Listener 19 December, 1992
Richard Titmuss’s The Gift Relationship: from Human Blood to Social Policy is one of the most insightful social-science texts of the 20th century. In it he shows that how a community handles its blood-transfusion service is a paradigm for its handling of overall social relations. Which makes it all the more telling to step back from the current row and place the quality of the blood supply in the context of the total health service.
I want to address two key features about the current situation, First, the Department of Health is undergoing yet another of its reorganisations, (Alan Maynard, a well-known British health economist, describes the British changes as “redisorganisation”.) Can officials in such circumstances focus on providing health advice? Are the new systems sufficiently bedded in to ensure that as a health problem arises it is identified and smoothly dealt with. Or is a problem likely to fall between the raw edges in the new organisation? One bureaucrat recalls it taking more than five years for his department to recover from a single major reorganisation,
Moreover, the changes have favoured the employment of accountants, business managers, economists, industrial relations experts, public affairs advisers, and sociologists at the expense of those with medical training. That means there is an increasing proportion of a diminishing staff (already distracted by yet another reorganisation) who have the competence to recognise a medical problem When some medical issue comes across the non-medic’s desk it is likely to be seen as a political, resource or social issue rather than as a health one. I am not knocking the rolc of the non-medical specialist, of which I am one, But do not forget our limitations.
The tension between health provision and the resources available to fund it has been central to medical policy in recent years as new medical technologies have leapt beyond the means to finance them, Given that the government has been cutting back on health spending (a greater proportion of which is on non-medical components), the tensions in parts of the health service are becoming unbearable, It is surely no accident that one of the last things the Minister of Health said about the issue was: “I have two options. I can raise more money, , , for the vote health. Or I must have a go at some tricky juggling of services to make hepatitis C a screening priority.”
Fair enough, but we must ask whether the current focus on public funding cuts is obscuring consideration of the quality of health care.
Things could be worse, A week or so before our case broke out, a scandal blew up in France over the provision of Aids contaminated serum – more than 5000 haemophiliacs and others could be affected. Reuters reported that one reason given for the failure to withdraw the tainted stocks was that the Natiollal Blood Transfusion Centre “was under Health Ministry pressure to become profitable and competitive in Europe”. The officials used up existing contaminated stocks rather than pay for disinfected imported blood products. Could such a scandal happen in New Zealand?
Currently Parliament has before it the Health and Disability Services Bill, which will corporatise much of the public health system and require each hospital (oops, I mean crown health enterprise) to act as ‘a successful business’ – the government’s euphemism for making a profit.
What is especially dangerous here is that we have few protections against medical malpractice that could arise from a rapacious medical provider, In the US, for instance, doctors are kept in line by the threat of litigation for damages, but that avenue has been all but closed by our Accident Compensation Act. Instead we have a ramshackle collection of professional ethics and self-enforcement, marginal legal remedies and (often impotent) public outrage inspired by the odd journalistic investigation, If there is some doubt about how effective our protections are in the present health system, common sense suggests they will be even less so in a profit-driven one.
The economist’s point is not about punishing the wrongdoer, but rather that we need an incentive system that discourages future wrongdoing, What will be the disincentive to stop medical enterprises ignoring health needs in the pursuit of profit?
The bill tidies up the present legislation on blood (in a supplementary order paper tabled after the public made its written representations to the select committee). It continues the limitations on advertising and the prohibitions on the paying of blood donors. But it also proposes to give the health minister wide discretion to permit competition in the blood-provision industry, including presumably – although the bill coyly does not mention it – competition from profit driven providers, We know the effect of competitive entry on other public-sector agencies. Warding off the threat of private firms has typically resulted in them making themselves more profitable and competitive … Possibly some mechanism is to be introduced to protect the quality of the blood supply and the overall quality of the health service, although none is provided in the bill.
Tltmuss’s insight was that the community’s treatment of blood provides insights into the whole of the health system. Have we not had a grave warning about the effects of the redisorganisation, the burgeoning numbers of non-medical staff, the preoccupation with resource usage, the reduction in funding and the profit line? The country’s health and best medical practice will have difficulties being priorities above that lot.