Becoming a “first contact” profession

In 1989 – the very year that Roger Douglas was sacked by Prime Minister David Lange – the Labour Party completed a process of devolution that had begun in 1983 with the Area Health Boards Act.  The act paved the way for the first major restructuring of health services since the formation of the welfare state, and this, in turn, created the impetus for physiotherapists finally to achieve recognition as a first contact profession. 

The 1980s was a tumultuous decade in New Zealand history.  Feeling the effects of rising welfare costs, the loss of guaranteed export trade with Britain, and the oil crisis of 1973/4, New Zealand came under the thrall of the “Rogernomic” free market policies of the 1984 Labour government.  Part of the government’s agenda was to separate clinical decisions made by doctors from their financial consequences.  The era of managerialism in health care had begun, and the medical profession was very unhappy about it. 

In a press statement delivered in late October 1988, David Caygill, the Labour Minister of Health, argued that, “When it comes to deciding whether money should be spent on heart surgery or health promotion, the ‘expert’ is no better equipped to decide than the lay person”.  Caygill’s intention was to “…force doctors into a reluctant marriage with their Area Health Boards.”

The devolution of health services to communities highlighted structural deficiencies in the way that health care was delivered.  Patients would have to visit their general practitioner every time they needed a referral to a physiotherapist, even for repeat visits. 

Questions over the need for physiotherapy to become a first contact profession did not have their origins in the 1980s however. 

In the early 1920s – in a break from the convention of following English-trained masseuses – the four branches of the Society agreed that mandatory medical referral would be unworkable in New Zealand with its widely dispersed population and no nationwide GP coverage.  Medical referral, however, became the norm from the 1930s onwards as physiotherapy moved into the welfare state.  The first challenge to this came in 1978/9 with the Chiropractic Commission, which resulted in the NZSP adopting a “co-operative referral” system which enabled physiotherapists to have direct access to patients as long as they notified the patient’s medical practitioner of their attendance.  The system was unworkable, however, not least because patients with private insurance needed no such referral.

By the early 1980s the picture had become confused.  There was no uniform system for referral; there were no ethical or legal barriers to patients seeking direct access to physiotherapists; and at least 20% of private patients were already being assessed without a referral.  Naturally, patients were reluctant to pay a doctor simply for a referral form – something that many saw as a rort – and the profession was concerned that the practice deterred patients from attending physiotherapy. 

Not surprisingly, the Society welcomed the Area Health Boards Act, and it became the vehicle to solve a number of institutional problems, not least the question of physiotherapy as a first contact profession, which was finally ratified in 1989.

Dr David Nicholls