Destiny rides again.

Abstract

The New Zealand Medical Association has emerged intact from its recent conflict with the Minister of Health. This outcome prompts memories of 45 years ago when the general practitioners success? fully prevented what would have been the nationalisation of the general practitioner services. The first Labour government in New Zealand swept into power at the 1935 general election with a big majority. At that time there were few welfare benefits despite New Zealand having had a means tested old age pension since 1898. In 1935 the New Zealand Branch of the BMA, as the New Zealand Medical Association was then, was considering the desirability of some sort of national health insurance with benefits related to income and for some reform of the public hospital system. The government's health proposals included a raft of benefits that included a free public hospital system and a series of free benefits for general practice. All this would have given New Zealand a national health service in all but name long before any other English speaking country and on a par with what was being developed in Scandinavia. The free general practitioner consultation and maternity benefits, however, proved to be a battle ground between the BMA and the government. Both sides had difficulty understanding the other's point of view and personality conflicts did not help. The arguments used against the government were that there was no need for sudden change, standards of medicine were best preserved by the private practice system, the patient would be denied a free choice of doctor, a contract system would reduce medicine to a common denomina? tor, medicine would be subordinated to the state, and there should be a payment that was related to the service provided. Nevertheless, despite medical opposition the Social Security Act 1938, a landmark in social legislation, was passed, establishing from April 1939 many welfare benefits as a universal right. At the 1938 general election the Labour party had won another big majority and this was a mandate for the welfare state?since added to by both political parties. The BMA continued its opposition to the general practice proposal of a generous capitation fee (15/-) in full settlement ?for the consultation. Though the doctors refrained from striking they resolutely refused to cooperate with the introduction of the medical benefits and the general practitioners managed to hold fast. The outbreak of war in 1939 made tittle difference to the struggle on the home front and if anything acted as a stiffener. The compromise over general practitioner services did not come until mid-1941, when the impasse was resolved by both sides agreeing to a fee for service that would not be in total settlement of the consultation fee. The patient would pay and a benefit (7/6, later 750) be reimbursed by the state, a generous offer as 10/was the average fee for a surgery visit. Thus the general medical services benefit came in. The government had won on the issue of universality and the BMA had triumphed in resisting a free general practitioner service either by a full capitation fee or a full fee for service. There are several accounts of the conflict13 and how much was a consequence of principle, power, or pence has never been fully resolved. But at least it can be said that money was not really at stake even if there was a final sweetener. As a leading Labour minister said of the doctors, they were tougher even to deal with than wharfies.4 Ups and downs of health benefits