 
### Different Stars for Different Times:

### Memoirs of a Woman Doctor

### by Margaret Guthrie

Smashwords Edition

Copyright © 2014 Margaret Guthrie

"All men have stars," he answered, "but they are not the same things for different people. For some, who are travellers, the stars are guides. For others they are no more than little lights in the sky. For others, who are scholars, they are problems..."

Antoine de Saint-Exupery

'The Little Prince' 1943

"An important freedom is the freedom to speak in one's own voice."

Wynton Marsalis

A documentary on post-Katrina New Orleans

### TABLE OF CONTENTS

Author's Note

Foreword

Introduction

Chapter One—Turning Points

Chapter Two—RNZAF Medical Officer

Chapter Three—Pauses and Causes for Reflection

Chapter Four—Burwood Hospital

Chapter Five—NZ Medical Women's Association

Chapter Six—A Turning Point

Chapter Seven—On Being a Civil Servant

Chapter Eight—Study Leave, May to Sept, 1982

Chapter Nine—Return to Reality

Chapter Ten—The Board of Health

Chapter Eleven—Health Promotion and Other Matters

Chapter Twelve—Change

Chapter Thirteen—Transitions and New Directions

Chapter Fourteen—Storm Clouds Gather

Chapter Fifteen—Complimentary Exertions

Chapter Sixteen—Strategies

Chapter Seventeen—Closer to Home

Postcript

Acknowledgements

### Dedicated to Mara and Mark

### Author's note

At around 8-9 years of age, Mother and I watched Kingsford Smith land on what was only a grassy field in Rotorua, no run way existed then. Flying machines have exerted a fascination ever since.

'Smithie' was raising money for his pioneering aviation by taking people up on a short flight to raise money to pay his expenses. I begged to go but Mother was too nervous to agree. Maybe it was that unfulfilled desire that fed the interest, but when the opportunity did arise to take up gliding at Omaka in the 1960s, it was also declined owing to responsibilities as the, by then, sole breadwinner for three children.

An offshoot of that interest has been the influence of the writings of Antoine de Saint-Exupery, the multi-talented French pioneer aviator, philosopher, writer, draftsman and inventor. So for the second time the theme of a work is encapsulated for me by Saint-Exupery, this time via his Little Prince.

Winton Marsalis, an inspirational figure in the development of Jazz , made a remark in a documentary about post-Katrina New Orleans which struck a cord. While being very aware of the racial restraints that prompted that comment others, who have not had oppressive backgrounds, may at times have laboured to find their own voice for one reason or another, including self- doubt.

### Foreword

Why has this book been written? The answer goes back to the fact that, more than once it was suggested to my father, he had such an interesting life he should write about it. He never did. His comment was that so much that was interesting was confidential it would not be appropriate. So there the matter rested while he was alive. Mother did leave the beginnings of what she planned to write about her husband's life and work, but she became ill and died all too soon herself.

In the early 1970s I received a letter from an Australian woman writer who, while visiting Fiji, had become intrigued about what she heard about Dr D W Hoodless. When she enquired how she might learn more she was told he had an only daughter who was in possession of his papers. Hence a request arrived, seeking access to those papers, so that she might write a biography. Upon reading the letter to the family at dinner that evening there was an immediate response -

"Why don't you write that biography? You know there are notes begun by Nana but she died soon after him. You should write the book."

Subsequently, I began sorting through the papers in Father's tropical tin trunk which had contained his possessions when he left from Tilbury for Fiji in 1910. There were also letters sent to and from people who knew him and other research from which emerged "Misi Utu: Dr D W Hoodless and the development of medical education in the South Pacific". It was published in 1979 by the University of the South Pacific, who edited it quite severely on the basis that they were short of funds. They eliminated most references about Mother, as well as the bibliography. The latter surprised me as a strange action by a tertiary institution, while the former upset me somewhat as Mother played such an important part in Father's life.

It was not until I ceased full time employment, which generated more time to do things of my own choosing , that I was able to write "Hilda Jane Adlington: 25 June,1891-31 December 1956" which was primarily for the family. Copies were also sent to the National Library for the Family Archives section. Subsequently requests for it came from the Universities, including Auckland from which Mother had gained her Masters in 1916 with first class honours in both Botany and Mathematics.

That led to other papers for the family on what I have been able to glean about both the Hoodless and Adlington ancestries, as well as reflections of a woman doctor on early influences in her life. Those notes led to "An Enduring Savour" which was self- published in 2009. It ended with the death of John Wray, my first husband and father of our three offspring. John's death was a personal watershed. As an only child of two scholarly parents life had been quite sheltered. John too was a nurturing, protective husband. When he died it became imperative that I return to full time work to adequately provide for our children. We were fortunate that in both the United Kingdom and in New Zealand support and kindness led to what became a succession of fulfilling positions, first with the RNZAF where I met Walter Guthrie, my second husband. Then, as a Medical Superintendent in Christchurch where Dr Lynn Berry, the Medical Superintendent- in-Chief, initiated the career defining move to have additional responsibility for geriatric and community services of the North Canterbury Hospital Board. By 1980 I had been headhunted to join the Department of Health and its Hospitals Division, primarily with a brief to have developmental oversight of health services for older people. There was as well regional responsibility for the South Island Hospitals as an Assistant Director. Promotion led to being Deputy Director and by 1986 Director of Hospitals, though Health of Older People always remained my main responsibility, amidst other changing duties. The last few years in the Department saw the disestablishment of the Medical Directorates, at which stage I became Manager of a Unit responsible for older people, younger physically disabled and intellectually handicapped person's health.

In the 1970s, on into the 1980s, there were those, including some among the medical fraternity, who argued that health of older people did not deserve to be a specialty. That phase passed. It was after I retired from the Health Department in late 1989 that New Zealand's older population felt the impact of that debate. That was when they were categorised as being disabled as a matter of health policy, along with the effect of market forces on the implementation of that policy. It was then that my previous experience and ongoing learning became a prelude to battle in the 1990s. The fight was for recognition of known changes in body and mind in older age, and that a great deal can be done to maintain wellbeing and function as people age. Research findings were consistently demonstrating that effective leadership of specific health services were essential for older people at risk of frailty.

It was a challenging but also stimulating time. Out of it emerged the overarching New Zealand Health Strategy, the New Zealand Positive Ageing Strategy and the Health of Older People Strategy together with the latter's ongoing development and implementation. That does not mean that all is totally well within the system. Plenty of challenges remain including workforce shortages, standards of care and the effects of financial constraints, though the general direction is firmly established and accepted within the health scene, as well as politically these days - well more or less so.

### Introduction

A Woman Medical Graduate of 1951 Looks Forward

In the early 1980s the National Council of Women asked a colleague, Karen Palmer to organise a panel to discuss social issues as they affected women doctors. Karen decided the title of the discussion should be Everybody Loves a Lady!

Thirty years afterwards the notes written for that panel discussion also serve to introduce this chapter.

### Everybody Loves a Lady!

In 1952 my first husband, the late Dr John Wray and I left the comparative professional shelter of hospital oriented life to start general practice in Havelock North, Hawke's Bay. I was somewhat gauchely uncertain in those days, with no illusions that I knew all that much about the real world of a General Practitioner. When we arrived in Hawke's Bay it was at a period of intense fund raising for the construction of the War Memorial Hall, now established on the Napier waterfront. On the very first Saturday we found ourselves swept along to a large garden party, being passed around to many people hitherto unknown to us, as we were to them.

I became aware of a woman who seemed to be piercing me with her gaze to the extent that I eventually smiled tentatively and quizzically at her, at which time she approached and said: "Sorry, I have been staring but I have never actually met a woman doctor before. Tell me – is it possible to be a doctor and a lady too?" I'm afraid I promptly confirmed her fear by exploding into startled mirth that was far from ladylike.

Eventually the woman who questioned me and I became friends – very different though we were in outlook. She had never earned a living, and had no wish to do so. She was the daughter of a retired officer in the Indian Army and an English gentlewoman. From that background she had had a distinct vision of what a lady should and should not do, which she herself was beginning to question. I was also an only daughter, but of a Yorkshire doctor who had helped develop a medical school for the South Pacific. He had married a New Zealander, who had come to Suva to be Headmistress of Suva Girls Grammar School. They both considered a daughter should be brought up to be educated and self-sufficient. When the widow of another Colonial Service doctor, whose husband died suddenly after a fall from a horse, could only find employment as a housekeeper, a job she hated, Mother cited that as a warning.

Another incident in those nine years in Hawke's Bay impressed itself on my mind. By then we had two little girls and I was in part time practice, the extent of which varied in timing with pregnancies and the birth of babies. I had also joined a group of women, all of whom had young children, who were raising funds for a kindergarten. When a shop day was to be held I was asked what I might contribute by way of cakes, sweets or sewing. I was feeling rather pressured for time by the combination of small children and practice commitments so suggested: "I'd find it easier to give a cheque if I may." The woman who had approached me drew herself up and responded: "It's not the money that counts, it's the personal effort that's important in making things." I was so taken aback it did not occur to say that there had been some effort on my part that enabled me to write a cheque.

That incident did though cause some reflection that there had been partly discomfort toward a woman who could offer to produce a cheque from her own earned income; partly resentment observed then, and at other times, towards women who appeared to be succeeding in careers. There was perhaps also a lack of confidence on both sides in that neither felt able to voice uncertainties, although as mothers of small children we knew each other comparatively well in some respects. It is a sad observation that women often feel more threatened than men by relatively high status women. As a colleague, Anne Hall has written:

There is a strong assumption that any successful career woman is going to be unpleasantly aggressive and not too nice to know. To put it bluntly I think women consider success unfeminine i.e. 'sexually unattractive'.

In the 1940s when we were training one was often aware that nice girls became secretaries, nurses or teachers, preferably prior to marriage. There was socially a distinct question mark about those who aspired to male dominated trades or professions. Such attitudes did leave their mark. In the 1960s when we moved to Christchurch and I was able to join the active branch of the Medical Women's Association I came to realise that the conflicts within me about the competing demands and desires for and of husband and children on the one hand, and career on the other, were shared with many other medical women. Those who graduated around the 1940s, 1950s were often an uncertain lot. We had been indoctrinated by Plunket, various writers on child care and society in general to the extent we had guilt complexes that we might be doing our children irreparable harm if we were working mothers. That was not aided by a school of psychiatry, then prevailing, which apportioned blame for much mental illness on mothers, as if fathers and other factors were of no account.

These days attitudes are more balanced, among health professionals at least, but areas of concern remain. For instance, in America the Anti-Equal Rights Amendment to the US Constitution granting women legal equality is headed not by a man but by a woman, Phyllis Schaffley, who has mobilised an army of frightened housewives by her ominous predictions. She has campaigned that passing the amendment would spell the end of protection women traditionally had from men. She has campaigned that family life as we know it would be devastated; that there would emerge unisex toilets and women would be conscripted to fight alongside men in the front line. It would be laughable if it was not so sad. Can you imagine men knocking men's rights so irrationally and emotively? What is family life these days any how. As a recent report from the Social Development Council says:

At first defining the family seems an easy task, but in fact no single definition meets with everyone's approval. Many New Zealanders would define a family in terms of 'mother, father and children', but they would differ among themselves over whether the unit can really be called a family if, for example, the parents are unmarried or the children are foster children.

One factor we have to keep in mind is that we are not just a European society. We have increasing Maori and Polynesian populations. A seminar of South Pacific Women was held in Papeete in July 1981. Their project recommendations included the formation of a Pacific Women's Resource Bureau based at the South Pacific Commission's headquarters which would work on issues such as a women and child health nutrition survey and a socio economic survey of women in the region.

Here in New Zealand the Social Development Council is making a special study of the educational and work difficulties of Maori girls. Northland has high unemployment areas and it is even harder for a Maori girl to find a job than a Maori boy. Should we not be concerned about the number of Maori girls who are prostitutes in Auckland and Sydney? We are all products of our cultural expectations. If our European culture has a low expectation of women in some respects may it not be worse for our Maori and Pacific fellow countrywomen?

But I do not wish to end negatively. If we can work positively towards less sex stereotyping and understanding of issues for both women and men surely we shall be happier. For instance amongst male doctors the incidence of alcohol problems is relatively high, suicide risks are increased, and there is often stress and feelings of neglect in medical families. As the Medical School produces more graduates of both sexes surely it would be good sense for more male doctors to decrease excessive work hours and to become more actively engaged parents.

Acknowledgement and acceptance of individual differences is important. From a woman's point of view Anne Hall summed it up when she wrote:

My main conclusion for better Mental Health for women is recognition of the individual differences of people. The possession of two X chromosomes and female sex organs are the only things that women have as a common biological inheritance. They are not 'naturally' anything – they are not by biological inheritance passive, nurturing, intuitive, woolly thinkers, physically weak or, above all 'neurotic'. This above all means much more varied roles – dropping the old stereotypes, being able to make more positive choices - just because I am a woman doesn't mean I should be good at all the things women are supposed to be good at – I'll do the best I can with the things that have to be done but I do not have to feel guilty.

The quotes attributed to Anne Hall are from a February 1977 paper Anne presented at a conference on, 'Women and Mental Health – An Overview'. Anne was at that time a psychiatrist at Wellington Hospital, active in both her professional capacity and the Wellington branch of the Medical Women's Association, as well as being a wife and mother, a stimulating and treasured colleague.

Her conclusion in 1977 is as valid today as it was then. Circumstances and attitudes of some, but not all, may have changed, but the conflicts for many women remain basically the same.

As female medical graduates of the 1940s and 50s we were no longer pioneers but were in a period of considerable change and activity, largely driven by advocacy on the part of the Medical Women's Association around issues including maternity leave, a retainer scheme to enable women with young families to maintain confidence and skills, and for part time training to be accepted by the various post graduate colleges.

We were also still dogged by prevailing societal values as well as conservative elements within our profession. Michael Belgrave in his paper, 'A Subtle Containment: Women in New Zealand Medicine 1893- 1941', contrasted the expectations of a 'lady doctor' with a 'medical man', terms which maintained much of the social ideology of Victorian respectability, attitudes which drove early women students to sit together as a group, partly for mutual protection, and partly because to sit with the men would be scandalous. Once graduated there were daunting social and financial hurdles to setting up in individual practice until a few including Emily Siedeburg in Dunedin, Alice Woodward in Auckland and Agnes Bennett in Wellington persevered and became role models for others to follow. Others practised as 'lady doctors' in roles such as school medical doctors, somewhat of a professional backwater, or by accepting other lesser paid positions in rural areas, while others withdrew after marriage altogether.

Nevertheless throughout that period role models did emerge who had attained higher professional qualifications. Jean Sandel stood out as the first female surgeon. Around the Otago Medical School in our day were: Marion Whyte, the anaesthetist, Muriel Bell, the nutritionist and intermittently, Helen Deem, infant health specialist. The latter two were both quietly encouraging when I was working in Student Health during 1951-52, as was my GP friend, Moana Gow at whose home I had stayed for a number of weeks before finding a place to board, on first arriving in Dunedin in 1946.

'An Enduring Savour' reflected upon early influences from school through to student days and marriage to John Wray, prior to us both commencing our third year at Otago School of Medicine. It followed on to eight years of General Practice in Havelock North, after which we sailed for England, primarily for John to be able to undertake post-graduate study in pathology, but also to be there as a family aware, between ourselves, that John's health problems lurked as a background to our lives. That book ended at 24 February 1963, the day John succumbed to a massive cerebral bleed. After a short overlap, the theme this time centres around a career which, while initially a response to the basic need to support a young family, became, over time, a vocation hitched to different stars at different times.

References

1. Hall Anne ' _Women and Mental Health: An Overview',_ February 1977. Paper presented at the Conference Women and Health, Wellington Feb 1977.

2. Belgrave Michael ' _A Subtle Containment: Women in New Zealand Medicine 1893-1944'_ The New Zealand Journal of History. April 1988 Vol 22 No1 p44-55.

### Chapter 1

Turning Points

In April 1960 having previously left New Zealand for Sydney we sailed to England via Suez on P&O Strathnaver. The planning for our departure centred around John seeking a training position in pathology. Only after the family was settled in a new home, the girls in a school and David in a nursery school would I follow suit.

Events on the voyage scuppered my aspect of the plan. David acquired a debilitating diarrhoea after Bombay when an E. Coli bug swept through the ship's nursery. While we were docked in Piraeus Anne fell, sustaining a greenstick fracture of a fibula. The Captain initially proposed off-loading us at Marseille as there was no Xray, or capacity to treat her adequately on board. He was persuaded to change his mind when John said he would carry Anne for the remainder of the voyage to take the strain off the leg in its temporary splint. As soon as we reached our B&B in Hampstead we took Anne to Hampstead Hospital where a New Zealand orthopaedic surgeon happened to be holding a clinic. So having departed with three healthy children we had a wan, lack lustre small boy and a girl with a fractured leg which persuaded both of us that I needed to be a stay-at-home mum longer, perhaps a year. Around that time a position in paediatrics did become available at St Lukes and the Royal County Surrey Hospitals where John was employed, but by then I was aware John himself was more easily fatigued. Sensing that it was important to keep the home fires burning, as the song says, the opportunity was declined.

During the latter part of our time in Guildford, on sleepless early morning hours aimless anxieties surfaced. Was I up to what lay ahead as a parent, provider and person? However much one thinks one has accepted the inevitable when it actually happens reality can rock composure, especially when a four and half year old starts waking every night around midnight sobbing inconsolably for Daddy. Uncle Dick, Dr Charles Rickwood Lane, the head of pathology soon saw that both mother and child had a short course of sedation. Then David, while playing in the garden, tripped on a rake which struck him just above the eye. Luckily the eye itself escaped injury. That had only settled when Anne developed abdominal pain. She too was admitted but it turned out to be constipation, and she came home in awe of the treatment, an enema.

By that time I was shattered, losing weight and sinking into a directionless state. A postmortem had proved that John's osteomyelitis was on the point of reasserting itself and the terminal massive cerebral bleed was deemed to be a sequel of war injuries. A war widow's pension enabled us to exist financially but I was not able to decide what our next step should be. Dr Ian Abernethy, who had bought our practice in Havelock North had written and offered a partnership. I knew that would be a mistake. Another medical friend wrote suggesting school medical officer positions that were vacant, which did not appeal. In that frame of mind we arrived to spend the school holidays with long time family friends of John's, Alan and Betty Rutter in Sidcup. Alan, who was Senior Surgeon at the Westminster and Roehampton Hospitals, upon discovering that I had not acted upon his earlier suggestion to write to Mr Lee, the Secretary of the New Zealand Branch of the BMA in Wellington, seeking information about employment possibilities, told me to go to my room and write that letter forthwith.

Ten days later I was able to ring Alan to let him know that the day my letter had arrived Mr Lee was having lunch with Group Captain Tony Marsh, then Director of Medical Services in the Royal New Zealand Air Force [RNZAF]. The Air Force was short of medical officers [MO] and Dr Marsh had just arranged to be allowed to employ State Services seconded civilian medical staff in an effort to fill the vacancies. Mr Lee's letter said an offer of one of those positions would be sent to me soon. It indeed arrived the next day with an offer of a three year contract as MO at RNZAF Base Woodbourne.

Quite apart from a partiality for flying machines on my part, the profile of RNZAF Base Woodbourne, the locale and nearby communities did seem to portray surroundings where the children might more readily ease back into life back home. So I made an appointment to meet the RNZAF Liaison Officer in London, Wing Commander Morgan. That went well, resulting in an agreement that the RNZAF would pay our airfares and shipping costs back to New Zealand in return for a three-year contract of service to begin in late August of that year.

Prior to making arrangements to sell the house and make all the necessary arrangements I received an invitation to join three other women, all friends since boarding school days together, who were going on a week's holiday to Paris. One of those women was a near neighbour in Meads Road, Guildford whose daughter was at the same state maintained Church School as Sarah Jane and Anne. Joyce and Stan Whitehead and ourselves had subsequently become friends. It was a warmly generous offer, which included my own three offspring spending the time we were away at the Whiteheads. Joyce also assured me she had talked it over with her friends, who fully concurred with my being invited to join them, and they had checked that a place was available for me on the tour. It was a turning point in my own adjustment to the huge change in our lives.

The tour was to take us to and from Paris, via air from Lydd to Belgium and then by coach to a pension in Paris for a week, spending time however we wished. Then the return journey would retrace the same route back to Lydd.

Organisation for the trip had been done by Beth, the Sheffield based friend, and most of the others on the coach were from Yorkshire. As we gathered to board the coach Beth remarked quietly:

Here we are looking forward to good coffee and eating different food in different places, but you can be sure when we get on the returning coach someone will heave a sigh saying: ' I'm so looking forward to a cup o' tea and a bun.'

Just as Beth said, we really did overhear that remark as we were about to depart.

The coffee and croissants with cherry jam breakfasts we had so looked forward to were followed by cheap, picnic style crusty French bread, cheese and an apple lunches bought fresh each day from a nearby market, then consumed on park benches in differing locations, as we systematically did our sightseeing. It only rained one day, the day we had spent the morning at the Museum of the City of Paris itself. We emerged into a downpour and, spying a cafe with outdoor seating under a verandah, went inside what turned out to be a deli-cafe where a group of men were clustered on stools along the bar counter. Our French was rudimentary; they had no English. When they realised we were asking for permission to eat our own food in the comparative shelter outside if we bought coffee, they convulsed with mirth. We soon picked up that only mad English would picnic outdoors on a cold, very damp day.

As it happened we did splurge out that lunchtime, going back inside to each order some of the deli food we had temptingly observed. Otherwise dinner was the meal. We researched menus, sought advice and tried a different restaurant each evening.

We were a well matched team. Two of us, Beth and I, were keen to see as much art as possible, the other two preferred to shop after they had been to the Louvre and the nearby Impressionists' gallery. It was a treat of a trip. There was though a defining moment for me when I came face to face with the fact that I was a New Zealander. On arrival at Tilbury in 1960 we had gone through the gate for British citizens. Not long before the Paris trip the situation changed for Commonwealth country citizens. If we were holders of only our own country's passports we no longer had the right to enter the UK via the British citizens' gate. My three companions were incensed for me when we were separated. I was initially bemused. Is this what our soldiers died for? Then philosophical. Maybe we need to grow up and acknowledge we are somewhat the same, only different, New Zealanders, many of whom have UK relatives.

A further experience served to cement the feeling of being different. As I had time and what seemed to be a straight forward estate to handle, my lawyer in Guilford suggested I seek probate myself and save added expense. That duly took me to an office in London before a very British woman civil servant. She became really angry when it was clear that, though John had worked in British hospitals, it was in a temporary training capacity. His ultimate aim was to return to New Zealand as a pathologist. In fact he had already applied for a position at the Princess Margaret Hospital in Christchurch before he died. Therefore British death duties did not apply. It was a really small estate but she made no bones about believing I was unfairly getting away by not having to pay death duty. We faced off somewhat grimly and there was no warm departure from that office; but I left feeling stronger for having stood up to quite a barrage of an emotional explosion, wondering if a personal experience may have triggered it.

Having been refreshed by both the trip and the probate result, it was also a relief to be able to arrange air travel, rather than the longer sea voyage for the journey home. If we were to fly via New York we would be allowed one diversion so, after a telephone call to my cousin, May Mills, we booked the first leg of the journey on a Canadian airline to be able to divert to her Ottawa home for a week with her family. Durward Mills, who had remained with the Canadian Army as an engineering officer, had spent time with us in Guildford while on a work trip to the United Kingdom, but it was the first time May and I had met, other than via letters. Barbie and Bill, a few years older than our girls, had completed their family. May remembered my father staying with them in Alberta while on his way to England on leave post World War 1, and we had plenty of time for personal family chat, as well as learning a little about life in a country where the brilliance of the autumn colourings in the trees, that so entranced us, was soon to be followed by weeks of snow laden ground that May hated quite vehemently.

Our flight schedule from Canada back to New Zealand involved flying to Montreal, thence to New York, from where we were to board a Qantas flight to Sydney, stopping off at Nandi and Auckland on the way. When the flights were being arranged in London we were told there would be a nine to ten hour gap between our landing in New York and the departure of the Qantas flight. We were also told that the regulations for transit passengers had just been altered so that a visa to visit America would no longer be needed. I had especially asked if that meant we should be able to spend a few hours going into the city itself and was assured that would the case. When it came to the actual situation on the ground it was a different story. As the flight from Montreal to New York entailed crossing the border into the USA passengers had to pass through US Immigration before boarding. When our documents were perused the immigration official accused me of overtly trying to slip into the USA in the hope that it would be an advantageous move for a widow with three children to live there. When I tried to explain that I had a good position to go to back in NZ he was not impressed. As this was happening time was passing and we were the last to board; if we were to be allowed to do so. A female cabin crew member appeared to see why that was not happening and she gathered the by now anxious family around her while the immigration official and I continued our rather tense discussion. Just when I thought we are not going to be allowed to board the official turned to the flight attendant and said we could board but Qantas must see that the four of us must be confined to the Qantas building until our departure flight. We literally ran for the plane whose gang way was promptly raised and we were off almost immediately. Our flight attendant simultaneously appeared by my side with a brandy and soda suggesting that I had earned it. Retrospectively I regretted not applying for that visa to the States and, in time actual facilities for transit passengers became the norm. That brush with a decidedly unfriendly US Immigration official was a truly stressful encounter.

When the girls learnt that we should be landing in Nandi they begged to be able to spend a day or two there to see where I had spent childhood. So we stayed a couple of days in Lautoka, unwinding on Sawene Beach where an obliging Indian boy shimmied up a coconut tree to provide us with young green coconuts refreshing juice. We visited markets, looking out for the sugar cane trains which intrigued David especially. That relaxing spell was just as well because the first days back in New Zealand were a continual revisiting of John's last days as we progressed from Auckland to Hawke's Bay. Amidst much kindness there was also strain. It was especially poignant meeting Grandma Wray in Havelock North. The loss of two of her three children blighted the remainder of her days.

While in Hawke's Bay I spent a day first visiting Group Captain Marsh in Wellington, then flying on to Woodbourne where the Base Commander, Group Captain Gartrell had arranged to meet me. I have a vivid memory of viewing Ern Gartell's erect military bearing as he stood watching the aircraft land, and having a moment of panic. What was I doing? What lay ahead?

Ern Gartrell was actually the epitome of graciousness, as was Rosemary, his wife when he took me home to lunch. There were a couple of moments, the first on being shown the Officers' Mess. It was described as 'the holy of holies', but it looked to be a very ordinary wooden building both inside and out. The second was when I was taken to see the house that was being allocated to us and asked where the dining room was. 'You are back in New Zealand, Doctor', was the comment of the accompanying Squadron Leader, as we stood in the small, furniture - less kitchen / dining area. I am sure we must have visited the Base Hospital, but it was a rushed affair by then that left little impression before catching a plane back to Napier.

During the short stay in Hawke's Bay Norman Wimsett, a close GP colleague advised about a couple of books which might help boost both my confidence and competence. He also arranged a personal tutorial session. As we were both short of time it took place in a Hastings Hospital theatre during and in between anaesthetic work, which proceeded smoothly the while.

Towards the end of August the four of us went by rail car and Cook Strait ferry across to Picton, telling ourselves we would enjoy the crossing. The reality was so rough a trip that it merited a newspaper photograph taken from the ferry of it diving into a trough. None of us were ill but we did not dare eat or drink anything. It was a relief and joy on disembarking to find the Transport Officer waiting to convey us to our new home but, first taking us to his home for welcome tea and sandwiches.

The next morning I attended the Base Hospital, the assembled staff being presented in turn. Then I was shown the door of the MO's office cum surgery, though no one came in with me. On the desk was a framed Giles cartoon in which a military officer lent on his stick while a Sergeant bent over beckoning towards bright eyes peering out from under a building saying: "Come on – be brave soldiers – there's no'arm in an inspection by the new lady MO". I laughed out loud at which the Sergeant and Nursing Sister came in remarking: "We wondered how you would react. Would you be happy for it to be hung outside your door?"

It hung there for over a year. Then one morning it had vanished. I was not the only one upset. Sergeant Grahame Gilmore, who had found it, could not remember which year book of Giles cartoons it had come from. So, after fruitless searches through various Giles books of cartoons I wrote to Giles seeking his help. No reply eventuated until one of our staff left for her OE. On arrival in London she visited the Daily Telegraph offices specifically to ask Giles if he was able to help. Giles recollected the letter, which he said he had not got around to answering, went to a heap of his cartoon books, found the appropriate page, tore it out and signed the cartoon before handing it over. When it arrived a copy was hung on the door, the original being too precious to risk losing again.

### Chapter 2

RNZAF Medical Officer

The RNZAF Base Woodbourne sits on the Wairau Valley plain. It was four miles, in 1963 parlance, from Blenheim, nearer to Renwick, where the primary school aged children were bussed to and from the local school, and where we bought groceries and meat next door from Jimmy, the butcher. The main housing area, nicknamed The Cabbage Patch, for those families, the majority then, who chose to live on Base, was nearby, on the opposite side of SH1 to the main Base. The entire surrounding area was farmland, not a vineyard in sight. Orchards and market gardens bordered the road into Blenheim at that time. The farm surrounding all the housing belonged to the Jordan family, whose front garden delighted everyone just prior to the Agricultural Show when prize dahlia blooms were protected from the elements by a host of multi-coloured umbrellas.

The MO's house though was in Bennett Street, on the Northern side of the Base, where a short row of houses lined one side of the street facing the Boy Entrant's School, the Post Office / Canteen building, the Chapel and barracks for single airmen. Our house was directly behind the Chapel, which more than once provided us with a glimpse of a boy entrant escaping around the back of the Chapel as they filed into compulsory Sunday Matins. The Protestant Chaplain, John Hamlin, with Gwen and their children and the Senior Warrant Officer, the SWO, of Boys School, Ralph Simpson and his family were our immediate neighbours, both making us feel most welcome. The other houses was occupied by NCOs on the staff of Boys School, including the Hawks, Dorothy, Des and their two daughters who were to become family friends.

Retrospectively, though one realises it made sense for a chaplain to be near the chapel and the MO to be across the road from the Base Hospital, it was also symbolic of an unwritten hierarchy. Officers who had Wings, especially in those days, who had also seen WW2 active service, saw themselves as superior to others who headed sections such as Transport and Catering. The Dental Officer, the Chaplains and Medical Officers were necessary professionals, but in a way somewhat separate too. In no time at all I was made aware of resentment about a particular extra allowance to attract recruitment of uniformed MO which was resented by some WW2 pilots.

Assimilating the culture was as much a learning curve as that of orienting myself back into medical practice. The 'holy of holies' became clearer as an indicator of exclusivity of membership, just as the Sergeants' Mess was exclusive to Warrant Officers, Flight Sergeants and Sergeants, while the Corporals had their own small club, and finally there was the Airman's Mess. I was informed it would be politic for me to attend the Officers' Mess around 5 pm that first evening. On entry a solid, middle aged man with a distinctly Scottish burr came forward, extending a hand in greeting while remarking that it must all appear rather strange. So began a lasting friendship with Squadron Leader John Hope which in time extended to his wife, Lynn and the family who lived in Christchurch; as did the Crawford family so that John and Jack Crawford were known as the Hunderlee harriers because every other weekend they drove back and forth over the Hunderlee hills to be with their families. John was one of the Education Officers, in other words teachers, at the Boy Entrants School, which was for secondary school leavers who were recruited to train over two years for the various air force trades. Wing Commander Ross Hill headed the School, while other 'Educators' included Ross Swap and his wife, Gretchen who had been a WAF officer, all of whom warmly helped us ease into life at Woodbourne in those early days.

The health and wellbeing of the boy entrants was a major component of the work of the Medical Section staff. At the beginning of each year when the new boys arrived there were those who found the adjustment from home life to living in barracks under service discipline more difficult than others. Some were homesick, which manifested itself in a variety of ways that quite often lead to their being on morning sick parade and, at times, complementary consultation with Boys School staff. I was also requested each year to take a session on sexuality, having first been asked if I felt it OK for a woman doctor to do so. Upon assurance that it was OK, I prepared and delivered my first talk followed by discussion, the sequel to which was an angry R C chaplain berating me for saying that masturbation was not a sin, which might result in blindness or imbecility. When told that was contrary to his instructions for his flock I responded that my role was to convey facts not dogma, which led to a cooling of relations for a while.

The orientation in Wellington had been brief. On the subject of RNZAF administration Tony Marsh had remarked that it was fortunate his most efficient Sergeant [NCO], Walter Guthrie was at the Medical Section at Woodbourne. That he would guide me. Then he gave a short laugh saying: "There's been a question around his drinking. I don't think you will have any trouble. If you do, do not hesitate to let me know."

The very first morning I was startled by the peremptory manner of the Sergeant as he ordered some boy entrants to stop fooling around, feeling I too might be barked at, unaware I was hearing a type of service speak for the first time. Later, upon querying why I was expected to follow a certain procedure, it was suggested I take home and study both Air Board Orders and the specific Orders for the Medical Section. To someone who was professionally bound by a Code of Practice it was soon obvious both documents were on the whole logically applied common sense that did not appear to conflict with how one was expected to practise medicine. Experience over time did raise queries about actual operational practice, particularly over questions of equity and fairness.

Over the first year or so the fact that each officer had a full medical assessment, whereas other ranks only had one if they were posted elsewhere, or were being discharged on completion of service, began to worry me. RNZAF Woodbourne was not a flying training base. What it did have was major repair and maintenance workshops. The SNCOs of those workshops were, at that time, mostly middle aged men recruited from the RAF when it was downsizing post World War 2 in the 1940s & 50s, while New Zealand was becoming more aware it might be politic to develop an air force. They had all had full medicals prior to recruitment but many had not had one since their arrival and, being men, did not visit doctors as early or as often as they should at times.

After some discussion with the President of the Sergeants Mess, all Warrant Officers and NCOs were offered a full medical to ascertain their health status and follow up if anything untoward emerged. I no longer have a copy of the report that eventually went to Defence Headquarters but do recollect that around a quarter had some degree of hypertension, one had undiagnosed angina which he thought was indigestion, a couple were diabetic and one had aortic valvular disease which responded well to surgery. Consequently it was agreed that a screening examination should be offered to all personnel on a regular basis.

The MO also acted as the Medical Officer of Health for the base, one aspect of which was regular inspections of all facilities including the various Mess buildings. Over time it became more and more evident that though the Officers' Mess was well maintained the same could not be said for other Mess buildings. The ablutions in the Sergeants' Mess were a particular concern. After repeated reports about the increasingly unhygienic state of those showers, with no follow up, when I heard that more work was to be done on the Officers' Mess instead, I decided that it was time to 'throw the book'. The Commanding Officer was informed in writing, which was personally delivered, that unless the Sergeants' Mess showers were replaced forthwith the Mess would be closed on public health grounds. The response was immediate. I had returned to my office when there was a knock on the door, first a hand holding a red rose plucked from the garden outside his office appeared around the corner and then Jack Scott, by then CO, appeared apologising: "Sorry Ma'am, you're right. They are dreadful. Work will begin tomorrow."

Jack Scott was quite a character. It was he who queried one day that it was a requirement that an Air Force MO should experience G-force and had that happened? It had not, though I too was aware of the requirement, agreeing it should happen. Jack decided he himself would take me up in a Harvard. We flew up to the Rainbow Valley where the boy entrants were in camp. The first aerobatics took place over the camp. Being very aware that if I threw up tradition called for me to clean up the mess, and also, that the Medical Section staff felt their honour was at stake, I did manage to hold back by swallowing hard. Then to relax me Jack, aware that we were borrowing a cottage in Ligar Bay for the summer holidays, decided to give me a birds-eye view of that part of Golden Bay, which on a fine day was a stunning flight. As we returned to Woodbourne there was a second longer session of aerobatics which was easier to cope with as I had become more attuned to what was happening; but it was a relief when over. I drove home to lunch. I had no desire at all for food, though a quiet, long brandy was settling. The relief of the nursing sister and staff was palpable. They obviously had not expected me to emerge unscathed; nor had I, looping over the Rainbow. It was not until mid-1967 when I was an MO at RNZAF Wigram in Christchurch, a flying training base then, that I undertook a short course in aviation medicine at Whenuapai.

Woodbourne had not been completely devoid of medical aid. Grahame Morice, a local GP, was available for medicals and restricted clinical work as he was also an anaesthetist and a part time farmer on his property on the outskirts of Blenheim. Grahame, who remained available for medicals a couple of mornings each week, became a good friend who introduced me to local colleagues. At 10:00 am each morning the medical common room at the Wairau Hospital was a gathering place for morning tea for all local doctors, as well as those working in the hospital. Grahame also introduced me to the charge nurse at A&E. She became a supportive ally on numerous occasions, both for relevant advice and assistance over admissions to clinics and beds.

Dr Gerard Wall, the Deputy Medical Superintendent, was primarily a surgeon but, as a controlled alcoholic himself, he was motivated to steer others in that direction. As there were no dedicated detoxification beds, he managed to admit a few alcoholics to the surgical ward: not an ideal situation, nor one without incident, but it was better than no facility at all. After I had referred one such airman to Gerry he suggested that, as Woodbourne had its own hospital, he would supervise us through the detoxification process with ongoing support. We accepted that offer, having at that time two UK male nurses among our staff who were keen to be involved. That in itself was my initial realisation that there was, at that time, a real anomaly in that only female nurses could aspire to be Nursing Officers. So those two men were only a Corporal and an Airman, a situation which shall be discussed in more detail later.

In the afternoon a clinic for families who wished to use the MO as their GP was held. Families, as well as personnel could also request a home visit if they lived on Base. It did broaden the interest of the role at Woodbourne, though later on at Wigram families had to have their own private GP, and home visits were restricted to emergencies. At Woodbourne that aspect of the work generated a particular conflict with the Commanding Officer when he informed me that a Squadron Leader's wife, who had had major surgery at Wellington Hospital, should be offered a convalescent period in the Base Hospital. I responded that our facilities were really basic with no private bathroom, no home comforts at all, but the Nursing Sister would be happy to do whatever might be needed to assist in effecting an early discharge back home, including home visits, which maybe the patient might prefer. I could tell that the CO did not appreciate having his idea being questioned when a written order arrived on my desk to offer Mrs So & So Base Hospital convalescence, though both he and I knew that it was laid down in standing orders that only a medical officer could admit to base hospital beds. So I rang DMS Air for advice and was told to send him a signal about the issue. It transpired that the wife much preferred to return home where she gratefully accepted nursing assistance after an initial visit by the MO. Peace reigned again.

Another incident was jointly dealt with by cooperative action between the MO and the CO. One family had several youngsters who were frequently ailing. On examination they invariably had grungy grey underwear, usually full of holes. A request to listen to the chest which exposing a tatty singlet would have the mother expostulate: "I told you to change your singlet."

I was beginning to wonder what the home background was like when a phone call early one morning sought an urgent house visit because the toddler was ill again and they were due to catch a ferry to begin their holidays. On entering the house it was littered everywhere with stinking rubbish. The bedroom where the sick child lay on rags reeked of urine. When I needed to dispose of a used syringe the kitchen tidy had long disappeared under accumulated rubbish. I began to remonstrate about the situation but was brushed aside. They were due to depart - and that was what they did.

Later that morning, discussing the situation with the CO it transpired that the family had previously won a lottery and consequently bought a house near Whenuapai. It did not deal with the fundamental problem, but the decision that the father would be posted back to Whenuapai did mean it was their own property that would be affected. Commercial cleaners brought in after their departure declared it was the worst house clean they had ever undertaken. It certainly was not the norm. Most base houses were well kept. These days one would refer such a family to CYFS.

The most extraordinary episode of the time at Woodbourne began with two of the wives consulting me because they were convinced another wife was in denial of an advanced pregnancy. They thought I should do something about it. I explained that as the person concerned had never attended the Base Hospital maybe they should themselves try to persuade their friend to seek antenatal care, or talk to her husband. A few days later, when I had just arrived home late afternoon, the phone rang. The Corporal, who I registered was the husband of the woman said to be pregnant, blurted out that he needed me to come to their house urgently. Sensing it really was a call for help I did not hesitate, calling in for the maternity pack at the hospital on the way.

On reaching the house I was taken to the lavatory where the wife was seated in her nightgown. When addressed she looked at me mutely but did not resist when I gently raised her bottom. A baby's heels were visible amidst a mass of meconium. Knowing that our UK trained male nurse lived over the back fence I promptly asked the husband to call Corporal Dampier to assist a.s.a.p., and to also find me some towels. Mercifully Gil Dampier arrived speedily and between us we cut the cord, shifted mother and extracted what initially looked like a moribund baby - then it cried. While I worked on the baby, Gil left to return with the ambulance. Meanwhile I had found that the one thing missing from the maternity pack, which I had presumed would be there, was the ergotamine we used to prevent post-partum haemorrhage. That turned out to be an important omission because, although our first instinct was to try and save the baby, in the end it was the mother who had a severe postpartum bleed. She also later had a psychiatric assessment and agreed to be sterilised.

A sequel a few months later was that, although my attendance at chapel was at best intermittent, I did happen to be there one Sunday when, unbeknown to me, the baby concerned was to be christened. It was quite surreal. I just could not get out of my mind that when Gil and I were able to reflect on our experience he had said to me: "You know what that baby should be called?" "No." "Harpic – it was 'half way round the bend'." [A 1960's TV jingle for Harpic referred to its efficacy because it reached half way round the bend].

### Chapter 3

Pauses and Causes for Reflection

This work is primarily about my professional life course but personal reality is always part of existence, as it was at Woodbourne.

Engaging a civilian MO, State Services seconded was not the way the RNZAF preferred to employ doctors so I was deemed to be a Squadron Leader equivalent and, thereby a member of the Officers' Mess. Having three children and no built in child minder at home I did not visit it very often but knew that I was expected to be present on occasions. Both the Nursing and WAF Officer were often there if I did appear. Jill Lapthorne, the WAF Officer did make a real effort to be helpfully friendly.

One early Saturday evening upon leaving the mess I had just seated myself in the car when, to my astonishment, one of the married male officers suddenly let himself into the passenger seat exclaiming that he knew I must be missing the man in my life, a situation he wished to remedy, while promptly attempting to fondle me. He was most disconcerted when I reacted angrily, shoving an elbow where it hurt, as he attempted his manhandling. He did depart. I felt my manner had not provoked the incident but his reference to 'an attractive widow deprived of sex' was thought provoking in that predominantly male world, a warning that circumspection was important. I avoided the mess for a while afterwards.

Before we left Guildford we sold our station wagon. The importation of a Hillman Minx to New Zealand was expedited by a neighbour with whom we had exchanged a few pleasantries until John collapsed beside the sports car he had been test driving in what was that neighbour's motor sales' forecourt. After John subsequently died, those neighbours went out of their way to be helpful, including lending David a large collection of Lego for the remainder of our stay, and assisting in deciding which model of vehicle would best suit our needs, then arranging the shipping details from the factory. We had only used the Minx for short local trips so when Marlborough Anniversary, 1 November 1963, enabled a long week end break we decided to spend it in Nelson. On hearing of our plans Sergeant Guthrie offered to put us in touch with his friend, Bill McCullough, the Town Clerk in Nelson. I demurred, but on the Friday evening of our arrival, Bill McCullough knocked on our motel door inviting us to lunch the following day. That turned out to be a relaxed family affair during which, not only were suggestions forthcoming on what we might enjoy doing around Nelson, but I also learned that Marion McCullough's family and the Guthries were Timaruvian friends.

Marion was amused at my reaction to Walter Guthrie's gruffness with boy entrants, recollecting a sensitive 13 year old who grieved when his father died suddenly from a heart attack, the youngest of three siblings,whose boon companion in boyhood was his spaniel, Darkie. She also referred to his being a 39 year old bachelor, mentioning that since their late teens he had, when at home in Timaru, dated her sister who still hoped they might marry, but that neither she or Bill thought that would happen.

Shortly after that trip we were given a kitten, almost too young to be separated from its mother. I took it in a shoe box to the hospital, asking June, another NCO's wife, who acted as our office secretary, if I could leave it with her while I was taking the sick parade. June did not hesitate to agree but, when I then collected a saucer of cold milk for the kitten, the Sergeant whose desk was opposite to June's expostulated: "You can't expect a kitten as young as this one to drink straight cold milk. It needs warm milk with a little glucose. I'll get some." Which he promptly did. In fact it was he, rather than June who looked after Susie the kitten until she was old enough to be left at home in Bennett Street.

From then until the Christmas break when Walter departed to spend that time with his brother Gordon's family in Mosgiel, we had been invited to join him and a group of Bennett Street families to a motor sports meeting near Renwick, after which I invited him to join us in a picnic to Onamalutu Reserve. We were beginning to enjoy each other's company, a situation which may have quietly carried on when suddenly a visitor arrived unannounced at the back door of our Bennett Street home on the evening of December 23rd.

The visitor, a Squadron Leader administrator, stepped inside the open back door immediately upon arrival while I was at the kitchen bench clearing up after our meal. He was a person I had only spoken to once or twice and the manner of his arrival was such that our conversation was conducted standing beside the bench.

He began by saying that he felt impelled to come and inform me that unacceptable behaviour on my part had been noticed which he felt it his duty to discuss with me. He continued by reminding me that, as I was deemed to be a squadron leader equivalent it was unacceptable for me to be seen going out with a NCO; that the situation was compounded as the NCO had driven his car to my house and he had then driven us in my car out of the base. He emphasised that officers and other ranks were not allowed to socialise in that way, nor should an NCO who had an older Volkswagon be seen driving an officer's vehicle, especially when it was bigger and newer. By that time I interrupted the flow declaring that, apart from five people fitting more readily into a Hillman Minx, not having been to Onamalutu Reserve before it made sense to be driven by someone who knew the way, and - in any case - I was a civilian. The situation was compounded when I was told, civilian I might be, but I was still breaking the rules as I was the MO, though I could have got away with it, as others had, if we had not been so obvious. We should have, I was told, individually driven out of the base and met up well out of sight at Onamalutu. That made me expostulate: "I'm 39, with three children. If you think I am going to take to the bush at this stage of my life to meet a man you're mistaken."

I was then informed he would recommend to the CO that Sergeant Guthrie be posted elsewhere, unless we guaranteed not to meet socially again. He left after that while, in turmoil, I went next door to the chaplain's home. John and Gwen Hamlin made a cup of tea and listened to what had been conveyed. We decided it would be wise to let Walter Guthrie know what to expect before he returned after New Year. It so happened the Hamlins were to pass through Mosgiel on their own holiday and they offered to call in to Gordon Guthrie's on Boxing Day for John to alert Wally in person.

Regardless, we did have a good first Christmas back in New Zealand. The girls had missed not having bicycles in Guildford, so three were secreted in the Hospital storage area which Gil Dampier delivered after dark on Christmas Eve, riding them over to the house conspiratorially, one by one. The Dampiers also invited us to join them and their two boys at Waikawa Bay in the Sounds for Boxing Day. Heedless of Gil being a Corporal, we went and had fun playing beach cricket on relatively uncrowded sands in warm sunshine. It was a real Kiwi Christmas again, very different from a Blackpool one which Betty Dampier recollected from her youth.

When Walter returned our meeting had a bizarre, unnatural aura. We were being confronted with the fundamental nature of our relationship when we should have had time to either develop it further, or let it drift into a friendship with no other overtones. We both realised the threat to have Wally posted was likely to be followed through. If it aimed to drive us apart it had the opposite effect. If that was how the system was reacting, we agreed we should declare our commitment to each other. Therefore the sooner I discussed the matter with the CO the better. In fact the Squadron Leader had already made his recommendation and the CO was mulling it over when he was approached. Group Captain Gartrell was not unsympathetic. He said he wished to discuss the issue with his superior officer and would get back to me shortly.

Within a few days I was summoned to the CO's office after sick parade to meet Air Commodore de Lange. After introductions Ern Gartrell withdrew. De Lange waved me to sit down while he perched himself on the edge of the CO's desk, a move which gave quite a short man more height to look down on me. He began by implying that as a civilian doctor I did not comprehend the need in the RNZAF for a system which maintained protocols of behaviour, but that as a doctor I should be aware that the world would not expect a doctor to consider a liaison with a Sergeant, who was obviously socially beneath me, as appropriate. At that stage I responded that my male colleagues quite often married nurses and in their view we should be reversing the gender roles, a male nurse marrying a female doctor. De Lange rubbished that, repeating that the world saw NCOs as inferior to Officers. At that stage I decided he would be angered by a suggestion that outside the RNZAF the world at large might not really be all that interested. The Air Commodore, after reiterating his theme, went on to say that if/when I did marry the Sergeant on that day my employment as MO would cease. I was then dismissed after being urged to think the matter over carefully.

When Wally heard what had happened he suggested I needed the support of colleagues and should go to the Wairau Hospital as it was morning tea time. It was relatively late when I arrived. The only other person remaining in the common room was Gerry Wall who, on hearing what had transpired, exclaimed unforgettably: "No wonder they are called the blue orchids."

Later that day Ern Gartrell came to see me to say he had not expected de Lange to react as he did; that he had himself just sent off an appraisal of my performance as MO as excellent; that he did not wish to lose me but, in any case, wished me well and I would have his and Rosemary's support. It was a very strange day indeed. Gil Dampier capped it off when he and I were together in the dispensary by saying quietly: "No matter what some have said there is one thing I can assure you. Wally Guthrie may be a Sergeant in rank but he is very much one of nature's gentlemen."

The following morning there was a call from DMS Air. Tony Marsh told me there were issues around the Air Commodore's edict, to carry on as usual and he would be in touch. A few days later a further call requested attendance at a meeting in Wellington with the Secretary of Defence, Mr Jenkins. When I told Wally that I wished he was to be at the meeting alongside me, having first stated that there was no way that would be considered appropriate, he offered a vital piece of advice:

You have over two years of a three year contract to run and have just received a good appraisal. If they ask you to resign, or make any other thought provoking suggestion, say you will seek legal advice.

Tony Marsh met me at the airport and, assuring me of his personal support, drove us to Mr Jenkin's office. There were one or more senior RNZAF staff present as well as DMS Air though they did not include Air Commodore de Lange. After brief introductions Mr Jenkins addressed me. He explained that while both of us, as civilians, might find some RNZAF protocols strange, and possibly irrational, they nevertheless existed. Therefore the liaison between me and the SNCO had created a situation the RNZAF found difficult to accept. He went on to say that in their view the best option would be for me to resign from my position. Remembering my advice I responded: "I shall seek legal advice about that request."

The expressions on some faces immediately indicated that the response was not what they wished to hear. Mr Jenkins did not beat about the bush. He thanked me for my response and closed the meeting. After ushering me out, Tony Marsh remarked that I had handled myself well. When I replied that he himself had said I would be tutored by his best medical administrator he laughed, and changed the subject to cricket, - 'What did Walter think of the latest test match results?'

Within another few days the CO invited me to his office to convey an instruction from Defence Department that my contract would carry on regardless of marriage. The CO did discuss with me what might happen if, as head of the medical unit an incident might occur which called for discipline of the NCO in charge. I responded that I could only truthfully answer that after any such occasion, but that I was sure ethics would ensure an appropriate response, which was accepted. The one request made was that we live off base after marriage so that our breaching of protocol was not visible within RNZAF Woodbourne. We concurred and soon found a house in Alabama Road in Blenheim which we bought but never occupied, renting it out to a Warrant Officer when Wally pointed out that, if an emergency occurred on Base, we would be 10-15 minutes away, instead of just across the road if we remained in Bennett Street. That was by then accepted as sensible, with the proviso that, after marriage, the lawn mowing and hedge cutting by Public Works Departmental [PWD] staff would cease. A blind eye was nevertheless turned to the fact that the PWD man responsible insisted on continuing to cut the hedge.

A few months later an Air Board Order was promulgated stating that no State Service seconded personnel were permitted to be dismissed by Defence staff without consultation with the State Services Commission, and then, only if there had been an adverse report of service.

Those events took place between late December 1963 and part way through January 1964 by which time we concluded that the sooner we did actually marry the sooner the furore would subside. In retrospect it was little wonder that there was speculation as to whether it would be a lasting marriage, as well as my Aunt Mary wondering if a 'decent time' since John's death had elapsed, and Molly Garland writing that it was a betrayal of her brother. A strangely sad reaction was that of the Chief Nursing Officer. She visited Woodbourne soon after the dust had cleared. After seeing Wally she came to my office, sat facing me and erupted: "How dare you snare a man for the second time when I have not been able to marry once." I was so floored by the honest, angry pain in her voice I just flannelled some forgotten inanity in a mercifully short encounter.

The children had their own reactions from quite strong reservation to relief on David's part that he had a father figure again. Wally and I had a mixture of emotions ourselves, though neither wished to back down from our commitment to each other. Mine was that I was still adjusting to life without John, as well the RNZAF culture. Wally, having spent all his vacations while posted within New Zealand with either his brother's or sister's families while their offspring were young, was still a 39 year old bachelor taking on not just a wife, but also three step children.

Overall we did have support too, both within the Air Force and from family and friends, including in the end from Aunt Mary and Nellie Wray. When we did begin to make arrangements to be married by John Hamlin in the chapel on 28 March 1964 Ern Gartrell did not hesitate to agree to give me away, while Rosemary arranged a pre-wedding shower where both Officer and NCO wives were invited, as they were to the wedding. Wally's friend, Grahame Gilmore, who lived in Blenheim, offered to have a marque in his garden for the reception. Grahame's parents and my maternal grandparents were coincidentally Auckland family friends. A further coincidence was that during his nursing training at Wellington Hospital Wally had nursed David's paraplegic godfather, Bill Spain. Wally's brother, Gordon and his wife Margaret came to the wedding and on a brief honeymoon we stayed with them in Mosgiel, as well as with Wally's sister, Bunty and Rex in Timaru.

Our personal lives and work proceeded after that with one change on my part. I ceased to attend the Officers' Mess, there being no attraction to be where I was unable to take my husband, but did attend social functions such as the quarterly dinner dances in the Sergeants' Mess where I was welcomed as Wally's wife, although the SNCOs nevertheless continued to address me as Ma'am, even if their wives called me Margaret. Those dinner dances were among the most pleasant events we ever enjoyed. The food was good, the music, with our near neighbour Des Hawks on drums, invited one to dance and the atmosphere was relaxed. We were also involved with the Woodbourne Players for whom Wally acted as stage manager and they too held willing after-show parties. There were cinema showings in the hall as well, one memory of which is going as a family to West Side Story from which all of us emerged with soggy handkerchiefs.

When Marjorie Traill took over as Chief Nursing Officer she particularly raised with me the possibility that by staying at Woodbourne with me Wally would be limiting his opportunity for promotion. She was startled when I said Wally had told me he was never again to be promoted after an issue in Fiji, asking if she was unaware of that order. As Marjorie was indeed unaware of the order I was only too happy to let her know of what seemed to me to have been a real injustice, but which Wally himself insisted was water under the bridge he had to live with, though in his mind it continued to affect him deeply.

When Wally was at Lauthala Bay in the early 1960s there was liquor rationing such that only one bottle of gin was available to each person with each monthly purchase. Wally was a beer drinker, so when the nursing sister, Yvonne Petley asked him to allow her to buy his gin ration off him he agreed. Sometime later the Sister developed hepatitis, becoming a patient in the hospital herself. As she was initially quite ill, Wally went back to the hospital around 9pm one evening to see if she was all right. He found her in bed with a WAF and another lying naked on it and withdrew promptly. When other WAF on the hospital staff heard about it they expressed surprise that he was unaware of the situation and had not realised the gin sought from him would have been used to soften up the girls. Hence, when Sister Petley asked Wally for gin again he declined, to Petley's annoyance, threatening that she 'would get him for that'. She then made an accusation to the CO, Group Captain Robbins that Sergeant Guthrie had been incapably drunk while on duty. Wally sought the assistance of the Squadron Leader MO to refute the accusation, but he did not want to be involved at all due to what might emerge. The outcome was that Wally returned from Fiji with a note on his file that he was not to receive any further promotion. Meanwhile, only a few months before Marjorie and I were speaking, Yvonne Petley had been murdered in her bed at Whenuapai by a rejected lover, so her predilection had become very public knowledge.

Marjorie, who had been turning paler as I spoke, said she must speak to Walter, after which she went to see the CO. Three days later Wally became a Flight Sergeant. Just who else was aware of Petley's behaviour may never be known. The attitude of the MO who did know, then washed his hands of any involvement though he was the senior officer at the medical section at Lauthala Bay at the time, appeared to me to be both unethical and cowardly. At least Marjorie Traill's opening up of discussion led to some justice for one affected person.

April 1967 was to be the time when Wally's 24 year contract with the RNZAF was to end. He had the option to apply for another term but, on mulling it over, we decided the time had come for both us and the family to move elsewhere. A position as medical records officer at the Princess Margaret Hospital, Christchurch was available for Wally and I transferred as one of the two part time civilian MOs at RNZAF Wigram.

Wigram was quite different in character from Woodbourne being the site of the officer training unit and a flying training base, as well as being situated in what had become suburban Riccarton as Christchurch city expanded. Air Force families were expected to have their own GP, so Ted Mayall, who was a local GP and I were only required to be in attendance on week day mornings, though we remained on call for emergencies. The house we had bought was in Papanui, and one ceased to feel as much a part of an air force community, but the work atmosphere within the medical section was as cooperatively convivial as it had been previously. There was also the same close relationship with the chaplains, who joined us for morning tea most mornings as had happened previously.

Over time I began to feel the capacity for professional development was limited. A recommendation from Medical Directorate that I become a uniformed Wing Commander MO actually prompted a different train of thought. Being the period of US adherence to the domino theory around the spread of communism and the Vietnam War in particular, there was widespread disquiet about the validity of our involvement, which was compounded for me by an article, 'Aesculapius and Mars', by Victor Sidel, in the Lancet of May 4, 1968. That article, though stimulated by the court martial of an American Army Medical service captain for disobeying a lawful order to 'train' combat soldiers in the techniques of dermatology, of which he was a specialist, dealt as well with wider issues such as the involvement of doctors as combatants, and in the development of biological weapons. I realised that, although our own New Zealand Army Medical corps were adhering to the Geneva Convention while serving in Vietnam and doing sterling work in difficult conditions, they were nevertheless alongside an ally which was blurring the boundaries and at times contravening them. Dr Sidel was unequivocal in his view about such activity:

To the extent that the military physician becomes a combatant or is unable to make his own ethical judgments he has stopped functioning as a doctor; he may be a good soldier, but he is an unethical doctor. And, as an unethical doctor, he weakens the effectiveness of all doctors, in the Forces and outside them. To the extent that these conditions prevail in the Army of the United States, or that of any other nation, it appears to me ethically clear that the doctor, qua physician cannot participate.

One alternative was to return to General Practice. Dr Michael Kerr, whom I had known since his family moved to Hawke's Bay when he was at secondary school, and I did discuss joining the St. Albans Medical Centre team, but that did not wholly appeal either. It would have been possible to negotiate a part time position but returning to a fee-for-service private GP role had become discomforting. Keith Simcock, a close contemporary and GP in Howick had encouraged me to join the new College of GPs during the Woodbourne days. During discussion at the time Keith declared he saw the fee charged to patients as being a contract between himself and the patient to provide good care. He then went on to contrast that with a salaried position where he did not believe any real incentive bound the doctor. My reaction was that one's ethic as a health professional was the prime motivator and that being salaried freed one from any financial issue affecting one's care and attention, including the allocation of time for a consultation.

While still wondering what course to take, an article in the Evening Post in mid1973 told of difficulties the North Canterbury Hospital Board [NCHB] was encountering in finding a replacement for the position of Medical Superintendent at Burwood Hospital, which had been vacant for some time. That did sound worth exploring. To find out more about the role I made an appointment to see the Medical Superintendent-in-Chief, Dr Lyn Berry. Dr Berry was not available so I met his deputy, Dr Ross Fairgray. On being made aware of the reason for the visit, Ross looked thoughtful and said that, as there had not been a female medical superintendent in Christchurch, and he had no idea how the Board might react to such an application, I had best return when Dr Berry was available. Dr Berry was more encouraging. After discussion he advised me to apply for the position.

The application was followed by an appointment for an interview which occurred in the office of the Board Chairman, Dr Leslie Averill. I entered the room to find it ringed by a circle of men all of whom bar one, the CEO, were hospital specialists. Dr Averill began by wondering if, as I had three offspring, that would interfere with my capacity to function effectively in a full time position, as well as being a good mother. One of the two surgeons present went on to question any relevance ten years as a RNZAF MO had to heading a general hospital. Dr Berry did at least smile as he asked me to clarify why there was a gap from 1960 to the latter part of 1963 with no apparent mention of employment. Upon hearing of my late husband's failing health and a desire to make our home life as supportive for him as possible that seemed to please him. [Later he told me that he knew the answer because the Berry's were Napier acquaintances of John Wray's family but, as someone had implied it might indicate a lack of professional motivation, the reason needed to be clarified]. I left feeling I'd answered what was implied, as well as asked directly, as cogently as possible but the tenor of the interview was such that little expectation of approval seemed likely.

Therefore, appointment as the first female medical superintendent of a hospital of over 100 beds in the country came as a surprise. It transpired that some, who had little to say while I was present, spoke up later in favour of the appointment, but it was not until the 1974 staff Christmas party that Dr Averill told me he had opposed my appointment. He followed by saying how well the, by then, dual role was being handled and how glad he was that others had talked him into agreeing to the appointment. Accepting his change of opinion with a smile, I was silently aware that his wife had never practised after marriage because I had asked her myself at a New Zealand Medical Women's Association meeting. She had answered candidly that when she married she felt obliged, and was indeed happy to be a full time wife and mother. Then she added she still wished to keep abreast with what other medical women were doing professionally, hence her membership of the NZMWA.

References

1 Sidel V. 'A _esculapius and Mars'_ in Points of View, Lancet 4 may 1968 p966-967.

### Chapter 4

Burwood Hospital

Burwood Hospital, whose staff I joined on 5 November 1973, was a general hospital of 280 beds including maternity, geriatric long stay, orthopaedic, plastic surgery and the maxillo-facial unit. There had also been approval by the Board for a new Spinal Injury unit and a physical rehabilitation facility that would see it become a specialist hospital in several aspects of rehabilitation. In addition it was the seat of Community Nurse training by the Christchurch School of Nursing, as well as providing a post certificate course in plastic surgical nursing.

In 1902 the first wards were four tents erected hastily in response to a bubonic plague scare at what was originally called Bottle Lake Infectious Diseases Hospital. Dr Symes, the District Health Officer was quoted in a 1902 edition of the Lyttleton Times as declaring that:

... heavy canvas structures were much superior to wooden buildings for the purposes of treating patients with consumption, also, as the air, though cold could circulate through the pores of the canvas it was much healthier than permanent structures of wood or brick.

It was several years later that timber and iron was salvaged from the International Exhibition held in Hagley Park to provide more permanent wards. While more modern wards had since been built, that early structure still existed as part of the training school and administrative offices in 1973, as Harry Owles, the House Manager, pointed out to me while he escorted me on a tour of the complex.

Harry Owles took pride in his adherence to protocol which I unwittingly broke on that very first day by wearing a Susan Small tailored trouser suit to work, though the female admissions staff and medical secretaries were delighted. They had been forbidden to wear the newly fashionable trouser suits by the House Manager and, as I learnt a while later, wasted no time informing Harry that it was henceforth in order for them to follow suit. Those women were delightful characters, mostly married women with families. They had just the right manner to cope with both the public at large and their immediate boss in particular. They collectively decided that one way to emphasise their pleasure that the Medical Superintendent was also female was to call her Dr Margaret. They did initially enquire if that was acceptable. When I told them it was how I had been addressed as a GP and, though it was then to distinguish me from Dr John, it was fine at Burwood too.

Harry also took pride in his adherence to Board policy, especially as enunciated by his immediate superior, the Chief Executive. One such instruction was to minimise expenses. Consequently upkeep of the buildings had been heavily cut at Burwood to such an extent that savings on expenditure were relatively greater than at the other

NCHB hospitals. When I exclaimed about the torn linoleum in the wards and the ablutions there was initially an argument as no one else seemed to have persuaded Harry that safety from falls was thereby being prejudiced, that the worst situation was in an orthopaedic ward where vulnerable patients had already suffered fractures as often as not. In time Harry took just as much pride in how well Burwood was being maintained, bolstered by support from nursing and medical staff.

He was, as well, a wry observer of the Burwood scene. The staff dining and sitting room was a comfortable, friendly place, but it had not always been so. A cramped, dingy, ill ventilated area had been replaced a few years beforehand. Upon remarking to him one day how much I enjoyed the times when one unwound with other staff over a cup of coffee or lunch there Harry remarked on the great to do there had been over choosing the carpet, the furnishings and, above all, the curtains. He then found me a copy of a rhyme he had penned.

What colour shall the curtains be?

We have a dining room so good,

Inverted ceiling of brown stained wood,

Where we rest with cup' a tea

But what colour shall the curtains be?

The floor is covered with carpet fine,

And cosy chairs where you recline

All blend together happily

But what colour shall the curtains be?

The Matron looks with practiced eye

From floor to window level high

One thing however worries me.

What colour shall the curtains be?

They stand and talk with muted voice

Who shall it be to make the choice,

From criticism to ecstasy,

What colour shall the curtains be?

One likes red, another blue

They really don't know what to do,

A pity that they can't agree

What colour shall the curtains be?

From nylon thu' to wooly fluff

To terylene and other stuff

But we are waiting anxiously

What colour shall the curtains be?

Consultants come from far and near

Their practiced talk you often hear,

While we are sipping morning tea,

What colour shall the curtains be?

They walk about with worried looks,

While some consult the colour books,

Why don't they stop and send for me,

What colour should the curtains be?

For at this stage I would bet

That they will choose a fancy net

Hanging there for all to see

Multi coloured they shall be.

In a pre-employment discussion Dr Berry had requested that specific attention be directed to the occupants and Charge Nurses of the three wards of long stay patients in ninety nine beds which were continuously fully occupied at Burwood. Dr McIntyre, the previous Superintendent and a physician, had been responsible for the clinical oversight of those patients. When he was on leave the GPs of a nearby Medical Centre stood in for him. Those GPs had not only held the fort over the year since Dr McIntyre retired but had now agreed to continue on a part time basis. Those arrangements had made the Charge Nurses uneasy. They missed the ready availability of Dr McIntyre and their feeling of a special relationship with him. Hence Dr Berry wished me to make it clear that, though I did not have clinical responsibility, I would be freely available for other support and advice. Therefore an early action I took was to ask the Principal Nurse, Ann Ensor to introduce me to those nurses and their charges. As we worked our way from ward to ward, and bed to bed, among other personal details the length of stay of each person was mentioned. Several years was frequent and a few had been there for twenty years or more. My growing disquiet at the wretchedness of being more or less cast in severe disability for so long increased as we progressed. That became obvious to Ann, who, between the last two wards quietly said: "I haven't booked a place here either." That experience exerted a profound influence on me ever after.

Ann Ensor assisted greatly in the induction of a fledgling partner into the triumvirate responsible for oversight of the administration of a New Zealand hospital at that time. That triumvirate was an arrangement which recognised the complexity of the health system with its many health professionals in a variety of disciplines along with the fact that hospitals also had a 'hotel' function as accommodation for patients. There are buildings, food, ablution and other facilities which were managed by the House Manager. The Principal Nurse headed the numerically largest professional group, and the Medical Superintendent the allied health professions, such as physiotherapy, social workers and occupational therapists, along with medical staff. It was a system which, while economic in its use of human resources, had its pros and cons.

It very much relied on good cooperation, especially as each of us was affected by the effectiveness of the other if the place as a whole was to function safely. The three of us did collaborate, greatly aided by an overall friendly atmosphere, which we continued to foster. There were those in the NCHB who felt that Burwood might eventually close but in strategic planning sessions I felt able to argue that, when the Spinal Injuries unit was built, along with comprehensive rehabilitation facilities for the hospital as a whole, it would provide a major rehabilitation centre for the region. In pressing that point I was aware that the plastic surgeons wished to transfer to Christchurch Hospital, which they did eventually, but orthopaedic activity increased at Burwood over time, so those rehabilitation facilities were well utilised when the spinal injuries unit was also operative.

One anomaly was that though the House Manager had a budget over the expenditure of which he had day to day control, the other two of us did not. Once a year we did have input into expenditure planning for the Board's following financial year but there was no consequent direct financial role. All other expenditure was dealt with centrally at the NCHB office. Doctors, nurses and allied health professionals as a whole were given little incentive to perform cost effectively by being so uninvolved with aspects such as the cost of various treatment options, as well as the clinical outcomes under those circumstances. Whether the tiers of management that have evolved since then have justified their own much increased cost is a moot point.

The Medical Superintendent did have direct responsibility for the working conditions within the hospital of junior medical staff, including rostering. I was blessed over five years at Burwood and a year and a half at the Princess Margaret Hospital by having a couple of excellent Personal Assistants, June Ransom and Shona Muir. They both, in turn, largely managed the roster, patiently coping with often frequent changes requested for one reason or another with patience and goodwill, in the knowledge that I was their backstop if any difficulty arose, which it did frequently. They also were invaluable in many other ways, including seeing that I adhered to daily appointments, though they were not gate keepers. They knew that, unless there was a reason for privacy, the door of my office was usually slightly ajar so that anyone who wished might feel free to enter. One of their consequent amusements was the number of people who, on encountering a woman, assumed that she must be the PA, despite the notices on the two doors.

The relationship with senior medical staff was more or less a partnership of equals where my role was to facilitate resource improvement and deal with a variety of issues around the functioning of the hospital which ranged from the number of feral cats which proliferated beneath the wooden wards, to the question of a pharmacist who, an astute physician realised, had a drug problem. When some incident contravened acceptable professional behaviour one had to act or, if of major concern, report it to the Medical Superintendent-in-Chief. Such occasions were thankfully few. I recollect two in particular minor instances.

At Burwood two consultants, whose relationship was known to be brittle, erupted into a ferocious shouting match in the busy main corridor. As I emerged to investigate the commotion they were on the point of coming to blows. I steered them to what was ironically the Quiet Room where they were cajoled into settling down to resolve their differences. Later both men separately visited to 'explain' their case. It was hard not to see them as two little boys battling in the playground, rather than adult professionals.

Later on at the Princess Margaret Hospital, soon after a well publicised 'No Smoking' notice was placed in the staff cafeteria two nurses drew my attention to one of the cardiologists who was smoking at another table, although they had requested he cease smoking there the day before. On being approached about the complaint, the cardiologist demurred initially, then stubbed out his cigarette grudgingly and departed. He and I were both in the habit of arriving for work more or less at the same time and the following morning he walked past looking the other way, declining the usual greeting. I persistently said ' Good morning,' followed by his name for about three weeks before a reciprocal greeting returned. Sadly, nicotine was not his only addiction problem.

After only a short while in the position I felt a need for further education to improve my background knowledge. Realising that some other Medical Superintendents had a Diploma in Public Health I asked Dr Berry if it might be feasible for me to enrol in the following year's course at Otago University, but he did not feel absence for the better part of a year was feasible. Soon afterward an NCHB newsletter described a newly established Massey University multi-disciplinary, post-graduate, extra-mural course leading to a Diploma of Health Administration. That did meet approval. The NCHB not only accepted that there would be two three-week sessions living in at the Massey campus in Palmerston North each year of the course, but also offered to sponsor my enrolment. The first intake in 1974 was a real stimulus. Assignments in all subjects could relate directly to issues arising on the job so it was indeed a relevant learning experience. The multi-disciplinary mix made the living in sessions invigorating, and we had great fun as well. Fitting the full time work role, the study, assignments and family life during those three years was an effort, but it was worthwhile. Sarah Jane was also completing her masters in history. So on a Saturday Wally would look after our grandson, Nicholas while Sarah Jane studied in the University library and I studied at home, before we all lunched together. It did seem strange that the first tuition in normal psychology for a medical graduate of my vintage had not been part of my education until that course, quite apart from it resulting in a better understanding of the complexities of health service administration and management. Complexities which are compounded by the range of professionals, all with their own collegial standards, as well as their overarching responsibilities to the system.

There was a wry twist to acquiring a DHA. The DPH was recognised as a specialist post-graduate qualification for Public Health Physicians but, though Dr Berry supported my application to have the DHA also recognised by the Medical Council, it was declined. There then ensued an interchange of correspondence including one internally from Dr Fairgray, then Medical Superintendent of Christchurch Hospital, who wrote to Dr Berry:

I have recently seen a letter from the Medical Council to you regarding Margaret Guthrie's status as a specialist apropos her Diploma of Hospital Administration examination and the DPH. I am staggered to read Mr Hinde's comment that 'most Medical administrators possess a higher qualification in either Medicine or Surgery and they are recognised by the Council on the basis of their experience in administration, and it was never the Council's intention that Medical Administrators should undertake the DPH course at Otago.'

In my particular case it was a condition of my appointment, and this was laid down by the then Chairman of the State Services Commission, that I attend the DPH course in Dunedin before being regarded as a suitable applicant for the position of Deputy Medical Superintendent of Middlemore Hospital. As far as I know a similar clause was made compulsory for Dr Maxwell, the present Superintendent of North Shore Hospital. I also know that when Dr Trevor King wondered about courses in administration he was advised by the then Director General of Health, the late Dr Kennedy, that the DPH course would be an adequate recognition and indeed the only post graduate qualification held by Dr Kennedy was the DPH. I am sure that when Dr Kennedy was a member of the Medical Council the Council would not have dared to suggest that the DPH was not an adequate qualification for specialist recognition.

I agree with Dr Guthrie that unless the whole question of adequate qualifications and suitable payment for Medical Administrators is sorted out in the immediate future the prospect for good medical administration is extremely bleak.

I note that Mr Hines has suggested that Medical Administrators usually have a higher degree in Medicine or Surgery and that this is acceptable to the Medical Council. Surely we should ask the Medical Council what instruction candidates for higher qualifications of the College of Surgeons, Physicians, Pathologists etc. should have in epidemiology, management accounting, staff relations, personnel psychology, letter writing etc., all of which are essential for a medical administrator. It would be interesting to know if the Medical Council thinks these disciplines are necessary.

Dr Berry again appealed for recognition of the DHA but the Council responded deferring further consideration of the DHA until after the Community Medicine workshop which was to be held later in 1977. That did in a manner let the Medical Council off the hook as it were because, as a consequence of that workshop the College of Community Medicine came into being and I was included among those who were grandfathered in officially as founding members, which in turn did accord me specialist status as a Public Health Physician. An oblique way of the Medical Council recognising specialist status but it solved a problem at the time. It was not until 1988 while I was representing the Director General of Health on the Medical Council, that the 1977 ruling was reconsidered. The decision was that the Council had been under the impression that the multi-disciplinary nature of the DHA might provide a loophole for someone to claim they had acquired access to medical graduate status. It was interesting to then learn that the decision had been challenged within the Council earlier but Dr Hiddleston as DG of Health at the time had strongly opposed it, an opinion that held sway. As a form of patch protection it still seems strange that someone as astute as John Hiddleston really saw the multidisciplinary nature of the DHA as a threat when that was not only one of the strengths of the course, but the medical qualification of MBChB in New Zealand, along with its registration requirements, was the fundamental basis for recognition as being medically qualified, not any post graduate qualification. Dr Hiddleston was also a specialist Physician, which explained the opinion that that qualification along with some administrative experience was adequate recognition of medical management expertise at that time. John Hiddleston was in some respects an enlightened DG of Health, including his genuine desire to see medical women achieve higher status, but in other respects he could be conservatively authoritarian. Being wary of the possible effects of a multidisciplinary post graduate course apparently aroused that aspect of his professional outlook, tensions which still exist.

Patch protection is not confined to doctors among health professionals. One area where Ann Ensor and I did not agree was the question of male nurses. Quite early on, after becoming aware that Burwood had male nurses working in both oral and plastic surgery, I mentioned that favourably to Ann. A cool response ensued. She stressed that male nurses were not fully qualified in the view of the Nursing Council and she believed that should be maintained. As she spoke I was aware that the Nurses Registration Act of 1901 excluded men from becoming nurses and that it was 1939 before the Nurses and Midwives Act [1925] was amended to allow men to be trained and registered, but only on a separate Male Nurse Register.

The fact that those male nurses were precluded from maternity work had resulted in what had seemed to me to be a bizarre situation during my husband's training at Wellington hospital in the late 1940s. He was assisting in theatre when an emergency Caesarean took precedence over the list cases. The pregnant woman happened to be the wife of an All Black at a time when they were playing in South Africa. The woman was brought into theatre already anesthetised and gowned up so that only her pregnant abdomen was exposed. The operation was about to commence when the theatre charge nurse declared that Wally had to leave as there might be a scandal if the press learned that a male nurse was present. The male Obstetrics & Gynaecology specialist remonstrated but the charge nurse prevailed despite the irony of the situation.

That distinction between male and female nurses also resulted in the Defence Force only recognising female nurses as officers, whether or not they had only recently qualified, whereas the male non-commissioned officers might have experienced front line triage along with a wide variety of other nursing tasks.

In 1974 when I was asked to speak at the Community Nurses Graduation ceremony at Burwood, being aware that two men were among those graduating, which was then deemed to be acceptable because that too was an 'inferior' form of nursing, I made a point of mentioning those men by saying:

It is particularly pleasing to see two men among this graduating class. The professions are stronger when barriers of male or female dominance are challenged, whether it be by male nurses or female doctors. There are probably more psychological hurdles for male nurses than for female doctors in New Zealand. Male nurses here can take heart from their United Kingdom colleagues who established their position in the early 1960s – they lead the way in negotiating long overdue equal conditions of service. They can also reflect on the fact that their position here is more firmly established than that of their Australian counterparts. In the April 1974 Australian Hospital and Health Journal it was reported that Austin Hospital is the first in Australia to provide live-in accommodation for male nurse trainees and that many Australian hospitals are reluctant, and, in some cases, refuse to train men as nurses. Again it is important for both male and female nurses not to feel threatened by each other. To me it seems that it is only when both sides can see themselves as equal professionals that right will prevail. Our feminists might show more impartiality if they were prepared to support male nurses in their wish to be allowed to participate in maternity training. Is it really so different from women looking after men in urological wards?

During the period from 1963 – 1973 when I was an RNZAF MO I did not actually personally experience any overt hostility between the female nursing officers and the male nurse NCOs though I was well aware that when two or more longer serving male nurses / medical technicians were together socially they quite often shared such past experiences. The one incident that did impact on me was at a social gathering in a Blenheim home soon after our marriage where several of the other wives were nurses. I found myself pinned in a corner at one stage being questioned as to why I had married a male nurse? Did I really think it appropriate for men to nurse? It was quite persistent for a while in its intensity. Group Captain de Lange might have been delighted to have known of that interrogation.

It was a real joy to read some years ago of the appointment of the first fully registered male nurse as the Senior Nursing Officer in the armed services, though some prejudice still exists within the health system towards male nurses.

References

1 Symes Dr. MOH Christchurch, Article from the _Lyttleton Times_ 1902.

2 Fairgray R Internal memo to Dr L Berry, ' _Medical Council re specialist recognition.' 4.2.77._

### Chapter 5

New Zealand Medical Women's Association

A meeting to which the Dunedin Branch of the Medical Women's Association [MWA] had invited any interested female medical students to meet and hear Dr Clara Stewart, an early Edinburgh graduate and a founding member of the British MWA, featured in 'An Enduring Savour'. The stimulus of listening to how those women achieved equal pay and conditions by virtue of the achievements of the Scottish Women's Hospitals in the Balkans in WW1, prompted me to wish to join the MWA upon graduation. That was not actually realised until the move to Christchurch in 1967, partly because we were living where an active branch of the MWA existed, and partly because it seemed the right time to do so.

As is recorded in 'Women Doctors in New Zealand: A historical perspective 1921-1986', Margaret Smith was the President of the Christchurch branch from 1960- 69. In 1967 Margaret recruited me to be Secretary, a position also held while Mollie Prior was President from 1970-72. During the 1960-80s our branch had a lively membership with a variety of meetings to discuss topics such as child health, fluoridation, homosexuality, student health services, oral contraceptives, alcoholism, as well as the presence of husbands in labour wards during birth, a practice which was still in the process of being generally accepted. Initially remits from discussions were channelled through the National Council of Women which maintained a strong political presence in Wellington. Such remits included:

• That a patient suffering from a psychiatric illness which is likely to respond to treatment be eligible for a social security benefit irrespective of the type of hospital where such treatment is administered.

• That homosexual acts between consenting adults should not be a criminal offence.

• That blood tests for alcohol should be mandatory for persons involved in vehicle accidents where the ingestion of alcohol is suspected.

By the late 60s and 1970s issues arose where we felt we needed to exert an independent voice. One such issue centred around a growing debate on abortion. Initially in 1969 the MWA sent a letter to the Minister of Justice seeking to have the law amended to allow a more liberal interpretation. In 1975 the Christchurch branch, of which I had become President from 1973, both became the National Office by rotation, and also notified the other branches in Auckland, Wellington and Dunedin that it had set up a sub-committee comprising Drs J Hay, N Walker, H McGill, R Hewland, M Prendergast and M Guthrie to prepare a submission to the Commission of Enquiry into Contraception, Sterilisation and Abortion.

The terms of reference of the Commission included:

Report upon the legal, social and moral issues that are raised by the law and practice relating to-section 1[a]- Contraception in all commonly existing and likely forms.

We unanimously agreed that our prime emphasis was to be that contraceptive education, advice and provision should be easily and freely available to all persons, male and female of any age.

A specific concern was the social and moral issue of the environment of the unwanted child. Research had shown that unwanted children are more likely to be battered, poorly nourished, exhibit physical and mental illness and present behaviour problems at school with a greater tendency to anti-social problems as teenagers by aggressive acts or sexual promiscuity, thus perpetuating a cycle of deprivation and further unwanted children.

Section 2 of the Police Offences Act 1954 did not allow contraceptive advice to people under 16 which we believed should be rescinded to allow the instruction of those under 16 years of age.

Looking at the issue from a moral stand-point, in no sense did we advocate irresponsible or promiscuous sexual activity, but we were well aware professionally that many young people were already sexually active and at risk; that we had a subsequently relatively high teenage pregnancy rate, often followed by physical and psychological sequelae.

Report upon the legal, social and moral issues that are raised by the law and practice relating to-

Section 1[b] voluntary human sterilisation whether of male or female.

We recommended that human sterilisation should be freely available to men and women after adequate counselling for the parties concerned; that divorced, legally separated or estranged spouses should not have the power to veto the individual's decision.

The state of the present law on abortion, its interpretation and its application in practice, and whether it meets the needs of society having regard to the social and moral issues relating to it including the rights of the pregnant woman and the status of the unborn child.

This was the aspect that caused the most contention among our membership, as it did in society as a whole. A few withdrew membership when they realised that the research we did persuaded our group that the existing law on abortion was of variable interpretation. It was ambiguous, and its more rigid interpretations by some Certifying Consultants were unacceptable to many people. Socially and economically deprived women were those who suffered most, along with their families, as those with sufficient finance could have legal abortions, if not in one centre then perhaps another, or could go to Australia, or further afield. Others, who sought back street abortions, all too often ended up in hospital with complications which might cause long term complications, or even death. In places such as the UK and New York statistics both before and after abortion law reform had seen illegal abortion practically disappear and maternal mortality figures decreased.

Hence, though we abhorred abortion, we recognised its need in our society, particularly for the young and women over 40. The incidence of psychological damage due to abortion we found to be minimal, and considerably less than if the baby was adopted. Good counselling could enable people to cope with grief reactions. The aim at all times must be to avoid repeating the situation.

We therefore recommended the repeal of all laws relating to decisions on abortion; that it should be an individual personal decision between a woman and her doctor after good counselling, which should enable the woman to consider all the alternatives, advantages, disadvantages and to express her associated feelings. The prospective father should be involved in the counselling when possible.

Retrospective perusal of the thirteen page submission does not in some respects convey the emphasis of our verbal presentation. That emphasis was on the primary need for effective contraceptive education, advice and provision, the argument for which, though it seemed cogent at the time, only occupied two pages. Sterilisation had half a page and abortion eight pages. That, in itself, indicated where the societal pressure caused by the existing system lay. There were some legal abortion services, highly variable both geographically and in the way they functioned, but they did include the Auckland Medical Aid Centre, a non-profit, out-patient service with good counselling facilities and follow-up services aimed at preventing recurrence as a sound model. It was not until August 1990 that a law change enabled contraceptive advice to be legally available for girls under sixteen years of age.

The Dominion of Friday 17 August 1990 reported that prior to a conscience vote of 54 in favour to 14 against on the second reading of the bill to rescind the restriction of advice arguments continued to be heated:

'Jenny Shipley [Nat, Ashburton] said....'Young people had to be told how it really is', and with the Aids epidemic and teen age pregnancies, it would be hypocritical to block the bill's passage.'

'During the debate of the bill, Peter Tapsell [Lab, Eastern Maori] said he had no doubt that time would show unwanted pregnancies were not caused by an ignorance of contraception, but by irresponsible promiscuity.'

'Bill Birch [Nat, Maramarua] said no one believed responsible instruction about contraception was undesirable, but the debate was about who should give it. The bill said anyone could, and that was going too far.'

'Amendments moved by National MPs Graeme Lee and Merv Wellington, aimed at overthrowing moves to liberalise the giving of contraceptive advice, were heavily defeated.'

Writing this twenty years later happened to coincide with a TV1 'Close Up' interview of Dr Sue Bagshaw, Senior Lecturer in Adolescent Health at Otago University, on Thursday 27 October 2010, about the fact that 4,000 Kiwi teenagers, 51% of whom were of European descent, had pregnancies terminated in 2009, and for some it was their 2nd or 3rd time. When questioned by Mark Sainsbury, Sue Bagshaw said there was not enough contraceptive advice, nor was it available early enough. She emphasised that all research shows that sexual education does not promote promiscuity. When asked if that was not the parent's job, Sue said that ideally it should be but there were many reasons why that was often not happening, including that 50% now come from homes which have broken up and which end up with confusing relationships and responsibilities for teenagers. Some are too embarrassed and not educated themselves in their own social skills and attitudes, let alone able to educate their offspring. The upshot is that New Zealand has the 2nd highest teenage abortion rate in those countries which record such statistics.

We not only do not appear to have made much progress in this direction but the social milieux has become increasingly complex, one factor being family models of binge drinking, along with industry advertising, which have encouraged adolescents to follow suit thereby increasing their vulnerability to unwanted pregnancies. Though an infrastructure of nurse and other health educators exists, not enough effective sexual education is being seen as needed by either health funders or politicians. Strong consumer advocacy for change is needed. Youthful advocates themselves, backed by informed, concerned family members, may well be one catalyst for change. We may also be relying too heavily on facts and data rather than storytelling in our desire to be seen to be backed by science. As Sean D'Souza, Chief Executive of Psychotactics wrote for the New Zealand Business Herald online 1 December 2010:

Stories have drama, flow and power that mere facts can never reproduce. And a story has one big added bonus: if it is not overly complex, it's easy to retell in close to exact detail, thus passing on the persuasion to a person who may not be part of your original audience.

Royal Commission of Inquiry into Sale of Liquor, 1974

The Medical Women's Association had earlier supported the National Council of Women in advocating that those involved in motor vehicle accidents should have blood tests for alcohol. When a Royal Commission of Inquiry into the Sale of Liquor was announced we yet again felt it was time we made our own submission as our members agreed that alcohol problems were the major New Zealand public health problem.

In hindsight our submission, though it makes some sound points, has a somewhat idealistic naivety that reflects the influences on our upbringing as a group of middle class, white, NZ women, offspring of a historical culture of heavy drinking among many males and a reactionary strong temperance movement led largely by females, all of which resulted in a set of social taboos around alcohol and related legislation mirroring that societal background. Our generation was reacting to some extent against both extremes. Time has shown that we underestimated the depth of the binge drinking culture and the skilful wiles of advertisers and the alcohol industry, along with unforeseen changes in family and societal dynamics, some of which flowed from the implementation of recommendations of that Royal Commission.

It is salutary to read what we wrote in the early 1970s:

" _Social Attitudes"_

Social attitudes of New Zealanders are such that what many feel is social drinking is at such a level as to produce the full pharmacological effects of alcohol. We feel that peer group pressures are very great among young NZ males, especially to drink to excess – the attitude that one is not a 'man' unless one can hold one's booze – especially in the rugby- racing - and beer fraternity. Sports clubs, working men's clubs, in fact most men's clubs, are bastions of this attitude. At an age when our adolescents should be solving their social, sexual, philosophical problems and maturing as people, they tend to block off this process of self-development in a boozy haze, and those with alcohol problems are becoming younger. The young female is also involved in this process but we feel that, on the whole, females with alcohol problems are in a somewhat older age group and are more the lone sippers who become the mother who burns the vegetables, is of uncertain temper and maudlin sentimentality. Such a woman may be in an advanced state showing the physical and mental signs of alcoholism before anything, if ever, is done for her. Sometimes the death of a spouse can precipitate such a person into a worsening state.

What is to be done about this situation which we consider is the major public health problem in NZ? Part of the problem is that New Zealanders do not like to admit this.

Firstly, we feel all means possible have to be utilised to improve New Zealanders' social attitude to alcohol. In our discussions, mention was made of the Jewish people's low incidence of alcoholism. To quote Kessel and Walton, 'Jews have no taboos against the moderate use of alcoholic beverages which indeed play an integral part in social and ceremonial activity' [page 52]. New Zealanders, on the other hand, have many taboos which may well influence them to misuse alcohol both in a rebellious and assertive manner.

The contrast between the high incidence of alcoholism in France and low incidence in Italy was discussed. Both these countries are wine producing with a considerable economic stake in alcohol production but, whereas many Frenchman misuse alcohol and consume wine steadily throughout the working day... Italians tend to disapprove of drinking during working hours, deplore drunkenness and drink at meal times within the family circle.

### How to change our social attitudes?

Education

This should be begun early, no later than late primary school, along with other aspects of daily living. Alcoholic parents tend to produce alcoholic offspring and we would wish such children to be educated and supported by society so that they may be helped to look at their family and society's problem more objectively.

Adult education should be positively pursued via all the means of mass media.

Counter- advertising

The liquor industry spends great sums on advertising. Surely it would reap rewards as preventive medicine if our Health Department used the tools of modern advertising to advocate a mature approach to our drug of social usage. NZ is a country that puts great store on sporting prowess. Could not leading sporting figures be asked to help sponsor such educative programmes?

Mystique

We have inherited Victorian attitudes which led to elaborate liquor laws to govern the sale, consumption and licensing of premises and which have tended to make it seem that alcoholic liquor is solely a source of evil. A climate has been created where the 'pub' was a dirty word; where alcoholism is a sin, not an emotional disturbance needing support. It is time the mystique of 'demon drink' was eliminated from this land. To this end we wish to make alcohol as freely saleable as possible i.e. at the corner grocer's and available within flexible hours so that publicans may open at times to suit them and their customers, more or less as eating houses do now. The old 6 o'clock swill has merely extended to the evening swill, along with problems of taverns surrounded by large car parks.

It should be mandatory for all taverns and hotel bars to serve tea, coffee or fruit juice, as well as food. We should also like to see non-alcoholic cordials more readily available at all official, sporting and social functions – that would not be in legislation so much as part of the social change that should evolve.

Drinking age

We are not altogether certain about the drinking age but do feel that unenforceable laws bring the law into disrepute and seem more fun to flout. On the whole we think the permissible drinking age should be lowered.

Drink Driving

We are very disturbed by the devastations caused by drinking drivers. Random breath tests should be initiated. 100mgm alcohol to 100 ml of blood is too high a level. 80mg is more realistic. We also believe there should be stiffer penalties for drivers over the limit. The Swedish system merits study in this respect.

Treatment

Wherever there is a population of a size that warrants a hospital there should be treatment facilities for drinking problems where people may be rehabilitated and sustained.

Research

A definite percentage of all the tax derived from the sale of liquor should be used to research problems associated with alcohol.

Labelling

There is justification for labels to be required as follows: "This beverage contains alcohol which could be injurious to your health."

The freeing up of availability both in regard to the sale of liquor and lowering the legal purchase age which was a sequel of that 1974 Royal Commission was a consequence of a shift in support in a number of the submissions which resulted in moves which many of those involved now recognise as having accentuated problems, not improved them, sadly.

One aspect that has yet to change is the capture of Government politicians by the alcohol industry. In my teens Grandma Adlington, who herself enjoyed a dry sherry on occasions, once firmly remarked that we need not expect Government ministers to act in favour of moderation because the trade made sure they were influenced by ample gifts and exhortations. Maybe as a nation we have placed too much emphasis on control of alcohol usage by legislation, and not enough on fundamental shifts in individual and societal attitudes. Though, as we already have a history of alcohol controls by legislation, there is a case for a truly objective overhaul of that legislation, as the Law Commission Inquiry has recommended. Professor Doug Sellman is currently one of the strongest champions for harm reduction by raising prices, raising the purchase age, reducing accessibility and marketing ploys, along with drink driving counter measures, as well as improving treatment resources for the 700,000 heavy imbibers in our society. The history of public health has demonstrated that strong, well researched, persistent champions can and do effect change by gaining the respect of the public at large over time.

### Women in Medicine

Apt as it was to be involved in topics of broader health interest the main reason for the existence of the Medical Women's Association [MWA] was to further causes particularly affecting medical women. In the 1970s, as in other Western countries, there was a sharp rise in the number and proportion of women entering medical schools. Before 1970 about 10-15% of medical entrants in this country were women. In 1976 women accounted for nearly 40% of the entrants at both Otago and Auckland Medical Schools. Questions were being raised, both here and elsewhere, about the effects that was bringing about for the future of medical practice, not to mention the productivity of those women who did qualify in medicine, with some suggestions of rationing for female studentships.

Professor Barbara Heslop and the Dunedin branch of the MWA were in the vanguard of research on medical women in New Zealand. A paper by Barbara and others, 'Women in Medicine in New Zealand', was published in the NZMJ, vol 77, pp 219-229 in 1973. The Dunedin Branch also developed a paper with suggestions for facilitating the 'Employment of Medical Women', as well as 'Guide to Career Opportunities', which was distributed to fifth year women students. Other branches of the MWA picked up the torch so the Association spoke with a strong voice throughout the 1970s into the 80s. For me personally it was a joy to be alongside Barbara again, as we had been friends in the same class at Epsom Girls Grammar School, a class which also included Beryl Howie, who had a long career as an obstetrician and educator in Northern India, and Glen Nicolson who left in 4th year after her marriage. Together with other supportive women colleagues in the MWA, Barbara and I were able to bring forward issues which were affecting women's capacity to advance professionally. As an editor in the BMJ of 7 September 1974 wrote:

• Changes in the social order take time and a receptive climate of opinion to make them acceptable.

• The persistence of generations of women is getting them even closer to equality of status and opportunity with men in medicine [and other professions].

• There is still some inequality but it seems to be diminishing.

Persistence and doing our homework thoroughly was important. So was our attitude. Only a few of our male colleagues were openly and conservatively against our aims at that stage; the majority were open to seeking ways to enable women to have two careers, motherhood and professional advancement, while recognising that some might choose to be childless, and a few might opt out of medicine altogether in favour of home and family. As the BMJ editorial ended:

They [medical women] can therefore have the best of both worlds if they wish to strive for them as so many have done and are doing. But let the element of choice remain, so that not even moral coercion is applied to those who do not wish to conform.

Negotiations with various medical organisations embraced governmental, educational and professional bodies. One particular series of events began in April 1976 when the Medical Council organised a workshop at Wairakei to initiate an ongoing study of medical manpower needs in New Zealand. Prior to the workshop study papers were circulated to invited participants from the specialist Colleges, the University Medical Schools, the Health Department, the NZMA and RMO's Association. Among the papers was one on Women in Training posing problems peculiar to their gender. It was not only written by a man, though in all fairness well and sympathetically written, but no medical women's representative, as such, was invited to speak to it. When the MWA heard about it via Dr Anne Hall, who had received it on behalf of the College of Psychiatrists, we wrote pointing out what appeared to be an anomaly to the organisers. They were taken aback and countered by saying that Dr Hall could simultaneously represent women to which she responded that she had quite enough to do to prepare herself to represent her specialty. Therefore she only felt able to keep a watching brief for the MWA, rather than prepare a second in depth study of women's issues. Subsequent to the workshop a Medical Manpower Advisory Committee was established which included MWA.

A further sequel of that Wairakei workshop was a decision of the Management Services Research Unit [MRSU] of the Health Department to undertake a major study of 'Women in Medicine in New Zealand' over which Janice van Rooyen, a sociologist was to exercise oversight. A steering group was set up, the membership being:-

Dr Elizabeth Berry—Haematologist, Auckland

Miss Anne Clarke—4th yr. Student, Auckland

Dr Margaret Guthrie—Health Administration/Management

Dr Anne Hall—Psychiatrist, Auckland

Prof. Barbara Heslop—Pathologist, Dunedin

Dr Hilary Liddel—House Surgeon, Auckland

Dr Marie Tait—G P Wellington

Mrs J van Rooyen—Sociologist, MRSU

as well as Dr G C Salmond, Director of MRSU, who had shown marked interest in initiating the project.

Prior to an initial meeting Janice prepared a background paper, including a survey of relevant literature and a synopsis of all surveys recorded of women doctors and a list of references. The material was analysed from three perspectives:

1. What are the facts of women doctors' employment patterns?

2. Why do medical women perform as they do?

3. What can be done to improve the contribution of medical women?

In the English speaking world, including New Zealand, employment patterns were of increasing numbers and gradually improving performance. Compared to men doctors women, particularly those with children, had earned fewer post-graduate qualifications and had been far behind in the climb up the medical hierarchy but their medical activity did appear to be increasing, while the hours worked by medical men were beginning to decline.

Career patterns of medical women were found to a larger extent to be the result of psychological, professional and family constraints. Though the three sets of determinates were interrelated, women doctors were most handicapped by family responsibilities. The medical profession was seen to be slow to adapt to the needs of married women doctors with children with consequent indirect discrimination. In spite of those difficulties deep seated attitudes were also seen to predispose increasing numbers of women to a full time continuous career. Ulyatt's research in the United Kingdom [1971] concluded that differences between women doctors who worked 90% of the time, as compared with those who had been minimally active, stemmed from the latter's desire to be close to their family and their great fear of damaging their offspring by any absence. Also, unlike full time colleagues, they felt that having accepted medical training, it would be in no way wrong to give up practice. What was implicit in that research was that a married woman doctor with children may give precedence either to her sense of professional obligation and responsibility or to her belief that her children's needs were paramount.

At that time medical women were seldom found to reach the top of their profession. In the book, 'Women and Success: The Anatomy of Achievement,' edited by Ruth Kundsin, Matina Horner postulated that women tended to fear success; that successful achievement is contrary to the traditional passive female role. The result can be a double blind situation which can be a source of high anxiety. It also appears that supportive family and childhood experiences provide some women with such strongly internalised feelings of self-esteem that they are less vulnerable to attacks on their femininity than they are to failure. Such women are less likely to experience intense anxiety as they reach for the top and are therefore more likely to reach it. Lozoff, in the same work, found that fathers who encourage achievement in their daughters, whilst simultaneously approving of their femininity, and working mothers who provide role models, seem to raise daughters who will aim high with minimal psychological stress.

There was little evidence that medical women were kept out of top roles by male leaders of the profession.

Improvements in productivity and wellbeing were dealt with under a number of headings:

• Initial selection

• Sense of obligation to practise medicine

• Minimising periods of withdrawal – retainer / reserve schemes

• Maternity leave

• Child care facilities

• Part time posts and training

When the steering group met in July 1977 we realised attitudes were changing. Younger male doctors were more prepared to themselves show an interest in part time work and interrupted careers. They were more often also prepared to share domestic duties and child rearing.

Nevertheless, covert and subtle prejudice did still exist. A woman had to prove herself, as I very much felt when appointed as the first Medical Superintendent of a major hospital of over 300 beds. I knew I did not have to be 'as good as a man'. I had to be as good as one could possibly be. As Barbara Miller Solomon, the Assistant Dean of Harvard wrote in 'Women and Success':

In the present successful women in the professions exhibit the same characteristics as comparable men; determination, self-discipline, self-esteem, acceptance of hard work and the ability to withstand discouragement. But the women need, as others have noted... a _superabundance_ of these qualities, which are tested every step of the way in their careers.

Career guidance was deemed to be especially important both prior to medical school entry and at all stages of a medical career for a source of reinforcement and support.

It was agreed that women did still find it harder to decide on future goals, though uncertainty affects men too, but the problem could be acute when career planning and parenthood coincided.

Anne Hall felt strongly that a formal statement should be made about what is known of the effects of mother substitutes on young children. Women, she felt, should be told clearly that mother substitutes were not harmful but that continuity of care and mothering was important. A mother's anxiety about harming her children can be more damaging than the actual harm of being away from them. Women should therefore be encouraged to come to terms with this anxiety and to accept that a wide range of domestic arrangements are possible and acceptable. Similarly, women should be encouraged to delegate as much of the physical housework as possible – medical women being in a relatively advantaged position because they are able to pay for quality child care and domestic help. Tax rebates for domestic or child care were deemed important, it being illogical to tax a professional woman's salary and then tax again that portion which is paid to a housekeeper; this is not the way it happens if you employ someone in business.

It was felt strongly that professional commitment could best be fostered in medical women by building confidence rather than attempting to induce guilt. Women needed to support each other psychologically and be prepared to be political advocates.

An aspect which the group believed was particularly important was a husband's attitude towards his wife's career. It can be the single most decisive element in those factors which combine to determine a medical woman's pattern of employment. That there were a number of husbands who did not encourage their wife's medical work was shown not only by Barbara Heslop's 1973 New Zealand and Fett's 1974 Australian studies, but also by similar overseas surveys, one of which reported that 'an understanding, helpful husband and adequate household help were repeatedly mentioned as factors essential to the success of a combined personal and professional career.' It was also important for women to accept that paid domestic help or child care can be a necessity. That, I found, was a sticking point in discussion with some younger graduates who baulked at the expense. I would counter that it was for a relatively short period of their lives when it could be an investment for their own and their family's future. In saying that, I was very aware how fortunate I was to have had such genuine spousal support at crucial career phases myself.

Late in 1976 Dr John Hiddleston, Director General of Health, invited Barbara Heslop and me to the Department of Health to discuss matters of concern around the employment of medical women. The apparent lack of ambition dismayed him. He urged the MWA to stimulate the sparks of ambition which women students had on entry to medical school so that it would continue to burn brightly to carry them through the reproductive years; to maintain a long term vision of the future. That gave us the opportunity to point out that a proposal from the Postgraduate Medical Education Committee and the MWA jointly to the Department to fund a Medical Reserve Scheme seemed to have foundered, or become lost in someone's too hard basket. The proposal was based on the premise that the loss of professional competence due to prolonged absence from medicine could be avoided by undertaking two sessions a week; that it is easier to maintain expertise than to re-learn after a long break, and that the child minding involved would not involve the large scale domestic organisation engendered by a heavier workload.

The Medical Reserve scheme was subsequently approved to commence from July 1978, when a circular letter to all Hospital Boards informed them of the conditions for appointments under the scheme which would be supernumerary to the Board's establishment and the cost would be by way of a supplementary grant.

We also discussed our campaign to persuade the various medical professional Colleges to allow part time training. All of which took up the time available that day so we made another appointment to broach the question of maternity leave.

The Departmental ruling that we were contesting as unfair stated that:

• Maternity leave may be granted to a woman as leave without pay; it is not granted as sick leave on pay.

• On return to duty from maternity leave of not more than six months, and after at least another six months has been served, applications for retrospective payment for such period of absence as is covered by the sick leave entitlement may be considered.

The MWA pointed out that the New Zealand situation compared unfavourably with that in the United Kingdom where, provided that she has worked for 12 months prior to applying for maternity leave, a doctor may qualify for 4 weeks on full pay and fourteen weeks on half pay. We were particularly critical of the tying in of any retrospective payment to sick leave entitlement for what was a normal female physiological role.

Dr Hiddleston agreed that our argument was cogent but told us he would have difficulty supporting our application as the granting of maternity leave for medical women working in public hospitals would have cost implications for all other women in the civil service. Afterwards Barbara and I realised he had given us even more reason to persist in our advocacy for change. That took a little longer but on 21 May 1979 circular letter No hosp. 1979/81 was headed, Standard Conditions of Employment – Maternity Leave.

With the promulgation of amending Determination no 48/29/2149 in August 1978 provision was made for maternity leave with full job protection on the following basis:

1. For those with 12 months service, 12 months maternity leave.

2. For those with less than 12 months service, 6 months maternity leave.

3. Those women who return from 12 months maternity leave and complete a further 6 months service, qualify for an ex gratia payment equivalent to 30 working days leave on pay.

Those provisions also were to apply to a woman who adopted a child under 12 months of age.

Some years later upon meeting Dana Glendining, who was then responsible for Equal Employment Opportunities at the State Services Commission, she said how delighted she was to be able to thank me in person for the role I had played in achieving fair maternity leave provisions. I assured her was a team effort by the MWA who saw the implications of an extension of the provisions to all women in the civil service as an increased impetus to work for change.

Part-time training advocacy was, and remains, complex. If a woman doctor is able to complete specialty training before having a family it, in many instances, makes the question of coping with two jobs more manageable, even if it may also mean being an elderly primipara with other possible risks. The MWA approaches to the specialist Colleges in the 1970s largely only initiated discussion with replies spanning a negative response from the surgeons to affirmation from those involved in the comparatively early days in the development of General Practice training. It is not surprising that the 1989 research detailed in 'Women and Men in Medicine: The career experiences', by Gillian Durham, Clare Salmond and Julie Eberly, found that in the 1974-82 cohort General Practice was the most attractive choice, especially for those with family responsibilities. Dr Hiddleston would note that many of those GPs work part time and are not principals of their practice team but, maybe a balance between family and work is a satisfying aim anyway. For others difficulties such as finding part time training positions in hospital based specialties can be a constraint, let alone part time positions once they are trained. There is no doubt that the present system of speciality training does disadvantage women in medicine with families. Despite difficulties medical women have risen up the ranks, including being Director General of Health. They have also ceased to perceive the need to maintain the MWA. It went into recess a few years ago after falling attendances at scheduled meetings over some time.

References

1. Maxwell M. _'Women Doctors in New Zealand: An Historical Perspective1921-1986'_. IMS [NZ] Ltd., 1990.

2. Submission from the Medical Women's Association to the Royal Commission on Contraception, Sterilisation and Abortion, 1976.

3. Submission from the Medical Women's Association to the Royal Commission of Enquiry into the Sale of Liquor Act, 1974.

4. Heslop B. _'Women in Medicine in New Zealand'_ NZMJ, vol77, p219-229 April 1973.

5. Heslop B. _'Suggestions for Facilitating the Employment of Medical Women in New Zealand'_ , Dunedin Branch MWA, 1974.

6. University of Otago Medical School _'Women in medicine'_ from the _'Guide to Career Opportunities'_ , 1974.

7. Medical Council of New Zealand Medical Manpower Planning Conference, Wairakei NZ, April 1976.

8. van Royen JC _'Women in Medicine'_ Medical Services Research Unit, Department of Health, Wellington, New Zealand 1978.

9. Advisory Committee on Medical Manpower: Report to the Minister of Health on Medical Manpower Requirements, May 1979.

10. Ulyatt K. et al. _'Some attitudes of a group of women doctors related to their field performance'_. BMJ.

11. Educ. Vol 5, p242-245, 1971.

12. Kundson R. [ed] _'Women and Success: The Anatomy of Achievement'_. Wm. Morrow and Co. Inc. New York, 1974.

13. Felt I. _'The Future of Women in Australian Medicine'_. Med. Journal of Australia, vol1, No 18, p689-698, 1976.

14. Department of Health Circular Letter to Hospital Boards _'The Medical Reserve Scheme'_ 1976/233; 1997/69; 1978/98; 1984/81; 1988/87.

15. Department of Health Circular Letter to Hospital Boards, _'Standard Conditions of Employment – Maternity Leave_ , 1989.

16. Durham J.,Salmond C.,Eberly J. _Women in Medicine: The Career Experience'_. Department of Health, MRS Unit. 1989.

### Chapter 6

A Turning Point

On the 6th June, 1973 Dr Berry wrote me a letter which included:

The position in regard to Burwood is now clearer and we are ready to advertise for a full-time Administrative Superintendent for Burwood Hospital. It is envisaged that this person would have certain duties at Board level delegated from my office, and the only clinical duties would probably be care of nurses' health.

No mention was made of 'duties at Board level' at the appointment interview, or before I began at Burwood. Indeed I had not really paid much attention to that part of the letter myself until early in 1974 when Dr Berry met me to discuss aspects of my role. After the usual generalities, he led into his belief that a major issue that was going to impact on health services was the now steadily increasing numbers of older people, including more who were surviving into a frail old age. He had himself looked into what was being done about that issue on a visit to the UK as an upshot of which he had recommended to the Board that they approve the appointment of an Assistant Medical Superintendent-in-Chief for Geriatric and Domiciliary Services, a role that he proposed I should fulfil. He also said he had arranged for me to liaise with and be tutored by Dr Graham Riley, the Physician-in-Charge of Geriatric Medicine who was based at The Princess Margaret Hospital.

I emerged from that revelation bemused, even thunderstruck by that bolt from the blue. Years later when asked, as has occurred a number of times - 'Why did you choose gerontology?' The answer has always been along the lines: 'I didn't. Dr Berry chose it for me.' It was sometime before I appreciated what an ongoing stimulus it was to become. The initial impression of the fate of those in the long stay wards at Burwood was not an encouraging introduction but it did make me understand why Marjorie Warren sought change.

Gerontology in New Zealand was initially associated with the development of Geriatric Medicine by Dr James Newman, a physician who became the Medical Superintendent of Cornwall Hospital in the grounds of Cornwall Park, Auckland. That hospital was originally built as a temporary USA armed forces hospital during WW2. When the Americans departed it became what was assumed to be a long stay hospital, only Dr Newman espoused the principles of Geriatric Assessment and Rehabilitation [A&R] as developed by Dr Marjorie Warren in the UK. Dr R A Barker, also a physician, began to work alongside Dr Newman in the early 1940s. Those two founded the NZ Society for the Study of Ageing which tended to be largely supported by doctors sympathetic to the aims of A&R. It is interesting to note that not all physicians initially believed there should be the need for a separate speciality. A debate raged in the medical press from the 1950s to the mid-70s by which time the UK led the world in Geriatric Medicine, especially in centres like Edinburgh, Glasgow, Nottingham and Southampton. So, New Zealand was quite early in following the lead set by Marjorie Warren that a great deal could be done to prevent disablement and maintain function in frail older people if they are assessed, treated and rehabilitated in a timely manner.

The Geriatric Assessment Unit, as it was named before the wider term Assessment, Treatment and Rehabilitation [AT&R] Unit more aptly depicted the aims of a specialised Old Age Service, had only begun to function in Christchurch in February 1972. Graham Riley was another specialist Physician who metamorphosed into a Geriatrician to develop the Christchurch unit. In the NZMJ, November 27, 1974 he published a paper, 'A Geriatric Assessment Unit; The First Twelve Months', detailing the facilities, mode of working, staff requirements and admissions policy, as well as recording the follow-up outcomes for 321 patients discharged during that first year and ending with suggestions for further service development. It was a privilege to have had such a dedicated initiating mentor.

Another aspect of my education was to attend monthly meetings chaired by Dr Tom Enticott, Medical Superintendent of Coronation Hospital of the Special Rest Home Scheme Joint Committee of the Department of Social Welfare [DSW] and the North Canterbury Hospital Board [NCHB] whose function was to:

a) Supervise and regulate classification and admission procedures.

b) To determine policy on the use of rest homes- i.e. which are suitable or not for subsidy purposes.

c) To periodically review subsidy cases.

It would be an understatement to say I was initially bamboozled by the complexity of it all. Everyone there carried on as if a newcomer would understand what they were discussing, having not been furnished with any background papers, just a few verbal snippets of introduction. At least it informed me that I was entering a minefield of differing funding streams complicated by some being administered by DSW, while others were the responsibility of the Department of Health, some directly and others via the various Hospital Boards. In the midst of all that were individual older people and their families, often in crisis mode, desperate for help. At that time little did I realise the degree to which so many of us working in the old age sector were going to exercise our minds about the ongoing problems around those funding streams.

### Age Concern Canterbury

Other connections broadened my gerontological outlook. The Aged Peoples' Welfare Council, the precursor of Aged Concern Canterbury, set up an Education Committee in the mid-1970s of which I was a member on behalf of the NCHB. It aimed to elucidate the needs of an ageing population. Initially Neil Scots and Peggy Koopman-Boyden studied 40 older people which revealed that not only was an adequate income and sound housing fundamental, as expected, but transport issues also emerged as being important to maintain independence, and a feeling of being in control of one's life. Subsequently Christine Prentice and others, after more specific research issued, 'Transport and Older People' in 1979, highlighting issues that were to remain problematic for many older people, especially those who became disabled. That specific research remained a professional beacon in later years when my association with Age Concern expanded again after retiring from the Department of Health. The grounding that those research projects, along with what was to become a long association with Peggy and her sociological perspective on the range of issues impacting on well-being as one ages, opened my mind to a broader view of health and wellness early on in the never ending learning process that still pertains.

### The Nurse Maude District Nursing Association

From 1922 onwards the NCHB contributed financially to the Nurse Maude District

Nursing Association [NMDNA], initially as an annual lump sum of four hundred pounds, which by 1975 had progressed to be 75% of the District Nursing costs, 100% of that part of the home help service for patients discharged from hospital who required district nursing as well as a subsidising the laundry service. Consequently the NCHB could appoint up to three representatives on the NMDNA Board, one of whom, Dr Fairgray, handed the role over to me in January 1974.

District Nursing managed by a charity distinctly separate from the local Hospital Board was nationally a unique arrangement in New Zealand due to its historical foundation. Other Hospital Boards subsequently developed their own District Nursing corps. I was not only soon to become familiar with that history but was also impressed by the founder's philosophical approach. At the first NMDNA Board attendance I was handed a copy of 'A Friend in Need: Nurse Maude Her Life and Work' by E Somers Cocks who told of Sybilla Maude returning to New Zealand from nursing training at London's Middlesex Hospital to become the Matron of Christchurch Hospital in 1893. She worked towards the betterment of conditions for both the patients and staff but felt increasingly hamstrung by a parsimonious, timid Board. When Sister Rose [Godfrey] of the Community of the Holy Name arrived at the hospital to undertake nursing training, the Matron learned of the Sister's work among the poor of Christchurch. She felt the Sisters "were striking right at the heart of things such as she longed to do herself. If she, as a trained nurse, were to go round to people's homes and nurse them there, what a lot she would be able to do for them".

Encouraged by the Hospital Chaplain, the Rev. Mr Averill, who persuaded Mrs Heaton Rhodes and a couple of parishes to promise annual funds, Nurse Maude was able to resign from the Hospital and in 1896 she signed an agreement with her supporters to be responsible for District Nursing in the city, a pioneer scheme for the country. She not only nursed, she educated and co-ordinated public efforts to provide food, clothing and fuel for the needy. She effectively created a caring community system. When she herself needed particular accessories she appealed to the public via the daily papers. Help was always forthcoming.

By 1901 the work had grown beyond the capacity of one individual. Upon the advice of the by then Lady Heaton Rhodes a meeting was called, a committee was formed and the District Nursing Association [DNA] was created. As the population grew so did the DNA workload. At the stage when I joined the Board it was the sole provider of both district nursing and home help in Christchurch and the wider Canterbury region, with two hospitals largely geared towards convalescent care, which were in effect in competition with other local providers. Additionally there was a laundry organised cooperatively with the Hospital Board.

Attendant at NMDNA board meetings were Mr Johnstone, the Secretary and Nancy Tait, who had been appointed as the Superintendent of Domiciliary Services in 1970. Nancy was a graduate of the Christchurch School of Nursing who had additionally completed maternity training in Nelson. After graduation she had nursed for two years in the Australian outback after which she returned to New Zealand to be a Public Health Nurse, prior to her return to Christchurch as a Medical Social Worker for sixteen years at both Christchurch and The Princess Margaret Hospitals. Those experiences had formed a belief that many chronically ill people could return to their own homes if they and their relatives received more help from ancillary health services, a philosophy akin to that of Sybilla Maude. Nancy and I soon found we had similar outlooks which probably partially explained the NMDNA Board Chairman's request late in 1974 that I become the Chair of the Domiciliary Services Committee of the Board, which then entailed more regular communication between the two of us.

Nancy was increasingly worried that the entrenched conservative view some of her older District Nurses had about issues such as the appropriate scope of their work, and the virtual breakdown in liaison with charge nurses of the acute areas of the public hospitals, were inhibiting her perceived need for change. Discussions we held made me wonder if it might be helpful for the Association if I took the opportunity to study the NMDNA, particularly its domiciliary services, as the subject of the Diploma of Health Administration requirement for a specific paper on a Study in Health Organisation Administration and Management. Both Miss Tait and Mr Johnstone encouraged that idea and cooperated whole heartedly when approval from Massey was granted, as did the Board.

The objectives of the study were:

1. To examine to what extent the NMDNA fulfils its objectives as laid down in the NMDNA Act,1967 as it is now constituted: "The provision of services for the care, nursing and general welfare of persons in and about the City of Christchurch or within the Provincial District of Canterbury and the investigation of and the relief of distress amongst persons in and about the City of Christchurch or within the Provincial District of Canterbury."

2. Whether there are problems of coordination and communication on the District nursing side, e.g. environmental boundary problems between hospital and district, and district and GPs.

3. Whether there are gaps and anomalies in the implementation of services.

4. Whether there are problems of coordination of the entire domiciliary scene in Christchurch.

The pattern of the assignment was to study the historical development of the Association from its inception in 1896 to 1975 along with an analysis of the current operating system. Then we compared and contrasted the NMDNA system with the Extra Mural Hospital in Auckland where Dr Lopdell, the Medical Superintendent made Nancy and myself welcome to spend several days of interviews and visits. To a minor extent a literature search enabled further comparison with British and Scottish District Nursing systems.

The main problems elucidated by the study were:

1. The effects of increased specialisation within nursing as compared with the role of the generalist district nurse and other limitations such as the lack of a 24hour/7 day a week service.

2. Boundary liaison problems particularly with the major hospitals.

3. Local fragmentation of domiciliary services between organisations.

The follow up of the recommendations over the following years were:

1. Two seminars, the first for all staff to present and discuss the paper, the second a meeting organised by Miss Tait to bring together the various branches of nursing to further nurse liaison and co-operation in a wider context.

2. Improved liaison between Hospital Board Charge Nurses by the appointment of specific Liaison District Nurses.

3. The secondment of District Nurses to group practices as an experiment in NMDNA / GP liaison.

4. The appointment of a night District Nurse and some experienced Home Aids to be night sitters to allow terminally ill people to continue to be nursed at home with that increased carer support.

5. The gradual appointment of specialist district nurses beginning with Stomal DN, Diabetic DN, Cancer DN, and midwifery DN.

Those appointments were facilitated by the retirement of the Supervising District Nurse, which also enabled the Association to streamline management. Nancy Tait's title was changed to Supervising Principal Nurse and Coral Gardiner became the Supervisor of District Nursing Services.

The Cancer Nurse Service began in 1978 with a second appointment in April 1979 and a third, mainly acting as a reliever, later in 1979. The role of the Cancer Nurses was to support cancer patients and their family carers to enable the patient to continue to live at home if feasible. Those nurses coordinated the other care, including that of District Nurses and home help, and they liaised with the doctor involved as well as the hospital treatment services. They were an immediate success as resource advisors and coordinators of services, as much for the family, as for the patients. It was to be the beginning of a wider palliative care service which was to develop over time. For me personally it also meant an ongoing strong interest in end of life care, a stimulus not unrelated also to nursing my own dying mother at home in 1956 and the death of my husband in 1963.

In the 1960s there had been discussion as to whether the NCH Board should take over the Association. The NMDNA Board then invited the Health Department to undertake an investigation into "the present state of the organisation, its aims as expressed in its charter, its management and routine day to day activities."

The conclusions and recommendations of the 1967 Nurse Maude Association Report were:

On the basis of the available evidence there can be no doubt that the Nurse Maude Association today is a viable and well run institution, offering the people of Christchurch a service that is comparable with and, in several respects, more comprehensive than those offered by Regional Hospital Boards in other centres. It is moreover, very doubtful if the existing service could be run more efficiently or cheaply if it were incorporated in toto into the framework of the Hospital Board services.

To safeguard the NMDNA's future a private members bill, An Act to incorporate the Nurse Maude District Nursing Association and to declare the trusts and powers of and concerning the same, was prepared and enacted on 13 September 1967. Nevertheless the senior nursing staff of the NCHB still openly resented not having control over district nurses as compared with other Hospital Boards. Unfortunately, when the availability of so-called 'beer and baccy' tax funds enabled the appointment of a Coordinator of Domiciliary Services he was a trifle unguarded in his comments as he tried to impose authority over the NMDNA. All too soon all cooperation between Nancy Tait and the Coordinator ceased and full coordination of domiciliary services overall foundered at that stage. Despite that unfortunate failure to achieve the original aim other efforts at coordination were more successful.

The delegated authority at Board level for the Assistant Medical Superintendent included the need to coordinate the social and rehabilitation services provided by the various paramedical and domiciliary extramural services in Canterbury. Hence, in March 1975 the Social Services Committee of the Board had been set up. The members included:

Chair, Assistant Medical Superintendent in Chief

Chief Physiotherapist

Chief Occupational Therapist

Chief Social Worker

Chief Speech Therapist

Chief Clinical Psychologist

Chief Nursing Officer through her proxy

Rehabilitation Medicine through Dr Julian Kirk

Geriatric Medicine originally through Dr G Riley

Dept. of Health through Mrs Selby Principal Public Health Nurse

NMDA, Miss N Tait

The Co-ordinating Council for the Handicapped, Mrs D Jackson

The Aged People's Welfare Council, Miss B Crawford

Christchurch City Council Welfare Officer, Mr J Fry

Those from outside organisations were invited to give breadth and be part of its community involvement.

That Committee did undertake a major study of Home Aid Services, as a result of which the Board recommended to the Health Department that changes be made in the rulings under which home aid was available free to patients, being at that time restricted to those who were also in need of district nurse assistance. Consequently, if such a person needed to be admitted to hospital free home aid ceased just when the remaining family carer could be most in need of that assistance. At the same time Social Welfare, as the Department of Social Welfare was then called, was operating a means tested home help service for older or disabled people who could not care adequately for themselves. The two schemes were meant to cater for different groups of people but inevitably some confusion and inequities arose over the application of the conditions under which the services were available. As a direct consequence of that report the Management Services Research Unit of the Health Department decided to undertake nationwide research on Home Aid services as it was realised other anomalies or gaps might well be uncovered elsewhere in the country.

The establishment of a multi-disciplinary staff training unit was recommended but never followed through by the Board. Recommendations for an improved discharge form for patients were also rejected by the College of GPs. Liaison within the board between the Geriatric Advisory Committee, the Psychiatric Advisory Committee and the Primary Health Care Committee was established and then linked in with the District Council of Social Services and the City Council Welfare Office.

The Secretary of the Committee, Tom Beeston, was a tower of strength who became even more helpful when as Minister of Health, Frank Gill, introduced what became known as the 'Beer and Baccy tax' to provide funding for community health projects. We promptly made application for funding for a Coordinator of Community Services as already mentioned, as well other projects including that of a Diabetes Education Officer. Those were not really what the Minister had in mind so he particularly requested Boards to establish Family Health Counselling Services. Boards were to provide free counselling which was to be complementary to any medical services, whether or not those medical services were provided by the Board. It was no secret that what the Minister, a practising Roman Catholic, had in mind was to counteract the changes that had been made to liberalise abortion services. In Christchurch a Family Health Counselling Service was able to be established in the Bishopdale Community Centre, though most of its clients were families with a wide range of problems which might benefit from professional counselling, rather than the narrower group of clients whom the Minister had envisaged. During his retirement speech, John Hiddleston noted that the Community Health Projects 'beer and baccy' funding was flawed: 'However brilliant a concept it may have been it was introduced in indecent haste'.

That funding sadly soon evaporated under a different philosophical approach but, while it lasted, Tom Beeston did his homework thoroughly when making applications which assured that most of our applications were funded under the scheme.

My Burwood role also involved being a member of the Board's services planning group. At one session Heath Thompson representing the PMH referred to our two hospitals as 'out posts of empire'. That made me reflect that the view that Burwood was fundamentally a long stay geriatric and orthopaedic backwater needed to be turned around. As well as the three long stay wards people did remain for weeks, even months in the orthopaedic Ward 3 up to around to the late 1970s when Dr Richard [Dick] Sainsbury returned to Christchurch imbued with the principles of Ortho-geriatrics which saw that, as soon as possible after surgery, rehabilitation commenced. What a difference in functional recovery rates that made. Also the planning for the Spinal Injuries Unit to be built at Burwood was well under way which included an opportunity to see that the accompanying rehabilitation facilities included provision for others, such as those ortho-geriatric people. Hence Burwood was a position to be transformed into a major rehabilitation centre for the region.

Dr Charles Dick retired from being Medical Superintendent of The Princess Margaret Hospital in July 1978. I applied and was appointed to that role carrying with me the Assistant Medical Superintendent-in-Chief work as well. Dr Dick's secretary had not had to deal with the work load those two roles generated for my PA. Over some weeks delicate negotiations led to an amicable exchange of personnel so that Shona Muir could once again work in the office next door. Shona was a remarkable person. She had a congenital heart problem that had not responded well to earlier surgery as was evident by the marked clubbing and rather purple hue of her nevertheless nimble fingers. She lived and worked as if health problems were not an issue. Burwood only had one Plastic Surgery Registrar, whereas The PMH had sixteen and correspondingly more house surgeons. Shona took to the more complex rostering process with aplomb, quickly gaining the respect of the RMOs - but if someone was consistently unreasonable they soon learned that Shona was no push over, and she always had the option of telling someone she would have to discuss the issues emerging with the Medical Superintendent. On my part I was grateful she genuinely enjoyed handling the rosters most of the time.

We did have a somewhat petty irritation in that all the equipment pertained to a particular hospital office. Shona had been granted an electric typewriter because of the additional workload of the Board work, but it was then part of the Burwood office equipment. Diplomatically it would have seemed better for us to be able to requisition another electric typewriter but a series of letters indicated that became a funding issue and, anyhow, it would take at least six months to requisition one from the Government Stores Board. Such are the wonders of bureaucracy In the end we exchanged not just personnel but also typewriters, which would have been less of a hassle if the full exchange had happened simultaneously.

The PMH was a very different scene from Burwood. One wing was occupied by the Specialist Geriatric team of the AT&R unit, while another housed a psychiatric inpatient and day patient unit whose Charge Nurse was a friend from RNZAF days, Betty Dampier. The central core of the building was home to both medical and surgical wards along with surgical theatres and the core services of a general hospital.

The Principal Nurse, Phyllis Caukwell, was also relatively new in her post. She had a history of advocating for the replacement of hospital based training of nurses by tertiary education courses, which incorporated a variety of practical nursing experiences. That strong advocacy had not endeared her to those who wished to preserve the Christchurch Hospital School of Nursing at all, but Phyl weathered the criticism with quiet persistence for what she envisaged as the right course for professional nurse training. She was fun to work with too, and we shared more time together simply because our offices were next door to each other. One project we really enjoyed was to improve the rather austere entrance to the hospital. When we found some funding was available we soon immersed ourselves in deciding on a new colour scheme for paint, curtains and flooring. Harry Owles could have penned another rhyme about it. The day came when we were surveying the finished renovation while Hamid Ikram, the cardiologist, was passing through. Hamid informed us that it looked far too much like a hotel in his view. We happily responded that hotels aimed to make their entrances welcoming for people and that was our aim too, particularly as so many arrived at our entrance anxious and afraid.

Julie Lowe too was appointed to be Supervising Social Worker around the same time. Julie's advocacy of carers' issues, along with a small but articulate group including carers themselves, led to the founding of Carers New Zealand over some years.

All in all it was a stimulating and interesting working environment. Then suddenly a light was extinguished. On Good Friday afternoon of 1979, Dr Lyn Berry was sawing wood in the pine forest behind Burwood hospital when he succumbed to a massive heart attack. His deputy, Dr Fairgray was informed and he, in turn, asked Dr David Andrews, who had been appointed to take oversight of the planning of the Christchurch Hospital rebuilding programme, and myself to meet him later that day in Lyn's office. David and I arrived together, both very shocked by Lyn's sudden demise. When we entered the office Ross was already there. After a brief reference to why we were there, he informed us he had wished to see us personally to receive assurances that neither of us would apply for the position of Superintendent-in-Chief. It happened a long time ago but I can clearly recollect looking at David and then Ross in startled, shocked amazement.

What David actually said is not remembered, other than he indicated he had no intention of applying. I said I had only recently transferred to the PMH and therefore would not be applying. We stayed on a while to make arrangements to cover what was required in the interim but did not linger, expressing our disgust at what had transpired once we had left the room. Nevertheless our professionalism saw us fulfilling our respective duties as if nothing untoward had occurred until the day the position was actually advertised when Ross took us aside from a meeting to request, yet again, that neither of us apply for the position. At that stage David was really angry, expostulating that he had previously given his word and did not expect to have that doubted. I emphatically concurred.

Recently upon meeting up with another former Medical Superintendent I learnt that when he became the only other applicant for the 'Chief's' role, he too was approached and requested to withdraw his application. He did not comply but was not surprised about the intense lobbying by the other applicant.

Over the same time period as my time at the PMH I received a couple of overtures from the Department of Health. Initially there was a letter from Dr George Salmond, then Director of the Management Services Research Unit [MSRU] inviting me to join the unit. At that time David, our son, was very unwell so it did not seem right to even consider leaving Christchurch. Then later in 1979 Des Ryan, Deputy Director General of Health [Administration], personally approached me with an invitation to apply to join Hospitals' Division at the end of the year when Dr John Boyd was to retire from the position of Assistant Director of the Division. The duties were to further the development of services for older people, especially the development of AT&R units as had been requested formally by the Department in a letter to all Hospital Boards in 1974, as well as to handle departmental oversight of the South Island Boards generally.

Not only did Des Ryan seem to propose a logical extension from a regional to a national scope of working to improve health of older people which I had begun to find absorbingly worthwhile, but David also appeared to be more settled. He was one of the first to join the Richmond Fellowship live in programme which Dave and Jeannie Loveridge had been recruited from the UK to manage in Christchurch. I was very aware of only having been at the PMH eighteen months but the NCHB did not have the same affable atmosphere after the loss of Lyn Berry. Wally too, though happily employed as an ACC rehabilitation officer, was keen to shift to Wellington, a city he had enjoyed when he was posted to Air Department. He could have transferred his ACC role to Wellington but preferred to seek other avenues and was soon offered a part time position fund raising for the rebuilding of the Outward Bound facilities at Anakiwa. That also enabled him to assist Sarah Jane with her boys on weekday afternoons.

My employment at the Department of Health [DoH] was to commence when that organisation re-opened after the 1979-1980 Christmas / New Year holidays. The following day I was expected to attend a meeting of geriatricians to discuss various funding issues which had been organised by Dr Ron Barker, Deputy Director General of Health and himself a pioneer geriatrician in New Zealand. We were aware that our Cook Strait ferry booking to take the car over the Strait was subject to a strike that the crew had threatened. By the time we reached Kaikoura, where we were to stay with Lloyd and Val Johnson the strike was full on and, if I waited for its end, the arrival in Wellington would probably be too late. There was no air service from Kaikoura but Lloyd knew a farmer pilot whom he approached. Yes, he was willing to help but he had what was officially a single seater aircraft. If he took me I would be seated behind him sitting on what would have to be a small suitcase. We accepted his offer.

It was a fine, almost windless day and I revelled in the idea of flying low up the coast to Wellington. When it came to the crunch it was Wally and Lloyd who were dubious about that idea. My departing view was of two solemnly anxious men standing at the edge of the paddock, where a strip had been mowed so we could take off more readily. In a short time we were able to ring and let them know all had gone well and we had landed safely in Wellington. It was over a week before Wally was able to board a ferry prior to which he had to spend two days in a slowly diminishing queue of vehicles. What he found upsetting about that wait in the sun was the plight of mothers and increasingly fractious babies in the heat.

References

1. Letter from Dr Berry to Dr Guthrie re Administrative Superintendent of Burwood Hospital. 6 June,1973.

2. Letter from Sr Salmond to Dr Guthrie re position at MSRU, Dept of Health. 1978.

3. Letters from Dr Dickie to Dr Guthrie re appointment to Dept of Health 17 Oct. 1979.

4. Letter from New Zealand College of Community Medicine to Dr Guthrie. 1979.

5. Letter from Dr Barker to Dr Guthrie re attendance at meeting with geriatric medicine physicians 6 Dec.1979.

6. Riley G. _'A Geriatric Assessment Unit: The first twelve months'_ NZMJ 27 Nov. 1974 vol80 No. 528 p435-442.'

7. Prentice C.,Whitehead S. ' _A Survey of Community Services for Older People in North Canterbury'_ Canterbury Old Peoples Welfare Council 1976.

8. Scotts N., Koopman-Boyden P. _Forty Older People in Christchurch: An Exploratory Study'_ Age Concern Canterbury 1977.

9. Prentice C.et al _' Transport and Older People'_ Age Concern Canterbury 1979.

10. Somers Cocks E. _'A Friend in Need: Nurse Maude, Her Life and Work'_ Nurse Maude District Nursing Assn. _1950._

11. Guthrie M.W. _' The Nurse Maude District Nursing Service in particular its Domiciliary Services and Problems of Coordination.'_ A Case study for the Diploma of Health Administration, Massey University, 1974.

12. New Zealand Govt. Nurse Maude District Nursing Association Act 1967.

### Chapter 7

On Being a Civil Servant

Having been a Hospital Board employee was only a partial education towards the transition of becoming a Department of Health staff member, a civil servant who was beholden to conform to implementing the policies of the Government of the day. One's own political views had to be restricted to personal and private life which could not be seen to impinge on the public work persona and activity. On occasions that might place one in a 'them and us' situation, a circumstance which did once cause me some embarrassment.

The first morning, upon meeting the Director General, he remarked that, recognising the role I had played on behalf of medical women's issues, I could still act as a bridge between the Department and the MWA. A year or so later when Government imposed a financial freeze on all departments, which the Ministry decided included a cap on the number allowed to join the Medical Reserve Scheme, the MWA expected me to plead for that not to be implemented. Upon seeking the Director General's advice about how to handle that pressure, and wondering if I should explain that I had no option but to support a government directed policy decision, the Director General suggested it would be better to quietly withdraw from attending meetings. I followed the advice, as was expected of me, but inwardly my preference would have been to be transparent about the reason why I was unable to advocate on the MWA's behalf over the matter. Hence it was not until after retirement from the Department that it was appropriate to resume being an active member of the MWA again, and at that time no one actually remarked on why I had not been actively involved for about 7-8 years; nor did I mention it. It was past history.

At the initial meeting that first morning in the Department with the Director of Nursing, she immediately connected me with the Nurse Maude Association, remarking indignantly about the fact that only in Christchurch was the Chief Nursing Officer not in control of District Nurses. I countered that remark with:

On the other hand the Treasurer of the NCH Board is happy that the NCHB only has to fund 75% of the cost of district nursing in Canterbury, leaving the Association with the task of raising the other 25% by means of donations or bequests. That financial advantage too is unique to the NCHB.

Two other happenings that morning influenced the directions in which departmental involvement was to progress. Firstly, lying upon my desk that morning was a draft report from Christchurch of' 'The Perceptions by Consumers and GPs of the District Cancer Service' by Carol Gardiner, Supervisor of the NMDN Association and Stewart Whitehead, Research and Planning Officer of the Health Planning and Research Unit, Christchurch. That prompted me to ask Peter Mackie, the Executive Officer of Hospitals Division what the Departmental policy was about Terminal Care.

Peter responded: "There isn't one. Do you feel there should be?" "Yes, there are policies around birth, and everyone born is sooner or later going to die. The circumstances around dying equally deserve attention." Peter promptly agreed, offering to assign one of his staff to investigate what might be happening in that regard both within New Zealand and elsewhere. The outcome and sequels to that exercise shall be continued later.

The second occurrence was that Peter Mackie was to attend a Health Select Committee meeting later that morning to hear any last submissions, before agreeing to pass on to Cabinet for approval the Old People's Homes Regulations 1980. Peter suggested it would be educational for me to accompany him, even though I might not be au fait with what changes were envisaged from the, about to be superseded, 1965 regulations. The one change that was agreed to by the Committee was proposed by the Member for Eden, 'Aussie' Malcolm, who was known to have the highest concentration of Residential Homes within his electorate in the country. Mr Malcolm made it clear that his constituents, the proprietors of the many private rest homes in Mt Eden, thought the minimal allowable dimensions of bedrooms was too generous and they should only have a minimum width of 2.2 metres and a minimum floor area of 6.0 sq. metres for one bed and 5.6 metres for more than one bed. I was shocked at the resulting stingy minimum sized rooms and the fact that the proprietor's wishes were more important than the wellbeing of the residents, but the Committee agreed to the change.

Little did I fully comprehend then how much the DG's delegation of authority to me to both grant and suspend the license of Rest Homes was to exercise a number of us before another improved, but by no means perfect set of those cumbersome, inadequate regulations could be presented for approval in 1987.

I needed to absorb so much in those early Departmental days. Again, I was fortunate that Dr Robert Dickie, the Director of Hospitals Division was such a wise, knowledgeable guide, but he did suggest that the Deputy Director General, Dr Barker should be my mentor for any questions arising from health of older people.

Dr R.A. [Ron]Barker CBE was born in Auckland in February 1922, educated at Mt Albert Grammar School and obtained his MB ChB from Otago University in 1949, and became a specialist physician in 1965. As the Medical Superintendent of Cornwall Hospital from 1960 to 1974, he was to the forefront, along with Dr James Newman, of the development of AT&R in New Zealand. As he himself wrote in 1982:

Until the 1950s it was widely believed that little could be done for an old person who was ill or disabled.... Hence they were usually housed in the oldest, most dilapidated wards of hospitals with few staff to care for them and little attempt to rehabilitate them.

By 1975, as the Deputy Director General of Health he had succeeded in persuading the Minister of Health, Mr Tizard, to urge Hospital Boards to appoint Geriatricians and develop AT&R Units as steps in establishing a comprehensive service to maintain function and well-being of older people.

Dr Barker was also one of the initiators of both the New Zealand Geriatric Society for medical geriatricians and the New Zealand Association of Gerontology [NZAG]. The formation of the NZAG was necessarily multidisciplinary if New Zealand aspired to attain membership of the International Association of Gerontology, the international body which aimed to study ageing in all its aspects. That in turn led to a series of conferences held at more or less 2-3 year intervals from 1974 onwards which became a vehicle for the expansion of knowledge for a wide range of health and other professionals who were increasingly involved in issues and services for older people.

Dr Barker's medical registrars at Cornwall Hospital had included John Campbell, who became our first Professor of Geriatric Medicine; George Salmond who at the MRSU had produced the Special Report No. 46 of the Department of Health, 'The Accommodation Needs of Older People'; Jonathon Baskett, who founded the New Zealand Stroke Foundation, and Graham Davison, who deeply involved himself in older driver licensing policy and nutritional issues. When I came under Ron's stewardship it was as a Public Health Physician with a specific brief to further policy and planning to improve and maintain the function and wellbeing of older people. Ron saw, among other matters, that I became actively involved in the NZ Geriatric Society and the NZAG, as well as maintaining an interest in Age Concern and other relevant non-governmental societies and associations. I was most fortunate in my early tutors in what was to become my own speciality, not the least of whom was Ron Barker.

Another influence in 1980-81 was the Minister of Health, George Gair. His polite, diplomatic style and background in Public Relations came to the fore if any change was proposed by departmental officials. We had to be seen to be transparent, to consult widely laying out the pros and cons of what was proposed. He then read through all the correspondence before summoning the officials concerned for discussion which was for a politician remarkably free of political ideology so much as what was the fair and proper course to take. The result was that we established a good working relationship. He extended the same type of relationship with Hospital Boards. When he decided to visit the lower South Island Hospital Boards Warwick Brunton and I were delegated to accompany him. It became a personal as well as an official visit in that he was so evidently pleased to be back in the Central Otago landscape he had enjoyed during his boyhood. When we were due to meet the South Canterbury Hospital Board at Oamaru from being at Ranfurly, Warwick thought it might be an idea to go via Dansy's Pass, instead of the more usual highway. That depended on whether the publican at Dansey's Pass Hotel was able and willing to provide us with lunch. He was willing. The Minister was unaware of the change of route until we had taken the relevant turn towards Naseby and Dansey's Pass. When he realised what had been arranged, as a surprise for him, he was far from displeased. The publican produced a very good buffet lunch for which he declined to accept payment he was so pleased to have been involved. As we stopped to let a flock of sheep pass by on the narrow dirt road of the Pass a startled farmer recognised the Minister in the Crown car by his acknowledgement. We were a few minutes late for our appointment, but the board Chairman had guessed we may have taken the longer route, which he too thought much the more interesting option.

Retrospectively I was to realise not all Ministers were as agreeable to work with as George Gair. His successor for the 1981-84 parliamentary term was 'Aussie' Malcolm. A more blunt individual which sometimes meant being openly honest: "That may be logically the best course - but it's politically a no-no."

One did know where the Minister stood on issues. It was no surprise when Ron Barker told me not to try to further any regulatory reforms pertaining to Rest Homes during that tenure which made me realise that one did not just work for the Government of the day, but one also tailored one's work according to the Minister of the day.

That did not mean that working towards improving conditions in Rest Homes ceased. The Office Solicitors, Olive Smuts Kennedy and Bob Sheppard were close allies, advising what was and was not possible, tutoring me in the niceties of natural justice; that any visits I made along with the Public Health nurse involved should be un- announced as issues needed to be substantiated by me in person as the delegated authority, prior to any action.

Of all the many aspects of my work in the Department that was the one with the highest public profile. On several occasions the media, both press and radio, sought interviews. There was a tendency for them to seek out the more lurid details of specific cases which, apart from the fact it would have been unethical for us to reveal personal details, would also have been illegal on our part. However we were influenced and assisted by the investigative journalism of Peter Trickett, who during 1976-77 on behalf of the NZ Herald had visited private rest homes and talked to residents which resulted in articles such as, 'Rest homes where the aged live in fear,' NZ Herald, 25 August 1976.

Trickett identified issues including:

• staff with no qualifications.

• retention of residents in need of hospital care.

• deprivation of fundamental human rights through the use of excessive medication.

• loss of personal freedom - through physical constraint, [being tied to a chair] or controls, e.g. being confined to rooms in the early evenings.

• suspicion of physical abuse, attributed to falls.

• fear of repercussions if complaints were made.

• financial exploitation, retention of discretionary income and the clothing allowance provided for residents in receipt of the private rest home subsidy.

• substandard accommodation and inadequate and inappropriate meals.

Later in the 1988 discussion paper that Bernie King and I produced, 'The Care, Mis-Care and Abuse of the Elderly', we noted that readers' response to Trickett's articles both confirmed his findings and also supported the many owners of Rest Homes who did provide good care in a pleasant environment. A subsequent national survey in 1976 confirmed there were problems in 43% of private homes as compared with 16% in those run by the religious and welfare sector.

From the Departmental point of view I was to become very aware that the 1980 Regulations, while detailing physical aspects such as room and window dimensions, made inadequate reference to standards of care. Although a licensee could have a licence revoked if the standard of care was unsatisfactory there were no actual standards laid down and incorporated into those Regulations. A Health Amendment Act 1979 had approved the prescription of minimum standards of care, as well as the prescription of the qualifications required for managers of homes and training courses required to be undergone by other persons employed in homes. Win Moynihan, an experienced Public Health Nurse, was engaged to produce a Standards of Care document which was published in 1982. From then onwards the inspecting Public Health Nurses at least had a persuasive educational tool to use alongside their monitoring role; but the Regulations were cumbersome and possible actions were slow in that 'natural justice ' had to be seen to be fulfilled, which added to the heavy cost in both time and money such investigations and legal follow-up entailed.

Over the decade that I held delegated authority from the Director General of Health to both grant and revoke the licenses of rest homes some 14 homes had licenses revoked, 12 of which surrendered their licence while 2 took the Department to Court before they had their license revoked. Many more homes were monitored for breaches of the standards over that period which, on the whole, most remedied relatively positively.

With the establishment of a national Rest Homes Association there was also effort on their part to create a code of ethics and to develop, in conjunction with training establishments, orientation and training programmes for staff. Writing about all that tends to simplify what was a convoluted, complex process. For instance hospital board social workers urged us to remove the word 'minimum' from minimum standards as implying that minimum was acceptable when they might not be sufficiently safe to be acceptable, which was indeed an issue.

In 1980 it had been 15 years since the 1965 Regulations were first promulgated. It was to be 7 years before an improved, new set of regulations were passed by Cabinet and that was certainly facilitated by the then Minister of Health, David Caygill in 1987. David Caygill's term as Minister of Health was sadly rather short as he was deemed to be needed, all too soon, to be in a more senior financial Cabinet position. So Bob Sheppard and I were fortunate to be in a position to present a draft revision of the Regulations while he was Minister. After he had perused our proposals we were both summoned to his office early one Friday afternoon. His keen legal mind had seen him go through the proposals in detail. Though he was basically in favour of what was being proposed we were told that, if we could return a draft, altered as he had suggested, by 9pm that evening he would present it to Cabinet for approval on the Monday morning. So we worked late that evening. We left the office around 8pm, depositing the altered documents as requested before we both headed homeward on our respective trains. On the Monday the 1987 version of the Regulations was passed. Section 22 stated:

[f] The standard of care available to the residents in the home is unsatisfactory; or

[g] Any resident has been ill-treated or neglected in a manner likely to cause suffering or has been kept in an environment that is injurious to the resident's mental or physical health; or

[h] The premises of the home are unsafe for residents or are unsanitary; or

[i] The premises, furniture, or equipment of the home are in such a condition, or the home is managed or conducted in such a manner, that the issue or renewal of a licence would not be in the interests of the residents or in the public interest.

Those 1987 regulations also laid down the qualifications expected of a manager of a home. The obligations of both the licensee and manager were detailed and staffing levels were also improved.

The implementation of the regulations remained cumbersome and too slow, all too often, for the wellbeing of affected residents, so their eventual demise in the 1990s was no cause for sorrow. Even though the standards of care are now embodied in the contracts that homes have with various DHBs problems persist, problems which have been heightened by the increase in age and frailty of the residents as the oldest old population has steadily increased over recent times. One issue that has never been satisfactorily resolved is whether it is feasible to adequately monitor homes by means of announced, as compared with unannounced visits. I preferred visits to be unannounced but was aware that some inspecting Public Health nurses felt they could pick up the necessary clues irrespective of their monitoring being by appointment. That did mean that they would not make a trip to a particular home unannounced in a distant country area and then find the manager out at that time.

________________________________________________

Reverting to early days in the Department, Dean Pooley, who was assigned to produce a position paper on terminal care, completed his task by late 1980. The paper, 'The Development of a Policy towards Hospice Care in New Zealand' , showed there were at that time three inpatient hospice units in the country, Mary Potter at Calvary Hospital in Wellington, a unit at the Mater Hospital in Auckland and Te Omanga in Lower Hutt which also had a large domiciliary team, while in Christchurch the NM Association had a domiciliary team but no inpatient facility.

Dean's research both within New Zealand and elsewhere led him to suggest that several questions had to be considered in the development of a policy, such as: why hospice care was found to be necessary overseas and were those findings applicable to NZ; the philosophy which underpins hospice and the definition of hospice care including the types of patients who are in need of it; the placement and operation of hospices; what educational role would a hospice have and should this affect the training of medical, nursing and paramedical staff who might work in hospice programmes; the number of hospice beds required; the extent of outpatient, day patient and community outreach facilities; how were hospices to be funded; what evaluation was necessary, and what form should it take? Each of those questions was dealt with in the paper which concluded with a list of recommendations.

It was a very good paper to be able to present to the Directorate, and later the DG, along with a proposal to set up a temporary task force to work on a policy paper for presentation to the Minister for approval. Coincidentally there were helpful articles in: the NZMJ, where Richard Turnbull, Medical Director of Te Omanga detailed their programmes [NZMJ Jan 28 1981, No 676, pp46-49]; and The NZ Family Physician, where Paul Davidson and Ivan Lichter dealt with Care of the Dying by a series of questions and answers [ NZ Family Physician 1981,8: 12-13]. The 3rd National Conference of Geriatric Medicine and Gerontology in Wellington in November 1980 had also been a platform for Marion Cooper of Te Omanga to present a paper on 'A Community Hospice Programme'.

As well as Peter Mackie, Margaret Duthie from Nursing Division, John Hyslop from MSRU and Louise Delaney, who acted as Secretary, the Task Group included the Reverend Ken Irwin from Presbyterian Support and Marion Cooper from Te Omanga, whose facilities we visited, while Louise sought statistical and other information from the four organisations that were then operating in NZ.

The 3rd National Conference of Gerontology was additionally an opportunity for me to both network more widely and to listen to international speakers, particularly from the United Kingdom, where what was to become specialist health services for older people had been first stimulated by Dr Marjorie Warren's demonstration that it was possible to rehabilitate people who had hitherto been condemned to moulder in the back wards of hospitals. It was the holistic attitudes of both Professor Brocklehurst from Manchester and Professor Tom Arie from Nottingham that impressed. The former's keynote address, 'Health and Morale in Old Age' theme was that health in old age depends partly on the extent to which old people are influenced by negative social attitudes concerning ageing, by retirement, illness, poverty and the fact that old age is the last phase of life. Health is affected by morale and the habits and outlook of a lifetime. However self-help and empowering people can help maintain well-being.

Professor Arie in one of his addresses, 'Clinical Psychiatry of Old Age', stressed that as, all too often, unrecognised dementia, depression or neurosis occurred at the same time as physical illness, services must be comprehensive and integrated if they were to be effective in assisting the whole person and their family. The style of the service was also of importance. It needed to be responsive and to generate confidence which would in turn increase job satisfaction of staff.

In another address, 'Future of Health Care for the Elderly', Tom Arie dealt with the inter-dependence of services and social policy, the potential and limits of the contribution by medical and other professionals to problems the solutions of which depended largely on society as a whole. He referred to those who warned against the medicalisation of old age when society was actually looking to medicine to help solve some of the problems of ageing. For instance one problem solution; joint replacement for worn out hips, knees and other arthritic joints was cost effective, particularly when followed by timely rehabilitation, as exemplified by the Southampton ortho- geriatric partnership model. That model emphasised the real need for prompt treatment if function was to be maintained and improved, mobility being so important for older people.

The impetus of the conference led to a discussion with Ron Barker if, just as my clinical colleagues had sought post graduate training in the UK, I could benefit by a period of study leave there too. Upon his encouragement I made a written application seeking to study systems of geriatric care in the UK, especially those working towards integration of general, mental health and community care. Palliative Care was to be the other study theme which would include visiting a variety of not only UK hospice systems, but also the Toronto programme headed by Balfour Mont. The latter visit led to also looking at Canadian health programmes for older people. Study leave was approved with the proviso that it included being a member of the NZ team to attend the first United Nations Assembly on Ageing in Vienna in August 1982.

Each member nation of the UN was expected to produce a written report on the circumstances of their older population for presentation to the Assembly. Dr Barker, as the head of the New Zealand delegation, asked 'Flos' Caughey and me to jointly edit our report along with him. In discussing the content we were aware that up until that time a document about 'Ageing in NZ' had not been previously available. Hence the more comprehensive we made it the more relevant it would be both internally and externally. As well as the obvious chapters on economic security, housing and health, the last two of which we wrote ourselves, we cajoled a variety of experts to provide relevant content. Consequently, 'Ageing New Zealanders: A Report to the World Assembly of Ageing 1982', contains chapters, such as: Fact and Fiction about Ageing by Graham Davison; The Elderly in Maori Society by Wiremu Parker; Work and Retirement by Margaret Smith and Jennifer Mark; Education by David Battersby; the Family and its Elderly Members by Peggy Koopman-Boyden; and Voluntary Agencies – Their contribution to welfare of the elderly by Wally Lake.

Engaging with the contributors was a stimulus to broadening my own knowledge and outlook, as had been the earlier contacts on the Education Committee of the Canterbury Aged Peoples' Welfare Council. Alongside reports from other nations our report did stack up well.

To complement the report, Dr Mahler, Director General of WHO, headed a series of WHO Fact Sheets to mark World Health Day, 7 April 1982, by one entitled, 'Add Life to Years'. We decided to seek parallel New Zealand Fact Sheets for the general public, as well as health professionals, commencing with one by Dr James Newman, 'The Challenge of Geriatrics', which were also compiled under the heading of, 'Add Life to Years'. They covered a wide range of subjects including 'Loss and grief', 'Urinary incontinence', 'Falls in old age', 'Medication in old Age' and 'Facts and Fiction about Ageing'.

References

1. Minister of Health, R. J. Tizard to Chairman of Hospital Boards, Letter urging Boards to develop Assessment &Treatment Services for frail older people. 8 June, 1973.

2. Barker R.A.,Caughey F.M.,Guthrie M.W. ' _Ageing New Zealanders: A Report to the World Assembly on Ageing'_ 1982.

3. Trickett P. ' _Rest home where people live in fear'. New Zealand Herald_ , 25 August, 1976 p1.

4. King B., Guthrie M. ' _The Care, Mis-Care and Abuse of the Elderly: A Discussion Paper'._ Elderly, Disabled and Handicapped Unit, Department of Health, September, 1988.

5. Department of Health, _'Standards of Care for Old People's Homes',_ 1982.

6. New Zealand Government, _The Old People's Homes Regulations,_ 1980.

7. New Zealand Government, _The Old People's Homes Regulations,_ 1987.

8. Pooley D. ' _The Development of a Policy towards Hospice Care in New Zealand',_ An internal paper, Department of Health, October, 1980.

9. Turnbull R. _The Te Omanga Hospice Continuing care Programme'_ NZMJ 1981:94:p52-54.

10. Davidson P., Lichter I. _Care of the Dying'_ New Zealand Family Physician 1981: 8: p12-15.

11. Davidson P.et al, _The development of a hospice for the continuing care of cancer patients,_ NZMJ, 1981:94:p52-54.

12. Cooper M. ' _A Community Hospice Programme',_ Address to Geriatric Medicine and Gerontology Conference, Wellington, November, 1980.

13. UN, World Assembly on Ageing, _'Add Life to Years'_ Fact Sheets Series. 1982.

14. NZ Govt. Department of Health, ' _Add Life to Years',_ Fact Sheets, 1982.

### Chapter 8

Study Leave, May to September, 1982

I largely spent May 1982 in Canada, in Ontario and Quebec, beginning at the Federal Ministry of National Health and Welfare. Here I was informed about the provisions of their Medical Care Act 1966, which governs how the Ministry operates grant-in-aid programmes, such as the Ontario Health Insurance Plan [OHIP] to provinces which operate medical care insurance plans. This established guidelines for specialist services, including geriatric units. They were also keen to inform me of a nationwide community programme, New Horizons.

New Horizons was established in 1972 to enable retired Canadians to join with others of their age group in activities which they themselves could plan and organise. The original objective was the alleviation of loneliness and problems arising from loneliness. A secretariat and field worker were set up and initially public meetings were held in every province where seniors and spokespeople for voluntary agencies working with seniors expressed opinions on how the programme should work.

During the first decade of operation some 8000 groups had undertaken more than 16,000 projects. The Groups represented approximately 1/3 of Canada's retired population of 2.3 million. The programme was designed to ensure that a wide range of projects could be considered with a minimum of 'red tape'. Grants were to be provided either to start up new activities or to expand existing ones; activities could be one off such as a seminar, or ongoing. Groups were encouraged to plan for the continuation of a project after the funding through self-support by the group, community support or other means. Should there be extenuating circumstances an extension of financial support of up to an additional 18 months might be granted.

Initially the applications for grants were for what the first report described as 'the type of things society expected of them', primarily social clubs for self- entertainment. Then they began to branch out into activities which enabled them to acquire new knowledge and skills, encompassing a wide variety of crafts, sport and the resumption of formal education. Groups then ventured into projects which provided services to foster grandparents, skills exchange programmes and many different types of counselling and information services. Their other major progression was towards leadership training courses and the formation of senior citizens federations. So it was felt that New Horizons had accomplished a great deal more than the alleviation of loneliness. It had turned out to be a social experiment in which older people have, with the encouragement of the field workers, become adventurous and innovative.

I was invited by Monique Begin, Minister of Health to attend a lunch at the Federal Parliament which celebrated New Horizon's tenth anniversary while it also opened Senior Citizens' Month in June 1982.

### Elderhostel

Elderhostel Incorporated is an international non-profit corporation whose goal is to serve the over 60s by offering them educational residential programmes at modest cost. It encompasses a network of over 500 colleges / universities / independent schools/ folk schools in the USA, Canada, UK, Sweden, Finland, and Norway which offer low-cost, short term residential academic programmes for older adults. Lack of formal education is not a barrier.

### Elder care

The system of classification of the types of institution for aged care was created to meet welfare objectives in caring for frail older people with few resources. Each type of care had a different jurisdiction, policy, funding and control which did cause confusion. In my discussion with Dr Schwenger, Professor of Community Health, University of Toronto, he said that:

the differences... are a serious challenge to the present efforts at co-ordinating extended care services in Ontario. It would be helpful if nursing homes and homes for the aged were under a single ministry, since patients in the former are becoming less and less disguisable from residents in the latter.'

Canada too had both an increase in frail older people and some confusion about how to deal with funding their care.

Another concern was the rate of institutionalisation, which at 8.9% was down from 9.5% in 1971-3, probably due to increased encouragement of community services. And yet another problem was misplacement. Different studies in both London and Kingston, Ontario had indicated that a significant number in residential care were misplaced.

Placement Coordination Services which assessed the needs of individuals and matched them to the services which best met those needs, was developed to try and overcome excessive institutionalisation and misplacement. The first Placement

Coordination Service was established by the Hamilton District Health Council upon the initiative of Dr Ronald Bayne, Co-ordinator of the Geriatrics and Gerontology Programme and Professor of Medicine at McMaster University. Dr Bayne generously had me to stay, as well as seeing that I was able to be well briefed about their system. On perusing the form they had developed to provide the necessary information it broadly fell into three categories [a] demographic [b] medical [c] functional capacity. The whole system aimed to identify problems. It was virtually what became the basis of the standardised assessment form that the 2003 NZ Guidelines Group, Needs Assessment Guidelines for Older People recommended, only we had to wait for another 20 years for that to happen, partly because there was an earlier assumption that assessments from the AT&R units were more consistent nationally than they were in reality, added to the fact that not everyone in NZ was assessed before entering residential care.

### Home care

A Canadian 65 and older who is covered by OHIP is eligible for Home Care. A doctor who heads the team providing health services for that person must apply for Home Care in either Acute Care and Chronic Care programmes. These programmes were evaluated from 1975 onwards in Hamilton, Kingston and Thunder Bay. Of the first 218 clients 20% had applied for admission to an institution before applying for Home Care and another 22% had considered applying. The Home Care staff judged that 61% would have needed institutional care without Home Care. Only 12% of the 218 left the programme to enter an institution, so it was deemed that the programme did delay admission to an institution. A policy decision was then made to expand Home Care, whereas steps were taken to constrain residential care spending.

Additionally there was a variety of Home Support programmes run by non-profit agencies which included meals on wheels, wheels to meals, day care, heavy cleaning and handyman services, transport to medical appointments and shopping, friendly visiting, security checks and inter-generational programmes where seniors could help young people and receive services from them in turn. It was pointed out that the eligibility criteria under different programmes could be confusing to people attempting to understand conditions under which they might or might not receive a service, a situation which pertained in NZ with regard to home help at that stage as well. The most highly developed home care system was that organised by the Canadian Red Cross where I spent time with Nancy Hamilton, a National Co-ordinator for Red Cross Health and Community Services. Their range of services was extensive but Nancy deemed their Friendly Visiting was of prime importance because she saw the need for a friend as basic as that for food and shelter. It had become the foundation from which other needs might be assessed and services initiated. Those services also included Vacation Care which permitted family carers to have respite time from a weekend to a month, a service which at that time was not available in NZ.

It was illuminating to see an intergenerational programme in action where some Niagara Home residents were serving as teachers' aides. The homecraft and woodwork shop in that home also made toys for nursery schools. The objectives were twofold; to help the young have positive contact with older people and to maintain seniors contact with the young. That home had also responded positively to those who wished to maintain contact with a pet dog or cat, noting that a confused, disoriented resident may respond alertly when a pet comes into a room. As well residents had been encouraged to tame squirrels and attract birds with bird feeders.

### Teaching Programmes

The Canadians were well ahead of us. At both Toronto and McMaster post-graduate, two year programmes leading to a Certificate of Competence in Geriatric Medicine were available to trained physicians. Dr Rory Fisher who coordinated the Toronto programme, and who was based at Sunnybrook Veterans' Hospital was himself a UK trained geriatric physician who had been in Toronto for 10 years. He remarked that the custom had been for Canadians wishing to study geriatric medicine to go to the States rather than the UK; hence their tendency to emphasise research and be technically oriented. The aim of the Sunnybrook course was not to produce geriatricians in primary care but consultants who will develop programmes in teaching hospitals and advise GPs. Undergraduates had 40 hours content in geriatrics which included 2 weeks in 4th year whereas, he noted, Saskatoon undergraduates had a month in 4th year.

### Psychogeriatric

There was a psychogeriatric wing at Sunnybrook Hospital where Dr Ken Schulman, a University of Toronto graduate who had done his post-graduate training under Drs Tom Arie and Elizabeth Taws at Goodmayes Hospital, London, UK, chose to return to Sunnybrook because it gave him the opportunity to develop a fully integrated psychogeriatric / geriatric programme in a teaching hospital. The Family Medicine trainees also rotated though the psychogeriatric area. The consultation area covered a population of 200,000 people, hence the presence of another consultant, a fellow and a trainee.

A terminal care study was among the research projects being undertaken at Sunnybrook. Dr Fisher felt that the terminal care impetus tended to concentrate on cancer patients but ignored older patients who were dying. Initially he wished to ascertain whether his wards should have a palliative care area, or whether steps were needed to inculcate all staff in good terminal care principles. He initiated a retrospective study of 486 deaths. From that he decided a specific unit was not the answer but, rather, all staff needed extra knowledge. The findings showed that pain was not so much a problem as distress caused by respiratory and renal disease. Also neurological complaints such as MS and motor neurone disease distressed both patients and relatives. He did remark that many older people died peacefully, and did not appear distressed by their impending demise, but tended to be philosophical and accepting.

I also visited Kingston Psychiatric Hospital where Dr Martin Rodenburg was Director of the Psychogeriatric Unit and also Assistant Professor of the Department of Psychiatry at Queen's University. Apart from the fact that Dr Rodenburg, his associate and two residents were overburdened by the sheer volume of their workload, he was very aware of what he saw as the limitations of his capacity to give an adequate service because [a] the stigma associated with a psychiatric hospital frightens off some families [b] the hospital lacked sufficient medical and investigative facilities of its own, as well as convenient access to such facilities in a general hospital, and [c] there were insufficient community support services to assist families to care for dementing relatives. Nevertheless others informed me that the strength of that unit was the quality of the service it gave to families. As well, by promising Nursing Homes and Homes for the Aged he would take patients immediately if need be, he had gained their co-operation.

In Ottawa Dr Stanley Goldstein was psychiatrist-in-chief of the Queensway Carlton Hospital which is a 240 general hospital with 28 psychiatric beds, 40 geriatric beds and a combined geriatric-psychiatric day hospital. Dr Golstein said his philosophy was that he was accessible. The quality of his team, including social workers, OT nurses and psychologist, made it possible. Dr Goldstein said the team ran the unit and a nurse with a very positive approach ran the day hospital. He was not in favour of the medical model where the doctor was all important. Nevertheless, it was evident that he was a dynamic person himself, with a capacity for much concentrated effort, who worked hard at team relationships to gain the confidence of other health professionals.

Care of the carers, for whom ongoing support and help was deemed essential, was stressed by Dr Goldstein as critical. He had his team working with relatives to find appropriate solutions such as intermittent care, day care, counselling and information. He was somewhat troubled that some social workers were becoming unbalanced in their attitude to 'granny abuse'. He was at that time working on an editorial for the Canadian Medical Journal, 'The Elderly – Abusers or Abused', which appeared as an editorial in the September 15, 1982/Vol 127, p455-56. The complexity of the relationship between the elderly and their families was, in his view, tending to be overlooked. Although the lives of the aged were often difficult, the problems of caregivers also deserved consideration.

As well Dr Goldstein questioned the attitude that all older people desired independence. He felt that was true for the achievers, the individualistic, but there were the relatively passive people who become hassled by the cares of maintaining a home, who prefer to be either in a Senior Citizens' apartment, if less affluent, or a Retirement Home or Home for the Aged, if more affluent.

The strength of the psychogeriatric scene in Ontario and Quebec was impressive to someone very aware that in mid-1982 there were only two psychiatrists of old age working in New Zealand under less than ideal circumstances. There was a clear message from the Canadians that psychiatry of old age was functioning best when closely associated with a specialist geriatric service based in a general hospital, along with a strong associated community presence. There was also a holistic approach evident from the first day when the New Horizons federal programme was so enthusiastically described to me to every new situation encountered. It was therefore no surprise in 1986 when the first International Conference on Health Promotion's venue was Ottawa and the outcome of that conference was called the Ottawa Charter of Health Promotion.

Individual Canadians, busy as they were, were most generous of their time both in their work environments and socially, over meals, when we talked shop most of the time regardless of whether we were in a staff cafeteria or outside sitting beside a river of an evening. I had also been able to connect in person again with a first cousin, May Mills, on my father's side with whom I stayed while in Ottawa.

### The Royal Victoria Hospital, Montreal, Palliative Care Unit – Professor Balfour Mount

Dr Thelma Bates, head of the St Thomas's Hospital, London UK Palliative Care Team on her visit to NZ in 1981 guided me on who best to contact in the UK. She had also recommended that I visit Professor Mount in Montreal, if possible, because he was leading an exceptionally broadly based, well staffed, resourced service.

In the early 1970s, Professor Mount, a neurologist, who had had personal experience of cancer, began by researching how those who were terminally ill were faring at the Royal Victoria Hospital. He demonstrated that patients were dying badly not just because of poor symptoms and pain relief, but also because the psychosocial and spiritual needs of both patients and their relatives were not being addressed. In

1973-4 he set up a pilot project to try and improve the situation and change attitudes. In the report of that project he was able to show that pain control had been achieved for 97%, as compared with 70% elsewhere in the hospital. Therefore the Royal Victoria Hospital decided to develop other arms of the service which, when I visited in 1982 included:

1. Inpatient Unit of 18 beds.

2. Home Care Service who at any one time had 35-40 patients. There is an understanding that PCU doctors do not work with a patient in a continuing primary care manner without the agreement of the family physician.

3. A Hospital Consultation Team who assessed and followed up patients as requested. That team shared a physician with the Home Care Team.

4. An Outpatient Clinic held a ½ day a week when patients who do not require a physician's home visit are seen.

5. Bereavement follow-up service. It is normal to follow up the family for 6 months to 2 years after the patient's death as need be.

Each arm of the service had its own team including a music therapist, physiotherapist, OT, pastoral co-ordinator [who had access to a variety of appropriate pastoral care volunteers], dietician, social worker, psychiatrist [½ day a week] volunteer co-ordinator, education co-ordinator, research nurse, and psychologist. The psychiatrists' role was both staff and family/ patient support.

There were 100 volunteers in the five arms of the service, all of whom had undergone training in the PCU for six months on an apprenticeship basis. If the volunteer happened to be a nurse or social worker they did not function in that capacity so as not to interfere with the professionals.

The stress was on philosophy of care, with flexibility of structure according to resources and need. Staff selection was deemed to be very important. Professional and personal maturity was sought. A recent loss of less than a year precluded recruitment. Outside activity was important, as being a workaholic was not good, nor was lack of tolerance or missionary zeal. Ability for team work is essential.

In discussion with Professor Mount he stated that if he was asked about setting up a service he advised that an inventory of what was and was not available in a particular place be made first. He felt very strongly that it was wrong, as had been happening in parts of the USA, to set up a service with only nurses and social workers. The result was inadequate care which reflected badly on the hospice movement as a whole. As pain and symptom management were the key clinical features, often in very sick, clinically complex patients, physician involvement needed to be significant. Medical solutions need to be solved in concert with psychosocial and emotional problems.

In the past a "nothing can be done" approach had all too often meant virtual withdrawal of physician involvement and he saw the need to train all doctors and nurses in care of the dying. He believed that only doctors and nurses who had training in palliative care should set up and run units; that it was an important factor that his PCU was established in a tertiary care institution with a major teaching and research role. If he had set it up in a community hospital it would have remained outside the main stream - "all right for them but not for us." That question did not arise because it began in a high pressure teaching hospital.

### United Kingdom

Initial meetings in London were at the Department of Health and Social Security [DHSS] where Dr Gillian Ford, Deputy Chief Medical Officer, and Mr Lawrence informed me about various research projects the DHSS was supporting such as three experimental nursing homes within the NHS in Sheffield, Portsmouth and Fleetwood as an alternative to a long stay ward in a larger hospital. Behind the schemes lay unhappiness over the capacity of nurses to cause dependence. That was a five year project which was just beginning.

Another project had been to assess the impact of short stay residents on the organisation of homes, the staff, the long stay residents, the short stay residents themselves and their family carers. The main beneficiaries were found to be carers, particularly those living with the older person who may be in receipt of less support from statutory services than they need. That had led to a hard look at what was needed to improve carers' support.

• During those discussions Mr Lawrence stated that he believed the concept of sheltered housing had 'gone sour'. The problems as he saw them were:

• People tended to all be of the same age originally, e.g. if all entered at 65, all advanced in years together.

• Wardens were saying they could not cope because residents were older and frailer. There was pressure to become frenetic. The wardens were often part time. They had free housing and the warden was often the wife.

• The key problem was that the warden perceived problems and sucked in services e.g. meals on wheels, home help.

• Sheltered housing was becoming another caring institution.

Mr Lawrence's solution would have been a system of smaller units in among larger housing units of all generations. The idea of an attached warden would have been abandoned but he realised the wardens could not be pulled out of existing sheltered housing because it would be too emotive. I was to find those views were considered unrealistic out in the field.

### Two Professorial Geriatric Units were visited.

Department of Geriatric Medicine Southhampton General – Professor M R P Hall.

An active geriatric service offering a comprehensive range of facilities and functions was associated with a professional academic unit and a psychogeriatric service under the direction of Dr Colin Godber.

Additionally the Southampton District Health Authority [DHA] had a Health Care Planning team to plan local services and advise the DHA on the special needs. Representatives of health, social services, the housing department, voluntary agencies and the Community Health Council were on that team. One project related to the provision of additional warden supervision to enable more dependent people to remain in sheltered housing longer than was usually possible. Further housing complexes along those lines were being developed. Professor Hall was interested to hear Mr Lawrence's views. He not only did not agree with them but believed it was both cost effective to add two additional part time wardens, and it also achieved the objective of enabling people to remain relatively independent and was an essential link in the geriatric service. A crucial factor to maintain staff confidence was that they were guaranteed immediate rescue by both the geriatric and psychogeriatric services, while someone from each service visited once week regularly additionally.

Professor Hall took me to visit Kinross House, the older complex, which did appear to have a positive community atmosphere and convenient small flats where one old man was repotting his African violets. They decorated not only his flat but also some corridors and day rooms. We later visited the newer Cranleigh Paddock because Professor Hall deemed it to be a model of its kind. The design had a central entrance with a shop, library, sitting areas and office from which radiated wings in which residents were in family groupings of 12 people who had their own living and dining area. One such grouping was for those with dementia. Cranleigh Paddock did seem to be a practical solution to increasing frailty and less expensive than residential care, whilst maintaining relative independence for the occupants which is what most of them desired.

Professor Hall thought that geriatrics was not taught well because teaching was often too medically oriented. He believed there needed to be a multi-disciplinary approach as it could be crucial that GPs knew what treatment to call upon in physiotherapy, OT and other modalities. Liaison with the GPs and community services should be a part of the tuition as well, a view which was also held in Edinburgh.

Dr Colin Godber, the Southampton psychogeriatrician worked in close liaison with the geriatric service. He was a professional who gave much time and thought to both the local service and wider policy issues. He questioned another DHSS policy, namely that every district should have one psychogeriatrician which he declared could not provide an effective service. He said he could only begin to manage dementia and felt he did not always manage the psychiatry of old age effectively. The College of Psychiatry guidelines recommended one consultant for approximately 22,000 65+ older people. Southampton had two full time consultants with a base population of 50,000. They also had several part-timers who added up to another full-timer, a registrar in training, a senior house officer and a senior registrar. Referrals were accepted from GPs and other consultants. Dr Godber declared that the major reason for such a service was because the functionally mentally ill had such a bad deal from GPs. He believed the Health Visitors were in a good position to spot treatable mental illness and they were more likely to make time to see problems when they badger GPs to make referrals. He also talked about the importance of joint referrals with the geriatric service and the use of joint beds as 40% of their patients had both medical and mental health problems. Support of the close family supporters was crucial in his view and he regularly visited Kinloss Court and residential homes as he believed it was vital to maintain staff confidence. He was refreshingly outspoken. When I mentioned that I kept hearing criticism of the NHSS from health of older people professionals out in the field he declared they were out of touch. That was a lesson in itself!

Lyndehurst, situated in the New Forest amid woodland scenery, where wild ponies used to pass motorists and walkers, was where our B&B was situated over that time, a place which colleagues in New Zealand had recommended for its history and attractiveness. In the early evening it was indeed a joy to be able to walk in those surrounds.

### Edinburgh

Professor J Williamson University Department of Geriatric Medicine

In the BMJ of 12th September 1981 in his article, 'An Evaluation of Home Visiting of Patients by Physicians in Geriatric Medicine', Professor Williamson had made a case for the value of home visiting as a crucial part of the complex assessment of an older person's functional situation. He believed that as well as the information gathered it gave the older person a 'better chance' by being interviewed in familiar surroundings where she 'remains in control', a situation which is of the greatest importance where patients show anxiety or confusion. He deemed it unrealistic to expect an anxious, mildly demented old lady to perform in an optimum fashion at a visit to an outpatient department with its clinical setting, so easily seen as threatening to the patient. And he was not being sexist when he referred to 'old ladies' because so many more of his patients were in fact females who had survived their men folk.

In expressing his views to me Professor Williamson stated that it is much easier to plan realistically for the return home if initial contact has been made by a home visit. Quite likely relatives will be around and they could be given a clear idea of the likely outcome e.g. the old person was going to be admitted for the attainment of certain objectives such as the cause of falls and to improve mobility. They therefore understood that when the objectives had been achieved the patient would return home. Without that, relatives might imagine the admission to be 'permanent' or for other vague and unstated objectives. It was one of those times that remains in my memory, listening to a renowned geriatrician expounding his strongly held views, which he had proved to his satisfaction to be the right way to do his best for his patients. As a former part time GP and wife of a full time GP in the 1950s, when we still did house calls on a daily basis, I understood why he felt so strongly about the value of home assessments, though our views had been instinctive, whereas he had established his by research and evaluation.

The Edinburgh Royal Victoria Hospital also had joint beds shared with the psychogeriatricians and 2/5th of the patients were seen jointly. In the six weeks I had in the UK I did tend to see the best, at least initially, but was aware that far too many psychogeriatricians had to work with beds in out-of-the way older psychiatric hospitals, a situation fraught with the difficulties parallel to those I had heard about in Canada.

It was at Goodmayes that I came face to face with one variation of reality upon greeting Dr Elizabeth Taws, who had herself just returned from working for a year in Dunedin. The foyer of the hospital had not been cleaned for six weeks due to industrial action by lower paid hospital workers, the cleaners, orderlies, laundry and some laboratory and sterile supply staff. It was a filthy mess of old cigarette butts, matches, litter and dust. Dr Taws was most distressed that a visitor should see it. She said she would have liked to bring her own vacuum cleaner to do something about it but that would have caused even more industrial action. There were reports elsewhere of striking health workers picketing entrances to hospitals, ostensibly to allow acute cases through but, as a result bona fide sick people were suffering. Also thousands of pounds worth of soiled linen heaped up in piles in hospitals had to be destroyed because it was so irretrievably affected, although in one hospital doctors and nurses took it upon themselves to do something about it in their anger. It was all a horrifying demonstration of just how vulnerable hospitals could be to industrial action.

Dr Conway, Sheffield's Northern General Psychogeriatric Service

Originally I had sought to visit Professor Arie's Unit at Nottingham but that was inconvenient so, as I had meanwhile heard about a Sheffield Home Care Scheme, I asked if it would be possible to meet the psychogeriatrician there. That was possible and arranged when Professor Arie made contact at the last minute to say he would actually be available. It seemed rude to cancel the Sheffield arrangements and there was no time to fit in both visits. As it turned out there was a great deal to learn in Sheffield, the industrial city where my Yorkshire father grew up as a boy.

Dr Conway was the psychogeriatrician at the Northern General, which was also affected by the strike, so we met in a nearby pub over a beer. His greeting was: 'May I ask what on earth brought you here? We are an example of how not to do things.'

It seemed best to be honest. That put both of us on a good footing and it was interesting to hear how Dr Conway had to cope. Three years previously there had been no psychogeriatric service. Then Dr Conway was appointed to the Northern General and Dr Myers to the Royal Hallamshire, dividing the city geographically. Each had 44,000 people who were 65+, twice the College of Psychiatrists' recommendation of one psychiatrist to 22,000 65+ population. Dr Conway had no official assessment beds, only the 3.0 beds per 1000 population 65+ as recommended for long stay patients with nursing staffed accordingly. So he used those beds for assessment anyhow. He had no physiotherapist, 0.5 of an unskilled OT aide, no psychologist, but one key social worker. Dr Myers was better off in the Hallamshire with specifically staffed assessment beds, so training was done over there.

Dr Conway described the work as hectic, so things were not done properly. It was community oriented and he aimed to assess 100% at home. He did say the key was being able to provide appropriate help when needed; that he needed to try to break the vicious circle created by a waiting list of 80-100, of whom 15 should be in the unit at any one time. He tried to compensate by seeing people at home as soon as possible, but he knew that some relatives were not coping. His liaison with the geriatricians was only moderate, as they too were short of resources and personnel. There were no joint beds. He felt that politically the Sheffield Health Board favoured acute services and did not see the problem of blocked beds clearly.

Nevertheless, others told me that in his quiet way, Dr Conway was making a difference. Janet Bennet, the social worker, because she felt that the people who needed most help were the caring relatives, particularly spouses, had approached the Volunteer Coordinator of the Sheffield Council of Churches and Age Concern Sheffield. Consequently 15 volunteers were given a seven sessional training programme and introduced to patients when they were still in the ward. When the patient was discharged the volunteer tried to offer the practical and emotional support the relatives wanted and needed. The volunteers themselves had regular meetings to discuss issues and problems and a relative support group also meets at the hospital.

That scheme had been going for a year during which there had been no change over of the volunteers, who were made to feel very much part of the team. So far no one had been mismatched either, so the original matching had been good. It was a really good example of how organisational co-operation could deal effectively with real problems, and the social worker herself was a key figure, as Dr Conway had mentioned, in the success of the project. If the number of volunteers was to be expanded it would mean having to employ a volunteer coordinator, so it had been decided to proceed slowly. Meanwhile they had approached Dr Myers to see if his team would support expansion on a parallel scale to the Northern General involvement.

I also met with Mr Cliff Tomkins, Deputy Director of the Family and Community Services of the Sheffield District Council who also agreed that Dr Conway was making a difference. Believing that isolation and loneliness undermines people physically and mentally, Mr Tomkins had been organising luncheon clubs, day centres and volunteer visiting with the help of the Sheffield Council of Churches which provided venues rent free and helped by recruiting and training volunteers.

He also did not agree with Mr Lawrence's view of sheltered housing. Having earlier assumed that wardens were more concerned with the fabric of buildings they were by that stage being recruited in Sheffield from the pool of home helps and then given extra training and support to cope with increasing frailty of the residents. They visited those at risk morning and night and were at the end of an alarm system all the time. He mentioned Kinloss Court as the model they had chosen to work towards.

Their most recent development had been Elderly Persons Support Units, the idea of which was to take the services to the people rather than placing them where the services exist. In five areas in Sheffield a building had become a base for staff providing services to all older people in a designated area roughly a mile radius from the building. The place was equipped to provide meals, have a communal room for social activities, a couple of smaller lounges, a hairdressing room, a room with multiple use, e.g. chiropodist, nurse etc. and a bathroom equipped for those with mobility problems. It was also a base for peripatetic wardens, home helps and meals on wheels. The idea was that flexibility of approach should allow local initiatives but a balance had to exist so that unrealistic expectations were not placed upon staff.

Sheffield had four Part 3 homes staffed and geared to those diagnosed as having irreversible brain damage or confusion as well respite beds and day centres. They were also trying to orient staff towards the concept that residential care could be rehabilitative and temporary, not just permanent. He admitted that families have a way to go before they too could embrace that concept. The impression gained was that, although the Area Health Authority might be relatively unenlightened about older people, the Sheffield District Council, Age Concern and the Churches provided a counterbalance with positive, co-operative approaches.

I did not actually visit any sheltered housing in Sheffield. The other region where that was arranged was in Edinburgh where I was taken to Muirhouse Parkway where a couple of social workers took me to visit a day care facility in a very deprived area. It was in the ground floor of a block of flats with many broken or blocked out windows and graffiti disfigured walls. The place looked appallingly run down both in and outside. They really wanted me to see where some older people lived in fear and loathing of the local gangs, but had nowhere else to go. When we locked the car it was mentioned that the windows might be smashed in if anything was left visible. It was an awful place, bleak and desolate. As sheltered housing it was a travesty, but that was reality for some poor, older people in Edinburgh at that time.

### Terminal Care in the UK

Dr Guido Pincherlie, Senior Medical Officer dealing with Medical and Surgical Specialties including terminal care, was my initial contact at the DHSS.

On 29 November 1972 the DHSS organised a National Symposium on Care of the Dying because as the then Chief Medical Officer, Sir George Godber noted:

It may seem obvious that the care of dying patients is an essential and inescapable part of the work of the NHS. However, many people have told us that in the circumstances of modern society the needs of such patients are not fully understood and the organised services do not adequately meet them. This symposium was set up to allow these views to be expressed and remedies to be discussed.

Subsequently a working party chaired by Professor Eric Wilkes produced a report, 'Terminal care 1980', which the DHSS came to accept as their policy document.

Most hospices in the UK had found their capital costs voluntarily and then the running costs have been taken over by the DHSS. The DHSS saw the ideal as a service which combined all aspects of a terminal care complementing each other e.g. hospice beds, support teams, domiciliary and bereavement services. Any type casting of facilities was not seen as workable, so flexibility had to be built into any system related to the way things work for different peoples and resources. An audit of what actually existed was seen as necessary prior to planning a new hospice. High quality medical care was essential and the rest would follow. The DHSS did not approve of a hospice being run by a doctor with less than six months training in a recognised, good quality hospice, accepting that training might be spread over a longer time. There had been a problem finding people with that experience hence if a new hospice was contemplated, the DHSS advised an organisation to start looking for a director a year before opening to enable that person to be trained.

Dr Pincherle said that an increasing number of medical, nursing and paramedical students were being exposed to palliative care in their curricula. Some hospices such as that at Oxford and in Sheffield did a considerable amount of GP training. The DHSS considered that GP training was very important as deficiencies in GP terminal care had been one reason behind the founding of St Christophers by Dame Cicely Saunders.

There was talk of a DHSS Working group being formed to consider where to go after the Wilkes report. By that they did not necessarily mean new services but how to improve services and situations. There was at that time a Terminal Care Study Group based at St Christophers of which Dr Pincherle was a member. It met 3-4 times a year and was concerned with clinical and scientific rather than organisational matters. The group had recently produced a paper on staffing under Dr Richard Hillier's name.

Later during visits to hospices it was notable that those at the work face felt they had a good relationship with the DHSS. It was particularly remarked that Dr Pincherle was constructively involved and had a good grasp of the scene. Points that were not lost on a relatively new civil servant as being in contrast to contrary remarks by geriatricians and psychogeriatricians on their DHSS relations.

As leaders in the field of palliative care, staff of the pioneer hospices in the UK were under some pressure from the number of those who wished to visit, observe and discuss issues. Hence I really appreciated the time and trouble many people went to let me engage with them beginning with St Christophers where Dame Ciceley Saunders was away at the opening of a new hospice and I spent a day with Dr Mary Baines, who had initiated the Home Care Programme and had been on the staff alongside the founder for 14 years. Discussion took place before, during and after a review of all current inpatients in the morning and during lunch. In the afternoon a problem airing discussion for both the inpatient and home care teams took place. Afterwards we held a separate session with the Supervisor of the volunteer bereavement counsellors.

At St Thomas's Hospital I met up with Dr Thelma Bates again so discussion with her began on the basis that I knew the beginning of the St Thomas's Team and conversation would carry on with points that Thelma considered important. She reiterated what became a recurrent theme on every occasion. Medical back-up was absolutely essential to achieve symptom and pain control in, all too often, complex situations. It must be by someone who had acquired extra knowledge. Kindness was not enough, nor was assuming one knew it all. Examples of particular US hospices that eschewed drugs and concentrated on counselling and emotional needs had begun to cause some criticism of hospices as a result when patients were not relieved of distressing symptoms.

Dr Bates had succeeded in having terminal care written in to the curriculum for 1st year clinical students at St Thomas's. Sixth year students had both lectures and practical experience. The other full time doctor was largely involved with training including Joint Board training of nurses. Because Thelma was an oncologist their team concentrated on cancer patients, but she believed that terminal care support was just as important for all who were dying, including children and the children of those who are dying. Dr Bates compared the work of her Home Care Team with that of the Nurse Maude Association for whom she had high praise, but she was relieved they had acquired the support of the radiotherapist at Christchurch Hospital. She said:

I look on nurses of the team as extensions of myself \- their work is synergistic. What can be done together is far greater than what can be done singly. If there is no doctor available that weakens the nurses and is very stressful. The nurses have to be trained though before they can start the work.

There was no waiting list. The teams saw a referral the same day. Availability was 24 hour, 7 days a week. Members on call carried a bleep and made it clear they did not mind being called.

Again like everyone else Thelma stressed the importance of good bereavement counselling. Before death the team members tried to facilitate communication between patients and their families. After death the team maintained contact for up to a year if they were asked to be involved. If not the social worker would contact the family once after the funeral – usually about ten days afterwards, when everybody else had gone home.

Adequate notes were important. The team kept separate notes from the rest of the hospital. Hence they could track all actions and treatment. As a result of such audit they tended to be using slow release morphine which did not suit everyone but was right for many.

At St Josephs, the Macmillan Service, the Home Care arm of the St Joseph's hospice covered four boroughs of London Hackney, Islington, Tower Hamlets and Newham. The team consisted of 8 specialist district nurses, 2 social workers, a domiciliary physiotherapist, medical staff, a chaplain and volunteers. I visited the Macmillan Service at a time of flux. The Medical Director, Dr Richard Lammerton, one of the early proponents of the hospice movement, had ceased work the day before. There was a certain sadness about his departure, both at St Josephs and everywhere else I visited. He had undoubtedly achieved a great deal, was very expert and deeply involved. He had also been somewhat less than easy to get on with, or diplomatic at times and was more or less the maverick of the movement, in that he tended to 'go it alone' and not involve GPs as much as some felt he should. In his defence he worked in a very depressed area of London where too many so-called 'lock-up' surgeries had GPs who lived in more salubrious areas, without providing any out of hours cover. He had had a tendency to tender his resignation from St Joseph's when annoyed and then allow himself to be persuaded to stay. The last time his resignation was accepted.

Both Drs Bates and Pincherle had commented that the Macmillan nurses were some of the best communicators and most expert drug manipulators and practitioners in the field. I was certainly impressed from the time of attending an 8am discussion on the events of the previous night to actually accompanying Sister Audrey McDermott on her day's visits. For a short time it was right down to basics, twice in neat, tidy flats where loving husbands were caring for mortally ill wives, but more often in somewhat grimy, grim flats where less fortunate East Enders tried to survive. It was a good balance to the ideas and talk of other visits, not to mention a contrast to Thelma Bates taking me into the Consultants' dining room for lunch at St Thomas's where a whole Stilton lay wrapped in a white napkin with a spoon in what had become a wonderfully gooey cheese crater.

While in I was in Southampton visiting the Countess Mountbatten Home, Moorgreen Hospital the topics were variations around recurring themes which confirmed their importance. It was informative and a pleasure to meet Dr Richard Hillier, who was a member of Dame Ciceley's 'Think Group' and who, in conjunction with Barry Lunt, was the author of the paper, 'Terminal Care: Present services and future priorities', BMJ Volume 283, 29 August 1981.

A Care Attendance Scheme whereby a helper was made available by the Local Authority for disabled persons who were under 65 years of age was denied cancer patients because they were seen to be dying, rather than disabled – unless they also had a disablement such as paraplegia. Nevertheless the district nurses were trying to set up a parallel pilot scheme to either have a live-in helper, or someone who could work in stretches of 2-8 hours doing shopping, cooking and other essential household work. The co-ordinator was to be a nurse to whom patients would be referred for assessment of need. The primary aim of the pilot scheme was to be able to support more patients at home.

Dr Hillier made the point that teaching about terminal care should take a positive approach, not at all funereal; one of the aims of good terminal care being to enable to live as well as possible until they died. He also reiterated the case for sound regional planning for services beginning with a survey of existing resources which might show for instance that good day care was already in place but needs may exist in another area.

In bereavement care they had found that young fathers were in great need, so had regularly held evening sessions for groups of them when they were most available. Those sessions involved both social workers because it enabled them to help the group talk through their most intimate problems without one female social worker, alone, being seen as a sex symbol.

### St Lukes Nursing Home Sheffield

Dr Eric Wilkes, Professor of Community Care and General Practice, Sheffield University and Medical Director of St Lukes

Sheffield was to be the last of the terminal care visits and at all earlier stops someone, at least once, had made reference to Professor Wilkes' work. In Wellington, after researching relevant papers we had found, 'Terminal Care, Report of a Working Group', was the most helpful publication, unaware at the time that it had become the accepted blueprint for DHSS policy on terminal care. When Dr Pincherle referred to it as the 'Wilkes Report' I asked how much input others had made and he replied: 'There is a lot of Professor Wilkes in that report. He wrote it basically.'

The words 'lot' and 'large' always seemed to enter into remarks about Eric Wilkes. When I finally met him it became evident why that was so. He was a large man, physically as well as mentally; a man who filled his suits with his person and a room with his warm, generous personality.

Early 1982 had seen the publication, 'The Dying Patient, The Medical Management of Incurable and Terminal Illness', edited by Eric Wilkes, a signed copy of which he gave me. It drew on a wide range of expertise including two prominent in the medicine of old age, Sir Fergus Anderson who wrote the chapter 'The Elderly at the end of life', and Professor Tom Arie who wrote, 'The Failing Mind', in conjunction with Dr Rob Jones. Medical texts can fast become out of date but, though some of the treatment aspects are out of date, 'The Dying Patient' still harbours some real wisdom. I treasure my copy with Eric's handwriting at the front.

St Luke's Nursing Home's 25 beds were mainly geared towards those who were dying but it also provided intermittent and respite care, as well as being available for some who were chronically disabled. In other words where gaps were seen to exist locally St Luke's tried to fill them.

Macmillan nurses also worked from a base at St Luke's and one of them was based in the Royal Hallamshire Hospital. The latter appointment came about because after St Luke's was established it was realised that the real area of deprivation, for those who were dying, was in the acute teaching hospital. Dr Wilkes emphasised the importance of appointing a local nurse who had a sound background of experience in palliative care. That consultant nurse was not just a cancer nurse. Others with terminal illness such as renal failure were helped. At the time of my visit some 18 of the 25 wards of the Hallamshire were using her. Dr Wilkes described the ward sisters who did not call on her as either very good themselves, or very bad. There had also been problems with some junior doctors whose pride at taking advice from a nurse had to be overcome. Consultant support was good and overall the appointment had been a success. It was a role that called for great tact and the nurse had to be careful to remain advisory and to resist taking over the primary nursing role. At all times that nurse was able to call on either Dr Wilkes or the other palliative care doctor. Consequently, the Northern General Hospital was considering appointing a Macmillan nurse consultant as well.

The Day Care Hospital had become a model for other regions in the UK which might be contemplating such a facility. It offered medical and nursing care, physiotherapy and social work intervention. The facilities were good to such an extent that they were also available for in-patients and some younger chronic sick people in need.

St Luke's was involved in GP teaching. Those sessions were not just for the GPs but the practice team as a whole for a series of sessions. A recent Sheffield research survey had shown that only one quarter of relatives of 262 deceased relatives had been satisfied with the terminal care by either GPs or the hospitals. Community nurses in a survey said that 50% of patients had uncontrolled pain. Relatives noted uncaring attitudes. So the teaching component importance had become ongoing.

I spent a couple of fruitful days listening and observing around St Luke's. As well Dr Wilkes, his wife and my husband, who had joined me in England, went out to dinner. On the last afternoon he sent us off to drive over the hills to Chatsworth, because he believed that 'all work and no play' did indeed make for a dull girl. It was good some years later to be able to take the Wilkes out for a leisurely meal in Wellington after a talk Eric had had with Department of Health staff.

Retrospectively the main lessons from that UK study visit was around good and not so good management styles, and the hours spent listening, observing and having time to think and talk about a range of issues was invaluable learning experience.

After driving from Yorkshire to Edinburgh, the meetings in that city ended that phase of my study leave. I had 10 days ordinary leave afterwards, which enabled us to meet up with Guthrie relatives in Scotland and spend some time with my cousin in Cambridge, whose husband had sustained a fatal stroke since we had been in the UK. Then Wally flew off to do some European sightseeing on his own, while I flew to Vienna to join the New Zealand delegation to the 1st UN Assembly on Ageing.

Dr Barker headed the delegation, while Margaret Bazley represented nurses, Joan Taylor of Braemar Hospital in Lower Hutt was from the Private Hospitals Association and Wally Lake of Presbyterian Support, Wellington, the Non- Governmental sector. Three of us, Ron, Margaret and I, stayed for the fortnight of the Assembly at a pension, the Christina, from where we walked each day past St Stephen's Cathedral to the Hofburg Palace where the Assembly sessions were held. At first Margaret and I just gazed in passing at windows full of mouth-watering pastries but eventually decided we just had to sample a different one each morning. Then we had to choose! Our evening meal also became an adventure as we sampled a different venue every time, except on our last evening when we returned to our favourite, an old restaurant where the walls were covered by years of signatures, said to also include Beethoven's, though we could not actually find it, but added our own to the mix. I also acquired an English version of an Austrian cookbook as a reminder of those dinners.

My husband had joined us for the last few days. While we were in the foyer waiting for the others one evening he asked an American boy of about 12 where they were eating that evening and was answered by: 'We always go to McDonalds wherever we are so we know what we are getting.' We thought what a wasted opportunity; but he and his family were happy with their choice and so were we.

The venue for the Assembly was magnificent, though entering the Hofburg was somewhat daunting. It was a time of much tension in the Middle East and soldiers with machine guns at the ready flanked either side of the main doors. Ron remarked that he presumed that was supposed to make us feel safer but it actually made him nervous. The photographic identification that was completed when enrolling remains as a memento of those days. No one was allowed in without one. If one thought the security might be overdone the day came when a black attired and bearded mullah from Iran made his country's presentation. The Assembly chair was the Austrian Health Minister, a charming 72 year old female physician. There was silence as the delegation leader stood before the Assembly. He held up a copy of a large tome, slammed it down before the Chair and declared that if Madame wished to know anything about old age it was in the Koran. He then proceeded to give us his views about Israel and the 'situation' with no further reference to ageing whatsoever. It was electrifying if nothing else. Hollywood could not have done better, except one knew the speaker meant every word he pronounced. No questions followed. Madame Chair did not show any emotion. The show was over, and the speaker and his team of similarly garbed and bearded men departed.

Apart from that incident there were many serious hours of country presentations, including our own delivered by Dr Barker in the main hall with its flanks of chandeliers hanging above us and walls covered with paintings. In a more sombre back room delegation members and UN staff worked on the agreed points of policy that finally emerged as a 100-page document. The condensed version was the single page United Nations Principles for Older Persons.

Ron ended up most of the time negotiating on the policy aspects, while Margaret, Joan and I moved from room to room. Wally Lake was hardly to be seen which annoyed Ron greatly because he had been badgered by Wally to find him the air fare to Vienna, and then he did his own thing regardless, whereas Joan was a regular attender. She and her husband were camping in what she said was a good camping ground but quite a distance away to save the Private Hospitals Association funds. Quite a contrast in attitude.

The presentation from Nigeria included the assertion from the delegation head, also a physician, that when an older rural person, especially a woman, became physically frail and unable to pull her weight any more her only option was to will herself to die. That tended to be achieved by withdrawing from the village, where the elder huddled down, abstaining from further food or drink. One also knew that there were so-called 'death houses' in other places such as Singapore, though no-where was their use openly official state policy. The Nigerian was in no way condoning self -sacrifice. In fact he deemed the practice to be a tragic, lonely end to what had most likely been a hard hand -to-mouth life from birth onwards. It was a sobering presentation. It was no wonder that the Principles contained an observation:

Appreciating the tremendous diversity in the situation of older persons, not only between countries but within countries and between individuals, which requires a variety of policy responses.

Principle 3, 'Older persons should be able to participate in determining when and at what pace withdrawal from the labour market takes place' was raised emphatically by the ILO [International Labour Organisation] in its recommendation that freedom of choice to determine the retirement age would counter the inflexibility and psychological effects of a rigid retirement age. That struck a cord with Margaret Bazley and me, so when we returned to Wellington we discussed the matter with Margaret Smith at the Department of Labour. She too was aware of the ILO stance and in favour of the concept, but when it was part of discussions we had with groups who asked us to speak about the recommendations of the Assembly, we soon discovered that the Federation of Labour held strong views about the rightness of 60 being the retirement age as, in their view so many workers were work-worn by that age. New Zealand does now have a more flexible retirement public policy but recently when there was a strike on the Auckland wharves I heard a Union representative on the radio stating that our workers have had a hard life and need to retire at what was currently 65 when they qualify for National Superannuation. Obviously he was oblivious or unimpressed by Sir Fergus Anderson's classic, gerontological dictum – 'Rest is Rust' – and some also needed at least a part-time job financially or just because they actually did like working, it enabled them to feel useful as well as providing income and companionship.

That study leave did improve both my understanding and knowledge base, as well as confidence about steering the directions in which we needed to head if progress was to be achieved. A personal enthusiasm had also been ignited which has never waned over the years since 1982 – thank you Lynn for your direction, which Ron and other colleagues encouraged and supported so magnanimously.

References

1. Guthrie M. _'Report of Overseas Study Leave: Health of the Elderly and Terminal Care'_ May-August 1982.

2. Williamson J. _'An Evaluation 0f Home Visiting of Patients by Physicians in Geriatric Medicine'_. BMJ, 12 September, 1981.

3. Wilkes E. _Terminal Care: Report of a Working for the Standing Medical advisory Committee'_ UK. March, 1980.

4 United Nations, _Report of the World Assembly on Ageing_ , Vienna, 26 July – 6 August, 1982.

### Chapter 9

Return to Reality

Upon returning to the Department, work on the Care of the Terminally Ill in New Zealand had continued. The draft paper outlining proposals for hospices had been cleared by the DG's meeting and the Minister to be referred for comment by the recently established Cancer Treatment Services Committee, as well as organisations such as the NZMA and Private Hospitals Association. I resumed the leadership role for that policy development at the stage where we were able to send the final paper from the Department to the Minister, who had earlier been made aware that financial pressures on Mary Potter Hospice in Wellington had been alleviated by a grant, and that a request for further aid was pending at a stage when Government had impressed on all Departments that there was to be a freeze on any new funding.

Subsequently 'Aussie Malcolm', the Minister of Health, announced the policy in late September 1983 at the Annual General Meeting of the Wellington Division of the Cancer Society. He stated:

The Government has therefore decided that separate funding to support hospice services would not be appropriate, whether these services are provided by hospital boards, private hospitals or by voluntary organisations. To guide and facilitate the kind of co-operation and co-ordination shown to be part of a sound hospice service, the Government has instead decided that funding should be provided through existing channels. In particular, our policy gives specific recognition to the advantages that hospital boards have because they are especially well placed to work in a variety of ways with different hospice groups. Since contractual arrangements between boards and hospices would benefit both parties, the Government has decided that such contracts should be encouraged. Under the terms of such contracts hospices can be provided with some public financial support by the board. They can also have access to the advice and guidance of board staff – clinical, nursing, or managerial. Formal agreements can also be included to facilitate attachments of board staff where this is considered appropriate and, more importantly, to co-ordinate the services provided in people's own homes. Similarly hospital boards will benefit by having an opportunity to ensure appropriate co-ordination of both institutional and community services, and by being able to draw on the expertise of the hospice staff to advise and train their own staff. Hospital boards will also find a financial incentive since patients supported by the hospice would no longer be classified under the equitable distribution formula as flows to the private sector.

Peter Butler, who had taken over Peter Mackie's position upon the latter's retirement, and I were delegated to visit those boards in whose area hospices already existed prior to which we were briefed by the Minister. On that occasion he bluntly described the policy as a Clayton's policy because up until then new policies had tended to be separately funded by new money. He wished us well but we were in no doubt he did not expect us to achieve much. We did face resistance and the outcome was that the boards agreed to fund 50% only of costs of hospice terminal care services. From experience at the Nurse Maude Association I was aware that raising funds entailed continuous effort, and so should have preferred a greater percentage. Only afterwards did I learn that Marion Cooper was actually happy with 50% because it did not make her feel wholly dependent on the hospital board, which she believed might threaten her capacity to make independent decisions. Peter, on the other hand, realistically thought a reasonable compromise had been reached. Both of us realised it was only a beginning of what continues to be an ongoing journey to enable people to live as well as possible until they die, and to support families who are coping with their loss.

Development progressed in 1986 when on 10 May the Inaugural Conference and General Meeting of Hospice New Zealand was held in Christchurch. At that meeting it was decided that the term Terminal Care was too narrow and negative; that Palliative Care was more in keeping with quality of life and support of the carers. So in February 2001 when the second Government policy document was launched it was 'The New Zealand Palliative Care Strategy'. Aspirational as it was, that strategy clearly delineated the issues, including circumstances when 'people continue to receive inappropriate levels of intervention when they would have been better served by a palliative approach'. A statement which would have been better expressed with the addition of another phrase such as, 'when they themselves may have preferred, and also may have been better served, by a palliative approach'.

In October 2005 when the CCDHB held a Cancer Control Workshop followed by the development of a CCDHB operational strategy, Helen Griffiths represented Grey Power and I represented Wellington Age Concern. We both told of instances where we were aware of older individuals who had felt pressured to undergo cardiac surgery who were not listened to when they tried to convey their questioning anxieties as to the appropriateness of surgery; surgery which resulted in complications, which were fairly predictable owing to the complexity of the person's health status, and death post-operatively. A positive outcome of that CCDHB strategy was the appointment of Dr Jonathan Adler, as a Palliative Care Consultant, along with two experienced cancer treatment nurses to Wellington Hospital with a brief that included the ongoing education of clinicians and nurses. Quite apart from actually hearing what patients are trying to convey at times, coming to terms with one's own mortality can be a problem for health professionals as well as for other people.

__________________________________________________

Because so many different topics cropped up at work in any one day I required a higher degree of organisation than had hitherto been the case. It was a situation that spilled over into my home life, where I reverted to relying on regular household help to enable me to spend more time with the family, though regrettably, I was not often able to attend school and other functions which occurred during working hours from RNZAF days onwards. Finding reliable help was not without fishhooks. For a while in Christchurch we appeared to have found such a person before we realised that the disappearance of various items, along with the realisation that another client whose family's silver tea service, which she thought had been safely packed away in the attic, had vanished, led to the revelation from police that our household help was a thief with a past history. Upon mentioning our conundrum to a near neighbour it turned out to be just the moment when she was about to seek part time work and would be happy to spend a couple of mornings doing housework. From then onwards Mavis kept the house refreshingly clean while her pending presence stimulated all of us to tidy up before she arrived. After our departure from Christchurch we remained in contact until Mavis died some years ago. Once in Wellington it was Wally, through contacts at the CAB, who found Vera, who fulfilled an equally reliable role for the decade in which I continued to work full time.

The brief for the position of Assistant Director of Hospitals was both general and specific. The general aspect was being the liaison person for the South Island Hospital Boards while the specific duties centred around health of older people and community services for all ages, though older people were the main clients, roles which Dr Barker felt had not been as actively pursued as the growing numbers of older people foretold the growing need. Progressing that role entailed developing a network of relationships in not only the public sector, but also the private and Religious and Welfare sectors on both national and various local scenes. As well it called for a strategic overview of a wide range of services including those whose primary national policy base was in other Departments such as Social Welfare with whom I worked closely on shared issues.

No one component of a comprehensive Geriatric service can exist in isolation. The right balance is important. Imbalance of too few or too many facilities or services may produce distortions of other aspects of the services. The effective co-ordination of services becomes more and more important with the primary care team being both the instigator and a provider of services. For those older people who are either at risk of becoming frailer the specialist Geriatric Assessment and Rehabilitation Units were, and remain, pivotal to enable as many as possible to have a timely, early assessment of need along with rehabilitation and treatment to prevent disablement through illness and maintain functional abilities. Hence the emphasis of my study leave on pioneering units in the UK. After discussion with Dr Barker it was decided that one way to progress the development of AT&R by Hospital Boards would be to seek information from them as to how they had, or had not followed through the recommendation to Boards to appoint Geriatric Physicians and Psychiatrists of Old Age by asking for details of appointments on a regular basis, and then to keep on persuading the Boards which were lagging behind. That did result in some interesting visits, such as an invitation to Wanganui where Lysbeth Noble, who as both a Hospital Board member and President of Age Concern Wanganui had persuaded a reluctant Board to listen to why they should have an AT&R unit. That was the beginning of a warm relationship, both professional and personal. At least in Wanganui there was an enlightened board member.

It was some time later, after Dr Thakshan Fernando joined the Department as Director of Mental Health, that he told me of his earlier interest in the Psychiatry of Old Age. He and Dr Barry Taylor, the Wellington Geriatrician had a vision of them both having complementary units in close proximity near Wellington Hospital in the late 1970s, the psychiatry of old age wards being at that time in ageing buildings tucked away at Porirua Hospital. They presented their case to the Wellington Hospital Board based on both the UK and Dr Barker's letter of June 1973 that physical and mental disorder of old age was so inextricably mixed that the geriatric services of a general hospital should provide both in proximity. The Board however decided, against their consultant's advice, on the basis that 'out of sight, out of mind' was preferable for those who were senile and, or psychiatrically disturbed. Dr Fernando was so disgusted by that decision that he decided to stick to adult mental health thereafter. It was far too late to follow up that specific matter but it did highlight the problem the Department had at that stage relative to the Hospital Boards. We could recommend and encourage, if we knew about issues, but that in itself did not guarantee the advised outcome. It was not until outcome goals were specified in legally binding contractual agreements between the Ministry and DHBs that the Ministry could set health targets. It was also not until a new facility for the psychiatry of old age was built next to Keneperu hospital in 2007 that both units were close to each other in the Wellington region.

Fortunately in the early 1980s money was found to fund a number of training positions for geriatric physicians which did stimulate interest to the extent that satisfactory numbers were soon in training. The worldwide shortage of psychiatrists of old age meant recruitment remained slower in that field so the geriatricians were quite often stepping in to fill the breach when they had no psychiatrist to whom to refer patients.

Another topic which cropped up in 1981 was for me a continuation of earlier recommendations from the Social Services Committee of the NCHB regarding the transfer to hospital boards of Social Welfare funded home help services which had led to a Cabinet decision approving that action. After several joint meetings between both Departments by 1982 Social Welfare admitted they were unable to separate out their administrative costs. Added to that was the fact that Social Welfare did not necessarily pay the award wage that was paid to hospital board home help staff.

So, if hospital boards had accepted the transfer, fewer hours of actual service for the funds passed over to them would have been available for clients. Hence on 18 August 1982 a Circular letter to hospital boards informed them that Cabinet had rescinded its earlier decision and agreed there should be no transfer of Social Welfare home help services but that the conditions under hospital board home help were to change. No longer were they to be free of charge only if a district nurse was in attendance but they should be free to persons who:

1. by reason of increasing or long term physical or mental ill health or disability, are unable to maintain themselves in their homes and for whom the only reasonable alternative would be imminent or accelerated admission to hospital or residential homes; or

2. by reason of short term physical or mental ill health or disability, would otherwise require to enter hospital, stay in hospital longer or have a longer and less satisfactory convalescence.

Theoretically that should have been a positive step towards enabling more older people to remain at home. In fact, hospital boards, faced as they were with increasing squeezes on funding and pressures from acute services, never allowed those conditions to be fully implemented. They imposed restrictions of their own on what was to be included in allowable 'home help' hours per week, and tended to limit their service to six weeks duration for most clients. They then cost shifted long term clients to Social Welfare home help services. Therefore by the late 1980s those deficiencies resulted in the 60s plus Home Support Project in Auckland which was funded by DSW, and the Horowhenua Pilot Project which did demonstrate that adequate home support could prevent or postpone residential admissions.

So some good came out of those deliberations, but the confusion arising between the health and social welfare services remained to be reconsidered another day.

On 27 January 1983 approval was granted for my appointment as Deputy Director of Hospitals Division. Both Drs Robert Dickie, the Director, and Dr Tom Lawrie, the previous Deputy Director, had retired over the previous year, those positions being assumed by Dr Alec Sinclair and myself. While I retained liaison with the South Island hospital boards and palliative care was formally deemed to be part of my brief, there was additionally membership of the Hospital Works Committee which scrutinised applications from all boards for major building proposals. Treasury and Works completed the membership of that committee. At times we met in Wellington but site visits were undertaken as deemed necessary. On a national scale we did at times tend to have discussions not unlike those around the size of bedrooms in old people's homes where a tighter control over bricks and mortar seemed more important than actual health services, but I did also learn more about the costs of auxiliary services upon which hospitals depended, not to mention the overarching power of treasury.

Dr Keith Ridings returned from Samoa where he had headed the health services to take over national and subnational specialities which at that time were deemed to be cardiac surgery, neurosurgery, renal dialysis, bone marrow transplantation and oncology. As well he had oversight of medical imaging, pathology, blood transfusion and tissue typing, medical technology services and emergency care services.

We may have all had our specific roles but at morning and afternoon tea everyone had their say about each other's issues in what could be vigorous but amiable discussions. The one period when it could have become bitter was when the Springbok tour divided the country. The Deputy Director, Administration was strongly pro-tour. He expounded at length day after day to relative silence. Apparently it never penetrated that silence that most of us did not wish to bring what could have been ongoing enmity into the office, so strong was the feeling about that tour. Wally and I both believed the tour should have been cancelled after the Hamilton fiasco. The closest we were to any actual protest action was when our daughter, Anne, her husband and two little girls came over from Golden Bay to join the protests around the Wellington match. We were left to look after our grand- daughters, a task we normally would have really enjoyed but, as we heard on the radio of the clashes between police and protestors, we became more and more anxious for the well-being of their parents. Our relief was marked when they finally arrived safe and sound later that evening.

From the 1960s Hospital Boards were funded on what was described as 'the block grant plus history' system, under which they received the same amount as in the previous year adjusted for inflation. In addition extra money was provided for commissioning grants for new services, as well as increases in patient services. As the basic grant was set on past spending, it did not take account of changing population needs. Also using increasing patient throughput as a measure of increased need had a snowball effect of calling for more beds and then more patients to fill those beds, a system which also encouraged political and other pressures. The Area Health Board Act enabled Hospital Boards to voluntarily move towards being integrated area health boards which were to "promote and protect the health of people in their area". They were to do that by co-ordinating the public, private and personal health sectors, as well as ensuring an appropriate balance between public and personal health spending.

As from 1 April 1983 funding of Hospital Boards was based on the principle that the need for hospital services is mainly related to the size of the population - the population based funding model. Under that system each board was to receive:

• A population grant; the boards share of the funds available for hospital care, based [with some adjustments] on the size of the population served. That was to equal 92.8% of the total available.

• Supplements; extra money to cover costs not directly related to population size, such as the cost arising from specialist medical services and educational activities. That was to equal 7.2% of the total available.

The concept of population based funding implied that boards were required to develop services for their population which necessitated strategic plans for services. Nationally working parties of board specialist staff and Departmental staff were also convened to produce guidelines for service development, including geriatric and psychogeriatric guidelines. The working party for those guidelines was chaired by Professor John Campbell of the Otago Medical School and included representatives of the health professions which would be involved in AT&R units, as well as a psychogeriatrician, a GP and myself as the Departmental resource person.

The service philosophy underpinning those guidelines was based on the needs of the 'whole' person, both mental and physical, promoting independence and enabling the maintenance of an optimal level of functioning in a person's own home for as long as was practicable. The provision of adequate assessment, treatment and rehabilitation was the key to the effectiveness of specialist health services for older people as that would determine a person's appropriate service provision and accommodation. To aid Hospital Boards' development of those services, bed and community support guidelines were recommended e.g. for AT&R unit beds 5 per 1000 of the population 65+, 1 of which was to be a psychogeriatric AT&R bed along with 2 per 1000 65+ day hospital places for both geriatric and psychogeriatric units. A weakness of those guidelines was that they did not encompass General Practice or other primary care as it was a different funding and administrative system, so they were only as good as they were able to be under those circumstances.

When the guidelines were issued it was pointed out that boards should not wait for the appointment of a suitably qualified physician or psychiatrist because, unless the services were actually in place, the chances of attracting professional staff would be slim particularly for the forthcoming decade which was seeing a worldwide demand for both geriatricians and psychogeriatricians at a stage when the demographic changes indicated that there would be a steady rise in the numbers of old, older people i.e. over 80 years of age. That meant that it was particularly important to develop the full range of services in the right balance, not just for the older people but to also enable all adult medical and surgical services to function more effectively, thereby overcoming what had been termed as 'bed-blocking' by people with complex conditions who were staying longer in acute beds because they were not being assessed and rehabilitated, or transferred to more appropriate care, in a timely, adequate manner.

References

1. Minister of Health, Hon A. Malcolm, _'Opening address to the AGM of the Wellington Division of the Cancer Society_ '. September, 1983.

2. Dept. Of Health, _Care of the Terminally Ill in New Zealand'_ Circular letter to Hospital Boards [Hosp.] No. 1983/116, to CEOs all Hospital Boards, 22 September, 1983.

3. Hospice New Zealand: _Report of the 1986 Inaugural Conference and General meeting'_ , Christchurch, New Zealand, 10 May 1986.

4. New Zealand Govt. Health Dept., _New Zealand Palliative Care Strategy'_. February, 2001.

5. Dept. of Health,[Hosp] _'Home Help Services'_ , Circular Letter No. 1982/114.

6. Dept. of Health, Hospitals Division, _'Hospital Boards Service Planning Guidelines: Services for the Elderly'_.

1986.

### Chapter 10

The Board of Health

Resurrection of the Board of Health took place in 1983 having been reinstated under the Health Amendment Act No. 2 1982. Among the committees it set up was a Standing Committee for the Health of the Elderly.

Historically the previous Board of Health's 1967 report, 'Report on Care of the Aged in New Zealand', stated aim had been:

To stimulate an enlightened interest in the needs of the aged and to encourage a desire amongst those actively involved in providing accommodation and services to become more expert in meeting needs.

It subsequently took a holistic approach on health, housing, residential care, preparation for retirement and the role of preventive medicine, education and training as well as administration and policy. Arising out of a recommendation of the report the MSRU of the Health Department, which was headed by a former geriatrician, Dr George Salmond surveyed accommodation and service needs of older people. The outcome of that extensive survey was, 'Accommodation and Services Needs of the Elderly', Report no. 46 Department of Health Special Report Series which virtually became a blueprint for development for a number of years.

The terms of reference of the resurrected Health of the Elderly Standing Committee was to advise the Board of Health on all matters relating to the health and welfare of older people, with particular responsibility:

1. to promote and foster independence.

2. to advise on the maintenance and standards of the quality of care.

3. to identify and assemble data, and advise on the planning of services for the elderly.

4. to explore and promote means of educating staff and others involved at all levels in the care of the elderly.

5. to investigate and advise on practical methods of co-ordinating liaison and co-operation between agencies in the public, private and voluntary sectors involved in the provision of services for the elderly.

6. to advise on any other relevant matters as may from time to time be referred to the committee by the Board.

The chair was a Ministerial appointment Dr Valerie Grant from the Psychiatry and Behavioural Science department of the Auckland School of Medicine.

The rest of the committee was appointed on the recommendation from our departmental team, after discussions around the sector. They comprised:

Mrs Ailsa Bailey, Principal Nurse of Talbot Hospital, South Canterbury Hospital Board

Mr David Battersby, Department of Education, Massey University

Professor John Campbell, Department of Medicine, University of Otago

Mr Mark Flowers, Social Work Dept., Napier Hospital

Mr John Fry, Christchurch City Council Community Advisor

Mr Ken Irwin, Presbyterian Support Services, Dunedin

Ms June Kendrick, Social Worker, Auckland Hospital Board

Mrs Peggy Koopman-Boyden, Department of Sociology, University of Canterbury

Mr Bill Parker, Kaumatua, Lower Hutt, who died during the term and Maiki Marks was then appointed

Dr William Parkes, Regional Geriatrician, Northland Hospital Board

Dr Margaret Guthrie, Department of Health Support Member.

It was as the Chair pointed out in an annual report, both an advantage and a disadvantage that members were drawn from a wide variety of backgrounds. It meant that time getting to grips with each other's viewpoints by a process of mutual education was necessary, but when members were better informed the collective expertise was impressive. The interdisciplinary nature of the group did enable the dissemination, both ways, of information between members and their colleagues in different settings, as well as increased and more direct contacts with older people from all walks of life. Deliberations included priority setting for projects members themselves decided to pursue.

The initial project was to determine an equitable long term care benefit for frail, disabled people along with proposals for a nationally consistent assessment process.

The project was timely because anomalies had become evident, generated by the differing funding assistance which prevailed between Religious and Welfare [R&W] residential and privately owned homes. Historically most of the early homes for frail older people had been publically owned and operated but church organisations such as the Salvation Army and the Little Sisters of the Poor also developed homes which were both designed and run in a manner of similar to nineteenth-century English poor houses. That situation gradually improved and by 1949, as demand outstripped supply, the R&W sector was offered a capital subsidy to build more beds and from 1955 it became Government policy to dissuade hospital boards from establishing residential homes in favour of R&W development. In 1983 assistance was available to them up to 100% of the approved building costs with a maximum level of $21,000 per bed for homes and $25,000 for hospital beds, limited to 50 and 40 beds respectively. Those subsidies were though only available in areas where the bed guideline of 30/1000 65 years and over was not exceeded.

In the private rest home sector a different system had developed as a consequence of action taken from 1962 when it was realised that there were nearly 90 older people in Cornwall Hospital who did not require hospital level care. When it was suggested that they be transferred to R&W homes those beds were not only full but also had long waiting lists. Hence the Auckland Hospital Board and the Department of Social Welfare [DSW] came to an arrangement whereby financial support as a special rest home subsidy was provided to enable those frail older people to be admitted to private rest homes. The subsidy was means tested and paid the difference between the person's income and the rest home fees. Over time the scheme was extended to twelve other centres, as well as to ex psychiatric patients only in Auckland. The result was a proliferation of private homes in those particular areas because the subsidy improved the profitability of homes to such an extent.

DSW believed that the scheme needed to be open ended because it existed for those in financial need. A change emerged when DSW began subsidising not only people assessed by geriatric units but also those who had been in the home for such a time that their capacity to pay the fee had ceased. A dilemma arose because geriatricians were then asked to perform what to them was a sham assessment due to the over-riding financial need. Hence the scheme had evolved to be very different from what was initially envisaged.

The different schemes also worked to the disadvantage of the R&W sector because the Capital Subsidy was limited to the bed guidelines but there was no such restriction on the numbers on the Special Rest Home Subsidy. Additionally many of the R&W homes had ageing buildings with increased ongoing costs while the private sector was able to increase their charges knowing that DSW would meet those increases. As well there was increasing discomfort within the R&W sector that the Capital Subsidy scheme had trapped them into developing 'beds' rather than services for people in their own homes. There was as well a real philosophical difference between the two Government Departments. In the Health Department we believed that the DSW subsidy was not always being suitably spent when the people who eventually ran out of funds had not only not been assessed as to their functional need for that level of care, but who also may have earlier been able to be maintained at home by means of home support services. There was also increasing disquiet that some private operators were overcrowding and skimping on care while cashing in on what had, at that time, become a bonanza, [a situation which shall be returned to in another chapter.]

Subsequent discussion led to a paper outlining, 'A Scheme for Continuing Care for Elderly People with a Disability', which aimed:

• to simplify and remove anomalies and inequities in current funding schemes.

• to develop a system whereby any level of care could be funded.

• irrespective of whether the care was provided by domiciliary services or in an institution.

• to ensure that there is a balanced development of institutional care and various types of community and domiciliary support services.

• to ensure that a professional assessment is made to determine whether the condition or circumstances leading to the request for care can be improved, and to ensure that the care provided is appropriate.

• to ensure that in times of limited resources those who receive care are those most in need.

• to ensure that all available forms of care are accessible to any person requiring them, irrespective of the particular system to which the person applies, and that individual choice is enhanced as far as possible.

• To ensure there is a balanced development of institutional care and various types of community and domiciliary support services.

• To have a system which fosters the development of new ideas in the provision of care.

• To ensure that all services meet adequate standards of quality of care.

In summary the proposed system replaced the range of existing subsidies and benefits with several funding options. There was an increased emphasis on the amount of care provided by an institution. The existing distinction between residential [rest] homes and long stay hospital levels of care was to be replaced by the concept of a total pool of institutional care. Within any institution there might be a mixture of clients with different levels of dependency as defined by level 1 - equivalent to hospital level care and level 2 - equivalent to residential level, though more specific definitions would need to be developed in practice. Institutions wishing to care for 'subsidised 'clients must be assessed and the number approved would be limited in any area according to the bed guidelines based on the population of 65+ or preferably for the population 75+.

Clients were only to be admitted to an institution with beds available for subsidy following assessment of need and priority. The home admission procedures would be evaluated as part of the process of assessment for suitability to take 'subsidised' clients. A subsidy for high levels of domiciliary, as an alternative to institutional, care was also proposed to enable a real choice for those willing and able to remain at home and for their carers. All subsidies were to be administered by the Hospital Board or Area Health Board.

As the Standing Committee was not equipped to do costings, the Department took over the financial work needed for the introduction of a disability benefit. In so doing it was decided that to be equitable the benefit needed to include younger physically disabled and intellectually handicapped people. What was proposed was to have been a three tiered benefit based on the level of disability as ascertained by a professional assessment of the person. That linkage to individuals rather than institutions was deliberately aimed to support the development of a wider range of innovative community and domiciliary services. When the subsequent paper was sent to the DG's Committee, although the principles behind the proposal were accepted, the amount of new money required was too high at a time when a funding squeeze was in place. The advice back was to put the paper to one side for a while and, when the timing was more appropriate, to re-visit the costings.

As that initial project called for innovative, flexible home support services it followed that the Committee's second project should be around developing those services. Whereas a number of our group, including John Campbell, Peggy Koopman-Boyden and June Kendrick, were closely involved with the first project this one owed a great deal to Mark Flowers who at the time was the Chief Social Worker of the Hawke's Bay Hospital Board. Mark furnished us with excellent papers for discussion covering the range of services including home help, district nursing, physiotherapy, occupational therapy, podiatry, speech therapy, meals on wheels, laundry services and others, the scope of which is still increasing. He initially had us discussing problems of definition. Up until then we talked about 'Community Care' as anything which occurred outside a hospital, whereas Domiciliary Care was used to denote services in the home which early on was primarily district nursing. Mark suggested a third possibility Home Support Services to encompass the range of services would be more appropriate and that is the term which has been used ever since.

From 5-6 March 1987 a Home Support Services Workshop was held. Karen Ruddlesden of our departmental team, Mark and I put together a folio which remains useful. As Mark wrote in the Introduction:

Unlike hospital services, which despite their diversity, can be classified and categorised relatively easily, care outside the hospitals' walls incorporates a miscellany of services and activities. These can range from intensive nursing care when a terminally ill person elects to remain at home, to the provision of a walking frame and modification of a person's home to enable a disabled person to retain a degree of independence. Between these two extremes a myriad of functions are either initiated or performed by a wide variety of individuals operating under different conditions.

The full extent of these services has not been well documented but it is known that some areas in New Zealand are better served than others. It is also known that even when a service is available, not all those who could benefit from it have access to it. Lack of access can be attributed to a number of factors, e.g. an established policy which specifies the meeting of set criteria by applicants or ignorance of the service by those in a position to advise.

As well, despite the apparent support for community care it has been difficult to transfer resources to home support. Indeed, there has been continued growth of institutional care in the private sector.

Committee members were well aware that community care was not a cheap alternative. To be effective it had to be well organised, comprehensive and of a high standard. Its strength lay in it being more appropriate for most older people, but to be most effective it must integrate public and non-public services, professional and voluntary workers, while retaining flexibility and choice. To achieve those aims the Committee concluded that:

• The Department of Health should develop guidelines for the provision of home support services in cooperation with the Department of Social Welfare and the Board of Health.

• The two main funders, the DSW and the Health Department should resolve their approaches and develop and equitable and consistent policy.

• Area Health boards should be the providers of home support services developed in a responsive and flexible manner. The role of the home help should be developed into a range of personal and home care functions.

• The option of a disability benefit to provide full home support care as an alternative to hospital care should be investigated.

• Other home support services, in particular meals-on-wheels and laundry services, require review.

• A method of protecting the funding of community health services against the rising costs of hospital care should be investigated.

While those recommendations might have provided a more realistic alternative to institutional care other factors were going to come into play, including political policy changes from the integrative, collaborative approach being fostered in the Area Health Board era to the more divisive competitive tendering for contracts of the Regional Health Authority era.

A third project culminated in a booklet: "Empowerment": The key to health enhancement for the elderly. Prompted by the Ottawa Charter of 1986 Peggy Koopman-Boyden and Ken Irwin encouraged the Committee to develop a paper to 'heighten awareness of empowerment mechanisms to enable improved health enhancement of the elderly'. In order to achieve that aim it was said that there was a need to acknowledge that:

Although legally equal, differences persist in the opportunities and choices available to people of different sexes, ethnic and cultural groups and age categories. Other factors [e.g. compulsory retirement and the stereotypes of the elderly] can also limit opportunities for social participation and choice for the elderly.

For individuals to gain more active control over their own lives change is required in attitudes, orientations and most importantly, in "structures". We are firm in our opinion that the shift required is major, e.g. in the health system it may mean moving from a treatment with a disease-perspective to one which emphasises health maintenance and enhancement [wellness]. This is already occurring to some degree with the establishment of wellness clinics for women.

We stress that the changes required don't just occur spontaneously. There needs to be deliberate structural change as well. A crucial mechanism for bringing about such change is to empower people by providing them with the means of enhancing their self-determination. Effective empowerment mechanisms include:

− Access to knowledge and information.

− Representation at decision making level.

− The end of discriminatory practises.

An example of strategies at a national level was universal National Superannuation targeted at older people. At a regional level an example was the change to Area Health Boards which were mandated to establish regional priorities by researching needs, and holding discussions and negotiations at a community level.

At a local level 'SPAN' in Dunedin was cited as a scheme of empowerment in action. It was based in a North Dunedin disused primary school classroom, assisted by two experienced community workers, to facilitate openings for around 75 older people to share their skills across generations, including discussions and activities with the children, thereby enhancing the wellbeing of both young and old.

The booklet which was meant to be a discussion document ended with a series of questions but before answers were able to be sought in early 1988 the Committee Chair, Valerie Grant was informed that the Minister of Health had decided that the present standing committees, in line with the legislation, should complete their current three year term of office and then be disbanded. In retrospect the Board of Health in its enthusiasm to achieve as much as possible had over-reached itself by setting up ten Standing Committees, all enthusiastically beavering away, involving departmental resource people in background tasks in what often became major projects. So a halt was called. The Minister agreed to establish 'some form of Maori Health and a Women's Health group' and in the end some of the money which would have gone to Standing Committees was allocated to Programme Managers to continue unfinished business.

Among the projects that were envisaged but not able to be completed was 'Prejudice, Neglect and Abuse of the Elderly', an awareness raising paper aimed at a variety of interest groups, including health professionals, carers and older people themselves.

Ailsa Bailey's experience as the Principal Nurse of a long term care hospital in Timaru, and, as President of Age Concern South Canterbury, prompted her to espouse that cause. As well David Battersby, who had been in correspondence with Claude Pepper, a member of the US House of Representative's Select Committee on Ageing and Long Term Care of the Elderly, and himself the oldest member of that House, presented a paper to the Committee in July 1985 headed, 'Elder Abuse: Is it a Problem in New Zealand?' It is interesting to note some of the findings of that American Committee at a stage when elder abuse was hidden from view in this country but which was to be subsequently confirmed.

The victims of elder abuse are likely to be old, aged 75 years and older. Women are more likely to be abused than men. The victims are generally in a position of dependency, that is, they are relying on others, be it their family or caregiver, for care and protection. The likely abuser will usually be experiencing great stress. Alcoholism, drug addiction, marital problems and long term financial difficulties all play a role in bringing the person to abuse his or her parents. It is interesting to note that the abuser in many cases was abused as a child and the abused elderly victim is less likely to report the incident of abuse than persons in other age groups.

Both David's and Ailsa's espousal was not in vain. The seed was germinating. Dr Bernie King and I agreed to follow up that beginning by undertaking a baseline, literature research which culminated in the Departmental paper, 'The Care, Mis-Care and Abuse of the Elderly', published in 1988. Bernie, who had joined our Departmental team after several years with the MSRU, did the background research in her meticulous manner, initially of overseas literature and research projects for 'Part 1 – An overview: International' which was also wholly written by her as well as that for 'Part 2 – The NZ Situation' which I wrote up as it impinged so much on my responsibilities for the licensing of rest homes. It has always amused me that as a result Parts 1&2 have different writing styles. At the time we were collaborating on that research we were struck by the fact that, at that time, the only reports we could find in New Zealand were two telling investigative journalism series in the New Zealand Herald about abuse in some private rest homes in their financial boom period of the 1970 and 80s. Factors such as fear of retribution and shame were undoubtedly hiding what was going on in some families, just as it was in the reluctance of those in some rest homes to protest about their ill-treatment and neglect. What it did confirm, wherever elder abuse was reported, was that dependency on others was a common factor. As we concluded:

By opening up the subject we have aimed to bring out in the open that in one form or another elder abuse does exist in New Zealand. We hope thereby to stimulate prevention and support measures for both those who may be abused and, as appropriate, their abusers, who may also need help in their way too.

A further topic that the Committee wished to follow through was a formal investigation into the role of territorial local bodies into the wellbeing of older people in their areas as we were aware that a review of local government and its responsibilities was under way and wished to draw attention to the innovative way in which some local bodies were acting. One Committee member, John Fry as the Community Advisor to the Christchurch City Council, had contributed to World Health Day 1982 Add Life to Years pamphlets: ' How local authorities can help improve the environment for older people'. John pointed out that the Town and Country Planning Act stated:

That Town Plans should make provision for social, economic, spiritual, recreational opportunities and amenities appropriate to the needs of the present and future inhabitants of the district.

Rental housing for pensioners was seen as a primary role as it had remained Government policy from 1951 for low-interest loans to be available for all Councils to develop Council flats, loans which were directed to keeping rents reasonable. The Christchurch City Council had at that time 1,467 units which they had constructed, managed. The units were largely self-supporting and no burden on taxpayers. Libraries, increasingly in buildings which also housed community services, recreational facilities, and making roads safer for pedestrians, also improved life for all ages.

Although the intention of the Committee to prepare a paper to go to the Ministers of Health, Housing and Local Government by 1988 was not able to be fulfilled, the subject was, over the following years, researched and a report with recommendations made by Susan Gee [PhD] and Kathy Glasgow. That was done on behalf of the 40+ Project of Victoria University, headed by Professor Sik Hung Ng, along with Age Concern New Zealand in 2000. The project outcome was published as 'Creating communities for all ages: Local government and older New Zealanders.' In its conclusion Susan and Kathy wrote:

The challenge for New Zealand Local Government and for all New Zealanders, young and old, will be to find innovative, practical and flexible approaches to maximise their ability to lead independent, positive and satisfying lives at all ages. By developing partnerships with community groups and older people to maintain a sense of control over their lives and by providing opportunities for influence over decisions which affect them, Councils can develop strategies and services with older people that are effective and empowering.

Other topics which the committee wished to pursue included:

### Standards of Care in Institutions

The Committee was aware of the dual standards of care in public, private and R&W institutions which involved issues of justice and equality. It had wished to set up a sub-group to work on that issue and to present a report within six months of its establishment.

### Education and Wellbeing of Carers

As Committee members we were aware that the quality of care of older, dependent people, whether it be by family, home helpers, nurses, doctors or other health professionals, depends on how well the carer understands his or her role and the nature of the disabilities carer education at all levels is a vital ingredient to the quality of care.

We were also aware older family carers, especially those who were caring for confused older people, needed additional support, including day care, respite and night care for their own wellbeing.

### Prevention

The clinicians on the Committee were convinced that more could be done to reduce medical admission rates by for instance improved knowledge and management of medication. That subject was also followed up by our Departmental team. Margaret Duthie, our nurse advisor, contacted Dr Robin Briant who had written a 1982 Add Years to Life Fact Sheet on Medication for the Elderly. Robin agreed it was timely to produce a 1988 revision which went out to all sectors, public, private and R&W sector. Whereas the earlier version had been largely aimed at the general public the 1988 version was directed to health professionals who would be prescribing the medication. As Robin Briant said:

There are three corners to the prescribing relationship, the patient, the doctor and the drug. If there are problems it is possible that any one, if not all three of these factors are causative.

She dealt with all three in turn, a task which had been made easier by the publication of a major research project in the UK by Cartwright and Smith, the findings of which had been published in the Lancet of 2 July of that year, 1988, 'Elderly People: their medicines and their doctors.'

Robin herself though was responsible for some rather nice turns of phrase in our fact sheet, such as:

There are many processes involved in getting a drug from a pill in the bottle to the site of action in the body, and out of the body again. Ageing and disease may influence many of those processes.

The doctor factor received curt treatment, as Oxford describes 'short shrift', from both the original article and Robin Briant, e.g.:

The findings of Cartwright and Smith indicate that the prescribing doctor must bear considerable responsibility for the drug morbidity of old age. Amongst their findings was the fact that a third of prescribed pills had been taken for more than five years, and ¾ for more than a year. Most worrying was that 23% of patients had been receiving repeat prescriptions for more than a year without ever seeing their GP. Other UK studies have shown that inappropriate drugs were being prescribed to 8% of 1100 presenting at A&E departments. All of these drugs had the potential for producing unwanted effects. Cartwright and Smith were quite unimpressed by the knowledge their doctors had of the exact medication their patients are taking.'

The figures for NZ are not known. I doubt they would be markedly different from these. It is essential that doctors who pay lip-service to the notion that medicines can be dangerous to the elderly, actually change their ways. A pill for every ill is not the proper response to disorders of the elderly, nor for the younger for that matter.

I believe that all drugs should be reviewed regularly by the family doctor; many could be stopped. No new agent should be given unless there's very clear knowledge of what's already being taken. A useful rule to work to, is that before prescribing any new pills, at least one old one should be stopped.

The drug section began with the truism that 'All drugs have the potential for adverse effect' following which she detailed five found to have caused 80% of drug problems in the admission of 685 older people in Auckland a few years before. The five troublesome categories were digoxin, diuretics, anti-inflammatory analgesics, anti-hypertensive agents and psychotropic drugs.' With regard to the latter she was blunt: 'For the elderly, as for other age groups psychotropic drugs should be used for psychiatric indications, and not to prop up a foundering social life or to cure society's ills. Sleeping pills likewise should be prescribed only rarely, and then in small doses and for a period not exceeding two weeks.'

Around that time I found myself attracting media attention at a public meeting by raising concern that some residential care nurses, in order to have a more peaceful night shift, were handing out far too many sleeping pills, creating zombie like elders who never had the chance to emerge from the effect of the drugs before another night's dose was administered. The Nurses Association rose up in protest to which the DG, with whom I discussed the situation, thundered: 'They would, wouldn't they?'

These days prescribing habits are much improved with most GPs only allowing one repeat of prescriptions without seeing the person for review, but the odd tale still crops up as well, so the principle of the least number of drugs for the lowest effective dose, still requires iteration.

The second life of a Board of Health came to an end in 1988 but health of older people had received a stimulating boost of activity for the three years of the Standing Committee's existence, which carried on after its demise in a variety of directions.

References

1. Board of Health: _'Report of the Board of Health Committee on Care of the Aged in New Zealand'_ Report Series No. 13 Sept. 1967.

2. Salmond G. _'Accommodation and Service Needs of the Elderly'_ Report No.46 MRSU Dept. of Health 1976.

3. Board of Health Standing Committee on Health of the Elderly discussion papers.

a. Continuing Care of the Elderly with Disability.

b.Home Support Services for the Elderly.

c.Empowerment – The Key to Health Enhancement for the Elderly.

4. Gee S., Glasgow K.et al, _'Creating Communities for All Ages: Local Government and Older New Zealanders_ :A report from the 40+ project of Victoria University and Age Concern New Zealand. August 2000.

5. Briant R. _'Medication for the Elderly'_ Dept. of Health Circular Memo Hospital/health boards No.1988/174, 31 Oct. 1988.

6. Cartwright A.,Smith C., _'Elderly People, their Medicines and their Doctors'_ London, Routledge, 1988.

### Chapter 11

Health Promotion and Other Matters

One potential bureaucratic tussle was avoided in the furtherance of health promotion for older people. When the department was still in its divisional structure I became aware that new money was available for a new health promotion project, the nature of which was originally unspecified. Public Health let it be known that they planned to divide the funding 50/50 between anti-smoking and breast feeding programmes.

Aware that there was already an active anti-smoking programme and that breast feeding also had active proponents, I made written application for the funding to be for a full time health promotion educator who would focus on ageing issues. I was subsequently invited to attend a meeting in the Public Health Division to argue my case, while Dr Brian Christmas argued for the 50/50 split proposition. On the basis of demographic urgency, and the fact that up until then the Department had no Health Education Officer [HEO] handling ageing matters we agreed such an appointment was needed and that person should be responsible to Health Promotion for employment and training purposes and to me for the gerontological aspects, both sides to work closely together.

Betty Kill of Health Promotion and I promptly set to work recruiting a former teacher, Margaret Earle, who attended a health promotion training course, while we negotiated with Radio New Zealand to run a pilot series of broadcasts about positive health initiatives around wellbeing of older people. We knew a slot existed because Dr Talbot had just ceased his long running weekly broadcasts but it took some persuasion on our part to convince RNZ that our proposal might be appealing to listeners. It was agreed that the new HEO should undergo a period of broadcasting training and then develop several pilot programmes, the first of which went to air on 21 February 1987. After evaluation and negotiations, the pilots were succeeded by a fortnightly series of ten minute programmes called; 'Lifespan' from August 1987. Feedback was positive and cassette copies of the programmes were in demand but in December 1992, Radio NZ dropped ' Lifespan' at a time of restructuring.

'Lifespan' did achieve a good public profile for health promotion alongside older people. The programmes were wide ranging from the first of the pilots focussing on 'Views of Age and Youth – looking at older people's relationship with children', to 'What a Relief – exercise in water for older people with arthritis'. A very practical session on 'Learning to Cook – a cooking class for older men' in February 1988 aroused considerable response from older widowers.

David Richmond, Professor of Geriatric Medicine based at North Shore Hospital, Auckland, with the co-operation of myself and Margaret Earle appointed an HEO, Helen McCracken, to assist with research as well as to develop programmes. Helen and Margaret jointly organised and held a national seminar, 'Health Promotion with Older People. Planning and Strategies' in February 1989. They also jointly went on to prepare and publish a series of working papers to empower action including 'Health Education Promotion Initiatives with Older People', July 1989; 'A Profile of Older New Zealanders: Research as a Resource', December 1989 and 'Senior Citizens' Resource' document, November 1990. During the period when the two HEOs worked together, often with other local HEOs such as Louise Croot in Dunedin, there was action a plenty.

An important aspect of that activity was the background research that was initially undertaken by Professor Richmond and Helen McCracken which was published as 'Health and Lifestyle' in February 1991. Simultaneously Age Concern NZ had commissioned Colmar Brunton to survey 1000 older New Zealanders on a face to face basis during August and September 1990. The questionnaire, designed in consultation with ACNZ and their sponsors, National Mutual, had been initially piloted in Auckland. The latter project highlighted the fact that almost a third of those 60 and over were responsible for looking after someone else; most often a grandchild or spouse/ partner. A quarter provided almost constant care and those carers did tend to lose their own social freedom, though the majority stressed that caregiving was something they had wanted to do. The groups expressing most dissatisfaction with their quality of life were women, lower income groups, those living in rental housing, those living alone, in poor health and ethnic minority groups.

Other action included the intergenerational Dunedin SPAN programme as well as the Senior Peoples' Network at Tauranga, a self-help programme all activities of which were suggested by older people themselves. Adopt-a-Gran was initiated by an older woman in Brooklyn, Wellington. While Ageing is Living in Nelson was designed to bring older people in contact with children in places such as a toy library, reading sessions at the local library, and involvement with a play centre. Two hui at Waiuku Marae for older Maori were, at their request, focussed on nutrition and living with arthritis. Y Walking and Fifties Forward low cost recreation and exercise programmes developed everywhere there was a YMCA.

The Health Reforms of the early 1990s resulted in the cessation of a central health education unit as the Department of Health metamorphosed into a policy and advice Ministry of Health. 'Lifespan' preparation and editing was one of the few service activities retained until Radio NZ also restructured which resulted in Margaret Earle moving to the Senior Citizens Unit of DSW. Concern that the impetus gained would be lost was only partly realised.

The Hilary Commission for Fitness and Sport was developing physical activity programmes through their Regional Sports Trusts. Under the name of Kiwi Seniors, line dancing, walks, aqua-aerobics and other activities gathered momentum. The manager of those programmes, Diana O'Neill, was well aware that social needs were also met by Kiwi Seniors. When she attended an international conference in Heidelburg Diana was struck by the earnestness of the Continental approach. They wondered why they had difficulty maintaining interest. Fun and friendship may well have been the key to ongoing support for Kiwi Seniors.

There were also some feisty older people stirring others into action, including Sister Monica Landy, a retired teaching nun who founded the Wairarapa Organisation for Older Persons [WOOPS] in Masterton. On a Churchill Scholarship she went to Toronto to learn about their, 'Through Other Eyes' workshops which educated designers and retailers about how to improve the everyday environments for older, disabled people after experience of simulated blindness or other disability. Sister Monica then persuaded the Retired Persons Association to work towards Senior Achievers Awards, another Canadian idea which received sponsorship from Tower.

Joan Cumming, another retired teacher and Chair of Age Concern Hamilton, was actively encouraging elder participation in schools. She also stimulated her Age Concern to produce a multi-media exhibition 'A Wrinkle in Time' at which I happily bought a dark green sweat shirt with 'Age is Attitude' printed across the front which often aroused positive comment.

In July 1999 because of the vacuum in furthering of Health Promotion at that period I wrote an occasional paper, 'The Evolution of Health Promotion Programmes for Older People in New Zealand: A history with lessons for the future.' It covered the briefer historical record in this chapter. I concluded that paper by noting:

What is lacking is a strategic planning framework which strengthens community programmes and individual recognition of the need to age as well as possible. The planning framework needs to recognise the innovation that older people themselves have demonstrated, as well as the cultural differences of Maori, Pacific, Asian and other ethnicities.

There was additionally an update to that paper shortly after it was distributed to all Age Concern Councils to acknowledge the role that Dwayne Crombie who, when the position of a health education officer was dis-established at the North Shore Hospital Professorial Unit, offered the funding to Age Concern North Shore to develop health promotion programmes in the region.

### Lifelong Learning

There were parallel developments in the field of lifelong learning and learning for life. Two years after the World Assembly on Ageing, the New Zealand Social Advisory Council published the 'The Extra Years'. It recommended that the National Council of Adult Education [NACE] encourage public discussion on attitudes in later life. Promotion of this concern was to be through existing educational networks.

In June 1984, NACE set up a working party on Ageing and Education [AEWP] for a three year term. Their November 1987 report 'Ageing and Lifelong learning in New Zealand' made a series of recommendations around combatting ageism e.g. promoting positive attitudes, developing educational opportunities for not only older people but also for carers, both formal and informal. It made a real impact leading to a number of initiatives including the establishment here of Universities of the Third Age [U3A]. There were close links between the work of AEWP, NACE and the health education programmes. In March 1987, AEWP brought Hillary Kirkland, Co-ordinator for the Lothian City Council in Edinburgh to lead seminars and workshops throughout the country. She was also happy to be interviewed for one of the pilot 'Lifespan' programmes about educational opportunities for older people in Scotland.

### Elderly policy issues

In May 1987, as the cost of Rest Home Subsidy Scheme was escalating rapidly and the stimulant effect it had on development was of real concern, the scheme was restructured. The main elements of the restructure were:

• The introduction of three maximum rates of rest home subsidy in respect of three different levels of care, which was seen as a means of overcoming the problem of monitoring open-ended and guaranteed payments to rest homes.

• The assessment of older people seeking rest home care, prior to placement.

• A system of grading homes and provisions to withdraw or not pay rest home subsidies in respect of homes which did not meet the required standards.

• A pilot scheme to be introduced initially in Auckland under the heading "Home Care 60s plus programme" to provide home-based support to provide a realistic and preferred alternative to residential care for those requiring minimal care.

Subsequently a joint DSW and Health working party engaged Coopers and Lybrand to conduct an in-depth study of rest home costs over both the private and R&W sectors. The working party also refined the introduction of assessment for residents and developed a protocol for the assessment of homes.

The Geriatric Hospital Special Assistance Scheme [GHSAS], which had been approved by Cabinet in February 1977 had always required patients to undergo assessment. It supplemented any public hospital long stay beds by allowing hospitals and AHBs to place patients in private beds when no public beds were available, and to make a direct charge on the Department of Health for the costs incurred. The basis of the payment was the difference between the patient's net income from all sources less a personal allowance and the net private hospital benefit. In the case of married couples, their incomes were aggregated and the living and other expenses of the spouse not in hospital was taken into account.

### Residential and hospital standards

This was ongoing as reports were received from around the country from public health nurses who inspected homes and private hospitals. From the time a Standards of Care document was available they had both a guide for the inspections and a teaching tool for rest home staff. The majority of homes reached the standards. Of those that did not do so most responded to persuasion, but those which did not called for an unannounced inspection from me as the holder of delegated authority from the DG of Health for the licensing and withdrawal of license of all homes. That meant flying in at short notice, being collected by the nurse involved and heading for the particular home. When it reached that phase it was as likely as not that withdrawal of the license was the outcome. Over the decade some 14 homes lost their licenses and most of those did not appeal against the ruling. A few argued their case and that started a further round of inspections, exhortations to improve that could be time consuming and not a little concerning as residents remained at risk, but we had to be careful about being seen to adhere to natural justice, as well as the standards. A couple challenged the ruling by taking us to Court.

The first was in Gisborne. After much preparation of the case with the assistance of a Crown Prosecutor who was to represent us I was reminded to be sure to have my written delegated authority with me because my predecessor had lost his only court case on the technicality of not having it to hand. I had also been rung up at home by the son of the proprietor two nights before that threatening me with bodily harm if the case proceeded, which was reported straight away. The judge ruled that the safety and well-being of the residents was so compromised the license should be revoked which was followed by the home's closure.

A few months later there was a similar case which was heard in the Waipukurau Court where another judge also agreed the standard of care was such that revocation was warranted but, he then added, that as the livelihood of the owner was at stake he should be given another chance. The nurses who had been threatened by two large dogs champing at leash as the proprietor opened the door, as had I experienced too, were shattered when the judge particularly exhorted them to do further inspections which they had to drive from Hastings to perform. The judge stipulated the dogs must be tied up safely but that did not appease the feeling among the nurses, that their professionalism had been disregarded when the licence was not revoked. At least the publicity of the case meant most of the few residents left anyhow, and the place soon became unprofitable, so it closed in a few months regardless.

Having written about those two court cases it is important to repeat that the majority of rest home owners really did aim to meet the standards, a situation that was not made easier by the increasing frailty and complexity of residents; needs, while the age of entry climbed steadily and difficulties over finding and retaining the right staff increased; a situation that persists as one writes, sadly.

### World Health Organisation, WHO, Programme for Research on Ageing

In May 1987 WHO called for the establishment of an international research programme on ageing as an integral part of the WHP Global Programme on the Health of the Elderly. Initially the focus was on four priorities which had been determined by their scientific group:

• determinants of healthy ageing.

• age associated dementias.

• age related changes in immune function.

• nutritional changes with an emphasis on osteoporosis.

As WHO was seeking extra funding over and above what they themselves were able to provide they called a meeting for 21-22 March 1989 at WHO in Geneva, not only for member states but also for Non-Governmental organisations and other 'interested parties' to discuss the programme.

The Chair of the Meeting was to be Robert Butler, the eminent American psychiatrist/ gerontologist, the person who invented the word 'ageism' and who postulated that developing public policy for later life should be based on a framework of a 'life cycle perspective'. He argued that 'education, work and leisure could all be distributed throughout the life cycle rather than concentrated in a distinct period: childhood, middle life and retirement. Flexible retirement policies should be a social goal. Being very aware of the many American older people living below the poverty line he argued for economic security, decent housing and high quality health, affordable health care. Robert Butler felt strongly about society's tendency to impose a sense of uselessness upon its older citizens. In an article 'Dispelling Ageism', Annals AAPSS, 503, May 1989 he concluded:

Older persons themselves need to be productive and develop a philosophy themselves on ageing if we are to fight ageism. Survival is closely associated with individuals' views of themselves, as well as their sense of continued usefulness. In 1963, our multi-disciplinary study of community - residing aged men found that people's experience of ageing and their adaptation to it, are influenced not only by disease, social adversity, economic deprivation, personal losses and cultural devaluation, but also by their personalities and their previous life experience.

The fact that I was going to be at a meeting Robert Butler was to chair was not a small part of my gladness to be the New Zealand representative in March 1989 at the Geneva WHO meeting. Robert Butler opened the meeting by stressing the essential unity of life – a strong unity between generations. The issue of denial in confronting the reality of ageing and death was one for both the individual and society to accept.

Notes taken included:

Research is the ultimate service to humankind. The keynote is to set the tone, to call nations together to confront this greying of nations which is the consequence of social evolution rather than biological revolution. The 1982 United Nations Assembly on Ageing made the first call for collaborative research but it was not effected until the 1887 WHO Assembly.

A declaration that a longitudinal perspective was needed. That there are painful topics such as dementia, immobility and incontinence. Geriatrics is developing side by side with gerontology. Health promotion must be sponsored as well as health services. He noted the four topics chosen when there are many other aspects of ageing but we had to start somewhere.

The new gerontology has led to a reduction in mythology and has led to the prospect of intervention. We know for instance that dementia is not inevitable but the consequence of a number of different conditions.

Ageing is everybody's business; governments at all levels; families; in terms of life planning, business, corporations, unions, and religious institutions.

He said he heard three major concerns:

− will ageing impair social productivity?

− will we see a rise in intergenerational conflict?

− will ageing become a burden on society?

Medical science becomes the ultimate cost constraint. Science will reduce the effects of dementias and osteoporosis.

He concluded that:

We each need to be reminded of our own individual destiny; freedom of spirit; right to be thought of as a person with autonomy. We need to translate the personal message to communications at large and to work universally towards a better old age.

There followed presentations from the four topic consultation groups of which only the immune function one was somewhat weak and its inclusion as a priority debatable; but WHO research was under way.

The following speaker Dr Osuntokum from Nigeria who was by then Director of Research for WHO, made a similarly impressive impact as he had in 1982 in Vienna. He stressed the impact of ageing on developing countries which were very ill prepared and usually have no form of income social security for the aged at all. The main buffer is the extended family and traditional respect for the aged. He repeated that at the bottom of the heap are older rural women. If it was looked at objectively it was hard to see how it could be otherwise when they still had a long way to go to have healthy babies and children too.

He did also outline the goals of the WHO research to:

• understand the ageing process.

• prevent and control age related disability.

• promote and intervene to increase support and ability of the elderly to be as independent as possible.

The meeting did vote to support the programme which allowed it to proceed within the available resources. We were though informed that different angles coming from some of the participants were important for the design of the projects.

References

1. Health Education Unit, Dept of Health _'Health Education and Promotion with Older People'_ July 1989; _'A Profile of Older New Zealanders: Research as a Resource'_ , Dec.1989; 'Senior Citizens Resource Document' Nov. 1990.

2. Richmond D., McCracken H. _'Health and Lifestyle in Older Age'_ , Dept of Health & Dept of Geriatric Medicine, Auckland, 1991.

3. Lifespan Radio Programmes, Radio New Zealand, 1-112, produced from 21/2/1987-15/3/1991.

4. Age Concern New Zealand Colmar Brunton Survey, _'The Lifestyle and Well-being of New Zealand's Over 60s'_ 1990.

5. Guthrie M. _'An Agenda for Well-being for the Elderly'_ The Journal of General Practice, vol 5 p5-7, Sept. 1988.

6. Guthrie M. ' _The Evolution of Health Promotion for Older People in New Zealand: A history with lessons for the future'_ Occasional paper, Age Concern New Zealand, July 1999.

7. New Zealand Social Advisory Council _'The Extra Years: Some implications for New Zealand society of an ageing population_ ' Feb. 1984.

8. Dept of Health, Hospitals' Division, _'Standards of Care for Old People's Homes'_ 1987.

9. Butler R. _'Dispelling Ageism'_ Annals AAPSS, 503, May 1989.

### Chapter 12

Change

This chapter commences with a quote from John Gardner:

Professions are subject to the same deadening forces that affect all other human institutions, an attachment to time honoured ways, reverence for established procedures, a pre-occupation with one's own vested interests and an excessively narrow view of what is relevant and important.

The true task is to design an institution that is capable of continuous change, renewal and responsiveness.

It was the UK Griffith's 1983 report that triggered change in the way health services were organised in New Zealand. Griffiths, who was the Chairman of Sainsbury's, believed that it was essential to gain efficiency by doing away with the doctor- nurse- administrator team with its philosophy of consensus management in favour of general managers, management budgets, value for money and management training and education. Transposing that philosophy to New Zealand resulted in the 1986 dis-establishment of the medically held Directorates of Hospitals Division, Public Health and Primary Health, including GP services. Hospitals Division was seen by the rest of the Department as the monster which consumed 80% of the health budget. The divisions did tend to be silos with comparatively few dealings with each other. Instead the Health Department was to be restructured into service oriented units headed by managers. That considerable change did not take place in five minutes. There were preliminary workshops held outside of the Department itself at a local hotel with conference facilities where a group photo of those attending recorded the old guard prior its disappearance, along with a great deal of discussion and not a little trepidation, varying from individual to individual. The Area Health Boards Act also did away with Hospital Boards over time by replacing them with Area Health Boards which had to include a wider brief for community services and community participation in service development groups, but did not originally include GP services. Cooperation between the public, private and R&W sectors was also an aim.

To me personally it was a change that resonated as being in tune with what we had been trying to achieve in the field of elder health care. There was though an ironic contrast in the change of attitude to when I was appointed as the first woman Medical Superintendent of a major hospital, amidst more publicity in the media than I had ever experienced, which in itself required becoming comfortable about the publicity. Just when I was about to say no to another request for an interview the phone rang. It was another woman, whom I did not know, ringing to say what an inspiration it was to read about a woman achiever, which put it more in perspective. In January 1980, when first appointed to the Hospitals Division, the DG also saw that there was media publicity. Then in 1985 when Alec Sinclair resigned from being Director of Hospitals to go the Waikato as Medical Superintendent-in-Chief, I was initially appointed Acting Director, and then on the 24th June 1986 was gazetted as Director of Hospitals. The first woman and last person to hold that position gave rise to almost audible silence. Not one of my colleagues said a word. Only one person made a comment to my face. That was Peter Butler, the CEO of Hospitals Division who came to congratulate me. By then it was very clear that the definitive appointment would be short lived as later that year the change was to take place. Medical Directors were about to become dinosaurs, as were those of a previous existence, Medical Superintendents. Meeting Dana Glendinning, who was responsible for Equal Opportunity at State Services, in the street she asked if I realised I was at that time the highest paid female civil servant. That was news to me, but I was able to tell her I had just taken steps to forego National Superannuation meanwhile, because with the 25% surcharge on the 60+s who happened to earn $5,200 plus above National Superannuation, I did not enjoy being taxed at the 55c rate of every dollar earned.

On Monday 11 August 1986, the DG, Dr George Salmond, confirmed my appointment as Manager [Elderly, Disabled, Handicapped] or [EDH] as we soon called it. I was appalled upon first hearing that name. The implication that all older people were disabled and handicapped was not seen by whoever decided it was apposite. Also younger, physically disabled people were not impressed to be, let alone be seen as part of what they saw as a 'sickness' brief. The basis of the decision to group those three categories of people together was the shared aim of maximising their capacity for independence and maintaining community based lives. It was a sound decision from that point of view, but a controversial one as far as all three of the groups involved in other respects e.g. older people were upset at the implication of automatic disablement.

A positive aspect was that as Manager I was allowed to nominate who I wished to have in the team. It was a delight that Bernie King, by then the first nurse in NZ to have gained a PhD, was happy to join us in her research capacity, as was Margaret Duthie, a companion of the founding Massey DHA course, who joined as our gerontological nursing expert.[Margaret and I also share a private joke around other's confusion over the similarities of our names.] John Gray, a health administrator with a legal background, joined to manage the budget and head the administrative aspects along with Karen Ruddlesden and Vicki Ruberl. Marjorie Welby, my personal assistant, also became a key person for the team as a whole. It was a small team which jelled well together from the start.

For a time the organisational environment was somewhat complex. Separate from the brief of the EDH I retained responsibility for International Health, which quite often entailed difficult decisions about the health of some of those seeking refugee status in this country. There was also the delegated role of being the DG's representative on the Medical Council, as well as its Education Committee, and working alongside the NZ Medical Association in developing a service for impaired doctors. The latter role was made particularly relevant because Alec Sinclair's last year or so was marked by an increasingly obvious alcohol problem. Alec was a superb medical administrator when on form, but when he became increasingly liable to be late on a Monday, and then one day did not arrive at all, or answer any calls when several heads of radiology services arrived for an appointment to discuss the distribution of MRI scanners in the public system, I informed the DG, by then Dr Barker. Not only was that to no real avail that was obvious, but, when Alec sought a referee's report from Dr Barker for his application for the Medical Superintendent-in-Chief's role at the Waikato AH Board, he received a positive response which made no reference at all to any problem. Soon afterwards the Chairman of the Waikato AHB contacted Dr Barker angrily asking why he did not disclose that Alec had an alcohol problem. When Dr Barker then mentioned to me that there was no proof I demurred, reminding him that I had twice reported evidence to him that called for follow up at the very least. Fortunately Alex responded well to the demand in Hamilton that he attend an in-patient rehabilitation programme, or resign, but he should have been confronted earlier while in Wellington, for both his and everyone else's sake. It was also a strange situation to be remonstrating with Dr Barker, whose mentorship in gerontology I treasured. Our relationship was such that it survived, as did the collegial friendship with Alec to whom I wrote a long supportive letter while he was in the hospital programme. I also feel free to write about this because the Chairman of the Waikato Board protested loudly and publicly about the referee's report, so the matter was far from confidential.

It was not until July 1988 when Dr Peter Talbot was appointed as Chief Medical Officer that I was able to hand over some of those tasks that I had undertaken as Acting Chief Medical Officer. Interesting experience, as it was, it did make working life rather pressured for a while, so having a really good team at EDH was particularly appreciated.

The intellectually handicapped aspects of the EDH brief were at a stage of major change in policy where there was to be a refocussing away from large hospital institutions to those provided in ordinary homes within the community, along with a recognition that intellectually handicapped people had the same needs for education, work and living conditions as everyone else. There was though much angst among a number of families who had offspring in institutions such as Templeton and Kimberly Hospitals, about proposals to transfer inpatients to smaller, community based houses, staffed according to the level of need. Those anxieties included a fear among some ageing parents that offspring might land back on them for care; that the standards of care might not be adequate out in the community; that it was merely a cost cutting exercise. Controversy spilled over into the media. It was therefore vital that we were sure that what was proposed was in the right direction where intellectually handicapped people would be well and safely cared for, as well as being able to lead lives that share the normal needs of the general population. Consultation with IHC led to my taking a trip to Queensland where what was deemed to be successful de-institutionalisation was already well underway.

The observations and findings of that visit to Brisbane, Ipswich and Toowoomba did convince us that people's lives were enhanced by 'normalisation'. It was not necessarily cheaper, and it calls for adequate numbers of well oriented and supported staff, but it was considerably more appropriate than large institutions with locked wards and systems which induced neurotic behaviours in those who were virtually incarcerated away from a sensitive populace.

The trip was not without its incidents. Angus Cappie, the IHC staffer who had arranged the details of the visit and who was to lead us, had not realised that, as he travelled on a British passport, he needed a visa to enter Australia until at the departure desk at the airport. So the rest of us flew off without him. He did manage to acquire a visa and catch up with us a day later, while, at Brisbane, those who met us had been made aware of what had occurred. I also embarked with a swollen right hand having inadvertently placed it on a bee which happened to have alighted on a windowsill at home shortly before Wally was to drive me to the airport. That did create a shiver of anxiety in both my nurse husband and me because it was the first bee sting since having had a couple of years' de-sensitisation injections after two anaphylactic shocks while at RNZAF Woodbourne. Luckily local swelling was the only obvious reaction so no adrenaline injection was needed that time, but by the next morning in Brisbane I had what seemed to be a mild wheeze. One of the joys of the visit was the coincidence of the November timing with the blossoming of the stunningly beautiful, blue, scented avenues of jacaranda trees. Lowering a branch, the better to enjoy the scent, intensified what had been a mild wheeze into full blown asthma. A first ever episode of what was to be described by my GP, at home again, as late onset asthma. Fortunately it is possible to buy a Ventolin inhaler over the counter in Australia, so there was enough relief readily at hand so as not to interfere with the trip's objectives. These days Flixotide works well as a preventive, but the tendency to wheeze brought on by a number of triggers has not left since that initial episode.

Back in the office we decided it was important to not only encourage the 'normalisation' processes but to engage all those involved in that process from Area Health Board level to intellectually handicapped people, as well the general public. A group including Anne Bray, Olive Webb, Ash Milne and others was brought together to advise us. John Gray and Olive Webb wrote papers for Board members and unions associated with involved staff, who also attended discussion meetings. Next of kin of all in-patients were sent the paper along with a covering letter and their feedback was encouraged. That did allow a range of concerns to surface which we did our best to address. The number of families who did not know or remember they had relatives in Psychopaedic Hospitals was one surprise. Some forgotten family members had been in hospitals for years hidden away, others were visited regularly.

One decision was that standards had to be specified and then well monitored, but before that an actual framework for services must be agreed. Margaret Duthie guided those projects with dedication to meeting the essential elements of the tasks. The expertise of Anne Bray was sought and readily granted, along with advice from Ann Adams and Barbara Rocco. The resultant booklet, with its introduction by David Caygill, Minister of Health, when it was ready for publication, 'Guidelines for Standards for services for people with intellectual handicaps' remains as relevant now as when it was released in 1988. A distinguishing feature which Margaret negotiated was that it was in two parts, one in English, and the other in Te Reo.

A service standards document was subsequently developed. As it became clear this was a high profile exercise with a fine line between success and failure, the assistance of John Stacey, a British expert experienced in the field, was sought for two years to assist us to so that the outcomes really did fulfil the stated objectives. Originally seven years was to be the time allotted for fulfilment of the change but the closure of the last of the psychopaedic hospitals, Kimberly in the Horowhenua extended beyond that time frame. The management of the process had also returned to DSW by 1990. John Stacey also remains in New Zealand, these days as the Managing Director of Enhancing Quality Services, a designated audit agency for disability care homes and related services.

Another major guideline endeavour that I was involved with as a Departmental representative, along with the Service Planning Section, was the development of 'Strategic Planning Guidelines for AHBs for Services for Adults with Physical Disability'. Dr Tudor Caradoc-Davies chaired the working group, not an easy role. In his introduction Tudor wrote:

We have tried to strike a balance between excessive innovation and die-hard conservatism, perhaps going too far for some people and not enough for others. The role of community organisations is now emphasised. The historical phenomenon of rehabilitation service provision originating from hospitals still has its influence, but the role of community organisations is now emphasised. Some groups feel that any role for medical personnel is 'medical dominance', but we feel that the medical profession has a role in both leadership and development of services.

At times the atmosphere in the working group was such that the project nearly sank between bitterness and anger towards the medical profession and other health professionals, as though they were the fundamental instigators of disablement. It called for much patient listening without reaction that might bring on yet another diatribe. Even my writing this may well bring on more admonishment, but, having had a number of other parallel experiences, I find it very sad that a few, who are disabled from an early age are so bitter they spend much time railing against their fate that might be more fruitfully spent accepting their situation, enhancing their abilities and being happier people within themselves while thereby being stronger promoters of care for those in need. In my late teens, when one tends to view the world from a black and white perspective, Father urged me to resist being a fanatic, that, whatever one's persuasion, being extreme clouded a balanced objectivity around the pros and cons of issues.

The outcome is an interesting historical document of evident compromise, which did not hesitate to acknowledge the weaknesses of the system as it existed, as well as the positives. The focus of the guidelines was 'not prescriptive but aimed at innovative, output oriented services and devoid of defining services in terms of bed and clinic numbers. Development of services by Area Health Boards must take into account the presence and scope of local community services'. It was a difficult exercise but the way it was handled did allow all voices to be heard and recorded. There was indeed cause for some disquiet, both societal and of individuals, including paternalism and conservative approaches from a number of quarters, not just in health services but within education, workplaces and in the community, which are still being overcome.

_________________________________________________

### Funding for Care of Frail Older People [continued]

In mid-1988 the Minister, David Caygill, instructed our unit to revisit work on funding for the care of frail older people in conjunction with work already underway by DSW staff to implement restructuring of the Special Rest Home Subsidy. By early October 1988 a comprehensive review was sent to both the Minister of Health and the Minister for Social Welfare covering all aspects of care, other than that by GPs, whether in public, private of the voluntary sector.

A number of inadequacies were found to exist in the planning and funding of those services. In summary they were:

• a lack of a uniform funding system.

• a lack of comprehensive planning over all sectors.

• dual agency and inter-sectoral involvement.

• lack of equity.

• a bias towards institutional rather than home supported care although there were two pilot schemes underway - ' Hospital at Home', a joint project by the Tauranga Hospital Board Department for the Elderly and the Presbyterian Support Services in Tauranga, and Anglican Social Services Home Service in Hamilton.

It was not until mid-December that a meeting with both Ministers could be arranged by which time Helen Clark had assumed the Health portfolio. Meanwhile on the instructions of the previous Minister, the Review paper had been circulated to interested organisations, including the Hospital Boards Association, the NZ Council of Christian Social Services, the Private Hospitals Association and to Treasury for comment. All responded that they were basically in favour of the development of an integrated subsidy system for people who had been assessed as having certain levels of dependency. They were also in favour of real choice being available between augmented home support and institutional care. Consequently both Departments were told to work together on a joint proposal for change which resulted in a paper recommending the transfer of funding of all services for older people to Health. It also set out various options around means testing to apply to eligibility for subsidisation of institutional care, as the two Departments were employing different systems. The recommendation was that a uniform income and asset test apply to both residential and private hospital level care, both levels requiring either geriatric or psychogeriatric assessment prior to acceptance for a subsidy.

Further work by officials of DSW resulted in their raising the subject of former psychiatric hospital patients whose care was being co-ordinated by DSW upon discharge to community care while on either sickness, invalid and other financial assistance.

That in turn led to discussion about which department should co-ordinate care for intellectually disabled and physically disabled people at which stage the two Ministers decided, after deliberation, which was said to have extended far into the night, that Health should be responsible for older persons and psychiatric patients, while intellectually handicapped and younger physically disabled people should be the responsibility of DSW. On 3 July 1989 Cabinet ratified those decisions and agreed that an officials committee drawn from Treasury, Health, Housing and Social Welfare be formed to work on the question of the transfer of allocations and assets between Health, Housing and Social Welfare, a Committee which became known as the Health Welfare Interface Committee. It had to report back initially on 3 October 1989.

At the time of my appointment the priority had been to further development of AT&R specialist health services for older people. The regular statistical updates did indicate that coverage had improved throughout the country for Geriatric AT&R steadily over the 1980s. Psychogeriatricians were still scarce worldwide but we were slowly recruiting more of them as well. The real concern was whether the increasing numbers of very old, frailer people would outstrip the capacity of the specialist teams to assess, treat and rehabilitate in a timely, adequate fashion. The increasing numbers relying solely on home support called for a needs assessment process to uncover underlying risks and potentially treatable conditions before they became irreversible. We were still at a stage where too many GPs, and a few specialists as well, were saying to patients: 'What do you expect at your age?' rather than actively seeking out reversible conditions which would respond to treatment and the maintenance of function.

There was also a persistent assertion from Tim Burns of the Private Hospitals Association that a consistent assessment process was not a reality as feedback indicated there were variable assessments of the different levels of disability in the different regions. Nevertheless, whereas in the 1970s there had been a tendency for those in their 60s, who were only marginally frail, to be presumed ready for rest home care, by the 1980s that was no longer the case. Not only was the age of entry into care rising steadily, so was the complexity of their medical / mental health needs. We were not dealing with a static situation. It was evolving into one which had been predicted by James Fries in an article ' The Compression of Morbidity' in, The Gerontologist; Vol 24. No 4. 1984, where he postulated that the age of onset of significant disability might move upwards more rapidly than life expectancy, thus compressing morbidity into a shorter time period at the end of life. Fries also postulated that, as increasingly heroic technology was being utilised to combat inevitable death, then both individual morbidity and national medical costs might continue to increase.

At the same time sociologists, among other disciplines, who were studying ageing were also actively researching the changing scene. Peggy Koopman-Boyden wrote a Leading Article in the NZMJ, 27 July, 1988 ' Is Old Age Socially Created?' Peggy began:

Recently, there has been concern over the increasing medicalisation of the problem of the elderly, a process through which the medical community attempts to create a market for their services by redefining certain events, behaviours and problems as diseases. Azzarto [in Health Social Work, 1986;11;189-95] suggest that medicalisation takes place on two levels with respect to the needs of the elderly. Firstly, the medical needs---are more likely to be met than their social problems, and are more likely to be addressed by public policy. Secondly, as an implication of the availability of these health-related policies, professionals are more likely to redefine social problems in medical terms in the interests of their patients getting services.

Peggy went on to describe three aspects of the debate that old age is a social creation. Those aspects were said to be the notion of retirement indicating that a person was past their usefulness; that internationally dependency of older people had increased in two ways: dependency on the state has increased through the introduction of compulsory retirement and the establishment of the old age pension: dependency on the family has increased through changes in demography and family structure and the establishment of social services. Both forms of dependency have been socially created: the social structures of income inequalities and differential access to jobs, gender stereotyping, ethnic differences and age stratification are only aggravated by retirement. In her own research in Christchurch, Peggy found that in some cases, older men whose whole life had revolved around work, had never had much of a relationship with their offspring. In retirement when they tried to control them, in a similar way to employees, the children objected. When they tried to control their wives there was also rejection. She argued that gender stereotyping at an early stage did not fit those men at all well for retirement.

For me though the research that was a particular influence was expressed in an article by John Rowe and Robert Kahn in Science: Vol 237,10 July 1987 ' Human Aging: Usual and Successful'. Their argument incorporated both medical and psycho-social aspects of ageing. The first part dealt with changes in blood pressure, bone density and carbohydrate metabolism which we had been taught were age related but which had been found to be influenced by a variety of factors such as diet, nutrition and exercise, while the second part of the article covered the effects of circumstances which resulted in loss of autonomy and control, as well as loss of social contacts and support. Their arguments pointed the way forward through health promotion and disease prevention, not only for relatively healthy older persons, but also for those at risk because of ongoing chronic disease to maintain and improve their capabilities.

Peggy's article had also concluded that the argument that old age had been socially created did not deny that there also existed biological aspects to ageing and appropriate medical responses; that both the social model and the medical model could have preventive/ health promotion modes and that strategies were most effective when they were long term and developmental. One could also argue that a holistic model covers all bases.

While the range of research findings was steadily increasing our knowledge base and thus broadening outlooks, other changes were afoot. Those changes involved the health service as a whole. The replacement of all Hospital Boards by Area Health Boards [AHBs] was finally achieved by October 1989.

The Minister of Health, David Caygill had commissioned Alan Gibbs to produce a report with recommendations on the directions in which change should occur. The report 'Unshackling the Hospitals' focussed on two issues; the extent to which a publicly funded system could eliminate waiting lists and the mandatory separation between the funder and provider. The Minister rejected the funding split in his own paper "Health: A Prescription for Change" in which he asserted that, 'For the first time ever, voters will elect a group of people who will have total responsibility for public health expenditure in their community.' There was further emphasis on the community with the set-up of Community Health Committees and integration of care at a local level. The Minister wished it to be a truly indigenous New Zealand health system with a positive health perspective. The principles for change espoused would be holism; empowerment for the individual; cultural and social determination; equity of access and efficient use of resources.

An update of the Service Planning guidelines was needed to incorporate the AHB concepts. The philosophy of the 1986 Services for the Elderly guidelines was sound, but the revised version had to include outputs against which services could be monitored as well as a broader perspective including community involvement and health promotion. The psychiatric component was re-written with the help of Dr Barbara Symons, the psychogeriatrician at Horowhenua and Palmerston North. Altogether it was a more succinct document but, sadly, it was never circulated to AHBs because it was part of a package of revised or completely new guidelines, some of which were not appropriate for the 'Prescription for Change.'

Departmental staff underwent another restructuring process during which all staff had to reapply for what were to be new positions. The Department had also long outgrown its main site on Lambton Quay acquiring other nearby offices with increasing separation of staff units. So the change to a Ministry was also to be to a new site at the top of Murphy Street where it was hoped that everybody would be on one site. EDH would metamorphose into HOPP as the Health of Older People Programme became known. The term 'elderly' was by the late 1980s deemed to be ageist whereas 'older people', sometimes expressed as 'older persons' was deemed to be more respectfully acceptable. Elderly also implied homogeneity, whereas the major longitudinal studies of people as they aged demonstrated how heterogeneous or individually different older people were, more so than any other age group.

Even without those changes there were to be two retirements from the EDH team. Dr Bernie King retired on her 60th birthday in July 1989 and I was due to depart on my 65th birthday, 24 September, 1989 as medical staff were allowed to work a further five years owing to the 13 + years before both graduate and specialist qualifications were able to be completed. The September date was extended to fit in with the crowded timetable around the same time before EDH broke for the Christmas holidays. I was also seconded to be one of the interviewers of applicants for 2nd level positions, along with an outside consultant and administrative help. That had to be one of the hardest tasks I'd ever undertaken. Compared with the earlier restructuring this process was not a particularly happy one. There was an atmosphere of anxiety overall. Candidates were all too often stressed. In the end when the consultant, whose identity I do not recollect, and I found that our recommendations were quite often ignored, the consultant was angry and I was disillusioned. It made me feel grateful to be departing. I had so enjoyed working with our close knit, hard working team but that phase was at end. I was happy with who was to head HOPP. Sonia Pinfield [Easterbrook Smith] and I dovetailed together closely over ongoing issues, such as the Health Welfare interface, for quite a while before she was seconded to other work. Margaret Duthie was also with HOPP. The rest of the team scattered in different directions to other towns or Ministries but Bernie, until breast cancer took her life, Margaret, John and I have remained friends, as well as former colleagues.

References

1. Gardner J. ' _Towards a Self-Renewing Society'_ Godkin lectures, Howard University, April 1969.

2. Griffiths R. _'Report to the UK Government on the NHS Management.'_ 1983.

3. NZ Government, Area Health Boards Act, 1983.

4. Dept of Health, Elderly Disabled and Handicapped, ' _Guidelines for Standards for Services for People with Intellectual Handicaps'_ 1988.

5. Dept of Health, _'Strategic Planning Guidelines for Area Health Boards for Adults with Physical Disability'_

Feb.1989.

6. Dept of Health to Minister of Health _, 'Review of Funding for the Care of the Elderly'_ 6 October, 1988.

7. Cabinet[89] M 45/30 Health / Welfare Interface Committee 18 Dec.1989; 23 Feb.1990 CAB[89] M 26/17; CAB[89]M 45/30.

8. Fries J. ' _The Compression of Morbidity', T_ he Gerontologist, Vol 1, 24 Nov. 1984.

9. Koopman-Boyden P. _'Is Old Age Socially Created'_ NZMJ Leading Article, 27 July, 1988.

10. Rowe J., Kahn R. _'Human Ageing: Usual and Successful'_ Science Vol 237, 10 July,1987.

11. Gibbs A. Report to the Minister of Health, _'Unshackling the Hospitals' 1989._

12. Caygill D, Minister of Health, _'Health: A Prescription for Change'_ 1988.

13. Dept of Health _'Guidelines for Geriatric and Psychogeriatric Services for Older People'_ Dec.1989.

### Chapter 13

Transitions and New Directions

For most of 1990 retirement meant being retained on, initially, a part time basis and then, by May 1990, on an hourly rate as an advisor to HOPP, as they requested. It was an arrangement which suited Sonja and her team, while it also enabled me to ease into my own changed situation. There had been a change of Government by 1990 and Simon Upton became the new National Government's Minister of Health.

The briefing notes for the incoming Government included a detailed section on Continuing Care Services for Older People which made the point that services for people aged 65+ accounted for 36% of total Vote: Health expenditure. It was also pointed out that:

Although the percentage of 65+ population using continuing care is at present estimated to be between 7-9%, the percentage of those aged 85+ in institutional care rises to 34 % of that age group. These demographic changes will have a major impact on demand for continuing care services. Policy initiatives must, therefore, seek to develop effective health services which can be sustained in the medium to long term.

How HOPP was aiming to progress that work was by:

• promoting provision of home-based services to prevent inappropriate institutionalisation of older people.

• comprehensive assessment and re-assessment prior to entry to the full spectrum of services which would be undertaken by AHB Assessment and Rehabilitation Services.

• a system of open referral to A&R [moving away from the existing practice of mainly medical referral].

• a standard national assessment process.

• the ranges and levels of service to be monitored through the Minister's contracts with AHBs.

• the principles of the Treaty of Waitangi to be applied to policies.

In detailing steps being undertaken to co-locate all funding of services for 65+ people within Health it was stated that:

For older people a variety of means tests have grown up with different criteria in place for different services. Existing regimes work against maintaining independence for older people and are unduly punitive when compared with other client groups.

By February 1990 HOPP had provided the Minister with a more detailed paper about the actual steps needed to transfer funds and services. The complexity of the processes involved between departments was such that a timetable for complete handovers was to be extended to July 1991.

A working group was set up by HOPP which included Dr Fred Hirst, President of the NZ Geriatric Society, representing the geriatricians, to discuss issues around matters such as a nationwide assessment process, levels of dependency and who should be referred to A&R teams. It was argued that it might not be possible with existing staffing levels for all older people receiving domiciliary care only to be seen by the A&R team. It was therefore suggested that, if home support was required for longer than three months, then an A&R assessment should be sought. As assessment of individual need was central to the evolution of the system, the earlier criteria of bed guidelines for differing service levels was no longer deemed to be relevant. Issues around means testing were still to be resolved. There was also discussion as to whether the transferred monies should be ring fenced to protect them from being swallowed up by acute services.

A tendency to act without broader consultation was creeping in so I advised that it was also important to consult with AHB administration, the Private Hospitals Association and the Council of Christian Social Services if levels of dependency, assessment protocols and changes to means testing were to have credibility.

By October 1990 it was rumoured that there was a strong possibility of the whole Interface project being relitigated in the future. Meanwhile Bill Cowie of HOPP was steadily working on funding sources, as well as issues such as linking the assessments of need with indicative costs of services, along with opportunities for development such as furthering the Home Care 60s Plus service nationwide at a cost of $10.25m; and funding for the establishment of eight health educator positions with a special interest in maintaining the health and well-being of older people at $800,000 a year.

Just in case it might appear that I was not really changing course, there does exist a note to Sonja:

Wally and I are so involved with the International Arts Festival that I cannot commit myself to any departmental involvement March 3-24. If at any time you wish to discuss anything or clarify something do not hesitate to ring me at home. Incidentally for the future, Margaret Duthie is very good at commenting on draft papers. I often floated drafts before her or mulled over ideas with her. You will find her a real strength.

There was also an art course run by Jeanne McCaskill, assisted by Rosemary Stokel at, initially the Teachers Training College, and later a church hall in Karori, one morning a week. In the early 1960s I had done a correspondence art course in the UK, followed up by a live-in week at the University at Bangor in Wales and always felt it would be pleasant to return to one day. This was the first opportunity since that earlier experience. After a while I joined a local art group as well. It was challenging and stimulating, and I met interesting people. After nearly three years, as shall become evident, time pressure arose as more and more gerontological activity competed. I knew I should always be a so-so painter. One bonus is that it heightened an appreciation of others' artistic endeavours. Eventually by 1992 the gerontological issues assumed more importance.

In September of 1989 the Chairman of the Nurse Maude Association [NMA], Colin Averill, invited me back to Christchurch to launch the Nurse Maude Foundation, which was to provide funding and financial support for its parent body, the NMA, also a registered charitable trust. Income for the NMA had for a number of years been derived from a combination of grants from the Canterbury Area Health Board and public donations. Canterbury people have always been generous supporters of their established charitable organisations, but neither their giving nor the contracts with the DHB had kept pace with the demand for the Association's services. It was for that reason that the Foundation was set up to help direct and divest funds to cope with service needs in the future. As the AGM and launch ended, amidst being back in familiar territory with familiar colleagues, Colin mentioned that, having heard I was soon to retire, he hoped I would rejoin the Board of the NMA. Responding that we intended to continue living in Wellington, so it might not be feasible, Colin disagreed. He said he knew of a number of boards which had out of town members. It was a re-appointment I was keen to renew as the NMA embraced a philosophy of free community care for those in assessed need that really did make a difference for its recipients. I felt being part of it kept me grounded.

During 1996 not only did the NMA celebrate its Centenary but it was also awarded a new contract to provide a combined palliative care and hospice facility for the entire Canterbury region. Previously the Association had provided palliative care in the home only. Although a hospice area was able to be organised by mid-year in the Nurse Maude Memorial Hospital, the need for a purpose built hospice became urgent. Stephanie Waterfield, the then CEO, was the right person to manage that development. Caroline Cartwright and I were also designated by the Chairman of the Board to visit the two well established hospices in Wellington to better advise the Board around issues which might arise as we had been advocates for further palliative care involvement for some time.

For a policy and planning person being on the Board of the NMA was close to what people in need of health and wellbeing assistance so often desired, the capacity to be well cared for in their own home. From the first Monday of the month in February, 1990 I flew back and forth to Christchurch regularly until mid-2004. A bonus was that a friend from RNZAF Woodbourne days, Dorothy Hawks, would regularly be at airport and we would lunch together, sometimes with mutual friends, before being delivered to McDougall Avenue. After the meeting one or other Board member who lived not far from the airport would drive me back again.

The house we had bought in Khandallah in 1980 was convenient for shops, library and a railway station but, being in the shade of Mt Kau Kau, was devoid of sunshine in the winter. Upon both of us being retired from full time employment, we shifted to Plimmerton and all day sun, along with Nor' Westers in the Spring, but a blessed absence of Southerlies when Wellington itself was in the midst of a gale. It was several degrees warmer than Khandallah, as I soon discovered while driving back and forth, delivering pot plants and household goods over three weeks prior to the full shift.

We were rate payers and citizens of Porirua from February 1990. In conversation with the previous owner of 6 Taupo Crescent, another Margaret, she remarked that she was sure we would enjoy living where we were but suggested we probably would not shop in Porirua much as there were too many not very nice people there. A neighbour nevertheless suggested we might like to know there was a market every Saturday from early morning to 9am, as the central car park it occupied then reverted to its main function. Going to the market in Suva on a Saturday morning with mother and Williami, our Lauan cook, had been such a childhood pleasure, we were off to see what Porirua's version might offer. As soon as we arrived there was a Tongan lady selling uncooked crabs tied together in a vertical stack. When approached she said they had been caught earlier that morning and asked if I knew what to do with them with a query in her voice that indicated she assumed I had no idea. In no time at all we were swapping stories around crabs and fish in the islands. When Wally found he could have a bacon buttie there for breakfast too we both knew we had come to the right place to shop.

A few months later the local paper advertised a meeting to discuss housing for older people organised by the Porirua City Council. Deciding to attend resulted in meeting up again with Des Ryan who, upon retirement from his position as Deputy DG of Health Admin, had shifted to live in Titahi Bay. Des had earlier persuaded me to consider joining Hospitals Division to further older persons' health matters. Again he promptly urged me to join the Executive of Age Concern Wellington [AC Wgtn] as an honorary member. Lysbeth Noble, while in Wellington from her home in Wanganui, had also, shortly beforehand, made the same suggestion, which I had decided to consider, and so conformed to Des's request. Within a few days Norman Wright, the Executive Officer of AC Wgtn rang to invite me to the next Executive meeting, which began an ongoing resumption of involvement, both regionally and, in time, nationally.

In May 1989 Ailsa Bailey, the President of Age Concern South Canterbury, had persuaded Lys Noble, the National President, to help her seek funding for a National Workshop on Abuse and Neglect of the Elderly. Bernie King, Margaret Duthie and I were involved from EDH. That workshop recommended that funds be found for Age Concern NZ to develop a resource kit to both inform people and point the way to combat elder abuse and neglect. Towards the end of 1990 Odette Waanders, who had left DSW to become the CEO of ACNZ, rang to say that funds from a variety of sources, including a 'Celebration of Age' Telethon appeal, had been found, so a core working group could be set to work on the development of the resource, which she hoped I would join. After initially demurring, because I had begun to enjoy the relative freedom to go, for instance, on a university extension trip to Nor West Nelson for a few days, duty called for what was to become a major exercise, but one that was a real response to need.

When one writes that Odette had become the CEO, she in fact, in those early days of a National office, was the sole full-time employee. It was the same at Age Concern Wellington. Norman Wright, a retired school master was also the sole full-time employee and, only when it was realised that he was inundated with phone calls for assistance, was funding found for him to have an office assistant for two days a week. At that stage the two offices worked closely together for not just support, but also survival against the odds of constantly having to seek funding sources.

AC Wellington and National office had already worked together to establish guidelines for operating a visiting service for people in residential care who had no family or friends. Between them they developed what was called the Accredited Visitors Service [AVS]. As volunteer visitors needed both preliminary training and ongoing support, a paid coordinator was an additional requirement. Although the AVS was apparently a needed service, most older people lived in their own home, and even more of those people were lonely and isolated, but they were scattered and often hidden away, so setting up a parallel Good Neighbour Service [GNS] was a more complex operation. When National Provident agreed to sponsor setting up that arm of the service both Norman and I worked together with Odette to draw up service guidelines. In those days there was no separation of executive and operational functions. If an Executive member had skills, along with the time and willingness to be available, they became volunteer workers.

The working group Odette gathered together for the Elder Abuse project also included Ailsa Bailey, Peggy Koopman-Boyden, Verna Schofield, Parekotuku Moore, Jenny Michel, Bonnie Robinson, Odette and Jane Yoong. We met in Jane's home in Brooklyn, Wellington. From the start we decided to emphasise that elder abuse and neglect was preventable; that something could and should be done to combat it and to assist those affected, both the abused and the abusers, who were all too often family carers. 'Promoting the Rights and Well-being of Older People and Those Who Care for Them: A resource kit about elder abuse and neglect' was published in September 1992. By that time Odette had followed her husband to Australia and Jane Yoong had accepted her mantle. Jane herself wrote the Resource Book, sifting through the group discussions to sort out the essential elements. When Lottery Aged allocated funding for the establishment of seven pilot schemes, Jane and another member of the working group, including myself, visited the seven areas to hold a seminar prior to the establishment of each service.

In 1995 the pilot schemes were evaluated. Two years on from their establishment the seven schemes had received 350 referrals of which 90 were deemed to be 'complex'. In 1997 the Minister for Senior Citizens, Robyn McDonald, succeeded in obtaining extra funding to enable the range of EA&N services to be increased but there has yet to be complete coverage throughout the country. Elder abuse may be preventable but we are a long way from eliminating its depredations.

The development of the Accredited Visitors Service and Elder Abuse &Neglect Service, with subsequent employment of staff to organise the ongoing operation of those services, led to discussion at Executive level as to whether that was an appropriate direction for AC Wellington. From the days of Wally Lake being the sole part time employee, [his other role being responsibility for Presbyterian Social Services, including a children's home], he ruled that in 1967 the Board of Health Report on Care of the Aged had stipulated that Old People's Welfare Councils should only coordinate services; that, if it saw a gap and developed a new service, it should hand it over to an independent organising committee as soon as possible. Wally Lake also claimed in a written letter to Dr Barry Taylor that his view of Age Concern's role was that of the Department of Health.

Hearing that from Dr Barry Taylor, the Wellington Geriatrician, who was as well an earlier Age Concern Wellington Executive member, he then expressed his belief that the Department and Wally Lake's rigidity was holding back the growth of AC Wellington. I discussed the matter with Dr Barker. We realised that in fact the Department had never expressed any opinion; nor was that one of its functions. We were well aware that other Age Concern Councils delivered services, including managing centres for older people in properties which they either owned or leased. It was clear to both of us that the 1967 report had not been rigid at all. It had noted 'that the functions and emphasis of councils vary considerably.' In recommending the 'Functions of an old people's welfare committee' section [c] 'To encourage the establishment of new or supplementary services, usually through the Committee's constituent bodies, but sometimes by direct cooperative action' enabled flexibility. Hence Dr Barker suggested that I invite Wally Lake to discuss the issue. The meeting took place sometime in 1986 or 1987, though no written record of it was made as I trusted Wally Lake at that time, and have not retained old appointment diaries. Nor, Des Ryan assured us sometime later, did Wally Lake ever mention any such meeting to his Executive. Hence his viewpoint continued to govern AC Wellington's policy. It may have involved a conflict of interest on his part in that, while acting as AC Wellington's executive officer, he was simultaneously seeing himself as protecting Presbyterian social services. The upshot was a policy change in 1974 with an Executive decision to the effect that, where it was appropriate, AC Wellington should both develop and operate services. The Constitution and Rules were amended so that the purpose of Age Concern Wellington read:

To enhance the welfare and interests of older people in the region in a way which may seem practicable or appropriate either directly, or through the coordinated or particular efforts of constituent agency members or individual persons.

A further aspect that has always exercised the minds of Executive members was how best to publicise what Age Concern Wellington had to offer. Communication both at a national and local level is recognised as of prime importance. The Standards of Membership state that all member councils shall agree to:

• be an authoritative and up to date source of information

• maintain integrity and enhance their public profile

• promote networking and consultation within Age Concern and with public, private and community sectors about matters affecting older people.

Over time AC Wellington has explored several avenues. The Yellow Pages offered NGOs free space some years ago, but eventually charged AC Wellington $1000, so that was dropped and a newsletter initiated instead. 'Seniority' continues to be published and is widely distributed. Access Radio monthly interviews were held for several years but ceased when it was concluded that no one had ever said they had heard about Age Concern via that medium. Websites both national and local exist. Probably the best method of advertising our services is via the growing number of recipients and their families. The office continues to add to its leaflets, reports, information kits, videos and other means of gathering information. Whoever mans the phone is expected to be either able to deal constructively with whatever question is raised, whether it be able to be answered then and there, or require some investigation, or perhaps referral to another agency such as Community Law. Both staff and some Board members conduct seminars, quite often assisted by speakers on specialist subjects. Initiatives in which we are involved include the Safe with Age older driver courses, the development and now the Board of Well Elder Counselling

Service, and the Men's Sheds movement, along with the DSW contracted visiting and elder abuse services. Health promotion programmes are contracted by the MoH regionally. The relationships with other member NGOs and the local authorities are ongoing. Funding remains a challenge, and there is some angst about being so reliant on Lottery Aged's gambling source as a major financial source, but we would be hard put to exist without their input. As sustainability is an issue, a few years ago the Age Concern Wellington Charitable Trust was established to reduce the risk and to improve the ability to not only maintain but also improve and increase services over time.

In the middle of 1991 our health system faced the most sudden and immense change ever experienced. It was expressed so cogently by John Martin, who was Deputy DG Admin in the mid-1980s that his words best describe what occurred:

The abolition of elected Area Health Boards was an extraordinary political act. Extraordinary because it was announced in a Budget, making a mockery of the parliamentary process. Extraordinary because it was in sharp contrast to National's election policy. Extraordinary because it reversed, without public discussion, the way in which our public health system had been organised for decades. (John Martin, 'The case for local voice' in 'Health Reforms: a second opinion'. December 1992).

AHBs, 14 in number, had been locally run, coordinated and accountable both locally and to the Department via funding agreements. There had been increasing community involvement and co-operation along with improving financial management. After two years AHBs vanished overnight, their elected Board members surplus to requirements. In their place Government's Green and White paper, ' Your Health and the Public Health' of July 1991, proposed changes which would be implemented via a Health and Disability Bill. Also included was the funder/ provider split. Four Regional Health Authorities were to be the public sector purchaser of all personal health and disability services. A separate Public Health Commission was to advise Government on purchasing of public health services. Hospitals were to become Crown Health Enterprises [CHEs] which were to be run as businesses which would aim for a profit, assisted by user part charges for services. Not that the latter user charges in our previously free public health system lasted all that long. They were such a disaster both for the public at large and administratively, they were the first aspect of that massive change to disappear.

There was a hint of what was in store for health of older people in 'Your Health and the Public Health' but we had to wait for the detail until March 1992 when Jenny Shipley as Minister of Social Welfare and Simon Upton as Minister of Health presented their proposed changes in, 'Support for Independence: A discussion paper' on the funding and delivery of disability support services'. Health of older people had become 'age related disabilities', a label that aroused anger in people like Lysbeth Noble, who was furious at the implication all older persons were disabled. It was evident that although there were proposals such a funder / provider split and only having one Government Ministry responsible for purchasing support services which had long been sought, there was also the disquieting emphasis on disability in old age, with no mention of health promotion or disease prevention because that had been segregated off to a Public Health Commission, when it should be an essential element of both primary and secondary care. When the definitive document, 'Support for Independence: A New Deal', emerged in August 1992 our concerns were not only confirmed but it was even more worrying that a unit called Disability Support Services was to be set up within the Ministry of Health to have oversight of all DSS purchasing for the aged, younger physically disabled and intellectually handicapped from within a fixed, ring fenced budget. Knowing that both younger physically disabled and intellectually handicapped services were underfunded led one to deduce that there was an unstated plan to take funding away from older people's health to meet the other sector's shortfalls for community services. Assessment & Rehabilitation teams were to be in another ring fenced funding entity, Personal Health Services. Integration of older people's specialist health services had been lost nationally. It was under further threat with the new emphasis on a business model of competitive tendering for service contracts, as compared with the more integrative approaches under the Area Health Board system.

As the potential impact of those changes for the increasingly aged population sunk in around late 1991 I realised that there was no longer time for a combination of hobby art and gerontological activity. The former had become an indulgence; the latter had to again become the professional imperative. Rosemary Stokell and I had a somewhat sad discussion, and she probably thought I was being quixotic, which was a fair enough assumption if one took a short term point of view. Realistically I knew it could be a protracted exercise over at least one, if not more parliamentary terms, and I still had to work out just what would be the best tactics. At that time, as an independent consultant gerontologist who had links into several Non-Governmental Organisations, there were a number of possible approaches and alliances. The latter included Age Concern, both locally, as an executive member of Age Concern Wellington, and Age Concern NZ as an advisor and then Board member, as well as being an executive member of the NZ Association of Gerontology and a member of the NZ Geriatrics Society, the medical society which included the three Professors of Medicine of Old Age, John Campbell, David Richmond, and Dick Sainsbury.

References

1. Dept.of Health: Health of Older People Briefing notes for Incoming Government on Continuing Care Services for Older People, 1990.

2. Record of the National Workshop on Abuse and Neglect of the Elderly, 3-4 May, 1989.

3. Age Concern New Zealand, ' _Promoting the Rights and Well-being of Older People and Those Who Care for Them: A Resource kit about elder abuse and neglect',_ September 1992.

4. Board of Health, _'Report of the Board of Health Committee on Care of the Aged in New Zealand',_ Report series No. 13, September 1967.

_5._ Wellington Old People's Welfare Council, Constitution,25 August 1976.

6. Age Concern Wellington, Constitution and Purpose, July, 1994.

7. Martin J.' _The case for a local voice,' p22-23,_ 'Health Reforms: A second opinion,' Wellington Health Action Group, December, 1992.

8. New Zealand Govt. Green and White Paper, ' _Your Health and the Public Health' ,_ July, 1991

9. Minister of Health, Hon. Simon Upton and Minister of Social Welfare, Hon. Jenny Shipley, ' _Support for Independence,_ March, 1992 and ' _A New Deal,'_ August,1992.

### Chapter 14

Storm Clouds Gather

In 1992 NZAG Wellington, on rotation, resumed the National Office functions. From that time until 1998 I was the President of both the Wellington Branch and NZAG New Zealand. My membership of Age Concern Wgtn also changed from being an Honorary Executive member to being the representative of NZAG Wellington. From 1992-94, I was Deputy Chair and from 1995-98 President of Age Concern Wgtn. During that period I was also elected on to the Board of Age Concern New Zealand of which I became President in 1998 until 2002.

As well, mid 1992 saw the creation of a Ministerial Advisory Council for Senior Citizens [MACSC]. The portfolio of the Minister for Senior citizens was created in July 1990, the inaugural Minister being Margaret Shields. A six person Senior Citizens Unit, managed by Natalie Lavery was established within the Social Policy Agency of DSW to support the Minister. The purpose of the MACSC was 'to provide expert, independent and confidential advice on issues concerned with the wellbeing of older people'. That stated purpose indicated a one way advisory role which was debated at the initial meeting. Subsequently it was agreed older people should be better served if the members could also raise issues in discussion papers to the Minister.

Lysbeth Noble initially chaired the MACSC which also comprised Ronald Francis of Te Aroha Care Centre for the Elderly in the Hutt Valley; Pihopa [Bishop] Kingi, Te Arawa; Anne Opie, Health Services Research Unit, VUW; Te Pehi Tahau, Ngai Tahu. When Lysbeth pointed out to the Minister that the group lacked old age health input I was invited to join the Council in December 1992. In accepting I was well aware that it was an opportunity for direct access to the Minister, who frequently attended part of the meetings which were held every two months. Lysbeth resigned from the chairmanship early in 1993 after which I became chair until 1997. Margaret Earle, who had, upon the dis-establishment of her Health Educator position found an appointment with the Senior Citizens Unit, was the MACSC secretary and administrator. So we had the boon of a knowledgeable, helpful staff member and I was back working alongside a former close colleague. It was a fact of our engagement that any papers were confidential to the Minister. They covered a broad spectrum of issues including income and asset testing for institutional care; the monitoring process of rest homes; quality standards for home based care; mental health of older people and housing issues. The submissions we made, on the other hand, were public. They too ranged widely from a joint submission along with Age Concern NZ's Jane Yoong on Mandatory Reporting in relation to Elder Abuse to a Select Committee. We did not support mandatory reporting as we already had a problem of older people not coming forward for fear of reprisal, or for shame because it was a family situation. We had done research which indicated it was likely even more cases would be hidden if there was mandatory reporting. Other submissions were made to the Land Transport Safety Authority around "The Older Road User", the first of several to that body; to the Core Health Services Committee on the draft report "Care for Older People in New Zealand" and to the Securities Commission on Resident Funded Retirement Villages, which did help pave the way for more disclosure about terms and conditions.

It was broad ranging, absorbing work which took up quite a lot of time but in a way it was a side-line. We knew that, though we hoped we were acting in the best interests of older people, our views were only 'heard' if they fitted in with Government policy. We were not 'Yes Minister' lackies; nor did we effect as much change in policy as we wished, but at least there was evidence from feedback that our papers were read by the Ministers we advised.

The 1990s contractual purchasing policy fragmented away previous attempts to achieve an integrated, coordinated health service for older people. What is more the Ministry of Health ceased to see the need for a manager of older people's health. So a real vacuum eventuated. At the 1989 NZAG / NZ Geriatric Society Conference in Christchurch, after I had delivered an arranged address, 'Reflections of a Bureaucrat', Professor John Campbell had wondered who might replace me upon my pending retirement. I had responded that no one was indispensable, but it never occurred to me at that time that the actual position would be disestablished because older people were assumed to be disabled, a burden on society. The specialist service of A T & R was subsumed into Personal Health, another ring fenced entity along with acute medical and surgical services. Those who fostered those arrangements did not recognise there were marked differences in how older people react to health challenges as compared with middle aged adults, just as there are differences in how infants and young children respond compared with young adults, which has led to specialist paediatric services. There was no consultation with health professionals about that decision. In fact such consultation virtually ceased on the assumption that provider expertise would predominantly be concerned with patch protection. Patch protection did occur but the prevailing attitude of health professionals was to aim for the best outcome for their clients and the deliberate gulf created had the opposite effect from that presumed to occur.

Paul Curry, himself a paraplegic who had previously managed the Disability Resource Centre in Palmerston North, was appointed to be the Manager of DSS and Ted Gallen from DSW joined him. Margaret Duthie was the only survivor from HOPP, and it was made clear to her that her brief was solely to manage issues around the licensing of rest homes. The fact that HOPP had been focussed on client outcomes was either not realised or ignored because it perpetuated a 'medical model', whereas DSS purported to serve a 'social model'. In 2002 Anne Bray, herself a leading expert on disablement and handicap, wrote in her 'Review of Policy Development in Needs Assessment and Service Coordination in New Zealand', a paper prepared for the NZ Guidelines Group:

The promotion of a **simple,** social model of disability also appears to have led, in some quarters, to an inappropriate rejection of any focus on health needs, which is ultimately **not** a holistic approach. [The bold highlights are Anne's]

The ring fenced funding included that from Social Welfare for younger physically disabled, intellectually handicapped and older people. 63% of funding available for DSS came from services for older people and 90% of that funding was from residential care provision. It soon became known that it was intended that markedly underfunded community care for younger disabled and intellectually handicapped would be boosted by transfers from what was perceived to be overfunded residential care services. I decided it might be prudent to visit Paul Curry and Ted Gallen to discuss on behalf of Age Concern and NZAG whether they had taken into account that the fastest increase among older persons was of the very old, 85 plus population, the very population of which 34% occupied those residential care beds. So their capacity to find fat in that area might be thwarted by demographic pressures. I was also aware that in the Midland RHA funding for A&R was being transferred elsewhere within their DSS.

The atmosphere of our meeting was distinctly cool. When patch protection was mentioned I was in no doubt I represented the so-called medical model. It brought home to me that not only was there a different political agenda, that the pivotal role of A&R had been side-lined by officials as philosophically unacceptable because it was deemed to medicalise frail older people. Its team, and holistic approach, linking into both secondary and primary services was no longer the acceptable mode of delivery of services for frail older people. That was later confirmed in writing in a reply to a letter from Residential Care NZ in which Carol Searle, who in time took over the management of DSS, stated:

A support needs assessment is carried out with clients and/or their families in response from referrals from a variety of sources...... The assessment identifies the range of support needs of the client. This process is quite independent from the solutions / service coordination function.....

People are not 'assessed' for rest home care, rather they have their needs identified. Geriatricians have responsibility for managing access to Continuing Care facilities only.

That was so extraordinarily ignorant of what older people really needed I kept the letter to remind me of what geriatrician colleagues, who I was certain did have their client's reality uppermost, were up against. The DSS approach saw assessment as a quite separate process. They had no concept of assessment, treatment and rehabilitation undertaken simultaneously from day one; timeliness, additionally, being essential. It was expected that AT&R's initial assessment would take place within 72 hours of referral. There was so much fragmentation and bureaucracy that older people became confused and distressed by SNAP, the Support Needs Assessment Protocol, while the waiting times for assessment lengthened into weeks and months in some areas so that, what would have been reversible conditions, had become long term chronic conditions or. In some recorded instances the patient had died.

Fortunately there were leading geriatricians who responded publicly to the challenges they were facing. Professor Richard Sainsbury wrote a leading article in the 22 April, 1992 edition of the NZMJ, 'Health funding changes and comprehensive services for the elderly'.

Old age is frequently seen as a social problem with the financial issues of increased spending on health and superannuation, resulting in negative and dramatic terms such as 'burden', 'rising tide', and 'impending crisis'. Professionals and planners should view the ageing of the population as a challenge rather than a problem. This requires a positive response through the development of more flexible, responsive services that help preserve the quality of life and autonomy of older people...

Most people now accept a geriatric service as an essential part of any general hospital, and the elderly, acute patient should have ready access to all the facilities available for younger patients. Separating acute hospital treatment from assessment and rehabilitation has the potential hazards of denying older people access to diagnostic facilities and high technology and delaying rehabilitation, yet the suggestion has already been made that assessment and rehabilitation should be contracted to the private sector.

Studies designed to assess the effectiveness of assessment and rehabilitation units have been reviewed by Ruben who concluded that the evidence suggests they were effective, practical and vitally important. That could lead to better diagnosis, treatment outcomes, functional status and living locations and lower use of long term institutional services.

Dick Sainsbury concluded:

The recognition of acute illness in an elderly person is often made more difficult by atypical, nonspecific presentation and social crisis. Rehabilitation should not be seen as coming after treatment of an acute illness. Quality services for the elderly have the elements of prompt general practitioner referral, rapid response, equal access to diagnostic and treatment facilities and immediate rehabilitation from the time of illness and injury. These features must not be lost in any reorganisation or compromised through funding reductions.

Another set of issues was around a nationally consistent approach to assessment. Sonja Easterbrook Smith had initiated the work to develop such an instrument which eventually emerged as the Support Needs Assessment Protocol [SNAP]. Again Dick Sainsbury gave an assessment of SNAP itself at an Association of Gerontology meeting in Tauranga in March 1994:

The SNA Protocol is a nightmare. It started out with the best of intentions, namely to try and ensure uniform assessments throughout the country, to provide national guidelines and standards and to assist those units that were under-resourced. Its other aim was to encourage multi-disciplinary assessment and to increase the choices available to elderly people and their families. It was also hoped it would allow a move towards more flexible home based care. The adoption of the protocol has, however, caused major problems since RHAs have insisted on its universal application for older people requiring every institution and domiciliary service. At the same time there have not been major initiatives towards home based care. There is real concern that it could be used by RHAs to restrict services rather than allow freer access. The gravest concern of all is that people are so busy assessing a person's level of disability that they are losing the opportunity for skilled diagnosis and treatment. Filling in the form becomes the total exercise of assessment, rather than the protocol being something which should occupy a minor place at the end of a patient's treatment and, only when they have reached their optimum level of function. It is distressing to see elderly people being referred to a unit, having someone fill out one of these forms, a decision about support needs made on the basis of their untreated function, and then, everyone going away thinking they have done a good job.

I believe there are excellent opportunities to enhance and improve services to the elderly in the new health environment. This can only be achieved, however, if people recognise and retain the good things of the former health system while developing and properly evaluating service innovations. The elderly will suffer if competition between providers causes fragmentation of services, particularly if care of the elderly is not seen as part of the mainstream of medical care. It will also be important to ensure that assessment is seen as a multi-disciplinary clinical skill and not merely a grading exercise. The clinical assessment should be separated from any gatekeeping role on funding. In the final analysis, whether the health reforms benefit the elderly or not will depend on whether they have been implemented to increase the care options available and the amount of service delivered for every health dollar or whether, in fact, they are a cloak for a restriction on health funding.

In August 1993 I arranged for the Ministerial Advisory Council and the Senior Citizens Unit staff to invite Dr Jonathan Basket, the President of the NZ Geriatric Society, to discuss issues around older people's health. Jonathan gave an address covering the issues followed by a prolonged question time. Afterwards I wrote him a personal thank you letter which also took up some of the points we had discussed. First, there was the question of resources to cope with increased work load on A&R staff and others by the introduction of mandatory assessment and, secondly, the quality of performance of A&R units which, however good the team spirit, largely boils down to the quality of the performance of the specialist physician[s] in A&R units. Those two issues were not unconnected, and I felt there might be a danger, if we became too hung up on resource deficits, the quality component and its role in the effectiveness and efficiency of the operation might be overlooked.

I then wrote that, "over my years in the Department, we tried, with the help of all geriatricians, to monitor the staffing resources of A&R units and to foster an atmosphere whereby Boards appreciated the sound sense of having adequately staffed units. Nevertheless, in the late 1980s...we were writing papers in which we said that if a reformed system for frail elderly people with integrated, freed up budgets and mandatory assessment were to be put in place, firstly an injection of resource to build up A&R units to better strength was needed. We had a scheme for implementation which came to a grinding halt when the then Minister of Health, Helen Clark, decreed that nothing further would be done in that direction until services for mental health, younger physically disabled and IH people were solved in parallel time frames. When Sonja Easterbrook Smith took over the restructured unit the financial climate had changed with increased pressures to reduce government expenditure. So no policy was accepted by government unless it was able to be done within existing resources... It is at this point that quality of performance shows up most clearly. It is not so much clinical quality of performance as organisational, time and team management practises that are exposed. There is a management component in all medical disciplines whether consultants acknowledge that or not, and none more so than in health of older people if the whole person in their social, psychological, emotional and physical sense is to be helped. Questions arising were – "Is a management component adequately covered in specialist training to be a physician in health care of older people? What are the physicians in health care of older people doing themselves to monitor the quality of their performance?"

I went on to inform them that I became increasingly aware of those quality issues when the Central RHA asked me to do an independent appraisal of their purchasing plan for services for older people about which I wrote to my colleagues:

It is incumbent on RHAs to measure quality of performance and they are looking to develop quality measures for all services. One does not have to look very hard to realise that when an RHA encompasses a number of A&R units there will be a range of energy, effectiveness and efficiency... One aspect of quality could be in communication with GPs e.g. the time taken to inform GPs of outcomes and a sample audit of reports. Other quality measures could be built around outcomes, including of stroke and femur fracture. Does the Geriatric Society want to be pro-active in suggesting quality assurance measures or do you want what is imposed upon you?

Another issue is income and asset testing prior to entry into residential care. Although both the Board of Health Standing Committee on Health of Older People and the EDH unit had previously observed that ideally those services should be free, it was realised that would not be sustainable; that equity called for a uniform system and favoured income testing alone. Then when the implementation of policy occurred the economic constraints meant that income testing alone would cost the government revenue over time. So Government chose income and asset testing. In that respect the Ministerial Advisory Council did play a constructive role and I was able to mention that effect because the Minister had referred to it when he was interviewed by Hadyn Shirley on Take Five. What the Council recommended was that if income and asset testing was chosen the extra income gained should be kept within the system to help develop community care, and that a spouse at home should be allowed greater assets. Those recommendations were accepted as valid.

I was also able to inform the geriatricians that the Advisory Council had written to the four RHAs and the Public Health Commission to ask what health promotion and health prevention programmes for older people they were purchasing for the 1992-3 year in that period and what, if any, new initiatives they were purchasing.

An invitation to me to discuss the issues raised in that letter at a forthcoming Clinical and Scientific meeting did result in a decision to undertake a bench marking exercise as a step to ascertain how units compared with one another.

Meanwhile it was not just health professionals who were worrying as increasing numbers of older people were contacting staff of Age Concern Councils to help them sort out their confusion around SNAP, the SNA Form and what it all meant; why fewer hours of home help were allotted than their assessed need indicated. Waiting lists for cataract and joint replacement surgery were lengthening. Then there were cases like the woman who put off going to the doctor for acute abdominal pain because she was afraid he would send her to a public hospital, where she thought she would be asset tested.

Being more and more concerned about the effect of the changes in older persons health services I sought an appointment with Wendy Edgar, Programme Director of the Core Services Committee. She suggested that I write to Alan Clarke, Director of the Burwood Spinal Injuries Unit, himself a paraplegic and a member of the Core Services Committee as he was himself so aware of the need for timeliness in rehabilitation. That letter, read retrospectively, so embodies what health services for frail older people should encompass that I quote it at length:

Dear Alan,

This week I visited Wendy Edgar....to express concerns at the way one of the tenets on which health care of older people has been based since Dr R A Barker wrote it into health policy papers in 1973 has become submerged by the changes over the past few years. That tenet is the principle that early referral, intervention and active rehabilitation are essential to enable as many as possible to return to optimal physical, mental and social functioning. Parallel to that is the need for a clinical assessment to underpin the habilitative and rehabilitative direction of treatment. Therefore Assessment and Rehabilitation Units were always considered as part of the acute treatment system.

In 1986, the Department of Health issued Guidelines for Services for the Elderly. Although health structures have changed, the philosophy remains as pertinent now as it was then. That philosophy includes the fact that a great deal can be done for old people by prevention and early ascertainment of disease; that services for older people should be comprehensive ranging through health promotion and prevention to acute services and a full range of support services in both the community and institutions as need be; that the general and psychiatric components of services... should be closely linked.

When the Ministry of Health was restructured for the fourth time Disability Support Services separated out continuing care services for older people from the rest, on the basis that that funding for DSS was a ring fenced entity. At the same time the implementation of the so-called SNA Protocol emphasised the assessment side of the A&R team's roles and somehow in the process the rehabilitation role slipped between the official cracks. No one in the Ministry nowadays is responsible for the total range of health services for older people and very few seem to have institutional memory.

Professor Dick Sainsbury has been mentioning the separation of services for the elderly from acute services in speeches for the past year. When I first heard Dick on the subject at the AGM of the NZ Association of Gerontology AGM last year, I thought he felt that way because in Christchurch services for the elderly are in Healthlink South along with other so called Disability Support Services. Then when the 1994/95 Policy Guidelines for RHAs was published, I realised to what extent that separation is part of ministerial policy papers. On page 48 of that document Service Obligation: Secondary and Tertiary Medical Services there is no mention of specialist medical services for older people. One has to turn to page 58 Service Obligation: DSS to find assessment services and rehabilitation/ habilitation services. When those policy guidelines were translated into the CRHA's purchasing strategy for services to older people [copy enclosed] assessment and rehabilitation are mentioned together on the first page, but by the third page assessment has become the key factor. Although identifying and addressing reversible conditions is to be one of the aims of assessment, there is no reference as to when and how that rehabilitation is to be delivered.

Anecdotally social workers of A&R teams who have been given the additional duties of service coordination particularly, have rued the fact that they now have less time to assist clients and their families to adapt socially and emotionally to their changing circumstances. Hard data on the resource implications of SNAP implementation on the overall effectiveness and efficiency of A&R teams has yet to emerge.

So, after consideration of what might be the most effective action at this stage I visited Wendy Edgar to enquire if it might be pertinent for the Core Service Committee to have a consensus conference on the role of early intervention and rehabilitation for older people. Wendy told me that by June 1996 there may well be consensus conferences on:

\- Care of the Elderly: Core Services priorities

\- Chronic disabilities and the ageing population: Core priorities and personal priorities.

\- Management of dementia and Alzheimer's disease, although these subjects have to be officially ratified.

On behalf of the NZAG and my medical colleagues in the Geriatric Society - not to mention older people, well and not so well - I hope the Core Services Committee considers that there is not only merit but also some urgency to enunciate the principles and philosophy for health services in terms appropriate for the 1990s in New Zealand.

Finally, I do hope you enjoy your role at the Burwood Spinal Unit. I retain much affection for Burwood and the five years worked there from 1973-78. It was during those years that I began to be involved with health of older people, initially from a hospital board point of view. Burwood in the 1970s had a friendly, almost relaxed atmosphere but there was plenty of energy and expertise there too, as I am sure there is now.

With kind regards,

Yours sincerely,

Margaret.

Subsequently the Core Health and Disability Support Services Committee, which had a legislative mandate to advise on the content and access to publicly funded health and disability services, commissioned a report on Care for Older People in New Zealand. Professor David Richmond, Dr Jonathan Basket, Ruth Bonita and Dr Pamela Melding were charged with furnishing the report. Initially they produced a detailed questionnaire for the 23 Crown Health Enterprises and another for voluntary and private sector organisations involved with older people, both of which elicited detailed responses. The draft report was also circulated widely for comment and the final report was published in early August 1995.

I shall always remember the occasion of the launch of the Report as my husband, Walter Guthrie, had died after a massive cerebral haemorrhage five days before the launch, which I was to Chair as the President of the NZ Association of Gerontology. I was tempted to excuse myself, but decided against doing so because there might have been the temptation to then continue excusing myself. It was though quite a tough assignment at that time. Pam Melding twigged that something was not quite right, and questioned me accordingly. Later on that evening when I mentioned that I was booked to attend the Conference of the International Association of Psychiatry of Old Age which was to be held in Sydney in November 1995, Pam suggested I keep in touch as she would be there too. We ended up going together to 'The Phantom of the Opera' in Sydney one evening, which had our own Rob Guest as the Phantom. There were 13 New Zealanders, mostly psychiatrists of old age and one or two psychologists who attended that conference. It was the first time it had been held in the Southern Hemisphere, and very worthwhile it was too. As a non-clinical gerontologist, I also really appreciated being part of the activities, as well being able to get to know more of my clinical colleagues in person.

The report, while acknowledging much had been accomplished over the previous quarter century, noted five deficiencies including:

uneven distribution of health services for older people with smaller centres and rural areas being especially disadvantaged. Older age psychiatry and support for confused older people and their families being especially under-resourced. There were no national health goals for older people, or comprehensive plans for the future, and central leadership is lacking.

It was noted that, "If voluntary organisations are to function effectively and efficiently, co-ordinating and supporting a large groups of volunteers, some financial support is required for their small salaried administration and field officer services."

That particular situation has not changed so that voluntary organisations like Age Concern NZ and its 27 Councils exist by having to put aside any feelings of guilt of accepting monies raised by gambling, by applying each year for Lottery Aged funding to cope with administrative salaries.

Six goals were advocated:

• The development of a national set of policies for health of older people.

• Agreement on a national framework for comprehensive services for older people.

• That all staff in the provision of health services for older people be trained to work to the work level skills appropriate to their contribution.

• That decision making in health care of older people be based as far as possible on researched information.

• That networks between the government, community and professional organisations be strengthened and formalised.

• That every older person will have readily available information about wellness strategies for living, and about different types of support and their means of access to them, should ill-health strike.

To achieve those goals three major strategies were highlighted:

• The formation of a national body to formulate health goals and policies for older people.

• There should be national consultation about a framework of support for older people in various settings, both geographical and cultural.

• The formation of an inter RHA Research Purchasing Agency, along similar lines as PHARMAC, to commission and purchase research on health service policy and development for older people.

At the time of its publication the climate did not exist for the implementation of those goals and strategies but the report was a stimulus and it provided cogent arguments for voluntary and professional organisations to mount an ongoing campaign to seek the required changes.

The chapter Defining Priorities in Health Care touched upon models such as Diagnostic Related Groups [DRGs] which categorised diseases into groups which were similar from a clinical perspective, and should therefore have a similar pattern of resource use. While DRGs have been shown to be useful in categorising acute inpatient care they are not so applicable to the multiple diagnosis and complexities which affect older persons, nor do they assist when there is also a prolonged recovery time.

Similarly economic theory-based methods of distributing resources such as the cost-benefit analysis system of Quality Adjusted Life Years [QALYS] in which the cost of health care intervention is factored by the quality of the life years it generates. The worse the quality of life generated the lower the score. QALYS would discriminate against all disabled people including older people. As the Report stated:

Justifying the withholding of 'high tech' interventions from older people on the grounds that increasing age reduces the likelihood of benefit is flawed. Firstly, the cost of doing nothing for an older person may in the long run be higher than the cost of the intervention, especially if the individual then requires long term care.

Secondly, the notion that age per se determines a person's physiological function is based on generalisations which are not valid. The Boston and other longitudinal studies have shown that physiological functions of older people differ widely; some actually improve with age.

The Report and submissions made about it also led to the National Advisory Committee on Health and Disability being stimulated to follow up with other work such as a report on carers; guidelines on the treatment of Alzheimer's Disease and for the government to work with older people, and the community and business sectors to develop the workforce.

Three months prior to the publication of Care for Older People in New Zealand Jane Yoong, National Director of Age Concern NZ, published a report written in conjunction with a group of agencies who were concerned with the quality of life of older people. That group comprised Age Concern NZ; Alzheimer's NZ; NZ Association of Gerontology; NZ Council of Christian Social Services; NZ Licensed Rest Home Association and the NZ Private Hospitals Association. The report 'Services for Older People' was sent to Government Ministers, key government officials, Regional Health Authorities, major political parties and other interested groups such as the NZ Geriatrics Society. A covering letter stated:

This report highlights the importance for the government to work with older people and the community and business sectors to develop a strategy to cope with the increasing numbers of older people in our population and their changing and growing need for services.

In its Executive Summary the report made a number of points including:

• Old age is not a disability. Older people should not be classified as disabled and have their services defined under Disability Support Services. Older age is not a disability but a measure of time.

• More emphasis should be placed on health promotion, prevention and early intervention to maximise independence.

• Changes in Government policy have resulted in the transfer of responsibilities from government to families, communities and voluntary agencies. This has placed increasing and onerous burdens on unpaid carers of older people.

• An integrated and co-ordinated approach to the provision of a continuum of health care services must be implemented to maximise the well-being and health of older people to enable them to continue to fully participate in society.

• A full review of services for older people is required. We suggest a task force be established by the Government to identify current and future demand of services ... and to develop a comprehensive strategy for the funding, provision and delivery of those services.

At a meeting to present the Report to the Minister of Health, Jenny Shipley, someone suggested to the Minister that quality of care was being compromised by the fragmentation of services. There was a quick retort: "I'm not interested in quality; gold plating has no place in what I see as essential."

A shocked silence followed as we digested the apparent fact that the Minister equated quality with 'gold plating' whereas we saw quality's main dimensions for health services as safety, efficiency and effectiveness. There was an air about the Minister's presence that had us all realising that to attempt to argue around the issue would be pointless, but I found myself wondering how much self-educating she was undertaking around her portfolio, or if she was only interested in her ideologically set aims and objectives. Strangely but interestingly, in the following week at the Nurse Maude Association Board meeting we were informed that we had not been successful over an application for a particular contract because the Association was deemed to have a 'gold plated attitude', but the rationale for the opinion was not given. Hence the Board sought an answer and the response was that our orientation and education of home help staff was not necessary, they merely required to be engaged. The Board subsequently passed a resolution that our orientation and education of home help staff was essential preparation for safe practice, and we were not prepared to cost cut that programme, or the ongoing supervisory support of those staff members. Eliminating 'gold plating' seemed to equate with cutting back to the absolute basics, irrespective of safety issues for clients, in that climate.

'Services for Older People' did complement 'Care of Older People in NZ'. Its suggestion of the establishment of a Task Force furnished the Prime Minister, James Bolger, who was receiving complaints about health services for older people from multiple directions, with what would be in fact a delaying tactic by actually appointing a Prime Ministerial Task Force on Positive Ageing which met for the first time on 14 May 1996.

The Task Force was chaired by Sir Ross Jansen, a lawyer who was also the chair of the Midland Regional Health Authority. Members were Mr David Harrison, Professor David Richmond and Ms Sue Suckling along with Alan Nixon of DSW who was an ex officio member as the senior member of the Department charged with servicing the Task Force.

The terms of reference were very wide. The Policy goal stated that:

1. Having addressed retirement income through the Multi-Party Accord, the Government now wishes to explore the issue and options for promoting positive ageing in the population. The Government's objective is to develop public consensus on:

a. the environment that is necessary to ensure that people move through their lives towards a healthy, independent, safe, secure and dignified old age in which they are able to participate in and contribute to society, to the extent of their abilities and wishes, and enjoy respect and support of their families and communities; and

b. the measures that need to be taken by individuals, families, local communities, employers, voluntary organisations and Government to achieve this end.

There were then two pages of 'Descriptions of the Task', beginning with a review of the work that had already been undertaken by the National Advisory Committee on Core Health and Disability Support Services. Also included was an exhortation for the members to consult comprehensively with both the general public and a long list of what were deemed to be relevant groups and organisations. The Task Force spent so much time trying to fulfil all those obligations that it became known there was pressure imposed to complete the tasks and furnish a report. At that stage Deborah Moran, who had succeeded Jane Yoong as National Director of Age Concern NZ, learnt that there was an inkling that Professor Richmond was feeling that health issues were being side-lined. So Deborah, the then President, and I managed to arrange a further meeting with the Task Force on the last day of its consultations.

It was indeed fortunate that we did have that meeting because quite soon Sir Ross Jansen remarked that he understood there was no difference between the health needs of older adults as compared with younger and middle aged adults. That opinion was not too surprising as it was in the Waikato that funds had earlier been diverted from AT&R Services for Older People towards other 'disability' services. I had anticipated that discussion by preparing some notes on how changes due to age as such affected how older people's systems reacted to illness or trauma. David Richmond quickly endorsed the approach, ending by suggesting that I submit a written statement. That was agreed, provided it could be done within the next 24 hours as the final text was being written. Subsequently Appendix D; Disease Effects in Old Age, a condensed version, did appear in the Task Force's Final Report.

### Disease Effects in Old Age

1. Both individuals and their doctors may mistakenly suppose that symptoms e.g. aches and pains or memory loss, are merely manifestations of the ageing process and accept them as such. In fact many symptoms may be the result of treatable conditions.

2. The ageing body's homeostatic mechanisms; that is the system's response to trauma and illness, react less effectively than those of younger people. Both physical and mental deterioration in an older person can be rapid and difficult, or impossible to reverse if there is failure to detect that a disease is present. Hence timeliness of response is important.

3. Ageing impairs the ability of the liver and kidneys to detoxify drugs. As a result, older people have more complications than younger people from medical drugs and should be prescribed the lowest possible dose of any drug to gain the needed therapeutic effect.

4. Older people are two or three times likely to experience the combination of physical and mental disability than younger people. Older people also tend to have multiple diseases, most of which are controllable with appropriate medication.

5. The symptoms of many diseases in older people may vary quite markedly from symptoms of the same disease in earlier life. For example, pneumonia is usually characterised by a cough, high fever and high white cell blood count in children and adults. In older adults there may be nothing but a cough. The typical chest pain of angina or a coronary is often absent in older people. They may just feel more tired than usual, or develop unexplained heart failure.

6. Mental illness in older people is often unconsciously manifested in a physical way. For example, a depressed older person rarely says "I am depressed", "I feel miserable". They say, "I have a headache that will not go away" , "I cannot sleep", or " My food does not agree with me".

The Task Force also endorsed the recommendations of Care for Older People in NZ 'as an authoritative basis for ongoing policy', assuming the Transitional Health Authority would assist by improving the consistency and continuity of care. Appendix E - Vision, Values and Goals:

Vision: People ageing confidently with increasing richness of life.

Values: Respect, responsibility, opportunity.

Goals: The 15 goals tended to be so general and, in some instances, so unrelated to the body of the text, without any attempt at prioritisation, to that the Task Force Report was side-lined almost immediately e.g. the one specific health goal was:

5 There is a community-wide commitment on the part of people to maintain their own health and well-being.

Resources:

11 Allocation and management of resources are driven by outcome-based approach and long-term, holistic and investment- focused philosophy.

Yet there were recommendations such as that a new Senior Citizens Division should be developed from the existing Senior Citizens Unit to implement the recommendations of the Task Force, as well as a recommendation that a National "Work and Age Conference be convened to highlight and debate new research and ideas that explore the relationship between work, both paid and unpaid, and age", which would have called for increased Government expenditure with no argument or evidence that positive outcomes would eventuate from those proposals let alone any attempt at costings.

The sad reality was that a great deal of time and resources were spent on a Task Force which in the end made very little difference. The report itself was compiled in haste, which shows in a number of errors of both omission and commission; unfortunate when so much energy employed in consulting widely was in effect wasted effort.

Health policy overall had become such a major political issue that the Listener of 1 November 1997 had an article by Denis Welch, 'The Nation's Health',stating: "With the health system in crisis, government, politicians seem immune to the public cry that enough is enough." Beside a photo of George Salmond, former Director General of Health, was his statement: "We blew the whole thing up and now we have a bunch of fragments and there aren't any established policies to put bits back together."

If someone in years to come happens to read that article without much background knowledge they may think that George said 'we' because he was part and parcel of 'blowing the whole thing up' when in fact he was the former DG because when, as DG of Health he listened to what the new Minister of Health, Simon Upton planned to do by means of his ideologically based application of market forces reforms on the health system, George unhesitatingly said they would not work. Gordon Davies, the Deputy DG Administration, a man very knowledgeable about health systems worldwide, who was also present that morning, concurred with George. The upshot was that the two top health officials proffered their resignation that day because they were convinced what the Minister was proposing was unworkable, a stand which made their own positions untenable. Time proved them right. Market forces do not lead to accessible, safe health systems for societies as a whole.

A year or so later, catching up with George one day, when I was letting him know the shambles health of older people had become, he shook his head and said: "I knew it would be bad, but it has turned out even worse than anticipated."

I was grateful to have reached the stage professionally where I was a free agent, no longer bound by the terms and conditions the civil service necessitated. Nevertheless I was grateful for that decade during which I had come to grips with what was required of a gerontologist working in the field of policy and planning - well more or less - as one never ceases to learn. That grounding was an important background for the later battle to overcoming the effect of the imposition of market forces to work towards an effective, accessible health service for an increasingly ageing population. George himself remarked that I probably did my best work after 'retirement' but then neither of us actually believe in retirement as withdrawing from effort. One changes direction, but to age positively, one keeps on living each day as if it matters.

References

1. Guthrie M. ' _Reflections of a Bureaucrat'_ Address to the 1989 New Zealand Association of Gerontology / New Zealand Geriatric Society Conference, Christchurch NZ.

2. Bray A. _Review of Policy Developments in Needs Assessment And Service Coordination in New Zealand: Paper prepared for the NZ Guidelines Group Project on Guidelines for Assessment of Older People,_ July 2003

3. Searle C., General Manager Disability Support Services, Health Funding Authority, letter ' _Referrals to rest homecare'_ 'Home News' Feb/March 2000.

4. Sainsbury R. ' _Health funding changes and comprehensive services for the elderly'_ Leading Article NZMJ 22 April,1992, p143-4.

5. Reuben D.et al. _'A Randomised Clinical Trial of Comprehensive Geriatric Assessment in the Care of Hospitalised Patients'_ New England Journal of Medicine, 1995, 332[20]:1345-50.

6. Reuben D. et al, _'A Randomised Trial of outpatient Comprehensive Geriatric assessment Coupled with an Intervention to Increase Adherence to Recommendations, '_ Journal of the American Geriatrics Society, 1999,47,269-276.

7. Sainsbury R. ' _The Effects of Health Reform on the Elderly'_ Address to Association of Gerontology meeting, Tauranga, 21 March, 1994.

8. Guthrie M. to Baskett J.letter re Dr Baskett's presentation at the Department of Social Welfare / MACSC,2 August,1973.

9. Baskett J. to Guthrie M. response and invitation to present issues to AGM NZ Geriatrics society re quality of performance of AT&R Units, 27 August, 1993

10. Guthrie M. to Clarke A.,Director of Burwood Spinal Injury Unit / Chair,National Health Committee,28 June, 1994.

11. Richmond D.,Basket J.Bonita R.,Melding P.,' _Care for Older People in New Zealand: A Report to The National Advisory Committee on Health Services in New Zealand,'_ August 1995.

12. Age Concern New Zealand, Alzheimer's NZ,NZ Association of NZ,NZ Council of Christian Social Services, NZ Licensed Rest Homes Association,, NZ Private Hospitals Assn. _'Services for Older People'_ 22 May,1995.

13. Prime Ministerial Task Force on Positive Ageing, _'Facing the Future; A Strategic Plan. T_ he Final Report, July,1997.

14. Ibid, Appendix D: Disease Effects in Old Age.

15. Ibid, Appendix E: Vision, Values and Goals.

16. Welch D., _'The Nation's Health,'_ New Zealand Listener, 1 November 1997.

### Chapter 15

Complimentary Exertions

Amidst all the health debate negatives there were some positives including;

### Public Health Group publications

Appendix F of the Report of the Prime Ministerial Task Force on Positive Ageing is headed 'Ministry of Health Public Health Group Goals' with no further explanation. One presumes the writers had read the 'The Health and Wellbeing of Older People and Kaumatua: A discussion document' which was published in April 1997 some 4-5 months prior to the publication of the Task Force Report. In the background Paulette Finlay, was its principal though unnamed author and herself an active member of the Wellington branch of the NZ Association of Gerontology. Paulette described how between 1993-4 the Public Health Commission identified and recommended six national public health goals in their publication, 'Strategic Direction to Improve and Protect the Public Health', 1994. The goal and objectives for older people and kaumatua were:

Goal:

To improve and protect the health of older people and kaumatua.

Objectives:

• to maintain and improve mobility amongst older people and kaumatua.

• to reduce death rates and disabilities from injury.

• to protect older people and kaumatua from preventable infectious diseases such as influenza.

• to reduce death rates and disability from depression and promote mental health.

• to reduce disability from incontinence.

• to improve and maintain social support for older people and kaumatua.

In its comment on Health and Wellbeing of Older People and Kaumatua the Ministerial Advisory Committee on Older People suggested that an additional objective could also be:

• to promote policies which are consistent across Ministries to improve housing and transport issues for older people and kaumatua.

There had also been a June 1996 discussion document from the Public Health Group, 'Mental Health Promotion and Mental Well-being of Adults Including Older People', which on page 31 recommended:

• Needs based support for older people living alone, those experiencing social isolation as a result of disability or chronic health problems, and those experiencing a major life transition such as retirement, bereavement, or diagnosis of a major life threatening illness.

• Developing positive community attitudes towards the role of older people in society.

Again the Ministerial Advisory Committee suggested that a further recommendation should be: "Recognition of early depression and early dementia in older people."

### Bibliographies of Research on Ageing

Cresswell and Wade edited the earliest bibliography of research on older people in NZ in 1971. The second follow-up bibliography was compiled under the auspices of the Health Services Research and Development Unit of the Department of Health by Angela Wither and Ian Hodges covering the years 1972-1985. The third bibliography was a collaborative effort between BERL [Business and Economic Research Ltd] and the NZ Association of Gerontology, when I was President. The project supervisory group was Margaret Duthie, Dr Bernie King and me, along with the two assiduous authors from BERL, Ana and Marg Gilling. The resulting Annotated Bibliography of Research on Older People in NZ covered from 1986-1996. Three major themes emerged.

First was the sheer scope of gerontological research extending to over 600 entries for the decade, as compared with 350 entries in the 1972-1985 edition.

Second was a change from research, which treated older people as a subject group, to research which treated older people as central to the research, involving them in the development, process and evaluation. Third was the perceived need for a wide ranging NZ programme of research on ageing which would involve older people, those working in the aged care sector and the research community. It was also deemed important to regularly update the Bibliography.

When it became evident that demand was such that a reprint of the 1986-1996 bibliography, NZAG, not being geared towards developing a sales arm, as compared with the free availability of the initial print run, we handed the 2nd print run to Age Concern New Zealand who then sold it at $15.00 a copy.

Demand was steady but when, in turn, it was evident that a further update was due Age Concern NZ did not have the capability to undertake that process, so I negotiated on their behalf with the recently formed NZ Institute for Research on Ageing [NZiRA] to take over the project on an ongoing basis, which was very much in tune with their objectives.

___________________________________________

### Sik Hung Ng, Professor of Psychology at Victoria University 1992-2000

### and subsequent developments leading to the 40 + Projects and the New Zealand Institute for Research on Ageing which was he shortened to the NZiRA.

Professor Ng's appointment to Victoria University of Wellington really stimulated a spate of research activity and scholarship centred around ageing and diversity to the Wellington scene. He mentored others associated with the Psychology Department including Ann Weatherall, Jim Liu, Susan Gee, Cynthia Loong and Kathy Glasgow with a consequent impact on the sector, not only upon those working in the aged care sector but also those involved in all aspects of ageing, including the Senior Citizens' Unit, members of the NZ Association of Gerontology and Non-Governmental Organisations such as Age Concern NZ and its Councils.

My own initial acquaintance with Sik Hung was when I was among those invited to the Psychology Department to meet staff involved in research on intergenerational relations and positive ageing as well as some of the elderly Chinese and European New Zealanders who were research participants. We learnt that the project aimed to explore three issues:

• Generational Cohesion; social cohesion between older and younger generations within the family and in the public arena.

• Life transitions in middle adulthood.

• The well-being and contribution of older adults.

The interim findings of that project were presented along with others emerging from the 40+ Project of the Psychology Department at what came to be biennial Conferences from 1966 onwards until June 2002, after Sik Hung had left to return to Hong Kong in December 2000. The final report was published in Vol 4 No1, 2002, p45-63 of the Hallym International Journal of Aging, as 'The Veneration Gap: Generational Dissonance and Well-Being Among Chinese and European Parents', Susan B. Gee, James Liu, Sik Hung Ng. It was found that:

The acculturation of younger generations may threaten the solidarity of Chinese families in Western Countries. Generational dissonance between parents and their adult children may be particularly distressing for Chinese parents given the key role of family, respect for parents, and family harmony in Chinese cultural values... Results showed that Chinese parents perceived greater generational dissonance than European parents. Greater generational dissonance predicted poorer subjective well-being and was also associated with depression in the Chinese sample of 100 Chinese NZers. The results challenged over-idealised views of Chinese families, and encouraged a greater recognition and response to the potential information and service needs of Chinese families in Western nations.

It was research of particular interest to me as my eldest daughter's husband was born and brought up in a Malaysian Chinese family instilled with traditional family values which he, in turn, also passed on to his three sons.

At the closing Address of the 1998 Conference Sik Hung introduced Te Ripowai Higgins of the Maori Studies Department of Victoria University of Wellington as they had agreed a third stream of Maori who were ageing should be also researched in a comparable manner to the two earlier streams but, because ageing occurred earlier in Maori, it was a 30 + project. Such cross departmental activity was typical of Professor Ng's approach. He worked hard to foster collegial relations with not only academics of other disciplines within the University, including with Judith Davey, who was to eventually succeed Sik Hung as Director of NZiRA after 2000, but also with other relevant agencies such as the Senior Citizens Unit, Age Concern New Zealand, The NZ Association of Gerontology and Tower. The latter organisation became the Principal Sponsor of not only a Conference but also, separately, on behalf of NZiRA, of the Tower Visiting Fellows for a five year period.

Age Concern NZ was actively involved in that 2002 Conference. As National President at that time I gave an address, 'Learning from the Past. Looking to the Future: Health Care in New Zealand' on the opening morning, while Claire Austin, the CEO, discussed 'National Policy on Ageing' in the section entitled 'Hot Topics' on the second afternoon.. In that same section Colin Blair, the Retirement Commissioner discussed 'Changing Nature of Generations', Pam Purdon of Greypower dealt with '50+ Issues', and John Jenson handled 'Retirement Income Policy: Principles versus Politics'.

It was also Professor Ng's dream that research on ageing should be promoted and coordinated throughout New Zealand. In an interim report on 'New and Priority areas of research in the Faculty of Science: Ageing', he concluded:

The very nature of contemporary ageing research is multi-disciplinary. Investment put in promoting multi-disciplinary collaboration, both within the Faculty of Science and between FOS and other faculties, has the potential of positioning VUW to become the national focus of basic and applied research on ageing at the postgraduate level. These ground-level activities would give further substance to the current proposal of setting up a cross faculty New Zealand Institute for Research on Ageing, which in turn would facilitate those activities by enhancing collaboration, raising funds from external sources [businesses and government], and linking with academics to end-users.

An Interim NZiRA Working Group was set up in the late 1990s to establish the purpose, structure and activities of NZiRA, the role of the working group and its successor, the Interim Advisory Board [IAB]. Sik Hung led the Group and then the IAB while Susan Gee acted as Secretary/ Administrator. Wellington based members including those from agencies which had been closely involved all along including Age Concern NZ and NZAG, both of which I represented, Professor David Richmond from Auckland and Sally Keeling from Christchurch were also members. As we were all acting in a voluntary capacity the latter two mostly joined meetings via teleconferencing, with occasional attendances in person.

On Friday 24 August 2001 Susan was able to email everyone that funding of $50k per year for three years to firmly establish the Applied Research Centre had been granted. A business plan including a budget was to be developed no later than 31 October 2001.

But a change of personnel had also taken place. Having inspired the inauguration of the NZiRA Professor Ng took stock of his 28 year absence from Hong Kong and decided it was time to return home, a return to head the Department of Applied Social Sciences at the City University of Hong Kong. He wasted no time organising a Symposium on Ageing and associated workshops to explore the development of research projects gerontologically. The first I knew about it was a phone call inviting me to present a paper to the Symposium and to participate in a workshop on Older Men in the Changing World, among other activities during the week of 20-27 May 2001. We agreed that my subject would be, 'The New Zealand Positive Ageing Strategy - Its genesis and implications'. I flew out of Auckland on 20 May feeling it was going to be a stimulating experience. Indeed it was. A short report written after the return to Wellington imparts the essence of that week:

It was 17 years since I had last been in Hong Kong. There was not just a vast new airport to one side of Lantau Island, but there was a spectacular suspension bridge, the longest in the world, and many, many more tall blocks of flats in clusters that were obviously home to thousands of citizens. The sheer density of housing makes one feel humble about our casual acceptance that we have living space in abundance. On the one hand Hong Kong has made a superb effort to house what are officially 6.7 million people [unofficially 8 m]; but on the other they live like ants. It was put to me by NG [NZer's nickname] that though the flats are tiny, the rents are low so that families have more to spend on essentials and education. When one thinks of the living conditions of the least well off in some cities, such as those in South America, the people of Hong Kong are comparatively well housed. Hong Kong also has eleven tertiary institutions serving thousands of students of which the City University is a vibrant example.

The workshop on Older Men began with Professor Jordan Kosberg from the University of Alabama Endowed School of Social Work talking about, 'The Invisibility of Elderly Men with Social and Psychological Needs within a Changing Society'. He was followed by Professor Philip Evans, Director of the Graduate Centre, School of Social and Behavioural Sciences at the University of Westminster, London, whose subject was 'Life Events, Life Satisfaction, Health and Immune Function in the Ageing Male'. I was invited to add observations. We all agreed that, especially if they become ill and disabled, or lose their spouse, men are more prone to undiagnosed depression for which they all too often do not seek help. One consequence is a rise in suicide rates for older men. So there are real gender issues for older men that are common to more than one society, though there may be variations on that theme in different cultures.

At the symposium itself Jordan and Philip gave more general accounts of their subjects, after I had presented my paper on the New Zealand Positive Ageing Strategy. At question time a senior official of the local Health and Welfare Secretariat bemoaned her difficulty in trying to persuade the Hong Kong Government to put more energy into such a strategy. When she said, 'There is such an emphasis on business here', I wondered if she might obtain more interest if she suggested there was a burgeoning market among ageing people. It did result in an interesting exchange. Mrs Fung now has a copy of the Strategy document and will I am sure use the research potential of both the City University and the University of Hong Kong, both of which have strong research arms.

Finally, though he did not actually present papers Richard Gribble, who is the Professor of Psychology at Cornell, New York, chaired the Symposium. He in turn left us copies of his papers on, 'Creativity and Ageing' which stressed the importance of retaining flexibility and innovativeness if one is to age well.

It was a joy to be in such stimulating company. There were some splendid meals together and Sik Hung and Grace Ng saw that we all did and saw as much as possible. On Sunday 27th I was to catch a 6.30 pm flight back to Auckland but not before we had a trip to the great Buddha at the Po Lin monastery up in the hills of Lantau. Grace said it might be 'tight' fitting it in. It was. I just made my appointment with the airport shuttle; but what an exciting ending to a remarkable week."

Back home again Judith Davey, as the new Director of NZiRA, was energetically involved with bringing Tower on board to fund a visiting NZiRA Fellow to undertake a nationwide lecture tour, as well workshops and other meetings both with relevant individuals and groups. The media, print, radio and TV were engaged for interviews so that the general public could also be informed about the recipient's area of research. The initial Tower Visiting Fellow was Professor Anthea Tinker, King's College, London whose research on long term care had shown that staying in one's own home was the best option for older people, enhancing physical and mental well-being by engendering feelings of autonomy and control gained from one's own environment. That led her to promote models such as co-resident care, intensive home support, assistive technology and very sheltered, extra care housing. Anthea Tinker's messages did arouse much interest and publicity.

When it came to deciding who to invite to be the second Tower Visiting Fellow I suggested Professor Jordan Kosberg as New Zealand's older men were in need of a champion to tell them it was OK to admit their self-esteem took a tumble if and when they became disabled by illness. Jordan also had a research background in elder abuse and neglect which he agreed to discuss. Coincidentally, as had happened with Anthea, there was an effort to see that in between the working part of their sojourn they had opportunity to see parts of the country and to be entertained in our homes.

It was a real pleasure to be able, in turn, to have both of them at home in Plimmerton for a Sunday lunch along with other members of the Association of Gerontology.

Judith's own research, often in co-operation with others including Susan Gee, led to NZiRA publications such as 'Life at 85+: A Statistical Review', and 'Aotearoa Ageing: An Annotated Bibliography of the NZiRA', both of which involved Susan Gee as collaborator.

This is not able to do justice to the full story of NZiRA but upon Judith's retirement when Sally Keeling inherited the role of Director on a half time basis the funding cuts the VUW had begun to impose impinged on NZiRA. In a personal reply to my questions about those cuts Judith wrote in an email:

About 6 months before the end of Sally's three year contract as half time director of NZiRA, the decision was made by the university that the institute would be closed and 'transferred' to the Institute of Policy Studies. Sally stayed out her contract time, although it was suggested she might resign. As Senior Research Associate, I have been carrying what is left of the NZiRA banner, although I have no official status - being an unpaid hanger-on at the IPS. However Geoff Rushbrook and Bob Stephens, also Associates, are interested in policy on ageing, especially retirement income policy. The three of us have run seminar series, a conference and published in the area, under the IPS...We have been asked by the Retirement Commissioner to organise another conference in early 2013 to contribute to the review of retirement income policy that year.

A sad state of affairs, particularly at a time when ageing policy is so relevant, raising issues around intergenerational conflict and sustainability among other matters.

### Ageing is Living – Age Concern NZ

During a period in the mid-1980s when health promotion was not high on health policy agendas, it was heartening that, when the position of Health Education Officer attached to the North Shore Professorial Unit was dis-established, Dwayne Crombie, then CEO of the Northern RHA, offered the salary involved to Age Concern North Shore to manage health promotion programmes on behalf of the seven Northern Region Age Concern Councils. Later in 1998 the Northern Regional Health Authority's Robin Northey also negotiated with Age Concern New Zealand to develop what has become the, 'Ageing is Living' project.

Without those initiatives there would have been a period in the 1990s when health promotion for older people would have had no funded health promotion focus.

The aim of the project was to develop a resource to:

• explore issues of ageing in NZ society.

• identify the contributions of older people.

• challenge attitudes, myths and stereotypes that create barriers to participation.

• describe elements of positive ageing which encourage an increase in physical, mental and social activity.

• identify strategies for the prevention of depression in older people.

Initially Kathy Glasgow was recruited to coordinate the project. Then a working party was set up to provide input and advice which was to be chaired by me as President of Age Concern and a member of the NZ Association of Gerontology. The working party also included:

Claire Austin, CEO ACNZ

Iris Mahuika, Maori Women's Welfare League

Matewai McCudden, Maori Women's Welfare League

Paulette Finlay, MoH

Diana O'Neill, Hillary Commission

Professor Sik Hung Ng, School of Psychology, VUW

Much of the material in the resource document drew upon the words of older people who attended a series of focus seminars, held around the country from Whangarei to Dunedin, which Kathy and I ran happily in tandem. Those were truly heartening occasions, when a wide range of older New Zealanders, enthusiastically enlightened us about what they believed were important factors to enable them to age positively; and then discussed disincentives. At every focus meeting attitude of mind emerged as being of prime importance. When we explored what they deemed to be key attitudes they identified learning to live within limitations-reinventing; optimism; faith or believing; confidence, courage and determination; maintaining a sense of adventure; a sense of humour. It very much brought to mind a quotation from Alice T Day's book, 'Remarkable Survivors: Insights into successful ageing among women', though our focus groups included both sexes, and a diverse range of cultures:

This quality of retaining a sense of self in the midst of a shifting of the very foundation of one's physical and social world is a major marker of successful ageing.

The name of the resource engendered much discussion among the working party. There was a feeling that the term 'successful ageing' implied that there could be unsuccessful ageing which was the antithesis of our objectives. It was Sik Hung who suggested, 'Ageing is Living' which promptly settled the issue.

The Resource was subtitled, 'An education and training resource to prepare for positive ageing'. Kathy's efforts to organise the material from not only the focus groups and the input of the working party, but also other relevant material, resulted in a training resource that we could be really proud to use. As well as the major document there was to be a companion 'Ageing is Living' booklet for people to take away. Fact sheets also were available from the national office. The material in the resource was also available to be photocopied for training, education and group discussions. Videos on related topics were also available on loan from the national office library.

In 1995 the resource document was revised by Kathy with input from others including myself. Copies of it remain in steady demand from the 27 Councils which is a testament to its usefulness, resulting in several reprints. Also further funding has been forthcoming for specific health promotion activities by Councils resulting in a wider spread of similar activity as was possible in the Northern region than had previously been the case. Health promotion for and together with older people therefore continues to be a major activity of Age Concern NZ and its Councils \- and so it should be. Age Concern is also about preventing and dealing with elder abuse and neglect, trying to alleviate the effects of social isolation and advocacy for timely, accessible and sound health and social services, but it also has the role of running programmes which enable older people within its purview, whether able or disabled, to live as well as possible and to maintain their wellbeing. Life itself is a precious gift, but quality of life can be an issue.

### Elder Care Canterbury

Earlier in this work reference has been made to the efforts to draw attention to the deleterious effect Government health policy was imposing on the wellbeing of older people, especially those who were becoming frail. The Christchurch-based geriatricians, Dick Sainsbury, Nigel Millar and Tim Wilkinson were especially active both in their national and local advocacy for positive change. By 1997 they had locally negotiated with Pegasus Health, the major GP led organisation in Christchurch to work in an inclusive, collaborative manner to co-ordinate health and social support of older people under a banner they named Elder Care Canterbury [ECC]. ECC was to be 'older person focussed' and community-based, a principle that has been well maintained to this day. So ECC became 'a collective of people representing organisations, service providers and consumers with an open membership' and an employed co-ordinator. Its aims were:

• Advocating for, developing and improving access to health and social services.

• Consumers having a formal voice and active involvement.

• Consultation exchange of information and communication between all stakeholders.

• All stakeholders working together towards common goals.

Despite that admirable and effective communicating and co-ordinating initiative, fundamental problems, which emanated from the 1990s 'Health Reforms', remained an issue both in Canterbury and the remainder of the country. There had been some positive change in 1997 when, after an election New Zealand First held the balance of power and a Coalition Agreement on Health resulted. The basic funder/ provider split was affirmed but the four RHAs were replaced by one Health Funding Authority [HFA]. The aim was to both reduce administrative costs and improve contracting by drawing on best practice, in place of the previous competitive tendering system. Crown Health Enterprises [CHEs] were no longer required to make a profit but were expected to operate in a business-like fashion. Claire Austin and I both made detailed submissions to 'Implementing the Coalition Agreement on Health'. Both submissions stressed that a central planning unit specifically for older people's health policy was a further requirement; the distinction between personal health and disability support was fragmenting both policy and service delivery and older people with health and disability needs are different from younger people with disability.

### Key Outcomes for Health of Older People

Claire Austin and I consequently decided, with the support of the Board, that a major advocacy thrust was required. That it would be strongest if we called together an Older Persons Health Care Forum of like-minded organisations to seek action on agreed points. Forum members were Age Concern NZ; Alzheimer's Society NZ; NZ Assoc. of Gerontology; NZ Council of Christian Social Services; NZ Home Support Association; NZ Hospitals Association; NZ Licensed Rest Homes Association. The Geriatric Society, the collective society for geriatricians, was also active with Roger Harris and Jonathan Baskett in Auckland, along with Nigel Millar in Christchurch producing a paper, ' Specialist Health Services for Older People'. The Ministerial Advisory Committee also produced a series of supporting papers most of which I penned on the committee's behalf. A distinguishing feature of all three of those papers was they not only demonstrated what was wrong, but also proposed what was required to rectify problems in a consistent direction. No longer could the health professionals be accused of patch protection when such a wide range of organisations, whose members included many consumers, were making parallel statements.

On 6 November 1996 the Forum met with the Minister of Health, Hon Bill English, for what turned out to be a lively discussion which led to agreement that the Forum would make written recommendations to him that addressed:

• The need for strategic policy from the Ministry of Health to the Health.

• Funding Authority [and within the HFA] which reflects accountable purchasing decisions.

• The need for consistent, nationwide standards of care delivery.

• The need for integrated services overall.

• Basic priorities for older people's health care which are focussed on credible and achievable outcomes.

The other Forum members asked Claire and me to prepare papers for discussion which subsequently emerged as a two-part paper, 'Key Outcomes for the Health of Older People in NZ; Recommendations to the Minister of Health' January 1998, which was signed by Claire and me on behalf of the other Forum members.

### Report of the National Health Committee on Health Care of Older People

### May 2000

Crowning all the foregoing effort was the report of the NHC on, 'Health Care of Older People'. The NHC had since 1995 issued 10 reports identifying consistent problems with the funding and delivery of health care for older people. The NHC identified 'a policy vacuum' as preventing effective corrective action.

The media release on Friday 26 May 2000 stressed three major funding issues:

• Ring-fenced Public Health, Personal Health and DSS funding streams which had contributed to fragmentation of care, gaps and overlaps in service provision which provided incentives for cost-shifting.

• A reduction in funding for comprehensive AT&R services had contributed to an unnecessary increase in spending on long-term residential care when appropriate community care and/or timely treatment of medical problems could have been effective.

• A more integrated approach such as Elder Care Canterbury had fostered could enable the bundling of funds to provide a range of services to promote good health and well-being, rather than a focus on institutional care and dependency.

The NHC proffered three recommendations:

• The MoH should develop strategic policy and planning by the end of 2000 to meet the health needs of older people, recognising that strategies for health care and home support for older people are distinct from generic DSS strategies.

• Access to multidisciplinary AT&R services is crucial to ensuring that services are matched to the health needs of older people and delivered in a timely and coordinated fashion. Health services for older people and their carers should be based on an accurate and holistic assessment of their health care and support needs followed by an integrated and coherent continuum of care including GP, acute medical, specialist multidisciplinary AT&R, community support or home care and long term care.

• Future funding arrangements should encourage integration between primary, secondary, DSS and public health services with appropriate priority being given to funding and implementing services that promote health, independence and support 'ageing in place'.

The launch of the report was undertaken by the Associate Minister of Health, Ruth Dyson and the Minister for Senior Citizens, Lianne Dalziel, both of whom, as Christchurch electorate MPs, were well versed in the work of Elder Care Canterbury and the efforts of the Christchurch based geriatricians, along with others, both health professionals and active older people themselves, to foster a coordinated service, despite difficult circumstances.

### Further Age Concern New Zealand Initiatives.

In 1996, when the late Jim Currie was President and Deborah Moran National Director, the Board decided to develop a policy document specifically because it was election year and ACNZ wished to alert all politicians, whether existing or aspiring, so that they were aware of what older people believed were important if they were to age as well as possible. Initially ten regional meetings were held to enable older people to discuss key issues and identify solutions. For me, as a relatively new member of the ACNZ Board, it was an opportunity to listen to the wider older age community support network. While much of the discussion was around care, support and welfare of older people there was an underlying positivity about the contributions of older people as volunteers, not just for welfare and health related NGOs, but also for sport, recreation, educational and other activities. One in three of them cared for a partner, parent, grandchild or other person; while one in four of those caregivers was the sole carer of another person. As Deborah put it in a neat summary of older New Zealanders, they were a diverse, ever growing group of individuals with a wide range of skills, experience, knowledge and needs who could be living in retirement for thirty years or more. During that period they may:

• paint their home three times

• replace major whiteware items at least twice

• pay for a hundred visits to the doctor, specialist and at least one surgical service

• care for a partner or friend

• face the deaths of a partner and friends

• win a Nobel prize

• run a marathon.

The specific policy statements ranged from human rights according to the UN Principles for Older People of independence, participation, care, self-fulfilment and dignity to responsibilities to use their skills and learn new ones, contribute to their communities and to be open and flexible to their and other's changing needs. The subjects covered included retirement income and policy, health and welfare issues, including elder abuse and neglect, carers, housing, transport and the volunteer sector. It was also noted that as 1999 was to be the United Nations Year of Older People so the Government, Age Concern, other appropriate organisations and older people needed plan a campaign to celebrate age and ageing because, "Older age is not a downhill progression. There are as many ways of growing older as there are older people. Older people have a lot to contribute to their communities. There are a number of mentor and volunteer programmes where older people work and play with younger people to share their skills, knowledge and experience."

In 1997 Deborah left to join the staff of the Ministry of Women's affairs and Claire Austin was appointed to what was then designated the CEO position.

Meanwhile in response to outrage at not only the persistence of the surcharge but also its increase, along with a rise in the age of eligibility to 65, Grey Power sprang into being. Its initial purpose was to have the surcharge abolished. On that premise its membership soared. A section of Grey Power declared that ACNZ had to be in the thrall of Government because it received Government funding. ACNZ did receive funding from DSW on a contractual basis to operate its Elder Abuse and Neglect Services, along with funding from the health sector to help operate its Accredited Visitors Services. We argued that in a democracy such as ours an NGO had every right to advocate for policies which might not suit the government of the day but in no way was our contractual funding tied in with any obligations such as Grey Power was inferring. That argument did impress upon us that, just as we took care over any submissions re: Government bills at the select committee stage, we must also make sure any policy we advocated must be on a well-researched basis.

Hence ACNZ employed Grant McLean to prepare two background papers as a 'first step towards review and revision of the current ACNZ Policy Manifesto'. The first paper was, 'Income Maintenance'. Up until 1998 the focus of ACNZ had been on the adequacy of Government provided income maintenance for those with little or no other income. It had never had a policy on whether NZ superannuation should be universally available [as it was by then] or targeted [the surcharge via taxation or means testing as a means tested benefit].Consideration of the pros and cons did lead to a policy which has been maintained to the present of espousing universalism on the basis of equal entitlement which, at the level Government provides, is relatively high in comparison to many countries. It nevertheless is sufficiently low to provide an incentive to save for one's older age, if at all possible, to enable one to live reasonably adequately.

The disadvantage, as the paper states is that equal shares makes it harder to achieve social justice aims of equity in that all people are not equal. A universal scheme effectively reinforces inequality by having a less redistributive effect. Universal payments also impact on sustainability. Hence the current discussions about raising the age of eligibility over time to be able to preserve universality as the number of older people increases over time.

As a historical document the paper remains interesting. Its page-and-a-half history contains a useful resume of public pension policies from 1898, when the Old Age Pensions Act provided a small means-tested pension for those aged 65, to 1998, when the hated surcharge was abolished. The early 1898 Act did tend to emphasise the so-called deserving poor from the rest, a hangover from our UK heritage.

The second paper was on 'Employment and Retirement', subjects which in 1998 were to the fore, partly because the Human Rights Act 1993 was to come into effect by 1 February 1999, when it would be unlawful to enforce 'compulsory retirement ' on older employees. There was also the fact that more people were living healthier lives into older age and that flexible retirement policies, such as changing from full time to part time employment were being seen as a way to ease ones way into a change in financial and work status. Such situations were though not so relevant for Maori and Pacific people, who were ageing around a decade younger than their Pakeha contemporaries, as jobs in industries such as forestry and railways abruptly disappeared under the market reform policies of those times. There were also issues around attitudes to older employees who were not being offered retraining opportunities because old dogs were still regarded as less teachable and too set in their ways.

At the 1998 National Council meeting, where I was elected President which became a three year term, a decision was adopted to revise the policy document prior to the 1999 election. Gaps and areas which required more detail were discussed, including issues raised in Grant McLean's papers. Subsequently the 1999 Policy Manifesto included the UN encouragement that all member states should develop a National Plan on Ageing in preparation for the 1999 International Year of Older People. It also developed a section on intergenerational relationships in support of the 'Strategies for a Society for All Ages', a document developed by the American Association of Retired Persons [AARP] in consultation with people throughout the world, including ACNZ. We had become all too aware that many NZ children were living in poverty with consequent increased ill health, inadequate housing and poor nutrition. Improving their quality of life was an investment to improve their ability to age as well as possible. Not only did we wish to adopt a life cycle approach to ageing but we were also aware that issues of intergenerational conflict might well follow if we did not recognise the interdependence of life stages and the interconnectedness of generations. NZ as a Society for All Ages needed to encapsulate the aim to optimise the lives of people for all ages and all cultures within our society. On the question of National Superannuation we urged the re-establishment of the multi-party accord, which has never been achieved, and supported the existing universal, tax funded scheme but recognised that with increasing numbers of older people sustainability issues might need constructive solutions to preserve it for future generations.

The ongoing revision of the policy document continued until recently when ACNZ opted in July 2012 for a Briefing to Government based on, 'What matters to older people', which does tend to read as if the aged generations were the only ones of and with concerns. The actual content of the paper is well researched but it does have the tone of a burden model of ageing with scant acknowledgement that ACNZ and its Councils have been reasonably well government funded for ongoing health promotion programmes whose aims are to combat some of the issues the Briefing deals with such as loneliness and social isolation. Older people contribute many hours of volunteer work and caring for both young and old, for family, neighbours and their communities, and in so doing they show that they care about the wellbeing of all generations, including some grandchildren, who did not ask to be born into relative poverty with all its associated consequences. A leavening of acknowledgment that the 1995 revised edition of 'Ageing is Living' is in such demand that reprints are needed; that Fact sheets and programmes ranging from Safe with Age Driving courses to a range of well-being, health and financial and other courses/ seminars are held throughout the country by Councils. That would have provided a balance of why Age Concern is needed and warrants ongoing support.

References

1. Dept. Of Health, Public Health Group, _'The Health and Well-being of Older People and Kaumatua: A discussion document_ ' April, 1997.

2. Dept. Of Health, Public Health Group, _'Mental Health Promotion and Mental Well-being including Older People_ ', June 1996.

3. MACSC response to 1.& 2. 1996.

4. Cresswell B., Wade R., _'Ageing and Care of the Aged: A Preliminary Bibliography of NZ Research_ ,' VUC,Wellington,1971.

5. Wither A.,Hodges H. _'Elderly People in View: A Bibliography of Research on Older People in NZ_ ,1972-1985, Dept. Of Health, MRSU,1987.

6. Gilling A.,Gilling M., _'An Annotated Bibliography of Research on Older People in NZ, 1986-1996_ BERL & NZAG,1997.

7. Gee S.,Davey J.,Eds. _Ageing Aotearoa: A Bibliography of NZ Research on Ageing 1997-2001_ ,NZiRA 2002.

8. Davey J.,Wilton V., _Update_ , NZiRA, 2001-2005.

9. School of Psychology and Health Service Research Centre, VU of Wellington, _Ageing and Intergenerational Relations Conference_ ,10-11 July, 1998.

10. Ibid. _Learning from the Past: Looking to the Future: Intergenerational relations in a new millenium_ , Conference in conjunction with Age Concern New Zealand and the Senior Citizens Unit, DSW, 31 August-1September 2002.

11. Ibid _Ageing in a Diverse New Zealand / Aotearoa_ , Wellington, 4-5 June 2002.

12. Gee S., Liu J.,Sik Hung Ng, _'The Veneration Gap:Generational dissonance and well-being among Chinese and European parents_. Hallym International Journal of Ageing, Vol 4,No1/2002,p45-65.

13. New Zealand Institute for Research on Ageing: A multi-disciplinary centre for ageing related research. Brochure, 1996.

14. Kosberg J. _'The Invisibility of Elderly Men with Social and Psychological Needs within a Changing Society,' Address to Workshop on Older Men in a Changing World_ , City University of Hong Kong, Dept.of Applied Social Services, May 20-21, 2001.

15. Evans P. _Life Events, Life Satisfaction, Health and Immune Functioning of the Ageing Male.' Address presented at Older Men in a Changing World Workshop_ , City University of Hong Kong. May 20-21, 2001.

16. Guthrie M. _The New Zealand Positive Ageing Strategy: Its Genesis and Implications' Address to 'Symposium on Positive Ageing_ , City University of Hong Kong, Department of Applied Social Sciences, May 24, 2001.

17. Davey J.,Gee S., _'Life at 85+: A Statistical Review'_ NZiRA publication., Victoria University of Wellington.

### Chapter 16

Strategies

The Labour Government, elected in late 1999, had campaigned vigorously on health issues which in 2000 saw the amalgamation of the purchase and provision of services and decentralised decision-making to 21 community focussed District Health Boards [DHBs]. There was misgiving which I shared about the number of DHBs for a country of less than 4 million at that time. Between 8-12 DHBs would have been more sustainable economically but government was keen to be seen to value the community voice. DHBs were required to enter into accountability agreements with the Ministry of Health [MOH] which was to determine the Health and Disability Strategies. The MOH was also to provide a link between the Minister and the DHBs [as well as other health organisations].

The New Zealand Health Strategy [NZHS] was promulgated in December 2000 as the high level framework within which DHBs and other health organisations were expected to operate. The development of the NZHS was guided by a Sector Reference Group chaired by Dr Karen Poutasi, the Director General of Health, along with some 21 health service users and providers which included Claire Austin, CEO of Age Concern NZ. At the time Claire became not altogether happy that, although the 61 goals and objectives decided upon included a number which should enhance health of older people, few were deemed to be priorities, viz:

1 Assess public policies which impact on health and health inequalities.

23 Ensure adequate support for caregivers in families with dependent members.

24 Support policies and programmes that enable people to be cared for in the community.

26 Support policies and programmes which promote positive ageing.

27 Reduce the incidence and impact of violence in interpersonal relationships, families, schools and the community.

34 Reduce the impact of stress.

39 Reduce the impact of dementia.

48 Reduce the incidence and impact of road traffic injuries.

49 Reduce the incidence and impact of falls in older people.

57 Ensure accessible and appropriate services for older people.

Only Number 27 - Reduce the impact and incidence of violence - was included in the 13 judged to be of the initial highest priority to implement in the short to medium term to improve the health status of the population and reduce inequalities. Claire's anxiety was assuaged by the knowledge that work was to also commence on what was to become the NZ Positive Ageing Strategy which would in effect be a national plan for ageing, but which did not include the word National, the title of the main opposition party.

### NZ Positive Ageing Strategy

In choosing the name Positive Ageing Strategy the Minister for Senior Citizens, Hon Lianne Dalziel was paying a nice tribute to Professor Sik Hung Ng whom she quoted in her forward as saying:

New Zealanders who are now 65 plus are more highly educated and healthier than their predecessors. Their capacity for productive work of all kinds, not necessarily for pay, is a national treasure. Their contribution to New Zealand society is and will continue to be immense. If they are ignored, undervalued, or otherwise excluded from society, New Zealand can hardly be competitive against other countries which have found a way of harnessing this immense resource.

The development of the Strategy involved several layers. Initially the Ministerial Advisory Council, of which I had ceased to be a member, drafted a set of Principles adapted from the United Nations Principles. Subsequently a Forum was held of over 100 people from a wide range of sectors which was funded by the Ministry of Social Policy and organised by Age Concern NZ. The Forum concluded that 'the Positive Ageing Principles failed to provide a clear and strong foundation on which to base the Strategy'. Hence they re-wrote the Principles as 'explicit and meaningful action statements' such as:

• Provision of secure and adequate income for older people.

• The establishment of a multi-party agreement on retirement income

• Provision of timely, accessible, co-ordinated and equitable health services for older people.

Volunteer coordinators recruited by the Senior Citizens Unit from the memberships of both Age Concern Councils and Greypower, along with separate Maori and Pacific consultations, also identified health, income support, home support, transport and carers as of importance.

Finally, a Sector Reference Group was established to provide input to the development. It included Brian Absolom of the Government Superannuitants Association; Frances Cook of the Nurses Association who was also nursing head of the Wellington Hospital AT&R Unit; Betty Cuthbert of the National Council of Women, Grey Power and Maori Women's Welfare League; Margaret Guthrie, NZ Association of Gerontology, Age Concern NZ; Wharekura Hornfeck, Senior Citizens Unit Volunteer Co-ordinator, Maori Women's Welfare League; John Patterson, Canterbury Development Corporation Third Age; George Potae, JP, Jaycee, Golden Shears; Wally Ranfurly, Fanau Centre, Nuie Community Porirua; Grahame Stairmand, Greypower, Christchurch; Di Valentine, Older and Bolder Collective, Taihape.

The Group reached consensus among themselves early on which included marked opposition to the attitude from the Social Policy Ministry representative, Jenny Nana, that our deliberations were not to include income maintenance because that was outside the brief of the Senior Citizens Unit. The Group unanimously declared it was impossible to develop a strategy which did not include income maintenance. The argument spread over a number of sessions despite which we worked steadily through a range of other issues. We were then informed that the Minister for Senior Citizens, Hon Lianne Dalziel, planned to spend a morning with us as we wrapped up our deliberations. The Minister wholeheartedly agreed about the importance of income maintenance. Hence the first goal became: "Secure an adequate income for older people." Then along with the Minister we worked our way steadily through the other goals: "Health, Housing, Transport, Ageing in Place, Cultural Diversity, Rural, Attitudes, Employment, and Opportunities."

It was quite the best of the group's meetings. The Minister had a sound grasp of the issues. She entered into discussions with dedication and afterwards relaxed over lunch with us. One had the distinct impression she was enjoying the session with us, as much as we were glad to have her present.

A two-tier review and reporting process was also put in place. The first tier involved monitoring and reporting on progress in the work items included in the Positive Ageing Action Plan. As it is usual for Government departments to report progress in July of each year, they were also to report back specifically on their Positive Ageing focussed programmes at that time.

At approximately three year intervals a report on the situation of older people and on Positive Ageing in New Zealand was to be the second tier of monitoring and review all of which should identify any areas requiring Government action.

That monitoring process has been maintained since the first 'baseline' report was published in 2001, except that from 2010 the reports were to be published online instead of in print.

There were several major effects that followed on from the Positive Ageing Strategy, apart from the Health of Older People Strategy which shall be dealt with later.

### Local Government's role

Although Local Government in New Zealand does not provide social services, as occurs in some countries including the UK, it does provide infrastructure, services and support locally. Therefore the VUW 40 Plus team's Susan Gee and Age Concern's Kathy Glasgow, with funding from the Foundation for Research, Science and Technology, explored Local Government Councils strategies and services with older people across New Zealand throughout 1999, the International Year of Older Persons [IYOP]. Their findings, published in August 2000 as, 'Creating Communities for All Age: Local Government and older New Zealanders', were widely distributed to all Local Authorities, Age Concern Councils and other interested organisations and individuals. So when work commenced on the Positive Ageing Strategy it was logical that it was not only to involve the role of Government departments but also that of Local Authorities. Subsequently the Key Actions included:

3.4 Work with local government to increase the supply of universal design and energy-efficient, low-rental housing, including pensioner housing complexes.

8.3 Foster collaborative relationships between central and local government, business, non-governmental and community sectors that promote positive ageing.

9.3 Work with local government and the business sector to promote mentoring programmes that harness the skills and expertise of older people.

Despite a policy to increase the supply of pensioner housing, Age Concern Councils were well aware it behoved them to continue to be on the alert when local authority councillors proposed selling off pensioner units. Not all those battles were successful, though in Porirua the late Des Ryan and I, along with Greypower and other activists, succeeded in at least maintaining the number of pensioner housing units in Titahi Bay.

The Gee / Glasgow research reported that three LA Councils, Christchurch, Hamilton and Dunedin, had spontaneously responded to their increasing older populations by involving them in developing an older citizen's policy. This led to a NZ wide movement by Age Concern Councils to advocate that all other LA Councils should follow suit. In the Wellington Age Concern region, as I lived in the Porirua City Council territory, I was delegated to lead the advocacy in that area, while Lys Noble was responsible for Wellington city and Joan Taylor the Upper and Lower Hutt.

At that time the Mayor of Porirua, Jenny Brash, and I shared a history of both being former employees of the Department of Health. Jenny having a Public Health Nursing background meant we were professionally on the same wave length. There was also a real community spirit between representatives of those organisations the PCC invited to form an Interim Advisory Group – Helen Griffiths and Kilian de Lacy of Greypower, Freda Tohill and Tania Torea of Healthlinks, Thom Kenny of Te Runanga o Toa Rangatira Inc.,Te Rongo Tekii of the Pacific Islands Forum, Sandra Davies and Lyle Davies of CAB, and Russell Kerse of the Porirua Disabilities Forum along with Cr Jasmine Underhill and Cr Nick Leggett. Very importantly Ben Peacey, who was at that time a policy analyst on the PCC staff, was allocated to assist us because he pulled together a draft Porirua City Council Strategy which used the framework of the 4 goals of the 40 plus project viz:

• Political voice – that, if a strategy was to be seen to work, an ongoing Older Person's Advisory Group needed to be appointed to monitor progress

• Housing and security at home

• Mobility and transport – The layout of both the Porirua CBD and the outlying suburbs was based on use of a car and needed to be more pedestrian friendly for all ages.

• Keeping Active – A Lifetimers Leisure Club already was run by PCC and Pataka provided an excellent library, arts and cafe facility.

The PCC sent the draft strategy out for public consultation in February 2005 and the final Strategy was launched by mid-2005. From then onwards OPAG, the Older Person's Advisory Group, which I chaired until my departure to live in Auckland in April 2010, met quarterly. Freda Tohill currently chairs OPAG which continues to facilitate two-way communication between the Porirua City Council and its older citizens. A strength of the group is that it has an open membership of participating organisations and individuals, each of whom has the opportunity to air issues at each meeting. The PCC support is well maintained and decisions to advocate for changes such as making the CBD more pedestrian friendly and urging the local buses to include a circular CBD route around that spread out area assists all ages, not just the old.

### Transport

The transport goal of affordable and accessible transport for older people includes the action point: 4.2 Review driver re-licensing provisions for older drivers to ensure they are based on ability, not age.

In the February / March 1999 edition of what was then the official bi-monthly publication of Age Concern New Zealand, 'Age Matters', I wrote a 'President's View' on Transport Issues which began:

When asked what is important to help them age well, older New Zealanders often cite transport issues. Those issues range through pedestrian safety, availability and access to public transport and the impact of losing a driver's license on independence versus older drivers' safety.

We are a very mobile people, oriented to car travel and car ownership. That has benefits in access to family and friends, shopping and services, recreation and social activities.

The downside is that older drivers, especially those over 75 years of age, statistically have increasing crash rates as compared with middle aged drivers. Analysis of the crashes shows a pattern of characteristics. They include a tendency to below average speeds, failure to yield right of way, disregard of traffic signals at intersections and severe injury outcomes.

The Safe with Age driving programmes were developed to improve older drivers' road safety. A number of Age Concern Councils actively provide tutors and support for safe with Age courses, but there remains the problem of how to balance the wish to retain a licence as long as possible with public safety.

This is not just a New Zealand issue. Sensibly the Land Transport Safety Authority [ LTSA] is now part of a joint project with the Australian Transport Safety Bureau, funded by Ausroads in a Monash University Research project. Its aim is to develop a systematic approach to the licensing and assessment of older drivers. The model itself would not be targeted at age as such, but on an ability to drive safely in terms of health, mobility, cognition and other relevant safety, health factors.

Norman Wright of Age Concern Wellington and I were involved from the start of work on the project from November 1998 along with Dr Graham Davison, an Auckland based geriatrician who had become particularly knowledgeable about older driver issues, an occupational therapist, a physiotherapist and organisations such as the Alzheimer's Society and the NZ Association of Gerontology. Discussions around matters such as the impact on older drivers of attitudes of those doing driver testing, testing officers training and the referral processes were all issues which had arisen in New Zealand as well as Victoria and Tasmania where the procedural aspects of the proposed model licensing regime had already been tested. In 2001 a second part of the project involved validation of four different off-road screening tests against a range of driving performance measures. Nearly 1000 older New Zealanders were recruited. The rationale of the research was a recognition of the inadequacies of some test procedures which prompted a search for obtaining off-road tests able to predict on-road performance to reduce the dangers of on-road testing for at risk drivers. Bill Frith, who was responsible for much of the local research for the LTSA, obviously relished the close association with colleagues from Monash. The fact that they were footing the bill made it doubly attractive for us to be involved.

To further broaden the research in this country the LTSA, the Ministry of Transport and the Senior Citizens Unit engaged Judith Davey and Katie Nimmo to undertake a scoping study of 'Older People and Transport', the findings of which were published in November 2003. The particularly relevant finding reinforced an ad hoc impression of the importance that private transport had assumed in older peoples' lives. As Judith wrote:

Owning a car not only provides choice and flexibility of movement but is also a symbol of independence. It appears to also have a psychological value-noted especially for older men – even a 'snob' value...

The physical accessibility of private transport is also greater than public transport. When people can no longer drive, or lose their access to a private car, they may not be able to use public transport either unless it has all the attributes of the car – door-to-door, 24 hour, on-call service... the evidence suggests that when older people can no longer drive they become heavily dependent on family and friends with private cars, or on specialist community transport services.

Thus a major concern for older people is to retain their private transport and their ability to drive. Present policy suggests that self-regulation cannot be relied upon and that older drivers require monitoring and testing to ensure their continued competence and safety... Informant opinions suggest that health status is the key factor rather than chronological age, but generally agree that driving skills may be challenged by personal factors [such as self-confidence], and external changes – including greater speed and density of traffic, new alignment of intersections, and additions to the road rules, such as those for negotiating roundabouts.

The retention of a driver's licence is so crucial to access to the preferred type of transport that the 80 Plus test has become a cause of significant fear and apprehension for some older people.

Subsequently the Ministers of Transport, Transport Safety and Senior Citizens set up a Stakeholders Consultative Group [SCG] to Review Older Driver Licensing Policy. It was necessarily a large group because as well as the usual NGOs representing older people, [and I was the ACNZ person involved], there had to be a range of professionals, geriatricians represented by Graham Davison, Occupational Therapists, Optometrists, and RNZ College of General Practitioners, along with the Automobile Association, the RSA, the Association of Road Safety Co-ordinators.

The terms of reference were wide to embrace the manifold issues around the policy such as what measures should be considered by government to enable it to provide a safe road environment, along with other policies and measures that could maintain the mobility of persons who can no longer drive their own car. It was a major endeavour and David Weinstein, the Project Manager, handled all the complexities of the exercise very well indeed.

The final package of proposals by the SCG to the Ministers recommended disbandment of the age based regime, replacing it with one which emphasised that the ability, or lack of it, to continue to drive was functionally health related. A stronger emphasis on driver education was also emphasised. Those recommendations were accepted by Government and on Friday 16th June 2006 the Hon. Harry Dynhoven, Minister of Transport announced the Land Transport [Driver Licensing] Amendment rule [No2] 2006 as the legal basis for changes to be made to driver licensing for drivers aged 75 and over. Under the new system:

• The existing mandatory on-road test for those aged 80 and over will cease.

• At ages 75, 80, 82 and at two yearly intervals thereafter, drivers renewing their licence will require a medical certificate showing they are fit to drive [as is the situation at present].

• The Medical Certificate for Driver licence will be revisited to make it simpler and easier for doctors to complete.

• GPs will have the option of referring a medically fit driver aged 75 and over for an on-road safety test if they are concerned about their ability to drive safely.

• An education and information package to be targeted at older people, their families and communities.

• Education and information to be targeted at GPs, including a series of regional seminars.

• A subsidy will be available for a private on-road driving lesson with an approved driving instructor for Safe with Age course participants from early 2007.

David Weinstein had rung me that afternoon to let me know of the signing. When he told me that the date the new system was to come into force was 4 December 2006 we both laughed. He knew that, because I had already been required to undertake the on-road test before turning 75, I had experienced the nervous build up to that test. Confidence was gained by undertaking a session with an AA driving instructor. The date of 4 December 2006 also meant that before my 82nd birthday in late September that year I should be repeating that process. Such was life. What was unknown was yet to happen.

A damp late August afternoon had seen me at the Lighthouse cinema in Pauatahanui. Upon emerging the rain had set in with sidewise drifts. Visibility was murky. Driving home around the Whitby side of the inlet I had time to observe that a red car with four males in it was approaching on the other side, rather fast for the conditions, when control of it was lost. As it swerved across to my side of the road, I turned in the same direction to try and avoid a collision, but there was a sudden crash into me from the rear. When I looked up from being slumped over the steering wheel a man was standing beside my car indicating he wanted me to lower the window. He then said, "It's no excuse, I am not supposed to crash into your rear even though, at the height I was in the truck, I was transfixed with the thought I was going to see you fatally crashed into". As I had looked up it had impinged that there was no red car in sight, so my response was, "Where's that red car ?" The response, "The bastards fled. They reversed just as quickly - and fled off."

We were in a rather awkward position on that winding road so we drove around the corner into a better position. That did inform me that, battered though my car's rear end might be, it was drivable. The young man, who was thoughtfully courteous, suggested that he should go to the Porirua Police station to let them know what had happened; that if I drove home he would get back to me afterwards. Good as his word, he rang back and let me know that the police knew that red car. They had stopped it only half an hour beforehand to check the driver's license. The occupants were gang members known to the police. They were probably high on something.

The following day at the panel beaters when I mentioned that I had an appointment to sit the 80 year on-road test in a couple of days, and wondered if it was still possible. They did a quick inspection, assessed the car as drivable and suggested I check that out with the testing office. They also deemed the car to be drivable. So I took the test the following day and passed.

### Lifelong Learning

The Goal: Increasing opportunities for personal growth and community participation.

Actions:

10.1 Improve opportunities for education for all.

10.2 Implement adult education and retraining initiatives.

10.3 Encourage utilisation of the experience and skills of older people.

In the late 1980s Norman Wright, in his Age Concern Wellington capacity, as well as harking back to his earlier days as a Primary School Principal, applied himself to organising a school project competition around poetry and prose, highlighting attitudes towards ageing and older people among the young, which drew entries from around the country.

Norman also promoted the development of University of the Third Age [U3A] in the Wellington region. The first U3A in the country was started by Dr John Stewart in Remuera in 1989. Also in that year Cliff Picton, then Director of the Australian Council on Ageing, addressed the AGM of ACNZ on U3A and life-long learning which stimulated Norman to found the first Wellington U3A.

The concept of U3A was developed in France in the early 1970s when attention focussed on an amendment to the French Constitution relating to life-long learning. A summer school for older people in Toulouse developed into a permanent organisation which adopted the title University of the Third Age, embracing the principles of self-help and self-determination. U3As structure their own programmes and select their own tutors. The membership decides the fields and level of learning and there is no rigid separation of teachers and students. Participants do so voluntarily. Tutors are students on other courses, and members perform all administrative functions.

The National Council of Adult Education in New Zealand set up a working party in mid-1984 to promote changes in attitudes about ageing, to identify learning opportunities for older New Zealanders and to highlight the contribution they made to society as a whole. In 1987, Louise Croot, Chair of the Council and Dunedin based, edited 'Ageing and Lifelong Learning in New Zealand' which reported back on the activities of the working party and noted its priorities which included recognition by politicians, policy makers and the Department of Education of the need for learning opportunities for older people. A need which still exists. There was also a perceived need for co-ordination of the many initiatives in the field of ageing and education. The funding of co-ordinators to liaise with groups and to provide information about learning opportunities was seen as a priority, a NCAE Priority which came to naught.

Another initiative, with what became a convoluted history, envisaged another way of co-ordinating the various adult educational initiatives based in the Wairarapa. In April 1992, 'Lifelong Learning and Living; an Age Wise Conference', was organised by the Wairarapa Community Polytechnic in conjunction with the Wairarapa Organisation for Older Persons [WOOPS]. Sister Monica Landy and Alison Clarke were the driving forces behind that enterprise. The conference flyer made it clear that the motivation behind the conference was to set up a Coordination Centre for Older People's Learning for New Zealanders the aims of which were:

• Education for being older which would enable older people to cope and younger people to understand and be prepared for ageing.

• Information about older people which would improve their self-image and remove barriers for them and better inform service providers.

• Information for older people to allow them choices and for family, advisors to create a bridge to overcome barriers.

The conference itself explored issues which either enhanced or set up barriers to positive ageing, ranging through architectural, disablement, economic and political issues – the last subject being dealt with by the former Prime Minister, David Lange. The most challenging discussion was from David Battersby, who was by 1992 Dean of Health Studies at Charles Sturt University, Australia. David explored three themes:

• Firstly, that education for older people should enable them to gain power over their lives.

• Secondly, that he wanted to challenge some of the conventional wisdom about the purpose and nature of education in later life.

• Thirdly, that he wanted to present a statement of first principles.

On his second theme David said that although Australia and New Zealand claim to be egalitarian we needed to admit that much of what was accepted, was essentially driven by our middle class notions of what constituted 'education'. Did everyone really have an equal chance? He believed we needed to constantly reflect on the aims and purposes; to ask ourselves some quite introspective questions, e.g. Have some courses been set up to really empower older people, or to gain funding for the organisation? The principles he enunciated included:

• We need to move away quickly from conceptualising old age as a social problem.

• We need to move to a more critical perspective around the role of education in later life, not to assume about what is wanted which seem to be programmes which enhance autonomy, emancipation and transformation.

• Education in later life needs to embody practises which allow people to ask 'Why do it?' and 'Where am I going?'

The last morning honed in on the formation of a Working Party to gather information, set up a plan, ascertain what resources might be available, and to feed back to the conference participants. I became a member of the Age Wise Working Party.

Therein began a sad saga of wasted effort and resources between 1992 and recent times. Alison in a paper summarised events which shall be include a little more information in brackets. Since the Conference in 1992 the Age Wise project has:

• been discussed with Wyatt Creech [local MP and National Government Cabinet Minister including being Minister for Senior Citizens].

• been handled by the Senior Citizens Unit.

• been sighted by the Ministers for Senior Citizens and Social Welfare.

• been through two feasibility studies – Price Waterhouse Cooper in 1993 and Deloittes in 1995.

• Has cost the NZ taxpayer over $60,000 in feasibility studies and administrative grants [which does not include the time officials spent in meetings with members of the working group, amongst themselves and with Price Waterhouse and Deloittes etc.].

• been announced as an item in Jim Bolger's election propaganda [at a speech in Waikanae] in 1996.

• made it to the budget round in 1997 and was then turned down.

• Monica and Alison met with Wyatt Creech in 1999 while National party still in government. He tried to gain support for us in Cabinet. [He probably did. I know he really respected Sister Monica and Alison].

• Monica, Alison and Margaret met with Lianne Dalziel, Minister for Senior Citizens [newly elected Labour Government] in 2000.

• Margaret arranged meeting with Susan Gee from the NZiRA in 2001 who was very interested and enthusiastic about the whole idea.

• Monica and Alison met with Dr Judith Davey, Director of NZiRA and Susan Gee. They had done their homework and were happy to take over the 10 year old Age wise project, its goals and aspirations. They have included Age Wise on the website for the NZiRA.

• [we have already seen how the NZi RA passed away as well].

Alison Clarke happened to be a daughter of Dr Tom Enticott, the geriatrician who initiated me, or rather tried to initiate me, into the intricacies of elder care funding in Christchurch in the 1970s, which helped create a bond from our first meeting at the 1992 conference, when Tom was also present.

Sister Monica Landy is one of those charismatic teachers, prepared to slog it out for something she believes should be done educationally, a real treasure herself. The first time we met Monica arrived at my office in the Department to let me know she had a Churchill Fellowship to study a system in Canada where participants learnt what it was like to be disabled and carry on working and living. This was to become the basis of WOOPS Thru' Other Eyes Programme.

The vision for Age Wise was admirable, as was the vision for NZiRA. A combination of factors dimmed both visions, including technology advances in the case of Age Wise, and parochial competitiveness for research funding for NZiRA, not to mention the role of politics for both endeavours.

### Health of Older People Strategy

There was some impatience with the delay imposed in the development of the Health of Older People Strategy [HOP Strategy]. A delay which was in fact logical as the overarching NZ Health Strategy, Disability Strategy and The NZ Positive Ageing Strategy needed to be in place before any other specific health strategies followed. The additional time it took for the NZ Positive Ageing Strategy to emerge also allowed some other health strategies such as the Palliative Care and the Primary Health Care Strategies, which impinged on aspects of HOP, to be completed during that waiting period. The NZ Positive Ageing Strategy had several goals relevant to HOP:

Goal 2:

Equitable, timely, affordable and accessible health services for older people

Actions:

2.1 Promotion of holistic-based wellness throughout the life cycle.

2.2 Develop health service options that allow integrated planning, funding and delivery of primary, secondary, residential care and community support services.

2.3 Ensure the availability of multi-disciplinary comprehensive geriatric needs assessment throughout New Zealand.

Goal 5:

Older people can feel safe and secure and can 'age-in-place'.

Goal 6:

A range of culturally appropriate services allows choices for older people.

Goal 7:

Older people living in rural communities are not disadvantaged when accessing services.

There was also the earlier National Health Committee's May 2000, 'Report on Health Care of Older People', which had highlighted shortcomings, which had been allowed to develop, and pointed the way to go which the three health action points of the Positive Ageing Strategy had endorsed.

A further guiding principle was that a life course approach should be taken, as advocated in a paper by Jacobzone S, Cambois E, Chaplain E et al in 1998, 'The Health of Older Persons in OECD Countries: Is it improving fast enough to compensate for population ageing?' That work recognised that interventions at both a population and individual level can create supportive environments, foster healthy choices throughout life and reduce health inequalities, which were needed to reduce the risk of functional decline in later life.

By mid-2001 an Expert Advisory Group had been appointed including Verna Schofield, Sally Keeling, Pam Greenaway, Jill Calveley, Pam Melding, Margaret Southwick, Lorna Dyall, Keith Gibb, Carl Hangar and myself. Judy Glackin of the MOH chaired the Group backed up by Pam Fletcher and Paulette Finlay. A vision was agreed that:

Older people participate to their fullest ability in decisions about their health and well-being and in family, whanau and community life. They are supported in this by co-ordinated and responsive health and disability support programmes.

Eight objectives identified where change was essential if the vision was to be achieved:

• Older people, their families and whanau are able to make well-informed choices for healthy care and/or disability support needs.

• Policy and service planning will support quality health and disability support programmes integrated around the needs of older people.

• Funding and service delivery will promote timely access to quality integrated health and disability support services for older people, family, whanau and carers.

• The health and disability support needs of older Maori and their whanau will be met by appropriate, integrated health care and disability support services

• Population-based health initiatives and programmes will promote health and well-being in older age.

• Older people will have timely access to primary and community health services that pro-actively improve and maintain their health and functioning.

• Admission to general hospital services will be integrated with any community based care and support that an older person requires.

• Older people with high and complex health and disability support needs will have access to flexible, timely and co-ordinated services and living options that take account of family and whanau carer needs.

As the summary booklet to accompany the full strategy document says:

Most older people are fit and healthy. A minority are frail and vulnerable and require high levels of care and disability support. The Strategy covers the full range of services available to older people to keep well and to continue to live safely in the community. This includes health promotion, treatment for acute episodes of ill-health, rehabilitation to support recovery, ongoing support for people who are disabled and need palliative care. The focus is on older people as participants in decision making at the individual, and community level, and at the broader policy and service development levels.

The Ministry officials realising that much follow up work was needed to flesh out key components of the eight objectives which they deemed would take until 2010 before all aspects could be operational. The MOH would monitor the progress of DHBs on implementing the strategy against their annual plans, and it would also undertake three yearly reviews of progress.

An early work programme was to develop a Service Framework for Specialist Health Services for Older People which saw a further Technical Advisory Group, chaired by Sharon Kletchko. It included a second geriatric physician, Elizabeth Spellacy, along with Carl Hangar and Pamela Melding, the psychiatrist of old age, and myself as a gerontologist. Simultaneously the NZ Guidelines Group was working to establish an "an effective and integrated assessment pathway for the health and disability needs of NZ's older population." The two groups shared research documents and progress reports. The principles and assumptions of the Framework were that:

• ageing is regarded as a normal part of the continuity of life.

• the wisdom and dignity of the older person and the key role of their family or whanau are respected.

• recognition of the potential diminution of personal control that older people frequently experience when accessing services that are unfamiliar to them

• valuing the role of family, whanau and appropriate others, particularly the principal caregiver.

• recognition that services need to have a holistic approach and the expertise to treat and rehabilitate older people with complex conditions [Holistic includes physical, psychological, social, cultural and spiritual dimensions].

When the question of why a framework should be developed arose, it was to provide guidance to sound practice to cater for an ageing population which was more likely than other age groups to have multiple health and disability problems and to be higher users of health services. It was also a fact that geriatric and psychogeriatric services were at that time highly variable throughout the country. That was due, in part, to different funding arrangements for psychogeriatric services and mental health services for older people [MHSOP]. In the lower part of the North Island and in the South Island psychogeriatric services are funded through DHB personal health services whereas MHSOP are funded through DHB mental health in the 10 DHBs in the top of the North Island. In practice contractual arrangements resulted in both overlaps and gaps depending how the services were managed in different localities.

Each funding stream had different priorities and different philosophical approaches to AT&R. For instance if an older person had both an injury requiring treatment and rehabilitation and a medical condition [such as a fractured hip and Parkinson's disease] ACC was required to fund only the injury related component. Care Coordination planning for older people with complex injuries and medical conditions could prove challenging when they needed both health and support services for both accident and medical conditions, particularly when planning for transfer from a hospital. To help rectify that difficulty ACC implemented a 'package based' process for accessing home based rehabilitation without an assessment. Variability in how protocols were interpreted in different regions remained an issue.

Whether the fact that the Framework merely required DHBs to 'manage the separate funding streams for different client groups so that they did not create barriers to good practice', rather than the earlier recommendation of the Technical Advisory Group that 'Geriatric, psychogeriatric and MHSOP should be integrated under a single funding and management structure' as important, recurred in 2011.

'Mental Health and Addiction Services for Older People and Dementia Services: Guideline for DHBs on an integrated approach to mental health and addiction services for older people and dementia services for people of any age' was published in 2011. Key issues included:

Different structures and funding streams within DHBs... Some people, particularly those aged under 65 years of age with dementia, have difficulty accessing appropriate services due to their age or to an intellectual disability. Across different DHBs specialist services for older people are being funded from different funding streams... The different funding streams appear to be influencing levels of access, resources and service. This complex situation has also made it difficult to make comparisons regarding the funding deployed and the services provided by different DHBs.

Despite the efforts of that well-intentioned, largely well-thought-out guideline which ties DHBs contractually to Nationwide Service Specifications and a clear seven tiered service model, one wonders how the scene will be working in yet another decade. Compounding the issues around funding differences are two other key issues.

• Older people failing to receive the treatment they require.

• Factors such as under-recognition and under-treatment of problems are prevalent. Early diagnosis and intervention can be vital to prevent progressive ill health and increasing cost to both health services and older people and their families.

• Lack of services and service development.

• Both primary and secondary level mental health care for older people remain under-developed in New Zealand and that is thought to contribute to the under recognition problems. Nationally, development of specialist community services for mental health and addiction among older people has generally lagged behind service development for younger people, yet research has shown that treating elders for depression is as effective as is treating other adults.

• Assessment processes for older people.

To further the NZ Positive Ageing Strategy recommendation 'to ensure the availability of multi-disciplinary, comprehensive geriatric needs assessment' throughout the country the NZ Guidelines Group [NZGG] was commissioned to develop an effective and integrated pathway for the health and disability needs of the older population. The aim of such an assessment was to identify all the needs of care and support of the person being assessed, including those needs being adequately met by services, family or whanau, as well as unmet needs.

The NZGG process was a revelation in the exactitude of its processes covering initial preparation for the task through to final publication. By the time those who were to serve on the Guideline Development Team [GDT] met, we had available to us professional reviews of the world wide literature, policy development and assessment tools. We had also participated in a tutorial about guideline development and, at the initial meeting in December 2002, we were presented with over 250 papers which we were exhorted to systematically study prior to meeting again in 2003. I was grateful for January being the quiet period with hardly any meetings, because it became such an absorbing study, a virtual refresher course in many aspects of one's work. The GDT was necessarily large to cover all aspects of our brief, which made it quite an exercise to both enable everyone to be heard, and to adhere to our objectives. When I realised I was to convene the last couple of meetings and that both the NZGG and MOH members, as well as some others of the GDT, were becoming anxious about the number of unresolved matters. That was a challenge; the sort of challenge I enjoy, even if it is preceded by a restless night. Everyone worked with a will in those last two meetings and the fact that the guideline is largely being followed, over time, is testament to the validity of the recommendations. The later dis-establishment of the NZGG and its absorption back into the MoH does not though engender confidence. Having been both a member of the earlier, virtually in-house Hospital Board Service Planning Guidelines and then the NZGG processes, the professional rigour of the latter led to better outcomes.

The key messages of the guideline were:

• Standardisation of assessment processes which should include the areas of life that older people consider most important: personal care, social participation, control over daily life. Food and safety, risk factors and areas of potential greatest impairment.

• A standardised assessment tool and standard methods of collecting, reporting and comparing data should be used.

• Assessors must receive specialist training... and have good awareness of older people's issues.

• Following assessment a treatment / management plan is essential with regular follow-up.

• Assessing and supporting carers' needs results in improved outcomes for both the carer and the care recipient, including reduction of abuse of older people.

• An older person should receive a proactive assessment if they have any risk factors, are in contact with health or social services, or are referred by carers or whanau.

• Screening of the asymptomatic population aged 75 and over has been shown overseas to produce the greatest improvement in health and well-being.

There were also specific recommendations for older Maori and Pacific peoples which these days should / would need to be expanded to cover those of Asian and other descents and cultural backgrounds.

The InterRAI MDS-HC was identified as the tool that would best meet what was required for both a standardised assessment process and a national data set. Wisely it was trialled over several years in five DHBs, including Capital and Coast [CCDHB]. When applications were called for organisations to apply to set up the necessary Care Coordination Centre I was invited to be the outsider on the small selection group from CCDHB; but when copies of the applications arrived I realised that I had a conflict of interest in that, though I had just retired from being a Board member, I was a Life member of the Nurse Maude Association [NMA]. At our preliminary meeting Margot Mains, the CEO who was Chairing the group said that two other applications came from groups within her CC DHB purview. So it was a matter of managing the situation. As it turned out one application stood out from the rest, that of the NMA.

When premises were found to set up the NMA C&C Care Coordination Centre for assessment, care planning and co-ordination for community-based health services in Porirua it was not only on my door step but Fran Cook who had been on the Positive Ageing strategy team was also appointed to head the initiative. There was some disquiet that an organisation from without the Wellington Region was appointed but that settled when the NMA made a point of appointing local staff.

The stage has now been reached when evaluation of the trials has demonstrated that, with modifications for local situations, the interRAI MDS-HC is very well suited for the NZ situation. Hence it is currently being established as the assessment tool throughout the country.

A collaboration between Waitemata PHO, Waitemata DHB and The University of Auckland has also led to an 'Evaluation of a Gerontology Nurse Specialist in Primary Health Care' which has trialled a proactive risk screening process, using the Brief Risk Identification for Geriatric Health Tool [BRIGHT] screen for older people in the community, along with the interRAI MDS-HC in several practices. The findings of that programme were presented at the 2012 Gerontology Conference held at Waipuna Lodge in Auckland. The potential to up-skill the Primary Care workforce in elder care issues as other such appointments of Nurse Specialists are made across primary care GP practices, hopefully ensue.

From the assessment and care coordination viewpoint there has been considerable progress in recent times but there is concern about the adequacy of the necessary follow-up services, whether in the home or in residential care.

Budget cuts arising from the impacts of the global financial situation have impacted on community services. Home help is one service that is vulnerable. When priorities are being considered a few hours chopped off a weekly allocation may seem minor to hard pressed financial administrators. To the frail older recipient and their immediate carer, it can make the difference between whether the elder, or their family carer can continue to cope in that home situation or not. The alternative of residential care then transfers costs elsewhere in the system which can be more expensive in the long run. If a family carer's own health also consequently deteriorates the cost to the individuals along with the system is amplified.

Also it has recently been pointed out to me that staffing cuts have resulted in increasing stress on those who remain. When that happens, aspects such as integration with other services can be just too much effort.

Then there are the ongoing issues of a lower paid, largely female workforce who are, all too often, not adequately supported or supervised, resulting in a steady trickle of elder abuse complaints. That situation is worsened by the fact that gerontological nursing has difficulty both recruiting and retaining staff. As around 40% of older people have only National Superannuation, or very little extra in the way of personal funds, they have no option but to put up with less than optimal care, whereas the relatively few, who can afford to shop around for better services, provide yet another example of a divide in our society. I do wonder if the flight of so many older New Zealanders to retirement villages, despite their financial impact, is partly because of a fear engendered by reports of abuse both within the home and in institutional care.

### Long-Term Conditions Framework

In mid-2007, a Long-Term Conditions Team was set up by the MOH in response to the NHC report 'Meeting the Needs of People with Chronic Conditions'. The large team was headed from the Ministry by Dr Jane O'Hallahan. Age Concern NZ asked me to be their representative. One third of NZ children have been diagnosed as having an LTC while 2/3rds of adults have at least one LTC. A life course perspective with an emphasis on prevention and management requires action in three particular areas:

• health literacy.

• supported self-management.

• proactive, co-ordinated care.

To assist the team develop a system dynamics model David Rees and Dr Jack Homer of Synergia spent two days with us, leading to both a written report and a LTC Concept Map which all had worked at developing.

The final report of the Framework does appear to have sunk into another deep hole. The last communication to the team in April 2009 included a copy of a draft paper, which we were not to circulate to others because it was an Internal Consultation Version and as such subject to review. It was not until earlier in 2012 when I asked for a copy of the final version from Jane O'Hallahan, by then the Interim CEO of the RNZCGP's so that it could be made available to ACNZ. The letter which accompanied the paper to ACNZ is as follows:

Ann Martin

CEO Age Concern NZ Inc.

Level 4 Education House,

178 Willis St.

Wellington 6011

Dear Ann,

Enclosed is a copy of the paper Long term Conditions which the chair of the team has sent me. Sorry to have been a while but I have only just received the final report myself. Jane O'Hallahan, who was formerly with the MOH has given it to me and she has personally authorised me to share her comments with you.

Jane told me that when she presented the final paper to the MOH she was informed it would be on the website. That has not happened. There have been changes at the MOH, as you are most probably aware. This subject, which is recognised worldwide as a major health/ societal problem, is no longer the top priority in NZ that it was when the team was set up. Its scope and philosophy of a patient centred approach embracing the societal setting, the range from infancy to palliative care is part of its strength. It is a well researched, thought out document. Sadly, instead of being promulgated widely, including to all DHBs it has been allowed to fall into a black hole. Nevertheless it is a public document. I was your representative on the team and I am able to provide you with it, which in turn you may use. I sincerely hope you do recognise its importance to people of all ages, including those who are old. In fact a major health issue for older people centres around the issues in this paper, including the issue of loneliness, which ACNZ has taken up and which is often associated with ill health and subsequent disablement.

ACNZ's ongoing role in 'Ageing is Living' health promotion is one aspect of health literacy issues discussed in this paper. So are the AVS and EAn programmes. I am sure when the paper is digested there will emerge aspects ACNZ wishes to further in their advocacy for a better old age. It is also related to the work on inequalities and the effect whereby 1 in 3 of the young suffer from a condition for more than 6 months, which may end up life long, and prevent them actually achieving old age, or being chronically ill and disabled throughout life. One needs to take a life course perspective to these matters to see the full impact on individuals, their families and society.

The MOH has included the management of LTCs in the reporting back to which DHB's are subject. The emphasis is though on the management of existing LTCs, more than a holistic scope commencing with improved health promotion/ health prevention efforts, except in a few areas such as immunisation and, hopefully soon, rheumatic fever. There is also an ABCC NZ Study Workbook on alleviating the Burden of Chronic Conditions was independently sent to DHBs from the Auckland Medical School which also tends to concentrate on the situation when people actually have an LTC. It would complement that Workbook if this Framework was available to them as well.

I have only one copy of this paper and should be grateful if you would return it when you have taken copies. Please feel free to discuss any matter arising from this paper.

Yours sincerely,

Margaret Guthrie

The main follow-up from ACNZ was a request to confirm their ability to share the paper with health promotion staff of the 27 Councils of ACNZ, a request which I was keen to encourage.

That was the last project emanating from the MOH with which I was associated. It is heartening to know that in 2011 the Ministry of Health appointed a Geriatrician, Dr Shankai Sankaram to be Chief Advisor in Older People's Health.

References

1. NZ Government, Ministry of Health, _The New Zealand Health Strategy,_ December 2000.

2. NZ Government, Minister for Senior Citizens, Hon. Lianne Dalziel, _NZ Positive Ageing Strategy: Towards a Society for All Ages._ April 2001.

3. Gee S., Glasgow K., _'Creating Communities for All Ages: Local Government and Older New Zealanders'._ Victoria University of Wellington 40 Plus Project & Age Concern NZ, August 2000.

4. Guthrie M. ' _Transport Issues',_ Age Matters, Age Concern NZ, Feb/ March edition,1999

5. Davey J., Nimmo K. ' _Older People and Transport'_ LTSA, Ministry of Transport and Senior Citizen's Unit, November,2003.

6. NZ Government, Ministry of Transport, Land Transport [Driver Licensing] Amendment Rule [No.2], 2006.

7. Picton C., Dir. Australian Council on Ageing, Address to AGM Age Concern NZ ' _U3A and Life Long Learning,'_ 1989.

8. Croot L., Chair National Council of Adult Education ed. _'Life Long Learning in NZ' 1987._

_9._ Age Wise Conference, ' _Life Long Learning and Living',_ Wairarapa Community Polytechnic, Alison Clarke, WOOPS, Sr. Monica Landy, Marsterton, 1992.

10. Jacobzone S., Combois E., Chaplain E., _'The Health of Older Persons in OECD countries: Is it improving fast enough?'_ 1998.

11. NZ Government, Ministry of Health, ' _Health of Older People Strategy: Health Sector Action to 2010 to Support Positive Ageing.'_ April, 2002.

12. NZ Government, Ministry of Health, _'Service Framework for Specialist Services for Older People,_ December, 2002.

13. NZ Government, Ministry of Health, _'Mental Health and Addiction Services for Older People and Dementia Services: Guideline for DHBs' M_ arch, 2011.

14. NZ Guidelines Group, Ministry of Health, ACC, _Assessment Processes for Older People: Best practice evidence-based guidelines,_ October, 2003.

15. Dagley E., Boyd M., Carior P., _Integrated Gerontology Nurse Specialist in Primary Care Project: Improved health care through earlier risk identification and intervention'_ Address to NZ Association of Gerontology Conference 2012, Ageing and Diversity, Auckland, August 2012 _._

16. National Health Committee: ' _Meeting the Needs of People with Chronic Conditions: Advice to the Minister of Health',_ November, 2006.

17. NZ Government, Ministry of Health, _' Long Term Conditions: NZ Directions for Action'_ Report of the Long Term Conditions Team. O'Hallahan J. Undated report.

18. ABCC NZ Study Group and University of Auckland Freemason's Geriatric Medicine Unit. _'Alleviating the Burden of Chronic Conditions in New Zealand',_ Workbook, 2010.

19. Guthrie M. to Ann Martin, CEO Age Concern NZ, letter re Long Term Conditions Report, 16 April, 2012.

### Chapter 17

Closer to Home

From 1980 onwards much of my professional activity was on a national scale but, as retirement from the Health Department was accompanied by a move to Plimmerton in Porirua, that city and its issues began to engross me more and more. Porirua and the Kapiti Coast have distinct population differences. In Porirua in 1991 the relatively young population was 45.5% Pacific island, 19.5% Maori and 21.4% European while unemployment was 20.3% whereas Kapiti had an 88% European, largely elderly population with an increasing number of retirement villages being developed in that area. When Kenepuru Hospital was opened in 1980 it was to meet the health needs of those two different local communities. It was always intended to be a community based hospital with a wide range of outpatient clinics to be held by specialists based either locally or visiting from Wellington Hospital. Its Accident and Emergency Services were limited in scope and covered daytime hours only. In times of financial restraints the Board had several times proposed closing Kenepuru, or at least its laboratory, or to cease in-patient surgery. Porirua City Council and its peoples had fought to retain those services whenever such proposals arose, attending meetings in large numbers where they voiced concerns unreservedly.

Therefore, when in late 1991 the Crown Health Enterprises [CHE] Advisory Committee called for applications to be approved as CHEs, it was not surprising that the Porirua City Council decided to examine whther it might be feasible financially and managerially for the combined Kenepuru / Porirua hospitals, which not only occupied the same campus but were also jointly administered, to be a CHE. They commissioned Sigma Consulting Services to undertake a feasibility study, and Jan Gould to undertake a Health Report. They also set up a small panel of local citizens to consider those reports, as well as to do any other investigation they deemed necessary. The group was chaired by a retired Judge, Jack Horne, and the other two members were Jim Callaghan, a former DG of Social Welfare, and myself. Marion Bruce was originally approached to be the health expert on the panel. Marion declined as she believed she would be seen to have a conflict of interest having only recently been the chair of the Wellington Area Health Board. In doing so Marion recommended that a senior staff member of the Department of Health, Dr Margaret Guthrie, who had recently shifted to Porirua, be approached. Although she was not officially a member of the panel, those of us who were, persuaded Marion to join our discussions informally as she had been so much a part of the Porirua scene in the days when her late husband practised there, apart from her own extensive health and social policy background.

The people of Porirua were well aware that Kenepuru suffered from being the most recently built hospital in the region. It had never been fully developed as envisaged because of a reluctance to transfer resources from Wellington to match growth to the North. Investigation showed that a Kenepuru / Porirua / Paraparaumu CHE was likely to have an adequate ratio of equity to debt ratio, and sufficient cash flow to cover expenditure and debt servicing. As a district it had a record of being able to manage within its budget. It could also provide cost competition, client choice and accessibility for all populations of the region with Hutt and Wellington. Such a CHE could be set up based on existing services and being allowed to contract for those it could provide in the first contract round; or it could be set up based on the need to increase services.

For me, as a relatively new citizen of Porirua, it was an opportunity to become immersed in the historical, social and cultural aspects locally. A characteristic of Porirua is that it is made up of a conglomeration of smaller communities with their own village centres, as well as the central business core. It is also a beautiful area where the harbour and the Pauatahanui Inlet are bordered by folded hills which attract artists of the calibre of Robin White, aiming to capture the essence of not only the landscape, but also the people and their built environments.

Involvement in other local community organisations followed, one such being the Porirua Healthy Safer Cities Trust [PHSCT]. I became that Trust's Age Concern Wellington representative, at one stage chairing the PHSCT for 2-3 years. It was set up to combine both the healthy cities and the safer cities movements, but its emphasis did tend to veer more towards the latter through its role in the development of the Porirua Community Guardians, promotion of CEPTED, [Crime Prevention Through Environmental Design], community violence/ property damage. There were projects which overlapped both health and safety, such as the Trust's espousal of the local Family Violence Network, including elder abuse and neglect, problem gambling and a tattoo removal project to improve employment prospects. One of the Trust's major roles was to act as an umbrella for emerging organisations by initially undertaking the administrative and financial aspects to foster their development e.g. a group of Porirua East women, who quite quickly became such efficient removers of graffiti, ended up with a PCC contract for the region. Another was to help expand the work of Tuakana, working with disaffected youth. Eventually Tuakana was able to be handed over to Ngati Toa oversight and support.

Having a gerontologist on board did ensure that the older person's voice was heard at times. For instance when the PHSCT was supporting Kidsafe's car seat projects or their burns campaign, one was both a concerned grandparent and mindful of Age Concern's life course, intergenerational focus.

A more direct link with health and wellbeing in Porirua was being jointly the Age Concern Wellington and the PHSCT trustee member of the Porirua Healthlinks Board.

The Porirua City Health and Disability Report and Plan 2000 was the result of a project initiated by the Minister of Health to identify ways to improve health and disability outcomes and better integrate services for the people of the Kapiti coast and Porirua City. There had been previous projects with similar aims but they had been undertaken by relative outsiders including the Department's MSRU which, though benevolent in purpose, had not in the end made as much difference as it was hoped it would do. The difference of this project was that it was led by locals, known as the Healthlinks Project Team [HPT] from the PCC, Kapiti Coast, Tangata Whenua and Taurahere, Pacific Peoples along with a Representative of the MOH, Dr Fran McGrath as Project Manager.

One concern of the HPT was to ensure that DHB decisions were not dominated by hospital issues – that project recommendations included that DHBs needed to be accountable to their communities, including building on what was already in place, instead of giving contracts to outsiders as had happened to the Waitangarua Community Health Centre which had once provided a range of services that were accessible, affordable and met the needs of the locals. These had included a social worker, dietician, antenatal classes, physiotherapist, counselling, an asthma nurse and education, but funding from some of those services had been taken away and offered to other providers.

Subsequent to the Report the grouping known as the Four Circles, the PCC, the Porirua Health Partnership, the Porirua Community Health Group and the PHSC Trust agreed to regroup into a Porirua Healthlinks Board to monitor the recommendation's progress. It was at that stage that I officially came on board. There was debate within the PCC, which partially funded the PHSC Trust, as to whether it should fully merge with Porirua Healthlinks but, as that did not occur, though it probably should have done so to better integrate services and conserve resources, the Trustees decided I should jointly represent the Trust, as well as be on Healthlinks on behalf of Age Concern Wellington. In time I also represented not only AC Wgtn and PHSCT, but also Porirua Healthlinks on the Housing Action Programme [HAP]. Retrospectively I have to say that HAP was the easiest of those involvements. Over the 90s and first decade of the twenty-first century the threat to sell off the pensioner flats in Titahi Bay was thwarted by active advocacy on several people's part, including Des Ryan. Phillipa Howden-Chapman's research into the ill effects on health of damp homes led to insulation programmes, and a considerable section of older state housing in Porirua East was refurbished. Some new housing was built, particularly for larger families and some for living alone older people.

In 2001 CCDHB produced a 5 year consultation plan which assumed that by 2005 Kenepuru Community Hospital beds would be reduced by 74, so that only 6 maternity beds would remain if indicators on reducing hospital admissions were met. The downgrade of KCH was to be part of the DHB's plan for the Regional Hospital at Newtown and upgrades of outpatients at Kenepuru and Paraparaumu hospitals, along with a new reception area and Accident and Emergency area at Kenepuru. The potential loss of beds really roused the locals.

Porirua City Council [PCC], Porirua Healthlinks and Ngati Toa made a community submission in August 2001 to CCDHB which in summary proposed that:

• The community supports increased integrated services as proposed in the CC DHB consultation document.

• Kenepuru hospital catchment covers Johnsonville north to Kapiti, and consists of at least 100,000 people and functions as the Coast's Community Hospital.

• No pre-emptive decision is to be made to close 74 beds at KCH in five years.

• No cost-shifting to families and communities of hospital reduced services.

• CCDHB invest in the community's capacity to work in partnership with CC. DHB by providing money and information.

• The community develops markers in collaboration with CCDHB that will monitor the effects on health outcomes of the increased services at both community and hospital levels.

• Porirua City Council, Porirua Healthlinks, Ngati Toa, CCDHB and service providers develop ongoing community deliberative processes, [including governance issues], based on the healthcare services cluster- 'Community of Excellence'- concept.

• START TOMORROW.

Wellington Regional councillors preferred to mount a petition. They gathered 13,000 signatures in 5 weeks, while submissions to the DHB numbered 1600, most of which opposed the move. The Minister, Annette King, was moved to write a stern letter to the DHB. On 12 September 2001 under the heading Kenepuru Hospital Beds Officially Safe, Anthony Paltridge, Health Reporter of The Evening Post wrote:

It's official. Capital Coast DHB has abandoned plans to cut the size of Kenuperu Hospital....

• The decision would now be factored into the overall regional hospital project.

• Mr Henare, Board Chairman said the retained beds would include some for rehabilitation and others to cover ... chronic medical illness, maternity, psychogeriatric and mental health adolescent services. He said work determining whether to retain beds at Kenepuru would continue but, given clinical viability issues he expected that innovative ways of delivering services would need to be implemented.

•... these innovations will involve greater involvement of local providers as we progress towards a community coast hospital. It also provided an exciting opportunity to engage with the Porirua and Kapiti communities on how to best configure these beds to address the needs of predominately coast communities."

• The Mayor of Porirua, Jenny Brash, said she was thrilled... "Its great news and a real victory for common sense and the people of the Western corridor of Kapiti, Porirua and Northern Wellington."

• Out of the ashes of that bush fire the germination of a Kenepuru Community Steering Group was generated "to provide expertise, advice and guidance on the community aspects of redevelopments as applicable to each site, and as outlined in the CCDHB Final Business Case, October 2001.

The Group was to be chaired by the CCDHB Relationship and Development Director, Fiona McTavish. It was to include Iwi, PCC, Healthlinks, GP, CCDHB Business Manager, Clinical Liaison advisor [Kenepuru/ Kapiti, Planning & Funding, Clinical Leader & Director Representatives. It was not lost on the community representatives that on the face of it we were outnumbered. That was dealt with that by just quietly seeing that Healthlinks not only sent their chair, Maureen Gillon, but also Louis Smith, the EO who happened to appropriately be Samoan, so he was effectively also a Pacific voice, and myself. The then two local CCDHB Board members, John Cody and Margaret Faulkner, also claimed their right to attend any Board sub-meeting. It was pointed out at the first meeting that, as the catchment for Kenepuru was the region from Johnsonville North, it would be wise to have a Tawa Community Board person, Dave Barnard, as well as one from Kapiti, Beverley Chapple. Later we suggested it would be wise to include regional PHO representatives.

In the somewhat tense atmosphere of the initial meetings it was made clear to us that, in the eyes of CCDHB management, the Group's function would cease when proposed physical alterations to cope with changes in function were deemed to be complete. We, though, made it clear from the start that some variation of ongoing community advisory input was our aim, if it was to truly be a community hospital.

As a former Hospital Board senior staff member, I was both fascinated by the manipulative tactics employed to try and keep us in our place, and appalled at the arrogance. From the start I determined not to be drawn into distracting minutia but to keep the big picture firmly in the frame. That did at times result in listening and silences, followed by a summing up, which gained an edge at times. We each tended to play our role and that became mine. We had a clear mandate of recommendations from the 2000 Report re Kenepuru and specialist medical and surgical services recommendations:

• funding 24-hr, 7-day access to high quality emergency services.

• organised around level 3, accident and emergency service at Kenepuru Hospital.

• ensuring that core health services were available and accessible locally, both in the community and at Kenepuru.

• providing a wide range and more frequent outpatient and day patient services.

• ensuring better access to and availability of inpatient paediatric, specialist maternity, orthopaedics, general medicine and general surgery, respiratory and ophthalmology services at Kenepuru. I added AT&R to that mix, especially drawing attention to the atrocious conditions for psychiatry of old age in dilapidated old Porirua Hospital buildings.

• frequent and convenient public transport services to both Kenepuru and Wellington Hospitals.

What is missing from that list was the status of the hospital. Margaret Faulkner was particularly keen to have the word community in the Hospital title. This was developed by the group, who largely wrote the community representatives' definition:

The Keneperu Community Hospital will provide secondary services as part of a Centre of Excellence in health care. It will contribute to meeting the needs of individuals and families through an integrated continuum of care. It will be known for:

• Community participation

• Cultural leadership

• Innovation

• Professional leadership

• Quality."

Prior to acceptance by management Maureen Gillon, Chair of Healthlinks, organised a discussion with Margot Mains, the CEO and senior staff. In the paper which the CEO then sent to the Board for approval there was broad agreement but also a slight put down:

CCDHB management are proposing that this be endorsed as an interim vision statement as it does not yet capture the focus on having family/whanau at the centre of service delivery. Nor does it strongly capture the need to focus services working in an integrated manner with primary care services to support these families.

What nit picking! As health professionals we all knew that 'integrated continuum of care' implies integration of primary, secondary and any other relevant services for a particular situation. Families/ Whanau were in the definition. In July 2002 the CC DHB board did agree to the interim vision statement, and as you now approach the entrance the sign clearly reads Kenepuru Community Hospital [KCH].

The first of the recommendations was to include the shutting down of the existing after hours GP emergency service in the Porirua CBD, the cost of which was prohibitive for too many of our peoples. That called for much negotiation and Dave Barnard was our representative on an advisory group which included the Porirua GPs so heavily engaged in the complications of the potential changes. What we finally ended up with was a 24 hour, 7 day a week Accident and Emergency Service with part charges for those aspects of the service which were fundamentally GP attendances. It is interesting that it is now a GP service but CCDHB provide the facilities.

There was great deal of angst and stress along the way, both within the community and within the burgeoning A&M services. So much so that an informal group of us 'community reps' and others, began to meet for coffee/tea at 8am on a Thursday morning to mull matters over. That meeting continues. The venue was somewhat fluid initially, but after we discovered the Peppermill was very tolerant of our, often, hour or more protracted coffee sessions [and their coffee was really good] we met there, mostly at the same table, week after week becoming year after year. It was not all work and no play. We were personal friends, as well as colleagues in a variety of disciplines, including law when Mary More came on board. Topics could range widely, including the subject of compassion in the world's religions and the works of the religious historian, Karen Armstrong, as John Cody and I discovered we had a mutual admiration for her scholarship and vision. George Salmond arrives regularly from his home in Karori to be part of the team, when he is not overseas in places such as the trans-Siberian railway, or tramping in our own high country. George had us reading Amartya Sen's discourse on 'Development as Freedom' at one stage.

Some join in for a while, but a solid core also exists. Leaving those Thursday mornings was one of the hard aspects of adjustment when I finally moved to be nearer family in Auckland in April 2010, but, when back in Wellington for a while being at the Peppermill early on Thursday remains a must do. This year at the PHA Conference in Wellington the Thursday group proffered a workshop on aspects of child deprivation and I was certainly present.

Helen Bichan also wrote a poem last year:

Thursday morning group

Green tea for clarity,

hot chocolate for comfort.

Long black for wakefulness

at the Peppermill.

Touch base with current news,

consider Porirua issues,

mull over local and national government-

at the Peppermill.

Tease out the meaning of actions,

look for sense in official statements,

make connections at different levels-

at the Peppermill.

Understandings clarified,

mutual support given

concerns and vigilance shared-

at the Peppermill.

Helen's way with words, combined with her grasp of concepts, emerged when she wrote a paper mirroring ongoing concerns about the management of the A&M service in a paper headed:

### Frog or Bicycle?

### Is Keneperu Community Hospital [KCH] a frog or a bicycle?

It depends on how you look at it. A bicycle goes places and its parts are easily repaired or replaced. Its functioning may be improved by replacement of faulty parts or adding new ones. The connections between parts are simple. To function it requires a human rider to provide direction, drive and to ensure it is kept in order. Those proposing to replace a component - a part of the Accident and Emergency department [A&M] - assume this is a simple procedure that will enhance future functioning.

On the other hand a frog is a living organism which also goes places. It has the capacity to respond to its environment and to grow when provided with sufficient nutriments and conditions. Maintaining good health ensures good functioning. If one part is damaged the whole frog is affected - parts cannot simply be removed or replaced.

In my view KCH is more like a frog - it is an organism which is responsive to its environment and depends on having the right resources supplied for its health and well-being. If one part is not functioning the whole organism suffers. If there are problems with running the A&M it is simplistic to assume that a malfunctioning component can be extracted and replaced without a major impact on the whole.

### Perhaps you prefer a medical analogy and see the KCH as a patient!

Good diagnosis is preceded by:

• listening to the patient.

• taking a proper history.

• eliciting the symptoms from the patient-i.e. what is being experienced.

• examining the patient through making observations and appropriate tests.

• considering the wider context of the patient-social factors, family observations etc.

Possible diagnoses are then considered. The patient is kept well informed at all stages of the process.

Once a diagnosis has been reached a variety of treatment options are considered, e.g. attention to environmental factors, life style, medication, aids or appliances etc., remembering that attention to the determinants of health is likely to be most effective for the long term future health of the patient.

Using that medical model Helen then proceeded to examine the KCH, arriving in the end at Medium to Long Term Treatment which detailed three main aims:

1. investment in training of health professionals.

2. continued close collaboration with PCC, Ngati Toa, Healthlinks, Centre of Excellence, communities of Kapiti, Porirua and Northern Wellington.

3. direction to its management staff for collaborative action which addresses reduction of inequalities, and integration of services across primary secondary and other relevant services.

Much positive good was also occurring at KCH. Day surgery and outpatient clinics range and numbers attending were steadily increasing. Paediatricians were using the observation beds but any subsequent referrals to PHOs are not possible when patients are unable to enrol. Some 20% of children under 6 are not enrolled. AT&R had its own ward which was working well while Psychiatry of Old Age had a new building adjacent to the main KCH. I T was better managed as are interface issues which senior staff have identified. A regular transport shuttle bus runs between KCH and Wellington Hospital with a connection with the regular Porirua bus service to KCH.

When the newly rebuilt areas were to be officially blessed and opened in 2006 the KCH Community Group did cease to exist, but a new KCH Reference Group which was to meet quarterly, took its place to continue to advise on issues, particularly those arising from access, integration and proposed service directions. A number of us stepped from one role to the new one but membership also widened to fill perceived gaps. In 2008 Luke Worth, Director of Change at CCDHB, realising that the KCH range of services was more or less stabilised in positive directions, managed further change in that membership of a renamed KCH Consumer Action Group depended on whether the person had been over the past couple of years, or was actively a day or outpatient. That situation still pertains. The linkages between KCH and its community are strengthened by the existence of KCH's educational facilities which are accessible to a variety of health related organisations, as well as the busy health services themselves.

### CCDHB Palliative and End of Life Care Services, HB

In 2004 Mary Potter Hospice which had been providing an outreach palliative care service on a limited scale to Wellington Hospital withdrew that service, an act which in fact led to a review of the overall situation in the CCDHB region. A Palliative Care Reference Group was set up by the Board in late 2004 which included a nominee from Age Concern Wellington, myself.

Helen Griffith, who was at that time actively involved with Grey Power's Porirua Branch, as well as being the community representative of Tumai PHO, was also a member, a felicitous pairing as we were both older ourselves and held similar desires to see all people who were dying being able to live as well as possible until they died. Where people are only given the option of palliative care at the very end of life, if they are given that option at all, their capacity to make informed choices is limited, one consequence of which can be increased pressures to legislate for voluntary euthanasia because of what may well be suffering which might otherwise have been relieved. Helen and I both came to the reference Group meetings with anecdotal stories of such suffering. In July 2004 that concern had prompted me to write to Professor Norman Sharpe:

9 July, 2004

Professor Norman Sharpe,

Medical Director National Heart Foundation,

PO box 17160,

Greenlane,

Auckland

Dear Professor Sharpe,

As a Public Health Physician / Gerontologist who is a Trustee of Porirua Healthlinks I heard your comments on Radio NZ about inequities in cardiac investigation and treatment among Maori and Pacific peoples, rural and low income people generally, with much interest. It really is time that there are best practice, evidence based guidelines for cardiac care. I was a member of the guidelines group which produced the Guidelines for Assessment Processes for Older People over an eighteen month period that culminated in their publication in October 2003. I emerged from that project with real respect for the objectivity of the process that the Guidelines Group follows.

The reason I am writing this letter is because I have a growing concern about another issue involving cardiac surgery, and have been wondering to whom it might be appropriate to voice this concern. It is about an apparently increasing tendency to perhaps over-treat some very ill cardiac patients.

It was two separate cases among people whom I know that first alerted me. One was in Christchurch which involved a man who I had known was hypertensive many years ago when I was an Air force MO. Some years ago he had a coronary which was fairly extensive, but from which he recovered. In time he developed CHF. Mentally he had great difficulty coping with his situation and was highly anxious, if not depressed. After months of increasing illness that did not respond very well to treatment, he was admitted to Christchurch Hospital, again very ill indeed. It was put to him that his only hope was surgical revascularisation. His wife said there was no discussion around options, and that her husband felt obliged to have surgery, although he really felt that he might have reached the stage when TLC and, as good a death as possible, might be a preference. He actually expressed the wish that he might not survive the surgery. His last week was spent in Intensive Care. He was miserable, so were his family, and part of that misery was because they were not sure he should have been subjected to the surgery. They were also realistic enough to comment that he was occupying a place that maybe someone with better prospects for recovery should have had.

The second case was of a man who was a long standing diabetic who had had a stroke on top of cardiac problems. He was transferred from Palmerston North Hospital to Wellington to have cardiac surgery. Again he felt obliged to have it, though both he and his wife where well aware of his multiple complaints and the fact that he was a poor risk. He too spent nearly a week in Intensive Care before he succumbed.

If there were just two such cases I would think it was coincidence but shortly after the second man died I was in social conversation with an experienced surgical nurse in Auckland. Quite out of the blue he told me how he was becoming increasingly upset because, both cardiac surgeons and some surgeons with cancer patients, were subjecting their patients to more and more procedures from which they died, after some time in Intensive Care at a stage when, in his view, they should have been allowed to die as well as possible with good palliative care. We ended up with a discussion as to whether those surgeons were carried away by the technological possibilities, or whether they had not come to terms with their own mortality, or perhaps were not listening to their patients well enough.

So I hope this issue is also considered by the cardiac guidelines group.

As an older gerontologist myself, I am very aware of all the ethical issues around all this. And I was closely involved in the early days of palliative care in New Zealand. In the HFA days we had arguments around their proposal to introduce the QALY framework to determine health priorities. At that time, along with my geriatrician colleagues we agreed that age should not be the issue as such: that it should be 'capacity to benefit'. That calls for real objectivity in weighing up any options and, in recent years, when I have become more and more a consumer advocate for older people I have come to realise how very important it is to have treatment truly patient centred. The better informed patients really are, and the more they feel in some control of their well-being, the better the outcomes will be. In the end all of us are going to die eventually; we should aim for as many as possible to live as well as possible until the last.

These issues are not unrelated to those of our people who are marginalised from best practice. The resources involved really do need to be used as effectively as possible. That is not some academic QALY argument, but really old fashioned common sense and sensibility, - and for the guidelines best practice and evidence based advice- hopefully.

Yours sincerely

Margaret Guthrie NZCM

BSc;MBChB;DipHA;FAFPHM

cc Catherine Marshall, CEO, NZ GG

On 24 August 2004 Professor Sharpe responded:

Dear Margaret,

Thank you for your letter re cardiac surgery. I agree entirely with your concerns and have passed these on to some of the Directors of Cardiac Surgery in the main centres, and will follow through with others. As inaugural chair of the NZ Guidelines Group I also agree with you on best practice statements.

We will continue to speak to these crucial issues in the course of our work on an everyday basis. I am promoting a plan of engagement for the Heart Foundation with the health sector, which is necessary to ensure better quality and equity, and which is underpinned by best practice guidelines.

Thank you for your thoughtful letter and helpful comments which are encouraging for us.

Best wishes

Yours sincerely

Norman Sharpe

Professor Norman Sharpe

Medical Director

Of course there was as well much wider discussion within the Reference Group and it was good to see the response of the CCDHB Board in the timely subsequent post review appointment of Dr Jonathan Adler to spearhead the Hospital Palliative Care Team, followed comparatively quickly by the appointment of two specialist palliative care nurses and other support. Not only did that mean offering palliative care as a choice for those who, while not yet dying, had reached a level of ill health where quality of life is markedly impaired and where a pro-active approach to intervene could have a positive impact on the level of distress and disability they may have reached. It also would be accompanied by the required ongoing medical, nursing and other health professional education to help create such a climate both within the hospital system and in the community for those who sought to die at home, or who might be in residential or long-term hospital care.

A further off-shoot was the creation of a Palliative Care Forum to meet quarterly, which aimed to improve collaboration in the development of integrated palliative care services within the region, as well as work strategically with palliative care providers in other DHBs. The direction was right, but no one was under any illusion that the road ahead was long, and not always going to be smooth travelling.

### Disability Support Advisory Committee [DSAC]

Each DHB was legally bound to establish a DSAC to advise on disability issues.

In April 2005 I was invited to be interviewed regarding external membership of CCDHB DSAC. In earlier discussion with Margaret Faulkner, who was the CC DHB's Chair of DSAC, she felt the committee needed a gerontologist / public health physician at the stage where the re-development of AT&R, both general and psychogeriatric, along with monitoring of the pilot Care Co-ordination Centre, and workforce issues, in both home support and residential care especially, were to the fore.

It was interesting, and I was glad to be able to encourage and support the progress a dedicated chair wished to achieve. But those few years on DSAC did not engender a positive opinion about the functioning of some elected members. In fact the lack of competence of some, and one track obsessions of others, made me wonder if we should not consider the Scott's system whereby those who aspire to stand for elected health office have to meet certain criteria before their application is approved. Whether a small country of just over 4 million people, who have no fewer than 21 DHBs, can actually find competent people to fill 7 places in 21 DHBs is debatable. Appointing external members has been seen as a solution, but it is a partial one at best. An initial first question is how many DHBs do we need anyhow, and the answer seems to hover between 8 to 12, at the most. The motivation to try and enable as many communities of interest to have a say in the operation of health services may be worthy socially, and perhaps politically, but it does not make fundamental resource and financial sense.

### Well Elder: Counselling Centre for Older People

Estimates of the extent to which reactive depression occurs in older people are fraught with difficulty, if for no other reason than we are certain a lot is hidden, simmering under the surface, threatening wellbeing. Anxiety, that state where people over estimate threats to their security while under estimating their capacity to cope, also affects wellbeing if persistent and unresolved. Both have tended in recent decades to be dealt with by medication if a person did visit a GP, when support through effective counselling could well have been more appropriate. If qualified counsellors are available the cost might also preclude their accessibility in any case. It was that situation which prompted the Presbyterian Campbell Centre in Christchurch to development an affordable counselling service. That in turn led to Anne Millar, who led that initiative, being invited to Wellington in 2006 to discuss the possibility of such a service locally.

Funds were found to set up a small group including Graham Millar, Practising counsellor who chaired the group, Raye Boyle for NZAG; Lysbeth Noble for AC Wellington; Justine Thorpe for South East and City PHO; Tom White for Wesley Care, along with Karen Swain, who was both a practising counsellor and Establishment Manager. Their aim was to develop a funding proposal for a similar service in Wellington. The proposal did secure a three year contract to establish what has become Well Elder. The objectives of the service were to:

• provide an affordable [subsidised] individual and group counselling service that will improve the quality of life for people over 55 years of age.

• provide a service that includes delivery in their own homes as well as residential care

• provide training for elder wellbeing counsellors and group facilitators.

• provide education about positive ageing for health professionals and the general public.

• provide telephone and voluntary services to reach home bound clients.

• Support research into practice-based evidence to assess / monitor the effectiveness of counselling with older people in routine practice and home settings.

When Lysbeth retired from Age Concern, due to failing health, I stepped into her shoes on the management group in early 2009, becoming involved almost straight away in the selection of staff for an outreach base in Paraparaumu. That called for submersion in the dos and don'ts of requirements to fulfil the standards of the NZ Association of Counsellors, while listening to and learning from Rosemary Nourse, the highly professional counsellor / manager of Well Elder, as she discussed issues and interviewed applicants. It was no surprise that an audit prior to the completion of the original three year contract was so positive, which in turn led to ongoing CC DHB and other financial support for the service to be ongoing. Upon my pending departure from Wellington in 2010, I wholeheartedly recommended to Age Concern Wellington that Ann Dalziel should continue our active support on the management group. Regrettably parallel counselling services remain limited in their availability in New Zealand at this stage.

### Consumer Liaison Committee [CLC]

### Royal New Zealand College of General Practitioners [RNZCGP]

The RNZCGP is a national body which happens to have its headquarters on The Terrace in Wellington, so that when I was invited in 2000 to become a member of its fledgling CLC attendance was close to home. The fact that Claire Austin was by then CEO of the College, while Maureen Gillon was Quality Assurance Research and Development Officer, later to be Director of Quality, meant I was well known to those College staff members. When a colleague, Dr Tom Farrar, heard of that appointment he was shocked that a doctor could be considered a consumer. I countered that we were patients ourselves at times. As well, over the decade since retirement from the former Department of Health, I had become increasingly an advocate for older people and was by 2000 within the older age band myself. Having said that, Tom did have a point. My usefulness to Age Concern, both locally and nationally, was largely based on being a professional public health physician/ gerontologist, a fact that the other members of the CLC lent on at times as well.

Initially Dr Phil Jacobs, a RNZCGP Councillor from Christchurch, chaired the CLC, guiding the four of us, Frances Acey, Linda Hall-Thorpe, Linda Moses and myself, along with Helen Glasgow who provided administrative support, as we established ground rules and a development vision of two-way communication with both the College membership and our community constituencies. Within the year Phil suggested it was time the CLC elected one of us to act as Chair, which happened to be me. Having been elected for a three year term also involved being an observer at College Council meetings, where I usually sat beside first Phil, and then Ros Gellatly, who took his place after Phil completed his spell on the Council. From the first we were closely involved in developments such as 'Aiming for Excellence, an assessment tool for general practice', which was periodically updated. In that first year the CLC also produced a paper for the College on Sexual Safety in General Practice as our first project.

Upon the completion of the three years I ceased to be a CLC member but the association with the College continued to enable me to attend what had become annual Quality symposia organised so effectively by Maureen Gillon until my departure in 2010 for life in Auckland to be nearer to family. The role the RNZCGP has played in developing training, raising the quality of practice, promoting patient centred care and encouraging rural practice commands respect. There are aspects of primary care that are a concern, not least of which is the increasing social and health divide between the best resourced fee-for-service medical centres for those who can afford those fees, and the well organised, more affordable but sometimes over-burdened community health centres, who look after the complexities of not only a less well-off proportion of our peoples but also one with, all too often, increasing long term health problems.

References

1. Porirua City Council / Sigma Consultancy Services, ' _Crown Health Enterprise Feasibility Study,_ September, 1992.

2. Gould J., Porirua City Council, ' _Health Report' July 1997._

3. Ministry of Health,: Porirua Kapiti Health and Disability Project, ' _Porirua City Health and Disability Report and Plan' A_ ugust 2000.

4. Capital and Coast DHB: 5 year Consultation Plan, 2001.

5. Porirua Community Submission to CCDHB on proposed Health and Disability Services for Wellington, Porirua and Kapiti; Ngati Toa, Porirua Healthlinks, and PCC, August 2001.

6. Minister of Health,Hon Annette King, letter to CCDHB, September, 2001.

7. Paltridge A. Health reporter, The Evening Post, ' _Kenepuru Hospital Beds officially safe', 12_ September, 2001.

8. CCDHB, Kenepuru Community Steering Group, Terms of Reference, October 2001.

9. Guthrie M. letter to Professor Norman Sharpe, Medical Director of National Heart Foundation,9 July, 2004.

10. Prof. Sharpe N. to Dr Guthrie, Response to letter, 24 August,2004 .

11. CCDHB, _'Palliative and End of Life Services: A Summary of the Review[Final]'_ August 2005.

### Postscript

Having passed the driving test at 80 and 82, as was legally required at that time, did leave me pondering how it would be living at 6 Taupo Crescent, Plimmerton, if I had not passed the tests, or the required medical. A neighbour who had died a few years earlier, Joan Harrison, had a sister-in-law locally who, once a week, took Joan and another woman shopping, after which they had lunch and then played cards at Joan's place. I had no such sister-in-law or other close relative nearby with a vehicle, so it might have entailed taxis or Driving Miss Daisy. Then there was the house. Was it, or its relatively steep site, suitable if one became physically frail? Those questions began to hover in my mind.

My previously Wellington based daughter, Sarah Jane, shifted to Auckland after her husband died. The one remaining close relative was David, my son, who does not drive. He has lived in his own particular world in the Heath Flats in Johnsonville for around eighteen years. We communicate regularly one way and another. While visiting Auckland, Sarah Jane suggested that her two storied dwelling in Onehunga could be converted into two apartments where we could be in the same dwelling, only self-contained when it suited. The more we discussed the matter, the more appealing it became for both of us.

Subsequently 6 Taupo Crescent, Plimmerton was sold; not without some anguish. What was an apparent sale at a favourable price collapsed when a building report showed that a corner of the house was subsiding, and that correcting that would cost thousands of dollars. That would have frightened off potential buyers but, fortunately, a builder was prepared to take on the property at a reduced price. That meant I had a sale and could depart, as hoped, before my granddaughter-in-law,Tanja's baby was due. As Sarah Jane was unavoidably working in China, and Tanja's parents lived in Zagreb, I was especially glad to be around when Mara was born. Being able to hold Mara soon after she was delivered was one of life's joyous moments. With her mass of dark hair she looked older than she really was, a precious bundle of humanity. Now Mara has a sibling, Mark, as well. So there are four generations of us in Onehunga and it is an ongoing absorption to be able to be close by, attend a day care's end of year function and listen to Mara's conversations, as well relish Mark too these days.

There were aspects of the shift which had its stressful moments. Leaving friends and close working colleagues, as well as David, was not easy. The re-build of 103 Arthur Street had its low points. There were breakages of furniture, water damage and mould destroyed some valued books when my goods were at last able to be delivered from storage. It did affect my well-being for a while, as is not unusual, but that phase has passed - thankfully.

Theoretically, the second volume of my memoirs should have been completed earlier, though at one stage I wondered if it would ever happen. It has, and I am grateful because I had the privilege of being deeply involved at a significant period of the development of health services for older people in New Zealand. That is a story which deserves to be recorded. I value all four of my life memberships, among other honours, but was moved to tears when, in November, 2004 a letter arrived from Professor Richard Sainsbury, on behalf of the NZ Geriatrics Society, to say the constitution had been amended at the AGM to provide for Life Membership. He continued:

I am delighted to inform you that you have been nominated as the first life member and this was greeted by universal acclaim. We would be honoured if you would agree to accept Life Membership.

Have I retired now? Retirement is not a concept that resonates positively for this older gerontologist. Life changes direction at times. That can be a stimulus. There is now more opportunity and time to be with family, to cook a meal for them at times, to help develop and maintain our garden, to meet new people. In Wellington I used to speak to various Probus Clubs around aspects of 'Ageing is Living', and would wonder if I should ever have time to join one. The shift to Auckland has made that possible, which in turn has opened up other opportunities.

There does remain a link with Age Concern New Zealand and the Wellington Age Concern Council. Age Concern's 'Ageing is Living' booklet is being revised to bring it up to date. Upon being asked if I was interested in being involved there was an immediate affirmation. One aspect that I initiated in this country was health promotion alongside older people. It is too important to abandon when there is an increasing recognition of the need for people to feel in control of their lives, including their own health and well-being as they age.

### Acknowledgements

Hopefully these memoirs offer tribute to many of the colleagues with whom I have worked alongside in a variety of situations. At times it has been in teams, both formal and informal, the latter including the Thursday group in Porirua. The hardest part of the shift to Auckland was physical separation from that group, but one way or another it is easier to maintain contact these days. The Medical Women's Association may have officially disbanded but in Wellington Aine McCoy has organised an annual lunch for former members with invitations to outliers like myself. Such ongoing connections enrich life, whether or not one is able to be present. I have hesitated to include a list of names because it would be very long, including colleagues not perhaps mentioned by name in the text whose presence has been important at one stage or another.

In the gestation of the book there have been individuals who have been of particular assistance for which I am most grateful. Maureen Gillon, in the early stages, read and commented on the first draft which resulted in changes and additions. Stephanie Waterfield and Verna Schofield have encouraged and cajoled me to persist over time. Anne and Bob Brown offered a bolt hole in Tauranga when accumulated stresses around the rebuild time here generated a hiatus for research and writing. Linda Bryder, as occupied as she is as an academic medical historian, has not only read and edited parts of the final draft but has also introduced me to Diana Holmes. Diana has designed the cover most pertinently, and undertaken the publication online with a 'print on demand' capacity.

To family and friends a warm thank you for your ongoing support.
