The New Zealand Herald, 19 September 2023

In an election campaign at full pitch with each party seeking to differentiate itself it is hard to detect areas of agreement that might underpin cooperation in any future government.

But look more closely and there is one area of agreement across all parties – health care. It is hard to find any party prepared to say they want to radically change our current health care arrangements or reduce taxpayer funding to health. Everyone wants to improve health care quality and access.

More specifically, the focus has been on increasing the number of doctors – by establishing a third medical school in the case of National and increasing numbers at the two existing medical schools for Labour – with an emphasis on tackling shortages in general practice. In addition, Labour wants to increase the number of graduates coming out of our one dental school to contribute to the expansion of subsidised dental care, starting with those under the age of 30.

According to recent figures from the OECD New Zealand is not particularly poorly provided for: compared with Australia at 4.0 doctors per 1,000 population we are 3.6, and well above the UK, Canada and the US. So, it’s hardly a crisis. More of a problem is that so many of our medical graduates leave the country and we are very reliant on doctors who have trained overseas.

But it hardly justifies building a new medical school, particularly if it just further fuels the exodus of our best and brightest as future doctors. Yet, if we were to take the associated suggestions of switching to graduate rather than school entry and training over four years rather than six – both of which are common overseas – we could raise the output of doctors from our existing medical schools by 50 per cent without even increasing class size. Furthermore, our entrants would have more life experience, perhaps more commitment to the country, and we would be in a better position to select them on criteria other than solely academic.

Even then, the numbers of extra doctors we end up training, particularly for general practice, needs to be looked at closely. For example, it has been estimated that 80% or more of the work in primary care can be carried out by nurse practitioners and physician assistants as part of a well-managed practice team with the doctor concentrating on diagnosis and more complex cases. Such an arrangement could reduce the cost structure of primary care, increase the resilience of the sector, improve access, and could also increase work satisfaction among medical graduates weighing up general versus specialist practice, especially if incomes matched hospital scales.

Much the same conclusion can be drawn in relation to Labour’s proposal for extending dental care: the standard dental course could be shortened from five to four years and it could be made graduate entry. There is also a very strong case for the use of dental nurse practitioners, who could do much of the routine work in general dental practice, with the dentist concentrating on diagnosis and advanced work. New Zealand has had dental nurse practitioners working in a restricted environment in schools for a century and it would not take much for these skills and this scope of practice to be extended. Again, this would increase the productivity of standard general dental practice, improve access and reduce costs.

These details on the proposals by the two major parties in the area of workforce development in health and dental care have not been agreed and publicly spelt out, but there is the opportunity post-election to work creatively in circumstances of fiscal tightness not only to extend access, but to do so in a manner that improves productivity, reduces costs, and marks a turn in New Zealand’s otherwise rather timid track record on workforce development where not much has happened since the creation of autonomous midwifery in 1990.

There is also no agreement on how these developments would be funded, nor is there any cross-party agreement on issues of public health – such as tackling obesity. Yet, it would not be hard to extend our pioneering social insurance scheme, ACC, from accidents and injury to non-hospital health care more generally. Furthermore, we could take a leaf out of the book of Conservatives in the UK who have come to agreements with industry on reducing sugar in the UK diet and are seeking to extend that model to other harmful ingredients.

It is recorded, probably apocryphally, that the German nineteenth century Chancellor Otto von Bismarck said that “Laws are like sausages. It is best not to see them being made”. On current performance New Zealand elections could be added to this striking analogy! But in the case of training more doctors – and maybe dentists – there does seem to be a case and, while such claims and counter-claims have been made in the heat of the moment, they do provide an opportunity to think creatively and constructively about repairing a very real deficiency in New Zealand’s health care delivery system.

Peter Davis, Emeritus Professor in Population Health and Social Science at the University of Auckland, and former elected member on the Auckland District Health Board.

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