The big health issues

What happens when we call 111 and an ambulance doesn't come? Photo / NZ Herald

The health portfolio has not been a happy one in New Zealand's government for as long as most people will be able to remember. Gone are the days when local committees effectively ran local hospitals, when in Kaitaia at least, and no doubt around the country, people like THE (Tom) Wilton, Millie Srhoj and Ivan Morton frantically spent money on anything they could think of before the end of the financial year to avoid their budget for the coming year being reduced.

Money didn't seem to be the issue then that it is today. By modern standards hospitals were pretty basic, places people went to when they were sick, needed surgery, or were simply too old to live in their own homes. The top floor at Kaitaia's Hospital was the geriatric wing, populated by the elderly, often not actually unwell, just in need of care. These days those people go to the Switzer Home, many of them much more frail than their parents had needed to be to qualify for a bed.

And they don't have a lot of choice. The very unwell can no longer rely on the hospital to provide the care they need long-term. They either go home, go to family or go to Switzer. The only other option would be to release them to live under a bridge, which so far doesn't seem to have happened.

And that it is one of the issues that a Minister of Health is going to have to address one day. Perhaps sooner rather than later, given the aged care sector's reluctance to continue tolerating a grossly unfair funding model.

The main reason why politicians probably don't rush to put their hands up for the Minister of Health job is that for years there hasn't been, and in future likely never will be, enough money to meet public expectations. The cost of health care has ballooned beyond all recognition over the last couple of generations, and, given that we see ourselves as inhabiting a First World country, we expect to have access to the very best equipment, procedures and drugs that the world can provide. That is becoming increasingly difficult, and won't be made easier by the likelihood that the financial cost of the Covid-19 pandemic will bring perhaps unprecedented pressure to bear on government budgets.

One day we will surely have to address the fact that a huge proportion of public health funding is spent on people who are in their last weeks of life, when it might be better spent on those who have many years ahead of them, but two funding issues in particular demand much more immediate attention. The first of those is the funding of rest homes. The other is the funding of St John.

No one would deny that the ambulance system is an integral part of our public health system, or that for many of us it represents the first link in a chain of services designed to save lives. Yet St John largely continues to function as a charity. The government has recently lifted its financial contribution, but even NZ First, which has been supportive of increasing its taxpayer funding, hasn't gone as far as it needs to go. Surely there can no longer be any argument that St John should be funded totally by the taxpayer, at a cost that, in the greater scheme of things, is affordable.

The Order (or 'company,' as TVNZ described it last week) is now preparing to shed jobs as it strives to deal with a $30 million shortfall. We are told that those jobs will not be cut from the frontline, the people who drive ambulances and respond to emergencies, but at management level. It is very difficult to see how $30 million could be saved that way, or how $30 million can be saved without services being reduced, but we have been assured that they won't be.

We have also been told that St John isn't particularly good at financial husbandry. If that is the case then whatever help is needed to fix that should be forthcoming, but the fundamental issue remains that the Order depends to a significant extent upon donations to keep its ambulances rolling. It should not have to do that, but nothing is going to change, one suspects, until calls to 111 go unanswered. There isn't a politician alive who wouldn't leap at the opportunity to argue the bleeding obvious when that happens.

The same crunch point might well be approaching for old folks' homes, whose registered nurses, we are told, earn $10,000 a year less than their DHB counterparts, a discrepancy that is the result of sheer ineptitude. A year or two ago the government gave extra funding to the DHBs so they could pay their registered nurses more, to resolve problems they were having with recruitment and retention. Clearly it didn't occur to anyone that upping one pay scale and not the other was going to lead to an exodus of RNs from rest homes to DHBs.

The issue of staff RN recruitment and retention in aged care is now acute, even at the likes of Kaitaia's Switzer Residential Care, which unlike its corporate counterparts does not have shareholders to placate. Switzer is not in the business to make a profit, but simply to provide an increasingly comprehensive level of care for the elderly within its own community.

For the aged care sector, the disparity in registered nurse pay rates goes beyond unfair. It is unconscionable, severely impacting on homes' ability to provide non-negotiable levels of care that are dictated by the Ministry of Health, yet are not adequately funded. The question that will have to be addressed one day is, what happens when that level of care cannot be provided? Will standards be reduced, or will the public health system take over?

The former would be unacceptable, the latter impossible. Certainly in Kaitaia's case, the hospital would be unable to care for those Switzer residents who need hospital care. So here we have a charity that has taken a huge responsibility off the state, but is not funded sufficiently to bear that responsibility.

Again the money needed, while not insubstantial, will be peanuts in terms of total public health funding, almost $20.3 billion this financial year. As always, it is a question of priorities, and while there are plenty of contenders, aged care should be near the top of the list.

The fact that aged care funding has not yet become a crisis speaks volumes for the people who care for our frail elderly, but their goodwill cannot be inexhaustible. The crisis can't be far way; perhaps that is what it will take to force the government, and governments to come, to reassess how it is funded and to come up with a model that is not only fairer but will enable homes to continue providing the level of care that we, and the ministry, expect.

The fact is that charitable organisations play a massive role in our public health system. From staging Pink Breakfasts to red noses made of plastic, sausage sizzles to garage sales, all manner of organisations make a substantial contribution to maintaining a system that will always be beyond the ability of the taxpayer to provide, but the ambulance service and caring for the frail elderly have a much greater claim than most. Ambulances should not be dependent upon charity, and rest homes should not have to compete against the state, at a massive disadvantage, to do a job that the state has shed.

Those aren't the biggest financial issues that our embattled Minister of Health, and one imagines his soon to be named successor, whatever the outcome of September's general election, will have to consider, but they might well be the most urgent.