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| Journal of the New Zealand Medical Association,
27-May-2011, Vol 124 No 1335
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Citizenship, work, welfare, education and health in
New Zealand
Des Gorman
The Welfare Working GroupI recently had the privilege of being a member of Minister
Bennett’s Welfare Working Group (WWG). The WWG, which was led by Ms Paula
Rebstock, recommends substantive reform.1 This
outcome arises from a recognition that our welfare system is often disabling and
that it is neither sustainable nor fit-for-purpose.
As an illustration of the cassis belli for reform,
31% of working age Māori are State welfare beneficiaries of one sort or
another. There is no comfort for any New Zealander in such a rate of
joblessness.
This essay is a personal review of the milieu of the
WWG’s report and the knock-on implications for our health services.
CitizenshipIn my opinion, New Zealanders have a sense of citizenship,
which is in part based on a commonly held set of values. Ironically, those
values are probably most appreciated by us when we are confronted by dissimilar
viewpoints. For example, many New Zealanders were bemused by much of the
argument against President Obama’s programme to increase health access in
the USA.2 The concepts and values of mutuality,
welfare and altruism were largely missing from the oppositional argument.
It is hardly surprising that we have common values; after
all, we are all ‘boat people’ who have come to New Zealand for a
better way of life.3,4 Some of my ancestors
(the Māori) arrived about 1000 years ago, whereas my father arrived on his
boat from Australia in 1952. We also have defining legislation, such as the
Social Security Act of 1938, and a unique treaty between the British colonisers
of the nineteenth century and Māori (The Treaty of
Waitangi).4
The WWG was frequently told by commentators and those making
submissions that social welfare was the centre-point of the national social
contract. The more I thought about this, the more it seemed to me that this was
not the case; surely the central social contract is that those of us who can
work do so, for pay or not, and by way of this work we contribute both directly
and indirectly to our society. In the absence of such a core commitment to work,
our society cannot exist.
For reasons that are unclear, work and work-related schemes
are often regarded pejoratively and both are frequently seen as being punitive
in rehabilitation programmes. The sadly commonplace nature of these views and
the resultant distortion of medical practice are such that the Royal
Australasian College of Physicians has felt the need for a public campaign to
argue that work is good for our spiritual, mental and physical health and that
without work, people often experience consequent ill health.
5 Indeed, positive vocational rehabilitation
outcomes should become a key accountability for our health services. At present,
they are not and the welfare system ‘inherits’ the poor outcomes of
what are somewhat deficient rehabilitation and mental health services.
If work is at the core of our social contract, then the
welfare system can be seen as consequential and to exist to support those who
cannot work until they can do so. In this way, a sensible relationship between
this analogous dog and its tail is affirmed.
Some expectations inevitably arise from this citizenship.
These include employment opportunities, which I will not discuss further, and
unlimited access to education and health care, which will be the subject of the
balance of this essay.
Citizenship and educationNew Zealanders assume certain egalitarian birthrights: these
include access to the highest quality of education; and, similarly, access to
the health care that they need, when and where they need it, again of the
highest quality, and without constraint. These expectations are essentially not
negotiable, are passive (as compared to being consumer-owned and proactive in a
health setting) and set a very high bar for service
provision.6
Despite considering themselves to being “Better
British”,4 which is reasonably argued to
have been a common feature of many early settlers from the UK, education is the
basis of social mobility in New Zealand and the principal ‘vehicle’
used since European colonisation began in earnest here to prevent a repetition
of the restrictive social classes of the immigrants’ countries of origin.
Our Prime Minister is an example of such mobility. Similarly, I went to a lower
socioeconomic (decile 1) secondary school and have not experienced any related
externally-imposed limitations on my ambition and/or employment.
Educational equity has nevertheless been eroded since my
school days, as evidenced by recent university-entrance attainment rates of only
13% for decile one, two and three secondary school
students.7 This relative educational failure
has self-evident and adverse employment, health and welfare, and justice-system
impacts.
Measures are in place to remedy the imbalance. The one that
has the greatest appeal to those of us in the health system is the advent of
health sciences academies at lower-decile and predominantly Polynesian (e.g.
Otahuhu College) and Māori (e.g. James Cook High School) secondary schools.
Cohorts of students are admitted to the academy for the last three years of
secondary schooling (years 11, 12 and 13).
In addition to core academic subjects, such as English and
Chemistry, students have work experience exposures through joint ventures with
local providers and medical societies, and undertake programmes and courses that
ensure they have (potential) access to the entire range of tertiary health
worker education programmes.
The direct benefits are three-fold by way of positive
education, health and employment outcomes. First, the academies render education
purposeful and are likely to increase student retention and to improve both
attendance and performance. Second, the students’ health literacy is
enhanced and these students will carry a health debate deep into their families
and Whānau, and communities. Third, there can be few more guaranteed
industries for employment than health.8,9
Citizenship and healthNew Zealand shares a health service
demand-supply-affordability mismatch with most of the industrialised World.
8-10 Some of our health services are especially
vulnerable and most of these are community- as compared to hospital-based.
Those with the greatest adverse impact on the welfare system
are the shortcomings in rehabilitation and mental health services, and the
essential absence of a managed care (Whānau Ora) workforce. Treasury
estimates that unmet mental health need is the single greatest contributor to
long term injury- and illness-related disability and consequent
welfare-dependency.11,12
Health Workforce New Zealand is well aware of these
vulnerabilities and appropriate clinician-led service reviews are
underway.13 These reviews are largely
vignette-based and predicated to resolve the conundrum of meeting a significant
growth in demand for health services (perhaps a doubling over the next decade)
in a way that both maintains overall quality and access and closes access and
outcome ‘gaps’,14,15 and that slows
the rate of increase in the costs of health care to something closer to the
likely growth in wealth of our country over the same period (about 40%).
A disruptively innovative reform of service configurations
and models of care is necessary and will need to be underpinned by a similarly
extensive reform of funding schema and rewards systems. The latter must include
the consumer if there is to be a meaningful shift to patient-centred and -owned
care. The landscape will inevitably involve both primary-secondary care and
public-private partnerships and integration.
Funding, management, provider and education integrated
models of care that include the health sciences academies cited above are also
being developed in partnership with Māori (see Figure 1); this recognises
and attends to current health outcome inequities. For example, the difference in
life-expectancy between European New Zealanders/Pakeha (as well as other New
Zealanders) compared to Māori is greater than the equivalent gap between
North American Indians and the European colonisers of that
continent.14
Across-sector alignment and governanceEducation, health, welfare, along with the accident
compensation and the justice systems are inexorably linked at a functional level
and a failing in one has knock-on effects for most of the others; and yet,
governance of these services is dislocated.
If I were to select any aspects of the WWG’s
recommendations for highlight here, it would be for a whole-of-sector conjoint
governance, for aligned and long-term outcome accountabilities (e.g. positive
employment outcomes as a headline health KPI) and for a consequential shift in
the management of our rehabilitation system to the sort of long-term actuarial
logic employed by the ACC. All are both overdue and necessary.
Figure 1. Schematic of Iwi Health Plan showing
integration of secondary school health sciences academy
 Competing interests: None.
Author information: Des Gorman, Professor,
The University of Auckland—and Executive Chairman, Health Workforce New
Zealand, The National Health Board, Wellington
Correspondence: Professor Des Gorman,
Health Workforce NZ, Ministry of Health, PO Box 5013, Wellington 6011, New
Zealand. Fax: +64 0(4) 4962191; email: d.gorman@auckland.ac.nz
References/Endnotes:
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