New Zealand’s health system is suffering the consequences of decades spent unravelling a once proud and effective network of public health and prevention.

Palmerston North-based kuia Ann Shaw, the first nurse to be named a New Zealand Public Health Champion, said it was “terribly sad” to see the current stress on patients and frontline health workers.

She was responding to a series of reports about pressures on emergency departments, waiting times for appointments in primary care, and delays in planned care at hospitals operating over capacity.

The situation was as bad in Manawatū as anywhere.

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Figures released by Health Minister Andrew Little in the past week showed Palmerston North Hospital held the national record for the number of people waiting more than 24 hours in the Emergency Department for admission – 97 people in April.

But it was not surprising, the 80-year-old grandmother said.

People knew in the 1990s what was going to happen, and she believed the health system had been in a state of crisis ever since.

Shaw speaks as a former public health nurse, health promotion manager, and the last principal public health nurse based in Tairawhiti, with more than 50 years experience in public health practice and advocacy.

She was most recently health promotion co-ordinator for BreastScreen Coast to Coast, and is still active in the Cancer Society and in other agencies.

Shaw said she was constantly surprised how few politicians and others responsible for making decisions about health services had any understanding or curiosity about what had worked in the past.

“In the 1950s and 1960s, we were one of the best in the world.”

There were public health nurses based in every school, offering a point of contact a team of practice nurses working in primary care today could not hope to match.

“Then we cut down on a system that was uniquely New Zealand.”

She could not understand why numbers of hospital beds had been reduced in the face of a growing population.

She thought moving nursing education to polytechnics and universities had undermined the ability of health staff to work in teams, and student loans had discouraged new trainees.

Most of all, she blamed the policies of Rogernomics in the 1990s when health services became competitive, and area health boards were turned into crown health enterprises.

The networks informing health, housing, education – the determinants of “Public Health” beyond the control of the health system alone – were eroded.

That undermined a long history of prevention of ill health through appreciating a Māori definition which used the whole continuum, from spirituality, environment, culture, housing, education, employment, justice to disability, illness and the medical model of hospitals.

“What has been missing since then is building on the strong NZ developed system of prevention.

“Prevention might cost more at the beginning, but less at the end.

“It’s interesting looking back, but it’s so annoying.”

Communities needed to be given the support and information to decide for themselves what needed to be done, not have it decided for them by some distant bureaucrat, she said.

In the latest health reforms, and from a recent meeting with Little in Palmerston North, she saw a glimmer of hope of that shift, with locality planning being rolled out in places including Horowhenua where there were already strong links between health and other services.

A key focus for Te Whatu Ora/Health New Zealand was on keeping people, their whānau and their communities well and out of hospitals – not just caring for them when they got sick.

The emphasis on equity for Māori also sat well with Shaw after being immersed in Tairawhiti – “what’s good for Māori is good for everyone”.

Shaw said a key challenge would be rebuilding the public health workforce.

Te Whatu Ora chief executive Margie Apa has already acknowledged long-standing issues of workforce shortages, burnout and under-investment, and believed the new system could better deal with them.

Shaw’s point of view resonates with the current Public Health Association of New Zealand.

Senior policy analyst Alana McCambridge said the current challenges in the health sector arose from a combination of issues, exacerbated by the Covid-19 pandemic, and while grappling with the biggest health reforms in 20 years.

The problems included a focus on illness rather than wellness, a lack of investment over many years in health and in the locally-grown health workforce.

Efforts at early intervention and prevention of ill-health had been undermined by a lack of spending on public health.

Public health averaged about 3% to 4% of the total health budget.

“If we are to truly address the underlying determinants of health and needs of the population now and in the future, we need to get that total up to 10% at least,” McCambridge said.

She said there had been a reluctance within the public health workforce to engage in political action, “which is where we used to be most effective”.

As for Shaw, she will keep on making submissions and advocating for better health, duties from which she said she would never properly retire.

“As grandmother of 10, I would dearly love for the mess of the health system to be improved, not only for everyone’s future, but also to ensure a fantastic employment future for the fourth generation of my whanau.”