 469. Delegation of authority leaves ultimate control in the hands of the members of the R.H.A., and, in the technical and professional sense, of its principal officers. Objectives set out in the annual plans will be effective criteria for evaluating the performance of District Management Groups. In the operational management and development of district services, District Officers will not be in a superior-subordinate relationship with their counterparts in the Regional Group of Officers. However, the Government proposes that the performance of the District Management Groups will be monitored by the Regional Group of Officers, collectively and individually. Individual members of the Regional Group of Officers will have the responsibility for keeping themselves fully informed of the management performance of their counterparts in the District Management Group, and encouraging their counterparts to improve those areas of performance which appear to be deficient. In this management context, issues of contention between regional and district officers will require resolution by the R.H.A. In many matters of service administration, routine direction will be acceptable; but, in handling emergency situations, powers of direction between regional and district officers will be necessary. 470. The monitoring relationship shown in figure V will, in many cases, be maintained by frequent informal consultations between regional and district officers on a wide range of issues, 148 problems, and plans. The successful operation and development of regional health services will depend • upon informal contact of this nature where difficulties can be Overcome, national and regional policies explained, service performance evaluated, and guidance for improvements obtained. 471. The formulation of comprehensive health plans will provide a proper basis for monitoring district performance. Achievements can be measured against objectives specified in each plan, and deficiencies rectified. Effective planning and critical evaluation is conditional upon the inception of adequate information systems. In the course of preparations for reorganisation, preliminary national guidelines will be issued on the nature of information systems ibemiiitained in each region. These, in turn, must be co-ordinated at the centre so that the effectiveness of the New Zealand health service can be studied and evaluated. This topic ! should be considered along with other meansisntral_control. j

Contractual and Voluntary Services 472. As has been indicated in paragraph 420.3 above, the work of a number of voluntary organisations will need to be co-ordinated with services provided directly by R.H.A.s. To--avoid-unnecessary duplication,R.H..shoul&attemptprovidetheir own the aegisof.yntary agencies, but should enter into arrangements by which these agéhcies would provide services of a standard specified by the R.H.A. The extent to which individual R.H.A.s will need to call upon the services of voluntary organisations will vary according to local need. There are, however, areas of concern such as infant welfare and institutional care for the aged or handicapped, where contractual arrangements can be readily foreseen. Current contractual arrangements between Hospital Boards and voluntary agencies for the provision of domiciliary nursing and ambulance services will be carried forward into the reorganised health service. Contracts will specify that the full cost is to be met by the R.H.A. while ensuring that the service is provided free of charge to the citizen. 473. The of contract proposals will have major repercussions for the finance and staff of voluntary organisations, and, equally as important, for the individuals using the services. As a consequence, aspects of the present varied pattern of subsidisation and social security benefits, on which many voluntary agencies rely, will need to be reappraised. It is intended, by, the means outlined, to encourage voluntary organisations and at the same time to facilitate the removal of salary differentials between 149 staff working in voluntary agencies and their equivalents in the statutory services. The contract scheme will also provide , wider opportunities for in-service training for staff of R.H.A.s and workers in voluntary organisations. In both cases this should be provided to the workers concerned at no cost. 474. Because the community has responsibility for the health services, R.H.A.s will need to be satisfied with the standards of contracted accommodation, care, and service. To ensure high standards, the need for appropriate staff of the R.H.A. to inspect the contracting institution or service should be made clear when agreements are negotiated. In this way the interests of the individual patient will be preserved, proper decisions taken on the placement, of patients, and available resources throughout the region used to better advantage. 475. In most instances the R.C.P. will be the regional officer concerned with the technical and professional standards expected of contractors. In the case of contracted nursing services, the R.N.O. will assume this responsibility. These officers, and other appropriate professional staff, will be expected to maintain a general oversight and surveillance of contract programmes, paying particular attention to the quality of life and physical environment of residents in institutions provided by contracting organisations.

Professional Advice 476. The Regional Group of Officers will be the principal professional advisers of the R.H.A. concerning services in their respective disciplines. In providing expert advice, it will often be necessary for the group and its members to obtain advice from officers of District Management Groups; from professional and technical staff of the R.H.A.; and from contracting agencies. Proper channels will also be established by which the Regional Group of Officers may be professionally advised by officers of the N.Z.H.A. For professional liaison purposes, contact will be maintained through various sector teams of N.Z.H.A. officers. 477. One of the most important aspects of the work of each regional officer will be the critical evaluation of advice and information presented to him before he, in turn, presents it as advice to others. Six main areas of advice will be required by R.H.A.s regarding: 477.1. the policies, priorities, plans and specific objectives of the R.H.A. in the management and development of health services in the region; 150: 477.2. the current use of resources of the health service and their administration, and areas of need for greater efficiency and modified performance; 477 .3. the design planning of buildings, and the selection of equipment required; 477.4. the co-ordination of services provided by the R.H.A. and relations with other agencies concerned with the delivery of health care; 477.5. liaison and co-ordination of R.H.A. services with educational and social welfare agencies; and 477.6. matters of discipline of staff. 478. In turn, the Regional Group of Officers will advise and guide District Management Groups and specialist staff regarding: 478.1. the interpretation of national policy guidelines and regional plans to the local situation; 478.2. methods and procedures which may require consideration to improve the efficiency of use of resources; and 478.3. medico-legal and ethical matters.

Liaison 479. Regional officers will also have public relations responsibilities, particularly in those areas where the health services boundaries meet those of social welfare, education, and the environment. They will be included individually in the membership of formal liaison committees concerned with these other services.

Supporting Administrative Staf 480. In order to discharge their administrative responsibilities effectively, each of the officers at district and regional level will require a staff of subordinate professional and technical officers to whom specific responsibilities are delegated. While this will be obvious in the instance of for example, the D.A.O. and the D.N.O., it is also the case with the D.C.P., who will probably need staff to supervise "patient services", such as hospital outpatient clinics and appointments systems, admission procedures, and waiting lists; to deal with domiciliary services which enable the support of patients in their own homes, thereby facilitating early discharge from hospital or avoiding the need for hospital admission; and to supervise the day-to-day administration of environmental health matters; Similarly, the R.C.P. may require officers killed in service planning, including capital development; in medical manpower and post-graduate education; and in health service information systems. 151 481. The foregoing are no more than suggestions and the detail of such supporting staffing will be a matter for further discussion. However, it is essential that the District Management Group be the last level of corporate management in the health services. If, for instance, there is any attempt to establish management teams below this level to deal with institutional management or public health, the concept of integration within the service will be totally vitiated. Undoubtedly, clinical teams will be required for the provision of care for such groups as the elderly, the nientally ill, and the physically handicapped; but these teams will be basically concerned with areas of patient care, and not with service management. The Management Process 482. The management of regional health services as outlined in this chapter effectively constitutes a process which "Can be seen as a scale, with the setting of objectives and allocation of resources at one end, moving through the designing of programmes and plans, to the execution of these plans at the other end. As one moves through the management scale, the balance between the two elements changes from member control with officer advice at the objective end to officer with member advice at the execution end." 483. The management arrangements set out in this chapter reflect a form of management which is already evolving in many facets of the health service, and where the need for active participation of the major administrative disciplines in positive management is accepted. The proposed system will provide for extensive delegation of authority by the R.H.A.s to Regional Groups of Officers and District Management Groups. Members and officers of the R.H.A. will understand their respective roles, so that they can forge an effective, smooth working partnership in the provision, planning, co-ordination, and management of the regional health service. Development of regional programmes in accordance with national policies and priorities will enable the equitable distribution of resources in a comprehensive New Zealand health service. Interim Arrangements 484. It is fundamental that the positions of the principal regional and district officers described in this chapter are in no way construed as similar to or extensions of the positions of Medical Superin- tendent-in-Chief Matron-in-Chief, Hospital Board Secretary, Medical Officer of Health, Principal Public Health Nurse, or Dis- trict Executive Officer. These will have no place in the restructured health service. Initially, however, there will be insufficient officers 152 with the depth of management or administrative knowledge, or sufficient breadth of experience across the whole field of health service, effectively to assume on 1 April 1978 the roles envisaged iii the new health service. Until these deficiencies can be overcome interim arrangements for health service management and administration will be necessary. These will be described in chapter XVI. 485. These interim arrangements are solely stopgap measures and it is the Governments intention that the organisational arrangements set out in this chapter will be fully implemented by 1 April 1981. As conditions permit, earlier implementation may be possible in some regions.

REFERENCES 4J.H.R., 1973, 1-12, P. 21. The Committee then went on to question the relevance of the existing Hospital Board system and suggested that this would be worthy of study at some future time. 2Board of Health Committee on Nursing Services, An Improved System of Nursing Services for New Zealand, Wellington, 1974, pp. 29-30. 5World Health Organisation, National Health Flaming in Developing Countries, Technical Report Series, No. 350, Geneva, 1967, p. 24. Department of Health, Review of Hospital and Related Services, Wellington, 1969, p. 92. M. A. Bains (Chairman), The New Local Authorities: Management and Structure, London, 1972, pp. 10-11.

153

A XIII. THE FUTURE OF CENTRAL CONTROL

486. Various means of central control over the health service are necessary to give effect to the principle that control should follow the source of finance. They are also nuessarsuo—ensure co-ordination and supervision of regiona services. Both the Minister of Health powers in the reorganised service and will be the agents of central control. The Minister of Health 487. The Minister of Health will have certain general functions: 487. 1. To establish,, maintain, and develop a comprehensive New Zealand Health Service to be made available to all citizens as of right and with no economic barrier; 487.2. To secure and account for funds for the maintenance and development of the health service; 487.3. To publish, 5- . and 10-year plans for the development of the health service, including the objectives of health care programmes during these periods; and 487.4. Generally to supervise the smooth development and operation of the health service. 488. The Minister will need to maintain regular contact with developments in the service. In the course of his official and public duties he will visit many of the health services and institutions operated by R.H.A.s. In addition, the Government believes, the Minister should have a prime and standing commitment to meet with the chairmen of R.H.A.s and those officers who will constitute the N.Z.H.A. The Government therefore proposes that the Minister will chair quarterly conferences of all regional chairmen and principal officers of the N.Z.H.A. Meetings of this Council of Chair- men will provide a practical means whereby the Minister may maintain direct contact with the opinions and aspirations prevailing in the regional health services, and should eliminate the present undesirable tendency towards a dichotomy of interest between the Department and some other operational agencies. 489. The Minister will have certain powers to enable—hi mto carry out his functions, j2rnembers of each R.H.A., and its chairman, will be appointed by the Minister of Health. The Minister will be required to have regard for the need to achieve a balance in members qualities and skills so that the team of

154 R.H.A. members will be capable of administering the wide.. range of functions for which the Authorities will be responsible. Appointment will be for a 3-year term. The Minister will also have the power to appoint the chief officers who will constitute the New Zealand Health Authority. As officers, and State servants, they will have the security of tenure normally accorded State servants. 490. The Minister will have the power to remove appointed members of R.H.A.s and, in circumstances which will be defined in legislation, to dismiss chief officers of the N.Z.H.A; The power of removal will be exercised only in extreme cases. The Government intends to carry forward into the reorganised health service power similar to that which at present enables the Minister to dismiss a Hospital Board which has failed to perform statutory responsibilities, seriously mismanaged its affairs, or has acted arbitrarily, improperly, or illegally to the detriment of its efficiency. In such circumstances, the Minister has the power to appoint a commission to act in place of the Hospital Board. 491. The dismissal of an Authority will be the ultimate sanction available to the Minister, and its use in the future, as in the past, will be very rare. In order to obviate the exercise of this power, the Minister will have authority to institute investigations of alleged or apparent abuses or deficiencies in the health service. - 492. A small proportion of the actions of health agencies or professions leaves the consumer dissatisfied and with grounds for complaint. The inadequacy of machinery for dealing with administrative complaints regarding service provision (as opposed to complaints about clinical matters) leaves the complainant with the options of referring the matter to a member of a Hospital Board, a member of Parliament, the Department of Health, the Minister, the Ombudsman, or the news media. An increasing tendency seems to be to forward more and more complaints, Often of a purely local nature, to the Minister, the normal administrative channels not having been explored. Complaints handled by these means are generally not of a nature serious enough to warrant investigation by a commission of inquiry. They d9, however, suggest a need to establish an additional and more formal means by which complaints can be fairly examined, and, independently assessed and criticised, where normal administrativ channels have failed. The public should be made aware of th complaints procedures as part of a general education programme dealing with the availability and working of the new, health service.

155 493. The Governments proposal to establish a two tier complaints procedure is shown in figure IV. A person tentatively styled the Regional Complaints Commissioner will be appointed by the Minister of Health in each region to deal with complaints against the actions of employees or contracting agencies of. the R.H.A. in dealing with the public where these are alleged to have been dealt with inadequately by the principal officers of the R.H.A. Regional Complaints Commissioners will be authorised to recommend to R.H.A.s such action as is considered necessary to remedy any justifiable complaint, and will report on their activities to the Minister of Health. The complaints procedure will extend to the actions of contracting parties. It is intended that these nominees of the Minister will also assume the powers of District Inspectors and Official Visitors currently provided for in the Mental Health Act 1969 in relation to psychiatric hospitals. The task of Regional Complaints Commissioners will require the degree of scrupulous impartiality and objective consideration, and appropriate training, possibly in law, as is demanded by such an office. These persons will not be servants of the R.H.A although they may if they wish receive clerical and administrative support from R.H.A. personnel. 494. The Ombudsman, as an independent officer of Parliament, will be the second and alternative person through whom complaints against the health service may be channelled. He has full powers to investigate, including the right of access to files and papers, the right to criticise and. publicise administrative actions, and the, right to report to Parliament. His current jurisdiction allows for full inquiry into administrative actions of the Department of Health, and to a limited extent, those of Hospital Boards. In the future, the Ombudsman will be the person to whom complaints about the actions of the N.Z.H.A. will be directed for consideration, and he will represent a source of appeal against the decisions of a Regional Complaints Commissioner. 495. Both Regional Complaints Commissioners and the Ombuds- man will be empowered to handle complaints about administration of the services provided by R.H.A.s and their contractors, but not to inquire into the actions of members of the health professions in relation to the clinical treatment of patients. Investigations of this nature are essentially professional, and appropriate machinery already exists for dealing with incidents of negligence, incompetence, or malpractice through professional registration authorities and the courts. 496. Speculation should be avoided at the moment on the possible role of regional government agencies, including the 156 proposed Community Councils to be established under local government legislation, in the instigation of complaints against health service provision. It is recognised, however, that the proposed Community Councils are intended to reflect community attitudes on a wide range of topics and to provide a forum by which these views can be expressed. 497. The inception of a systematic complaints procedure logically derives from the Ministers authority generally to supervise the smooth development and operation of the health service. For this purpose, it may be necessary for the Minister to issue directions to a R.H.A. or the N.Z.H.A. to perform some function or to exercise some power set out in law which the agency has failed to do. The power. of direction will be supplemented in other cases by granting the Minister the power to revoke any authority which he has delegated in the event of that authority being improperly or inefficiently used. The New Zealand Health Authority 498. Transferring the bulk of the Departments remaining operational functions to R.H.A.s would restore the historic, supervisory and advisory role over regionally administered health services, and facilitate the surveillance of the efficiency of these services. The N.Z.H.A.s work as the executive "arm" of the Minister will then become much clearer. Under the Minister, and consonant with Government policies, the N.Z.H.A. will be responsible for administering the health services in a uniform manner and therefore will lay down the principles and guidelines which must be observed in the organisation and activities of health services, and be responsible for the surveillance of the efficiency of these services. An - outline of the proposed functions and responsibilities of the N.Z.H.A. should give a clearer appreciation of its supervisory role in the health service. 498.1. To undertake national planning for a comprehensive health service; 498.2. To set policies regarding current management and future development of the health service, and to issue guidelines on these to R.H.A.s; 498.3. To allocate fairly and equitably available resources among the R.H.A.s in consultation with them; 498.4. To co-ordinate and supervise work of the R.H.A.s, including their relationships with voluntary agencies and local government authorities, and to ensure that national policies are implemented; 157 498.5. To evaluate and constructively to criticise health services in New Zealand, and to publish reports and disseminate information on conditions and trends in the health service; 498.6. To advise and support the Minister of Health in the formulation and amendment of legislation relating to the health service, and in the exercise of his official and public duties; 498.7. To provide and operate such technical services as are necessary to maintain national standards or to conserve scarce manpower resources; 498.8. To participate in negotiations involving professional bodies and trade unions on the rates of remuneration and conditions of service to be applied throughout the New Zealand Health Service; and 498.9. To co-operate with and assist national and international agencies in improving international health services. Organisation of the N.Z.H.A. 499. The complete recasting of the head office of the Department of Health as the New Zealand Health Authority, an integral part of the administrative structure of the health service, with a positive primary commitment to the provision, management, and development of health services, demands extensive internal reorganisation. In so doing, comments made before departmental reorganisation in 1960 are appropriate: "Hitherto the Department has been organised on a divisional basis. This met its needs when the task was simpler and less complex than it is today. Problems in public health in this day and age are not the prerogative of any one specialty. Their solution demands a team effort • with a pooling of knowledge and resources. This requirement in its turn calls for an administrative organisation which will provide the means for co-ordination and consultation." The reorganisation of 1960 grouped various divisions into bureaux, which had a common affinity and unity of purpose. The bureau system has been subject to minor modification, but its basis remains the same today. . 500. The bureau system will be an effective means of co-ordinating the services of the N.Z.H.A. Thus it is proposed to establish three bureaux, concerned with operational services, technical services, and administrative services. These bureaux will comprise a number of divisions, each of which would deal with specific areas of administration. They will not he divisions of health service such as were used as the basis for the departmental structure of 1920. Within the Operational Services Bureau there will be a 158 strengthening and extension of the scope of activities of the multi-divisional sector teams which have been established in the Department. 501. The Operational Services Bureau will be the main area of contact between the N.Z.H.A. and the activities of the R.H.A.s. Most of the issues relating to health service management and development will be processed by this bureau, which will also take the leading role in the formulation of national policies for health. It is possible that the bureau will comprise three divisions, concerned respectively with primary care, specialist services, and community health, along the lines of the major functional components of regional health services. 502. To ensure that an "integrated" approach prevails in the conduct of business of the bureau, it is intended that the bulk of the routine administrative work will be undertaken by perhaps three sector teams, which will have geographical responsibility for a group of R.H.A.s. Each of the sector teams will have a permanent nucleus of officers of the three divisions of the bureau, and these officers will maintain contact with their counterparts in the regions comprising each sector. Sector teams will be augmented, as necessary, by ôfficers from other bureaux contributing tEeir expertise in the evaluation and consideration of particular issues. Supervision of management and review of development plans will be undertaken by these sector teams, which should meet frequently, at least fortnightly. In matters of service development and planning, each sector team will have collective or collegiate responsibility to the bureau head. 501 As at present, in the head office of the Health Department, the Administrative Services Bureau will provide and co-ordinate the administrative services required to support technical and operational activities. While the detail of the divisional structure will require further consideration, it would seem that four divisions may be necessary. The functions of a possible manpower division, concerned with staffing establishments, training, salaries, and conditions of service, will be considered in the next chapter. The role . of a proposed finance division, to deal with the allocation of funds to R.H.A.s, and with funding the limited range of services to be provided directly by the N.Z.H.A., will be discussed in chapter XV. A legal division will almost certainly be needed to deal with the preparation and revision of health service legislation and with matters of law as they affect the health services. A secretarial division should have as its main purpose, provision and co-ordination of office support services required by all bureaux. 159 504. The Technical Services Bureau will deal with those matters relating to national standards, or activities involving sophisticated technical expertise and scarce manpower resources referred to in Tara. 498.7. 505. Many specialised activities have evolved within the various divisions of the Department of Health, or have been undertaken by specific units created for the purpose. Consideration must be given to the formal recognition of the importance of these activities by forming appropriate technical divisions. For example, the range of work undertaken in work study, data processing, and statistical surveys by the Departments Management Services Research Unit may warrant the establishment of a Management Services Division, which should also embrace health service statistics and information services. The extent of the problems in electronic data processing will increase dramatically as the health service becomes a large user of computer facilities. The future organisation of computer services for use by the Government and its agencies is at present being studied by management consultants. One of the major factors to be taken into consideration will be the reorganisation of health services. 506. Similarly, the technical work undertaken within the Hospi- tals Division in relation to the scrutiny and approval of proposals and plans for capital development may also warrant an independent division, incorporating as well the field of work of the Design and Evaluation Unit. There is need for a division concerned with supplies and equipment which, on behalf of R.H.A.s, in addition to arranging bulk, contract, and indent purchasing, will also collect and collate much more information about the technical capabilities and performance of particular items of sophisticated technical equipment, used especially in radiology and pathology, than is currently available to the Department. It may also be desirable to establish an independent division to deal with activities relating to the control of pharmaceutical products and services. 507. It is also necessary to consider those scientific services both in the laboratory and the field, which are currently provided by the National Health Institute, the National Radiation Laboratory, and the National Audiology Centre. Current departmental policy aims to establish a New Zealand Health Institute, which should unite and rationalise these services in laboratories concerned, respectively with biology, physics, and chemistry; and perhaps extend the range of work now undertaken to include applied physiology and a broader field of epidemiology. While the work entailed in the maintenance of national standards would place the New Zealand Health Institute within the Bureau of Technical Services, there are 160 arguments for its inclusion within the Operational Services Bureau because of the nature of the practical. work undertaken. The resolution of this issue requires. further detailed discussion. 508. In situations where an extended advisory service is provided for R.H.A.s, as might be the case in relation to atmospheric pollution, food hygiene and management services, it may be necessary to consider the outposting (as opposed to secondment) of staff to decentralised units; however, this will depend upon the volume of work undertaken and the availability of manpower. 509. A separate field of work, really lying outside of the New Zealand Health Service, which is coming to assume increasing importance, is international health, both through the active involvement of New Zealand in the affairs of the World Health Organisa- tion, and in the provision of technical advice, and practical assistance to the developing countries of South-east Asia and the Pacific. It is intended to establish a division to deal with international health, under the control of the head of the N.Z.H.A. 510. A suggested arrangement of the N.Z.H.A.s bureaux, with organisational divisions, is shown in figure VI. This is very much a traditional and hierarchical representation of the organisation structure which, while serving to indicate areas of activity, levels of decision-making, and the main streams of responsibility and authority, is an inadequate mode of depicting the dynamics of organisational activity. The two-dimensional nature of the diagram con- veys an impression that the bureaux are self-contained and watertight compartments; but only the most decadent and ineffective bureaucracies endeavour to function in this way. Some attempt has been made to demonstrate continuing lines of contact between various administrative or technical divisions and sector teams, which will be the "front line" of the N.Z.H.A. in relation to regional service management and development. It may be more appropriate to seek the type of bureau interaction illustrated in figure VII, where the resources of all bureaux are brought to bear on particular issues or problems, to an extent determined by the nature of the problems rather than the nature of N.Z.H.A. organisation. The Role of the N.Z.H.A. 511. In the reorganised service the heads of bureaux and the head of the N.Z.H.A. will constitute the actual New Zealand Health Authority, whose responsibility will be to the Minister. It will be observed in figure VI that the suggested designation of the head of the N.Z.H.A. is "Director-General", a title which has been used since 1920, for the permanent head of the Department of Health. The reasons for the original choice of this title are obscure but, in 161 Figure VI: Suggested Organisation Structure for New Zealand Health Authority NOTE: This is illustrative only at this stage. The final structure will be determined during the consultative process. BUREAUX POSSIBLE TEAMS DIVISIONS

p[INTERNATIONAL HEALTH

LEGAL

SECRETARIAL 1 j ADMINISTRATIVE 1 SERVICES

MANPOWER - - -I

FINANCE ---I

PRIMARY CARE SECTOR 1 DIRECTOR-GENERAL J OPERATIONAL SPECIALIST SECTOR 2 OF HEALTH I SERVICES SERVICES SECTOR 3 COMMUNITY HEALTH

CAPITAL L_J WORKS J I MANAGEMENT L j SERVICES H [ TECHNICAL SUPPLY AND L__J SERVICES • EQUIPMENT

PHARMACEUTICALS

NEW ZEALAND1 1- HEALTH INSTITUTE V

162 Figure VII: Schematic Representatio-n of Interaction Between Bureaux of the N.Z.H.A. ADMINISTRATIVE SERVICES BUREAU

OPERATIONAl SERVICES WA &"q—qb" BUREAU

TECHNICAL SERVICES BUREAU

163

6 practice, the designation has been something of a misnomer. Large sections of the health services have been conducted by supposedly autonomous agencies or independent private practitioners over whose activities the Director-General has had little actual authority. This does not hold true of public health services, control over which has at all times been general and direct.

512. Whatever may have been the intention of 1920, the Director- General of Health has had little authority vested in him to direct the course of the health service. 1f, for the future, the old principle of control coinciding with the source of finance is to be restored and given its rightful emphasis, the authority of the N.Z.H.A. must be clearly established from the outset. Equally as important, the designation ultimately chosen for the head of the N.Z.H.A. must also reflect more accurately his role, and that of the N.Z.H.A., in the total health service. It may well be that the title Director- General of the New Zealand Health Service would convey the correct impression when studied anew • and apart from its historical implications. 513. Members of the N.Z.H.A. will be well informed of trends and opinions in the health service from information derived from the contacts of sector teams, meetings of the Council of Chairmen, and from continuing consultation in matters of service management and administration. It is intended that regular meetings will be held, perhaps on a quarterly basis, of Regional Officer Liaison Groups. This will enable Regional Community Physicians, Regional Administration Officers, Regional Nursing Officers, and so on to meet their counterparts in the N.Z.H.A. to discuss current problems and future developments which are of mutual interest. These meetings will serve as valuable channels of communication, and should lead to a greater sense of unity throughout the health services than at present prevails. The right of unimpeded access in certain circumstances by Regional Community Physicians to the head of the N.Z.H.A. has been mentioned in para. 380. 514. The functions and authority of the N.Z.H.A. over R.H.A.s will confirm the role of the former in directing the course of the New Zealand Health Service. Its projected role in planning the health service, by establishing priorities for health care within the limits of available resources, has been referred to in paras. 297-299. Once national and regional health plans have been issued, R.H.A.s will have full authority to implement them. In this task, they will be supervised by the N.Z.H.A., which will issue national policy guidelines on a wide range of matters relative to service development and management. 164 515. While R.H.A.s will have a good deal of authority, it will be necessary for the N.Z.HA. to ensure that national guidelines are implemented. Appropriate safeguards, in the form of inspection and audit, and the power to issue instructions to R.H.A.s, or to revoke delegated authority, will need to be embodied in revised legislation. Reorganisation should enable a reduction in the current "paper war" between Hospital Boards and the Departments head office, by which approval must be obtained for a wide range of matters, many of them comparatively trifling. Many of the powers at present exercised by the Minister of Health will pass to the N.Z.H.A. in the reorganised service, and that agency will be free to delegate them to R.H.A.s subject to the safeguards indicated. 516. For 90 years, annual reports on various aspects of the health service have been publicised in Parliament and in the news media. The use of reports as a means of central control is therefore an old one. Originally devised as a method of ensuring that deficiencies in the service were drawn to public attention, for many years, unfortunately, the annual report of the Department of Health has been a catalogue of departmental activities. It is envisaged that, in future, the annual report on the New Zealand Health Service will be in the nature of an analytical appraisal of the state of the service, which will also record achievements towards specified objectives of national health plans, along with reasons for the failure to attain them. The annual report will provide another means of measuring performance throughout the health service. R.H.A.s will be required to report to the N.Z.H.A. on the management and development of their services. 517. Further means of control will be necessary in the areas of finance and staffing. These will be mentioned in the chapters dealing respectively with those subjects. Health Services Advisory Council 518. It is essential that the N.Z.H.A. be kept fully informed of developments and difficulties in the technical and operational areas of the health services, and that national policies for health service development be directly related to the practicalities of the provision of health services. While this can be achieved, in some measure, by continuing contact between officers of the N.Z.H.A. and the officers and staff of the R.H.A.s, it is also necessary to establish and maintain formal consultative and advisory mechanisms. 519. From the historical background set out in this document, it is clear that the Board of Health and the Hospitals Advisory Council will be unsuitable for this purpose, in that their purview and methods of operation are not designed to meet the needs of a 165

A comprehensive and integrated health service. It is, therefore, intended to abolish both these bodies, and to establish new machinery for advisory and consultative purposes. 520. The forward planning of health services, and the formulation of national policies on which these plans will be based, requires forecasting of technical developments and assessment of the priorities which must be accorded to these developments. A Health Services Advisory Council (H.S.A.C.) will be established to advise the head of the N.Z.H.A. in these matters; it will have no executive role. The Council will operate through a series of expert standing committees, comprising representatives of all appropriate health professions. Each committee will be concerned with technical and operational developments in a particular area of the health services, such as primary health care, geriatric services, mental health services, laboratory services, occupational health and so on. 521. The work of these committees will be co-ordinated by the Health Services Advisory Council which will also reconcile conflicting priorities. Recommendations will then be made relating to future policies and objectives for national planning purposes. The composition of the H.S.A.C. will be of considerable importance to the shape of future health planning programmes. The Council will need members with a good understanding of the health problems ofthe community and an ability to recommend programmes which will improve the health of the nation rather than the advancement of particular specialities. A method of appointing persons to the Council other than nomination by selected groups is therefore required. The Government proposes to seek a wide range of opinions on this matter before it reaches a decision on the composition of the H.S.A.C. Secretariat for the Registration of Health Professions 522. Statutory registration of members of health professions offers an assurance to the community that persons practising a certain skill are professionally competent and qualified to do so. It also enables professional groups to maintain high standards, ethics, and traditions. Professional registration bodies therefore have responsibilities to the members of their professions and to the public at large. 523. The growth of health professions in New Zealand has left a trail of independent and dependent registration authorities in its, wake. While the older established health professions have enjoyed statutory registration for many years, some newer professions have not .yet attained this status. Current policy envisages a situation where professional registration agencies will be independent of

166 financial and administrative support at present provided, in a number of cases, by the Department of Health. With the exception of larger occupational groups, it is doubtful whether individual registration authorities are capable, in terms of the numbers of professional staff involved, of sustaining an independent status. 524. The work of all registration authorities has much in common; all are concerned with the establishment and supervision of minimum educational standards, training programmes, standards of professional practice and ethics, and with the maintenance of statutory registers of members of the profession. 525. The Government believes that it is now opportune to attempt to unify the work of registration authorities for all health professions, including specialties within professions, in a positive manner. To this end an independent Secretariat for the Registration of Health Professions is proposed to provide a common administration for those registration authorities now in existence. The N.Z.H.A. will retain the existing interest and control of the Department of Health over the establishment of new registration authorities for particular professional groups for whom statutory registration does not yet exist. This is necessary because of the detailed negotiations and legislative amendments which have to be undertaken. As the new authorities are established the proposed Secretariat will assume responsibility for them. Negotiations with interested parties will take place with the objective of establishing and co-ordinating a Secretariat, which would, however, leave the activities of individual health professions to be handled in much the same way as at present, by professional boards, which would become constituent members of the Secretariat. The Secretariat would be the channel through which the N.Z.H.A. would communicate with the constituent boards on professional matters. A Mean Between Extremes 526. In attempting to define the pattern of working relationships between the central and regional agencies to be established for the administration and development of the health service, it is important to remember that, while the service will be a national one, the New Zealand Health Service should not be administered in such a way as would allow the undesirable effects of monotonous and monolithic bureaucratic uniformity to appear. It is equally as important to ensure that R.H.A.s do not disregard the principle that control must follow the lines of finance, to the extent that they considered themselves to be autonomous bodies. 527. The failure to overhaul thoroughly the administration of health services at various crucial stages in its development has led 167

A to the point where the relationships of central and regional agencies must be defined anew. The decentralisation of health service activities which has taken place in New Zealand in recent years, coupled with the altered financial arrangements for Hospital Boards, may have had the unfortunate effect of creating a sense of insecurity throughout the health services administration because agencies may not be certain of their precise responsibilities for service provision and development. It would be wrong to graft a new health service on to existing agencies. 528. Because of the principles upon which . this reorganisation is based, the new health service requires a new administration in which the relationships and responsibilities of the agencies concerned are clearly laid, down and understood. Quite obviously it is not possible to define these matters absolutely in a document of this nature. Thus the broad areas of responsibility and, the shape of relationships have been suggested. In the transitional period before reorganisation these concepts and principles will, be translated into a series of practical arrangements so that, on the due date, the N.Z.H.A. and R.H.A.s will be fully aware of their respective functions, responsibilities, and powers for the co-ordinated development of a fully integrated New Zealand Health Service.

REFERENCE A.J.H.R., 1960, 11-31, 0.6.

168 XIV. STAFFING THE HEALTH SERVICE

529. Staff are the most important single resource in the health I service so the goodwill of all present and prospective employees should be attained and maintained. 530. The Government, therefore, gives an undertaking that representatives of employee organisations will be fully consulted on implementing the proposals for staffing the service. A further undertaking is given that no employee will be financially disadvantaged on translating to the new service.

A Career Health Service 531. Integration within the New Zealand Health Service will be more easily attained by staff who recognise in it a common career service, extending through all levels and spheres of activity, with the potential for providing a first-class health service of which they, and the community they serve, can be proud. The sought-after improvement in the standards of delivery of health care in all its aspects could well be diminished if staff in the service do not themselves break down the barriers and divisions which separate them from their colleagues and become a fully integrated career service. 532. It would not be sufficient to establish a health service for Regional Health Authorities which would leave the central agency separate and appearing to stand aloof from the rest of the service. The full concept of a career health service will only be attained if the New Zealand Health Authority becomes an integral part of the total health service rather than a separate department of State within the Public Service. 533. The establishment of a unified health career service will promote interchangeability and mobility of staff throughout the New Zealand Health Service, at both regional and national levels. New • ideas will thus be stimulated for the benefit of the service as a whole. In addition, the move will facilitate promotion on merit throughout the service. A single career service will also attract into it people who can see, in a service of nearly 50,000 staff, improved career opportunities. 534. Some elements of a career health service already exist for medical, nursing, and other health related professions, but more needs to be done to attain this goal. The proposals contained in this 169 paper go much further than present patterns of career service development, as they will extend throughout the health service and will not be confined to the hospital service. 535. Staff working in the health services are now employed under a multitude of differing awards, agreements, and determinations. These are negotiated by a large number of employee organisations. In many respects these reflect the fragmented nature of the health services at present. Some indication of the scope of this problem can be gauged from information contained in appendix XI. Remuneration and Conditions of Employment 536. The Government intends to incorporate in new health legislation provisions which will enable the establishment of a career health service. Employees of this service will be remunerated from funds appropriated by Parliament. Thus it is essential that there should emerge effective machinery for central negotiation of salaries and conditions of employment which must be fair to both the employee and the taxpayer. As far as other State services are concerned, for example the Education Service, the Post Office, the Public Service and the Railways Service, and indeed the majority of Hospital Board employees, co-ordinatidn is achieved by the provisions of the State Services Remuneration and Conditions of Employment Act 1969. The New Zealand Health Service will be, as much as these other services, an instrument of the Crown. The appropriate machinery for fixing remuneration and conditions of employment within the health service should, therefore, be co- ordinated in the same manner. . 537. Machinery to allow for full conciliation and arbitration between the "employing authority" and employee organisations will be set up in accordance with established principles. 538. The head of the New Zealand Health Authority will become the "employing authority" for the entire health service (with the exception of those coming within the purview of the Higher Salaries Commission) and will issue instruments fixing scales of remuneration and conditions of service for employees of the health service. The aim shall be to. set for each occupational group a Scale which will enable the service to recruit and retain an efficient staff and take account of the special responsibilities of the occupational class. . 539. Because of the great number of separate unions and employee associations in the health field (excluding those which are solely concerned with professional matters), the Government hopes -that some means may be found by which a national organisation may be formed. . 170 540.. The fixing of salaries and conditions of employment is only one part, although an important part, of the total personnel requirements of the reorganised health service. The establishment of a career health service calls for the resolution of many other matters affecting staff. It should be the aim of consultative groups to settle these in accordance with the principles underlying the reorganisation. Appointments and Promotion 541. Although the head of the New Zealand Health Authority will be the ultimate employing authority for the national health service, it is intended that the power to appoint officers of Regional Health Authorities will be vested in these bodies. The Regional Health Authorities themselves will be required to make appointments to designated senior positions. Officers of the Regional Health Authorities will have power to make appointments below that level subject to the requirement that they obtain the advice of professional advisory committees in appropriate cases. 542. The health service will issue at regular intervals its own official circular notifying vacancies and appointments throughout the service. Staff will have adequate opportunity to apply for vacancies notified in this circular. To ensure equitable treatment of staff, appointments to positions of responsibility will be required to be made solely on merit. 543. The determination of levels of responsibility, skill, and merit within a unified career service for occupational groups will materially affect career prospects, and therefore the recruitment and retention of staff. Grading patterns are necessary to ensure a uniform approach and to provide proper recognition of the worth of each position and opportunitites for individual progression. The Government proposes that career structures for occupational groups and the relativities between groups will be determined centrally. 544. The N.Z.H.A. will issue guidelines on levels of staffing and grading which will be revised from time to time to meet changing . circumstances. The N.Z.H.A. will also monitor the performance of R.H.A.s in implementing the guidelines. 545. It is proposed that appointments to the four principal positions in the N.Z.H.A. will be made by the Minister of Health on the advice of an independent expert panel. At first sight this may appear to infringe the principle of administrative independence from political influence, but there is precedent for this in other State agencies such as the Railways and Post Office. The composition of the panel and the criteria for appointment at this 171 level will be considered in the course of preparations for the reorganisation of the health service; Parallel machinery to that applying in the R.H.A:s will be provided for making appointments to other positions in the N.Z.H.A.

Appeals 546. Within certain limits to be specified, the right of appeal by staff aggrieved in circumstances such as non-appointment to an advertised position of responsibility for which they have applied, or against dismissal, have become fundamental conditions of service of staff in the Public Service. In recent times, some rights of appeal have been established for staff: of the hospital service, again in certain circumstances. The system is of value in • any large organisation both to the employer and the employee— the greatest value being that it exists. It makes for careful and considered decisions by the employer and protects the employee •against arbitrary judgments, personal prejudices, and influence. 547. The Government therefore proposes to introduce an appeal system into the reorganised health service, based • on the accepted criteria that the appeal board should be independent; that the chairman should be appointed by the Minister of Health and, that the chairman be assisted by assessors.

Education and Training 548. In the establishment of a New Zealand Health Service, the oppOrtunity for staff to realise their full personal career potential through continuing education and, training thust be provided. A point made in connection with continuing education for general practitioners is relevant not only to doctors, but also to all professions in the health service "How can the general practitioner, be persuaded and find the time and the means to attend courses to refresh himself on changing and advancing therapeutic practice? How can his undergraduate training be supplemented and refethd so that :he cax1:cortinue to preserve a critical and appraising mind in rition to treatment?. This relates so c1arly to the core of his work that schemes need to be devised whereby he has an accepted ,commitnient to attend uch course at some flexibly regular intervals." 549 Continuing education is of vital importance , for the. health •service as much as its staff; and should • therefore be related to eth needs bfthe service. R.H.A.s will : be responsible for providing facilities andsersevicevices for this urpOse equally in terms of basic education as Ontinuing educatiOn. They will be expected to p±ovide iiicCntives for staff to participate in in-seivice training pogrammes in accordance with nationalguidelines.

172 550. It is intended to establish a committee of the Health Services Advisory Council which will be responsible for advising the N.Z.H.A. on matters concerning needs and programmes for continuing education in the health service. This body will consist of representatives bf professional associations and vocational colleges, universities and technical institutes, as well as appropriate personnel from the statutory and voluntary health agencies.

Manpower. Pbnning 551. Manpower is one of three basic, health and medical resources, which are manpower, facilities (including equipment and supplies), and biomedical knowledge.. In simple terms, health manpower planning is the process of -trying to ensure that the health service has enough workers of the right type to meet effectively, but not exceed, its future needs. Such planning involves specifying the numbers and categories of staff required to deliver health care through various agencies to different patient or population groups. 552 Manpower planning also involves estimating the knowledge and skills necessary for the satisfactory performance of staff and planning for these to become available according to a predetermined schedule. Bearing in mind continually advancing knowledge and technical innovation, a close collaboration with educational agencies is therefore required. . . 553. Manpower planning must be a continuing process and not sporadic. With national and regional implications, health manpower planning is only one component of total manpower planning and liaison with the Department of Labours Manpower Planning Unit, which must be maintained so that the needs of the health service can be related to the total labour needs of the country. 554. Prime responsibility for health manpower planning must, therefore, rest with the N.ZH.A.; but even so,. R.H.A.s should regard manpower planning as part of the normal process of management with the objective of making the best use of available manpower resources. But no matter at what level undertaken, manpower strategy must be regarded as part of a total management activity directly linked to planning and to the budget process. Personnel Responsibility 555. Administration of personnel matters within the national health service will be shared between the N.Z.H.A. and R.H.A.s. As a very large proportion of expenditure on the health services relates to staffing there will be need in the 173 reorganised service. for some measure of central control of remuneration and conditions of employment, staff establishments, manpower planning, and liaison with education and labour agencies. R.H.A.s will have wide powers of appointment, discipline, promotions, and gradings subject to national guidelines which may be set from time to time. 556. It is not possible at this stage to state with precision many of the details which will need to be finalised in order to create a unified career service. An attempt has been made to give present and prospective employees of the service some idea of the type of service that the Government wishes to provide for them. In the course of consultations before the reorganisation, many matters will arise. Questions about retirement, superannuation, membership of the Public Service Investment Society, Public Service Welfare Society, or the Hospital Welfare Society are immediately foreseen. These and other issues will be referred for negotiation with the bodies concerned. The Government cannot anticipate the outcome of these talks, but reaffirms its intention that terms and conditions of employment for transferred staff will be not less favourable than those they enjoyed under their former employers. 557. Employment within the career health service will involve participation in an exciting development for the improvement of delivery of health care in New Zealand. The Government believes that with the assurances already given about their conditions of employment, staff will face the future not with foreboding, but with an appreciation that reorganisation will enable them to provide a better service to the community.

REFERENCE Board of Health Committee on Drug Abuse and Drug Dependency, Drug Dependency and Drug Abuse in New Zealand, Wellington, 1973, p. 66.

174 a more comprehensive basis for allocation than is currently used for the hospital service. It is a. ;o intended to introduce further modern management techniques into the financial allocation and expenditure control systems. 569. Health care is not subject to the same forces of supply and demand that operate in the general market place. This means that incentives to optimal utilisation of resources have to be built into any funding system. Efficiency in resource utilisation can not be taken for granted, although care must be taken in introducing incentives. Any method must avoid penalising the efficient or, even worse, encouraging R.H.A.s to periodic inefficiency so as to Igain for themselves future incentives. Nor should any method of incentives penalise the inefficient to the extent that it so deprives them of resources that they cannot hope to improve their position.

177 F__

a more comprehensive basis for allocation than is currently used for the hospital service. It is also intended to introduce further modern management techniques into the financial allocation and expenditure control systems. 569. Health care is not subject to the same forces of supply and demand that operate in the general market place. This means that incentives to optimal utilisation of resources have to be built into any funding system. Efficiency in resource utilisation can not be taken for granted, although care must be taken in introducing incentives. Any method must avoid penalising the efficient or, even worse, encouraging R.H.A.s to periodic inefficiency so as to Igain for themselves future incentives. Nor should any method of incentives penalise the inefficient to the extent that it so deprives them of resources that they cannot hope to improve their position.

Plans, Programmes, and Budgets 570. Public demand for health services is, for practical purposes, limitless, but clearly the money and other resources which can be allocated to meet this demand are finite. Random and unrestrained development of health services is therefore a luxury which can not be afforded, and R.H.A.s will be required to plan for the provision and expansion of health services in a rational and co-ordinated manner. The planning, programming, and budgeting system which has been applied to the operations of the State services in recent years has proved its worth as an aid to the allocation of scarce resources and to the fulfilment of stated objectives. 571. The resources management system is not devised to trim health service funds; rather it is designed to relate finance to the wise management and effective planning and the measurement of results. The adoption of the system has major implications for traditional methods of funding the health service, because the annual basis of allocation will be made within the framework of a 5- or 10-year programme. It will also have to take into account current and prospective financial and economic conditions. 572. One of the first tasks of R.H.A.s will be to prepare objectives in health service planning for discussion with and approval by the N.Z.H.A. These should take account of service deficiencies revealed by inventories of regional health services which will be prepared in the course of preparations for reorganisation. R.H.A.s will be guided in this responsibility by the N.Z.H.A. after advice has been received from the Government of the sums likely to be available for health services, and the priorities of health, care have been established. 178 573. Regional health plans will need to state clearly the programmes and activities required to attain the specified and realistic objectives of planning. Due allowance must therefore be made for priorities and for forecasting manpower, capital, and operational requirements, along with their estimated cost, for each of the functional programmes. Development plans can then be revised and scrutinised as necessary in the light of annual allocations and the availability of resources. 574. Five- and 10-year regional health plans will be in the form of a rolling plan, capable of being updated each year. The characteristics of these plans would include the planning objectives for each programme, priorities, an analysis of the resources required, and a time scale for achieving progress towards the attainment of targets. The various stages of the plans would be clearly identified and would show the input of resources required at each stage. R.H.A.s would be accountable for a predetermined quantity and quality of service. 575. R.H.A.s will be funded according to functional programmes, for example, primary health care, environmental health, domiciliary care, specialist care, diagnostic services and so forth, each of which may be further divided into a number of subsidiary programmes. Inherent in the concept of the resources management system is the necessity for positive management of programmes and accountability for the attainment of objectives. This fact in itself may determine the nature of programmes to be established. Thus, it is easy to envisage the diagnostic services programme being divided into radiology and pathology, each with a service director. Other diagnostic services, such as electrocardiography and electro- encephalography, would be less easy to organise in this way, and might best be incorporated in the specialist services with which they are mainly concerned. Again, it would be difficult to envisage a rehabilitation programme because of the several paramedical disciplines and clinical specialties involved, and the present lack of any obvious director of rehabilitation. Programme details will be determined by a consultative group of experts in order to be operative from the time of reorganisation. 576. Among the principal bases for determining the pattern of programmes for which finance would be allocated would be the population served by the R.H.A., taking into account the age structure of the population and socioeconomic factors. Thus, for example, a geriatric programme in a region which has a higher proportion of people over 65 years old than other regions would receive due weighting for this. Similarly, regions which experience problems with regard to a higher Maori and Polynesian infant mortality rate could also receive due weighting. 179 577. If the N.Z.H.A. is to consider the use of population and sdcio- economic factors in the funding of programmes there will be an urgent need to develop a, comprehensive health service information system which would indicate, among other things, the patterns of service utilisation. Statistics of the sort required . are generally un- available at present, and the N.Z.H.A. will need statutory powers for their collection. A great deal still needs to be done to develop adequate information systems, especially in the application of computer services as they apply to financial and budgetary mechanisms. 578. The existence of well documented and approved forward plans specifying R.H.A. objectives in detail, coupled with the programme basis of funding, will provide a strong motivation for R.H.A.s to attain their objectives. The management information systems required throughout the health service for co-ordination, supervision, and national planning will enable R.H.A.s to gauge their comparative performance in various programmes and for deficiencies to be rectified. It should be stressed that while information systems are not required exclusively for the support of the resources management system; without them, it can not function effectively. 579. The system of planning, programming, and budgeting has its own in-built system of expenditure control. Once finance has been identified with the attainment of measurable and specified objectives, funds may not be transferred from one programme to •another, except where the required quantity and quality Of service provided in one" programme can be achieved at a cost below the amount allocated. This will prevent ihe.disparate and unco- ordinated development of programmes which catch the public eye. A further means of responsibility will be ensued because a person will be identified and accountable for the attainment of programme objectives at each stage. They must be guided, in turn, by accurate and up-to-date information which clearly records progress rates 580 The system outlined has great advantages over existing and traditional methods of funding the health service, and has the following characteristics:, 580.i. P,rioritiesin service management: and development will be determined "on the: basis, of overall national policy. 580.2. Quantified objectives.will be defined, .in keeping with ,policies and priorities. 580.3. . Programmes of action in particular areas will be constructed, to permit achievement of objectives. . • 580.4. .. Finance will be allocated to. the. programmes, taking account of existing commitments and the, growth of activity necessary to achieve objethies. 1.80 580-.1 Continuing critical review of progress will be undertaken, in relation to, costs incurred and results achieved. 58Q.6. On an aitnual basis, objectives can be redefined and fur- •ther finance allocated according to progress made; at the same time, failure to achieve agreed objectives will be accounted for. - Financial Responsibility .• 581,. As with all funds appropriated by Parliament, the N.Z.H.A. and R.H.A.s will be accountable to Parliament through the Minister of Health for the, proper and prudent expenditure of funds.. The Government has been concerned about the public controversies surrounding the alleged insufficiencies of allocations made to llôspital Boards. For this reason, emphasis has been placed On the need to develop further modern concepts of planning, programming, and budgeting. When these concepts are properly Applied there should ,be ,no valid reason for R.H.A.s to overexpend their allocations. The corollary to this is that R.H.A.s will be subject to the minimum of controls regarding expenditure within approved programmes. 582 Parliamentary supervision of expenditure follows its consideration of the Estimates, which contain detailed items on which appropriated funds may be expended. The Government of the day has the responsibility for, determining the levels of ,total Govern- ment expenditure and the details of individual departmental votes. Pàrliáment ässeits its control by its debates oil theEstimates and Supplementary Estimates, and through the :public Expenditure Comm, ittee and othei select committees of the Hóuseof Represen- tatives. The Controller And Auditor-Géneràl has the duty of auditing the financial transáctioiis of the Goveinment, local authorities, and certain statutory corporations 583 Expenditure should follow appropriate authorisation For certain categories of expenditure, the approval of the Cabinet is required, although this function can be delegated to Cabinet Committees, such as the Cabinet WOrks Committee, to Ministers or to departments. In this connection, the Hospital Works . Committee should be mentioned. Its functions and method of operation have been discussed in para. 173 Consisting of representatives of the Depàrtmént of Health, the Treasury, and he Ministry of Works and Development, the Hospital Works Committee considers the development of capital works in the hospital service and secures the necessary authority to proceed. It is desired to retain this body in the reorganised health service in a form suited to deal with the capital development required throughout the entire health service. l81 584. The control of public money is further achieved through the activities of the Treasury. The N.Z.H.A. and R.H.A.s will be subject to the Public Revenues Act 1953, the Treasury Regulations and Government Stores Board Regulations and Instructions. 585. The long-term expenditure plans of the Government are subject to scrutiny by a Committee of Officials on Public Expenditure (C.O.P.E.) which consists of the permanent heads of 11 major spending[ departments, together with two additional members drawn each year from different departments. The Director-General o Health is one of the permanent members. Because of the implications of expenditure on health services for overall Government economic and financial objectives, the head of the N.Z.H.A. will be a member of C.O.P.E. 586. Existing financial information requirements relating. to the Department and overall Government expenditure are at present met through a System of Integrated Government Manage- ment Accounting (S.I.G.M.A.). To continue the co-ordinated approach to health service management and development which has been adopted throughout this paper, the Government intends that the New Zealand Health Service accounting procedures will conform with those followed in S.LG.M.A., so that all financial transactions throughout the service are recorded under standard groups and recorded under common programmes and activities. 587. Health service finance accounts for a significant proportion of Government expenditure. With the proposals contained in this paper, the State will bear an even greater share of the financial burden of maintaining and developing health services for the community. It is most important, therefore, to ensure that these funds are used to best advantage. The Government considers that the suggested methods of finance, through planning, programming, and budgeting health service expenditure, closely linked with adequate information and accounting systems, will provide a proper basis for effective management and financial responsibility through.- out the New Zealand Health Service.

REFERENCE For a discussion of possible health service expenditure, see J. T. Ward, "The Economics of Health Services" in R. J. Latimer, ed., Health Administration in New Zealand, Wellington, 1969, p. 57 if.

182 XVI. TRANSITIONAL ARRANGEMENTS 588. The Government is satisfied that the general thrust of ) its proposals for the reorganisation of the health service is soundly based and appropriate to New Zealands future health needs. It is therefore determined to press ahead with the task of revitalising our health services and to set a firm date for the reorganisation to come into effect. This date will be 1 April 1978. ,, The achievement of this target date will, in no small measure, depend kJ, 4 upon the co-operation and initiative of people in the health services to resolve the many difficulties inherent in any new approach towards health services available to the people of this country. 589. Translation of the Governments proposals from the broad outline set out in this paper into administrative reality will require much detailed planning, negotiation, and agreement with those directly concerned with the delivery of health care The processes through which these proposals must pass and the detailed timetable set by the Government are discussed below. Figure VIII graphically illustrates the enormous amount of work to be carried out before the target date and should, imbue those associated with the changeover of administration with a necessary sense of urgency. 590.. While the target date of 1 April 1978 may appear to be i rather distant at first glance, it is, in view of administrative and legislative considerations which need to be taken into account, the earliest which can be achieved if we are to rebuild the health service on firm foundations. A timetable for the achievement of the suggested target can be broken down into phases which, while identifiable as distinct aspects, will overlap and intermesh. . Response to the White Paper 591. It would be futile to reconstruct the health services unless the end result improves the services which, contribute to the maintenance of good health and the well-being of the community, and leads to a better delivery of health care to New Zealanders. It is to everyones advantage that ample provision should be made for all individuals and groups with an interest in improving the countrys health service to put forward considered and informed opinion on these proposals. The Government expects that proposals 183 FIGURE VIII: FLOW CHART: PROPOSED HEALTH SERVICES RE-ORGANISATION COMMENCEMENT ESTABLISHMENT PUBLICATION OF INFORMATION OF DEPARTMENTAL OF PROGRAMME DIRECTORATE WHITE PAPER & ISSUE OF STAFF BULLETINS RESPONSE FROM RESPONSE FROM RESPONSE FROM RESPONSE FROM RESPONSE EXISTING HEALTH EMPLOYEE OTHER HEALTH MEDICAL FROM PUBLIC AGENCIES ORGANISATIONS PROFESSIONS PROFESSION -STATUTORY -VOLUNTARY -AD, HOC RECRUITMENT! REDEPLOYMENT - FORMATION BY DIRECTOR- ....A MINISTER OF STAFF• DIRECTORATE OF GENERAL OF OF HEALTH CONSULTATIVE HEALTH GROUPS -

CONSULTATIVE GROUPS

FINANCE REGIONAL TERRITORIAL VOLUNTARY OTHER HEALTH MEDICAL LEGAL AND LIAISON LOCAL AGENCIES SERVICE PROFESSION ADMINISTRATIVE AUTHORITIES STAFFS

+ + CONSIDERATION DISCUSSION DISCUSSION NEGOTIATION DISCUSSIONS ON OF EXISTING OF SERVICE OF SERVICE OF CONDITIONS CONDITIONS FOR REGIONAL ARRANGEMENTS ARRANGEMENTS OF EMPLOYMENT SERVICE RESOURCES AND DEVELOPMENT PLANS DEFINITION OF ARRANGEMENTS FOR FINANCING IF NEW AUTHORITIES REGIONAL DEFINITION DEFINITION AGREED AGREED AND TRANSFER - INVENTORIES OF SERVICE OF SERVICE CONDITIONS OF CONDITIONS OF EXISTING AND PLANNING ARRANGEMENTS ARRANGEMENTS EMPLOYMENT FOR SERVICE COMMITMENTS STATEMENTS N ".4. in DRAFTING F OF LEGISLATION

PARLIAMENTARY + PROCESSES

• PROMULGATION OF DETERMINATION OF INTRODUCTION . STATUTORY REGULATIONS REGIONAL BOUNDARIES SECOND READING AND PUBLICATION OF BY LOCAL GOVERNMENT OPERATIONAL MANUALS COMMISSION PRO-FORMA PARLIAMENTARY: SELECT COMMITTEE ELECTION AND APPOINTMENT APPOINTMENT ABLISHMENT N IV SECOND READING OF SHADOW REGIONAL 4- OF N.Z.H.A. 4------OF STAFF HEALTH AUTHORITIES OFFICERS COMMISSION COMMITTEE OF THE HOUSE co THIRD READING REGIONAL ADMINISTRATIVE _ APPOINTMENT ENACTMENT AND FINANCIAL OF REGIONAL ARRANGEMENTS FOR THE OFFICERS TRANSFER OF RESPONSIBILITY FOR SERVICE MANAGEMENT AND DEVELOPMENT APPOINTMENT OF DISTRICT OFFICERS

TRANSFER OF • OTHER STAFF

TRANSFER DATE contained in the White Paper will evoke a positive response from a wide range of individuals and organisations. These proposals should bring forth a wealth of informed suggestion and constructive criticism as well as highlighting transitional problems. Such comments will be welcomed and should be sent to the Minister, of Health for his consideration. Consultative Groups 592. Information and suggestions received in response to the White Paper will be of value to an appropriate consultative group. The task of these consultative groups will be to define future service arrangements in line with the Governments concepts for reorganisation. Consultative groups will consist of the best available people within the health services, senior officials of Government departments, and individuals or groups with a particular expertise in the specialised areas to be studied by particular consultative groups. Seven consultative groups are proposed. 593. Legal and Administrative: This group will be responsible for defining in detail the interrelationships and administrative arrangements among several components of the reorganised health service, and for preparing a preliminary draft of the legislation required. It is proposed to consolidate relevant parts of the Health Act 1956, the Hospitals Act 1957, the Mental Health Act 1969, the Social Security Act 1964, and a number of other Acts into a Health Service Bill. Because of the comprehensive nature of this task, this consultative group will require the advice and guidance of the remaining consultative groups. They can not complete their task until the principles developed have been approved by the Government. 594. Medical Profession: This consultative group will negotiate and propose to the Government arrangements for the delivery of services by the profession within the reorganised health service. Consequences of the proposed unified system of medical administration which will affect this profession will also be an appropriate subject for consideration by this consultative group. 595. Other Health Service Staff: The role of this consultative group will be to devise the most satisfactory way of implementing a personnel policy which would ensure a unified career service and a high standard of public administration. It will also be required to make proposals for national • salary and. wage scales and conditions of employment, and machinery for fixing and reviewing remuneration and conditions of employment. 596. Voluntary Agencies: In the interests of providing a better health service and to ensure that the Governments financial assistance is allocated and used to the best advantage, the Government intends

196 that the activities of voluntary organisations. should be melded in with the national health service for the greater benefit of those requiring care. This consultative group will therefore propose the service arrangements to achieve a better co-ordination of services provided by voluntary health agencies with other activities in the reconstructed health service in line with the principles set out earlier in this paper. 597. Territorial Local Authorities: The definition of arrangements for the transfer of health responsibilities from territorial local authorities to R.H.A.s, and the enunciation of powers and responsibilities of R.H.A.s vis-à-vis territorial local authorities, will need to be studied by this consultative group. 598. Regional Liaison Groups: Within each proposed health region a consultative group will be formed to prepare an inventory of existing and planned health services and facilities in the region, including those provided by general practitioners and voluntary agencies. Gaps in those facilities and services, and notes on services provided on an extraterritorial basis, should be listed. These inventories will serve as the basis for the planning of R.H.A.s and will be available as a reference document of value to both the R.H.A.s and the N.Z.H.A. for the planned development of the service. 599. Finance: This consultative group will consider the basis on which financial resources should be distributed among the R.H.A.s, and appropriate mechanisms for budgeting and expenditure control. It will also formulate proposals for the transfer of accounting procedures and records from existing health service agencies to the N.Z.H.A. and R.H.A.s, and for the introduction of resources management systems throughout the service. 600. The tasks set out above for the various consultative groups are not exclusive. Other questions for consideration will become apparent as discussions proceed. They will be referred to appropriate consultative groups accordingly. 601. Consultative groups may require up to 10 months from their 40 initial meetings in February 1975 to consider the many issues requiring resolution. Conclusions and agreements reached by them will then be sent to the Government for consideration. Many of the decisions made by the Government will need to be included in the Health Service Bill and its associated Statutory Regulations and priority. must be given to these major matters. After completing consideration of the priority issues, the consultative groups will then need to:consider a multiplicity of operational matters in conjunction 187 with other interested groups, the results of which will need to be reproduced in the form of operational manuals, determinations, and other instruments.

Parliamentary Process 602. After the main work of the consultative groups is completed in January 1976, legislative proposals will be prepared by the Department of Health. On completion of the draft, the proposals will be circulated to the major groups and parties consulted for comment before they are transmitted to the Parliamentary Counsel. 603. The proposed Health Service Bill will be introduced towards the end of the parliamentary session of 1976. Subject to the leave of the House of Representatives being obtained, the Bill will then be referred to a select committee for detailed consideration during the recess. This step will provide a further opportunity for consultation and exchange of viewpoints on the legislation which will sanction the reconstruction of the health services. The Government intends to subject its proposals to the widest possible scrutiny both inside and outside Parliament. 604. After consideration and report by the select committee, the Bill will be the subject of further scrutiny and debate in the House of Representatives before enactment as early as possible during the 1977 session.

From Enactment to Implementation 605. Several distinct but interwoven administrative processes need to be set in train to prepare for the transfer of the health services to the new agencies and to implement fully the management arrangements outlined earlier. 606. The Local Government Commission will need to review the provisional boundaries of R.H.A.s. It is expected that much of the country will already have been divided into local government regions by that time. 607. In October 1977 members of R.H.A.s will be elected. The balance of the membership will be appointed by the Government after the October 1977 local authority elections. Four or five months will then elapse during which time members will be able to come to grips with the nature of the new organisation they will duly administer before they are required to take executive responsibility for the service. (It will be appreciated that until 1 April 1978, Hospital Boards and territorial local authorities will retain responsibility for services.) "Shadow" R.H.A.s will need to appoint 188 senior regional and district officers and to consult with them before the date of transfer. Familiarisation courses for both senior officers and members will be conducted during this period. • 608. The Government does not wish to be committed to the precise procedure and mechansim for the recruitment, selection, and appointment of senior staff of the N.Z.H.A. and R.H.A.s, but prefers to await specific proposals from the appropriate consultative groups. Whatever the mechanism ultimately agreed upon, it will not become effective until the N.Z.H.A. and R.H.A.s have been established. It is proposed, therefore, that an interim Staff Com- mission be established, to advertise and consider applications for senior positions in the new service. The Commission will make recommendations to the Minister of Health in respect of the N.Z.H.A., and to the shadow R.H.A.s in respect of their principal officers. The actual appointment of senior regional officers will be made by the R.H.A.s. 609. The great majority of staff will not be affected by the activities of the Staff Commission. They will continue with their usual duties, in their usual places of employment, under the same, or substantially the same, conditions of service and remuneration. On 1 April 1978 they will become employees of R.H.A.s or the N.Z.H.A. within a unified career service, rather than employees of a Hospital Board or the Department of Health which will cease to exist, or another separate employing authority, such as a local authority. 610. As soon as they have been prepared and printed, all regulations, operating manuals, determinations, and other instruments relating to terms and conditions of service or remuneration will be issued, even though they will not become effective until the target date. This will enable all persons directly concerned, both members and employees, to become familiar with their provisions and effects. 611. The Governments proposals for managing regional and district health services are designed to provide a single principal medical administrator for each region and district. The community physician will take charge of the administration of all medical services, whether preventive or treatment. If the objectives of this paper are to be achieved the removal of outdated and artificial distinctions between the various branches of medical services is vital. An in health service will come about only when the responsibility for the full range of these services can be vested in the community physician. 612. There is a paucity of medical administrators with the special training and experience which would fit them to assume

189 adequately the full range of responsibilities envisaged for Regional and District Community Physicians on 1 April 1978. Present medical administrators must be prepared for the functions of proposed D.C.P.s and R.C.P.s in the reorganised service. It is intended that this will be brought about by the establishment of relatively short reorientation programmes. Responsibility for de- vising suitable training programmes will be entrusted to a special working party, whose proposals will need to be formulated so that training programmes can start in 1976. The Government wishes urgency to be given to the establishment of these programmes so that there are sufficient qualified medical administrators available to take appointments as community physicians in regions and districts not later than 1 April 1981. 613. The working party on education should also prepare schemes for the training of potential Regional and District Admini- stration and Nursing Officers. As with medical administrators, there is a need to conduct reorientation courses to prepare these officers for their roles in the reorganised health service. Wherever possible, these should be set up on a multidisciplinary basis. Admin- istration and nursing officers will assume regional and district appointments on 1 April 1978. 614. As a purely interim measure, District Management Groups and Regional Groups of Officers will have initially two medical administrators; the Regional and District Medical Officer will be primarily concerned with specialist services and institutional care, and the Regional and District Health Officer will deal with matters of community health and environmental hygiene. 615. It is emphasised that this arrangement will be of a temporary nature and will be instituted because of the current inadequacy in the numbers of medical administrators with the qualifications and experience to co-ordinate all aspects of medical care. It is intended that all dual appointments will be replaced by a single community physician by 1 April 1981 at the latest. If R.H.A.s are in a position to institute the system proposed in Chapter XII before 1981, they should do so, after consulting the N.Z.H.A. 616. During the 3 years after reorganisation, Regional Groups of Officers will be joined by the Chairmen of R.H.A.s, who will chair their various formal meetings. Their role as a co-ordinator will assist the administration of the R.H.A.s in the period in which the regional administrators become accustomed to their new roles in the early formative years of the service. Thereafter, it is expected that the groups will be able to operate on the basis of consensus management without the assistance of the chairmen. 190 Communications 617. Throughout the whole period from the publication of the White Paper to its implementation, the public will be kept fully informed of developments. In particular, health service staff will be continually apprised of the nature of the changes envisaged and their , effects on them. Widespread publicity among the public generally and the health service staff will help to forestall misunderstandings and misconceptions which, in themselves, could form impediments and hazards to the reorganisation at its birth.

1:91 XVII. CONCLUSION

618. New Zealands system of health services administration , has never been overhauled thoroughly to take account of progress in the delivery of health care or of important changes in financial and administrative interrelationships among the various agencies. Present administrative fragmentation hardly allows for comprehensive health service management and planning which are vital in order to meet challenges to the health of the community. Re- organisation is long overdue. 619. Renovation of existing structures would not meet the need for change; neither would a drastic innovation which snapped links with the past. The progress achieved during the past 134 years must not be demolished, but used as a foundation for future organisation of the health service. The Government has therefore based its proposals for reorganisation upon principles which are anchored deep in the mainstream development of health services in New Zealand. The proposals constitute the next step in the evolution towards a system which promotes the health of New Zealanders rather than treats their illnesses. 620. Reorganisation can be achieved, given the will to bring it about. The Government is sure that the envisaged New Zealand Health Service will commend itself to those working in the health service and the public they serve, because it is to be created from an acceptance of the citizens right to health, made available to him with no economic barrier. The Government confidently presents its proposals to the community, and will welcome constructive comment on the White Paper. The views of interested parties will be considered by the Government, and, where appropriate, will be included in the final scheme, for the New Zealand Health Service should be the product of common endeavour, and something of which the whole community can be proud.

I92 S CS Appendix I SOURCES OF HOSPITAL BOARD INCOME 1882-1957 Table I: Hospital Board Income by Source () 1882-1957 Patients Balance from Local Voluntary Fees and Other Miscell- Year PreviOus Government Authorities Contribu- Social Boards Rents Loans aneous Total Year tions and Security Bequests Payments

1882 35714 387 7,180 3,174 N. 1,440 50,8952C 1883 49,833 2,591 9,270 4,454 N.S. 2,059 68,207° 1884 44,994 2,729 7,209 3,965 N.S. 1,325 60,222 1885° N.S. 1886 31,472 26,0595 7,396 5,3406 N.S. 5,3040 75,5716 1887 23,714 31,020 6,833 6,635 N.S. 9,466 77,668 1888 2,965 34,564 26,344 6,573 7,490 N.S. 2,966 682° 81,584° 1889 7,214 29,544 24,789 6,419 7,712 N.S. 2,879 965 79,522 1890 5,340 27,896 21019 6,532 9,043 N.S. 3,347 746 74,023 1891 3,296 30,659 23,560 8,229 9,318 N.S. 3,132 995 79,189 1892 5,010 29,906 24,658 6,874 10,604 N.S. 3,431 616 81,099 1893 4,088 35,298 25,052 6,981 10,432 N.S. 3,690 4,375 89,916 1894 5,302 36,373 27,758 7,915 10,228 N.S. 4,568 953 93,097 1895 3,679 39,937 29,412 7,975 11,079 N.S. 3,938 1,183 97,203 1896 3,321 41,034 31,010 12,275 12,468 N.S. 3,795 1,028 104,931 1897 8,322 38,687 31,524 11,521 12,728 N.S. 4,053 1,375 108,210 1898 10,897 41,052 33,864 11,991 13,066 N.S. 4,372 1,182 116,424 1899 9,898 44,815 35,006 9,188 16,503 N.S. 4,139 958 120,507 1900 11,128 47,074 36,812 7,330 15,998 N.S. 4,896 2,012 125,250 Patients Balance from Local Voluntary Fees and Other Miscell- Year Previous Government Authorities Contribu- Social Boards Rents Loans aneous Total Year tions and Security Bequests Payments £ £ £ £ Ic Ic IC 1901 8,540 54,387 40,637 11,154 18,083 N.S. 4,877 2,711 140,389 1902 19,433 55,881 44,013 11,539 19,612 N.S. 5,159 3,063 158,7008 1903 19,285 59,099 43,960 14,260 21,185 N.S. 5,566 11,583 174,938 1904 21,115 59,947 50,323 20,052 21,798 N.S. 5,559 10,783 189,577 1905 24,526 67,615 48,984 16,992 24,156 N.S. 5,848 8,915 197,036 1906 31,354 68,726 56,985 15,966 26,578 N.S. 5,668 5,599 210,876 1907 26,322 88,957. 64,957 15,401 30,492 N.S. 5,820 15,096 247,045 1908 19,150 102,024 75,360 17,341 31,612 N.S. 6,482 19,186 271 ,155 190910 34,229 93,975 86,543 20,854 38,178 946 8,132 5,535 288,392 191012 63,900 155,690 131,525 26,908 54,367 2,621 10,059 5,988 451,058 (0 1911 64,378 167,707 149,203 27,071 56,742 2,592 9,300 28,549 505,542 1912 63,917 184,866 166,281 18,414 67,886 3,501 9,992 22,272 537,130 1913 63,114 205,089 175,120 40,318 75,887 5,297 10,358 34,871 610,053 1914 55,268 205,434 189,886 20,021 81,270 4,710 10,397 16,916 583,900 1915 28,251 239,009 208,901 24,235 89,359 5,502 10,294 18,960 624,511 1916 92,932 209,186 199,638 12,639 219,311 5,591 10,465 11,754 761,516 1917 194,727 224,652 214,020 14,980 215,627 6,786 11,176 10,466 892,434 1918 232,084 278,873 264,063 12,620 327,468s 3,373 14,749 22,397 1,155,627 1919 273,252 322,515 297,326 11,604 361,579 16,437 40,737 1,323,450 1920 241,958 369,081 429,599 35,988 420,651 17,120 24,440 1,538,837 1921 321,140 363,550 436,619 17,442 481,762 18,694 22,880 1,662,087 1922 358,221 363,408 428,954 17,816 592,340 19,33614 22,224 1,802,299 1923 482,259 367,562 427,699 20,971 610,545 15,527 21,917 20,310 1,966,790 1924 483,204 463,476 393,797 24,097 686,317 16,018 25,070 24,829 2,116,808 1925 529,864 479,952 432,035 11,989 763,899 28,663 25,215 28,644 2,300,261

-3 1926 150,97515 631,446 562,656 24,888 327,100 38,274 26,496 404,257 11 23,212 2,189,304 1927 184,091 712,323 626,127 32,217 348,392 38,158 27,791 231,898 20,628 2,221,625 1928 164,843 729,696 675,238 35,907 368,984 35,411 27,884 91,698 21,754 2,151,415 1929 228,584 747,445 688,279 31,668 398,357 33,688 27,235 97,526 33,982 2,286,764 1930 102,578 737,799 693,269 28,489 381,293 37,911 27,835 224,794 24,812 2,258,780 1931 101,856 580,321 564,134 15,120 362,164 46,034 27,273 126,509 25,335 1,848,746 1932 64,030 624,267 578,901 20,801 320,923 29,996 26,858 167,460 23,717 1,856,953 1933 45,521 611,920 586,315 13,465 315,129 56,490 24,371 83,693 22,702 1,759,606 1934 52,674 626,236 601,715 25,645 328,863 71,968 25,382 75,922 20,442 1,828,847 1935 78,795 658,312 621,271 16,760 345,241 79,176 26,609 124,099 19,803 1,970,066 1936 62,238 783,940 714,251 31,322 402,339 87,966 26,710 115,283 23,099 2,247,148 1937 36,915 864,072 821,765 52,649 473,881 103,611 32,102 801,579 34,851 3,221,425 1938 109,859 1,002,147 944,070 36,218 498,184 120,068 32,057 825,109 25,702 3,593,414 1939 105,401 1,138,067 1,093,457 10,943 906 96016 90,037 31,523 746,544 20,887 4,143,819 1940 346,968 900,556 966,230 21,732 1,164,055s 76,704 37,768 827,458 20,723 4,362,194 1941 N.S. 1,248,147 1,065,500 9,666 1,530,614 N.S. 31,419 497,213 51,411 4,433,970 1942 N.S. 1,402,479 1,316,694 12,762 1,761,083 N.S. 31,611 323,526 115,698 4,963,853 1943 N.S. 1,148,872 1,251,498 11,248 2,384,274 N. S. 30,391 1,199,626 96,199 6,122,108 1944 N.S. 1,284,477 1,317,339 10,671 2,357,005 N.S. 32,752 993,239 115,061 6,110,544 1945 N.S. 1,618,751 1,537,271 8,913 2,625,296 N.S. 38,987 408,471 158,094 6,395,783 1946 N.S. 2,010,983 1,897,440 20,742 2,585,990 N.S. 41,759 368,981 146,799 7,072,694 1947 N.S 3,016,121 1,347,605 5,022 2,548,546 N.S. 37,696 1,024,387 89,310 8,068,687 1948 N.S. 4,881,832 1,413,962 6,779 2,734,324 N.S. 39,141 697,195 68,010 9,841,243 1949 N.S. 5,181,968 1,503,821 9,051 2,722,816 N. S. 42,518 508,296 71,386 10,039,856 1950 N.S. 6,029,425 1,667,793 4,397 2,822,326 N.S. 46,528 713,045 98,492 11,382,006 1951 N.S. 8,195,054 1,852,880 2,903 2,769,121 N.S. 47,303 911,958 125,975 13,905,194 1952 N.S. 10,137,098 1,748,186 23,503 2,905,209 N.S. 45,396 1,508,301 131,349 16,499,042 1953 N.S. 10,632,603 1,657,825 5,667 3,014,109 N.S. 45,201 3,284,712 276,817 18,916,934 1954 N.S. 10,886,037 1,454,324 7,511 4,294,464 N.S. 68,638 1,988,003 213,998 18,912,975 1955 N.S. 10,952,103 1,080,154 6,032 5,660,386 N.S. 73,235 2,129,789 280,122 20,181,821 Patients Balance from Local Voluntary Fees and Other Miscell- Year Previous Government Authorities Contribu- Social Boards Rents Loans aneous Total Year tions and Security Bequests Payments :6 £ 1956 N.S. 12,972,324 657,660 4,914 5,749,621 N.S. 68,106 3,764,819 245,237 23,462,681 1957 N.S. 15,390,25218 .. 6,907 5,906,034 N.S. 82,694 2,777,420 319,352 24,482;659

.,Votes: 1. Includes Hospital Boards until 1908. 2. Excludes several hospitals which failed to submit returns. The arithmetical error in the original table has been rectified. 3. Excludes figures for Patea Hospital. Arithmetical errors in the original table have been rectified. 4. No figures were given in the 1885 report. 5. Includes contributions from hospital boards to hospital trustees. - 6. Amended figures. 7. Figures are for the financial year 1888-89. Prior to this information was based on returns for the calendar year. 8. Excludes figures for Waikato Hospital which failed to fumisha return. These figures are not amended. 9. Amended total includes Otaki Sanatorium and the Dunedin Medical School Maternity Hospital. In 1908-09 totals included income of St. Helens Hospitals, but these figures have not been reproduced in this table. 10. Amended total to include Otaki Sanatorium, Dunedin Medical School Maternity Hospital, and infectious diseases hospitals under hospital board control. Income of St. Helens Hospitals has not been included. - 11. All patients fees other than those met by the Government or other hospital board governing authorities are included in this column from 1909-40.

V 12. Hospital boards only. V 13. Includes "charitable aid recoveries". V 14. Amended total. The original incorrectly reads ;C19,442. 15. Includes loan money in hand at the start of the year and that received during the year. 16. Includes money from Social Security Fund, i.e.,J5i3,4OO (1938-39) and £951,376 (1939-40), total-1,524,776. It is not possible to determine the precise amount derived from social security payments thereafter. Subsequent figures in this column therefore include receipts from residents in old peoples homes run by hospital boards, and hospital fees outstanding at the introduction of hospital benefits as well as social security payments. See appendix VII for further details. 17. Totals after 1941 do not include balance from previous year. 18. Designated "grants". Sources: Hospital and Charitable Institutions Department reports in A..J.H.R. (1882-1909); Appendices to the Annual Report (Hospitals and Charitable Institutions Statistics), table I (1910-40); and Hospitals and Charitable Institutions in New Zealand Official Tear Book (1941-58).

Table II: Summary of Sources of Hospital Income (percentage), 1882-1957 Total Government Local Voluntary Patients - Income Less Contribu- Authority Contribu-- Fees and Years Balance from tions (3) Contribu- (5) tions and (7) Social (9) Loans (11) Other (13) Previous (2) tions (2) Bequests (2) Security Year (2) (2) Income (2) £ £ .% £ %- £ % £ % £ % £ 1882-84 179,324 130,541 72.8 8,707 4.8 23,659 13.2 11,593 6.5 4,824 2.7

1886-90 372,849 147,190 39.5 129,331 34.7 33,753 9.0 36,220 9.7 26,355 7.1

1891-95 419,129 172,173 41.1 130,440 31.1 37,974 9.1 51,661 12.3 26,881 6.4

1896-1900 531,756 212,662 40.0 168,216 31.7 52,305 9.8 70,763 13.3 27,810 5.2 1901-05 767,741 296,929 38.7 227,917 29.7 73,997 9.6 104,834 13.7 64,064 8.3

1906-08 652,250 259,707 39.8 197,302 30.2 48,708 7.5 88,682 13.6 57,851 8.9

1909-10 641,321 249,665 38.9 218,068 34.0 47,762 7.5 92,545 14.4 33,281 5.2

1911-15 2,586,208 1,002,105 38.7 889,391 34.4 130,059 5.0 371,144 14.4 193,511 7.5

1916-20 4,636,911 1,404,307 30.3 1,404,646 30.3 87,831 1.9 1,544,636 33.3 195,491 4.2 1921-25 7,673,557 2,037,948 26.6 2,119,104 27.6 92,315 1.2 3,134,863 40.8 289,327 3.8

1926-30 10,276,817 3,558,709 34.6 3,245,569 31.6 153,169 1.5 1,824,126 17.8 1,050,173 10.2 445,071 4.3

1931-35 8,921,342 3,101,056 34.8 2,952,336 33.1 91,791 1.0 1,672,320 18.7 577,683 6.5 526,156 5.9

1936-40 16,906,619 4,688,782 27.7 4,539,773 26.9 152,864 0.9 3,445,419 20.4 3,315,973 19.6 763,808 4.5

1941-45 28,026,258 6,702,726, 23.9 6,488,302 23.2 53,260 0.2 10,658,272 38.0 3,422,075 12.2 701,623 2.5

1946-50 46,404,486 21,120,329 45.5 7,830,621 16.9 45,991 0.1 13,414,002 28.9 3,311,904 7.1 681,639 1.5

1951-55 88,415,966 50,802,895 57.4 7 ; 793,369 8.8 45,616 0.1 18,643,289 21.1 9,822,763 11.1 1,308,034 1.5

1956-57 47,945,340 28,362,576 59.2 657,660 1.4 1.1,821 0.02 11,655,655 24.3 6,542,239 13.6 715,389 1.5 Wote: The notes attached to table I also apply to this table. Appendix II

THE DISTRIBUTION OF POWERS, FUNCTIONS AND RESPONSIBILITIES UNDER HOSPITALS LEGISLATION

NOTES 1. The powers, functions, and responsibilities of Hospital Boards are set Out in historical perspective. Four columns represent the periods- (i) 1885-1908; (ii) 1909-1925; (iii) 1926-1956; and (iv) 1959-1974. 2. Figures at the far left of each column refer to the appropriate section of the major Act of the period from which the power is derived, i.e.: (a) The Hospitals and Charitable Institutions Act 1885. (b) The Hospitals and Charitable Institutions Act 1909. (c) The Hospitals and Charitable Institutions Act 1926. (d) The Hospitals Act. 1957.. 3. Subsequent amendments to the principal. Act of the period are prefixed by the legal reference to the amending Act, e.g., 1907, No. 41, s. 3. This reference is in bold type. The short title of amending legislation is indicated below. For conciseness, some of the powers of BOards have been paraphrased. 4. Where a particular provision has been carried forward into subsequent legislation this is shown in the following column or columns by the section of the new Act and an ellipsis alongside. Where the provision in the principal Act has been repealed and incorporated in a subsequent amendment, the appropriate reference is shown in round brackets and indicated by the prefix "cf." before the reference. The effect of the Amendment on the section of the principal Act is shown in square brackets.

AMENDING LEGISLATION REFERRED TO IN THE TABLE

Year No. Short Title (i) Hospitals and Charitable institutions Act 1885 1886 36 Hospitals and Charitable Institutions Act 1885 Amend- ment Act 1886. 1889 20 Requisitions Validation Act 1889. 1900 35 Hospitals and Charitable Aid Boards Act 1900. 1903 82 Public Health Act Amendment Act 1903. 1907 41 Hospitals and Charitable Institutions Act 1907. (ii) Hospitals and Charitable Institutions Act 1909 1913 56 Hospitals and Charitable Institutions Amendment Act 1913. 1915 74 Hospitals and Charitable Institutions Amendment Act 1915. 1920 72 Hospitals and Charitable Institutions Amendment Act 1920 (No. 2). 1923 44 Hospitals and Charitable Institutions Amendment Act 1923. 1924 64 Finance Act 1924. . 1925 .. 45 Hospitals and Charitable Institutions Amendment Act 1925.

198 Year No. Short Title (iii) Hospitals and Charitable Institutions Act 1926 1926 46 Finance Act 1926. 1928 39 Hosoitals and Charitable Institutions Amendment Act 1928. 1932 22 Hospitals and Charitable Institutions Amendment Act 1932. 1932/33 45 Finance Act 1932/33 (No. 2). 1934 31 Finance Act (No. 3)1934. 1936 36 Finance Act (No. 2)1936. 1936 50 Hospitals and Charitable Institutions Amendment Act 1936. 1938 20 Statutes Amendment Act 1938. 1939 38 Finance Act (No. 2)1939. 1940 18 Statutes Amendment Act 1940. 1941 4 Finance Act 1941. 1941 26 Statutes Amendment Act 1941. 1943 19 Social Security Amendment Act 1943. 1946 16 Finance Act 1946. 1946 41 Finance Act (No. 2) 1946. 1947 9 Hospitals and Charitable Institutions Amendment Act 1947. 1948 36 Tuberculosis Act 1948. 1948 58 Hospitals Amendment Act 1948. 1950 57 Hospitals Amendment Act 1950. 1951 49 Hospitals Amendment Act 1951. 1955 103 Finance Act (No. 2)1955.

(iv) Hospitals Act 1957 1961 84 Hospitals Amendment Act 1961. 1962 43 Hospitals Amendment Act 1962. 1964 91 Hospitals Amendment Act 1964. 1966 35 Hospitals Amendment Act 1966. 1967 80 Hospitals Amendment Act 1967. 1968 57 Hospitals Amendment Act 1968. 1970 12 Hospitals Amendment Act 1.70. 1971 49 Hospitals Amendment Act (No. 2)1971. 1972 68 Hospitals Amendment Act 1972. 1973 43 Hospitals Amendment Act 1973.

199 CONTENTS Powers, Functions, and Responsibilities of Hospital Boards, 1885-1974 1. Status. 2. General Functions, Responsibilities, and Powers: Institutions. Joint Services. Charitable Aid. Information. Liability. Directions of the Minister. 3. Conduct of Business: Proceedings. Committees. Sealing Documents. Bylaws. Dissolution. 4. Finance: Estimates. Expenditure. Levies. Loans. Accounts and Audit. Miscellaneous. 5. Land and Property. 6. Contracts. 7. Staff: Appointments. Review and Appeal. Access of Professional Staff Not Members of Hospital Staff.

Powers, Functions, andResponsibilities of the Minister of Health, 1974 1. General Duties. 2. Powers Over the Hospitals Advisory Council, etc. 3. Reorganisation of Hospital Districts. 4. Powers over Hospital Boards. General. Hospital Board Services. Procedure and Administration. Finance: Estimates. Expenditure and Remuneration. Borrowing Powers of Hospital Boards. Accounts and Audit. Miscellaneous. Land and Property. Contracts. Staff: Appointments. Reviews and Appeal. 5. Private Hospitals. 200

S V

Powers, Functions, and Responsibilities of Hospital Boards, 1885-1974 1885 1909 1926 1957 STATUS 11. Shall be a body corporate 8. ... 12.(2) 25. (2) . . . capable of acquiring, having perpetual succession holding and disposing of real and a common seal, capable and personal property, and of of holding real and personal suing and being sued. property. GENERAL FUNCTIONS, REs poNssBIunEs, AND POWERS Institutions: 31. May establish new hospitals 61. (1) . . . May establish new institu- 75.(1) 54. (1) . . . With the Ministers prior or charitable institutions in its tions as under: consent: district. (a) Hospitals for the reception (a) (a) "A hospital". or relief of persons needing medical or surgical treatment for diseases. (b) Institutions for children, (b) (b)—(c) aged, infirm, incurable or destitute persons. (c) Maternity homes. (c) (d) Convalescent homes. (d) (e) Tuberculosis or, other (e) sanatoria. (f) Habitual inebriates institu- (f) tions. (g) Reformatory institutions for (g) women or girls. (h) Institutions declared by the (h) (e) . .. by Order in Council to Governor in Council to be be an institution which for public charitable Boards may establish. purposes. (i) . (f) Any two or more. (i) Any two of the above. 1948, No. 58, s. 8: [gg] Residen- (d) tial nurseries or day nurseries for the reception and temporary care of young children.

1885 1909 1926 1957 GENERAL FUNCTIONS, RESPONSIBILITIES, AND POWERS---continued Institutions—continued 1903, No. 82, s. 5 (1): Shall 63. (1) Shall make adequate provision 77. (1) 4. (1) (d) Shall receive into any receive any sufferer from an for persons suffering from in- institution in so far as there is infectious disease if the Chief fectious and other diseases as the adequate accommodation, any Health Officer directs. Inspector-General determines. person of, any class for whose reception, relief, care, treatment or isolation the institution is established. (2) In so far as accommodation 77. (2) 4. (1) (c) Shall provide as -. the is available. Minister thinks necessary, for the reception, relief, care, treatment, isolation and removal to any hospital or place of persons suffering from any injury or disease, women requiring care or treatment in respect of childbirth and persons who have been in Contact with others suffering from any infectious•

IND disease, and aged, infirm, incurable or destitute persons. ND 1966, No. 35, s. 3 (1) added and any person willing to donate any organ or part of his body or undergo medical or surgical procedure for the relief of another or. for the advancement of medical knowledge, education or research. 1973, No. 43, s. 3 (1) added or for any other lawful purpose. 1973, No. 43, s. 3 (2): Shall provide, maintain and equip a public mortuary subject to such conditions and limitations- as the Minister thinks necessary. - 4. (1) (e) Shall provide for other Hospital Boards such services as the Minister thinks necessary. 1970, No. 12, s. 3 (2) [s. 4 (1) (f)J: Shall provide such other hospital and medical services and facilities as the Minister specifies. Ah

4. (2) Shall have other functions, duties and powers conferred on it or imposed on it by this or other Acts. Note: (1) The Mental Health Act 1969, s. 7 (6) expands s. 54 of the Hospitals Act to include the power to establish psychiatric hospitals if the Minister declares the hospital to be a psychiatric hospital under the Mental Health Act. (2) The Mental Health Act 1969, ss. 6-7 makes -further provision for Hospital Boards to consent to the transfer of psychiatric hospitals conducted by the Crown to Boards; and for the gradual integration of services under Boards. 60. May provide facilities for training health or hospital related professions as the Minister thinks are required. • 1970, No. 12, s. 8 [64A]: (1) May, with prior consent of the Minister, establish health centres at which medical, - obstetrical, - - dental,- nursing, pharmaceutical, and other health services may be provided, (2) after it has consulted the professional organisations likely to be affected. • - (4) May provide what furniture, • - equipment, amenities and facilities • - - are needed in the health centre.

1885 1909 1926 1957 GENERAL FUNCTIONS, RESPONSIBILITIES, AND P0wEP.s—continued Institutions—continued 1903, No. 82, s. 4 (1): Shall provide and maintain infectious diseases hospitals. 1903, No. 82, s. 7 (1): Shall provide consumptive sanatoria or consumptive annexes if required by the Chief Health Officer.

1932, No. 22, s. 12: Shall provide maternity hospitals and make such other provision for maternity cases if Director-General instructs, subject to ministerial approval if buildings cost more than £250. -. 1936, No. 50, s. 3: Shall provide IND ambulance services if Director- General considers them requisite. - 1947, No. 9, s. 3: May, with 63.. . . such arrangements and Ministers consent and shall if he provisions as the Minister approves. directs, make such arrangements - and provide accommodation and services approved by him for: (a) Carrying out x-ray, medical (a) and other examinations of persons who may submit themselves for same. (b) Vaccinating, inoculating or (b) otherwise treating persons - who desire immunity against disease. (c) Carrying out laboratory tests - (c) ... (Amended by 1966, No. and examinations to deter- 35 s. 9: for the purposes of mine whether or not persons diagnosing, treating or asses- are suffering from or have - sing any disease, ailment or sufficient immunity from illness or determining if infectious disease, persons have sufficient resistance to any disease.) S 1948, No. 36, s. 18: Shall provide for the isolation of carriers of tuberculosis if the Minister directs. 61. (2) May build an institution 75. (2) 54. (2) . . . or in any place outside its anywhere in its district. district. (3) Shall obtain the approval (3) 94. (1) . . . or such other amount of the Minister before proceeding, as may be prescribed. - if works cost £250 or more. 12: Shall have exclusive super- 26. (1) . . . control and management 28. (1) 53. intendence and control of its of: institutions. (a) Institutions under the old (a) (a) . . . or becomes vested in the Act. - - Board afterwards. (cf. s. 4 (1) (b)) (b) Infectious diseases hospitals - vested in the Board. - -- (c) Institutions established (b) . . (b) ... - ND - under the Act. U1 (d) Separate institutions trans- (c) (c) . . . (Repealed by 1970, ferred to the Boards control. No. 12, s. 14 (2)) 33. May close any institution it 62. May close any institution with 76. 55. (1)_ . . and on the recommenda- deems is no longer required, Ministers consent. tion of the Hospitals Advisory and make alternative provision Council to the Minister. for inmates. ------(b) May also, subject to the above, restrict any institutional care, treatment or relief. 1968, No. 57, s. 7 [s. 55 (2)], May, without obtaining the Minis- ters consent, close any institution for up to 3 months. 1973, No. 43, s. 8 [s. 54A] may, with the prior consent of the Minister, combine two or more institutions into one, or divide one institution into two or more institutions.

1885 1909 1926 1957 GENERAL FUNCTIONS, RESPONSIBILITIES, AND POWERS—continued Joint Services 66. (1) May agree with another 81. (1) . 56. (1) . . . with the consent of the Board to operate a joint institution. Minister. (2) Shall agree in which Board (2) . (2) . . . the property, etc., of the joint institution shall be vested. (3) Shall agree on the constitu- (3) . (3) . tion and procedure of the joint committee of management. (4) Shall determine what powers (4) (4) . . . subject to any conditions of the Board are to be vested in which might be set by the the joint committee. Minister. (5) The Board in which the (5) (5) . institution is vested shall not exercise any of its powers in respect of the institute except by recommendation or consent of the joint committee. (6) The Board in which the (6) (6) All expenses and liabilities institution is vested shall meet incurred in acquiring and estab- C) • all expenses and liabilities in- lishing the institution shall be curred in acquiring, establishing those of the Board in which the or maintaining the institution, institution is vested. and all contracts made, rights • acquired and liabilities incurred by the joint committee shall be deemed to be those of that Board (7) Shall contribute towards the (.) maintenance of the institution as agreed upon by the contributory boards. (9) May agree to vary or termi- (9) (9) . . . Subsequent agreements nate the agreement. (Note: Times to vary or terminate the agree- not specified in this paper.) ment either mutually or unilaterally must be made with the Ministers prior consent. (10)–(12) May determine and (10)–(l1) . execute the disposal of assets and liabilities on the closure of the joint institution. Ah a. 1932, No. 22, s. 7: Shall operate a joint institution if required by Order in Council following a Commission of Inquiry. 1947, No. 9, s. 4: May combine 64. with another Board to establish and maintain any medical, nursing or laboratory service, mobile x-ray or any other service approved by the Minister. Charitable Aid 13. Shall administer charitable 27. Shall administer charitable aid. 29. 76. May administer relief. (Relief aid and may apply money for includes maintenance and every this purpose. - other form of aid or relief (whether medical or otherwise) given to persons whether or not they are inmates of a Boards institution). 1886, No. 36, s. 25: May subdivide its district for the a. purposes of administering charitable aid. 1886, No. 36, s. 29: May appoint local authorities, to administer charitable aid. 44. May object to the incorporation of a separate institution and transmit a copy of a resolution to this effect to the Minister. 60. May appeal against amount required by Trustees of a separate institution. 61. May Consent to trustees of a separate institution borrowing money for capital purposes. 2. Shall maintain destitute children in industrial schools. 1886, No. 36, s. 4: May, with the consent of the Minis- ter, appoint guardians of orphans in .charitable institutions. 1885 1909 1926 1957 GENERAL FUNCTIONS, REsPONSIBILerIEs, AND Powas—continued Information 1940, No. 18, s. 17: Shall 82. (2) furnish any information required by the Director-General. Liability 1936, No. 50, s. 2: Shall be liable for the negligence of its 86. professional staff. Directions of the Minister 5. (3) Shall comply with all directions, conditions and restrictions given or imposed by the Minister under the Act. CONDUCT OF Busiss Proceedings 69. May regulate own proceedings 28, 37. . . . (Quorum was 30, 41. 42. (1), 47. May regulate the and conduct of business, deter- defined in s. 31 (3), and further procedure of the Board and its mining what constitutes a defined in 1913, No. 56, s. 3) committees. quorum, and calling special meetings. May make rules to regulate proceedings. 9-10. Shall elect a chairman. 29. ... 31. (1)... (cf. 1953, No. 16, s. 102) 38. Note: limes and frequency of elections are not specified in this table) 1947, No. 9, s. 2: May appoint 41 a deputy chairman. 31. Shall make decisions by majority 34. (1) . . . 43. (1) vote. Committees - 64. (1) May appoint institutional 78. (1) . . . (cf. 1950, No. 57, S. 4: 44 (1) . . . (The Public Bodies, committees of management. Standing or Special Committees Contracts Act 1959, s. 5 (1) for institutional management or Allowed the power of contract.) reporting on such matters as the Board thinks fit. May delegate any powers and duties (except those of borrowing, by-laws, contract or power to start an action) of the Board to such Committees.) W

S (2) May include non-members (2) ... (cf. 1950, No. 57, s. 4 (2)) (2) on such committees. (3) Shall have control of such (3)... (cf. 1950, No. 57, s. 4 (5)) (5) . . . and may direct the conirnittees. committee to carry out instructions. (Note: s. 44 (4) enables committees to exercise delegated powers and p&form- those duties as if conferred by the Act and not by delegation by the Board.) (4) May approve proceedings of (4) committees. (5) May make regulations re- (5) . garding the proceedings and power of committees. 1950, No. 57, s. 4 (3): May at -(3) • any time change, alter, continue or discharge any committee- of its members and appoint others. 1948, No. 58, s. 5 (2): All Acts 58. (11) • and proceedings of a committee shall be reported to the Board, to and unless otherwise provided for in the Order in Council establishing the committee, shall - not be operative or effective until approved by a meeting of the - - - Board. Seating Documents 36. May seal documents providing 40 . . . 46. . . . (cf. 1970, No. 12, s. 6 (2) they are - attested to by two [s. 46 (2)]: Seal shall be affixed members. (Note: This is a genefal and attested by two members.) power not included under one of the methods of signing contracts which had been in existence since - 1885.) 1913, No. 56, s. 5: Shall affix 40. . . . 46. . . (Repealed by 1970, No. 12, seal pursuant to resolution. - • s. 6 [s. 46 (1)]: Unless required to have a document sealed, may direct it to be signed by the Chairman, Secretary or any two members.)

1885 1909 1926 1957 CONDUCT OF BusINEss—continued By-laws 62. May make by-laws regarding: 65. . . . 79. (1) 65. (a) Conduct and regulation of elections. (b) Prescribing what constitutes life membership of an institution. (c) Regulating the admission (a) Regulating admission and (a) (c) . . . including outpatients. and discharge of patients discharge of persons entitled on nomination of con- to care. tributors or contributory local authorities. (d) Maintaining order, dis- (b) . . . (b) . . . (b) . . . including outpatients. cipline, decency, and - - cleanliness amongst the inmates. (e) Prescribing the duties of (c) . . . (c) . . . (e) employees. (f) Preventing trespass on (d) . . . (d) . . . (f) premises. (g) Preventing disorderly behaviour on premises. - (h) Prohibiting the intro- (e) . . . (e) ... (g) duction of any item to premises. - (i) All matters affecting the (g) . . . (h) . . . (a) . . . and services provided general management, by the Board and the care, control and super- fulfilment of their purposes. intendence of institutions. (j) Affording out-door relief. (f) . . . (f) . . . (h) Regulating the provision of care, treatment or relief of patients or peisons who are not inmates. (g) Prescribing fees for main- (i) . . . - • tenance of patients. S 66. May provide penalties of up (h) (i) (i) . . . £ 10 ($20) fines. to £5 for breaches of by-laws. 1948, No. 36, s. 12: Shall make (d) Prescribing precautions to by-laws regarding tuberculosis if be taken by patients and required by the Minister. staff to prevent the spread of any infection. 1970, No. 12, s. 9 [s. 65 (1) (if)]: For ensuring the safety of the public using Board land, for preserving the land, for better control of traffic using the Boards land- (i) Prohibiting or restricting the entry of vehicles to such land. (ii) Prohibiting or restricting the parking or stopping of vehicles there. (iii) Fixing the maximum speeds of vehicles on such roads. (iv) Generally regulating traffic. Note: 1973, No. 43, s. 12 repealed subsections (i)–(ii) above. By-laws may now prohibit or restrict the entry or parking of vehicles on Hospital Board land, and may prescribe parking or stopping charges. 67. May recover fines in a (2) . . . 79.(2) (2) . summary way. 63. Shall print by-laws. 63. Shall display copy of by- laws in institutions. 63. Shall forward copy to the 65. (3) Shall have by-laws approved 79. (3) (4) . . . including any amend- Minister, by the Minister. ment or revocation of a by-law. 1923, No. 44, s. 18 (1): Shall 80. (1) 66. Shall comply with any direction make by-laws prescribing fees if from the Minister to make by-laws the Minister directs a Board to on any or all subjects specified in do so. s. 65.

1885 1909 1926 1957 CONDUCT OF BUSINESS—continued Dissolution 1886, No. 36, s. 9: May 82 (1) . . . with contiguous Boards. 10 (1) 17. (2). . . (Note: The request is in resolve to form a united dis- (Note: "united" in 1909 meant effect a recommendation to the trict for charitable aid purposes. united for hospital land, charitable Hospitals Advisory Council.) aid purposes, and not charitable aid alone.) (2) Shall provide due notice of (2) (2) the resolution. 1886, No. 36, s. 9: Shall (3) . . . (3) (2) forward notice of the resolution to the Minister. 35. A United Board shall have all powers, duties, and functions of its predecessors. 1932, No. 22, s. 4: Re-enacted 20. the provisions abolished in 1909 for the rights, powers, duties and functions of abolished Boards to devolve upon their successor. - 25. New Board shall then assume 11. (1) . . . 19. (1) (1) property; and 11. (2) . . . 19.(1) (2) contracts, debts and liabili- 1932, No. 22, s. 3 (5): Shall 19. (2) ties of its predecessors. comply with any apportionment of property of abolished Boards. 81. (1) On the alteration of hospital 106. (1) . . . 22. (1) . . districts, may request the Governor to include an institution in its district. 22. (3) May request the District Land Registrar to register the new Board as proprietor of any land vested in the new Board, without conveyance or assignment - and which was formerly held by the old Board. 11. (5) Should an Order in Council 15(5) 28. (5) . require a reduction in the number of representatives on a Board, and the representatives cannot agree who shall retire, lots are to be drawn in such manner as the Board directs. in L-]

FINANCE: Estimates 21. Shall make an annual estimate 41. (2) . . . including any: 46. (1) • . . 88. (1) . . . (Words changed to read of expenditure for following (3) Deficiencies from previous 47. • • . "proposed payments for all pur- year. (1%/ate: Time of meeting year. poses, and of its receipts from all not specified in this table.) (4) Estimated income and sources (other than the grant revenue (includingsubsidies) which payable to the Board . . shall be deducted from gross estimate2 of expenditure. (cf. 1923, No. 44 ss. 4-7) 1923, No. 44, s. 4(1).. . including amounts intended to be bor- rowed by way of loans.- (2) Shall confirm the estimates 46. (2) 88.(2) at a special meeting. (3) Shall forward estimates to 46. (3) • • 88. (i), (4) . Minister and amend them if required... 88. (6) Estimates shall be prepared, confirmed and sent to the Minister in accordance with regulations or in the absence of regulations, as determined by the Minister. They shall Contain such particulars required by the regulations or by the Minister. 88. (3) Shall send to the Minister any preliminary estimates required by him. 1968, No. 57, s. 11 [s. 88 (1A)]: In preparing its estimate, shall have regard to the probable amount of the grant to be paid during the ensuing financial year from appropriation. 1923, No. 44, s. 7 (2): Shall 49. (2) forward a copy of estimates and a summary of expenditure in the previous year to contributory local authorities. 1885 1909 1926 1957 FINANCE—continued Expenditure 88. (5) Following approval of a Boards estimates by the Minister, the Board may, with the Director- Generals prior approval, apply any amount specified for capital payments towards the payment of any other capital item for which no or insufficient provision has been made. 30. May expend money towards: 60. . . . subject to obligations of 85. 93. . . . and subject to the Act and trusts. its regulations: (a) Building and maintain- (a) Maintaining institutions. (a) (a) . ing institutions. (b) Establishing new institu- (b) (b) tions. 93. (2) Except with the prior consent of the Minister, shall not apply any estimate money to any purpose IND for which money has been raised by loan. (c) Acquiring land for new (c) (c) Acquiring land for the pur- institutions. poses of the Board. (d) Purchasing, erecting or (d) (d) equipping buildings. (b) Repairing, altering or (e) (e) (e) ... adding to buildings. (c) Maintaining and re- (f) Providing charitable aid by (f) (f) . . . lieving the indigent, sick, granting money, food or infirm or aged. other requisites to the indigent, sick or infirm who are not inmates. (g) Providing medicines, disin- (g) (g) ... fectants, surgical requisites 1968, No. 57, s. 13: and denta1 and medical, surgical and requisites and dental attendance. nursing attendance for the sick and infirm who are not inmates. (h) Isolating sufferers or persons (i) (i) . who have been in contact with infectious diseases.

is 1886, No. 36, s. 14: MayS pay (i) Paying wages and salaries. (j) employees. (j) and upon general (j) (k) ... (p) administration. 1913, No. 56, s. 10 [(gg): (h) . . . (h) . . . and to licensees of Making grants or subsidies to private maternity hospitals, medical, nursing or benevolent associations maintaining associations or, private philanthro-. - blood transfusion or volun- pic organisations approved by the tary ambulance services, Minister. associations for charitable purposes and benevolent institutions. 1920, No. 72, s. 11 (a): (k) Paying, subject to the Minis- Establishing, subject to the ters approval, bursaries for Ministers approval, nursing or students of any health or massage student bursaries. hospital service profession or activity, or grants to persons for training (including post-graduate training) in those areas. 1920, No. 72,.s. 11 (b): Paying pensions for retired staff, subject to the Ministers approval. 1936, No. 50, s. 4 [(m): Making payments subject to the Ministers approval to nurses who have contracted pulmonary tuberculosis. (Repealed by 1948, No. 36 s.23.). 1938, No. 20, s. 23 [(n)]: Paying salaries, grants or travelling expenses to any servant of the Board while he undertakes special training in New Zealand or elsewhere; providing that the Minister has approved the payment for training lasting more than four months. (Repealed by 1948, No. 58, s. 9: [(n)]: Paying, (1) -. :. and expenses. subject to the Ministers approval, salaries, grants or travelling allowances to any servant of the Board undertaking training or attending conferences or meetings.) 1885 1909 1926 1957 FINANCE—continued Expenditure—continued 1948, No. 58, s. 9[(o)]: Paying, (n) . . . and expenses. Payment subject to the Ministers approval to be paid if travel is on salaries and travelling allowances behalf of the Board or the to anyservant of the Board Crown in accordance with carrying out inspections or investi- rates or conditions approved gations on behalf of the Board by the Minister of Finance. whether within or outside New Zealand 1948, No. 58, s. 9 [(p)]: Paying, (o) . . . and to any other body subject to the Ministers approval, approved by the Minister. annual contributions to the Research Institute of Launderers, Dry-cleaners and Dyers of New Zealand (Inc.). (m) Paying travelling allowances and expenses to employees or officers travelling on Board business in accordance with rates and conditions approved by the Minister of Finance. 1973, No. 43, s. 16 [s. 93 (1) (na)]: Paying transfer expenses for persons taking up appointments in the Hospital Board service. - 61. (3) Shall obtain Ministers 75. (3) 94. (1) . . . $500 or such other sum as consent before proceeding with any may be prescribed. capital works costing more than £250. 1886, No. 36, s. 14: 32. 35. 95. (1) . . . in accordance with the May pay actual travelling Fees and Travelling Allowances expenses of Board members on 1915, No. 74, s. 2: Rate Act 1951. Board business. specified in Act. Repealed by 1920, No. 72, s. 24: At rate set by Governor-General in Council. S

1923, No. 44, s. 16 (1): May 83. . . . 95. (2) pay travelling expenses to members of joint committees. 1938, No. 20, s. 22: May pay 95. (3) travelling allowances to members 01 committees 05 management. - (cf. 1948, No. 58, s. 5 (3): to apply in amalgamated areas). - - 1946, No. 16, s. 24: May pay 52. (3) . . . on application of the restrospective increases of remuner- former employee. (Altered by ation to former employees. State Services Remuneration and Conditions of Employment Act 1969. Now s. 52 (6)). 1962, No. 43, s. 2 [s. 52A (l) May pay grants on retirement of employees not exceeding 183 days pay in all on a scale prescribed by regulations. (2)—(3) May pay gratuity to his dependents if he dies. (4) Shall deduct from any gratuity, any gratuity he shall have received on previous retire- n-lent. 1920, No. 72, s. 5: May 32. ... 39.... (Repealed by 1967, No. 80 pay Chairman an honorarium of s. 2 (1) [s. 39]: May pay not more than £100. honorarium approved by the (cf. 1924, No. 64, s. 50) may Ministers of Health and Finance remunerate Chairman accord- . . . providing it is not more than $2,000. ing to the size of the Boards 39. (2) May make payments either by expenditure - monthly or other instalments.) 1940, No. 18, s. 16: May concur 57. (2) . . . ($200) with remunerating the Chair- man of a Joint Committee not more than £100.

1885 1909 1926 1957 FINpaqca—continued Expenditure—continued 1913, No. 56, s. 13: Shall 101(l) 81. refund any money expended by a constable or local authority in rendering emergency aid to the indigent sick or in removing and burying deceased destitute persons. 1924, No. 64, s. 55: If affiliated 42. 97. May pay to the Hospital Boards to the Hospitals Association of Association of N.Z. (Inc). the New Zealand, may subscribe there- annual subscription payable by to and pay travel expenses to the Board. delegates attending its conferences. 1900, No. 35, s. 6: May contribute towards additions to separate institutions. 1913, No. 56, s. 12: May put 87 IQ aside sums approved by the Minister towards a building fund. 150. (2) Where any person in an institution dies leaving a sum of Money under £200 in the custody of that institution, that money may be distributed, if probate is not produced within a reasonable time, to persons specified by the Act. (cf. Administration Act 1964, s. 4 (1). This amendment increased the amount to $1000. Payment is to be in accordance with the provisions of s. 65 of the Administration Act 1969 and not to the specified persons.) - (3) May retain any amount • lawfully recoverable therefrom, including amounts used to meet funeral expenses. (cf. Adñilnistra- tion Act 1964, s. 4 (4).)

is S

(4) May require by bond any person to whom such estate is paid to apply such money. (Re- pealed by Administration Act 1964, s. 4 (4).) Note: s. 150 was repealed by 1970, No. 12, s. 14 (1) 1968, No. 57, s. 12 [s. 89 (4]: Shall manageannual its affairs so that the total payments do notgrant exceed and in the aggregate the supplementarypp grants which may be made to the Board, Levies and the Boards other income. 18. Shall take all steps for providing its and charitable " 2122Shall net 1923, No. , S. 7 (1)) 49. (1) estimatedcontributory expenditure nditureamoflg 41. (6)... (cf. 1920, No. 72 s: 10 (6): 60. (6) Apportionment shall as estimated terest charges as well include in- repayments of loans, 1943, No. 19, s. 28: Where a Board has forwarded estimates for the financial year 1943-44 and has not taken into account the amount estimated to be received under increases in Hospital Bene- fits, it may and shall, if Minister requires, amend the apportionment, instalments and interest payments. 1951, No. 49, s. 2 (2): Shall make no more levies after the financial year 1956-57. 1885 1909 1926 1957 FINANCE---continued Levies—continued 1886, No. 36, s. 26: Shall 41. . . . 50. (2) declare what local authorities shall contribute, and shall collect contributions on a uniform scale. 28. May recover contributions 41. (7) ... (cf. 1923, No. 44 s. 8 (1)) 50 (1) in arrear from contributory local authorities as a debt in Court. 1923, No. 44, s. 8 (2): May 50. (2) May fix a day for payment of determine whether payments are contributions and give 14 days to be made by monthly or quarterly notice thereof to local authorities. instalments. - 29. May apply to the Colonial 41. (8) . . . (cf. 1923, No. 44, S. 9) 51. Treasurer (Minister of Finance) to deduct subsidies payable to a local authority should it fail to contribute or fall into arrears. 1886, No. 36, s. 27: May 43. . . . 55.. . . (Repealed by 1946, No. 41, resolve to release local authors- S. 16 (3).) ties from further contributions for the year if Board has over estimated. 1886, No. 36, s. 28: May 46. (4) ... 58. (4) . . apply to the Minister of Finance to have Property-tax Commissioner (Valuer-Gen- era!) raise contributions in areas where no rates are levied. 1889, No. 20, s. 2: If local 44. (6) . . . 56. (6) ... authoritys appeal against its apportionment is successful, the Board may amend the apportionment.

fl I& 45. May spread apportionment for 57 capital works over two or more years. 42. May make supplementary esti- 53. . . .(Repealed by 1946, No. 41, mates and apportionment. s. 16(3).) 1923, No. 44, s. 11: Such 53.. . . (Repealed by 1946, No. 41, estimates and apportionment may s. 16 (3).) be for capital expenditure only. 90. (1) 1923, No. 44, s. 12: May apply 54. (1) ... (cf. 1946, No. 41, s. 16(1).) to Minister of Finance for a supplementary advance if necessary. 1946, No. 41, s. 16 (2): The advance shall be repaid in the following year instead of being deducted from the -following years 1886, No. 36, s. 23: Shall subsidy. carry forward surplus funds ND into following year. 89. (4) Shall apply to the Minister for an annual grant from appropriation at such times and in such manner as the Minister determines. 1907, No. 41, s. 3: May 42. (5)... (cf. 19239 No. 44, s. 4) allocate and collect levy for capital purposes as well as - for recurrent expenditure in like manner. S Loans 32. May raise loans for capital 57. (1) . . . providing the Minister 60. (1) 87. (1) . . . Subject also to Parts I purposes on security of income has approved the loan. (Security and VI of the Local Authorities or endowments, of income was abolished in 1909, Loans Act 1956. but that of land retained.) (cf. 1920, No. 72, s. 10 (1) and 60. (1) subject to any conditions the Minister might impose.) 1920, No. 72, s. 10 (1): Capital 60. (1) 87. (1) . . . or converting all or any purposes may include loan repay- part of a loan. ments. 1885 1909 1926 1957 FINANCE—continued Loans—continued 1907, No. 41, s. 2: Security 57. (1)... (cf. 1920, No. 72, s. 10 (1)) 60. (1) . . . 87.(2) must contain no power of sale of land over which the Board has no power. 1920, No. 72, s. 10 (1): May 60. (1) ... 87. (2) also borrow on security of debentures, if Minister approves. 87.(2) 1955, No. 103, s. 12: May issue 57. (2) May meet ordinary recurrent stock as a security for loans. 87. (3) expenditure by bank overdraft 60. (2) up to the level of contributions 87. (3) The prior consent of the still payable. (cf. 1920, No. 72 Minister only is required. s. 10 (2)—providing the Minister has approved and subject to any conditions he might set.) 87. (3) 1928, No. 39, s. 3 (1): May borrow by overdraft for either maintenance expenditure or capital purposes, in anticipation of revenue. 1932, No. 45, s. 29: In financial year 1932-33 may borrow in excess of limits of s. 60 of the principal Act to the extent of one quarter of the estimated contributions payable during that year and one quarter of the estimated subsidy thereon. cf. 1934, No. 31, s. 24; 1936, No. 36, s. 17; 1939, No. 38, s. 37; 1941, No. 4, s. 31 for years 1934-35, 1936-37, 1939-40, and 1913, No. 56, s. 9: Shall keep 1941-42. loan money in separate account 62. ... and expend it solely for the purposes of the loan. - 1926, No. 46, s. 41: May deposit unexpended loan balances with approved local authorities. L]

Accounts and Audit 89. To keep books and accounts, 69. (1), (3) . . . 89. (1), (3) 98. (1), (3) which shall be open for inspection by Board members at reasonable times. 69. (2) Separate accounts to be kept 89. (2) 98. (2) for trust funds. 90. Shall prepare an annual 68. (1) . . . and contracts. 88. (1) 99.(l) balance sheet containing details (cf. 1913, No. 56, s. 11 (1): of income, expenditure, assets (a) Contracts. (a) (a) . . . (Repealed by 1961, and liabilities. No. 84, s. 3 (2).) (b) Money received and ex- (b) (b) . . . providing that the pended. Audit Office may dispense with this requirement. (This proviso was repealed by 1961, No. 84, s. 3 (2) (a).) (c) Income and expenditure. - (c) (c) . . . (Repealed by 1961, No. 84, s. 3 (2).) (d) Assets and liabilities. (d) • .. (d) . . . (cf. 1961, No. 84, s. 3 (2) (b)) 1961, No. 84, s. 3 (2) [s. 99 (1) (C)]: of financial aspects of such of the Boards activities determined by the Minister. 91. Shall have accounts audited 68. (3) . . . Audit Office. 88. (2) 99.(3) by the Comptroller and Auditor-General. (4) Shall forward a true copy of 88. (3) 99.(4) the annual balance sheet to the Minister. 1913, No. 56, s. 11 (2): Shall 88. (3) also forward a copy to contributory local authorities. 89. Shall keep separate accounts for trust funds. N

1885 1909 1926 1957 FINANCE—continued Accounts and Audit—continued 64. (1) May establish an Imprest 92. (1) Account: 1950, No. 57, s. 3 (1): at 92. (1) Treasurers Office or at any institution of the Board. 64. (2) May authorise a member and the Treasurer to operate the Account. (Repealed by 1950, No. 57, s. 3: 92 (1) (a) . . . if the Account is held at Either a member or an officer the Treasurers office. appointed by the Board may hold and operate the Account along with the Secretary or Treasurer.) 1950, No. 57, s. 3: May appoint 92. (4) a responsible officer to hold and operate an institutional imprest account along with another person approved by the Board providing he is a member of the Board or on a committee of management or • responsible officer of the Board. 1950, No. 57, s. 3: May appoint 92. (5) • single officer to operate an imprest account providing that the Audit Office has expressly approved the appointment. 64. (3) Shall resolve what constitutes 92. (6) ... the maximum sum which may be held in an imprest account. (cf. 19502 No. 57, s. 3.) 1950, No. 572 s. 3 and 1951, 92.(6) No. 49, s. 4 specify limits on the maximum amount. 64. (4) A monthly summary of 92. (9) payments from imprest accounts must be submitted for approval by Board. (cf. 1950, No. 57, s. 3). 1950, No. 57, s. 3 (2): May 92. (2) . . . Money belonging to any determine at which bank the imprest account shall be kept account is to be kept. at a bank approved by the Minister of Finance. S Miscellaneous 20. May select its own bank, 48. . . ., All money to be held in 63. 1948, No. 58, s. 7: Cheques may 91. (1) ... Boards selection of bank shall pay income into its the account pending investment be signed by the Treasurer and any to be approved by the Minister bank account and - authorise or application. Cheques to be one authorised member of the of Finance. Cheques may be cheques to be drawn on tie signed by the Treasurer and two Board signed by the Treasurer and only account, .providing they are members authorised to Counter- one Board member authorised by signed, and countersigned by sign cheques. the Board. two members chosen by the 1973, No. 43, s. 15: Cheques and Board. - instruments other than promissory notes or bills may be so signed. 1928, No. 39, s. 5: May 15 1. - advertise and sell unclaimed patients property. 1961, No. 84. s. 2 rs. 91 (2)1 Board may, subject to the approval and conditions of the Audit Office, pay money by cheques issued by a cheque-writing machine bearing the appropriate facsimile signatures of those persons authorised to sign and countersign cheques: (Re- pealed by 1964, No. 91, s. 3 (1): Subject to approval and conditions of the Audit Office, may pay by cheques bearing facsimile signatures of the Treasurer or of the Treasurer and an authorised Board member.) 17. Shall expend subsidies on 39. (1) . .. 44.(l) bequests as part of the bequest. 18. May appoint collectors of 53. (1) . . . for the establishment 69. (1) 83. (1) . . . and may authorise voluntary contributions, or maintenance of its institutions voluntary associations or commit- or for special or general purposes tees to collect and expend the of the Board. contributions for the provision of amenities and facilities for the recreation, welfare and comfort of inmates and outpatients, Board staff, or for a special purpose approved by the Minister.

1885 1909 1926 1957 F1NcE—continued Miscellaneous—continued 53. (2) Shall apply funds derived 69. (2) • . 83. (2) . . May. consent to the from voluntary contributions to expenditure of any surplus money the purpose for which collected. for any other purpose permitted under s. 83 (1). 83. (4) May appoint any member, officer or employee to be its representative on a voluntary association or committee. 83. (5) May authorise any officer or. employee to undertake clerical or accounts services to voluntary associations or committees as part of his ordinary duties. 19. Shall keep Contributors Book and make entries therein. 74. May recover maintenance 72. (1) 92. (1) . . . (Repealed by 1947, costs from another Board if No. 9, S. 5.) the person was resident in that Boards district before the grant of relief for a specified period. (Note: Periods of residence are not included in this thL. 1925, No. 45, s. 6 (1), (5): To 92 (3), 94.1 .. . . (Repealed by 1947, apply only when Boards are No. 9, s. 5.) contiguous. Shall assist the other Board to recover costs. 1903, No. 82, s. 5 (2): May charge maintenance for persons admitted by direction of the Chief Health Officer..., . 91. (1) 77.(1),79 . 71.. May sue for, and recover 70. 1966, No. 35,..s. 10 [s. 77A]: debts for maintenance., . May agree to provide free care of persons, donating organs of the body for the relief or treatment of another or the advancement of medical knowledge, education or research. S CO 16. Shall invest trust money 49. . . . or on first mortgage of 65. 75. (1) Shall invest such money as prior to application in terms of freehold land in New Zealand. directed or authorised by terms the trust in Government or of the trust, or for any purpose local body securities. under the Trustee Act 1956. (2) Shall apply income in accordance with the terms of the trust, or where the, trust is not for a specified purpose, for any Board institution or service. (1968, No. 57, s. 9 (2) added for any purpose for which the Board can lawfully apply its own property or for any other purpose for the time being approved by the Minister.)

LAND AND PROPERTY ... ! 84-87. May lease its lands. 56. (1) 72. (1) 71. (1) . . . providing the Minister Note: This paper does not has given his prior consent. specify terms, etc., of lease. 55 May, with Ministers consent, 71. (1) 69. (1) May, with prior consent of the sell or exchange land, other than Minister, sell or exchange land, trust land. vested in it other than trust or Domain Board land. 69. (2) To apply proceeds in such manner as the Minister directs on the recommendation of the Hos- pital Works Committee towards acquiring other land or capital works. 58. May sell, exchange or mortgage 73. 74. (1) . . . Similar trusts must be lands held in trust, if approved by approved by the Minister. Minister, but the proceeds thereof shall be used in terms of the trust or similar trusts as far as possible. 1885 1909 1926 1957 LAND AND PROPERTY—continued 1941, No. 26, s. 32: With the 70. (1) Ministers consent, may dedicate to a municipal corporation for street purposes, any of its endowment lands affected by certain building line by-laws made by (3) Shall apply money received as such municipal corporation. compensation in terms of direction of the Minister. 1973, No. 43, s. 11 [s. 64 (5A)]: May lease the -whole or part of a health centre- for up to 10 years with a right of renewal for a further 10 years, the rent being determined by valuation. 59. With the Ministers prior consent 74. 67. to the proposed establishment of an institution, may take or acquire - land under the Public Works Act for such purposes. 16. May accept property in 51. ... 67. (1)—(2) 73. (1)—(2) . . . May accept property trust for its existing or pro- in trust for any purpose to which posed institutions, and shall the Board canlawfully apply its appropriate trust money in own property or for any purpose terms of the trust. approved by the Minister. 16. If no terms are attached 52. ... 68. 73. (3) May apply trust money to to the trust, may expend trust any purpose lawful to the Board or money as it thinks fit for any of any other purpose approved by the purposes outlined above. the Minister. 50. New Boards which have succeeded 66. 72. . old Boards and acquired trusts shall remain subject to such trusts.

Comrrstcrs 75. May make contracts. (Note: 35 39. 45;... (Superseded by Public Con- Modes of preparing documents tracts Act 1959, s. 5.) are not outlined in this0 table.)

W 45. (5) Subject to any general or special direction of the Minister, may make contracts for the supply of any fuel, goods, stores or equipment for any period; but if more than three years, shall - - obtain the consent of the Minister. 78. May compound with any 78. ... 104. ... 80.... (cf. 1966, No. 35, s. 11) other person in default for breach of contract. 1966, No. 35, s. 11 [s. 80 (b)]: with the consent of the Minister, • may release any person from his contractual obligations or from his - liability to pay any debt. 70. May make contracts for 70. (4) -.. . e.g., another Board, 90. (1) ... 77. (1) . . . (List of contractors the maintenance, care or separate institution, or friendly simplified to read any person attendance of inmates, society, and recover costs, or body of persons".) 1920, No. 72, s. 16: subject to 90. (2) 77. (2) . . . (Repealed by 1970, No. the Ministers approval 12, s. 11.) .77. (3) May charge less than the actual cost specified in the contract. 71. (1) May contract with another 91. (1) 78. (1) body to care for its inmates - (in, e.g., an institution conducted . • by the Crown.) 1932, No. 22, s 10: May 51. (1)—(2) . . . (Specifies terms of •. .. . --- . .- . . contract with its employees as to Contracts for whole-time and other ...... tenure of office for up to 3 years than whole-time employees. In = ...... -- ... . with the possibility of renewal, some cases, contracts require the prior consent of the Minister). (cf. 1968, No. 57, s. 5) State Services Remuneration andConditions of Employment Act 1969, s. 58 (1) [s. 52(12) May contract with an employee providing conditions of employment are not inconsistent with -- - awards, industrial agreements or - . apprenticeship orders.

1885 1909 1926 1957 CoNrit.cTs—continued 1940, No. 18, s. 15: May enter 96. into contracts to insure members against loss from personal accident while en00g ,ic, pcl in diities 1970, No. 12, s. 8 [s. 64A (5)]: May contract, with persons. provide services at a health centre. STAP1? Appointments 68. May appoint a Secretary 33. (1). . . as it thinks are required. 36. (1) ... 49. (1) Treasurer, medical and other (Note: This section makes no officers, nurses, attendants and mention of the power of dismissal.) servants, and may remove them. - . - 19511, No. 57,8. (): Subject to 49. I) subject to tue provisions oi notification of the appointment to the Act. - the Minister in certain cases (3 (see s. 38 below). 49.- (1) May combine the offices of - Secretary and Treasurer. (2) May appoint district nurses. 36. (2) 1920, No. 72, s. 6: Shall appoint 37. such numbers of medical -officers, nurses and midwives considered necessary- by the Director-General. 1923, No. 44,8.20: The above to 37. include dentists and dental nurses. 1947, No. 9, s. 7: Auckland 156. (l)–(6) Hospital Board shall appoint as - Medical Director of its Obstetric and Gynacological Hospital the --- person occupying the Chair of - - Obstetrics and Gynaecology at the - - Auckland University College. (Note: The 1947 arrangement was designed to meet a particular situation applicable to one Board - - only, and to one person.)

S U

156. (7) On the expiry of the 1947 - - arrangement, the Auckland Hospi- tal Board shall conclude an agreement with the Auckland University • Council making adequate pro- - - vision for: (a) The treatment and care of - - an agreed number of patients - in the - Nnnh.i +h person occupying the Chair. • (b) Post-graduate medical instruction. - (c) Teaching students obstetrics • and yn (d)Undarch relat- iñg obstetrics and gyn- áecology. (e) Provision by the Board of adequate facilities for the Above. 49. (2) With the prior consent of the Minister, may appoint any employee to perform services for that and any other Board; or • - may combine with another Board • - -• to appoint an officer to serve both Boards upon such conditions and apportionment of duties as the Boards agree. 1970, No. 12, s. 10 [s. 66 (1)]: May appoint persons as special traffic óffiets. (2) and shall supply them with a distinctive uniform. 1885 1909 1926 1957 ST.n—continued Appointments—continued - - 34. Shall notify the Minister of 38. (1) . . . "approved of such 50. (1) . . . Any other class of its intention to appoint a medical appointment" changed to read occupation can also be prescribed. officer, master or matron of an "approved a proposal to make (Repealed by 1971, No. 49, s. 15: institution 21 days before the such appointment", to apply only to the principal appointment is made unless the medical officer, principal nursing Minister has previously approved 1948, No. 58, s. 6 (1): Sub- officer and the Secretary.) of such appointment. stituted for the 21 days requirement, the prior approval by the Minister, of a Boards proposal to - appoint the specified members of stafi 1950, No. 57, s. 2 (4): Restored 50. (4)(b) . the 21 days prerequisite. 1913, No. 56, s. 4: Section 34 38. (1) ... 50. (1) . . . (cf. 1971, No. 49, s 15) tso to apply to the Secretary of the - Board. 1923, No. 44, s. 2 (1): Section 38. (1) ... 50. (1) . . . (Repealed by 1971, No. 34 to apply to engineers. 49, s. 15.) 1950, No. 57, s. 2: Notification -. of appointment also required for architects and dental officers. - 1950, No. 57, s. 2: Notification 50. (1) . .. (Repealed by 1971, No. of appointment extended to that 49, s. 15.) of Chief Engineer. - 1923, No. 44, s. 2 (2): Before 38.(2) ... 50. (3), 50. (4)... making the appointment, shall first submit a list of applicants, - and give the Ministers recommendations thereon due and fair - - consideration. 1948, No. 58, s. 6 (2): Shall 50. (3)-. .. - also supply to the Minister any further information about the - - appointment required by him. - - (cf. 1950, No. 57, a. 2) 0 LI 50. (2) Except where the Minister approves, shall invite applications for the appointment of specified staff (see s. 50 (1) above). 50. (4) Having duly considered the reports and recommendations of the Minister, a Board: (a) may appoint any applicant whose appointment the Minister has indicated that he would be prepared to approve. (b) or shall notify the Minister of the name of any other applicant a Board proposes to appoint instead and shall • defer making the appointment until 21 days after (3 notifying the Minister. (0 1971, No. 49, s. 16 [s. 50A (2)]: Shall invite applications for such other appointments in the manner specified in regulations unless the Minister has given his prior approval. Review and Appeal 1968, No. 57,s. 6 [s. 51c (3)1: May make submissions to a Review Committee hearing an appeal by a Board employee against dismissal. (Repealed by 1971, No. 49, s. 19: Shall reconsider the dismissal if a dismissed employee complains to the Board, and after consideration, either confirm or revoke the dismissal and notify the complainant accordingly.) • The 1950 Amendment Act reverted in substance to the procedure laid down in 1923 and extended the range of appointments requiring notification. The 1957 Act combined the urocedures of 1948-and 1950.

.1885. 1909 1926 1957 STAi—continued Review and Appeal—continued 1968, No. 57, s. 6[s. 51c (10)1: May withdraw a dismissal notice at any time. (cf. 1971, No. 49, s. 19 [s. 51c (4)].) 1968, No. 57, s. 6 [s. 51D]: Should the Board decide to re-engage a dismissed employee after considering his complaint, shall re-engage him on similar terms and conditions as before, (cf. 1971, No. 49, s. 19 [s. 51c (2)] Shall pay him any salary, etc., to which he would have been entitled if he had been employed in the interim. • 1971, No. 49, s. 19 [s. 51n (3) (7)]: Shall reconsider any decision on appointment if an aggrieved applicant complains. Shall then either confirm the - appointee, or revoke the appointment and appoint the aggrieved person in his stead. Shall also - give notice to all applicants of the provisional appointment which is subject to the right of appeal. 1971, No. 49, s. 19 [s. 51E (1)]: Shall reconsider any decision to transfer an aggrieved employee to another Board institution, and shall either confirm or revoke the decisiOn.- • • • - 1971, No. 49,5.19 [s. 51F (10)]: Shall àoplym with any decision of the Minister - in the event of appeals. fl n Access of Professional S Members of Hospital . 67. A Hospital Board in whose 84. 59. (1) . . . remunerate such V district is situated a university honorary medical staff. May medical school may agree to also agree as to the carrying grant access to academic staff out of tutorial duties in the (as honorary hospital staff) and hospital with consequent remune- to students subject to any condi- ration to the Board. May also tions imposed by the Minister. agree as to the provision of tutorial facilities by the Board (2) May vary or determine unilaterally such agreement. (3) Shall have any such agreement or variation approved by the Minister. (6) Shall appoint a joint committee with the medical school for the administration of s. 59, providing the Committees constitution, function and procedure are approved by the Minister with the concurrence of the Minister of Education. 61. Where any woman in any maternity ward, annexe or hospi- 01 tal operated by a Board is entitled to select with the Boards concurrence the medical practitioner by whom maternity benefit services are to be rendered under the Social Security Act, the Board may require as a condition of concurrence, any such medical practitioner to enter into an agreement, in terms approved by the Minister, as to the conditions on which the medical practitioner is to be entitled to treat his patients in that ward, annexe or hospital. 1970, No. 12, s. 8 [s. 64A (5)]: May enter into agreements (whether contract or otherwise) with any person so as to enable that person to provide any service at a health centre. Powers, Functions, and Responsibilities of the Ministerof Health, 1974 GENERAL DUTIES 3. On behalf of the Crown, the Minister shall: (a) Ensure the provision and maintenance by Hospital Boards, to .the extent he thinks necessary to meet all reasonable requirements throughout New Zealand, of hospitals and medical, dental, obstetrical, nursing, and other hospital services. (b) Ensure and encourage the provision, maintenance, and equipment by Hospital Boards of public mortuaries. . . (c) Encourage the provision and maintenance by Hospital Boards to the extent he thinks necessary, of medical education and research services and facilities in connection with hospitals. (d) Encourage the provision and maintenance to the extent he thinks necessary, of private hospitals. (e) Encourage the provision and maintenance by Hospital Boards, or by voluntary agencies or bodies of such institutions, homes, or services he thinks necessary to care for aged, infirm, or incurable persons or persons requiring care but not constant medical and nursing treatment. (f) Encourage Hospital Boards to establish and run health centres. (g) To co-ordinate and generally guide and supervise the work of Hospital Boards and other bodies for the above purposes.

PROCEDURE AND ADMINISTRATION General Powers over the Hospitals Advisory Council, etc. 7. (3) Shall recommend the appointment of two Hospital Board members and a medical practitioner as members of the Hospitals Advisory Council. 8. (1) May refer to the Council questions relating to the performance of his functions or those of Hospital Boards. 13. (1) May appoint advisory or technical committees. (2) May determine the functions of such committees. (2A) May authorise or require such committees to charge fees. (3) May appoint committees to inquire into the management of institutions, complaints or disputes. May include members of the Hospitals Advisory Council in its membership, and grant to it the powers of a Commission of Inquiry.

Reorganisation of Hospital Districts 17. (2) Shall refer to the Hospitals Advisory Council resolutions of a Hospital Board to amalgamate with another Board. 18. (6) May notify in the Gazette the date of election of a Hospital Board in a reconstituted district, and may do all things necessary to enable the election to be held. 19. (2) May in writing apportion the property, contracts, debts, and liabilities of abolished Hospital Boards to their successor or successors. Shall make the final decision in the case of any dispute between the Boards.

236 22. (2) May in writing apportion the property, debts, liabilities, or contracts of an institution transferred to another Hospital Board on the alteration of the boundaries of a hospital district. Shall make the final decision in the case of any dispute. 23. May request the Minister of Internal Affairs to refer the question of hospital district union, reconstitution or alteration to the Local Government Commission. POWERS OVER HOSPITAL BOARDS General 5. (1) May give such directions to a Hospital Board as he thinks necessary or expedient for the purposes of the Act. (2) May give directions as to the exercise of duties, powers, or functions by Boards, or may refuse to consent to or revoke his consent to the exercise of a power, function, or duty. May give his consent subject to conditions. (4) Shall sign any direction or consent or have it signed by the Director- General. 84. (1) If he thinks a Board has failed to perform its duties or has seriously mismanaged its affairs, or has done something illegal or improper, he may, on the recommendation of the Hospitals Advisory Council, appoint a Commission to act instead of the Board. Shall make such an appointment by notice in the Gazette, having first given the Board an opportunity to rectify matters. (2) Shall appoint one or more suitable persons as a Commission. (3) Shall appoint a chairman. (4) Commissions shall hold office during the pleasure of the Minister. (5) May replace members of a Commission. (8) May by notice in the Gazette, vary the powers of a Commission. (9) Shall forward a copy of every Gazette notice to the Board. 85. (3) May bring an information against an officer of the Board for failure to perform statutory duties. 62. (2) May impose conditions on the supply of information to unspecified persons. 147. (2) May appoint Inspectors of Hospitals who shall not be public servants. Hospital Board Institutions and Services 54. May consent to the establishment of new institutions, hospitals, or residential nurseries or day nurseries. 54A. May consent to the division or combination of an institution. 55. May consent, on the recommendation of the Hospitals Advisory • Council, to the closure of an institution. 56. (1) May consent to Hospital Boards combining to establish a joint institution. (4) May impose conditions or restrictions on an agreement by Boards to establish such an institution. (9) May approve any agreement, and may consent to the termination of the agreement. (10) In default of agreement, may determine matters, and-.give directions. 60. May determine the facilities, accommodation, and equipment required for training health service staff.

237 63. May approve the provision of X-ray, immunization, and laboratory services by Hospital Boards. 64. May consent to the provision of joint services. 64A. (1) May consent to the establishment of health centres by a Hospital Board. By-laws 65. (4) May approve by-laws. (5) May, on the recommendation of the Hospitals Advisory Council, disallow any by-law by notice in the Gazette. 66. (1) May require a Board to make by-laws.

Access of Professional Staff who are not Members of Hospital Staff 59. (3) May consent to any agreement made between a Hospital Board and a university medical school for access by teachers and students. (4) In default of agreement, the Minister may give directions to a Board if he thinks fit, having regard to the representations of the Board and university medical school. (6) Shall approve the constitution, functions, and procedure of any joint committee of a Board and university medical school. If the agreement is inadequate, shall be rectified by the Minister in conjunction with the Minister of Education. (7) The Ministers of Health and Education shall determine any dispute between a Board and University medical school. 61. May approve terms of agreements by Boards to allow medical practitioners access to maternity wards. FINANCE Estimates 88. May require a Board to send estimates for his confirmation or amendment. 89. (4) May determine the time and manner in which applications for grants shall be made. Expenditure and Remuneration 93. (1) May approve the payment by Boards of grants or subsidies to licensees of private maternity hospitals, associations maintaining blood transfusion or ambulance services, philanthropic and certain professional associations. May also approve the payment of grants or bursaries to students of health services professions. May also approve the payment of salaries, grants, and travelling allowances for Board employees undertaking training, attending conferences, or carrying out inspection or investigation on behalf of the Board or Crown. May also approve the payment by a Board of annual contributions to the Research Institute of Launderers, Drycleaners, and Dyers of New Zealand, or to any other body approved by the Minister. (2) May consent to the application of money towards purposes for which loans have been approved. 94. (1) May consent to the expenditure for capital purposes by Boards of more than $500 or other prescribed amounts. 39. (1) May concur with the Minister of Finance as to the amount of an honorarium to be paid to the Chairman of a Hospital Board. 238 83. (1) May approve purposes for the expenditure of voluntary contributions. - 52. (1) Shall fix the remuneration and conditions of employment of medical officers and all other persons employed under contracts of service to Hospital Boards. (2) May issue, revoke, amend, or consolidate determinations. (5) May specify the date on which such will come into force. (7)Shall appoint a Hospital Medical Officers Advisory Committee to advise him on remuneration and conditions of employment of medical officers employed by Hospital Boards, and similar committees for other groups as he thinks fit, and provided for in regulations. 52A. (lA) May consider the cause of any interval during employment as service for the Board or exclude it for the purpose of making grants on retirement. (5) May determine the rates of retirement allowance. Borrowing Powers of Hospital Boards 87. (1) May consent to a Board raising loans for capital purposes, subject to the provisions of the Local Authorities Loans Act 1956. (2) May consent to the issue of debentures or stock or mortgage of land as security for loans. (3) May consent to a Board borrowing money by bank overdraft. 57. (4) May authorise a joint committee to overdraw its account. Accounts and Audit 99. (1) May determine which financial aspects of Board activities shall be required for presentation in a Boards annual statements. (2) In the absence of regulations, may determine the form and particulars required for a Boards annual statement. Miscellaneous 98. (4) May give directions regulating the receipt, custody, banking, expenditure, and accounting of Board money, and specify the accounts and returns to be furnished to the Director-General, their form, manner, and required particulars.

LAND AND PROPERTY 67. (1) May consent to the purchase or acquisition of land by a Board. (2) With the Minister of Works, may agree to, the acquisition of land under the Public Works Act. . 68. May vest Crown land in a Board by notice in the Gazette. 69. (1) May consent to the sale or exchange of land by a Board. (2) May consent to the sale or exchange of endowment land by a Board, and direct the application of proceeds in accordance with the recommendation of the Hospital Works Committee towards the acquisition of other land or the provision of institutions. (4) May, on the recommendation of the Hospital Works Committee, declare that hospital reserve lands are no longer required, and by notice in the Gazette, vest that land in the Crown. 70. (1) May consent to a Board dedicating endowment lands to the corporation of a borough for street purposes.

239 (3) May give directions as to the application of money given in compensation. 71. (1) May consent to the lease of land by a Board. 73. (1) May approve purposes for which trust property may be used. (3) May approve purposes for which bequests or trust funds may be used. 74. (1) May consent to the exercise of the powers of sale, exchange, mortgage, and charging trust lands by a Board, and may approve the trusts for which proceeds shall be subject. 75. (2) May approve purposes for which the income of trust funds may be expended where the trust is not for any special purpose. Contracts 45. (5) May impose general or specific directions on contracts made by a Board for works, services, or the supply of goods. 80. May consent to the release of a person from his contractual obligations with a Board or from his liability to pay any debt. 51. (1) May approve any contract made by a Hospital Board to secure the services of whole-time staff. (2) May approve a Boards replacement of such contracts by an agreement with an officer, providing that he shall not be removed except for conduct justifying summary dismissal or after three months notice. STAFF Appointments 49. (3) May direct a Hospital Board to appoint such numbers of staff as he thinks necessary for the efficient performance of its functions; or limit the numbers of persons to be appointed by it to any specified class of employment; or not to appoint staff of any specified class. 50. (2) Shall give his prior approval to the appointment of a principal medical officer, principal nursing officer or Secretary without a Board first inviting applications for the position. (3) May require information about applicants for senior staff. Shall submit to the Board for its guidance such reports and recommendations, and indicate the names of applicants whose appointments he would be prepared to approve. (5) If a Hospital Board proposes to appoint another applicant other than the one whom the Minister has approved, and has notified the Minister thereof (as required), the Minister may notify the Board of his intention to refer the matter to the Hospitals Advisory Council, and may, if he acts on the Councils advice, decline to approve the appointment. 50A. (2) May allow a Hospital Board to make appointments without first inviting applications. 49. (2) Shall give his prior consent to appointments of employees serving two or more Hospital Boards. Reviews and Appeals 51A. (3) Shall appoint members of a Review Committee, and may nominate persons from an organisation which he thinks will represent the interests of the class of employees to which the complainant or appellant belongs. (4) Members shall hold office at the pleasure of the Minister. 51B. (1) May notify in the Gazette, after consultation to the relevant organisations, classes of hospital employees to be within the jurisdiction of Review Committees. 240

(2) May vary or revoke such notices. 51c. (1) May specify the period of time beyond 14 days during which a person might appeal against dismissal if the ex-employees Board confirmed the dismissal. 51D. (4) May specify the period of time beyond 14 days during which an appellant against a certain appointment might appeal against the appointment if the Board confirms the other appointment. (6) May direct or advise a Board that made the appointment or inform the Board that he does not intend to give advice regarding the appeal. 5 l. (I) May specify the period of time beyond 14 days during which an appellant against transfer by the Board might appeal if the Board confirms its decision to transfer him. (3) May direct or advise a Board regarding the appeal. 51F. (I) Shall refer complaints or appeals to the chairman of the Review Committee. (9) Shall consider any report of a Review Committee and give a direction or advice to the Board as he thinks appropriate.

PRIVATE HOSPITALS 122. (1) Shall be satisfied as to the character and fitness of applicants before granting a licence. 124. (2) May, if he thinks fit, limit a licence to particular classes of patients and specify the purpose for which any room might be used and the maximum number of patients which might be accommodated.. (3) May vary the terms of a licence in terms of the purpose for which it was granted, the classes and numbers of patients and the purpose for which rooms might be used. 127. May transfer a licence on the application of a licensee. 128. (1) May transfer a licence to any person nominated by the executors or administrators of a deceased licensee, or a dissolved corporation. (3) If no transfer has taken place within two months of the death of the licensee or dissolution of a corporation, may revoke the licence by notice in the Gazette. 131. (2) If necessary alterations or improvements required by the Director-General to be made to the buildings or equipment of a licensed hospital have not been complied with, after a period of time, the Minister may vary the terms of the licence or revoke it. (3) Before varying the licence, the Minister shall give notice of the grounds on which he proposes to do so and give the licensee or manager reasonable opportunity to show cause why the licence should not be varied. . 132. (1) May revoke a licence at any time on a number of specified grounds. (2) Before revoking a licence, shall give notice to the licensee or manager of the grounds on which it is proposed to revoke the licence, and give reasonable opportunity for explanation. 134. (1) May issue a temporary licence for up to one year. (3) May extend the period during which a temporary licence may operate, up to a period of two years. 135. (7) May exempt a licensed hospital from the requirement that its resident manager should hold- approved medical or nursing qualifications and have such other qualified medical and nursing staff. 241 Appendix rn HOSPITAL DISTRICTS IN NEW ZEALAND, 18854974 .Poiit: 1. The total number of Boards given for 1885, 1909, 1926, and 1957 are taken from the First Schedule ofthe various Acts. 2. The Hospital and Charitable InstitutionsBills 1885and 1909 are located at the General AssemblyLibrary. The draft Hospitals and Charitable Institutions Bill 1906 is found in A.J.H.R., 1908, H-22, pp. 55-76. 3. The number of Boards indicated under "developments" are those at the end of the period. - 4.- The Hospitals Commission Report (1921) gave no list of Boards, but recommended three amalgamations. See appendix IV. - 5. The Consultative Committees recommendations are contained in appendices D and G of its report. 1885 Bill 1885 Act Developments 1886-1908 1906 Bill 1909 Bill 1909 Act 1. North Auckland 1. North Auckland 1 North Auckland 1. North Auckland 1. Bay of Islands 2. Kaipara I. Auckland . 2. Auckland 2. Auckland 2. Auckland 2. Auckland 3. Auckland 3. Coromandel . 3. Coromandel 3. Coromandel 4. Coromandel 4. Thames 4. Thames 3. Thames. 4. Thames 5. Thames 5. Waihi-(l902) J 6. Waihi 4. Waikato 5. Waikato 7. Waikato 5. Bay of Plenty 6. Bay of Plenty 5. Bay of Plenty 6. Bay of Plenty 8. Bay of Plenty 7.. Waiapu (1903) 7. Waiapu 9. Waiapu 6: Cook 8. Cook } 6. Cook 8. Cook 10. Cook 2. Hawkes Bay 7. Hawkes Bay .9. Hawkes Bay Ilawlces Bay 9. Hawkes Bay 11. Hawkes Bay 8. Waipawa 10. Waipawa } 7. 12. Waipawa 11. Palmerston North 8. Palmerston North 10. Palmerston North 13. Palmerston North - 3. Wanganui - 9. Wanganui 12. Wanganui 9. Wanganui II. Wanganui 14. Wanganui 10. PatePates, 13. Patea 12. Patea 15. Patea 4. Taranaki 11. Taranaki 14. Taranaki 10. Taranaki 13. Taranaki 16. Taranaki 15. Hawera (1902) 14. Hawera 17. Hawera 16. Stratford (1904) 15. Stratford 18. Stratford 12. Wairarapá 17. Wairarapa 16. Wairarapa 19. Wairarapa 5. Wellington 13. Wellington 18. Wellington II. Wellington 17. Wellington 20. Wellington 6. Marlborough 14. Wairaü 19. Wairau 12. Marlborough 18. Marlborough 21. Wairau 15. Picton 20. Picton 22. Picton 7. Nelson 16. Nelson 21. Nelson 13. Nelson 19. Nelson 23. Nelson 17. Buller 22.. Buller 20. Buller 24. Buller 18. Inangahua 23. Inangahoa 21. Inangahua 25. Inangahua 8. Westland 19. Grey 24. Grey 22. Grey 26. Grey 20. Westland 25. Westland J 14. Westland 23. Westland 27. Westland 9. North Canterbury 21. North Canterbury 26. North Canterbury 15. North Canterbury 24. North Canterbury 28. North Canterbury 10. South Canterbury 22. Ashburton 27. Ashburton 25. Ashburton 29. Ashburton 23. South Canterbury 28. South Canterbury } 16. South Canterbury 26. South Canterbury 30. South Canterbury 24. Waitaki 29. Waitaki 17. Waitaki 27. Waitaki 31. Waitaki 25. Central Otago 30. Vincent 18. Central Otago 28. Vincent 32. Vincent SI. Maniototo 29. Maniototo 33. Maniototo 26. .Tuapeka 32. Tuapeka 11. Otago 27. Otago 33. Otago 19. Otago } 30. 34. Otago 12. Southland 28. Southland 34. Southland 20. Southland 31. Southland 35. Southland 35. Wallace (1905) 32. Wallace 36. Wallace

a U w Developments 1910-25 Hospitals Commission 1926 Bill and Act Developments 1927-56 Consultative Committee 1957 Bill and Act Developments 1957 (1921) (1953) Auckland R gion: 1. Bay of Islands 1. Bay of Islands 1. Bay of Islands I. Northland (1950) 1. Northland I. Northland 1. Northland 2. Mangonui (1919) 2. Mangonui 2. Mangoniu 3. Hokianga (1919) 3. Hokianga 3. Hokianga 4. Whangaroa (1919) 4. Whangaroa 4. Whangaroa 5. Kaipawa 5. Kaipara 5. Kaipara 6.Whangarei (1913) 6. Whangarei 6. Whangarei 7. Auckland 7. Auckland 7. Auckland, 2. Auckland 2. Auckland 2. Auckland 2. Auckland 8. Coromandel 8. Coromandel 8. Coromandel 9. Thames } 9. Thames 9. Thames } 3. Thames (1939) 3. Thames 3. Thames 3. Thames 10. Waihi 10. Waihi 11. Waikato 10. Waikato 11. Waikato 4. Waikato } 4. Waikato 4. Waikato 4. Waikato 12. Taumarunui (1914) 11. Taumarunui 12. Taumarunui 5. Taumarunui 5. Taumarunni 5. Taumarunui 13. Bay of Plenty 12. Bay of Plenty 13. Bay of Plenty 6. Bay of Plenty 5. Bay of Plenty 6. Bay of Plenty 6. Bay of Plenty 14. Tauranga (1917) 13. Tauranga 14. Tauranga 7. Tauranga 6. Tauranga 7. Tauranga 7. Tauranga 15. Opotiki (1924) 15. Opotiki 8. Opotiki 8. Opotiki 8. Opotiki 16. Matakaoa (1925) 16. Matakaoa 17. Waiapu 14. Waiapu 17. Waiapu } 9. Waiapu (1940) 9. Waiapu 9. Waiapu 18. Cook - 15. Cook 18. Cook 10. Cook 7. Cook 10. Cook 10. Cook Pnlmer.cion Worth Region: 19. Wairoa (1910) 16. Wairoa 19. Wairoa 11. Wairoa 11. Wairoa 20. Hawkes Bay 17. I{awkes Bay 20. Hawkes Bay 12. Hawkes Bay 8. Hawkes Bay 12. Hawkes Bay Ill. Hawkes Bay (1971) 21. Waipawa 18. Waipawa 21. Waipawa 13. Waipawa 13. Waipawa 12. Waipawa 22. Dannevirke (1924) 22. Dannevirke 14. Dannevirke 14. Dannevirke 13. Dannevirke 23. Palmerston North 19. Palmerston North 23. Palmerston North 15. Palmerston North 9. Palmerston North 15. Palmerston North 14. Palmerston North 24. Wanganui 20. Wanganui 24. Wanganui 16. Wanganui 10. Wanganui 16. Wanganui } 15. Wanganui (1968) 25. Patea 21. Patea 25. Patea 17. Patea 17. Patea 26. Taranaki 22. Taranaki 26. Taranaki 18. Taranaki 11. Taranaki 18. Taranaki 16. Taranaki (1968) 27. Hawera 23. Hawera 27. Hawera 19. Hawera 19. Hawera 28. Stratford 24. Stratford 28. Stratford 20. Stratford 20. Stratford Wellington Region: 29. Wairarapa 25. Wairarapa 29. Wairarapa 21. Wairarapa 12. Wairarapa 21. Wairarapa 17. Wairarapa 30. Wellington 26. Wellington 30. Wellington 22. Wellington 13. Wellington 22. Wellington 18. Wellington 31. Wairau }27. Marlborough 31. Wairau } 23. Marlborough (1930) 14. Marlborough 23. Marlborough 19.- Marlborough 32. Picton 32. Picton 33. Nelson 28. Nelson 33. Nelson 24. Nelson 15. Nelson 24. Nelson 20. Nelson 34. Butler 29. Butler 34. Butler 25. Butler 25. Buller 35. Inaisgalsua 35. Inangahua 26. Inangahua 26. Inangahua Christchurch Region: 36. Grey J 30. Grey 36. Grey 27. Grey 27. Grey 37. Westland 31. Westland 37. Westland 28. Westland 116. Westland 28. Westland J21. West Coast (1967) 38. North Canterbury 32. North Canterbury 38. North Canterbury 29. North Canterbury 17. North Canterbury 29. North Canterbury 22. North Canterbury 39. Ashburton 33. Ashburton 39. Ashburton 30. Ashburton 18. Ashburton 30. Ashburton 23. Ashburton 40. South Canterbury 34. South Canterbury 40. South Canterbury 31. South Canterbury 19. South Canterbury 31. South Canterbury 24. South Canterbury Dunedin Region: 41. Waitaki 35. Waitaki 41. Waitaki 32. Waitaki 20. Waitaki 32. Waitaki 25. Waitaki 42. Vincent 36. Vincent 42. Vincent 33. Vincent 33. Vincent 26. Vincent - 43. Maniototo 37. Maniototo 43. Maniototo 34. Maniototo 34. Maniototo 27. Maniototo 44. Otago 38. Otago 44. Otago 35. Otago J2l. Otago 35. Otago 28. Otago 45. South Otago (1920) 39. South Otago 45. South Otago 36. South Otago 22. South Otago 36. South Otago 29. South Otago 46. Southland 40. Southland 46. Southland } 37. Southland (1938) 23. Southland 37. Southland 30. Southland 47. Wallace and Fiord 41. Wallace 47. Wallace Appendix IV

COMMISSION TO INQUIRE INTO AND REPORT UPON PROPOSALS TO AMEND THE HOSPITALS AND CHARITABLE INSTITUTIONS ACT 1909, 1921 TERMS OF REFERENCE: 1. (a) The extent to which the Government should contribute towards the capital requirements of Hospital Boards, and the basis upon which such contributions should be given; (b) Generally as to the best means of meeting the heavy cost of proposed capital works. 2. (a) The extent to which the Government should contribute towards the net maintenance requirements of Hospital Boards in the Dominion. (b) The basis of allocation of any such contribution amongst the individual Boards. 3. The extent to which the Government should continue to subsidize voluntary contributions. 4. The extent to which the Government should contribute towards the funds of separate institutions under the Hospitals and Charitable Institutions Act. 5. The extent to which the Government should make grants in aid of various charitable societies and institutions. 6. (a) The fees that should be charged for maintenance and treatment in public hospitals. (b) The establishment of paying or private wards in public hospitals. 7. The present method of allocation of representation of contributory local authorities and the ratepayers on Hospital Boards, having regard also to the nature of the suffrage. 8. The desirability or otherwise of providing for Government representation upon Hospital Boards by means of nominated members. 9. The constitution and area of the present hospital districts, and whether the present grouping of local authorities in the various districts is the best and fairest method of distributing the cost of the base hospitals throughout the Dominion amongst the various local authorities. 10. To what extent economy might be effected by the adoption of stricter business methods, more especially in the purchasing of medical and surgical supplies. SUMMARY OF RECOMMENDATIONS: Capital Expenditure 1. (a) The Government should contribute one-half of the capital requirements of the Hospital Boards. The basis of such contributions should be a flat rate subsidy of JJ1 for C 1 on capital expenditure, and on • interest on loans current in respect of capital expenditure. (b) The cost of minor capital works, and all plant and equipment, should be provided for otherwise than by loan. The cost of erecting buildings, or of making additions or alterations to buildings, or of purchasing land, may be raised by loans. Loans should be repayable by sinking fund within a period not exceeding twenty years for permanent buildings and land, and ten years for wooden or other non-permanent buildings. The Government should provide facilities for Hospital Boards to obtain loans on the most advantageous terms.

244 Maintenance Expenditure 2. (a) The Government should contribute one-half of the net maintenance requirements of Hospital Boards. (b) The basis of allocation of nineteen-twentieths of such contribution among the individual Boards should be on the principle that the heavier the burden of a Boards requirements on the rateable capital value of its district the higher the subsidy, but that the rate of subsidy, per Cl levy should not exceed 26s. nor be less than 14s. in the case of any individual Board. The remaining one-twentieth of such contribution should be specially allocated in equal proportion to the hospitals at Auckland, Wellington, Christchurch, and Dunedin, for the purpose of developing and extending the work of special departments essential to base hospitals, but be not used in any case for ordinary maintenance purposes. In view of the special subsidy contribution, the other Hospital Boards should have the right to send patients for admission to these hospitals for special treatment, on payment of the maintenance fee. In arriving at the burden of a Boards requirements on the rateable capital value of its district, a deduction be made from such rateable capital value of the capital value of all non-rate-producing Native lands.

Voluntary Contributions 3. The Government should subsidize voluntary contributions to Hospital Boards for general maintenance purposes or for specific maintenance purposes approved by the Minister at the rate of Cl for Cl. The Government should, on the recommendation of the Minister, subsidize voluntary contributions, bequests, and devises for capital purposes, or endowments, at the rate of Cl for Cl.

Separate Institutions 4. (a) The Mercury Bay Hospital should be merged in the Coromandel Hospital District. (b) The Oamaru Hospital should continue to be treated as a separate institution under the Hospitals and Charitable Institutions Act, and receive the same scale of subsidies as Hospital Boards. • (c) The Jubilee Institute for the Blind, Auckland, is an educational institution, and as such should be removed from the list of separate institutions under the Act, and in future should receive financial assistance from the Education Department. (d) The Reefton Ladies Benevolent Society be removed from the list of separate institutions and affiliated with the Inangahua Hospital Board. • " .• (e) The Wellingtoon[sic] Convalescent Home, St. Andrews Orphanage (Nelson), Wellington Ladies Christian Association,. Hawkes. Bay Childrens Home, and the Wellington Society for Relief of the Aged Needy should be continued at [sic] separate institutions, and receive the same scale of subsidies as- Hospital Boards on voluntary contributions and bequests.

Voluntary Organizations - 5. The Plünket Society and Salvation Army should continue to receive financial assistanëe from the Government through the headquarters of each organization. • • •

245 The Government should make an annual grant to other charitable societies and institutions, and allot same on the recommendation of Hospital Boards, having regard to the amount of voluntary contributions and the number of inmates. Maintenance Fees 6. (a) A uniform fee of 1J3 3s. per week for adults and £11 Is. 6d. for children under fourteen years should be charged for maintenance and treatment in public hospitals. Boards to have permission to reduce such fees in necessitous cases. Boards to have the power to contract with friendly societies for the maintenance and treatment of their members on a guaranteed payment of one-half the above fees. (b) In order to extend further their usefulness, there should be established in connection with public hospitals, wherever the conditions are favourable, private wards to which patients would be admitted on payment of adequate fees for maintenance and nursing attendance. Such wards to be under the control of the Medical Superintendent, but patients to choose their own medical attendant, and make their own arrangements as to his fees. Representation 7. (a) Section 9 (2), Hospitals and Charitable Institutions Act, 1909, should be amended so as to allocate the representatives of contributory districts in proportion to their respective rateable capital value and papulation [sic], at a ratio of two-thirds on rateable capital value and one- third on population. (b) The existing system of representation and suffrage should continue, except where local contributory bodies having different forms of suffrage are united in one combined district; in such cases the ratepayers suffrage should apply over the whole area. 8. Considering the full power of control of expenditure already possessed by the Minister, Government representation upon Hospital Boards by means of nominated members is not recommended, except that in the case of Auckland, Wellington, North Canterbury, and Otago Hospital Boards, to whom it is proposed to give special financial consideration for base-hospital purposes, it is recommended that there be one member on each Board appointed by the Government; and, further, that in the case of the Otago Hospital Board an additional member be appointed by the Government, to be nominated by the Medical Faculty of the Univer- sity of Otago. Hospital Districts and Hospital Board/Department Interrelationships 9. The constitution and area of the hospital districts should continue as at present, except that the following hospital districts should be amalgamated: Picton with Wairau; Inangahua with Grey; and Waihi with Thames. The public hospitals at Auckland, Wellington, Christchurch, and Dunedin should be constituted base hospitals: See also 2 (b). Economy would be effected to a very large extent by the adoption of the following recommendations: (a) Hospital Supplies Purchase Board should be constituted under the Health Department, composed of one responsible officer of and appointed by each of the four base-hospital Boards, one from 246 the Health Department, one from the Mental Hospitals Depart- ment, and two business men nominated by the Minister. This Board should arrange for the standardization, purchase, and distribution of equipment and supplies for all institutions under the Hospital Boards, Health Department, and Mental Hospitals Department. Hospital equipment and supplies, where possible, should be standardized with a view to economical buying by placingcombined orders, for Dominion requirements for delivery -at centres as required. (b) An Inspecting House Steward should be a permanent officer of the Department. He should introduce an efficient system of recording and checking the receipt and issue of supplies at each hospital, and should report fully to the Department and the Hospital Board , affected, after each inspection. . . (c) Two Inspecting Accountants should be appointed atoncé to introduce a uniform system of accounts and returns. They should check the accounts, stores, and equipment of each hospital at least once a year, and introduce an effective system for the collection of fees by each Hospital Board, and report to the Department from time to time on the operation of such system. They should introduce a uniform system ,of costing at each hospital, and examine into and report to the Department on the cost of maintenance. (d) With, a view to assuring the most efficient design and construction of: hospitals, and the standardizing of buildings, where possible, a specially qualified architect should be appointed, who would be • expected to make a continuous study of the latest developments of hospital-construction. "Wherever possible complete ground- plans providing for ultimate extensions should be prepared, and be conformed to in subsequent building operations. (e) A skilled dietitian should be appointed at once by the Otago Hospital Board, to organize at the Dunedin Hospital, in conjunction with the Home Science Department of the University of Otago, the training of pupil dietitians. As soon as possible dietitians should be appointed at the Auckland, Wellington, and Christ- church Hospitals by the respective Boards. f) A uniform system of medical records should be introduced into all hospitals. (g) It is suggested that as additional accommodation for patients becomes necessary in the largest centres the policy be considered of building secondary hospitals for convalescent and chronic cases. (h) In section 72 (1), The Hospitals and Charitable Institutions Act 1909, in line 1, after the words "When a person receives," there . should be added the words "charitable aid". A clause should be inserted in an amending Bill empowering the Boards of the Auck- land, Wellington, North Canterbury, and Otago Hospital Districts to recover from another Hospital Board the cost of special treatment given by any of them to any bona fide resident of that Boards district. (i) Medical research and the preventive work of the Health Depart- ment should be further developed with a view to improving the national health and thus lessening the need for hospital accommodation. .Source: A.J.H.R., 1921, H 31A, pp. 2, 5, 20-22. 247. Appendix V HEALTH SERVICES ORGANISATION, 1922-74 Table I: Health Services Organisation, 1922 Table la: Health Services Organisation, 1922—Divisional Functions Table lb: Health Services Organisation, 1922—Health District Organisa- tion Table 2: Health Services Organisation, 1947 Table 2a: Health Services Organisation, 1947—Divisional Functions Table 2b: Health Services Organisation, 1947—Health District Organ- isation Table 3: Health Services Organisation, 1974 Table 3a: Health Services Organisation, 1974—Bureau of Medical Services and Drug Control Table 3b: Health Services Organisation, 1974—Bureau of Public Health and Environmental Protection Table 3c: Health Services Organisation, 1974—Bureau of Administra- tive Services Table 3d: Health Services Organisation, 1974—Health District Organis- ation

248 w

Table 1 Health Services Organisation, 1922

MENTAL HOSPITALS INSPECTOR GENERAL Medical Super DEPARTMENT OF MENTAL HOSPITALS intendents HOSPITAL BOARDS (Appendix III) - SECRETARY ----- I Assistant - HOSPITALS DIVISION. Inspectors ..Assistant - - NURSING DIVISION .. - Inspectors - CHILD WELFARE DIVISION MINISTER DIRECTOR- [HEALTH OF HEALTH GENERAL:.. - .-- .. : -. - ...... DISTRICTS OF HEALTH . . . (fabl DENTAL HYGIENE DIVISION Dental Officers ...... , . DEPUTY -...... I School Medical - School L - - SCHOOL HYGIENE DIVI$ION Officers Nurses

OF HEALTH ...... , I -. MAORIHYGIENE HGWNP DIVISION . Maori Health LJ Village Councils Committees I I I I t - PUBLIC HYGIENE DIVISION • I TERRITORIAL BOARD OF HEALTH LOCAL AUTHORITIES

See Table la for divisional functions. - Table la: Health Services Organisation, 1922—Divisional Functions Secretary Administration Hospitals Division Inspection of Hospitals Finance Co-ordination of Development - Departmental Hospitals Nursing Division Registration of Nurses and Midwives Licensing of Private Hospitals Child Welfare Division Publicity on Child and Infant Welfare • Co-ordination with Plunket Society Programmes Dental Hygiene Division School Dental Service Dental Nurse Training Education School Hygiene Division •. Medical Inspection of Pupils and Teacher Trainees Education Maori Hygiene .Division, Maori Health Service Maori Nurses Education Public Hygiene Division Disease Control Food and Drug Administration Quarantine Sanitary Work Bacteriology Laboratories Sera

Table ib: Health Services Organisation, 1922—Health District Organisation IPort Health Officers - Medical Officers of Health iInspectors of Health Health Districts: North Auckland, Auckland, Hawkes Bay, Wanganui-Taranaki, Wellington, Canterbury, Otago. Table 2: Health Services Orianisation, 1947 HOSPITAL BOARDS (Appendix III) • CHIEF CLERK! Inspecting .....J SECRETARY Investigational Officer Accountant I L Accountant - - HOSPITALS DIVISION Inspectors Assistant -- ••1 Inspectors I L. Inspecting House I Manager I • L Architectural & Tech---j nical Inspectors I Special Departmental l4ospitals - ___ J MENTAL HYGIENE DIVISION DIRECTOR- NURSING DIVISION 13 HEALTH MINISTER GENERAL DISTRICTS OF HEALTH OF HEALTH TUBERCULOSIS DIVISION (Table 2b) SCHOOL HYGIENE DIVISION DEPUTY MATERNAL WELFARE DIVISION L DIRECTOR DENTAL HYGIENE DIVISION - Dental Officers - Dental Nurses GENERAL OF HEALTH HEALTH BENEFITS DIVISION. INDUSTRIAL HYGIENE DIVISION— Nurse Inspector of Industrial Hygiene Principal Inspector PUBLIC HYGIENE DIVISION of Health TERRITORIAL BOARD OF HEALTH ______• LOCAL AUTHORITIES See Table 2a for divisional Source: Department of Health, Outline of Health functions. - Administration in N.Z, Wellington, 1946. Table 2a: Health Services Organisation, 1947—Divisional Functions

Chief Clerk Staff Training Staff Diiön Librarian Typists Records and Despatch . Correspondence Board Administration Secretarial Duties -.

Secretary ... - Departmental Accounts Hospital Accounting Inspection of Hospital Board Offices - Finance Statistics Revision of Hospital Board Estimates Inspection of District Offices. Division of Medical, Hospital, and Related Benefits

Hospitals Division i Inspection of Hospital Board Administration Stores. Accounting ...... Purchase and Control of Transport Departmental Stores Sera and Vaccine Advisory Services Technical Advisory Services

Mental Hygiene Division.... Mental. Hospitals.. . •. -- -. Psychiatric Clinics.... w Nursing Division Nursing Inspection - Nurses Registration Departmental Nursing Services Nursing Advisory .Services Islands Nursing Service Tuberculosis Division Co-ordination and Direction of Tb Services Inspection of Services Development of Public Health Institute Supervision of Health of Nurses School Hygiene Division Medical Inspection and Health Supervision of School Children Inspection of School Buildings Diphtheria Immunisation Admission to Health Camps Medical Examination of Teacher Trainees (1 Maori Hygiene Milk in Schools Health Education Maternal Welfare Division Maternal Welfare Licensing and Supervision of Private Hospitals St Helens Hospitals Inspection of Public Hospital Maternity Services Dental Hygiene Division School Dental Service Dental Health Education Dental Nurses Training and Hostels Dental Bursaries - Health Benefits. Division Social Security Health Benefits Control Pharmaceutical Committee Medical Bursaries Table 2a: Health Services Organisation, 1947—Divisional Functions—continued Industrial Hygiene Division Industrial Hazards Factory Supervision Liaison with Labour Department Public Hygiene Division Infectious Diseases Food and Drugs Water Supplies Sanitation Offensive Trades Dangerous Drugs Cemeteries and Cremation Port Health Quarantine Health By-laws Ui International

Table 2b: Health Services Organisation, 1947—Health District Organisation District Chief Clerks Medical Officers ) Nurse Inspectors ji District Health Nurses St Helens Hospitals Medical Officers of Health Port Health -Officers. Medical Officers to Maoris Principal Dental Officers District Inspectors . Inspectors of Health Dangerous Drugs Inspectors Health Districts: North Auckland, Central Auckland, South Auckland, Thames-Tauranga, Taranaki, East Cape, Wellington - Hawkes Bay, Central Wellington, Nelson-Marlborough, Canterbury, West Coast, Otago, Southland. Li w Table 3: Health Services Organisation, 1974 HOSPITAL BOARDS (Details App. III) Bureau of DIVISION OF HOSPITALS DEPUTY Medical. DIVISION OF MENTAL HEALTH - DIRECTOR- Services I. GENERAL and Drug DIVISION OF CLINICAL, OF HEALTH Control . . SERVICES ...... (Table 3a) DIVISION OF NURSING

DIVISION OF PUBLIC HEALTH DIVISION OF DENTAL HEALTH Bureau of DEPUTY Public NATIONAL HEALTH 18 HEALTH MINISTER - Health DISTRICTS - GENERAL - - GENERALOF HEALTH nviron-.£. NATIONAL AUDIOLOGY OF HEALTH OF HEALTH (Table 3d) n . - ._Li1 I flLI (rUuuC Protection . . Health) (Table 3b) NATIONAL RADIATION LABORATORY NATIONAL HEALTH STATISTICS CENTRE

MANAGEMENT SERVICES RESEARCH UNIT DEPUTY Bureau of,-. FINANCE. DIRECTOR- - GENERAL - 1:1s.ADMINISTRATION OF HEALTH Services ADMINISTRATIVE SERVICES (Table 3c) TO: Hospitals Division TERRITORIAL . 1.11. Other Divisions 1 . J LOCAL BOARD OF HEALTH AUTHORITIES Source: A. J. H. R., 1972, H-31, p. 128. F7

TàbleSa: Health Services Organisation, 1974—Bureau of Medical Services and Drug Control

Division of Hospitals Medical and Paramedical Education Physical Medicine and Rehabilitation Private Hospitals PUblic Hospital Services, Staffing and Works Welfare Services

Division of Mental Health Child Health Clinics Mental Health Community Services Psychiatric Hospitals Psychiatric Security Unit Psychopaedic Hospitals

Division of Clinical Services Drugs, Narcotics, and Therapeutic Poisons Pharmacy Services Primary Medical Practice Services Social Security Health Benefits ---Special Area Medical Practitioners

Division of Nursing Hospital and Domiciliary Nursing Services Nursing Education Public Health Nursing Services

a Aft w

Table 3b: Health Services Organisation, 1974—Bureau of Public Health and Environmental Protection Division of Public Health Air Pollution Disease Control Environmental Protection Family Health Food and Nutrition Health Education Publications and Production Occupational Health and Toxicology Division of Dental Health Dental Health Education Dental Nurse Training School Dental Service , Social Security Dental Benefits (1 National Health Institute National Audiology Centre National Radiation Laboratory National Health Statistics Centre Table 3c: Health Services Organisation, 1974—Bureau of Administrative Services Finance Budgets and Forecasting Finance and Accounts Investigations Supply

Administration Accommodation, Transport, Works and Office Equipment Office and Library Services Remuneration and Conditions of Employment Staff Administration and Training

Administrative Services to Hospitals Division Advisory Services Clerical and Executive Services Conciliation and Arbitration Public Hospitals Equipment, Land and Works Finance Staff Administration

Administrative Services to Other Divisions Clinical Services Computer Services Mental Health Dental Health Office Inspection and Management Services Nursing Public Health

a Am w

Table 3d: Health Services Organisation, 1974—Health District Organisation

C Medical Officers I (Family Health) Medical Officers of Health—Deputy Medical Senior Inspectors of Health—Inspectors of Health Officers of j District Executive Officers Health (Administrative Services) 1Nurse Inspectors—Public Health Nurses I Health Education Officers 1Principal Dental Officers—Dental Nurse Inspectors—Dental Nurses Health Districts: Whangarei, Takapuna, Auckland, South Auckland, Hamilton, Rotorua, Gis borne, Napier, New Plymouth, Wanganui, Palmerston North, Hutt, Wellington, Nelson-Greymouth, Christchurch, Timaru, Dunedin, Invercargill.

cT- (0. Appendix VI DR MACGREGORS VIEWS ON HOSPITAL AND CHARITABLE AID SERVICES IN NEW ZEALAND, 1898 In studying year after year the working of our, hospital and charitable- aid system I am more and more struck with two things: First, the tendency in every charitable movement to look to the initiative of the State; and, second, the consequent ostracism of charity. I desire to draw attention to the genesis and effects of that extraordinary development among us of the sentiment of benevolence so impulsive in its character, and so strongly vicarious in its methods, and which I consider to be one of the greatest characteristics and one of the chiefest dangers of our colonial communities. In searching for causes we must often go far afield. In trac- ing down the stream of tendency the chief thing is to make sure that you have got into the main current. There is no doubt that the main current of this impulsive humanitarianism, so markedly vicarious, of our people has it main source in the Christian doctrine of the brotherhood of man that, like sunrise on the sea, marked the inauguration of our era. Up to the great reaction of the sixteenth century the kings justice, supplemented by Christian charity, covered the functions of law and (optional) morality. That part of conduct which society has to make compulsory if it would secure its own existence is law. Now, among us, the wonderful thing is, that we seem to have despaired of charity and duty, and perhaps our most marked tendency is to place under legal compulsion as large an area of human conduct as possible. Up to almost our own time the movement of progress was in the contrary direction. The goal was to confine the States action so far as possible to the security of person and property, and the measure of Britains superiority over other nations was held to lie in the extent to which the activity of her citizens could with safety be left free from compulsion. How has it come about that our idea of freedom has been so transformed? The Protestant reaction was against the supremacy of the Church and the king. Private judgment in matters of faith and private enterprise in action were the new ideals of freedom. The whole movement which culminated in England just before the birth of her younger colonies meant the reinstatement of the individual, and the curtailment of community. Once it was admitted that in matters of faith every man was free, it became manifest that this freedom carried with it the right and duty of every free agent to provide also for himself and his family. If, however, the worker so takes his destiny upon himself here as well as hereafter it must be at his own peril. Success, may indeed, crown his efforts—he may become a millionaire; but then, on the other hand, what if he fail? Oh, that is another matter. Then, indeed, he must be handed over to the minimum compulsory charity whose symbol is Bumble. Surely this can never be what our fathers meant by freedom. This means for most of us simply freedom to starve. Just so, but you would have it; and that is the alternative offered by justice from the basis of your own claim for the right of the individual to think what he likes and do what he likes. Hume, Adam Smith, and Mill were the prophets of this individualistic dispensation. Under it private judgment, emancipated from the restraint of authority, rushed headlong into sectarianism, and while the sects were quarrelling the capitalist ran away with the profits of the whole period of Englands industrial supremacy, and the masses of her people lapsed. Lassalle, like a new Peter the Her- mit, had proclaimed a new crusade to recover the Promised Land, for

260 had not the Chartists made it clear that there was no road thither through individualism. Civilisation had got into a cul-de-sac, like the Nile, the river of civilisation, where it is imprisoned and its current lost in the Central African morasses. Wordsworth said of this time, "England, thou art become a fen of stagnant waters." The outlet for which England was tentatively groping she found through the colonies. The colonial system of Wakefield contained germinal ideas secreted from the blood of an individualistic civilisation, which were destined to inoculate the whole maternal system with a generative impulse issuing in an amazing trans- figuration, first of the colonies, and then, reflexively, of the empire itself. Britain was painfully, yet obscurely, conscious that something was very much amiss in her organization, some grevious maladjustment between the workers and their environment, and, behold, she was already in labour with a new birth, a renovating idea. That is natures method of reformation. Somewhere in the organism, and somehow impregnated, a vital germ is lodged without observation and waits till the time is ripe. In this new idea of the true relation of the individual to the community, which found expression through Kant and Darwin, there lay latent portentous presages of change. The great popularising writers, as, for instance, Carlyle and Ruskin, and the poets, transformed the dismal view of society presented by the economists. A new revelation was given of the peril to the nation of an inadequate view of the nature of the individual. It was not safe to substitute the frying-pan for the censer. The old idea, self-love, as defined by "each man for himself," had led to chaos. It was not true that, given security by law for person and property, the individual reason and conscience might be safely trusted for all the rest. It was not true that charity would supplement the shortcomings ofjustice, and that national harmony would result from that ideal of freedom. This the majority were driven at length to see meant for them that each man must work out his own salvation or damnation, as the case might be. That theory had actually issued in damnation for large masses of the people. Men must recast their ideas of freedom and justice, for was it not clear at length that in capitalistic England freedom had come to mean freedom to go to the devil each in his own way, and that justice meant "Devil take the hindmost"? Not merely justice, but faith and hope and charity, must be recast in another mould. Of the sister graces,. Faith, Hope, and Charity, Hope alone is always inextinguishable: she springs eternal. Faith has always been liable to periods of eclipse during which the timorous, the real infidels, are terrified she may expire in the clutch of the dragon. The reason is that because of her unappeas- able yearning for systematic completeness Faith will persist in crystal- lizing herself too soon. She is impatient of the slow march of science with its exhaustive method. Life is too short, so she takes the selective. method of the poet—selective for a purpose discernible by the individual—and accordingly her reign is catastrophic. The socialist has despaired of her last individualistic construction where heaven is defined as a deferred consolation for the injustice and misery of life. He will have none of this bourgeois ideal of heaven by double-entry, so he is going to found a new heaven and a new earth, from which faith is to be excluded just as. Plato banished the poets from his republic, for did they not calumniate. the gods? Faith is discredited in his eyes, and Charity must bundle and go with her sister, for did she not cling to her like ivy, round a ruined. tower? The democracy hate her, for was it not she with her meretricious allurements that glorified the sanctuary of Mammon? . .

261. In the early life of the colonies, while the traditional spirit of laissez faire was still powerful, it was gradually found that the social sanction (richesse oblige) was too weak to enable commercial charity to make up for the defects of justice The social sanction, in spite of its power in an old country, had failed with all its hold upon the past, "the heroic wealth of hall and bower." Some of its most potent elements at Home were incapable of transplantation here, . while others were slow growing and took too long to mature. So it came to pass that the inadequately restrained rapacity of the individual in the "early days" was allowed to appropriate our most valuable lands in unreasonable quantities. This gradually brought about an acute struggle between the old ideas of property and the new colonial spirit of collective community with its resolve to nationalise the lands. The example of the colonies in this department of public policy reacted most powerfully on the legislation of the Empire, for did it not array the national conscience against its own policy in Ireland? Here we find ourselves, then, in the midst of a violent recoil of our majority against the bourgeois construction of earth and heaven. The humanitarian reaction which began, approximately, with the Victorian era has armed itself here in New Zealand with the trident of taxation in despair of Justice, for has not her bandage simply prevented her from seeing the capitalist sitting in the scale of her balance, and is not her sword rusted through? This three-pronged taxation, our new-found means of social salvation for the democracy, is to raise revenue, but also to foster native industries and nationalise the land. I believe that my experience of the working of our charitable-aid and hospital system has shown such dangerous elements in this humanitarian reaction as makes it dangerous to go further in the direction of using taxation not merely for revenue, but also as an instrument for social reform. I crave indulgence if I seem to introduce matters which may be considered irrelevant, but let us ponder this new departure, for the question is vital. What is the one thing needful for our humanitarian reaction arming itself with the trident of taxation as its great means of social reform? The old prescription, "Know thyself." What means this new spirit, and what are its elements of danger? As I have indicated, charity has among us become vicarious, and therefore hateful to the working-classes. Even an old-age pension becomes offensive if she is allowed to touch it. And can we wonder at it? Was not she, as well as Faith, her sister grace, seduced into an improper intimacy with Mammon? But society has now to face the demands for their rights in the name of Justice of those who heretofore asked only for a dole from Charity. The whole of the helpless and dependent poor have so effectually been taught to consider themselves members of the family, and such undoubtedly they must be acknowledged by their mother society to be, however degenerate they have become. She is their mother. They will no longer be kept in ignorance of their rights in such a nursery as State Charity kept. What if we are weak, deformed, vicious, criminal, insane, idiots, imbeciles, inebriates, many of us incorrigible? Did we ask you, 0 mother, to bring us into the world? Why have you farmed us out so long to the salaried tenderness of Charity, who is no better than she should be, and, besides, has brutally ill-treated us, . earning her wages by simply keeping us out of sight? The time has come when the clay can and does say to the potter, Why hast thou made me thus? Charity must be discharged, we demand 262 justice. A seat at the board and by the fireside of our mother. Even if we are bad, you, at any rate, must put up with us, for your neglect has made us what we are. At any rate, you have got to keep us. Society, convicted of sin, stands aghast at the appalling task which her own neglect in the past has set her. At first, as was natural, her distress was hysterical and paroxysmal. She would rush headlong into all sorts of irrational and fantastic atonements. She has actually spent in hare- brained and futile schemes much more a thousandfold than would have prevented these Helots from ever existing. Observe, her immediate impulse was merely to recover her self-respect, and not to show any intelligent regard for the outcasts. This was the characteristic of that movement of social reform which coincides roughly with the Victorian era, and which may be called modern humanitarianism. The first fruits of the frantic repentance of society were subtly and spiritually selfish. Gradually reason and common-sense are beginning to interpenetrate her remorse, and it is becoming apparent to the reflecting among philanthropists that Charitys new alliance with science shows signs of emerging in a rational philanthropy. Societys remorse and repentance must cease to be merely self-regarding. She must think more of her victims and less of herself. Above all, she must form a clear idea of the magnitude of her mission of amelioration. She must try to understand her victims and the influences which have made them what they are. This axiom of rational remedy she is now almost prepared to hear discussed. She will accept it as her postulate by-and-by. The Victorian era, as I have said, may be taken as coextensive with this reforming reaction. Though a hundred and twenty-four years have elapsed since John Howard began his crusade, yet it was as late as 1813 when Elizabeth Fry revealed the state of things in the Newgate of her day. She found "women chained to the ground lying in a dark cell, on straw changed only once a week, clothed only in a petticoat hardly visible for vermin." That was a harrowing sermon, containing seed which, however slow to germinate, at length sprang up as in the parable. The reforming movement went on, gathering in volume as it went. The long peace, the rapid multiplication of wealth and luxury, generally softened down the indifference to pain which accompanied the rugged strength of our grandfathers. They were careless of the infliction of pain, but then they were willing to endure it. Meredith has given us an immortal type of this masculine age in "Kirby the Old Buccaneer." Dickens and Reade were, however, the more congenial prophets of sympathy, and they have largely formed the public sentiment of our time. It would take me too far to analyse the incalculable effects on our sympathy with pain, of the abolition of surgical pain by anaesthetics, or to show (as no good can come to man but evil shadows it) how our rapidly intensifying sensitiveness to pain (hyperaesthesia) has at length developed in us an intolerance of, and a shrinking from, pain so great and even effeminate that our grandfathers would scornfully deny that they could have had anything to do with the begetting of us. Hard on the advent of the anaesthetic came the widespread craving for narcotics, a most momentous and influential ingredient in our neurotic pathology to-day. Consider in this connection Exeter Hall, and all that it symbolizes, whilst the old Adam is at work among Matabeles (Trooper Halkett), Soudanese, and Afridis. Consider, also, how nature is trying unconsciously, through the tremendous invasion of athletics, to save herself from total emasculation. She is afraid, without being clear

263 as to the meaning of it, that the rough animal may disappear before she can afford it. Will even war be required.• to save our manhood? Who can estimate the loss or gain in the exchange we seem to be making when we replace our grandfathers carelessness in inflicting an enduring pain with a far smoother but deadlier unscrupulousness, such, for instance, as lately marked the action of some South African syndicators. it is to the full as perilous to our national welfare to make passionate pity, for all pain our guide as we have found it to be to erect the individual as an end for himself. This gives rise to many evils which, I fear, we are shutting our eyes to, and these evils I would sum up in our fostering those tendencies that make for degeneration. The central fact in organic nature, and the fact which makes the whole intelligible, is the struggle for existence, if we will only look at it in its twofold aspect. Looking on the one we see in it natures provision for all kinds of superiorities, without which all goodness would .rot off the earth. The other side (separable only by the conditions of our intelligence) shows us natures method of eliminating all incompetence by the slow process of degeneration. The dread alternative is nakedly faced. No humanitarian sentiment here. The universe of life could not exist on any other terms. To be strong is happiness; to be weak is misery. So far as nature goes, without human co-operation justice means success, and mercy is called forth by failure, with its various stages of vice and disease. Before the advent of man, on whom nature has laid the whole burden of amelioration, justice and mercy meant this simply: Succeed and be blessed; fail and be damned. De- generation takes charge of the elimination of the unfit; vice and disease, its ministers, marshal the recalcitrants to death. With the graving-tool of destiny God is disclosing the statue immanent in the block. But what of the chips and the shavings? Is there no mercy for them? The mercy of God must flow through the intellect and conscience of man. God made man in his own image, his coadjutor and fellow-worker. Happiness for man is the unfolding of this Divine kinship. Mans reward is the smile on the stern face of Duty, and his proper work to raise the fallen. But how? By patient investigation of the laws of degeneration. Thus, Degeneration is the awful minister of Justice, and her processes are slow and hidden as the evolution she subserves. This fact has always been known to the wise, but science at length is able to decipher the processes of decay. Ceasing to aspire we begin to die; decomposition sets in the moment the vital force begins to ebb. Decay begins at the top in the dissolution of our latest and most precious acquisitions. We can demonstrate, at any rate, its grosser effects in the cortical cells and fibres of the brain. On the mental side it is easier to grasp the significance of the facts with which every one is familiar. At any rate, no intricate scientific apparatus is required. Degeneration first manifests its insidious effects in diminished resisting-power under temptation. All mental superiority has for its elements vivid sensations, vividly recalled as images by memory; and all inferiority, conversely, has dulled and blurred feelings, dimly recalled as images or motives. This is the fundamental fact both on the intellectual and moral side. Vividness or dulness of feeling in all varying degrees is the common measure of excellence or defect. All education has for its end to stimulate the dull into vividness both in thought and conduct. Omitting the intellectual side of the fact, consider the rationale of motives to action (assuming the instinctive simply as such). The power that deters from, or urges to, an action under deliberation depends on our vivid grasp of the consequences of former deeds. A mans action is vigorous

264 according as his memories are vivid and clear. Feebleness of original impression and distance in time are the enemies of vivid recall. The strong man in thought and conduct is he who can allow for this diminishing effect of distance, who has a high endowment for moral perspective, and who has a keen appreciation of the relative greatness and real attractive- ness of things. As a great sage once said, "The good man is he who is able now to realise what he will feel in the retrospect"—when the chickens have come home to roost. This diminishing effect of distance in thought and conduct is most easily resisted by those whose feelings are keen. Their powers alike of appreciation and resistance when temptation assails depends on the degree in which former experience returns vividly. The able man, then, whether in thought or action, in science or conduct, is he whose vision is vivid. This is the point at which degeneration grips us. For its essence is that it blunts the feelings and blurs the image under recall. The drunkard resolves mightily while as yet his head aches and his mouth is like a lime-kiln, but, alas, it is a vanishing gleam. Vice generally thus means callous and blunted feelings, and that means weakening will, requiring ever a stronger and stronger dose of stimulant to make it respond: that is why man never is but always to be blest. The whole significance of stimulation is here—i.e., in the law of fading vividness—and the wise know that mans proneness to the use of stimulants lies in the power of certain things to brighten and recall the gleam that vanishes with such accelerating rapidity each time we avail ourselves of their influence. Failing alcohol, men will fall back on an alkaloid. The cells of all our bodily tissues obey the same universal law, and all disease is essentially loss of power in these cells to respond to normal stimulation. It is habit that corroborates every acquisition of power, and it is habit that is the agent of degeneration with its inveterate accumulation into vice and disease, whether bodily or mental. "Can we prohibit degeneration?" is like asking, Can we prohibit excretion? Can we retard it? Yes, up to a certain point; beyond that, reason bids us to facilitate the process. But how? By secluding degenerates from the possibility of procreation. I have traced in outline the great movements that have resulted in making charity vicarious and therefore abhorred of the democracy. The new demand is for the legal enforcement of the rights of the "submerged tenth," the means—taxation. This is the key-note of our legislation. It behoves us, therefore, to make clear to ourselves above all things what exactly is meant by this demand for justice. Are we on the basis of an extended municipal and county franchise to give a legal right to maintenance, without restraint on propagation, to all who can successfully simulate inability to earn their own living? That is the question of questions for our legislators to ponder. This sentimental philanthropy operating through taxation prevails among, us to an extent that has . probably never been equalled anywhere. Nowhere is this spirit so plainly manifested as in our charitable-aid and hospital administration. As long ago as 1888 I wrote in my report as follows: "The law of competition, being coextensive with organic life, has for its maxim, The wages of sin is. death, no matter whether the sin be individual shortcoming . or inherited defect. Without this as its fundamental law human society would either never have originated or, having, like Minerva, been miracu- lously born full-grown, it would straightway have, rotted = out existence.. This is the condition—namely, that each should be able to hold its own— that nature has made the test of survival or mere existence as distinguished

265 from well-being. In human society, however, this law, that each herring must hang by its own neck, is modified and controlled by a higher law on which depends the possibility of the family, the tribe, the nation- i.e., the golden rule of conscience. All our social problems—charity, land-nationalisation, sanitation, protection, education—come to nothing more than this: How far is it safe and salutary to suspend the former in favour of the latter—i.e., to be good-natured at the expenses of justice? Our circumstances have stimulated our good-nature to an unnatural degree, and we will soon be in the midst of another reaction. We are beginning to find that we cannot shelter our weakly plants from the wind of selfishness by any hedge that does not induce the still more deadly blight; nay, more, finding the hedge inefficient, must we not pray for the abolition of the wind itself; and demand prohibition of all temptation, because we are too weak to stand it?" To the cold-blooded question of Cain—"Am I my brothers keeper?" —the best of our race in all generations have instinctively replied, We at any rate feel ourselves to be so, and, if we would escape bloodguiltiness, we must be. Every heroic deed has its root in this. To what is due the forlorn struggle of the trades-unionist? Is not even our co-operative worker trying to carry his weaker brother on his back? Surely in past reports I have made it obtrusively clear that our subsidised propagation of the unfit is grotesquely absurd. If want of keen feeling, inherited or acquired, is the beginning of degeneration, and vice is due to increasing bluntness, intellectual and moral; if want of vividness in sensation passing into stupidity is vice merging into crime, then surely whatever tends to petrify feeling is condemned. Could human ingenuity invent a system so perversely adapted to blind all feeling of self-respect and independence in our people as our subsidised charity? My experience as a public officer whose chief business is to analyse the social significance of the tendencies manifested within my departmental scope leads me to say, with all the emphasis at my command, that any community that attempts to concede the right of the degenerate to procreate without restraint is merely subsidising the survival of the unfit. A law tacitly admitting, as ours does, not the right to a bare subsistence merely, but even to modest comfort of all who can assume a sufficiently plausible appearance of poverty is simple delirium. Our lavish and indiscriminate outdoor relief; whose evils I am tired of recapitulating—our shameless abuse of the hospital system—the crowding of our asylums by people in their dotage, kept there because there is no suitable place to send them to, and many of them sent by friends anxious only to be relieved of the duty of supporting and caring for them—what is it all coming to? If society is to be saved from breaking down under the tremendous load of degenerates in esse and posse that it will persist in carrying on the taxes we must accept the portentous significance of degeneration. We must try to grasp its rationale, and see to it that our attempts at palliation no longer are permitted to intensify the process of blunting the peoples self-respect. To use taxation as we are doing—as an instrument of social reform—with any safety, we must somehow provide for the elimination of the unworthy who have become incorrigible. Otherwise the burden will become too heavy for the whole available motive-power of all the religion, all the virtue, and all the good-fellowship extant among men. It will simply. leave the field clear to the predaceous demagogue. It is the old task of Sisyphus: You must alter the grade of that hill, else for ever that "shameless" stone will continue to roll back. Is it not

RM time that, on the hustings, in Parliament, the Press, and the pulpit, this mawkish sentimentalism should be made ashamed of its imbecility? Is there no longer extant among us enough robust manhood and common- sense to cease this sickening cant of cheap philanthropy—cheap, i.e., to our private pockets, but insanely lavish with the taxes? As if all this were not enough, we have enfranchised women, and it remains to be seen whether she will prove herself the apostle of common-sense amidst this abyss of insincerity and humbug. Surely they as a sex are interested in purifying the fountains of life. Must the mother always weep alone? I used to be hopeful of the sobering effect of Direct Taxation, but now the outlook is less promising. Until we make up our minds to seclude— till they become safe—our degenerates and incorrigibles even direct taxation in the interests of the "have-nots" can only bring universal beggary. Taxation of the few by the many in their own interest is the rock ahead of our democracy, especially with our notions of tridental reform. As if the State had a vested interest in the degradation of its people, I find that they, as fathers, mothers, brothers, sisters, are responding to our efforts to sap their self-respect by doing their utmost to throw the cost of maintaining their relatives on the taxpayers. I constantly hear the plea urged that as taxpayers and old colonists they have a right to send their relatives to State institutions. One of the heaviest and most thankless of my multifarious duties is to resist to the best of my ability the swelling tide of pauperisation. Given on one side the full current of our vicarious philanthropy, all the believers in our sympathetic taxation, with direct. access to members and Ministers by those who do not like compulsion to pay what they see their neighbours so easily get out of, and on the other a public officer of whose duty it is a mere trifling addendum that the whole onus of resistance should rest on him, and what can the democracy expect? Consider that nobody cares whether the officer collects the money or not, but that anybody who can be got at cares a great deal indeed, and takes care that he shall feel it if he is too persistent in his exactions, and who can wonder if the time be approaching when the public shall have such servants as its supineness deserves? In all our hospitals and charitable institutions the enforcing of payment for maintenance is le to local bodies, many of whose members are full of this humanitarian zeal, while they are absolutely ignorant of the evils which attend its exercise. Many more of these members are ambitious of a public career, and utilise our charities as stepping-stones to popularity. All the inmates of our charitable institutions and all the adult recipients of outdoor relief have votes, and that,. I say, is a great evil in such circumstances as ours. We have the worst possible form of ad-f ministration for our charities. The local bodies are multiplied so absurdly that the ratepayers and contributors are absolutely tired of voting at the . endless elections, and their representatives are year after year elected in the most haphazard fashion. Nobody cares anything about it. . Another serious evil is that these members are appointed annually; Now, universal experience proves that there is no public office where inexperience is so mischievous and its effects so terribly expensive as in dispensing public charity. Even the shrewdest and hardest-headed defenders of the public purse are unable to resist the appeals and the sights of misery, real and feigned, that come before them, and by the time they are beginning to understand a little their year is up and they mostly retire in despair. Let there be but one or two persistent men on

267 the Board, and nothing is more certain than that, in the present comatose condition of public feeling, they, with the secretary, will get control of the whole expenditure. The evil results of such a state of things are infinite, and nobody takes the slightest trouble to even notice them. Some day the Demos will cry out in its dreams, and some poor official victim will be sacrified to its repose. One of these evil results has often thrust itself on my attention. I mean the impossibility of enforcing any discipline whatever in these institutions. There are so many in search of a mission to secure popularity, and there is no means so cheap and effectual to this end as an agitation to expose some abuse of authority— as if it were still anywhere extant—or, if possible, something like cruelty. Any drunken old reprobate, quite incapable of truth, can easily be found to bring horrible charges against the officers. A letter or two in the papers act like a spark in a magazine, so susceptible and inflammable is our humanity, so explosive our virtue, and so cheap. Nothing short of a Royal Commission will serve as a sop to Cerberus. I have seen dozens of them, and never one worth a penny of the money squandered on them. There is hardly a week that some Commission or other is not at work keeping up turmoil in one or other of our institutions. . . . In the existing mood of public sentiment no popularly elected body can govern these institutions, and much less can any public officer, until these incorrigibles and degenerates are restrained. Our hospital system is also greatly abused. The trustees, everywhere except in Auckland, are lax in enforcing payment from persons who are able to pay their maintenance. . . . I have drawn attention to it year after year, and I have personally remonstrated with members of the Board. They, too, are naturally afraid of resisting the popular demand for cheap medical treatment, and are apt to forget that they are administrators of a public charity. They say they do their best, and perhaps it would be unreasonable to expect them to resist the current of vicarious human- itariansim that runs so high in this town. Here, whenever any movement of a philanthropic kind is started, the first thing as a matter of course is to get up a deputation to wait on the Minister for a subsidy. Medical fees are so high and the hospital doctor so popular that it is difficult to refuse a permit to the hospital. I am glad to find that this year the doctors are beginning to try to check this evil. It never seems to occur to people that medical fees must be high wherever a doctor has sufficient standing to enable him to exact them. For the rest, what with friendly societies on the one hand and the hospital on the other, the pressure on the profession is very great. In all our centres of any size this pressure creates a demand for hospitals, in order that an existing doctor may be subsidised or a new one induced to settle. The usual procedure is: The doctor suggests to some of his influential friends that the district is entitled to a hospital quite as much as such-and-such a place. The local editor isenlisted, letters appear in the paper, some active and ambitious member of the local body sees possibilities in the movement. He heads a deputation to the Minister. Nobody counts the cost. I have resisted to the utmost in such cases, but always in vain. At this moment claims on claims are being urged, and all the obstruction naturally falls to me, and everybody who is interested knows the fact. If things go on as they have been doing, I see nothing for it but that the practice of medicine be taken bodily over by the Government. Certainly this is the point at which the tide of socialism can most easily break through, for the gap in the bank is a big one already. 268 The question is very serious, and is daily becoming more so. Ever since Lister taught the world the part that is played by the microbe and sepsis in disease, it is clear that to operate successfully in serious cases the doctor must have the fullest control of the conditions of treatment. It cannot be denied that hospitals properly constructed, drained, lighted, and ventilated, with skilled nurses and suitable appliances, offer, both to the patient and the doctor, such advantages as no private house can afford. The plea for the extension of the States functions in this direction is therefore becoming steadily more irresistible. This is what the argument comes to. Why not in every place where a doctor can settle found at least a cottage-hospital, that we may get his services cheap; and, where one cannot yet make a living, also found a hospital to enable him to do so? What does it matter if there be no longer any prizes in the profession worth struggling for? That, they think, is no concern of theirs. There are always plenty more doctors. Little do they know that there is no such dangerous enemy of society as an unscrupulous doctor, nor one that the State ought to look after more sharply. This would be going a long way towards taking over the whole practice of medicine by the State. We are half-way there already. Has not the State control of the medical register, and can it not regulate fees far more easily than it can fix the living-wage? It can be done by a Bill, just as you can regulate the weather by fixing the barometer at "Set fair." Our hospitals have practically ceased to be charitable institutions. We have done our best to teach people that it is now a matter of justice, and tridental justice at that. All modern hospitals must have private wards for those who can pay for them. Very good; why not? How many persons from a distance have to come to our large towns for medical treatment? How many lodgers in private houses and hotels who cannot be properly cared for except in a hospital? Are we not to make any provision for these? Admit them to the hospital, then. Are you prepared to allow the doctor to charge for operations done in the hospital a fair fee over and above all hospital charges? Are you prepared to face the consequences of this and allow hospital rooms, hospital nurses, hospital medicines, and other public appliances to be used for the doctors private patients. If you are not, do you expect men of any standing in the then conditions of practice to give their services for nothing, or for a mere paltry salary, to persons who would, in ordinary circumstances, be their private patients outside? One of the inevitable consequences of this tendency will be to throw all our hospitals into the hands of inferior men. And then, how are you to prevent a doctor in practice and who is also attached to a hospital from foisting on it any patient from whom he has taken all he can get in fees, in the well-assured confidence that he will not be asked to pay there; or, if by chance he should be, all he need say is that he cannot pay?... - The ways and devices are numberless in which our hospitals must continue to be abused even as :they are now; and what can we expect if the stigma of charity be removed, and justice takes her place? This . is where we are drifting to. I only ask that we should do it with our eyes open. The real difficulty in this as in all our other institutions is that, in the present state of public sentiment, the right men—the men who in point of ability and integrity can be safely trusted with such functions— are not available. We are -like the swine of Gadara plunging down a steep - place into the sea, possessed by this devil of vicarious charity masquerading as one of the Christian graces. Even the Churches have become infected-.

Me For their rescue-work the Anglican and the Catholic Churches, as well as the Salvation Army, are subsidised. The Presbyterian Church of Otago tried it, but, reminded of their traditions, they retired. Again, look at the leaps and bounds by which our system of female nursing is growing. Stimulated by the demand for an eight-hours day, so desirable in itself if we could only organize society so as to get it, our hospital trustees show a tendency to grant this even where it is not required—I mean in such hospitals as must have a considerable staff to cope with the typhoid season. This happens in some hospitals which, yet, as a rule have easy times because the patients are few. I know hospitals where the nurses are increasing far too rapidly in number—during the slack times they are simply in each others way—where their demands for every comfort are so loud and persistent in the mouths of their humanitarian champions that it looks as if the whole system must break down of its own weight. In all these things I have pointed out, together with much that no one sympathizes with more than I, there is still to be discerned much that comes of thoughtless extravagance fostered by State subsidies, and a very great deal of a corrupting and degenerate philanthropy. The practical outcome of our overlooking the continued accumulation of degenerates among our people by our fostering of all kinds of weakness will necessarily be, if it continues, that society will itself degenerate. Taxation will increase by leaps and bounds, and the industrious and self-respecting citizens will rebel, especially if taxation is expected to meet all the demands of a Legislature that puts our modern humani - tarian idea of justice in the place of charity. Even if the socialist does come, there is a hope that he will see the absolute necessity of prevent.ig the present subsidised propagation of the unfit. He may be expected to see what degeneration means, and to insist that its increase shall stop. While the State is bound to admit that these unfortunates are her children, for whose birth and parentage her own selfish neglect in the past is responsible, yet she must in self-defence take control of them. All of a certain degree of inveteracy must be committed to State institutions, where they shall be kindly but firmly treated—well fed, well lodged, well clothed. Their faculties for improvement must be carefully estimated. and tasks set them which are not beyond their strength. Their lives, left to themselves, have been hopeless failures, because their passions are beyond their control. By our former and existing treatment they are only made worse at enormous expense, atterpting their punishment, their control, or their cure by methods confessedly absurd. r I venture to agree with President Alexander Johnson, of the American National Congress of America last year, that the time has come when every civilised State must say to the degenerate, "I have tried punishing, curing, reforming you, and I have failed; you are incurable, a degenerate, a being unfit for free social life. Henceforth I shall care for you; I will feed and clothe you, and give you a reasonably comfortable life. In return you will do the work I set for you, and you will abstain from interference with your neighbour to his detriment; and one other thing you will abstain from—you will no longer procreate your kind; you must be the last among your feeble and degenerate family." As for the cost of all this—we are already wasting far more by our present foolish methods than wise and complete care would cost. This was contained in embryo in the Bill of 1890.

Source: A.J.H.R., 1898, H-22, pp. 1-7. 270

Appendix VII

SOCIAL SECURITY HEALTH BENEFITS Hospital Services State mental hospital treatment .. .. 1 April 1939 Maternity .. .. 15 May. 1939 Hospital inpatient ...... 1 July 1939 Hospital outpatient .. .. 1 March 1941 X-ray diagnostic services .. .. .. 11 August 1941 District nursing services .. .. 1 September 1944 Laboratory, diagnostic services •. .. 1 April 1946 Artificial aids (outpatient benefits)-- Contact lenses ...... 1 June 1947 Hearing aids ...... 1 November 1947 Artificial limbs ...... 1 April 1948 Surgical footwear .. , .. .. 1 December 1951 Ileostomy and colostomy bags .. .. 5 May 1955 Wheelchairs .. ...... 1 January 1973 Medical, Dental, and Health Related Services Medical benefits (capitation) .. .. 1 March 1941 Pharmaceutical ...... 5 May 1941 General medical services . . 1 November 1941 Physiotherapy .. ...... 1 September 1942 Domestic assistance , ...... 20 December 1944 Dental ...... 1 February 1947 Specialist consultation ...... 1 October 1969 .JIotes: 1. On 1 October 1969, benefit rates were increased for social security beneficiaries and pensioners, and on 1 November 1972, for children until their tenth birthday. 2. Initially for children until their sixteenth birthday, on 1 November 1973, the dental benefit scheme was extended to include dependent children until their eighteenth birthday. Source: Royal Commission to Inquire into and Report upon Social Security, Social Security in New Zealand,Wellington, 1972, p. 555.

271 Appeüdix VIII

THE CONSULTATIVE COMMITTEE ON HOSPITAL REFORM (BARROWCLOUGH COMMITTEE), 1953 Order of Reference The Committee is asked to inquire into and report on matters affecting the administrative control of public hospital and other services provided by Hospital Boards, and, after taking evidence, to make recommendations to the Government for the reform of the present hospital system. In particular, having regard to the changes which have come about since the present system was inaugurated and to the purpose of ensuring that hospital and allied services are organised on an efficient and economical basis, the Committee is invited to report on the following matters: (1) The changes, if any, which should be made in the present functions, powers, and duties of Hospital Boards. (2) (a) With a view to providing adequate hospital services without unnecessary or uneconomic duplication, whether there should be a reduced number of hospital districts each centred on a base hospital with modern equipment and facilities and specialist services. (b) At what centres should base hospitals continue to be maintained and at what centres should base hospitals be newly developed and what aea should be served by each base hospital. (c) If it is not considered that each hospital district should be centred on a base hospital, what other changes, if any, should be made. (3) The changes if any which should he made in the present constitution of Hospital Boards, and in particular: (a) Whether, any change should be made in, the present, basis of representation and method of election. (b) Whether the Government should appoint members of Hospital Boards, and, if so, to what extent and on what basis. (c) Whether any change should be made in the size of Hospital Boards. (d) Whether any change should be made in the term , of office, of Board members. (e) If hospital districts centred on base hospitals are recommended under paragraph 2 above, whether the subsidiary hospitals within the area served by the base hospital should have the services of local committees of management, and, if so, how these committees should be constituted arl what their functions, powers, and duties should be. (4) The system of hospital finance and the steps which should be taken to provide for more effective and efficient control of expenditure. (5) Generally as to any further matters relating to the administration of public hospital and allied services which may be referred to the Com- mittee by the Minister of Health. Summary of Principal Recommendations (a) Reversal of the policy, adopted as long ago as 1885 and even earlier, of placing primarily on local Boards the responsibility of providing hospital services—services which were necessarily of an unintegrated and local character—and replacing it with a new policy under which the Minister is charged with the duty of establishing a comprehensive and 272 integrated hospital service for the whole Dominion. That change in policy is dictatednot only by the new concept of the role of the State, but also by the increasing complexity of modern hospital services. - (b) The setting up of five regional authorities so that the Minister can the more readily and the more effectively discharge his duty through these regional authorities acting as his agents in their respective regions and under his general supervision and control. It is a feature of the suggested regional authorities that neither the members of them nor their staffs should be in the Government service and that the majority of their members will be engaged in their duties on a part-time and voluntary or unpaid basis. An important function of each regional authority is "to determine, in consultation with the Minister and as a fluid and continually developing process, the part which each Hospital Board is to play in an integrated service". (c) The setting-up of twenty-three Hospital Boards in lieu of the existing thirty-seven Boards, each responsible under the general direction and control of its regional authority for the actual management and administration of the institutions in its district and for the provision of hospital and specialist services in that district. In the case of five Metro- politan Boards—one in each region—it is recommended that, because of their special duties and functions, four of their members should be appointed, the others being elected by popular franchise. In the case of the eighteen other Boards it is proposed that all their members should be elected. In the case of all Boards the number of members has been revised to prevent them from being unduly large, and changes in the basis of representation have been recommended. In the case of the Auckland and Otago Hospital Boards provision has been made for University representation, in view of the fact that the Auckland and Dunedin Hospitals are teaching hospitals. Finally, proposals have been made to bring about more co-operation with the Medical Officers of Health. It is claimed that the proposed new scheme of hospital administration will result in a much improved hospital service and that it will facilitate the effecting of economies. It has the merit also of "blending central direction with decentralised voluntary administration". Our hospitals in the past have owed much to the work of voluntary administrators, and though, under modern theories, the State must figure much more prom- inently in the administrative picture it is nevertheless desirable to retain as far as practicable this voluntary element in the control and management of our hospital services. That clement can be retained if the State on the one hand and the voluntary administrators on the other are regarded as members of a partnership to which each brings his own qualifications and experience. Our recommendations in regard to the establishment of this new administrative scheme will, of course, require legislative sanction and the drafting of various rules, orders, and regulations. 10 Principal Recommendations for the More Efficient and Effective Control of Expenditure Upon this topic we have made a number of recommendations which do not call for detailed enumeration here. Few of them require any legislative action. Most of them can be adopted and effected by appropriate action on the part of the three partners in the new service which we envisage (viz., the Department of Health, the regional authorities, and the Hospital Boards). We feel confident that in the recommended new scheme there is

273 machinery which is well adapted to the task of supervising the financial aspects of hospital administration and checking wasteful and uneconomic expenditure. Our recommendations for additional financial assistance to persons entering private hospitals and for private and charitable organisations who undertake the care of aged persons requiring social rather than medical attention may call for legislative action. This seems to be a matter for consideration by the law draftsman. Source: Report of the Consultative Committee on Hospital Reform, Wellington, 1953, pp. 37-40.

274 Appendix IX

VOLUNTARY AGENCIES

NATIONAL VOLUNTARY HEALTH ORGANISATIONS IN NEW ZEALAND AS AT NOVEMBER , 1973 Family Health Childrens Health Camps Board. The New Zealand Family Planning Association (Inc.). Royal N.Z. Society for the Health of Women and Children (Plunket Society). Society for Protection of the Unborn Child. New Zealand Crippled Childrens Society Inc. New Zealand League for Hard of Hearing. Mental Health Al Anon Family Groups. Alcoholics Anonymous. National Society on Alcoholism and Drug Dependence (N.Z.) Inc. Intellectually Handicapped Childrens Society Inc. Recovery (New Zealand) Inc. New Zealand Trust Board for Home Schools for Curative Education. Disease Control Cancer Society of New Zealand. Glaucoma Society. New Zealand Haemophilia Society Inc. National Heart Foundation of New Zealand. National Multiple Sclerosis Society. New Zealand Asthma Society Inc. Muscular Dystrophy Association. New Zealand Federation of Tuberculosis Associations. The Arthritis and Rheumatism Foundation of New Zealand Inc. Paraplegics Associations of New Zealand. Neurological Foundation. Cystic Fibrosis Association of New Zealand. Diabetic Association of New Zealand Inc. Psoriasis Association of New Zealand. Public Health Nutrition Society of New Zealand. Miscellaneous 10 New Zealand Red Cross Society Inc. St. John Ambulance Association. Rehabilitation League (Inc.) Council of Christian Social Services. New Zealand Association of Health Physical Education and Recrea- tion. • Australian and New Zealand Clean Air Society..• Laura Ferguson Trust for Disabled Persons. Royal New Zealand Foundation for the Blind. •

275 Overseas Welfare - - CORSO. Medical Aid Abroad. Volunteer Service Abroad. Lepers Trust Board. Leprosy Mission of New Zealand.

NOTE—There is no national index of voluntary organisationi working in the health field. This list has been drawn from several sources, but may well be.incomplete.

276

Appendix X HOSPITAL BOARD REPRESENTATION AND ELECTION RESULTS 1971 Table I: Representation on Hospital Boards, 1971. Table II: Population Projections (1976-9-1) and Elected Membership on Hospital Boards. Table III 1971 Hospital Board Elections—Results by Constituent Districts. Table IV 1971 Hospital Board Elections—Results by Candidates. Table V: 1971 Hospital Board Elections—Voting Patterns.

Table I: Representation on Hospital Boards Numbers of Repre- Population Hospital Board Constituent Districts 1971 Census sentatives on per Repre- Population Hospital sentative Board Northland Mangonui Co. (P) .. .. 7 116 1 10 617.0 Kaitaia Bor...... 3 501 J Whangaroa Co. .. .. 1 950 1 1 950.0 Bay of Islands Co. (P) .. .. 13 247 . Kawa Kawa Town Dist. .. .. 1 441 2 9 014.0 Kaikohe Bor...... 3 340J Hokianga Co...... 4 338 1 4 338.0 Whangarei Co...... 13 402 2 6 701.0 Whangarei City (P) .. .. 30 746 3 10 592.3 Hikurangi Town Dist. .. .. 1 03lJ Hobson Co. (P) .. .. 5 398 1 1 9 499.0 Dargaville Bor...... 4101 f Otamatea Co...... 6 202 1 6 202.0 Board totals ...... 95 813 12 7 984.4

Auckland Auckland pity (P) 151 580 3 51 310.7 Waiheke Co. 2352 New Lynn Bor... 10029 Mt. Albert Bor. (P) 26151 Newmarket Bor. 1229 2 39 124.0 Mt. Eden Bor. 20084 Onehunga Bor. 15693 Ellerslie Bor. 5062 Otahuhu Bor. 9916 Papakura Bor. 17210 Howick Bor. 12008 3 54991.3 Manukau City. (P) 104024 Papatoetoe City 2.1816 Franklin Co. (P) 17034 Pukekohe Bor. 7590 29 317.0 Waiuku Bor. • .. 2.879 Tuakau Bor. • .. 1814 Devonport Bor. 11022 Takapuna City (P) 24033 60 455.0 NorthcOte Bor...... --9581 Birkenhead Bor. --158191

277

Table I: Representation on Hospital Boards-continued Numbers of Repre- Population Hospital Board Constituent Districts 1971 Census sentatives on per Repre- Population Hospital sentative Board Auckland-cont. Waitemata Co. (P) .. .. 103 769 Rodney Co...... 7 402 Great Barrier Is. Co. .. .. 267 Glen Eden Bor...... 6771 2 71 371.0 Warkworth Town Dist. .. .. 1 425 Henderson Bor...... 5 889 East Coast Bays Bor. .. - .. 15 929 Helensville Bor. .. .. 1 290 One Tree Hill Bor. .. .. 12 961 • Mt. Roskill Bor. (P) .. .. 33 849 1 66 988.0 Mt. Wellington Bor. .. .. 20 178 Board totals ...... 696 656 13 53 588.9

Waikato Waikato Co...... 15 586 1 15 586.0 Hamilton City ...... 74 784 3 24 928.0 Waipa Co. (P) ...... 15065L 1 21 994.0 Te Awamutu Bor. .. .. 6 929 Raglan Co. (P) ...... 9 366 HuntlyBor...... 5 310 1 18671.0 Ngaruawahia Bor. .. .. 3 995 Morrinsvillë Bor. .. .. 4 452 TeArohaBor...... 3200 1 19 163.0 Piako Co. (P) ...... 11 511 Waitomo Co. (P) .. .. 6 419 1 11 261.0 Te Kuiti Bor...... 4 842 Otorohanga CO. (P) .. 8 016 1 9 980.0 Otorohanga Bor. .. 1 964 Matamatâ Co. (P) .. 29 750 Matamata Bor. .. 4 057 2 22 413.5 Cambridge Bor. .. 6 435 Putaruru Bor. .. .. 4 585 J Rotorua City .. .. 31 265 1 31 265.0 Rotorua Co...... 244 1 17 244.0 .Taupo Co. (P) .. .. 14 054 1 24 617.0 • Taupo Bor. .. .. • 10 563 1 Board totals ...... 289 382 14 20 670.1

Thames .. Thames Bor. 5780 2 2 890.0 Paeroa Bor...... :3431 1 3 431.0 Ohinemuri Co. 4072 .2 2 036.0 Thames Co. .3852 3 852.0 Hauraki Plains Co. .5309 2 2 654.5 Waihi Bor. 3 071 3 071.0 Coromandel Co. 3 370- .1 3 370.0 Board totals 28 885 10 2 888.5

Tauranga .. Tauranga Co. 15 655 3 5 218.3 Mt. Maunganui Bor. 87.71 .1 8 771.0 Tauranga City 28188 5 5 637.6 • Te Puke Bor. 3406 1 3 406.0 Board totals 56020 10 5 602.0

2.718

Table I. Reprecentation on Hospital Boards-continued Numbers of Repre- Population Hospital Board Constituent Districts 1971 Census sentatives on per Repre- Population Hospital sentative Board Bay of Plenty .. Whakatane Co...... 14 706 4 3 676.5 • Murupara Bor...... - 2 760 1 2 760.0 Whakatane Bor. .. .. 9 748 2 4 874.0 Kawerau Bor...... 6 687 2 3 343.5 Board totals ...... 33901 9 3 766.8

Opotiki .. Opotiki Co...... 3 948 5 789.6 Opotiki Bor...... 2 608 3 869.3 Board totals ...... 6 556 8 819.5

Taumarunui .. Ohura Town Dist. .. .. 5581 4 1 701.0 Taumarunui Co. (P) .. .. 6 246f Manunui Town Dist. .. .. 8511 4 1 673.0 Taumarunui Bor. (P) .. .. 5 841 f Board totals ...... 13 496 8 1 687.0

Waiapu .. Waiapu Co...... 4 974 8 621.7 Board totals ...... 4 974 8 621.7

Cook .. .. Gisborne City ...... 26 726 7 3 818.0 Cook Co...... 9 919 3 3 306.3 Waikohu Co. .. ;. .. 3 247 2 1 623.5 Board totals ...... 39 892 12 3 324.3

Hawkes Bay .. Hawkes Bay Co. .. .. 21 056 3 7 018.7 Napier City •.. •.. .. -40 186 •. 3 13 395.3 Hastings City (P) .. .. 29 753 3 12 345.7 Havelock North Bor. .. .. 7 284f Wairoa Co...... 5 869 1 5 869.0 Wairoa Bor. ..., .. .. 5 418 1 5 418.0 Board totals ...... 109 566 11 9 960.5

Waipawa .. Patangata Co...... 3 038 3 1 012.7 Waipukurau Co. .. .. 1 200 1 1 200.0 Waipawa Co...... 3 586 3 1 195.3 . : Waipukuraü Bor. .. .. 3 598 3 1 199.3 Waipawa Bor. .. •-.. .. 1 725 1 1 725.0 Board totals .. •.... 13 147 11 1 195.2.

Dannevirke .. Dannevirke Co. .. .. 3 886 3 1 295.3 Dannevirke Bor. .. .. 5 610 4 1 402.5 WoodvilleBor...... 1 517 1 1 517.0 Woodville Co...... 1 497 1 1 497.0 - Board totals ...... 12 510 9 1 390.0

279

Table 1: Representation on Hospital Boards-continued Numbers of Repre- Population Hospital Board Constituent Districts 1971 Census sentatives on per Repre- Population Hospital sentative Board Taranaki .. New Plymouth City .. - 34 314 4 8 578.5 Waitara Bor. (P) .. - 5 1251 1 7 205.0 Clifton Co .. 2 080f. Egmont Co...... - 5 748 1 5 748.0 Taranaki Co. .. 8 682 1 8 682.0 : Inglewood Co. (P) .. 2 9621 1 5 048.0 Inglewood Bor. .. - . 2 086f Stratford Co. .. 5 298 . 1 5 298.0 Stratford Bor. .. 5 398 1 5 398.0 Hawera Co. (P) .. 4 522 Waimaté West Co .. 2 460 1 7 903.0 Manaia Town Dist .. 921 J Eltham CO. (P) .. 30651 1 5 386.0 Eltham Bor. .. . 2 3211 Hawera Bor. .. 8 134 1 8 134.0 Board totals ...... 93 116 13 7 162.8

Wanganui .. Patea Bor. .. .. 1 50 Waverley Town Dist. .. 1 085 - 2 2 995.5 Patea Co. (P) .. .. 2 956. Waitotara Co. .. .. 2 824 1 2 824.0 Wanganui Co. .. .. 2 924 . 1 2 924.0 Waimarino Co. (P) - .. I 583 Ohakune Bor. .. .. 1 418 1 4 360.0 Raetihi Bor...... I .359J Rangitikei Co...... 14 515 ... 2 7 257.5 Marton Bor. .. . . - .. 4 700 . 1 4 700.0 Hunterville Town Dist. .. . 6081 1 3 401.0 Taihape Bor. (P) . .. - 2 793 f Wanganui City ... 35 .782 . 5 7 156.4 Board totals .. .74 497 14 . 5 321.2

Palmerston North Palmerston North City...... 51 893 6 8 648.8 Manawatu Co. (P) 6 4701 1 9 278.0 Foxton Bor...... 2 808 j Feilding Bor. .. .. 9 780 1 9 780.0 Horowhenua Co (P) ...... 12 237 2 8 005.5 Otaki Bor...... 3 774J...... 1 Levin Bor. 13 051 2 6 525.5 Kiwitea Co...... 1. 872...... Oroua Co. (P) ...... - 4763 1 7 559.0 Pohangina Co.. .9 Kairanga Co. 5 747 1 5 747.0 Board totals .. - .. 113 319 . . 14 8 094.2

Wairarapa .. Featherston Co. (P) 3 032 Martinborough Bor...... 1- 390 - . 2 .. 3 256;0 Featherston Bor...... - 2090 Greytown Bor...... 1 725 - Wairarapa South Co. (P) ...... 2.572 :2 4 015.5 Carterton Bor...... 3.734...... Masterton Bor. ..18 494 , 5 3 698.8 ...... MastertonCo...... 4-092...... 1...... 40920- 280

Table I. Representation on Hospital Boards---continued Numbers of Repre- Population Hospital Board ConstituentDistricts 1971 Census sentatives on per Repre- Population Hospital sentative Board

Wairarapa-cont. Eketahuna Co. (P) 14371 •l -. 2159.0 Eketahuna Bor...... Pahiatua Co. (P) 2 238l 2 2 424.0 Pahiatua Bor...... 26105 Akitio Co. 940. 1 940.0 Board totals 45 076 14 3 219.7

Wellington Wellington City 135 677 6 22 612.8 Hutt Co. 50 869 2 25 434.5 Upper Hutt City 20 001 1 20001.0 Porirua City (F) 30-372 2 20 808.0 Tawa Bor. 11 244 Lower Hutt City (P) 58 561 Eastbourne Bor. 4 727 3 24 250.7 Petone Bor. 9464. Board totals 320 915 14 22 922.5 Marlborough .. Marlborough Co. .. .. 9 316 4 2 329.0 Awatere Co. .. .-. .. 1 669 1 1 669.0 Blenheim Bor...... 14 859 5 2 971.8 Picton Bor...... 2824 1 2 824.0 Board totals ...... 28 668 11 2 606.2

Nelson .. Nelson City ...... 29 282 5 5 856.4 Richmond Bor. .. .. 5 707 1 5 707.0 Waimea Co...... 15 825 3 5 275.0 Golden Bay Co. .. .. 3 375 1 3 375.0 Motueka Bor...... 3 874 1 3 874.0 Board totals ...... 58 063 11 5 278.4 West Coast .. Westport Bor...... 4 985 2 2 492.5 Buller Co...... 3 259 1 3 259.0 Greymouth Bor. (P) .. .. 7 9361 4 2 346.3 Runanga Bor...... 1 4495 Grey County ...... 4 437 2 2 218.5 Inangahua Co...... 2 219 1 2 219.0 Hokitika Bor...... 3 332 1 3 332.0 Ross Bor...... 4291 2 2 838.5 Westland Co. (P) .. .. 5 2485 Board totals ...... 33-294 13 2 561.1

•rth Canterbury Amuri Co. 2 706 Kaikoura Co. (P) . .. 3070 1 10 020.0 Cheviot Co. 1 520 Waipara Co. 2 724 Mount Herbert Co . 683 Chatham Islands Co .. 716 • AkaroaCo. 1 552 1 14501.0 Wairewa. Co. .. 687 Heathcote Co. (P) -7 582 Lyttelton Bor...... 3.281-- Malvern Co. - 6,413. . . . 1 13 925.0 -Ellesmere.Co. .(P)...... 7-l2...... --- ....----- ......

281

Table I: Representation on Hospital Boards—continued Numbers of Repre-. Population Hospital Board Constituent Districts 1971 Census sentativeson per Repre- Population Hospital sentative • Board North Canterbury Rangiora Bor. 4 854 —cont. Rangiora Co. (P) ...... 4 020 Oxford Co. 1 561 1 19 834.0 Ashley Co 2 913 Eyre Co. 2 524 Kaiapoi Bor. 3 962 Christchurch City 165 637 7 23 662.4 Paparua Co. (P) 27 147 1 34 283.0 Riccarton Bor. 7 1361 Waimairi Co. 61 490 2 30 745.0 Board totals ...... 319 690 14 22 835.0

Ashburton .. Ashburton Co...... 11 209 4 2 802.3 Ashburton Bor. .. .. 13 312 4 3 328.0 Board totals ...... 24 521 8 3 065.

South Canterbury Temuka Bor...... 3 316 1 3 316.0 Mackenzie Co...... 5 159 1 5 159.0 Levels Co...... 4 804 1 4 804.0 Waimate Co. (P) .. .. 5 3461 2 4 287.0 Waimate Bor...... 3 228f Timaru City ...... 28 326 5 5 665.2 Geraldine Bar...... 1 93fl 1 6 406.0 Geraldine Co. (P) .. .. 4469 f Board totals ...... 56 585 11 5 144.1

Waitaki . .. Waitaki Co...... 9.425 4 2 356.2 OamaruBor...... 13 078 5 2 615.6 Board totals ...... 22 503 9 2 500.0

Otago .. Dunedin City. .. 82 235 7 11 747.9 St. Kilda Bor. (P) . .. 6 4531 1 12 602.0 Green Island Bor. .. 6 1491 Mosgiel Bor. .. 8 377 1 16 517.0 Taieri Co. (P) .. 8 140 Tuapeka Co. (P) .. 4 130 Lawrence Bor. .. 604 1 6 338.0 Roxburgh Bor. ..7501 Tapanui Bor...... 854. Waihemo Co. .. 1 714 Waikouaiti Co. (P) ...... 4 029 . . 18 7.50.0 Port Chalmers Bor. .. 3 007 Board totals , ...... 126 442 11 11 494.7

South Otago Clutha.. Co. . 5713 4 1,428.2 Bruce Co ...... 3.574 2 1 787.0 Balclutha Bor...... 4 601 3 1 533.7 Milton Bor. 2.164 1 2 164.0 Kaitangata Bor...... 1 099 1 1. 099.0 Board, totals ...... 17 151 Il 1 559.2

282

Table I: Representation on Hospital Board.—continued Numbers of Repre- Population Hospital Board Constituent Districts 1971 Census sentatives on per Repre- Population Hospital sentative Board Vincent .. Vincent Co. .; .. .. 3 981 5 796.2 Alexandra Bor. .. .. 3 551 3 1 183.7 Cromwell Bor...... 988 1 988.0 Board totals ...... 8 520 9 946.7 Maniototo .. Maniototo Co...... 2 628 7 375.4 Naseby Bor...... 109 1 109.0 Board totals ...... 2 737 8 342.1 Southland .. Southland Co. (P) 26 847 4 7 225.5 Winton Bor. 2 055 Lake Co. (P) 2 985 Queenstown Bor. 2 159 1 5 404.0 Arrowtown Bor. .. - 260 Invercargill City (P) 47 098 Bluff Bor...... 3 241 6 8 458.8 Stewart Is. Co. .. 414 Gore Bor. (P) 8 648 Mataura Bor. 2 549 1 ii 932.0 Wyndham Town Dist . 735 Wallace Co. (P) . 12 038 Riverton Bor. 1 311 2 7 141.5 - Otautau Town Dist .. 934 Board totals ...... 111 274 14 7 948.

Elected membership only. Sources: The Hospital Boards Representation Order, 1971 (SR. 1971/177); Department of Statistics, Into-ease and Location of Populatios, Wellington, 1972.

283

Table II: Population Projections (1976-91) and Elected Membership of Hospital Boards Elected Projected Populations Projected Population per Representative Present Hospital Board Representatives 1976 1986 1991 1976 1986 1991 Northland ...... 12 100 700 114 000 121 750 8 391.7 9500.0 10 145.8 Auckland ...... 13 813 070 1 080 070 1 225 620 62 543.8 83082.3 94 278.5 Thames ...... 10 29950 33400 35 250 2 995. 0, 3 340.0 3 525.0 Waikato ...... 14 316 200 391 300 433 250 22585.7 27950.0 30946.4 Taumarunui ...... 8 13 650 14550 15 150 1 706.2 1818.8 1 893.8 Tauranga ...... 10 65 750 89250 102 100 16575.0 8925.0 10210.0 Bay of Plenty ...... 9 36650 42 450 45 350 4072.2 4 716.7 5 038.9 Opotiki ...... 8 6 150 6 150 6 150 768.8 768.8 768.8 Waiapu ...... 8 4 300 4 000 4 000 537.5 500.0 500.0 Cook...... 12 42 000 47 000 49 500 3 500.0 " 3 916.7 4 125.0. Hawkes Bay ...... 11 122 600 154 600 172 000 11 145.5 14054.5 15636.4 Waipawa ...... 11 12 550 12 650 12 700 1 140.9 1 150.0 1 154.5 Dannevirke ...... 9 11 900 11 900 11 900 1 322.2 1 322.2 1 322.2 Palmerston North .. .. 14 122 350 145 400 157 900 8 739.3 10 385 : 11 278.5 Wanganui ...... 14 73 600 74800 75400 5 257.1 5342.9 7 5 385.7 Taranaki ...... 13 95 400 103 800 108 500 7 338.5 7984.6 8 346.2 Wairarapa ...... 14 45700 48800 50350 3264.3 3485.7 3 596.4 Wellington ...... 14 356 250 435 700 480 200 25 446.4 31 121.4 34 300.0 Nelson ...... 11 61 600 70 900 76 050 5 600.0 6 445.5 6 913.6 Marlborough ...... 11 31 100 36 750 39850 2 827.3 3340.9 3 622.7 North Canterbury .. .. 14 347 150 407 760 442 040 24 796.4 29125.7 31 574.3 West Coast ...... 13 31 600 32 400 32 800 , 2 4308 2492.3 2 523.1 Ashburton ...... 8 24 800 26 300 26 900 3 100.0 3:287.5 3 362.5 South Canterbury .. .. 11 60 500 59 900 - 61 950 5 500.0 5 445.5 5 631.8 Waitaki ...... 9 21 100 21 100 21 100 2 344.4 2-344.4 2 344.4 Otago ...... 11 128 700 136 550 140 900 11 700.0 12 413.6 12 809.1 South Otago ...... 11 16900 17450 17 750 1 536.4 1 586.4 1 613.6- Vincent ...... 9 9 000 10 400 11 100 1 000.0 1 155.6. 1 233.3 Maniototo ...... 8 2 600 2 600 2 600 325.0 325.0 325.0 Southland ...... 14 117 800 134 550 143 990 8 414.3 9 610.7 10 285.0 Totals .. .. 334 3 121 620 3 766 480 4 124 100 Av.9 346.2 Av.11 306.8 Av.12 347.6 (NI) 2 268 770. 2 809 820 3 107 070 (SI) 852 850 956 660 1 017 030 Excludes appointees. Source: Town and Country Planning Division, Ministry of Works, Population Forecasts 1971.-91, Wellington 1972. Table III: 1971 Hospital Board Election Results by Constituent Districts No. Constituent Districts Districts Districts Where Hospital Board or Combined Where Where No Requisite Districts Election Nominations Number Held Received Nominations Received shburton ckland 5 2 tay of Plenty 2 2 Cook I 2 Dannevirke 1 Hawkes Bay 4 Maniototo Marlborough 2 Nelson 3 2 North Canterbury 5 2 Northland 2 & Opotiki 2 Otago 2 a Palmerston North 3 4 South Canterbury 1 5 Southland 3 2 South Otago 5 Taranaki 1 & Taumarunui 2 Tauranga 2 Thames 4 a Vincent 2 Waiapu Waikato 6 5 Waipawa 5 Wairarapa 4 Waitaki 1 Wanganui Wellington 4 West coast 4 3 Total 153 65 86 Percentage 100.0 42.5 T 56.2 Table IV: Hospital Board Elections 1971—Results by Candidates Total No. Candidates Members Hospital Board Vacancies Elected Elected Unopposed and Appointees Ashburton .. .. 8 4 4 Auckland .. .. 13 2 11 Bay of Plenty .. .. 9 3 6 k...... 12 5 7 evirke .. .. 9 5 4 kesBay .. .. 11 3 8 Maniototo .. .. 8 1 7 Marlborough ...... 11 2 9 Nelson ...... 11 2 9 North Canterbury .. .. 14 2 12 Northland .; .. .. 12 7 5 Opotiki ...... 8 8 Otago ...... 11 3 8 Palmerston North...... 14 5 9 South Canterbury .. .. 11 - 6 5 Southland .. .. 14 5 9 South Otago . . .. 11 11 ..

285

Table IV: Hospital Board Elections 1971-Results by Candidates-cont. Total No. Candidates Members Hospital Board Vacancies Elected Elected Unopposed and Appointees Taranaki ...... 13 12t 1 Taumaranui ...... 8 8 Tauranga ...... 10 7t 3 Thames...... 10 4 6 Vincent...... 9 1 8 Waiapu...... 8 .. 8 Waikato...... 14 6 8 Waipawa ...... 11 11 Wairarapa ...... 14 3 11 Waitaki ...... 9 4 5 Wanganui ...... 14 9 5 Wellington ...... 14 1 13 West Coast ...... 13 4 9 Total ...... 334 144 190 Percent...... 100.0 43.1 56.9 Elected members only. tlncludes one appointee. Table V (a): 1971 Hospital Board Elections-Voting Patterns (1) (2) (3) (4) Percent Hospital Board Registered Electors Maximum Possible Valid Votes Cast (4). Votes (3) Ashburton .. .. 11 546 46 184 5 653 12.2 Auckland .. .. 378 601 844 266 242 788 28.8 Bay of Plenty .. .. 14 562 39 462 15 612 39.6 Cook ...... 19 620 111 847 40 141 35.9 Dannevirke .. .. 6 868 20 489 6 532 31.9 Hawkes Bay .. .. 51 322 141 768 30 201 21.3 Maniototo .. .. 1 819 11 497 7 079 61.6 Marlborough .. .. 15 950 64 604 34 427 53.3 Nelson .. .. 33 260 120 964 58 095 48.0 North Canterbury .. 160 962 695 297 347 924 50.0 Northland .. .. 50 727 100 395 32 883 32.8 Opotiki .. .. 3 136 13 052 .. Otago .. .. 72 963 368 151 156 133 42.4 Palmerston North .. 64 982 234 151 90 810 38.8 South Canterbury .. 28 220 96 221 42 763 44.4 Southland .. .. 55 150 226 916 66 944 29.5 South Otago .. .. 9 703 26 422 Taranaki .. .. 46 272 102 393 2 696 2.6 Taumarunui .. .. 5 904 23 616 Tauranga .. .. 33 369 116 551 15 236 13.1 Thames .. .. 19 632 26 907 10 817 40.2 Vincent .. .. 4 895 17 899 6 307 35.2 Waiapu .. .. 1 885 15 080. 10 610 70. Waikato .. .. 129 718 219 801 74 248 33. Waipawa .. .. 6 868 18 398 Wairarapa .. .. 29 967 90 708 34 400 37.9 Waitaki .. .. 10 881 51 029 20 586 40.3 Wanganui .. .. 38 175 131 199, 51 699 39.4 Wellington .. .. 161 680 633 497. 258 182 40.8 West Coast .. .. 20 269 45 935 22 031 48.0 Total.. .. 1 488 906 4 654 628 .1 684 799 36.2

Suree: Returns from territorial local authorities, and Local AsMority ELections, 1971, unpublished report prepared by the Depart- ment of Internal Affairs, 19 July 1972. 286

Table V (b): 1971 Hospital Board Elections— Voting Patterns by Local Authority Number of Repre- Voting Constituent Registered sentatives Maximum Number Hospital Board Proced- Districts Electors on Possible Valid Per- ure Hospital Votes Votes Cent Boards Cast orthland .. PV Mangonui Co. (P) Kaitaia Bor. 6 115 1 6 115 Whangaroa Co. .. 1; 241 1 1 241 I NA Bay of Islands Co. (P) 8 UK815 Kawakawa Town Dist. 2 17 630 Kaikohe Bor. PV Hokianga Co. .. I 2 211 1 2 211 PV Whangarei Co. .. 7 929 2 15 858 9 564 60.3 Whangarci City (P) UK Hikurangi Town Dist. r 16 462 3 49 386 23 319 47.2 PV Hobson Co. (P) I 5132Dargaville Bor. J 1 5132 Otamatea Co. .. 2 822 1 2 822 Auckland .. Auckland City (P) PV Waiheke Co. 90 376 3 271 128 93 465 34.5 New Lynn Bor. Mt. Albert Bor. (P) I Newmarket Bor. ( 45354 90 708 27 589 30.4 Mt. Eden Bor. I 2 Onehunga Bor. I Ellerslie Bor. J Otahuhu Bor. Papakura Bor. I Howick Bor. 78 873 3 236 619 61 882 26.2 Manukau City (P) I Papatoetoe City PV Franklin Co. (P) I SV PukekoheBor. Waiuku Bor. I 11 412 1 11412 • Tuakau Bor. I SV Devonport Bor. I SV Takapuna City (P) 1 35 897 13 704 38.2 SV Northcote Bor. I> 35897 Birkenhead Bor. I SV Waitemata Co. (P) PV Rodney Co. I PV Great Barrier Is. Co. I Glen Eden Bor. UK WarkworthTownDist. 81 813 2 163 626 46 148 28.2 • NA Henderson Bor. I PV East Coast Bays Bor. I Helensville Bor. .1 One Tree Hill Bor. Mt. Rosklll Bor. (P) . 34 876 1 34876 Mt. Wellington Bor. J Waikato .. Waikato Co... .. 4 125 1 4 125 607 14.7 Hamilton City 36.000.. 3 108 000. 37 560 -34.8- Waipa C. (P) • SV Te Awamutu Bor. 9 805 1 9805 PV Raglan Co. (P) I SV Huntly Bor. •, 9 986 1 9 986 5 652 .56.6 SV Ngaruawahia Bor. I Morrinsville Bor. Te Aroha Bor. - - . 8 319 1 8 319 4460 53.6 PV Piako Co. (P) PV . Waitomo Co. .(P) . Te Kuiti Bor. 1 6 554 1 6554 Ot6rohanga Co. (P) I 4 731 4731 Otorohanga Bor. . f 287 Table V (b): 1971 Hospital Board Elections---Voting Pattern by Local Authority—continued Number of Repre- Voting Constituent Registered sentatives Maximum Number Hospital Board Proced- Districts Electors on Possible Valid Per- ure Hospital Votes Votes cent Boards Cast Waikato—cont. PV Matamata Co. (P) :1 iviaaniaa nor. 36 166 18 940 52.1 Cambridge Bor. 18 083 2 sV Putaruru Bor. - J Rotorua City . 13 651 13651 PV Rotorua Co... 7 735 .7735 PV Taupo Co. (P) 10 729 10 729 7 029 65.5 PV Taupo Bor. } Thames Thames Bor... .. 2 901 2 5802 Paeroa Bor. .. .. 1 567 1 1567 PV Ohinemuri Co. .. 2 704 2 5 408 3 620 66.9 • PV Thames Co. .. .. 5.095 5095 2 807 55.1 • PV Hauraki Plains Co. .. 1 670 2 3 340 3 082 92.3 Waihi Bor... .. 1 955 1 955 1 308 66.9 PV Coromandel Co. .. 3 740 .3740 Tauranga .. PV Tauranga Co. .. 9 363 3 28 089 15 236 54.2 Mt. Maunganui Bor. .. 5930 5930 Tauranga City .. 16 114 S 80570 Te Puke Bor. .. 1 962 1962 Bay of Plenty .. PV Whakatane Co. .. 5 723 4 22 892 13 335 58.3 Murupara Bor. .. 1 108 1108 SV Whakatane Bor. .. 5 163 2 10326 Kawerau Bor. .. 2 568 2 5 136 2 277 44.3

Opotiki PV Opotiki Co. .. .. 1 822 5 9110 SV Opotiki Bor... .. 1 314 3 3942 Taumarunui UK Ohura Town Dist. 4 12828 NA Taumarunui Co. (P) ) 3 207 UK Manunui Town Dist. I 2 697 4 10788 Taumarunui Bor. (P) f Waiapu PV Waiapu Co. .. .. 1 885 8 15 080 10 610 70.4 Cook SV Gisborne City .. 13 560 7 94 920 40 141 42.3 PV Cook Co. .. .. 4 807 3 14421 PV Waikohu Co. .. 1 253 2 .2506 Hawkes Bay SV Hawkes Bay Co. .. 9 168 3 27 504 7 577 27.5 sV Napier City .. 19 638 -3 58914 Hastings City (P) 49 251 19 974 40.6 sV Havelock North Bor. } 16 417 3 Wairoa Co. .. .. 3 289 3 289 662 20.1 Wairoa Bor. .. .. 2 810 2 810 1 988 70.8 Waipawa PV Patangata Co. .. 1 643 3 4929 PV Waipukurau Co. .. 725 1 725 PV Waipawa Co. .. 2 082 3 6246 SV Waipukurau Bor. .. 1 821 3 5463 Waipawa Bor. .. 1 035 1 035...... Dannevirke PV Dannevirke Co. .. 2 081 3 6243 Dannevirke Bor. .. 3 153 4 12612 6532 5 Woodville Bor. •.. 842 1 842 Woodville Co. .. 792 1 792 Taranaki New Plymouth City .. 18 707 4 74828 Waitara Bor. (P) Clifton Co. 4 469 4469 Egmont Co... .. 2 314 2314 Taranaki Co. . 3 625 3625 PV Inglewood Co. (.P) } 2 604 SV Inglewood Bor. 2604 PV Stratford Co. .. 2 265 2.265 SV Stratford Bor. • .. 2 761 2761 288

Table V (b): 1971 Hospital Board Elections— Voting Pattern by Local Authority—coxitinued Number of Repre- Voting Constituent Registered sentatives Maximum Number Hospital Board Proced- Districts Electors on Possible Valid Per. ure Hospital Votes Votes cent Boards Cast , aranaki—cont. PV Hawera Co. (P) Waimate West Co. 3 497 3497 UK Manaia Town Dist. Eltham Co (P) Eltham Bor. 1 300t I 1300 SV Hawera Bor. 4 730 4 730 2 696 57.0 Wanganui .. PV Patea Bor. UK Waverley Town Dist. 3 038 2 6076 Patea Co. (P) } PV Waitotara Co. .. 1 540 1 1540 Wanganui Co. .. 1 369 1369 Waimarino Co. (P) Raetihi Bor. 2 014 2014 Ohakune Bor. J PV Rangitikei Co. .. 3 634 2 7268 Marton Bor.. 1. 3 376 3376 UK Hunterville Town Dist. } 616 1616 Taihape Bor. (P) 47•9 Wanganui City 21 588 5 107 940 51 699 Palmerston North SV MB } Palmerston North City 29 958 6 179 748 82 527 45.9

Manawatu Co. (P) } 4 242 I 4242 Foxton Bor. Feilding Bor. .. 5 570 1 5570

Horowhenua Co. (P) } 11 759 2 23518 Otaki Bor. Levin Bor. .. .. 7 620 2 15 240 7 682 50.4 PV Kiwitea Co. PV Oroua Co. (P) . 3 529 1 3529 PV Pohangina Co. j Kairanga Co. .. 2 304 1 2 304 601 26.1 Wairarapa .. PV Featherston Co. (P) • Martinborough Bor. . 7 163 2 14 326 4 389 30.6 • Featherston Bor. J SV Greytown Bor. PV Wairarapa Sth. Co. (P) . 4 415 2 8 830 4 928 55.8 Carterton Bor. J Masterton Bor. .. 11 696 5 58 480 23 074 39.5 Masterton Co. .. 2 347 1. 2347 PV Eketahuna Co. (P) 1296 Eketahuna Bor. 1 296 Pahiatua Co. (P) 4 758 2 009 42.2 Pahiatua Bor. j. 2 379 2 Akitio Co. .. .. 671 1 671 Wellington ... Wellington City .. 68 591 6 411 546 173 447 42.1 . Hutt Co... .. 23 430 2 46 860 10 953 23.4 Upper Hutt City 9 216 1 9216 SV Porirua City (P) 30 908 13 855 44.8 Tawa Bor. 15 454 2 Lower Hutt City (P) Eastbourne Bor. 44 989 3 134 967 60 030 44.5 Petone Bor. Marlborough .. PV Marlborough Co. 5 914 4 23 656 14 325 60.6 PV Awatere Co... .. 863 1 863 Blenheim Bor. .. 7,728 5 38 640 20 102 52.0 Picton Bor. .. .. 1 445 1445 Nelson.. .. Nelson City .. .. 19 011 5 95 055 45 326 47.7 Richmond Bor. .. 3 755 1 3755 1232 32.8 PV Waimea Co... .. 5 830 3 17 490 11 537 66.0

289

I 10 + Inset

Table V (b): 1971 Hospital Board ElectionsVoting Pattern by Local Authority--continued Number of Repre- Votihg Constituent . Registered sentatives Maximum Number Hospital Board •:Proced Districts Electors on Possible Valid Per- ure Hospital Votes Votes cent Boards Cast Nelson—cont. SV Golden Bay Co. .. 2 146 1 2 146 • . MotuekaBôr. .. 2 518 1 2 518 West Coast .. Westport Bor. . 2 707 2 5 414 Buller Co. .. .. 2 669 1 2 669 SV GreymouthBor. (P) }5 737 Runanga Bor., 4 22 948 12 969 56.5 PV Grey Co. ... 3 156 . 2 6312 4683 74.2. • , InangahuaCo. . ." 1 341 1 1 341 726 54.1 PV Hokitika Bor. .. 2 067 1 2 067 Ross Bor. 2 5 184 3 653 70.5 PV Westland Co. (P) f 2 592 North Canterbur.y. Amuri Co. PV Kaikoura Co. (P) L Cheviot Co. I 5 686 1 5686 SV Waipara Co. • NA Mount Herbert Co. • Châtham Islands Co. .....PV. Akaroa Co. Wairewa Co. 9 432 •- 9 432 5 037 53.4 Heathcote Co. (P) NA Lyttelton Bor. PV Malvern Co. PV Ellesmere Co. (P) 6 908 1 6908 • - . SV Rangiora Bor. PV Rangiora Co. (P) PV Oxford Co. PV Ashley Co. .10 686 10686 7 174 67.1 PV Eyre Co. Kaiapoi Bor. SV Christchurch City .. 84 273 7 589 911 307 126 52.1 SV Paparua CO. (P) L 15 280 1 15 280. 6 630 43.4. PV Riccarton Bor. J SV Waimairi Co. .. 28 697 2 57 394 21 957 38.3 Ashburton .. Ashburton Co. .. 4 271 4 17 084 5 653 33.1 Ashburton Bor. , .. .7 275. 4 29100 South Canterbury, Temuka Bor. . 2 117 1 2117 PV Mackenzie CO. .. 1-515 1 1519 • PV Levels Co. .. .. 1 871 1 1871 - - Waimate Co. .(P) 2 561 2 5122 Waimate Bor. 5 - • NA Timaru City.-. .. 16 360, 81 800 42 763 52.3 Geraldine Bor. ..- PV Geraldine Co (P) - 5 3 792 1- 3792 Waitaki PV Waitaki Co 3-376 4 13 504 . SY Oamaru Bor. .. 7 505 5 37 525 20 586 5 Otago Dunedin City. 49 198 7 344 386 153 250 4 St. Kilda Bor. SV Green Island Bor. 6 758 1 6 758 2 875 42.5 Mosgiel Bor. Taieri Co. (P) 8 917 8917 Tuapeka Co.(P) . Lawrence Bor. Roxburgh Bor. 2 239 2239 - Tapanui Bor. PV Waihemo Co. Waikouaiti Co. (P) . 5.851 5851 Port Chalmers Bor. .

290

Table V (b): 1971 Hospital Board Elections—Voting Pattern by Local Authority—continued Number of Repre- Voting Contituent Registered sentatives Maximum Number Hospital Board Proced- Districts Electors on Possible Valid Per- ure. . Hospital Votes Votes cent Boards . Cast South Otago . .. Clutha Co. .. .. 2 761 . 4 11:044 Bruce Co...... , 2 036 , .2 4072 Balciutha Bor. . .. , 3 200 3 9_600 .. Milton Bor. .. 11 071 1 1:071 KaitangataBor. .. 635 . 1. 635. Vincent . . Vincent Co...... , 2321 5 11 605 3677 31.7 SV Alexandra Bor. . 1 860 3 5 580 . 2 630 47. Cromwell Bor. . 71,4 . 1. 714 Maniototo .. Maniototo Co. . .. , 1 613 . 7 11 291 7 079 . 62.7 Naseby Bor. .. .. 206 1 206 Southland .. PV Southland Co. (P) Winton Bor. 12 364 4 49 456 Lake Co. (P) Queenstown Bor. 4 058 1 . , 4 058 . . 1 317 32.5 Arrowtown Bor. Invercargill City (P) Bluff Bor. 25 529 6 " 153174 57 134 37.3 Stewart Is. Co. . .. , . . . SV Gore Bor. (P) . . . . . Mataura Bor. 6 170 1. . 6 170 UK Wyndham Town Dist. PV Wallace Co. (P) Riverton Bor. 7 029 , 2 , 14 058 8 493 60.4 UK Otautau Town Dist. Abbreviations: (PV) Postal voting. (SV) Voting spread over several days. (MB) Mobile booth. (NA) Not available. . . (UK) Unknown. Number of voting papers issued and returned. fEstimated by the county clerk.

291 Appendix XI

HEALTH SERVICE PERSONNEL TABLE 1: INFORMATION SUPPLIED BY HOSPITAL BOARDS CONCERNING EMPLOYEES SUBJECT TO AWARDS AND INDUSTRIAL AGREEMENTS AS AT 31 MARCH 1974 Employee Group P/Time W/Time Employee Organisations Title of Award I. Accountants See No. 3 Administrative Clerks, etc. 2. Accounting Machinists See No. 3 Administrative Clerks, etc. 3. Administrative Clerks, Switchboard 24 3778 Auckland Provincial District Clerical Northland, Thames, Tauranga, Bay of Operators, Storekeepers, Typists, Local Authorities Officers Indus- Plenty, Opoti]d, Taumarunui, Waiapu Clerical Assistants, Accounting trial Union of Workers Hospital Boards Clerical and Other Machinists, Admitting and In- Workers Industrial Agreements.

quiry Clerks, Telephonists, EE Auckland Hospital Board—Clerical and House Manager, Accountant, Other Officers Industrial Agreement. Receptionist Northland, Thames, Tauranga, Bay ox - Plenty, Opotiki, Taumarunui and Waiapu Hospital Boards Clerical and Other Workers Industrial Agreement. Auckland Clerical Workers Union Auckland Provincial District Local Authorities Officers Industrial Union of Workers. Northland, etc., and other Workers Industrial Agreement. Auckland District Local Authorities and Cook Hospital Board Clerical and Other Other Workers Union Officers Industrial Agreement. Wellington, Marlborough, Westland, Taranaki, Wellington, Marlborough, Nelson,- and Taranaki Local Bodies Nelson, Westland Hospital Boards Officers Industrial Union of Workers Clerical Workers Industrial Agreement. Local Bodies Officers Union Wellington Hospital Board Clerical Workers Agreement. Canterbury Clerks, Cashiers, and Office North Canterbury, South Canterbury, Employees Industrial Union of Ashburton Hospital Boards Clerical Workers Employees Industrial Agreement. Otago Clerical Workers Union Otago Hospital Board Clerical Workers Industrial Agreement. - - Southland Clerical Workers Union Southland Hospital Board Clerical fl Employees Industrial Agreement. MV

4. Admitting and Inquiry Clerks See No. 3 Administrative Clerks, etc. -

5. Ambulance Drivers 2 34 N.Z. Road Transport and Motor and N.Z. Ambulance Driving Officers Award. Horse Drivers and their Assistants Industrial Association of Workers Otago Transport and Motor and Horse Drivers and their Assistants Industrial - - Union of Workers N.Z. Ambulance Drivers Union N.Z. Ambulance Driving Officers Award. Otago Drivers Union ,, - 6. Boiler Attendants See No. 20 Engine Drivers and Boiler Attendants

7. Bootmakers 2 Footwear and Bespoke Workers Union N.Z. (Except Otago and Southland) Footwear Repairers and Bespoke - Workers Award. N.Z. Federated Footwear Trade In- (,0 dustrial Association, Unions of Workers

8. Butchers 8 Northern (Except Gisborne) Butchers, Northern Industrial District (Except Small Goods, and Bacon Factory Gisborne Judicial District and Auck- Employees Industrial Union of land 21 miles radius) Butchers Award. Workers N.Z. Shop Employees Union N.Z. (except Northern .District) Butchers • Award. Southland Retail Butchers Union

9. Canteen Assistants 7 N.Z. Dairy Confectionery and Mixed N.Z. (Except Northern Industrial Dis- Business Shop Assistants Union trict other than Gisborne Judicial District) Dairy, Confectionery, and • - Mixed Business Shop Assistants Award. N.Z. Shop Employees Industrial Union of Workers N.Z. Dairy Confectionery and Mixed Business Shop Assistants Award. INFORMATION SUPPLIED BY HOSPITAL BOARDS CONCERNING EMPLOYEES SUBJECT TO AWARDS AND INDUSTRIAL AGREEMENTS AS AT 31 MARCH 1974—continued

Employee Group P/Time W/Time Employee Organisations Title of Award

10. Carpenters, Painters, and 560 Northland Branch, New Zealand Car- N.Z. (with exception) Building and Plasterers penters and Related Trades In- Related Industries Tradesmen. and dustrial Union of Workers Other Workers Award. Auckland Carpenters and Related Trades Industrial Union of Workers (Auckland Branch) N.Z. Carpenters and Related Trades Canterbury and Westland Plasterers Industrial Union of Workers Award. N.Z. Painters and Decorators Union N.Z. Painters and Decorators Award. N.Z. (Except Hawkes Bay, Wanganui, N.Z. (Except Hawkes Bay, Wanganui, Westland, Otago, and Southland) and Otago) Paintersand Decorators Painters and Decorators, Glaziers Award. and Signwriters Industrial Union of Workers Auckland- Painters and Decorators and N.Z. (except Hawkes Bay, Wanganui Glaziers and Signwriters Industrial Districts, and Otago) Painters and Union of Workers Decorators Award. N.Z. Federated Painters and Decorators Industrial Association of Workers Timaru Society of Painters and N.Z. Painters and Decorators Award. Decorators Industrial Union of Workers N.Z. Painters Union Timaru Sub-branch N.Z. Builders N.Z. Building and Related Industries Union Tradesmen and Other Workers Award. Otago Carpenters Union Otago Hospital Board Carpenters and Joiners Industrial Agreement. Otago Hospital Board Painters Industrial Agreement Southland Building and Related Trades N.Z. (with exceptions) Building and Union Related Industries Tradesmen and Other Workers Award. N.Z. Carpentry and Joinery Industry Apprenticeship Order.

Aak

Li MW

Southland Painters and Decorators N.Z. (Except Hawkes Bay and Wanga- Union ganui Districts and Otago) Painters and Decorators Award. N.Z. Painting and Decorating Industry Apprenticeship Order. Otago and Southland Plasterers Union Otago and Southland Plasterers, Fibrous Plasterers and Tile Fixers Award. 11. Cleaners and Caretakers See No. 34 Nightwatchmen, Cleaners, and Caretakers. 12. Clerical Assistants See No. 3 Administrative Clerks, etc. 13. Clothing Assistants See No. 1-7 Domestics, Porters, etc. 14. Cooks See No. 17 Domestics, Porters, etc. 15. Dental Technicians and Assistants 57 N.Z. Federated Dental Technicians Northern, Wellington, and Canterbury and Assistants Industrial Association Hospital Boards Dental Employees of Workers Award. 16. Dietary Staff See No. 17 Domestics, Porters, etc.

17. Domestics, Porters, Wardmaids, 24 6253 Auckland Hotel Restaurants, Related N.Z. Hospital Domestic Workers Award. Qn Cooks, Kitchenmaids, Orderlies, Trades Industrial Union Laundresses, Clothing Assistants, Canterbury Hotel, Hospital Restaurant Domestic Labourers, House- and Related Trades Employees maids, Male Workers, Dietary Industrial Union Staff and Theatre Orderlies, Taranaki Hotel and Restaurant and Medical Orderlies Related Trades Industrial Union of Workers N.Z. Federated Hotel, Hospital, Restaurant, and Related Trades Employees Industrial Association of Workers Otago Hotel, Hospital, Restaurant, and Related Trades Industrial Union of Workers Southland Hotel, Hospital Restaurant, and Related Trades Employees Industrial Union 18. Domestic Labourers See No. 17 Domestics, Porters, etc. INFORMATION SUPPLIED BY HOSPITAL BOARDS CONCERNING EMPLOYEES SUBJECT TO AWARDS AND INDUSTRIAL AGREEMENTS AS AT 31 MARCH 1974—continued

Employee Group P/Time W/Time Employee Organisations Title of Award

19. Electricians and Fitters, Motor 457 North Island Electrical and Related Northern Taranaki, Wellington, Otago, Mechanics, and Garage Atten- Trades Industrial Union of Workers and Southland Electrical Workers dants Award. N.Z. Engineering, Coachbuilding, Air- New Zealand Hospital Boards Engin- craft, Motor, and Related Trades eering Fitters and Allied Tradesmen Industrial Union of Workers Award. N.Z. Motor Trade Employees Award. N.Z. (except Canterbury, Marlborough, Northern Taranaki, Wellington, Otago, etc.) Electrical Workers Industrial and Southland Electrical Contractors, Association, of Workers Electrical Workers Award. Engineering Fitters, and Allied Trades N.Z. Hospital Boards Engineering Fitters Union and Allied Tradesmens Award. C) N.Z. Electrical Workers Industrial Northern Taranaki, Wellington, Otago, Union of Workers - and Southland Electrical Contractors, Electrical Workers Award. Marlborough, Nelson, Westland, and Canterbury Electrical Workers (Other than Electrical Contractors Em- ployees) Award N.Z. Engineering Union N.Z. Hospital Boards Engineering Fitters and Allied Tradesmens Award. Otago and Southland Electrical Workers Northern, Taranaki, Wellington, and Industrial Union of Workers Southland and Otago Electrical Workers Award Industrial Agreement—Electricians Otago Hospital Board Electricians In- dustrial Agreement. Southland Metal Tiades Union N.Z. Hospital Boards - Engineering Fitters and Allied Tradesmen Award. N.Z. Metal Trades Employees Award.

a 20. Engine Drivers and Boiler 210 N.Z. Engine Drivers, Firemen, Greasers N.Z. Engine Drivers, Boiler Attendants Attendants and Assistants Industrial Union of Firemen and Greasers Award. Workers Southland Engine Drivers, Firemen, Hospital Boards Engine Drivers, Boiler Greasers and Assistants Industrial Attendants, Firemen and Greasers Union of Workers Award. 19. Firemen 110 N.Z. Industrial Union of Workers N.Z. Engine Drivers, Boiler Attendants, Firemen • and Greasers (Hospital Section) Award. N.Z. Engine Drivers, Firemen, Greasers and Assistants Industrial Union of Workers 21. Fitters See No. I q Electricians and Fitters, etc. 22. Gardeners, Groundsmen, and 505 Northern and Taranaki Labourers, Northern Industrial District (Except Labourers General Workers and Related Auckland 10-Mile Radius) Local Bodies Trades Industrial Union of Workers Labourers Award. Auckland and Suburban Local Bodies Auckland Hospital Board Gardeners Labourers and Related Trades In-, and Labourers Industrial Agreement. .0 dustrial Union of Workers Northern and Taranaki Labourers, N.Z. Local Bodies (Rural Section) General Workers and Related Trades Labourers Award. Industrial Union of Workers - ,, General Labourers Award. Wellington, Nelson, Westland, and Wellington, Marlborough, Nelson, and Marlborough Local Bodies other Westland Hospital Boards Gardeners, Labourers and Related Trades Labourers, and other Workers In- Industrial Union of Workers dustrial Agreement. Canterbury and Otago and Southland North Canterbury Hospital Board Gar- General and Builders Labourers and deners Industrial Agreement. Related Trades Industrial Union of Workers Canterbury, Otago and Southland Wellington, Marlborough, Nelson, West- General Labourers Union land, Canterbury, and Otago and Southland Building Quarries, Con- tracting Civil Engineering Con- structional and Allied Industries Labourers and other Workers Award. I • - . - INFORMATION SUPPLIED BY HOSPITAL BOARDS CONCERNING EMPLOYEES SUBJECT TO AWARDS AND INDUSTRIAL AGREEMENTS AS AT 31 MARCH 1974—continued Employee Group P/Time W/Time Employee Organisations Title of Award 23. Gardeners, Groundsmen, and N.Z. Engineering Union N.Z. Metal Trades Employees Award. Labourers—continued The Canterbury, Otago, and Southland Canterbury Local Bodies (Urban General Builders, Labourers, and Section) Gardeners and Labourers. Related Trades Industrial Union of Taranaki Builders and General Labourers Workers Award. Otago Local Authorities Labourers Award. Otago Hospital Board Gardeners Industrial Agreement. Otago Labourers Union Otago Local Authorities Labourers Award. Southland Labourers Gardeners Union Southland Local Bodies Labourers Industrial Agreement. 24. Garage Attendants See No. 19 Electricians, Fitters, etc. NO 25. Hairdressers 7 N.Z. Hairdressers Union N.Z. (Except North Auckland District) o(0 Ladies Hairdressers Award. N.Z. Shop Employees Industrial As- ,, sociation of Workers N.Z. Male Hairdressers and Tobac- conists Assistants Award. 26. Housemaids See No. 17 Domestics, Porters, etc. 27. Kitchenmaids See No. 17 Domestics, Porters, etc. 28. Laundry Workers 1347 Northern District Laundry Dyers and Auckland, Waikato, Cook, Northland, Drycleaners Employees Industrial Tauranga, Taumarunui, Thames, Union of Workers Opotiki, and Bay of Plenty Hospital Boards Laundry Employees Industrial Agreement. Taranaki, Wellington, Marlborough, Taranaki, Wellington, Marlborough, and and Nelson Laundry Workers, Dyers, Nelson Hospital Laundry Workers and Drycleaners Union Award. Canterbury Laundry Workers, Dyers Canterbury Hospital Boards Laundry and Drycleaners Industrial Union of Workers Award. Workers Otago and Southland Laundry Em- Otago and Southland Hospital Boards ployees Industrial Union of Workers Laundry Workers Industrial Agree- ment. Aft MW 29. Laundresses See No. 17 Domestics, Porters, etc. 30. Labourers See No. 17 Domestics, Porters, etc. See No. 23 Gardeners, Groundsmen, etc.

31. Lorry Drivers and Passenger Trans- 189 Northern Drivers Union N.Z. General Drivers Award. port Drivers N. Z. Road Transport and Motor and Horse Drivers and their Assistants Industrial Association of Workers N.Z. Local Bodies Drivers Union of N.Z. Local Bodies Drivers Award. Workers Hawkes Bay Drivers Union N.Z. General Drivers Award. The Blenheim Road Transport and Motor and Horse Drivers and their Assistants Industrial Union of Workers Canterbury Drivers Union N.Z. Passenger Transport Drivers Award. Southland General Drivers Union 32. Male Workers •See No. 17 Domestics, Porters, etc. 33. Motor Mechanics See No. 19 Electricians and Fitters, etc. 34. Nightwatchmen, Cleaners, and 7 Auckland Cleaners Caretakers,. Lift N.Z. Cleaners, Caretakers, Lift Attend- (.0 Caretakers Attendants, and Watchmen Industrial dants, and Watchmens Award. Union of Workers N.Z. Caretakers, Cleaners, Lift Attend- dants, and Watchmens Union 35. Orderlies See No. 17 Domestics, Porters, etc. 36. Painters See No. 10 Carpenters, Painters, etc.

37. Pharmacists 4 195 Auckland Retail Chemists Employees Auckland, Northland, Tauranga, Industrial Union of Workers Thames, and Waikato Hospital Boards Pharmacists Industrial Agreement. N.Z. Hospital Boards Pharmacists N.Z. Hospital Boards Pharmacists In- Industrial Union of Workers dustrial Agreement. N.Z. Shop Employees Industrial As- sociation of Workers and the Auckland Retail Chemists Assistants and Related Trades Industrial Union of Workers N.Z. Federated Shop Assistants In- dustrial Union of Workers Otago Shop Assistants Union Southland Retail Chemists Assistants and Related Trades Union INFORMATION SUPPLIED BY HOSPITAL BOARDS CONCERNING EMPLOYEES SUBJECT TO AWARDS AND INDUSTRIAL AGREEMENTS AS AT 31 MARCH 1974—continued

Employee Group P/Time W/Time Employee Organisations Title of Award 38. Plasterers See No. 10 Carpenters; Painters, etc. 39. Plumbers 132 N.Z. Plumbers,. Gasfitters, and Related New Zealand Plumbers and Gasfitters Trades Industrial Union of Workers Award. Plumbers and Gasfitters Agreement Otago Hospital Board Plumbers and - - - Gasfitters Industrial Agreement. Southland Plumbers and Gasfitters N.Z. Plumbers and Gasfitters Award. Union Auckland Plumbers and Gasfitters Union 40. Porters See No. 17 Domestics, Porters, etc. 41. Seamstresses 303 Auckland Tailoresses and Other Female N.Z. Clothing Trades Award. V V Clothing and Related Trades Em- N.Z. Shirt, White and Silk Workers ployees Industrial Union of Workers V Award. N.Z. Dressmakers and Milliners Award. N.Z. Federated Clothing Trade Em- N.Z. Shirt, White and Silk Workers ployees Industrial Association of Award. Workers Wellington and Taránaki Clothing V V and Related Trades Industrial Union Of Workers •_ Canterbury, Westland, Nelson, and Marlborough Clothing and Related Trades V

Canterbury Clothing Trades Union V N.Z. Textiles and General Manu- facturers Industrial Unioti of Workers Otago and Southland Clothing and Related Trades Industrial Union of V VWorkers V Li MW 42. Storemen and Packers 194 Auckland Storemen and Packers and Northern Industrial District Stores and Warehouse Employees Industrial Warehouse Employees Award. Union of Workers ,, N.Z. Storemen and Packers Award. Storemen, Packers, and General Ware- Northern Industrial District Stores and housemens Union Warehouse Employees Award. Hawkes Bay United Packers and N.Z. (Except Northern Industrial Storemen and Warehouse Employees District) Storemen and Packers Award. Industrial Union of Workers Wellington United Warehouse and Bulk Store Employees Industrial Union of Workers - - N.Z. Federated Storemen and Packers (Other than in Retail Shop) and Warehouse Employees (Other than Drivers and Clerks) Industrial As- sociation of Workers Canterbury Warehouse and Storemens Taranaki, Wellington, Marlborough, (3 and Packers Union Nelson, Westland, Canterbury, and Otago and Southland Storemens and Packers Award. The Canterbury and Westland Corn- N.Z. (Except Northern Industrial Dis- mercial Travellers and Warehouse trict) Storemen and Packers Award. Employees other than Drivers and Clerks and Storemen and Packers (Other than in Retail Shops) In- dustrial Union of Workers The Otago and Southland Wholesale N.Z. (Except Northern Industrial Di g -Storemen and Packers and Ware- trict) Storemen and Packers Award. housemens Industrial Union of Workers Southland Storemen and Packers Union 43. Switchboard Operators See No. 3 Administrative Clerks, etc. 44. Storekeepers See No. 3 Administrative Clerks, etc. 45. Theatre Orderlies See No. 17 Domestics, Porters, etc. 46. Typists See No. 3 Administrative Clerks PK

INFORMATION SUPPLIED BY HOSPITAL BOARDS CONCERNING EMPLOYEES SUBJECT TO AWARDS AND INDUSTRIAL AGREEMENTS AS AT 31 MARCH 1974—continued

Employee Group P/Time W/Time Employee Organisations Title of Award 47. Upholsterers 16 Auckland Furnishing Trades Union N.Z. Furnishing Trades Employees Award. N.Z. Federation Furniture and Related Northern, Westland, Canterbury, and Trades Industrial Association of Otago and Southland Furnishing Workers Trades Employees Award. Apprenticeship Order Furniture Glassworking and Wicker- working Industries Apprenticeship Order. Furnishing Trade Union Taranaki, Wellington, Marlborough, and Nelson Furnishing Trades Employee Award. Wellington, Taranaki, Nelson, and Marlborough Federated Furniture and Related Trades Employees In- dustrial Union of Workers C Federated Furniture and Related Northern, Westland, Canterbury, and Trades and Brushes and Broom Otago and Southland Furnishing Union Trades Employees Award. 48. Wardsmaids See No: 17 Domestics, Porters, etc.

Table 2: INFORMATION SUPPLIED BY HOSPITAL BOARDS ABOUT EMPLOYEES, AND EMPLOYEES ORGANISATIONS RECOGNISED IN TERMS OF THE STATE SERVICE REMUNERATION AND CONDITIONS OF EMPLOYMENT ACT 1969 AS AT 1 APRIL 1974 No. of Whole-time Employee Group Employee Organisation Determination No. Equivalents Architects SHEO DG 26 6 Chiropodists SHEO DG 27 3 Dental officers N.Z. Hospital Boards Dental Surgeons Association/ DG 25 56 SHEO Dietitians N.Z. Dietetic Association (Inc.)/SHEO DG 47 154 Draughting staff SHEO DG 29 11 Engineers N.Z. Hospital Engineers Association (Inc.)/SHEO DG 23 119 Farm managers SHEO DG 43 2

Ask MW

Fire officers SHEO DG 30 9 Food supervisors SHEO/PSA DG 31 99 Gardening staff and ground supervisors SHEO/PSA DG 32 59 Home aids—domiciliary SHEO DG 45 287 Home supervisors SHEO DG 42 180 Household staff supervisors SHEO/PSA DG 33 33 Instructors SHEO DG 34 16 Laboratory workers. N.Z. Institute, of Medical Laboratory Technology (Inc.)! DG 19 1,454 SHEO Laundry managers SHEO/PSA DG 35 •43 Masters and matrons (old peoples homes) SHEO DG 13 18 Medical officers The Medical Association of N.Z. M9 1,859 Medical photographers N.Z. Institute of Medical and Biological Illustration (Inc.) DG 46 30 Nursing (including males) N.Z. Nurses Association (Inc.)/SHEO DG 21 17,453 Occupational therapists N.Z. Registered Occupational Therapists Association/ DG 41 325 SHEO Orthopaedic technicians N.Z. Orthopaedic Technicians Association (Inc.)/SHEO DG 20 150 Orthopists SHEO DG 39 6 0 Physiotherapists N.Z. Society of Physiotherapists (Inc.)/SHEO DG 17 481 Physicists N.Z. Physicists Association/SHEO DG 10 17 Pre-school activities officers SHEO DG 49 9 Psychologists PSA/SHEO DG 36 75 Secretarial and clerical officers N.Z. Hospital Officers Association (Inc.)/SHEO DG 22 46 Shift engineers N.Z. Hospital Engineers Association (Inc.)/SHEO DG 24 26 Social workers -- SHEO/PSA DG 40 236 Speech therapists SHEO DG 37 14 Sterile supply staff SHEO DG 28 280 Technicians and technical assistants N.Z. Society of Biomedical Technology/PSA DG 38 428 Works supervisors SHEO/PSA DG 13 42 X-ray workers N.Z. Society of Radiographers (Inc.)/SHEO DG 16 649 Nursing—psychiatric and psychopaedic PSA DG 3001 3,168 Institution instruction and welfare PSA DG 3002 118 Water and Waste water treatment officers PSA DG 3003 5

Total 16 Organisations Grand Total = 27,966 Employed under section 52 of the Hospitals Act. V

Itz

Table 3: EMPLOYEES OF DEPARTMENT OF HEALTH AS AT 31 MARCH 1974 Number in Group in Employee Deter- Organisation Employee Group Head Office District mination Offices 377 P. S.A. Administrative 4 371 Executive 45 9 370 Clerical 173 397 372 Investigating 2 373 Accounts 2 262 Legal 1 376 Office assistants 21 19 368 Typing 28 56 253 Machining 4 8 204 Storekeeping 11 52 277 Editorial and Journalists 276 Art and Display 169 Science 42 3 279 Science technicians 41 281 Technicians - 3 53 219 Engineering - 5 212 Architectural 6 272 Manual (non trades) 5 349 Social workers 3 404 Dietitians - 3, 259 Psychology 229 Medical 27 53 167 Dental offiéers 6 36 146 Dental nursing 1771 438 Nursing 24 283 245 Occupational therapy -2 3 246 Physiotherapy 2. :1 260 ,;. Health education -5 :19 194 Pharmacy - 3- 12. 207 Library 11 193 Health inspection 12 77 (P.S.M.) Wage workers 11 143 237 Institutional welfare 5 282 Mental health 1,10 271 Trades 11 267 Landscape and Gardening. 3 244 Hostel and Domestic 26 S 502 3158

Public Service Manual.

304 w

Appendix XII -: HEALTH SERVICE FINANCE, 1974-75 Expenditure, $rnillion Funded from Local Authorities $milhion Capital expenditure—mainly vehicles Operating costs—mainly salaries and vehicle running 1 3 3 T.I 1 ,k f Rates, charges, and possibly a- little from loan money spasI.ssIcuI.fl ._ .US .LJ.C4.LUI Capital— Loans made ...... Major items of buildings and equipment .. .. 4 Minor items ...... - Lperaung costs .. .. ,...... 24 Government loans ...... 4 Health benefits ...... 95 General taxation, etc...... 143 Grants and subsidies ...... 23 Miscellaneous receipts .. •...... —148 Hospital Boards — 148 ci Capital— Loan repayments from proceeds of redemption loans raised...... 2 Major buildings and equipment ...... 33f Loans raised ...... 35 Minor buildings and equipment .. .. 8 Repayments of loan principal and payments to sinking funds ...... 13 General taxation, etc. (through Department of Health) .. 320 56 Interest on loans raised .. 9 Operating Costs .. . .. 291 Miscellaneous receipts —356 - 356 - 507 507

- - Approximate figure. INDEX

References are to paragraphs uni.ess. otherwise stated. The prefixes "p." or "pp." refer to page numbers.

Accident Compensation, 356 Consultative Committee on Hospital Allocations Committee (see unde Finance) Reform (1953) (see also Finance; Ambulance Services, 474 Hospital Boards), 140, 162-6, 173-82, American College of Surgeons, 100 188, 245, 411, pp. 272-4 Atkinson, Sir Harry, 84-5 Consultative Committee on Infant and Pre-school Health Services (1959), 265 Consensus Management (see also District Barrowclough, Sir Harold (see Consultative Management Groups; Regional Groups Committee on Hospital Reform) of Officers), 446-9 Base Hospitals (see Hospital Services) Consultative Groups, 540, 592-602, p. 184 Benevolent Societies (see also Charitable Finance, 575, 599 Aid Services; Voluntary Agencies; Legal and administrative, 593. Welfare Services), 17 Medical profession, 594 Board of Health (see also Department of Other health service staff, 540, 595 Health; Public Health Services), 9, 19, Regional liaison groups, 598 38-9, 43, 45, 141-4, 150-1, 168-9, 174, Territorial local authorities, 597 396, 441, 519, pp.249, 252, 256 Voluntary agencies, 596 British Medical Association (see Medical Contracts, 357-61, 472-6, 493, 495, 567, Association of New Zealand) 598 Bryce Case (1923), 101 Controller and Auditor General (see also Finance), 582 Council of Chairmen, 488 Cabinet Works Committee, 137, 583 Charitable Aid Services (see also Welfare Services), 5-8, 16-7, 21, 28, 30-4, 53-6, 58, 84, 86-9, 102, 285 Child Health Services, 72-8, 83, 199, 206, Dental Services, 19, 49, 72, 75, 151, 287, 265, 317, 331, 339,348, 467, 576 452, 467, 482, 558 Christie, Professor R. V., 186 Department of Health, 60 65-9, 72, 78, Cleary, Mr Justice T. P. (see under Social 94, 100, 102, 168, 193, 206, 234, 317, Security) 492-4, pp. 248-59 Colonial Hospitals (see under Hospital Origins, 60, 65-8 Services) Districts, 46, 67, 271, pp. 248-59 Colonial Surgeons, 11 Divisions, 72-5, 77-8, 83, 136, 164, Commission of Inquiry into the Influenza 173, 198, 506 Epidemic (1919), 65-8 Other Responsibilities- Committee of Inquiry into Social Security Design and Evaluation Unit, 202, 506 (1947) (see also Social Security), 121-4 Lake Alice Hospital, 173, 206, Committee of Officials on Public Expe n- 327-30 diture (C.O.P.E.), 585 Management Services Research Unit, Community Councils, 496 • 173, 202, 505 Community Health Care, 101-12, 219, Medical Statistics Branch, 202 223, 225, 236-46, 306, 310-1, 349-50, National Audiology, Centre, 202, 507 355, 360, 367-9, 371-81, 420, 428, National Health Institute, 201, 507 430-7, 445, 454, 458-61, 474-5, 480, Operational Research Unit, 202 a 487, 496, 501, 513, 521, 560, 575, 591, Professional Registration, 197-8, 204, 611-2, 614-5, 618, 620, pp. 97, 104 523-5 Community Hospitals (see Hospital Ser- Special areas, 126, 356 vices) Staffing- Community Medicine Specialists (see also Director-General, 79,100, 137, 160, District Management Groups; Regional 163, 320, 511-2, 585 Groups of Officers), 378-9, 433, 614-5 District Executive Officers, 484 Community Physicians, 375, 378-81, 428, • Medical Officers of Health, 38, 46, 430-6, 445, 454, 458, 463, 475, 480, 48, 66, 124, 166, 230, 320, 376-7, 611-2,615 380, 432, 434-5, 447, 484 306 Department of Health-continued Finance-continued Relationship with- Allocations, 176-9, 560, 562-9, 571, 576, Local authorities, 71, 153, 168, 227, 579, 581, p. 305 321, 511, pp. 249-59 Benefits and pensions, 88-90, 92-3, 108, Other State agencies, 317-8, 320, 110, 114-6, 118-20, 149-51, 154, 168, 326, 330 244, 353, 356, 467, 473, 558, 564-6, Hospital administration, 60, 137, 160, p.305 164-6, 170-81, 193-5, 199, 205-6, 227, Expenditure and control, 87, 102, 137, 251, 253, 265, 272, 286, 394, 412, 506, 155-7, 159-60, 172-3, 176-81, 188, 511, 515, pp. 249-59 394, 422, 465, 527, 554, 560, 564, 566, (see also Board of Health; Hospital 568,570-87. Boards; Hospitals Department; Local Health services, 351, 370, 444, 457, 465, Authorities; Public Health Services) 473, 487, 498, 503, 512, 517, 526-7, Diagnostic Services, 50, 149, 160, 189, 554-5,558-87,598,618,p.305 200-2, 236, 280, 292, 310, 349, 368, Hospital, 13, 17, 20-1, 24-31, 134-8, 420, 445, 506, 575 150, 154-63, 182, 217, 527, 561, 563, District Administration Officers (see Dis- 568, 581, 583, pp. 193-7, 305 trict Management Groups) Hospital Board, 31, 55, 57, 59, 60, 93, District Community Physicians (see Dis- 155-61, 163, 173, 182, 188, 194 trict Management Groups) 393-4; pp. 193-7, 213-27 District Executive Officers, 484 Sources of finance, pp. 193-7, 213- District Health Officers (see also Public 27,305 Health Services), 614 Allocations, 176-9, 560, 562-9, 571, District Health Services Advisory Councils 576, 579, 581, p. 305 (see also District Management Groups), Bequests, 32, 57 450-3, p. 136. Donations, 32, 61 District Management Groups, 426-52, Endowments, 13, 32 454,466,468-9,476,478,481,483-4, Fees, 32, 56-7, 61, 96, 98, 100, 103, 607-8, p. 136 118, 120, 122, 140,240-1 District Administration Officer, 428, Government, 17, 24, 26, 29, 31-2, 442-4, 480, 613 56-60,63-4,133-4,154-60,175- District Community Physician, 428, 81, 244, 370, 559, 561 430-6,445,480, 611-2 Hospital benefits, 134, 138, 150, District Nursing Office, 428, 437-41, 154-5,244 480,613 Loans, 59, 155, 175, 228, 559, 561 Responsibilities, 426-9 Rates and levies, 56, 61, 63-4, 154- (see also Consensus Management; 7, 162-3, 170-1, 228, 244, 393-4, District Health Services Advisory Coun- 408 cils; Regional Groups of Officers) Rents and profits, 32 District Medical Officer, 614 Voluntary contributions, 17, 24-5, District Nursing Officer (see District 29, 32, 56-7, 85 Management Groups) Loans, 133-4, 173, 558-9, 561, p. 305 Doctor Shortage (see General Practitioners) Patients fees, 32, 56-7, 61, 96, 98, 103, Domiciliary Services (see also Hospital 118, 120, 122, 140, 240-1, pp. 19377 Services; Nursing Services), 480, 575 Private health services, 13, 114, 118, 131-46,368-70,558,560 Education and Training of Health Per- Resources management systems, 465, sonnel (see also Professional Registra- 554,560,570-81,599 tion; Staffing), 164, 198, 260, 317, State responsibility, 13, 29, 32, 47, 55, 331-5,337,355,357,415,417,436,442 63, 105, 107-9, 113-4, 116-9, 121, 457,464,467-8,473,475,477,480,493: 146, 158-60, 163, 227-8, 233-5, 237- 503, 524-5, 548-50, 552, 555, 607, 70!312,359,370,472,487,560 612-3 Subsidies, 17, 24, 26, 29, 31-2, 57, 59- English Health Services, 4, 5-9, 29, 84-5 60, 63-4, 132, 134, 156-7, 370, 473, Environmental Health Services (see also 561, 566-7, 595, pp. 193-7 Public Health Services), 230-2, 236, System of Integrated Government Man- 254, 273, 279, 286, 317, 319-22, 337, agement Accounting (SIGMA), 586 434, 480, 575, 614 Voluntary services, 222, 261-2, 265-7, 472-3,567,596 (see also General Practitioners; Legisla- Fee for Service (see General tion; Local Authorities; New Zealand Practitioners) Health Authority; Regional Health Finance- Authorities; Voluntary Agencies) Accountability, 3l 55, 61, 116-7, 119, 158, 160, 171, 175-6, 181, 194, 227- Findlay, Sir George (see Consultative 8, 233-5, 244-5, 256-7, 395, 465, Committee on Infant and Pre-School 486, 564, 575, 579, 583, 598 Health Services (1959))

307 Friendly Societies, 92-3, 108, 110 Health Services-continued Integration of services, 51-2, 87, 153, General Practitioners, 128, 193, 212-6, 193, 223, 236, 239, 254, 265, 267, 224, 268, 281, 284, 343-61, 436, 511, 280-7, 293, 317-8, 333, 336-9, 342, 598 348, 363-5, 369, 371-81, 420, 431-3, Community hospitals, 310, 350, 355, 435-7, 460-1, 472, 477, 481, 488, 360 501-2, 519, 522-5, 528, 531-2, 575, Continuing medical education, 355, 578, 595, 597, 611, 618, p: 97 357,548 Manpower planning, 173, 299, 334, 459, Contracts, 357-61, 598 462, 464, 480, 498, 503-5, 508, Doctor-patient relationship, 213-6, 224, 551-5, 573 351, 361, 377, 565 Medical administration, 374-5, 379-81, Group practice, 128, 130, 214, 343, 347 421-2, 425-34, 442-71, 477-8, 480- Health centres, 128-30, 214, 343, 347- 5,611-6 8,367 - Planning, 234, 239, 253, 288, 291-8, 374-5, 381, 395, 420-6, 442, 456-71, Hospital employment, 356 477-8, 480, 483, 487, 502, 505, 514, Integration with other services, 128, 518-21, 554, 560, 570-87, 598, 618 281, 284, 355, 367, 436, 598, p. 97 Health Services Advisory Council, 518-21, Population/doctor ratio, 211-2, 215, 550, p. 107 351 Hospital Committees of Management, Practice nurses, 127, 352 185-6,228 Private practice, 116, 118, 128-8, 357, Hospital Services- 511 Administration and control, 10, 13, 18, Remuneration 115, 118-20, 122, 345, 20, 25-8, 33-6, 42, 47-9, 51, 53, 102, 351-61 171-5, 182, 187, 194, 244, 272, Accident compensation, 356 385-95, 418, 422, 490, 494 Accountability, 118-24, 354, 359 Fees, 118, 120, 122, 352-6 Admissions and delays, 13-4, 33-4, G.M.S. Benefit, 115, 118-20, 353 51-2, 94, 96, 100-1, 104, 211, 217-9, Immunisation Benefit, 356 242, 292, 296, 301, 349-50, 368, 480 Maternity Benefit, 356 Ambulance services, 474 Rural Practice Bonuses, 127, 212 Base, 51, 187, 304, 306-7, 309-10, 350, Salaried Service, 126, 356-8 p.104 Reorganisation, effects on, 343-61, 433, Community, 306, 310-1, 350, 367, 453, 459, 461, 511, 598 p.104 Shortage, 2114, 215 Colonial, 1, 12-3, 15 (see also Primary Health Care) Infectious diseases, 48, 51 Geriatric Services, 51, 173, 217, 222, 310, Infirmaries, 6, 8 324, 348, 350, 366, 467, 481, 576 Old peoples homes, 51, 173, 324 Grabham, Dr G. W., 29-30 Out-patient clinics, 310, 367-8, 480 Grey, Sir George, 12, 27 Private, 49, 98-9, 111, 114, 125, 131-46, Group Practice (see also General Prac- 151, 173, 220-1, 405 titioners; Primary Health Care), 128, Satellite, 306, 308-9, p. 104 130, 214, 343, 347 Single speciality, 303, 309, p. 104 St. Helens, 34, 49, 51, 199, 205 Health Act (see under Legislation) Subscription, 17, 31 Voluntary, 2,.3, 8, 10, 13, 18 Health Camps, 77 (see also Hospital Boards; Lake Alice Health Centres, 128-30, 214, 343, 347-8, Hospital; Psychiatric Services; Psycho- 367 paedic Services; Queen Elizabeth Hos- Health Department (see under Department pital; Queen Mary Hospital; Rotorua of Health) Sanatorium) Health Education Services, 224-5 Hospitals Act (see Legislation) Health Inspection Services (see also Local Hospitals Advisory Council, 172 174, 396, Authorities; Public Health Services), 43, 519 S 67, 230-32, 321, 434-6, 560 Hospital Boards, 27, 33-4, 36, 48, 51, 58, Health Services- 61, 87, 94, 96, 102, 132, 138, 153, Bill, 593, 600, 603-4 155, 161-6, 171-88, 194-227, 229, Fragmentation, 151, 209-10, 226-7, 253-4, 278, 286, 292-3, 372, 383-95, 236, 238, 271-3, 378, 481, 511, 527, 402, 410-11, 418, 422, 439, 472, 484, 535,618 490, 492, 494, 515, 561, 581, 583, 607, Information and statistics systems, 137, 609 202, 293, 368, 381, 425, 436, 442, 459, Accountability, 158, 160, 164, 171-2, 468, 471, 477, 480, 498, 505, 577-9, 227-8,244-5,393-4 587 Amalgamation, 184, 187-93, 286

308 Hospital Boards-continued Legislation-continued Commission of management, 183 Lunatics Ordinance 1846, 14 Committees of management, 185-6, 228 Mental Defectives Act 1911, 104 Districts, 51-3, 64, 161, 163-6, 172-3, Mental Health Act 1969, 206, 493, 593 184-7, 191-2, 271, 409, pp. 242-3 New Zealand Constitution Act 1852, 15 Integration with other services, 51, 54, Public Health Act (U.K.) 1848, 9 153, 166, 193, 236, 254, 280-1, 284-7, Public Health Act (N.Z.) 1872, 19, 38 303, 349, 363, 369, 372, 377-8, Public Health Act (N.Z.) 1876, 38, 45 430-3, 447, 460-1, 472, 575 Public Health Act (N.Z.) 1900, 43-6 Membership, 27, 31, 36, 62, 165-85, Public Revenues Act 1953, 584 228, 383-95, 398, 406-7, 410-2, 418, Social Security Act 1938, 112-3, 121, pp. 277-91 126, 138 Planning, 292-3, 299, 302, 305, 310 Social Security Amendment Act 1941, Staffing, 51-2, 59-60, 160, 193, 308, 120 310-1, 346, 395, 439, 534, 536, 546 Social Security Act 1964, 149-50, 152, (see also Consultative Committee on 593 Hospital Reform; Finance; Legislation; State Services Remuneration and Con- Department of Health; Hospitals Com- ditions of Employment Act 1969, 536 mission; Hospital Services; Hospital Vaccination Act 1863, 83 Works Committee; Minister of Health) Vaccination Act 1871, 83 Hospital Boards Association, 100, 179 Loans (see under Finance) Hospitals Commission (1921), 64, 100-1, Local Authorities, 18-9, 24-6, 32-3, 35-6, pp. 244-7 38-40, 42, 44, 47-9, 61, 69-70, 153, Hospitals Department, 21-3, 29, 33, 39, 48 168, 184-5, 227, 229-32, 273, 278, Hospital Welfare Society, 556 286, 317, 321, 385, 398, 407, 412, Hospital Works Committee, 137, 172-3, 416, 435, 498, 560-1, 568, 597, 609 583 Relationship with Health Department, 35, 37-9, 69, 71, 153, 168, 175, 286, Infectious Diseases Hospitals (see under 321-2,412 Hospital Services) Hospital rates and administration, 18, Infirmaries, 6, 8 20, 24, 26-9, 32-3, 36, 48, 51, 56-7, Information and Statistics Systems (see 61-3, 153-4, 156-7, 162-3, 175, 185, under Health Services) 193, 227, 383, 408-9 Influenza, Commission of Inquiry (1919), Integration of services, 187, 596 65-8,94 Public health, role in, 19, 38, 40, 43-5, International Health, 498, 509 51, 67, 69, 71, 168, 193, 230-2, 273, Inspectorate of Lunatic Asylums and 317,319-32,435,560-1,568 Hospitals (see Hospitals Department; (see also Finance; Local Government; Psychiatric Services) Public Health Services) Islington, Lord, 95 Local Government, 35, 273, 278, 317, 435 Commission, 161, 278, 413-4, 496, 606 Community councils, 496 Xing, Sir Truby, 73, 78 Districts, 413 Regions, 278, 413, 606 Lake Alice Hospital (see also Psychiatric Lunatic Asylums (see under Psychiatric Services), 173, 206, 327-30 Services) Legislation, 498, .503, 515, 593 English Poor Law 1601, 5 MacGregor, Dr D., 42-3, 48-9, 53, 85-6, English Poor Law 1834, 7 88, 91-2, pp. 260-70 Financial Arrangements Act 1876, 24 Manpower (see Staffing; Health Services) Financial Arrangements Act 1878, 24 Martin, F. H., 100 Finance Act 1946, 156 MacEaehern, M. T., 100 Finance Act 1951, 157 McMillan, Dr D. G., M.P. (see also Nord- Food and Drugs Act 1907, 50 meyer, A. H.), 105-7 Health Act 1920, 69-72, 168 Medical Association of New Zealand (see Health Act 1956, 150, 152, 168, 593 also Social Security), 98, 100, 109, 110, Health Service Bill, 593, 600, 603-4 117, 121, 124,347 Hospitals and Charitable Institutions Medical Council (see Professional Reg- Act 1885, 28-33, 36, 56, 58, pp. 200-- istration) 35 Medical Laboratory Technologists Board Hospitals and Charitable Institutions (see Professional Registration) Act 1909, 53, 62, 161, 285, pp. 200-35 Medical Officers of Health, 38, 46, 48, 66, Hospitals Act 1926, 170, pp. 200-35 124, 166, 230, 320, 376-7, 380, 432, Hospitals Act 1957, 87, 128, 136, 170, 434-5,447,484, pp.249-59 172, 176, 181, 185, 187, 409, 593, Medical Research, 164,200, 260, 355 pp. 200-41 Medical Research Council, 200

309

A Medical Schools, 165,186, 383 Nursing Services and Administration (see Medical Superintendents Association, 179 also Professional Registration), 49, 51-2, Mental Health Act (See Legislation; 76, 104, 127, 197-8, 230, 310, 324, Psychiatric Services and Administra- 331-2, 335, 346, 352, 355, 437-42, tion) 446-7, 452, 454, 461-3, 472, 475, 484, Mental Hospitals (see Psychiatric Services 534, 613, pp. 97, 249-59 and Administration) Minister of Health, 42, 46, 58-9, 70, 97, 123-4, 126, 129, 137, 149-50, 158, 160, 163-5, 172-4, 182-4, 228, 234, 289, 591, pp. 236-41, 249, 252, 256 Oakley Hospital, 207 and New Zealand Health. Service,P. Old Peoples Homes (see Hospital Services) 247-51, 298, 394, 397-8, 418, 487-93, Ombudsman (see also Regional Complaints 497-8, 515, 545, 547, 581, 104 Commissioners), 492, 494-5 Optical Services, 287 Otago University, 165, 186 National Health and Superannuation Outpatient Services (see Hospital Services) Committee (1938), 107,111-2,143 National Health Corporation, 246 National Health Institute (see Department of Health; Public Health Services) Paediatric Services (see Child Health National Insurance, 84-5 Services) National Provident Fund, 559 Paramedical Services and Administration, Neill, Mrs Grace, 49 130,331-5,346-8,355,360,445-6,459, 534, 575, p. 97 New Zealand Farmers Union, 96 Parliament, 24, 228, 247, 251, 494, 516, New Zealand Federation of Voluntary 581,603-4 Welfare Organisations (see also Voluntary Plunket Society (see also Voluntary Agencies), 259 Agencies), 73, 348, 355 New Zealand Health Authority, 251-55, Practice Nurses (see under General Practi- 289, 297-9, 320, 380, 459, 488, 494, tioners; Nursing Services) 497-8, 511, 520, 525, 555, 608, pp. Primary Health Care Services (see also 136,162-3 General Practitioners), 212-6, 223, 236, Accountability, 256, 471, 486, 498, 512, 254,279-80,287,296,343-61,367,420, 515-6,555,581 432, 459, 501, 520, 575, p. 97 Composition, 489-90, 511-3, 538, 541, Private Health Services (see also Finance), 545,585 49, 92-3,98-100,104,111,114-48,151, Organisation and responsibilities, 500, 153, 173, 211, 219-20, 225, 227, 240, 502, SO7, 510-11, pp. 162-3 268-70, 352-3, 356-9, 368, 370, 404-5, Administrative services, 500, 502-3 558, 565, p. 241 Finance, 233, 238, 245, 312, 486, 503, Private Hospitals (see Private Health 555,558-67,577,581-4,598,618, Services) Functions, summary of, 498 Private Practice (see Private Health Information and statistics, 459, 471, Services) 577 Professional Registration (see also Education • International health, 498, 509 and Training), 49, 76, 197-8, 204, 495, Lake Alice Hospital, 32 7-30 522-5 Legal, 503 Psychiatric Services and Administration • Operational services, 500-502, 507, (see also Legislation; Psychopaedic Ser- 510, pp. 162-3 vices), 14-5, 18, 21-3, 29, 34, 36, 42, Planning, 297-9, 320, 486, 498, 513-4, 48-9,73, 78-9,90, 103-4, 107, 116, 153, 518,544,581, 173,198,206-7,219,222,303,317,325, Sector teams, 502 327-30, 339, 366, 460, 467, 481, 493, • . Staff, 532, 536-8, 541 3 544-5, 553-5 PD. 97, 249-59 Technical services, 500, 504, 507 Psychopaedic Services (see also Psychiatric Relationship with Regional Health Services), 198-9, 206, 317, 325, 328, S Authorities, 233-4, 290, 298, 319-20, 331339,366 336-7, 380, 415, 466, 471, 486, 498, Public Health Department (see Public .501-10, 512-21, 526-8, 532, 536, 538, Health Services and Administration) 541-4, 555, 560, 563, 565-7, 572, 577, Public Health Services and Administration, 580-1,585, 597, pp. 104, 162-3 19, 34, 36-41, 43-6, 48-51, 60, 65-75, Voluntary Organisations, 336-7, 566-7 77-8, 83, 94, 160, 168-9, 199-200, (see also Health Services Advisory 230-2,348,371-2,376-9,430,434-6, Council; Ombudsman; Regional Health 507, pp. 97, 249-59 Authorities; Professional Registration) Environmental health, 230-2, 236, 254, Nordmeyer, A. H. (see. National Health 273, 279, 286, 317, 319-22, 337, 434, and Superannuation Committee (1938)) 480, 575, 614

310 Public Health Services and Adntinjjtratjon -continued Regional Health Authorities_contip,wd Integration of preventive and curative Regional Group of Officers, 426-7, 454-. services, 51-2, 54, 153, 166, 193, 236, 5 457; 254, 267, 280-7, 293, 316-8, 333, 462,.465-9,,476, 478, 616, 336-9, 342, 348, 363-4, 369, 371_:81, P. 395, 420, 430-3,4 35-7, 461, 611 Regional Administration Officer, 454 National Health Institute, 200-1, 507 464-5,513,613 Role of Regional Health Authorities, Regional Community Physician, 378, 254, 276,, 279, 281, 320-2, 371, 380, 433, 435, 454, 458-9, .463, 430-6, 480, 508 475, 480, 513, 611-2 Regional Community Physician, 435, Regional Nursing Officer, 454, 462-3, 459, 611 475, 513,613 Staffing, 475, 489-90, 517, 529-57, Regional health districts, 276, 480 607-9 Regional Health Officer, 614 Voluntary agencies, relationship with, District Community Physician, 430-6, 472-3, 567 480, 611 (see also District Health Officer, 614 Consensus Management; Dis- Vaccination, 83, 160, 348 trict Health Services Advisory Councils; District Management Groups; New (see also Board of Health; Department of Zealand Health; Legislation; Local Authorities; Health Authority; Regional New Zealand Health Authority) Complaints Commissioners) Regional Groups of Officers (see Regional Public Service Investment Society, 556 Health Authorities) Public Service Welfare Society, 556 Regional Health Officers, 614 Regional Medical Officers, 614 Queen Elizabeth Hospital, 199, 205 Regional Officer Liaison Groups, 513, 598 Queen Mary Hospital, 199, 206 Registra tion, Professional (see Professional Registration) . Rehabilitative Services, 236,254, 279, 420, Reeves, W. P., 82 575 Regional Complaints Commissioners (see Resources Management Systems (see Fin- also Ombudsman), 493-5 ance) Regional Health Authorities, 254-6, 275, Robb, Sir Douglas, 128 281, 289-91, 313, 420-1, 424, 429, Rotorua Sanatorium, 34,199 442, 444, 454, 456-7, 462-9, 472, 474, Royal Commissions of Inquiry- 476-7, 483, 488, 490, 493, 496-8, Hospital and Related Services (1971-3), 501-3, 506, 508, 514, 516, 518, 526, 142,207 528, 541, 544-5, 554-5, 560-7, 569- Social Security (1969-72), 114, 119, 123, 78, 581, 584, 597-9, 606, 609, 615-6, 1423145-6,207 pp. 93-4, 107, 136, 185 Accountability, 233-4, 238, 256, 418, State Services (1961-2), 193-4, 203 526, 560, 573-5, 579, 581 Rural Practice Bonuses, 127, 212 Ad ministration, 338, 375-8, 381, 418, St. Helens Hospitals, 34,49, 51, 199, 205 420-85, 495, 502, 570, 578, 581, 616, p. 136 Satellite Hospitals (see Hospital Services) Boundaries, 275, 413-4, 606, Secretariat for the Registration of Health pp. 93-4 Professions (see also Professional Reg- Contracts, 357-61, 472-6, 493, 495, 567, istration), 522-5, p. 136 p. 104 Finance, 465, 472-3, 503, 554-5, 560- Seddon, R.J., 76 9, 575-6, 578, 581 Social Security, 84, 105-50, 152, 244, 565- Functions, 420 6, 593, p.271 Health plans, 374, 456-9, 570-4 Benefits, 107-8, 114-5,118-20,134,138, Health districts, 276-7, 309, 413-4, 149-50, 154-5, 168, 244, 353, 356, 427, 440, 446 473, 558, 565-6, pp. 271, 305 Committee of Inquiry (Cleary Com- Health regions, 238, 252, 274-5, 278-9, mittee (1947)), 121-4 0 281, 298, 304, 413-5, 421, 426, 446, Royal Commission, 114, 119, 123, 142, 145-6,207 Membership, 382-400, 405-6, 409, (see also 413-9, 421-5, 457, 469, 483, 489- Finance; Legislation) 90, 541, 5622 Specialist Services, 107, 187, 189, 217-21, 607 225, 236, 254, 274, 279-80, 287, 296, Chairmen, 401-31 417, 424, 488-9, 616 304-10, 346, 349, 362-70, 372, 420, Relationship with N.Z.H.A., 255-6,290, 432-3, 459, 463, 501, 575, 614, pp. 313, 320, 337, 374, 380, 415, 420-13 97,104 468, 476, 488, 498, 501, 510, 513-6, Integration of services, 280, 287, 303-4, 518, 526-8, 544-5, 555, 598 349,363-5,372,420,p.104 Multidisciplinary services, 339, 346-65, Public relations responsibility. 479, 492 36714-48,463

311

I/ Specialist Services-conlinaed Subscription Hospitals, 17, 31 Primary medical care, 367,446 System of Integrated Government Man- Reorganisation, effect of, 362, 372, 420, agement Accounting (SIGMA), 586 433,446-7,452,501,614 Community medicine specialists, 378-9 Vaccination, 83, 160,348 Staff. Commission, 608-9 Valintine, DrT. H. A., 48,51,53,95 Staff, Health Service, 341-2, 517, 529- Vogel, SirJiiliu, 28-30,36 57,515 ,617, pp. 292-304 Voluntary Agencies, 222-3, 258-67, 317, Appeals, 546-7 323-6,336,348,355,372-3,395,420, Appointments, 541-5 459,472-5,498,550,5583566-7,596, Commission, 608-9 pp. 275-6 Conditions of service, 503, 517, 529-57, Accountability, 265-7,472-5, 567 595,609-10 Functions, 260,262-3 Establishments, 60-1, 159-60, 517, 551, Integration with other services, 222-3, 555 258-67, 317, 326, 336, 348, 955, 395, Grading, 543-4 420, 459, 472-5, 493, 495, 4983 567, Hospital, 2, 51-2, 59, 160, 308, 310, 596 346, 395, 432, 439, 447, 484, 534, 536, New Zealand Federation of Voluntary 546 Welfare Organisations, 259 Integration, 339, 346-7, 355, 365-7, (see also Welfare Services) 448,463,481,613 Voluntary Health Insurance (see Private Official circular, 542 Health Services) Salaries and finance, 345, 351, 473, 498, Voluntary Hospitals, 2, 3, 8, 10, 133 18 503,536-40,595,609-10 Superannuation, 360, 556 Welfare Services (see also Charitable Aid (see also Education and Training; Pro- Setvices; Voluntary Agencies), 131-2, fessional Registration) 317,323-6,336-9,381 Statistics and Information Systems (see World Health Organisation, 334,509 Health Services) Constitution, p.5

H. 342

Ime CJIACK vi LElectrothe issue only 4o KL 50211 HKA

50912G-74 C LIBRARY. DEPARTMENT OF HEALTH, P.O. BOX 5013. WELLINGTON.