Doctors began to take control of primary health care in the late 19th century. Improvements to hospital services in the late 19th century greatly assisted medical aspirations to control of health care. Hospitals became more popular and GPs were gatekeepers to a growing range of specialist medical services, which required GP referral.
Doctors are self-regulated, but achieving this wasn’t plain sailing. The Medical Practitioners Act 1867 gave doctors self-regulatory powers, but the government removed this power two years later in the wake of a dispute between orthodox doctors and homeopaths. Doctors did not regain self-regulation until 1914.
Medical advances, including the introduction of anaesthesia and X-rays, advances in microbiology and genetics, and the ability to control harmful bacteria during surgery, dramatically increased the status of medicine and highlighted its scientific aspirations. These advances contributed to control of primary health care by doctors.
In the decades prior to the First World War, doctors increasingly separated themselves from other practitioners such as homeopaths and came to dominate primary health care. Opticians, chemists and dentists were the few professions that were able to provide health services largely free of medical control.
While doctors made hygiene and sanitary improvements to their practice in the 1920s, problems still occurred in this area. A committee investigated maternal mortality during childbirth in 1921 and found the greatest cause of death was puerperal sepsis, a form of blood poisoning. This was attributed to low resistance to infection, unhygienic homes and maternity hospitals, and over-use of medical instruments like forceps, which were often contaminated with bacteria. Midwives and nurses were not allowed to use these instruments, so blame was squarely laid at doctors’ doors.
However, doctors could not persuade the government to outlaw alternative practitioners. They did not gain a complete monopoly over primary health care. Traditional Māori healers were outlawed by the Tohunga Suppression Act 1907 (which in practice was rarely invoked), but most other alternative practitioners, including chiropractors, faith healers, herbalists and Chinese practitioners, continued to advertise and practise.
Training and professional associations
The establishment of the Otago Medical School in 1875 provided a local source of doctors, whose common education ensured increased standardisation of practices among medical practitioners.
The New Zealand Medical Association was established in 1886, and was known as the New Zealand branch of the British Medical Association from 1896 to 1967. The association provided a platform for advancing the profession’s political aspirations and from 1887 published the New Zealand Medical Journal, which combined professional debate, political advocacy and publication of medical research.
Advertising by GPs was prohibited, but demonstrations of social and economic success were not. Doctors were quick to give the impression of wealth and gentility as indicators or professional ability and scientific respectability. They often had the grandest houses in smaller cities and towns, and had a reputation for owning fine carriages and horses, and later, driving the newest and best motor cars.
GPs worked alone – group practices were a late-20th-century phenomenon. For rural doctors in particular, general practice was physically demanding. Their practices covered large areas and, particularly before the days of cars, much time and effort was spent riding to see patients on horseback, sometimes through challenging terrain and in poor weather.
Nurses and midwives
Women continued to provide health information and care, and some were professionalised as nurses and midwives from the late 19th century. Training courses at hospitals were available from the 1880s, and New Zealand became the first country to recognise the professional status of nurses when registration became compulsory in 1901. This was extended to midwives in 1911. Registration was an advance for women because it meant they could attain professional status and qualifications. However, the cost was professional control by doctors and limited opportunities to practise independently.
Ray of sunshine
Nurse Maud was well-loved and respected. The New Zealand Truth described her as ‘the Sunbeam Sister’ and a ‘self-sacrificing woman, whose sole aim in life is to serve and help those who cannot help themselves’.1
In 1896 in Christchurch, Sibylla Maude (known as Nurse Maud) started the first district nursing service in New Zealand. She provided free treatment for people unable to pay for medical services, seeing them in their homes and at a clinic. Nurse Maud’s work led to the development of district nursing services throughout New Zealand. Initially, these services were privately funded and in urban areas. Public hospital boards provided free district nurses in rural areas from 1909. The first Māori nurses were also appointed that year.
The Society for the Promotion of the Health of Women and Children (later called Plunket) was established in 1907 to improve the health of mothers and babies. It mobilised middle-class women and families through its prescriptive and effective self-help health programmes. Although Plunket was led by medical practitioners, it was largely staffed by women nurses and volunteers who worked independently from local GPs. Founder Dr Frederic Truby King was director of child welfare at the Department of Health in the early 1920s, which contributed to Plunket’s rare autonomy from the medical profession.