Primary health care is professional health care received in the community, and is usually delivered by a general practitioner (GP), practice or district nurse. It is the first port of call for most people with health issues, who may then be referred to hospital and specialist services by their GP.
In the mid-19th century life expectancy was higher for Pākehā in New Zealand than for people in Britain. Immigration guides advised doctors to come to New Zealand for the benefit of their own health, but warned them that the population was too healthy to need many more medical practitioners.
However, infectious diseases were still major killers, and Māori had lower immunity to introduced diseases than Europeans did. The Māori population plummeted in the mid-19th century and only started to recover in the 1890s.
Vaccination provided protection from smallpox, but the causes of diseases such as tuberculosis, typhoid, poliomyelitis and diphtheria were poorly understood, and there were no effective medicines to treat them. Divine causes of illness were as likely to be accepted as scientific explanations, by Māori and non-Māori alike.
Cod liver oil was used to treat a range of conditions. Dr de Jongh’s oil, which was advertised in the Otago Daily Times in 1864, was grandly described as ‘the safest, speediest and most effective remedy for consumption, chronic bronchitis, asthma, coughs, rheumatism, general debility, diseases of the skin, rickets, infantile wasting, and all scrofulous affections’.1
For much of the 19th century, primary health care for most people was a combination of folk and patent medicines and the occasional doctor’s visit. The vast majority of doctors were male. Midwifery was undertaken by women whose skills were recognised in the community, as well as by medical practitioners. Women provided informal health care to their families and to other women and children during times of illness. Families also diagnosed and treated themselves. Doctors’ scientific claims were based as much on their educational and social status as their ability to cure. They were primarily called to ease the pain of the dying, and during other crises such as accidents, which were an everyday reality in unsafe workplaces.
The rich used doctors more frequently. Elite doctors treated the wealthy in their own homes, but many doctors were more like pharmacists, making much of their income from dispensing medicines, rather than consultations. Most doctors were general practitioners, even if they worked in hospitals. Some doctors whose income was derived from general practice also had honorary positions in hospitals, where they worked for free.
In June 1890 the Thames Star newspaper printed a joke about homeopathy, based on the fundamental homeopathic principle of like curing like – meaning that substances that cause particular reactions in a healthy person will relieve the same symptoms in a sick person. The joke went:
‘I don’t believe that like cures like.’
‘Can you disprove it?’
‘I can. A piece of my wife’s mind is not good for my peace of mind.’2
Health care was divided into conflicting camps of orthodox medical practitioners and alternative practitioners. In the mid-19th century the orthodox majority competed with a range of different practitioners. Most prominent of these were homeopaths, who were popular because of their gentler treatments. Because medical education was not standarised, alternative practitioners could claim respectable professional qualifications.
Māori continued to use a mixture of natural medicines and spiritual healing, but were increasingly interested in European medicines and health care. In the 1840s missionaries dispensed large amounts of medicines imported from New South Wales, including massive doses of cod liver oil, to Māori.
Medical practitioners in some areas were paid a subsidy by the colonial government to treat Māori free of charge. From 1867 Māori schools were established and children were taught about European principles of healthy living, such as hand washing.
The first Māori were trained in European health care at the beginning of the 20th century, including doctors Māui Pōmare and Peter Buck (Te Rangi Hīroa) and nurse Ākenei Hei. They encouraged hygiene and improved sanitation, and were concerned with transforming community standards rather than individual health needs.
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.
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.
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.
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.
The growing status of medicine increased popular demand for medical practitioners. However, consultation fees were too expensive for many. In the early 1930s the standard fee was 10 shillings and sixpence – this was costly for a working person earning £2 (40 shillings) per week. Friendly societies provided a way for lower-middle-class and working-class families to access medical care through a weekly payment to the society. Societies paid doctors a moderate fee per person for looking after a family over a 12-month period.
Friendly societies were popular and had many members, so it was hard for GPs to avoid providing health services to them. The clubs drove a hard bargain. One irritated doctor wrote: ‘The majority of thrifty members of the community belong to clubs … These are people who think they ought to receive the best possible medical and surgical attention and skill at the lowest possible remuneration.’1 Some doctors resented effectively being employed by people they saw as their social inferiors.
In the early 20th century access to medical care became a political issue. The first Labour government (elected in 1935) wanted to give all New Zealanders state-funded, universal access to health care. The establishment of a national health system was a major priority and one that promised huge political benefits for Labour.
GPs also wanted reform, but for very different reasons. They wanted to give their patients access to an increasingly sophisticated range of services in public hospitals, which reform of maternity services, in particular, would provide.
The government’s plan was to pay GPs a fixed fee to cover all consultations, rather than the traditional fee for service (a payment for each consultation). This would have substantially undermined the entrepreneurial activities of GPs, leaving them as little more than salaried civil servants. They reacted to this scheme with almost unified hostility, and were determined to maintain the fee-for-service system and to have private patients. They lobbied for a system that would allow patients to have their medical bills refunded by the Department of Social Security.
In 1939, under the maternity benefits scheme, the fee for a normal delivery was 5 guineas (about $485 in 2010 terms). Further payments were made for antenatal visits and complicated labours. Midwives were paid £2 ($185 in 2010), and assisting maternity nurses £1 ($92 in 2010) for home deliveries. Visiting nurses were also paid 5 shillings per day for 14 days to cover postnatal care. If they stayed with the family, this increased to 13 shillings a day.
Although maternity benefits, which gave GPs free access to hospitals for deliveries, were introduced in 1939, there was no agreement with the government regarding general practitioners until 1941. After 1941 GPs retained their autonomy and the fee-for-service system. They were paid 7 shillings and sixpence for each consultation and could charge an additional fee on top of the state subsidy. In return, the government got a system that was largely free for patients. At the time, GPs rarely charged more than the government’s subsidy.
Once the government began paying for doctor visits and for maternity care, GPs had an overwhelming advantage over alternative therapists. Only chiropractors survived in any numbers on the edges of the medical market without state subsidies. Sophisticated pharmaceuticals increased dependence on doctors, who had a monopoly over prescribing.
The government’s failure to implement the population-based primary health system in the 1930s and 1940s had dramatic implications for health-care funding and reform for the rest of the century. The government subsidy paid to GPs did not rise with inflation, and direct patient fees increased accordingly. Patient fees created a two-tiered health system where the free public hospital system remained substantially distinct from the primary health care system.
By the late 1970s the standard one-doctor practice was being replaced by group practices and medical centres, which brought together a number of GPs, other health practitioners and support staff under one roof. This improved the support available to GPs and allowed them more family and recreational time.
By the late 20th century doctors had a much greater capacity to cure than at any stage in the past. Immunisation, antibiotics and new pharmaceuticals dramatically increased doctors’ ability to relieve pain and reduce suffering. Infectious diseases as a cause of death and illness had declined, as had infant and maternal mortality in childbirth.
However, as the threat of epidemics receded, doctors seemed less necessary to ensuring longevity. GPs’ dominance of primary health care came under threat – from patients, other health professionals and alternative practitioners.
Fertility Action (FA), later called Women’s Health Action, was founded in 1984 and is probably New Zealand’s best-known women’s health activism group. In its early days the group campaigned for safer contraceptive devices. In 1987 FA brought the treatment of cervical-cancer patients at National Women’s Hospital to public attention.
Until the late 1970s doctors were accustomed to caring for patients and prescribing treatments without much consultation with those patients – the ‘doctor knows best’ approach. Women’s groups in particular challenged this approach, as feminism contested male doctors’ control of women’s bodies and health. Māori questioned the ability of Pākehā doctors, many of whom had little understanding of Māori society and practices, to adequately treat Māori patients. The medical profession was slow to respond to these challenges, and doctors were often unwilling to acknowledge failings in their practice.
A 1987–88 inquiry into the treatment of cervical-cancer patients at National Women’s Hospital during the 1960s and 1970s led to the establishment of a Health and Disability Commissioner in 1994. The commissioner investigated patient complaints about GPs and other medical professionals. How GPs worked was made public to a much greater extent than before, and they were encouraged to share information more freely with their patients.
The New Zealand Bill of Rights Act 1990 contains two sections relevant to health. Section 10 states that ‘every person has the right not to be subjected to medical or scientific experimentation without that person's consent’, and section 11 that ‘everyone has the right to refuse to undergo any medical treatment’.
In the early 1970s midwives began to re-establish their independence from doctors, supported by women who argued that childbirth should be treated as a natural process rather than a medical event. At the same time, GPs’ control of birth was increased – from 1971 midwives could not legally deliver babies unless a doctor was present.
However, the dramatic reduction in the risk to women’s and children’s lives in childbirth undermined GPs’ attempts to justify their dominance of midwifery. This argument had been used effectively (if inaccurately) to suppress independent midwifery in the 1920s and 1930s, and to shift almost all New Zealand deliveries into hospitals under the control of doctors. From 1990 midwives could deliver babies independently, without a doctor present. From 1996 they were required at all births, and GPs who delivered babies had to pay a midwife out of the lump-sum maternity payment they received from the government. Offering maternity care was no longer financially viable for GPs and they gradually stopped providing it. They continued to care for children and mothers after birth.
From the 1970s nurses were trained independently of doctors, at polytechnics (and later universities) instead of hospitals. However, they were unable to establish themselves as autonomous primary health care practitioners to the same extent as midwives.
The government first funded practice nurses within rural general practices in 1969 to relieve overworked GPs. This scheme was extended to urban practices in 1970.
Practice nurses were doctors’ employed assistants, but were unable to extend their scope beyond routine medical and administrative tasks. When government funding was cut in the 1980s and 1990s, some practice nurses were made redundant or had their hours reduced. Despite this lack of independence, practice nurses were an important part of the primary health sector and delivered crucial services such as immunisation.
Chiropractors and osteopaths gained ground after the Second World War. Chiropractors were regulated from 1960 and osteopaths from 1978. These practices, along with acupuncture, were later subsidised for accident-related treatments by the Accident Compensation Corporation (ACC). This went against the advice of doctors. From 1999 consumers could go straight to these practitioners for ACC-subsidised treatment – previously, referral from a GP was required. In the late 20th century alternative therapies in general became more popular, which constituted a challenge to GP care.
From the 1970s successive governments tried to address the two-tier health system, which by then comprised a largely user-pays primary health sector sitting alongside a fully funded secondary (public hospital) sector. Health insurance, which was first available in the 1960s, covered GP visits and widened the gap between the upper and middle classes and the less well-off, who were disadvantaged.
The general health system was under almost constant review from this period. Underlying these reviews was a desire to limit state spending on health, better coordinate primary and secondary health care, provide more support to those with the greatest health risks, and later, to introduce more consumer choice in the system. Hospitals were the major focus of reforms, but increasing attention was paid to the primary health care sector.
Reform of the primary health sector by the mid-1980s was directed at the issue of patient charges and access. While there was a broad consensus among political parties that a fully funded primary health service was not financially viable, attempts were made to control the fees GPs charged their patients. The aim was a targeted system which provided subsidies for low-income people only.
Governments struggled to realise these aims because, as in the past, GPs objected to government control of patient charges. For instance, an attempt in 1985 to reduce child fees in exchange for higher subsidies was rejected by GPs.
In 1991 the National government wanted to replace all universal subsidies for primary health care with state provision for those on low incomes, while the rest of the population would have to rely on private insurance. Competitive contracting for services was a step in that direction. However, this goal proved politically impossible to achieve, and universal services were actually extended after 1996.
Community services cards for low-income people were introduced in 1992. They entitled users to higher GP and prescription subsidies, but their effect was limited because not all eligible people obtained a card.
Studies carried out in the 1990s found that around 25% of eligible people did not have a community services card. Eligible Pākehā were more likely to have one than other ethnic groups, and Pacific Island people were the least likely. In one study, 64% of people who did not know what a community services card was, actually held one.
From 1993 all GPs had to sign contracts with regional health authorities, which were created to purchase primary and secondary health services from both public and private health providers, thus creating a competitive market. At first the contractual process allowed the government to exert control over subsidies and fees, and also over where GPs were located.
In response, GPs grouped together as independent practitioner associations (IPAs). By 1998 nearly 70% of GPs belonged to IPAs, which strengthened their negotiating power. The previous year, despite the government policy of free primary health care for children under six, GPs had continued to charge.
While most GPs were firmly in favour of the fee-for-service system, a small number prioritised social objectives through the provision of free services. In the 1970s the Department of Health funded free primary health centres in some areas. Trade unions set up union health centres from the late 1980s. Māori, and to a lesser extent Pacific, providers of primary health care increased dramatically in the contracting environment after 1991.
GPs staffing these centres were salaried employees, and because they did not rely on individual consultations for their income, they could spend time on activities not directly related to individual patients, such as health promotion. Nurses in these practices were able to take on greater responsibilities with respect to patient care.
In 2001 the nurse practitioner role was introduced in New Zealand. Nurse practitioners are expert registered nurses with a master’s degree and can practise with far more autonomy than their non-practitioner counterparts. Some can prescribe medicines.
The most significant reform of the primary health sector since 1941 occurred in the early 21st century. The government resurrected the population-based approach of the first Labour government and created a model based on the non-profit sector. This time, the government gained the support of GPs. Group practices, Māori and community health providers (including other professionals like midwives) grouped together as primary health organisations (PHOs).
This was not, however, a universal, fully funded model – PHOs with enrolled populations identified as high need (Māori, Pacific and low-income people) received more funding per person than those with lower-need populations. As a result, visiting a doctor in South Auckland was considerably less expensive than one on the North Shore.
From July 2015 over 90% of general practices in New Zealand opted into a new scheme that offered zero-fee visits to children 13 years and under. The $5.00 per item cost for prescription medicines was also removed for this age group. This scheme extended the under 6s-zero fees programme introduced in 1996. General practitioners could decide whether or not to offer zero-fee visits in practice hours for children 13 and under. Those who offered this service received capitation funding for children enrolled in their practice and an extra subsidy from the Government. District Health Boards were separately funded to ensure that children 13 years and under received free after-hours general practice and pharmacy services.
This initiative was directed at ensuring that children had access to health care services, regardless of parental income and also to avoid visits to no-fee hospital A&E departments that were often used by low-income parents
By the early 21st century the concepts of consumer choice and patient rights were firmly embedded in the primary health care system. Health professionals had to recognise the cultural and social preferences of patients. Doctors were one of many types of health provider – as in the mid-19th century. However, the population-based funding approach and attempts to ensure equality of access harked back to the 1930s, while the retention of a user-pays element acknowledged one of the key elements of the 1980s economic reforms.
Allan, Vivienne. Nurse Maude: the first 100 years. Christchurch: Nurse Maude Foundation, 1996.
St George, Ian. A special general practice: the story of John Street Doctors. Wellington: St George, 1998.
Bryder, Linda (ed). A healthy country: essays on the social history of medicine in New Zealand. Wellington: Bridget Williams Books, 1991.
Donley, Joan. Save the midwife. Auckland: New Women’s Press, 1986.
Gauld, Robin. Revolving doors: New Zealand’s health reforms, the continuing saga. Wellington: Health Services Research Centre and Institute of Policy Studies, 2009.
Wright-St Clair, Rex Earl. A history of general practice and of the Royal New Zealand College of General Practitioners. Wellington: Royal New Zealand College of General Practitioners, 1989.