I would like to make the following comments on the editorial "And now Auckland" (NZ Med J 2002; 115: 89-90).

It is remarkable that the editorial failed to mention the financial realities which the Auckland DHB faces. It has an $80m deficit that is not sustainable. The New Zealand government already spends $8 billion a year on health. In the last year, the Minister of Health gained for the sector fully half the new funds available. Education, social welfare, housing and all the rest of the government services made do with a share of the remaining half.

The editors focus on the need for excellent health care. We all aspire to this but as a society there is a limit to what we can afford. Our economy now ranks poorly in international rankings - just above Portugal. In order to continue to provide the services we currently provide our economy needs to get a lot stronger, quickly, or we will need to find creative ways to curtail expenditure.

The editorial suggests entrusting hospitals to a clinical board as a solution to these problems. It is suggested "most, but not all, will be doctors." Strangely, despite the talk of teamwork mentioned earlier in the editorial, the majority of the health care workforce - nurses and allied health - do not seem to feature significantly in this vision. I am surprised this attitude exists in a city where "doctor knows best" led to the unfortunate experiment at National Women's and more recently the Green Lane heart retention scandal.

Even more significantly, the editorial ignores the advent of District Health Boards. These Boards recognise that health cannot be looked at in silos - primary health is crucial, as is hospital care. They also recognise that health, including hospitals, is owned by the community. Policy setting is incorrectly attributed by the editorial to managers. In fact it is the Boards of DHB's, the majority elected by the community, that set policy. Managers and staff are then responsible for implementation of the policy. I am confident that at least one deputy editor of the New Zealand Medical Journal understands this, as he sits beside me as a member of the Canterbury District Health Board.

Leaving aside these issues, I agree with much of the thrust of the editorial. It is true that clinical decision making by doctors, and other clinical staff, has a huge impact on expenditure and that clinicians must be empowered and trusted to make decisions not only in the best interest of the patient in front of them, but of the population as a whole. I am also heartened that the editorial acknowledges fiscal constraints are well understood by hospital staff. I also suspect that commercial realities are well understood by the majority of the New Zealand Medical journal readers. After all, many are successful business people in their own right, either as owners of general practices or specialist practices.

Working constructively in partnership with clinicians who understand the fiscal constraints we face can help address the myriad of difficulties that make our health system less efficient. Issues that could be addressed in a constructive partnership include:

It would be helpful if the New Zealand Medical journal, as the leading medical publication in the country, desisted from constantly recycling the same old message and instead generated debate on the issues listed above. It might also be useful if the editors recognised the the New Zealand Medical journal is a national journal, not the newsletter of a tired old cliché trapped in a time warp of their own making, somewhere deep within Christchurch hospital.

Thank you for the opportunity to reply to Mr Bradley. He is critical of the Journal's Editors, so, for the record, we would like to say that our unsolicited editorial represents an independent viewpoint and derived no input from "deep within Christchurch Hospital." Notwithstanding the tenor of this letter, Mr Bradley states that he is in agreement with "much of the thrust of the editorial". Furthermore, his other comments taken collectively, would seem to endorse our opinion that all is not well in the state of our public hospitals, and that doctors have little influence in their running. Since the editorial our CEO has made it explicitly clear at a minuted meeting that the alleged Auckland Healthcare "clinician-manager partnership" is one in which, at every level, the manager is, by default, ultimately in charge. Our editorial advocated a genuine role in strategic planning for the longest term and most highly qualified participants in our health service - its doctors. This is fundamental to addressing Mr Bradley's aim, which we endorse, of making public hospital practice more attractive to specialists, who at present can earn more, and have genuine influence, in the private sector. We think the public should be aware of the degree to which our public hospitals are driven by the agendas of politicians and managers - whether clinicians agree with them or not. In particular, we, the authors of the editorial, wished to dissociate ourselves from decisions taken by management which we consider unnecessarily ruthless, and of whose benefit we are far from convinced. We concluded our editorial by saying "It is time the country re-considers the way it wants its hospitals run." We find nothing in Mr Bradley's letter to dissuade us from that view.