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JUDY YARWOOD rediscovers a nearly 20-year-old primary healthcare report in her quake-trashed study and ponders why so many issues still remain the same.

If we’ve learnt nothing else in Christchurch over the last year it’s that 20 seconds is all it takes to change lives. Leaving home for work on the morning of 22 February, everything was as it should be. Arriving back later on that fateful afternoon, the place was a shambles. It’s amazing how far a bottle of sweet soya sauce can spread when it smashes onto floor tiles along with flour, sugar, cereal, assorted pantry ingredients, glassware, and crockery! Not a room escaped damage, including my upstairs study, where the floor-to-ceiling bookcases, fortunately securely fastened to the wall, had been emptied into a pile along with folders, lamps, furniture, and laptop.

Apart from extricating the laptop that day, it took about a week before I could face the chaos. When I did start sorting, discarding and re-filing, I found long-forgotten books, newspaper cutings, photographs and articles that hadn’t seen the light of day for a number of years.

Hidden among these treasures was a slim report of a 1992/3 pilot study of the Wellington Professional Nurse Case Management (PNCM) project. Described as an innovative nursing initiative, the project aimed to see if a PNCM scheme could address the needs of families in complex health circumstances. Nearly 20 families with diverse backgrounds and health situations participated in the project over 12 months.

Sitting on the floor amid the dust, clutter and paper, flicking through the report, I thought, despite the passing of 15-plus years, not to mention constant change in our healthcare system, some things had stayed the same. Take a look at the eight significant issues of healthcare this 1992/3 pilot project aimed to address:

fragmentation of healthcare according to professional and service divisions; the complexity of the health circumstances has been inadequately addressed;

duplication of healthcare where services overlap, often with inconsistency, confusion for clients and waste of resources;

the health system’s emphasis on professionals providing services rather than client/family accessing services;

a focus on the cure or management of the disease/disability of individuals, at the expense of attention to the health circumstances of people in a family/group context;

emphasis of public health expenditure on hospitals and acute care rather than support of the everyday living of people;

health increasingly viewed as a commodity rendering invisible the predicament of lower income families where there is a member with chronic illness or disability;

inadequate attention given to children, their health and welfare, which has significance for the health of the nation in the immediate and extended future;

recognition of the potential for some people to live with less dependence on public health and welfare services.

All eight points sound familiar one way or another, which had me thinking how many of these significant issues have been addressed over the last nearly 20 years. One could argue very few, as we still see duplication of health services, confusion for clients and their families, health professionals leading care, wasted resources, and an emphasis on public health expenditure in hospitals and acute care rather than supporting people in the circumstances of their day-to-day lives. Our health system remains locked into diagnosis, treatment and management of long-term health conditions rather than preventing disease in the first place, while our record on children’s health and welfare trends downward.

The recently released child poverty report suggests over 200,000 children in New Zealand live in poverty, with at least one in five experiencing severe hardship that compromises their health, education and future. How is it that: (firstly) 40,000 children in New Zealand rely on charity for food, in particular, breakfast; (secondly) so many families are unable to provide decent food because of low wages and high food costs; (and thirdly) the current government cannot grasp the notion that ensuring children of today are well fed, educated and healthy will ensure the country’s success in the next generation.

Social Development Minister Paula Bennett’s answer is to dismiss the poverty report as a political document, one the minister believes rehashes work already done by the authors. Were this the case, the fact that the same ideas keep appearing might suggest to the minister that there is some validity in this message. Whatever, this report follows close on the heels of several others, including the Green paper on vulnerable children, all of which make it clear that as a country we have major social problems, including violence, particularly family violence. Being almost at the top of the list of OECD countries for youth suicide, family violence and child abuse is grim to say the least.

Going back to the future, so to speak, I jumped to the PNCM report’s conclusion and recommendations to find that as a primary healthcare initiative the project was highly successful. Not only were the health needs of families effectively addressed, but the actual and potential cost savings for families, healthcare agencies and society were also achieved. All of which made me think, isn’t that what we’re constantly being urged to do today as health costs soar? Aren’t we urged to come up with innovative ideas while bearing in mind that the prime imperative is economic benefit? And nurses are doing that throughout the country in so many ways. Visiting health clinics in rural and remote communities, I see stunning nursing work sustaining communities’ health and wellbeing, just as I do when working with nursing students in district nursing and palliative care. Researching with public health nurses, I hear of family/nurse interactions arising from patient, non-judgmental therapeutic relationships that can take weeks or even months to nurture, relationships that with time heal so much more than disease and physical illness.

Which takes me back to the report recommendations, two of which were:

attention to be given to the predicament of many families experiencing long-term illness or disability in complex health circumstances;

nurse case management be acknowledged as a feasible scheme to support a cost-effective family-oriented approach to providing care for families with highly complex health circumstances.

What I’m wondering is what happened to this report’s recommendations and ideas? They are as relevant today – if not more so – for many families who struggle to make ends meet and who have few personal or economic resources with which to access healthcare. A growing number of families are finding themselves in this predicament as the gap between rich and poor widens, creating an unequal society. The sobering point here is that income inequality within a country not only disadvantages those with very little resources but all members of society.

Little doubt remains that the relationship between health and social disadvantage has major significance not only because of economic cost to many, but also due to the social injustice caused by health inequalities. On a recent visit to New Zealand, Sir Michael Marmot had no qualms in stating that health inequalities – the unfair, unnecessary and avoidable health differences in health between people within and between countries – develop through the social determinants of health: the circumstances in which people live.

Life circumstances, the central theme of two of the project’s recommendations, are as pertinent today in our nursing endeavours to promote and maintain family health and wellbeing as they were 18 years ago. Finding this no longer hidden treasure reminded me of real primary healthcare in action. ✚

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Professional portfolio workshops

A workshop day providing nurses with the skills and information to maintain their professional portfolio. Also receive a certificate for six hours of professional development hours. Registration is open to all registered nurses. Cost: $190 or $170 for CNA (NZ) members. Dates: Auckland, 17 November ,10am–4pm; and Hamilton in a date to be arranged in December. To register or find more information go to:

www.nurse.org.nz/professional-portfolios

Living legend at college AGM

American Academy of Nursing “living legend” Professor Donna Diers will be guest speaker at the College of Nurses Aotearoa (NZ) annual general meeting on October 11. The meeting will be held at 5.30pm at Waiariki Institute of Technology, Rotorua.

For more information go to www.nurse.org.nz