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Each political regime has reconstructed health services in New Zealand, maintaining ideological alignment with the economic and social reform taking place at the time. These in turn have shaped the available range of possibilities for the medical and nursing professions and for the population in general. Individuals either take up or refuse various positions made available by these discourses. The following sections examine the spaces created by these discourses from which an advanced nursing role, the nurse practitioner, eventually emerged.

Welfare health reform

Public hospital care under welfarism in the 1940s came to be entirely funded by the state and provided specialist outpatient, elective surgery and acute services. The present-day composition of the public health sector is based on this funding model and an ideology of universal access to care.

However, general practitioners offering primary care services had always operated within a private business model (Fougere, 2001) and during the 1940s rejected the welfarist regime, taking it to infer state control over business independence (Baker, 1992; Blanc, 1949; Sutch, 1966). Choosing rather to remain aligned with a liberal ideology, the introduction of free access to primary medical care for all New Zealand citizens was met with intense general practitioner resistance. Although radical reform of the health care system was the goal of the state at the time, a compromise solution was eventually reached in 1941 with a dual system of subsidised private enterprise that continued to operate alongside the state public hospital system (M. Burgess, 1984). The right of GPs to charge patients co- payments was eventually secured in legislation by amendment to the Social Security Act 1949, and thus secured the future income of GPs (Baker, 1992; R. Barnett, Barnett, & Kearns, 1998; Sutch, 1966).

A doctor writing in 1949, Albert Blanc, described the new era of state-paid medicine as: “where the doctor is not restrained at all in his prescribing and where there is encouragement to over-visit and, therefore, to over-prescribe…” (Blanc, 1949, p. 68). Exploitation of the new provisions resulted in the state pharmaceutical bill alone exhibiting a quarter-of-a-million pounds straight-line

growth, year on year, from 1941–1948 and the income of GPs benefiting tremendously (Blanc, 1949). Illustrating the range of discourses at play, it seems the context of state welfarism paradoxically permitted the natural self-interested behaviour of Homo economicus to flourish in both general practice and the pharmaceutical industry. That is, there was a massive increase in market demand for pharmaceuticals (now ‘free’ to the public with a prescription), and also in the demand for medical monitoring of patients newly prescribed (also substantially paid for by the state). Furthermore, the material consequences of the fee-for- service agreement reinforced an approach to health based on the curative biomedical model that stressed the importance of a medical consultation when sick.

In a scheme initiated by the New Zealand Medical Association and the Department of Health (Hart, 1980), nurses came to be positioned within primary care services by way of a state subsidy intended to relieve “the serious problem of the overworked general practitioner” and in which doctors employed nurses to work as their “extensions” ("Practice nurse scheme extended," 1974, p. 19). In contrast to the position taken by general practitioners to welfarism, a condition insisted upon by the New Zealand Nurses’ Association (NZNA) in 1974 when the practice nurse scheme was extended from rural to urban areas was that nursing services would be free to patients. Along with the general medical subsidy, the practice nurse subsidy served to further embed state funding practices of payment to the owners of general practices (that is, general practitioners) and not their employee nurses.

Although universal access to health care served to increase the demand for nurses, it did so predominantly in medically supervised service areas. The possibilities for nurses and nursing in the hospital and in primary care were limited by a representation of nurses as a docile and useful workforce that made it inconceivable for nurses to be considered as other than assistants to doctors (see chapter five). Nonetheless, nurses came to be located in the primary care sector as indispensable, albeit positioned as the employees of doctors in a relationship complicated by vicarious liability. The long-term significance of these practices, along with the insistence of general practitioners to maintain autonomy in fee-

setting, continue to resonate in the 21st century and to construct the primary care sector within a business model, despite an intended regime of state provision. As discursive practices, these issues have continued to resurface and are examined further in chapter eight as constraints on the advanced nursing practice role of nurse practitioner in the primary care sector.

Neoliberal health reform

The neoliberal health reforms of the 1990s occurred within the context of radical social and economic reform described earlier. Similar changes to health care services were occurring throughout the developed world, influenced by changes in medical technology as well as a neoliberal political ideology (McGregor, 2001). Based on generic management principles (or managerialism) introduced by the State Sector Act, 1988 and proposed by a team with management not health experience, the Gibbs Report (Hospital & Related Services Taskforce, 1988) introduced a competitive contracting private sector management model to New Zealand health. It is important to note that the Gibbs Report was dismissed by many, including the Labour government when it was written, as extreme (Kelsey, 1998), but was nonetheless implemented by the National government in 1993.

Implementing a market model, the fiscally austere budget of the National government in 1991 betrayed an ultimate agenda to privatise health care not only by introducing a purchaser – provider split, but by providing people with the choice “to take their entitlement to Government funding for health care with them … to pay the annual fee of their health care plan” (Upton, 1991, p. 61). The government plan to privatise health care never eventuated, but the Minister of Health at the time, Simon Upton, did intend to reduce medical capture of the primary care market and introduce and fund more services to be delivered by nurses and other professionals. The idea was to encourage more health education and health promotion than doctors were currently providing. Importantly, Upton’s Green and White paper was the first policy document to recognise that inadequate primary health care escalated the costs of secondary care services, and for this reason, to challenge the GP monopoly of the primary sector. The paper became the precursor for the deregulation of the sector and many of the changes later instituted under the Primary Health Care Strategy (Ministry of Health, 2001b).

However, due to escalating costs, state-owned and funded secondary care (and not primary care) became the focus for reform during the early 1990s in an effort to enhance efficiencies and improve access to specialist services and reduce waiting lists. Hospitals were restructured based on a competitive business model, with the purchase and delivery of health services explicitly separated. There was a requirement that public providers compete with private providers, as well as return a profit (Health Reforms Research Team, 2003).

These reforms were later ‘re-formed’ in 1996 under a new Coalition government of National and New Zealand First parties and reflected a retreat from the market model. The ‘for-profit’ objective was removed as well as threats of privatisation (P. Barnett & Barnett, 1999). A greater emphasis was to be placed on monitoring health outcomes, especially in primary care, where there was little accountability (Gauld, 2001). While relieved of the requirement to return a profit to the shareholders (i.e. Cabinet), hospitals continued to bear the burden of debt as they sought to provide services at contract prices that failed to cover real costs. Rationalisation of the workforce and closing or downsizing services became the only options for reducing financial deficits.

During this period of neoliberal health reform, a variety of third-sector primary care centres were established with the support of state funding. The term ‘third- sector’ refers to the non-government, non-profit sector (Crampton, 1999). Mā_ori,

as disproportionately represented in areas of high deprivation (see Ajwani, Blakely, Robson, Tobias, & Bonne, 2003), sought greater autonomy over health care services and established iwi15 based primary care initiatives in many sites around the country. The Ministry of Health was active in their support of these initiatives due to the “sustained failure of the state and private sector to provide freely accessible services for low-income populations, rural communities and Mā_{ori populations” (Crampton, Woodward, & Dowell, 2001, p. 12). Providing}

services of similar quality, restraint on profit distribution is the main difference between third-sector organisations and for-profit organisations (Crampton, 1999). Consistent with neoliberal practices, state support and finance for the

development of iwi-based primary care services encouraged Mā_{ori communities}

to take responsibility for health care problems and attended to the neoliberal concern about special-interest group capture by facilitating entry of this new competitor to the health care market. As well, the location of these services in the third-sector simultaneously withdrew the state from overt and direct control. That said, Foucault (in Lemke, 2000, p. 11), citing the example of non-government organisations, cautioned them as being not “a reduction of State sovereignty … but a displacement from formal to informal techniques of government and the appearance of new actors on the scene of government”. Nonetheless, Crampton (1999, p. 15) viewed iwi-based non-government initiatives as “one of the principal successes” of the reforms. Spaces created for nurse practitioners in third- sector trusts are examined further in chapter ten.

The impact of a decade of neoliberal reforms on nurses in hospitals caused a massive shift in their representation as well as the normative culture of health care management and delivery. The effects of managerialism on nursing are described by Tilah (1996) as shifting the power of decision making from the original triumvirate management of hospitals to policy makers and planners without professional health affiliation. In contrast to the fragmented voice of nursing at the time (see chapter five), the medical profession fared reasonably well under the reforms, perhaps due to their solidarity and experience with resistance to government interference. The Employment Contracts Act (ECA) 1991 applied contract law to health care contexts because they, too, along with the economy, were now operating on a competitive basis. A representation of nursing as a unionised workforce is discussed further in chapter five. Suffice to say here, in addition to a dramatic effect on nurses’ wages with the loss of award conditions (Blake, 1997; NZ Nurses Organisation, 1993 June), the New Zealand Nurses Organisation (NZNO) was rendered virtually powerless in contract negotiations on behalf of its members.

Consequently, nursing became an easy target for staffing cuts, which resulted in substantially increased adverse clinical outcome rates for hospitalised medical and surgical patients (see McCloskey & Diers, 2005). Connor (2004) describes nursing during that time as practising under a functionalist discourse, whereby the

drive to cut costs positioned nurses as responsive only to client functional deficits. The managerial perception then followed that nurses added value only when providing direct bedside care. Consequently, much of nurses’ hierarchy in management, clinical leadership and education were lost to generic managers thought to be better placed to manage nurses than nurses themselves (Carryer, 2004).

In terms of power relationships having a “directly productive role wherever they come into play” (Foucault, 1990, p. 94), the consequence of managerialism ‘writing’ nursing was to produce a disaffected nursing workforce unable to provide efficient care without the support structures of clinical nursing leadership. Service provision contracts designed in a non-nursing management structure tended to circumscribe nursing practice, restricting innovative and effective intervention that fell outside the boundaries of the contracts.

However, it could equally be argued, as has Papps (1997, p. 278), that the health reforms of the 1990s disestablished the “ritualistic authoritarianism” of nursing hierarchies (examined further in chapter five) and positioned both nursing and

medical staff in a subordinate position to general management. The official relationship between nursing and medical staff therefore became egalitarian and collegial and presented an opportunity for nurses to be free from the disciplinary techniques normally used by medicine to manage the doctor – nurse relationship. It could also be argued that the reforms opened up new spaces for a discourse of advanced practice nursing to develop, spurred on by the need for workforce retention strategies and solutions to address an almost flat career structure and lack of nursing leadership in clinical practice.

Third Way health reform

According to a number of commentators, the neoliberal health reforms of the 1990s were an experiment that had failed dismally (R. Barnett & Barnett, 2004; Easton, 1994; Gauld, 2001; Jesson, 1999; Kelsey, 1998). The incoming Labour government of 1999 subsequently initiated another round of health reforms based on election promises and refashioned the health sector to be non-competitive under the New Zealand Public Health and Disability Act, 2000.

Although key structural changes were made to the management of hospitals, this round of reforms impacted most on primary care. In conjunction with a number of over-arching health strategies set to central priorities, the New Zealand Public Health and Disability Act, 2000 made provision for the establishment of 21 District Health Boards (DHBs) that would own and manage the public hospitals, directly purchasing and providing de-centralised services for geographically defined populations. The Act aimed to reduce health disparities, to provide a community voice in health-sector decisions, and to promote the integration of all health services, especially primary with secondary services. Intent on tackling what was essentially a private primary care service, one of the over-arching strategies that support the Act, the PHC Strategy (Ministry of Health, 2001b), became the first government document to enact policy related to primary health care, despite a national and international discourse indicating its necessity since the 1970s. Primary health care nursing was identified as being crucial to the Strategy’s implementation.

Modelled on the iwi-based primary care organisations that had flourished during the 1990s, and similar to Primary Health Trusts in the UK, the PHC Strategy provided for the establishment of community trusts called Primary Health Organisations (PHOs) to be funded by DHBs for the provision of services that met local needs (Ministry of Health, 2001b).

Although modelled on existing third-sector not-for-profit primary health care, where doctors and nurses are paid a salary (Crampton, 1999), in reality, the collective groupings of privately owned general medical practices known as Independent Practitioner Associations (IPAs) simply re-branded as PHOs and maintained their membership with the IPA Council. They employed a broader range of health professionals but in many cases took charge of governance, essentially continuing to operate as private businesses on public money (Morrissey, 2003). Resurfacing liberal notions seemingly embedded in medical discourse, many individual GPs continue to be paid a fee-for-service for each patient consultation rather than a salary (Kumar, 2004). Due to a growing trend amongst younger GPs away from the stresses of owning a medical business, one isolated and mostly rural DHB directly employs salaried GPs to staff the medical

centres it owns in the area (Powell, 2005, Feb 3). Nurses otherwise remain in the employ of the GP-owned practice and are paid a salary from the capitation funding pool. Discussed further in chapter eight, funding and employment structures in the IPA-type of PHO have constrained the expansion of nursing practice by limiting the clinical autonomy of nurses (Minto, 2006).

Notwithstanding the limitations of IPA focused PHOs, discourses of primary health care and the Third Way in the meantime have together played a productive role in expanding the autonomy of nursing practice (Affara, 1995). The philosophical congruence of nursing education with key primary health care principles is particularly salient (Carryer et al., 1999). With some notable exceptions, particularly in public health and in district nursing (see Arcus, 2004), traditional nursing practice had been confined to inside the hospital walls or general practice rooms, where nurses are always visible and subject to the gaze of medicine (Foucault, 1977a). However, the possibilities for PHC nursing go beyond the traditional surveillance or gaze and have led to consideration of ways to extend nursing’s accepted roles.

In sum, two philosophically opposed positions have emerged in reference to the provision of health care: the egalitarian view congruent with the Alma Ata Declaration on Primary Health Care (1978) that regards access to health care to be the right of all citizens, connecting physical and mental well-being with social

well-being; or the market liberal view that regards access to better quality health care to be part of society’s reward system for those on higher incomes (T. Ashton, 1992). Health, to a market liberal, is a commodity to be bought and sold on the level playing field of its particular marketplace (Kelsey, 1998) and utilises the language of the market to position ‘patients’ as health care ‘consumers’. Social justice discourses, on the other hand, associate the right of access to welfare with improved health status.

The tension between discourses of social welfarism and of neoliberalism has been, and still is, exemplified in the tension between the state and private general practice. On the one hand, the welfare state has sought to provide a free health service to New Zealand citizens, while on the other, promoted a free-market

approach to business. General practitioners, however, while endorsing in principle free access to their services via state payment, have resisted relinquishing the clinical and business autonomy implied by state provision, calling it in 1941 “a condition of state helotry” (Dr. Jamieson in Sutch, 1966, p. 242). Little has changed in the intervening years:

There’s a very fierce independence in general practice, and there’s always a debate and a tension that goes on between – you know – government funding always comes with strings attached. And whether you want to take the subsidy with one hand, but actually put the noose around your neck with another is certainly something that the sector will look at carefully (Cathy O’Malley, Chief Executive of WIPA, in Graham, 2005, November 27).

Significantly, the tension between these discourses shapes the relationship medicine has with the state and with other health professionals such as nurses, and with the population. It has constructed health discursively as the expert province of medicine alone, entitled to the status, income and privilege such a representation merits.

Summary

The assumption of state responsibility for the provision of health services has been interpreted to greater or lesser extents within different truth regimes. Essentially, discourses of welfarism and the Third Way achieve many of the goals of neoliberalism by taking ‘another way’ or route via the enhancement of social health. Each of the discourses discussed structure health services in particular ways, employing legislative change as the means of implementation for respective regimes of truth. The population, as well as health practitioners, are made subject to these regimes and are expected to adjust their conduct accordingly.

Within a discourse of welfarism, health is constructed as the right of all citizens