• Open Access

Democratic Governance & Health: Hospitals, Politics and Health Policy in New Zealand

By Miriam J. Laugesen and Robin Gauld . Published by Otago University Press , NZ , 2012 . ISBN 978-1-877578-27-4 ; 214 pages ; RRP $40.00 .

Reviewed by Dr Pauline Gulliver

New Zealand Family Violence Clearinghouse, University of Auckland

Laugesen and Gauld have produced a fascinating and very readable account of political involvement in the design of New Zealand health services. Once the scene is set, by briefly comparing the organisation and funding of NZ's health services with that of other developed countries, the book guides the reader through the development of elected health boards in NZ from the 1920s to the modern day, interweaving political involvement along the way. The concluding chapter discusses lessons learnt through this analysis and questions whether elected health boards are the best tool for the organisation of an efficient, responsive health service.

For those not interested in modern history or politics, the book sounds as though it would be hard work and potentially irrelevant to the current delivery of health services. However, one of its strengths is that it paints a picture of what local health boards represent to local communities, “The endurance of hospital boards suggests they embodied community values” (p165). Boards are also formulated as an ‘institution’“infused with value and symbolises community aspirations and sense of identity” (p166). As such, reducing the involvement of hospital boards in health service delivery, as many governments attempted, was a tumultuous process.

It would have been easy for Laugesen and Gauld to take a political or ideological stance. However, the book is well balanced, presenting the influence of local politics (including business people and advocates) as well as national politicians, the Department of Health, Treasury and successive ‘task force’ groups. Each of these stakeholders has influenced the number of boards and the balance between central vs regional or local service planning and delivery, and attempted to reduce the fiscal burden of the health service. Of interest is the degree to which centre left or centre right NZ governments have benefited from the environment created by the preceding government's drive to implement incremental change. The process by which change has occurred highlights the degree to which successive governments agreed with the direction required, yet which the community was not prepared to accept.

The second half of the book provides a more detailed discussion of the impact of having elected officials, who may not have the required experience, guiding service design and delivery. This is an honest evaluation of the problems faced when the ‘right’ person is not on the board, resulting in issues such as fraud and lack of clinical governance and clinical leadership. However, there is also an acknowledgement of perceived political manipulation when hospital boards are appointed, resulting in public dissatisfaction with the health service.

The authors aspire for the book to be a launch-pad for “greater political scrutiny and societal debate about the merits and shortcomings of the representative model and its alternatives” (p171). They also suggest giving the public the opportunity to review the model and the potential to hold a referendum on the issue. These are lofty goals, especially given that the authors also acknowledge that, although the general public appear wedded to the institution, only a small proportion engage, either through voting for hospital board members or by attending board meetings. Perhaps a less lofty aspiration is to require every member of parliament to read this book, understand how closely aligned they are, and agree on a cross government approach to service structure and delivery.

This concise and readable review of the place of hospital boards in NZ would interest students intending to practise medicine in NZ, as well as political science students and members of the public with aspirations to serve on hospital boards. It is so well written that it would appeal to people with even a passing interest in health service design and parochial loyalties in NZ.