MOUSOURAKIS: Health Care Services for the Elderly in New Zealand

73

Health Care Services for the Elderly in New Zealand:a Critical Perspective on Current Policy and Practice
MOUSOURAKIS George 1, 2, 3, 4
1: Faculty and Graduate School of International Relations, Ritsumeikan University,
Kyoto, Japan
2: Graduate School of Social Sciences, Hiroshima University, Hiroshima, Japan
3: Max Planck Institute, Frankfurt, Germany
4: The New Zealand Centre for Human Rights Law, Policy and Practice, University of
Auckland, New ZealandE-mail: geomous@fc.ritsumei.ac.jp

Abstract
In New Zealand, as in many other countries around the world, a rapidly ageing population, combinedwith rising rates of dementia and chronic conditions, has necessitated the development of health care models
capable of meeting the rising demand for service provision in a resource-constrained health environment.
The call for high quality, affordable and sustainable health care services in both residential and homebased settings has prompted an increase in long-term care funding along with the promulgation of policy
initiatives which emphasize the importance of the elderly for society and the need to adequately plan forrising service needs. Following an overview of the connection between New Zealand’s rapidly changing
demographics and health care demands, the present paper will outline the development and main featuresof the country’s health care system with particular reference to the services available to elderly persons anddiscuss some of the challenges the current system faces or is expected to face in the future. With a publicly
funded health care system that offers a high standard of emergency and acute care services, as well as
legislation that limits how much older people have to contribute towards the cost of long-term residentialcare, it could be said that the older sector of New Zealand’s population is relatively well serviced in termsof access to health care services. It is argued, however, that the system should continuously be adjusted andimproved to ensure that the long-term implications of the changing demographics and ageing population
can successfully be met through the implementation of high quality and sustainable models that could better
address patient needs through the delivery of comprehensive and effective heath care services.
Key words: ageing, elderly people, health care legislation, health care services, health care system, New Zealand

Received: 27 March, 2017
Accepted: 16 February 2018

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South Pacific Studies Vol.38, No.2, 2018

New Zealand’s Changing Demographics and Health Care
Ageing is a process that applies to all persons, without exception. It is measured
by time and proceeds continuously to affect us during the whole of our lives. Whileindividual ageing has always been a human characteristic, the phenomenon of societal
ageing is a more recent one in developed or industrialized countries. Until the 19th
century, most societies had a relatively steady balance between births and deaths;
but the 20th and 21st centuries have brought about the new phenomenon of ‘ageing
societies’, in which the number of middle-aged and older people is rising. The ageingof the population is occurring due to two principal factors: first, the birth rate of thepost WWII generation greatly exceeded that of previous generations; second, since theearly 20th century, older individuals have experienced unprecedented increases in life
expectancy. In particular, the so-called ‘baby boomer’ generation, which represents
people born between 1946 and 1961, has substantially contributed to the size of older
population in many countries.
Ageing is a critical driver in the demographic changes taking place in New
Zealand. At the 2006 Census of Population and Dwellings, there were 495,600 New
Zealand residents aged 65 years and over (in a population of 4,027,947), up by 45,200
on the 2001 Census. This represented the largest growth recorded between censuses
for this group in our demographic history. From 2011, the post-war baby boomers havebegun to move into the 65+ age group in large numbers. Projections from Statistics
New Zealand indicate that 100,000 people aged 65 and over will be added every 5
years from 2012 to 2036. The largest increase is expected to take place in the decade2021 to 2031, when a further 276,000 people are projected to move into this older age
group. The 65+ population is expected to more than double to between 1.17 millionand 1.48 million by 2051, when they will make up 25% or more of all New Zealandresidents.1 The ethnic constitution of the New Zealand population is also expected
to change during this time, with the proportion of Maori, Pacific and Asian groups
increasing relative to the current majority of those of European descent. The Maori
population aged 65 and over is projected to increase from 3% currently to 7%, theequivalent Pacific group from 3% to 6%, and the Asian group from 4% to 8%.2 The key
issue here is that the growth in the elderly sector of the population is not balanced by acorresponding increase in the younger population. With the number of births per capita
projected to decline over the next decades,3 the ageing of New Zealand’s population istherefore inevitable (Table 1).

１ See on this BRYANT (2003).
２ Statistics New Zealand (2004).
３ See POOL et al. (2005).

MOUSOURAKIS: Health Care Services for the Elderly in New Zealand75

Table 1. Projected New Zealand population of ages 65, 75+ and 85+ years from 2011 to 2051 as apercentage of the total population (Statistics New Zealand 2000).
Age

2011

2016

2021

2026

2031

2036

2041

2046

2051

65-74

13.7

15.8

17.9

20.3

22.6

24.3

25.2

25.4

25.6+

75-84

6.3

6.9

7.8

9.3

10.8

12.6

14.1

15

15.3

85+

1.9

2.2

2.4

2.7

3.2

4.1

4.8

5.7

6.3

This fundamental shift in the demographic structure of New Zealand’s population
is expected to have a significant impact on, among other things, the quality of social
services and accommodation, the composition of the labour market and the rights andself-determination of older people. The combination of these factors is increasingly
viewed as one of the main issues of the 21st century that will require considerable
organizational changes and long-term care policy development and implementation.
Among the most important issues requiring long term planning, strategy and action
include: the recognition of the social and economic contributions that older people
make; the role of older people in employment and the work place; the transition fromwork to retirement or part-time retirement; ensuring that older people have sufficient
income to live comfortably; ensuring that there is adequate housing for older people;
the social isolation of older people; respect for the autonomy and self-determinationof older people; issues of safety, abuse and neglect, and the quality and increasing costof healthcare services. All these issues are essentially about the value society placeson older people and the factors pertaining to the future sustainability of their lifestyle:their health, income, and participation and inclusion in society.
In New Zealand the state has recognized the importance of rights and entitlements
for the population in general through the inclusion of rights as a key element of social
welfare.4 In this context, rights are measured by reference to participation in civil
and political affairs without being subject to discrimination and abuses of power.
The protection of these rights is deemed essential to the organization and functioningof society in a way that enables all people to develop to their full potential. Fromthe point of view of older people, the issue of rights and expectations relates to thequestion of what they can expect in terms of the availability of five sources of support,
namely financial security, residential care, support from the family and support fromgovernment agencies and adequate health care. In particular, the provision of goodquality, affordable and sustainable healthcare services in both residential and homebased settings is of paramount importance and this is reflected in various statesponsored initiatives such as the Health of Older People Strategy, which draws
attention to the importance of the elderly for society and the need to adequately planfor growing service needs.5 Health issues form the cornerstone for the wellbeing ofolder people. But they have an even wider significance. Internationally, questions
４

See, e.g., Ministry of Social Development, Annual Social Report (2008).

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South Pacific Studies Vol.38, No.2, 2018surrounding the future trajectory for longevity constitute the focal point of some of thegreat philosophical and biological-demographic debates on the future of humanity.6
Because of the immense cost and service implications surrounding elder health care,these theoretical debates are often highly applied and are constantly being referred toin the fields of population economics and public policy, especially in connection withissues such as income support, service planning and institutional needs.
Older people, especially those aged 85 years and over, are intensive users of healthcare resources, experiencing high rates of chronic illness, disability and morbidity
as compared to other age groups in the population. With universal entitlement to nofault accident insurance through the Accident Compensation Corporation (ACC), a
publicly funded health system that offers a good standard of free emergency and acutecare, as well as legislation that limits older people’s contribution towards the cost of
long-term residential care, it could be said that New Zealand’s older population is atpresent relatively well serviced in terms of access to healthcare services. However,as the number of older people continues to grow, with an expected increase in life
expectancy, the overall demand on health services is on the rise. It is clear that this will
have a significant impact on how healthcare services for older people are structured
and delivered in both the short/medium and long-term. First, the proportion of public
expenditure on health services for older people will need to increase in order to meetdemand (Table 2).
Table 2. Projected expenditure on older people as a percentage of Vote Health* (New Zealand Treasury2003).
Age

2002

2011

2021

74-84

16.0%

17.7%

9.9%

85 +

16.0%

12.9%

15.0%

* Each year the government decides how much public money will be spent on healthcare. This is called‘Vote Health’. The government, through the Minister of Health, allocates money to the 20 District Health
Boards (DHBs) to purchase health services for the people of New Zealand. This money is allocated using
a weighted population-based funding formula.

Furthermore, it will be increasingly difficult for the health workforce to keep
pace with the growing demand for life-sustaining interventions for older people withincreasingly complex health needs.7 As the demographic change reduces the supply
of informal caregivers and increases the quantity of formal care required to meet the５

See Ministry of Health, Health of Older People Strategy (2002). Health is one of the diﬀerent domains
identiﬁed by the Ministry of Social Development as a key determinant factor of what is referred to as
successful ageing , positive ageing , or wellbeing among older citizens. Consider on this matter
KOOPMAN-BOYDEN and POOL (2006).
６ Consider, e.g., TULJAPURKAR et al. (2000: 490-91); LUTZ et al. (2008: 716-19).
７ See PAWAR et al. (2009). It should be noted that the New Zealand Ministry of Health (2006) has
anticipated a shortfall of 23,000 in the regular health workforce by 2021.

MOUSOURAKIS: Health Care Services for the Elderly in New Zealand77

needs of the elderly, it is expected to considerably decrease the formal workforce pool.
The quality of the workforce pool will also be adversely affected in an employment
market where people who are work ready with residual skills can get access to higher
paying jobs with better conditions than community healthcare agencies are currently
able to offer.8

The New Zealand Health Care System: an Overview
In New Zealand the NZ Public Health and Disability Act 2000 supplies thelegislative framework for the public funding of health care and provision of publicly
funded health services. This enactment follows a series of important structural reforms,
from an area health board system (1989-1991), a competitive internal market system(1993-1996), a central planning and purchasing system (1997-2000), to the current
district health board (DHB) system (from 2000).9 It will be instructive at this juncture
to consider briefly some of the main features of New Zealand’s current health caresystem.
New Zealand’s health care system is a publicly funded, tax-based system.10 Publicfunding is derived from general taxation (87.7 %);11 the Accident Compensation
Corporation (ACC) (11.3 %);12 and local government (0.9 %). The government sets
an annual budget for most publicly funded health services. This is distributed to 20
geographically based District Health Boards (DHBs) using a weighed, populationbased formula.13
The principal goals of the publicly funded health system are broadly to:14 (i)improve, promote and protect the health of New Zealand’population; (ii) reduce
health disparities by improving health outcomes of Maori and other population groups(equity);15 (iii) ensure community voice in matters relating to personal health services,public health services, and disability support services (participation); and (iv) provide
appropriate, effective and timely services (access). Furthermore, the integration of all
８ See MOLONEY (2005).
９ Consider GAULD (2001, 2003); ASHTON et al. (2005).
10 Government health expenditure amounted to about 81 percent of total health expenditure in 2010-2011.
11 The allocation of public taxation is made by the government under the Public Finance Act 1989 (s. 4)
and the relevant appropriation Act.
12 ACC is an independent, quasi-governmental agency regulated by s. 259 of the Injury Prevention,
Rehabilitation and Compensation Act 2001 and funded by general taxation and levies. It is responsible
for accident-related prevention, care and rehabilitation.
13 It should be noted that the Ministry of Health directly funds around 25 percent of public services.
14 New Zealand Public Health and Disability Act 2000, s. 3(1).
15 Disparities in health care have been a central concern in New Zealand, with Maori people and peopleof Paciﬁc Island origin having an average life expectancy around eight years shorter than that of other
New Zealanders. Maori and Paciﬁc people are also known to experience greater diﬃculty in assessing
health services. Since the late 1990s, governments have introduced a series of measures designed toreduce health disparities. Reference may be made in this connection to Whanau One, a recent policy
initiative designed to integrate the various social services providers, including health, to improve
services for disadvantaged Maori who often fall between the boundaries of diﬀerent agencies.

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health services, in particular primary and secondary services, and the coordinationof care are explicit objectives. At the same time, resource constraints are expressly
recognized: the objectives of the system are to be pursued “to the extent that they arereasonably achievable within the funding provided.”16
Hospital care, community mental health care, and public health services havetraditionally been provided to New Zealand citizens and persons ordinarily resident
in New Zealand free of charge.17 Government subsidies partially fund primary healthcare services and community-prescribed drugs, with co-payments by patients (NZ$10 to $60 depending on the level of subsidy, with higher subsidies for those with low
incomes or high health care needs).18 Subsidies for long-tern care for the elderly aremeans-tested ― this means that once a person’s assets fall below a prescribed level,
they become eligible for public funding. Access to subsidized long-term residential
care or home help is also subject to a needs assessment.19
Most public funding is allocated via funding agreements made by the Minister/
Ministry of Health with District Health Boards, which agree to provide or financially
support health services in their districts.20 A number of services, such as, for example,
public health and disability support, are funded directly by the Ministry of Health. The
DHBs provide services at government-owned hospitals and community health centres.21
They also purchase other services from private providers, such as GPs, private surgical
hospitals for some publicly funded patients, disability support services and communitycare. Many elderly people receive long-term in-home care funded by DHBs. Accident
and injury care is funded by the Accident Compensation Corporation (ACC).
A District Health Board (DHB) is a ‘publicly-owned health and disability
16

17
18
19
20
21

New Zealand Public Health and Disability Act 2000, s. 3(2). In principle, the Minister of Health sets thestrategic direction for the health and disability sector by setting and reporting publicly on a healthstrategy, disability strategy and strategy for standards and quality assurance and the monitoring
thereof in the health sector, and by setting up key ministerial consultative committees (New ZealandPublic Health and Disability Act 2000, ss 8, 9, 11 and 13-18). These committees include: the National
Advisory Committee on Health and Disability, which is charged with, among other things, advising
the Minister on the kinds and relative priorities of public health services, personal health services
and disability support services that should, in the committeeʼs view, be publicly funded; the Health
Workforce Advisory Committee, charged with advising the Minister on health workforce issues;
the National Ethics Advisory Committee, charged with giving advice on ethical issues of nationalsigniﬁcance in respect of any health and disability issues, including issues relating to medical researchand health services; the National Health Epidemiology and Quality Assurance Advisory Committee,
charged with providing advice on any health epidemiology and quality assurance issues; and theMortality review committees, whose job is to review and report on speciﬁc areas of mortality with aview to reducing the numbers of death and developing strategic pans and methodologies to reducemorbidity and mortality.
Non-residents, such as tourists and illegal immigrants, are charged the full cost of services provided bypublic hospitals or primary health care providers.
Primary health care is mostly free for children under the age of 6 and subsidized for the 96 percent of
the population enrolled with Primary Health Organizations (PHOs). See para (i) below.
Complementary and alternative medicines and treatments are paid for in full, as are private hospital or
specialist care and adult dental care.
New Zealand Public Health and Disability Act 2000, s 10. The 20 DHBs cover populations ranging fromabout 30,000 to 520,000.
New Zealand has a mix of public and private hospitals, but the former make up the majority, providing
all intensive and emergency care.

MOUSOURAKIS: Health Care Services for the Elderly in New Zealand

79

organisation’22 responsible for assessing and monitoring the health needs of its resident
population; planning health care services in its district; supplying hospital care;funding services delivered by community and primary care providers (under‘service
agreements’),23 setting into place processes for Maori participation; and promoting
Maori health workforce development. 24 The statutory objectives for the DHBs in
essence replicate the system’s general objectives, namely promoting population healthand equity (partly through community participation), with the further objectives of“exhibiting a sense of social responsibility” for the population and “upholding the
ethical and quality standards commonly expected of providers of services and of
public sector organizations.”25 Decisions pertaining to a DHB’s operation are made byor under the authority of a board of up to 11 members (including at least two Maori
members). These are partly elected (seven members) by the people of a geographic
area,26 and partly appointed (up to four members) by the Minister of Health. 27 The
DHBs are accountable to the Minister of Health, who must grant approval to a board’s
district strategic plan and district annual plan.28 DHBs are required to adhere to broader
national strategies, national service frameworks and operational requirements. Theseset out national priorities for health spending and prescribe the minimum range andstandard of the services that must be supplied or funded in each district.29
Primary health care is provided by not-for-profit primary health organizations(PHOs): networks of self-employed providers, including GPs, practice nurses, and otherpractitioners, funded by the DHBs to provide care services for an enrolled population
with a preventive, health improvement focus.30 The providers work collaboratively,
with nurses playing a significant role in managing and supplying services, especiallyfor patients with chronic care needs. PHOs are expected to involve their communities
in their governance, be responsive to community needs and allow all their members toparticipate in decision-making.31 Patient registration is not mandatory, and practitioners
are not required to affiliate with a PHO, but physicians and PHOs must have a formally
22
23
24
25
26

27

28

New Zealand Public Health and Disability Act 2000, s 6(1).
New Zealand Public Health and Disability Act 2000, s 25.
New Zealand Public Health and Disability Act 2000, s 23(1).
New Zealand Public Health and Disability Act 2000, s 22(1).
As Gauld observes, a primary motivation for creating the DHB system was to democratize healthcare governance, particularly in terms of increasing opportunities for public participation in healthcare planning and decision-making processes . GAULD (2005: 345). It has been noted that the creationof the DHB system can be seen as an attempt to increase community understanding and support forthe diﬃcult decisions required to deal with the funding/health-service dilemma ― at the same time as
making more diﬃcult to achieve national decisions to resolve these dilemmas . See ADAM (2003: 29).
New Zealand Public Health and Disability Act 2000, s 29. If the Minister is seriously dissatisfied
with the board s performance, he may, by written notice, dismiss all of its members and replace itwith a commissioner. See New Zealand Public Health and Disability Act 2000, s 31. It should be noted,
moreover, that board members are not liable to third parties for any act or omission of the DHB, nor
to the DHB itself, insofar as they acted in good faith, and with reasonable care, in pursuance of thefunctions of the organization . New Zealand Public Health and Disability Act 2000, s 90.
New Zealand Public Health and Disability Act 2000, ss 38(3)(c) and 39(1). Although the majority of a
DHBʼs members are elected and may be said to be accountable both to the government and theirconstituency, under the New Zealand Public Health and Disability Act 2000 DHBs are accountable
mainly to the government. It is required that a DHB strikes a balance in the allocation of funding
between its public hospital provider arm and other community health service providers.

80South Pacific Studies Vol.38, No.2, 2018

registered patient list to be eligible for government subsidies. The PHO system is one
vehicle through which the Government’s primary health care objectives are sought
to be implemented in local communities. The aim is to ensure GP services are better
linked with other primary health services to ensure a seamless continuum of care, inparticular to better manage long-term conditions.32
The quality of health services in New Zealand is regulated by a range of genericlegislation, encompassing the Health and Disability Commissioner Act 1994, which
introduced the office of the Health and Disability Commissioner33 and furnished thelegislative framework for the creation of the Code of Health and Disability Services
Consumers’Rights; 34 the Health Practitioners Competence Assurance Act 2003,
which provides mechanisms to ensure that doctors and other health practitioners arecompetent and fit to carry out their tasks; and the Health and Disability Services (Safety)
Act 2001, which provides for service standards and the certification and audit ofproviders of health and disability services.
The purpose of the Health and Disability Commissioner Act 1994 is “to promote
29

30

31
32

33

34

As Crown agencies, DHBs are also subject to the ﬁnancial planning requirements of the Public FinanceAct 1989 (s 42). Although they are required to operate in a financially responsible manner (New
Zealand Public Health and Disability Act 2000, s 41), they are not required to be as successful andeﬃcient as comparable businesses that are not owned by the Crown. From 2004 to 2010, the Ministryof Health published a quarterly Hospital Benchmark Information Report aimed at enhancing the eﬃciencyof the DHB system. The report encompassed, among other things, patient satisfaction, hospital-acquired
infections, acute readmissions and other indicators. From 2010, DHBs are held formally accountable to
the government for delivering eﬃcient, high-quality care, as measured by achievement of targets acrossa variety of indicators similar to those included in the Hospital Benchmark reports. Public reports on DHB
performance rate each DHB on indicators pertaining, for instance, to hospital waiting times, access toprimary care services and mental illness outcomes. Information on individual doctor performance is
not regularly available. In 2010 the Health Quality and Safety Commission was established with a viewto coordinating the varied approaches to quality improvement across DHBs. Moreover, the National
Health Board, created in 2009 as a business unit of the Ministry of Health, is also concerned with quality
improvement in DHBs, with special attention to managements systems and clinical services.
In New Zealand GPs are usually independent, self-employed providers, paid through fee-for-service andco-payments with government subsidy through PHOs. PHOs are free to determine their own payment
arrangements for individual practitioners. The latter receive additional per capita funding for healthpromotion, for coordinating care and providing additional services for chronic disease patients, and for
reducing barriers for patients that experience diﬃculties in accessing the health care system. PHOs
also receive performance payments for meeting certain quality and service delivery targets underwhat is known as the PHO Performance Program. This requires GPs to reach targets for, among otherthings, vaccinations, diabetes, cancer and cardiovascular disease screening and follow up. Reports
comparing PHO performance are published on a regular basis.
See Minister of Health, The Primary Health Care Strategy (2001).
Since 2008, the government has ordered PHO mergers to improve their functioning. Furthermore, inan eﬀort to improve access to integrated health care that is provided by networks of practitioners
in more convenient locations for patients (outside of hospital settings) the current government hascommenced development of a larger Integrated Family Health Centers. While still at an early phase ofdevelopment, there is some expectation that the new larger facilities will see services and providers colocated, or coordination services improved, with funding from both primary care budgets and DHBs.
The Health and Disability Commissioner, the government-funded yet independent patients advocate
within the health care system, investigates and reports on patients complaints arising from, among
other things, simple breaches of patients rights and cases of medical malpractice that may haveoccurred in either public or private practice. The Commissioner, who reports directly to Parliament,
has been an important source of pressure on DHBs for enhanced quality services.
The Health and Disability Commissioner (Code of Health and Disability Services Consumers Rights)
Regulations 1996.

MOUSOURAKIS: Health Care Services for the Elderly in New Zealand81

and protect the rights of health consumers and disability services consumers, and, inparticular, to facilitate the fair, simple, speedy, and efficient resolution of complaints
relating to infringements of those rights”.35 The Code of Health and Disability Services
Consumers’Rights specifies ten rights of consumers, and corresponding dutiesof health care providers: the right to be treated with respect; the right to freedom
from discrimination, coercion, harassment and exploitation; the right to dignity andindependence; the right to services of an appropriate standard; the right to effective
communication; the right to be fully informed; the right to make an informed choiceand give informed consent; the right to support; rights in respect of teaching andresearch; and the right to complain.36 The intention of the Code and the Act is topromote resolution of health care-related complaints at the lowest appropriate level.
If a complaint is made to a provider, the latter is required to take it seriously and put
in place whatever changes are needed.37 Consumers also have the right to lodge acomplaint with the Health and Disability Commissioner, who is required to conduct
an investigation with a view to determining whether there has been a breach of theCode. If the relevant investigation reveals such a breach, the Commissioner can:report an opinion and recommendations to the service provider; report an opinion andrecommendations to the Ministry of Health;38 complain to the relevant professional
body; or refer the matter to the Director of Proceedings.39 After reviewing the casereferred to him by the Commissioner, the Director of Proceedings may decide toinitiate civil proceedings before the Human Rights Review Tribunal.40 This body
35
36

37

38
39

Health and Disability Commissioner Act 1994, s 6.
It is important to note that the Code applies to all health care providers, which are deﬁned in s 3 of
the Health and Disability Commissioner Act 1994. This deﬁnition, as well as including all categories of
traditional health care providers such as the members of the medical profession etc, also includes anyother person who provides, or holds himself or herself or itself out as providing, health services to the
public or to any section of the public, whether or not any charge is made for those services (s 3(k)).
This all-encompassing deﬁnition will capture anyone that consumers are likely to obtain services from.
Patients rights are also covered in the New Zealand Bill of Rights Act 1990, which gives any person
the right to refuse medical treatment (s 11). Furthermore, a health care provider has obligations under
the Crimes Act 1961. Section 151 of this Act puts a duty on everyone (not only health care providers)
to provide the necessaries of life to a person in their charge that is unable to make that provision
themselves. Tort law also covers the area of patients rights: inappropriate treatment may giverise to any of the three torts in the category of trespass to person, namely assault, battery and false
imprisonment.
If a provider receives a complaint directly from a consumer, the Code states that they must: (1)acknowledge the complaint in writing within five working days, and also inform the consumer
about the providerʼs complaint procedures, as well as the consumers rights under the Code, andthe availability of an independent advocacy service; (2) within ten working days, the provider must
consider the complaint and advise the consumer whether or not the complaint is accepted, or if moretime is required to consider it. In the latter case, the provider's reply must be given to the complainantas soon as practicable.
The Commissionerʼs recommendations might include: an apology from the provider; introducing
measures to ensure the matter will not happen again; training of providers; and payment ofcomplainant s costs.
The Director of Proceedings is a lawyer appointed under the Health and Disability Commissioner
Act 1994. When the Commissioner has found a breach of consumer rights, he may refer the service
provider concerned to the Director of Proceedings. The latter reviews the case and makes an
independent decision on whether or not to take any further action. The Director of Proceedings is
assisted by a team of lawyers and other experts, who review ﬁles and prosecute cases.

82South Pacific Studies Vol.38, No.2, 2018

determines afresh whether there has been a breach of the Code of Health and Disability
Services Consumers Rights. Where such breach is upheld, there are a number ofremedies available including: a declaration that a provider is in breach of the Code;an order restraining the provider from continuing or repeating the breach, or fromengaging in or causing or permitting others to engage in conduct of the same kind asthat constituting the breach; an order that the service provider perform any specified
acts with a view to redressing any loss or injury suffered by the consumer owing to thebreach; damages for pecuniary loss, expenses and loss of benefits suffered as a resultof the non-compliant activity, and for humiliation, loss of dignity and injury to the
feelings of the aggrieved person.41

Care and Support Services for the Elderly
Older people, especially those aged 85 years and older, are intensive usersof healthcare services, experiencing high rates of chronic illness and disability ascompared to other age demographic groups in the population. There are numerous
risk factors for ill health in older people, the most prominent among them being highblood pressure, physical inactivity, high blood cholesterol and dietary insufficiency.
Moreover, while most older New Zealanders enjoy good mental health, dementia inparticular is a major mental health issue. Dementia, which is considered a neurologicaldisorder, is caused by a range of illnesses, most of them currently incurable. Its
symptoms include memory loss, difficulty in carrying out everyday tasks, personalitychanges and progressive incapacity to act independently and without assistance. It
is anticipated that the incidence of dementia will rise considerably as the populationof older people continues to grow. The number of people diagnosed with dementia
in New Zealand is at present approximately 41,000 and is expected to increase toapproximately 75,000 by the year 2026.42
Gerontology and elder health care have, until relatively recent times, been
dominated by the prevailing biomedical understanding of ageing. The ageing process
was perceived mainly as a process of physical and mental decline characterized bydisability and disease.43 The biomedical model paved the way to theoretical constructs
like the disengagement theory of ageing (prevalent in the 1950s and 1960s), which
40

The Human Rights Review Tribunal (HRRT) was established in 1977 under the Human Rights
Commission Act, as the Equal Opportunities Tribunal. It became the Complaints Review Tribunal
in 1993 and the Human Rights Review Tribunal in 2002. Matters likely to come before the Tribunal
include not only alleged infringements of the Code of Health and Disability Services Consumers
Rights, but also alleged violations of the Human Rights Act 1993, the Privacy Act 1993, or the Health
Information Privacy Code 1994.
41 Damages, apart from punitive damages, will not be awarded if injury to the consumer is covered by
the Injury Prevention, Rehabilitation, and Compensation Act 2001. The limit on damages is $200,000,
although in practice awards do not usually exceed the $20,000. For a closer look on the jurisdiction andpowers of the Human Rights Review Tribunal see MANNING (2004).
42 New Zealand Dementia Economic Impact Report, 2008.
43 See in general HOOYMAN and KIYAK (2010); ESTES et al. (2003); PHILIP (2002).

MOUSOURAKIS: Health Care Services for the Elderly in New Zealand83

institutionalized withdrawal from society by promoting more passive roles for theelderly and by emphasizing a move from extroversion and sociability to introversion
and withdrawal as normative behaviour. 44 Critical gerontologists, especially theadherents of political economy perspective,45 also include aspects of power andopportunity in the notion of ‘slowing down’: social, political and economic constraints,
not individual factors, play a prominent role in shaping the experience of ageing
and are connected not only to age and class, but also to gender, sexual orientation,functional ability and race. Beliefs about ageing can be disempowering, and health careproviders are not immune to the prejudices of the larger culture.
The traditional biomedical approach to ageing seems to ignore the fact that the
majority of older people actually get along quite well.46 In recent years, a more positive
discourse has emerged in opposition to the notion of ageing as an inevitable decline
into disease, disability and death. This new discourse is reflected in The New ZealandPositive Ageing Strategy, which was released by the Ministry of Social Developmentin April 2001. In it special emphasis is placed on the need to promote engagementof all agencies impacting on the lives of older New Zealanders (such as Work andIncome, District Health Boards, District Councils and the State Services Commission)to achieve the vision of a society where people can age positively by directing ourcollective efforts towards meeting specific positive ageing goals. Among the targeted
objectives are equitable, timely, affordable and accessible health services; secureand adequate income; affordable and appropriate housing; affordable and accessible
transport; culturally appropriate services; elimination of ageism;47 and increasing
opportunities for personal growth and community participation, allowing for successful‘ageing in place’.48
44

According to the disengagement theory of aging "aging is an inevitable, mutual withdrawal ordisengagement, resulting in decreased interaction between the aging person and others in the social system
he belongs to." Cumming and HENRY (1961: 227). And see HALE et al. (2010); HOOYMAN and KIYAK (2010).
45 The term "critical gerontology" is used to describe a rather broad ﬁeld of theoretical interests, ranging
from constructions and deconstructions of to the issue of power and control in contemporary society.
What ties these diﬀerent perspectives together is that all of them, in one form or another, have been
critical of a theoretical understanding of gerontology dominated by an idealized concept of naturalscience as the representative of 'objective' knowledge. The issues raised have focused primarily on theideological and socially constructive features of age conceptualizations. Three theories in particular−critical theory, political economy, and social phenomenology−are exemplary in this regard. The
political economists argue that to understand the problems of elderly people, one should pay attention
to the political and economic conditions surrounding them. This turns attention away from the
problems of elders as largely lying, according to gerontological theorists, in "their private troubles" andtoward the political economy of growing older. See in general BAARS (1991); COLE et al. (1993); ESTES etal. (1996); HAZAN (1994); LYNOTT and LYNOTT (1996); MOODY (1988); HOOYMAN and KIYAK (2010: 323).
46 As Philip points out: A perception of decline in late life extends to the psychological and social as well
as physical features of late life ageing, characterized by loss of health, autonomy, ﬁnancial status andthe comfort of family, friendship and marital relations. Yet the experience of late life ageing for many
people is not dominated by decline, but by accomplishment and satisfaction with life . P HILIP (2002:
381-82).
47 The term ageism is used to denote a process of systematic stereotyping and discrimination against
people because they are old. This term was introduced in 1969 by Robert Butler, the ﬁrst director of
the National Institute on Aging at the University of California, Berkeley. Butler likened ageing to otherforms of prejudice, such as sexism and racism. See PALMORE (1990:172).
48 Oﬃce for Senior Citizens, Ministry of Social Development, 2004. And see HOOYMAN and KIYAK (2010).

84South Pacific Studies Vol.38, No.2, 2018

Another important policy initiative is the New Zealand Health of Older People
Strategy, launched by the Ministry of Health in April 2002. This required developmentof models of care for older people capable of promoting a number of objectives.
Among the targeted objectives are the ability of older people and their families to makeculturally appropriate, well-informed choices for healthy living and health care from
integrated health and disability support services and to benefit from population-based
health initiatives and programmes capable of supporting older people with complex
health and disability support needs.49 An integrated approach to health and disability
support services is expected to better meet older people’s varied and changing needs
by facilitating access to the relevant services at the right time, in the right place andfrom the right health care provider. The development of the required health services
for older people also needed to be aligned to broader population-based strategies, suchas the New Zealand Health and Disability Strategies,50 the Maori Health Strategy,51 thePrimary Health Care Strategy,52 the Mental Health and Addiction Plan and the New
Zealand Palliative Care Strategy.53
The combined objectives of the New Zealand Positive Ageing Strategy and Healthof Older People Strategy emphasize: a life course approach to positive ageing; thepromotion of healthy lifestyles throughout life; early intervention to avoid or delay ill
health and disability; rehabilitation and maintaining independence through ageing inplace.54
Ageing in place’ represents a policy ideal of the ability of older people to remainin the community, either in their family homes or in supported accommodation of some
type, as they age.55 Its underpinning assumption is that it provides for the maintenanceof independence in the community, and particularly a continued competence andcontrol over one’s environment.56 A number of studies have shown that there is arelationship between place and wellbeing. 57 Therefore, older people who feel incontrol of their environment are more able to adjust to the process of ageing, which
49
50
51

Ministry of Health, Health of Older People Strategy, Wellington, 2002.
These set out general principles, goals and objectives for New Zealandʼs health system.
The Maori Health Strategy sets the direction for Maori health development in the health and disability
sector. It provides a framework for the public sector to take responsibility for the part it plays insupporting the health status of the Maori people.
52 This Strategy provides a clear direction for the future development of primary health care so that it
can play a central role within New Zealandʼs health system.
53 Palliative care is the care of people who are dying from active, progressive diseases or other conditions
that are not responsive to curative treatment.
54 The National Health Committee has also been very involved in the Health of Older People with several
publications since 2002. These include: Living at Home; Self Assessment: A Process for Older People;
Guidelines for the Support and Management of People with Dementia; Care for Older People in New
Zealand; Health Care for Older People; and Health and Disability Services for Older Maori.
55 In 1994, the health and social policy ministers of The Organisation for Economic Co-operation andDevelopment (OECD) countries reached an agreement on the general objective of policies for thecare of older people: Elderly people, including those in need of care and support should, wheneverpossible, be enabled to continue living in their own homes, and where this is not possible, they should
be enabled to live in a sheltered and supportive environment which is as close to their community as
possible, in both the social and geographical sense . (OECD 1994:3).
56 See PASTALAN (1990); CUTCHIN (2003); LAWTON (1982); HALE et al. (2010).
57 Consider, e.g., LAWTON (1983); Oswald et al. (2007).

MOUSOURAKIS: Health Care Services for the Elderly in New Zealand85

in turn enhances their wellbeing. It is recognized that the interaction between locationand personal characteristics, such as gender and health, affect a person’s ability tosuccessfully age in place. Furthermore, commentators differentiate between three
aspects of ageing in place: choice, location and support. Choice relates to the decisions
older people make in the context of personal and environmental factors; location is thehome, which provides a sense of identity and connection to the community; and, lastly,
support for older people who live at home may be either formal or informal. These
three elements combined account for the increasing diversity of the ageing populationand define ageing in place as care and support in the place of the older person’s
choice.58
The ageing in place discourse first emerged in New Zealand in the early 1990s.59
Free or in some cases income-based in-home services have been available ever since,
after eligibility and needs have been determined through comprehensive geriatricassessment. As more people now live to their 80s or 90s, a growing number ofservices are required to allow ageing in place. Thus, new community and home-based
programmes, including home health care, adult day care, nutritional programmes,
transportation, personal care and homemaker services, have all become more widely
available in the last two decades. Government and care service providers in New
Zealand have embraced ageing in place because of its potential to more effectively
meet the care and support needs of older people. A recent New Zealand pilot scheme(Assessment of Services Promoting Independence and Recovery Services or ASPIRE)
evaluated three ageing in place support services.60 This research found that all threeservices assessed significantly reduced the risk of mortality and that of entry into
residential care as compared with usual services. Moreover, a recent qualitative study
on older people and their attachment to place indicates that attachment to place isdeveloped through the relationship between a number of physical and social features,such as location, comfort, proximity to family and involvement in neighbourhood
activities. This constantly changing equilibrium between the practical and socialpsychological aspects of living in a certain place has a strong influence on the
wellbeing of older people. It should be noted that, notwithstanding the positiveeffects that aging in place may have, the policies that the ageing in place discourse
58 See Schoﬁeld et al. (2006: 275-306).
59 Ashton (2000: 72-85).
60 Ministry of Health, 2006. The three ageing in place programmes were: the Coordination of Services
for the Elderly (COSE), Christchurch; the Promoting Independence Programme (PIP), Lower Hutt;
and Community FIRST (Flexible Integrated Restorative Support Team), Hamilton. The services
provided varied in content and intensity. The COSE programme gave priority to care management
and coordination at the basic or primary care level, whilst the Community FIRST programme adopted
a more restorative approach to service provisions for people with acute needs. Residential admissions
were reduced in every case, with a reduction in mortality also observed in some of the services.
Furthermore, a trend for improvement in daily activities was noted in older people in the Community
FIRST service as compared to usual care. For a closer look see Parson et al. (2006). Reports fromsimilar studies conducted in several other countries also testify to the eﬃcacy of in-home care for older
persons. See, e.g., TINETTI, et al. (2002); LEWIN et al. (2006); RYBURN et al. (2008); BESWICK et al. (2008: 72535); ELKAN et al. (2001: 719-725).

86South Pacific Studies Vol.38, No.2, 2018entails cannot be regarded uncritically, for what takes place behind closed doors cansometimes be isolating, abusive, violent and far from the ideal notions permeating
ageing in place. Furthermore, in New Zealand the relevant programmes are fragmented
and there are too many regional disparities in terms of quality of and access to careservices.61 Services require reorganization and a coordinated and interdisciplinary
approach to improving elderly people’s quality of life and participation.62 They must
be more targeted and aimed principally at restoring the elderly person’s ability to
manage independently at home with a reasonably good quality of life. Of course, there
will always be frail elderly persons in need of ongoing in-home care and support.
But for the many others who are able to rehabilitate, skilled, effective, restorative
and time-limited in-home support has the potential to significantly contribute to therecipients’wellbeing.
In New Zealand basic services available to older adults include: personal care(e.g., medication management, assisting with personal hygiene); supplying equipment
to help with one’s safety at home; household support (e.g., meal preparation, cleaning);
and caregiver support, i.e. help for the person who lives with and looks after the elderly
person for more than four hours a day. If specialist care is required, this can be provided
by: a medical specialist; a geriatrician, who manages an elderly person’s health and takes
care of his/her specific medical issues; a dietician, who assesses and advise the elderly
person on his/her nutrition needs and eating habits; a physiotherapist, who assesses theelderly person’s needs for help to maintain his/her physical activity by treating injuries,
showing him/her how to prevent future injuries, and advising him/her on enhancing
mobility and alleviating painful conditions; a speech or language therapist, who assesses
and assists the elderly person with his communication needs; and a social worker, who
supports the elderly person through his/her decisions and provides information about
advocacy and other community support systems. A recipient’s care and support needs aremonitored on a regular basis (at least once a year), and the person concerned can ask for areview of the services provided at any time.
Currently, health care and support services, including geriatric assessment,
treatment and rehabilitation services (AT&R),63 for older people are financed in themain, though not exclusively, by District Health Boards (DHBs) with funding from
the Ministry of Health.64 Delayed entry to long-term care is one of the principal goals
61 WILES et al. (2009: 664-671); PLATH (2008: 1353-1369).
62 See on this RYBURN et al. (2008).
63 These services are provided by multidisciplinary or inter-professional teams in inpatient, day hospital,
outpatient or community settings. ACC defines rehabilitation as: a process of active change andsupport with the goal of restoring ... a claimantʼs health, independence, and participation. It comprises
treatment, social rehabilitation and vocational rehabilitation .
64 Geriatric AT&R services are generally located in inpatient units in a districtʼs main hospital, with
outpatient clinics and day hospital services often provided at the same site. Most DHBs offer
general geriatric AT&R outpatient clinics. Some DHBs also provide specialist clinics, but they varyconsiderably in range and number. Community-based AT&R services are generally provided in
the main urban centres. These services employ fewer staﬀ than inpatient units and tend to focus onassessment more than treatment or rehabilitation. About half the DHBs provide outreach clinics insuburbs or small towns to varying extents.

MOUSOURAKIS: Health Care Services for the Elderly in New Zealand87

of DHB-funded disability support services, as approximately 75% of a DHB’s budget
for elderly health care is spent on long-term residential care.65 Service provision varies
across the DHBs: some boards offer separate autonomous services; others have fully
integrated services; others provide geriatric AT&R beds as part of generic AT&R units
for people aged 16 and over. Furthermore, some boards have separate mental health
units for older people; others incorporate beds in general adult mental health units.
Geriatric AT&R services are generally located in inpatient units in the district’s main
hospital, with outpatient clinics and day hospital services often provided at the samesite. Most DHBs have general geriatric AT&R outpatient clinics. Some DHBs also
have specialist clinics, but they vary considerably in range and number. Communitybased AT&R services are generally provided in the main urban centres. These services
employ fewer staff than inpatient units and tend to focus on assessment more thantreatment or rehabilitation. About half the DHBs provide outreach clinics in suburbs
or small towns to varying extents. Moreover, the DHBs have systems that enablegeriatric and mental health service staff and clients to access Maori and Pacific cultural
services and advice. Population ageing is now beginning to create pressure on somegeriatric inpatient services and psychiatry of old age inpatient services. Psychiatry ofold age services tend to have a higher proportion of staff working in community teams
compared to geriatric services. They also have access to adult mental health community
crisis assessment teams for out-of-hours backup. However, psychiatry of old age
services are generally much smaller than geriatric AT&R services. In some DHBs withsmall populations and/or difficulty recruiting specialist staff, services are provided byvisiting specialists who are unable to provide the same level of service provided toolder people in larger DHBs.
District Health Boards of New Zealand (DHBNZ) co-ordinate a national Healthof Older People Steering Group, which is composed of representatives from all DHBs
and comes together on a regular basis to coordinate DHBs’ activities at a national levelon selected issues impacting on the sustainability of health services for older people.
The Steering Group monitors the effectiveness of the currently available DHB-funded
services and assesses services that may be developed in the future to meet identified
needs. Key priorities include: efficient funding of long-term care; nation-wideconsistency in the purchase of home-based support services; developing service models
for long-term support of people with high and complex care needs; and developing
service models to support the expected increasing prevalence of dementia in the
65

Delaying entry to long-term care is achieved by way of increasing the range of community-based
services available to support ageing in place, thereby reducing the demand for institutional care;increasing access to early intervention for acute care needs and reducing the rate of functional decline;
and by restricting access through modifying eligibility criteria for services, such as raising the age
threshold for eligibility. Eligibility for health care services for older people is currently linked to theretirement age (65 years). It should be noted here that there is no compulsory retirement age in
New Zealand, but 65 is the current age of eligibility for NZ Super, the government pension. The age
required for access to health care services for older people might rise if the age of retirement goes up,
but that will probably have little eﬀect on expenditure on the relevant services as the majority of older
people using them are aged 75 years or older.

88South Pacific Studies Vol.38, No.2, 2018

community.66
Significant developments to date have generally focused on services for people
with high and complex health care needs. Special attention has been given to issues
such as: needs assessment and service co-ordination; flexible and responsive healthcare packages with a rehabilitative or restorative focus; and the use of multidisciplinary
teams, including doctors, nurses, social workers and other health professionals. In
general, service development can be a slow process because it takes a long time
to consult with the community, to implement the changes needed and to adapt
the infrastructure. In this process it is important that shifts in attitudes and public
expectations occur alongside service changes if the changes are to succeed in the longrun.
A number of projects have recently been developed that focus on the need toensure sustainability of health care service delivery for a rapidly ageing population.67
At the same time, new health strategies have been devised to manage the consequencesof loss of health care services when there is cost-shifting to other sectors.68 The
development of a variety of models for both home-based support services and longterm residential care services allows for consistent planning decisions in relation to
the sustainability of the relevant services. Special emphasis is placed on the need toform an aggregated local, regional and national data set that will inform the further
development of funding models and ensure the sustainability of the services created tomeet identified needs.
It is recognized, further, that Primary Health Organizations (PHOs) can play
an important role in supplying health promotion and disease prevention services forolder people, as well as case co-ordination of persons with complex needs relying
upon a variety of community services. PHOs links with community-based services
are generally underdeveloped at present, but current policy initiatives promise betterinterfaces between primary health care, specialist health services, community-based
health services, mental health services, home support services and population healthservices to prevent service duplication and unnecessary wasting of scarce resources.
Publicly supported socialization services69 are currently also limited, even thoughdemand is high. Such services have been proven to be effective in dealing with the
problems of isolation and loneliness that often beset older people leading to healthproblems associated with self-neglect and depression.70 Service gaps have also been
observed relating to delays in older people’s needs assessment or delays in funding
decisions concerning their environmental needs. Such delays can result in older
66
67
68
69
70

It should be noted that individual DHBs have taken diﬀerent areas of focus in service development.
The scope and pace of development so far has to a large extent depended on the relative priority thata DHB has placed on funding older peopleʼs services against all other health services.
See, e.g., Aged Residential Care Service Review, Grant Thornton New Zealand Ltd, 2010.
For instance, the New Zealand Carers Strategy (New Zealand Ministry of Social Development, 2008)
stresses the increasing pressure experienced by informal caregivers of ageing parents, siblings,
partners or other relatives.
These include, for example, community access services and befriending services.
See on this CHAL (2004).

MOUSOURAKIS: Health Care Services for the Elderly in New Zealand89

people not getting timely access to the care and support needed, and this can delay
their treatment or rehabilitation and precipitate entry to higher levels of care. Possible
solutions to this problem include better targeting of services, modifying procurement
practices by District Health Boards and altering access criteria. As previously
noted, informal caregivers, such as family members, are an integral part of support
programmes for older people and a key element in the continuum of care. A further gap
in the current system pertains to the lack of adequate support and training for informal
caregivers. Addressing this gap is becoming a priority for many District Health
Boards.71
The growing prevalence of dementia in the older population is expected to posesignificant challenges for care and support systems and service providers. Specialist
rehabilitation programmes tend to exclude people with dementia where the patient’s
cognitive and learning difficulties may lead to the impression that there is no benefit
to be gained from such programmes. However, the increasing pressure on the elder
health care system to include services for the growing number of people with dementia
has necessitated the development of initiatives that will make a difference for this
sector of the older population and their caregivers. In response to this need, Alzheimers
New Zealand72 issued the National Dementia Strategy and action plan in 2010. The
following strategic goals are identified in the Strategy: recognizing dementia as anational health priority; increasing public awareness of dementia; providing access toaffordable and appropriate medication; improving early diagnosis and managementof dementia; providing appropriate services to all people with dementia; providing
support to family and carers of people with dementia; recruiting and retaining theworkforce necessary to deliver quality dementia care; and increasing dementia researchand evaluation of dementia practices.
Recognizing dementia as a national priority will ensure that adequate government
funding is allocated to address the problem. Early diagnosis and management
presuppose the development of education and training programmes for medical
practitioners as well as adequate future planning for people with dementia and theircommunities of care. Of note in the strategy goals is also the section for family andcaregivers that includes financial support along other resources. This supports thecontinued implementation of the New Zealand Carers Strategy launched by the
Ministry of Social Development in 2008. 73 Finally, workforce development calls
for the introduction of minimal standards for dementia specific training for all staff
71
72This is also the focus of the New Zealand Carers Strategy launched by the Ministry of Social
Development in 2008. See note 74 below.
Alzheimers New Zealand Inc is a not-for-proﬁt organisation with 21 Alzheimers member organisations
throughout the country that provide support, information, educational programmes and services
appropriate to their local community. These services include: support for families and friends copingwith the demands of caring; providing information and education to assist with understanding diagnosis
and assessment; and supplying information to help cope with the ﬁnancial challenges of providing careand support; and supporting services and day programmes for people with dementia. At a national
level, Alzheimers New Zealand represents people with dementia and their caregivers and families
through advocacy, raising public awareness and providing information.

90South Pacific Studies Vol.38, No.2, 2018

caring for people with dementia. Culturally appropriate skills for dementia care are
required to ensure that the needs of people from different ethnic groups are recognizedwhen developing educational packages and resources for people in dementia care
employment.

Concluding Remarks
In New Zealand, as in many other countries around the world, a rapidly ageing
population, combined with rising rates of dementia and chronic conditions, hasnecessitated the development of health care models capable of meeting the risingdemand for service provision in a resource-constrained health environment. The callfor high quality, affordable and sustainable health care services in both residential andhome-based settings has prompted an increase in long-term care funding along with thepromulgation of policy initiatives, such as the Health of Older People Strategy, whichemphasize the importance of the elderly for society and the need to adequately plan forrising service needs. Resources dedicated to the health care of the elderly increasingly
focus on effective management and prevention, which have long been promoted as thebest way to improve the health of the elderly in the long run and reduce health carecosts.
With a publicly funded health care system that offers a high standard of
emergency and acute care services, as well as legislation that limits how much older
people have to contribute towards the cost of long-term residential care, it could besaid that the older sector of the population is relatively well serviced in terms of accessto health care services. Fundamental to the success of the relevant programmes is the
adoption of more client-centred approaches to care that provide older persons withgreater choices of service support. This emphasis on choice is reflected in the visionof the government’s Health of Older People Strategy, which seeks to support positive
ageing, in part, by enabling older people“to make well-informed choices about options
for healthy living, health care and/or disability support needs.”At the same time, it isrecognized that health care providers have a professional responsibility to help theirclients achieve their own goals. This presupposes that care providers are familiar with
their clients’overall health situation including, for those clients who experience a
decline in function and require help to remain at home, their in-home care and support
73

The New Zealand Carers Strategy covers all informal caregivers in New Zealand, such as family
members, friends and significant others involved in supporting a person with a disability. Fourgoverning principles are drawn attention to: (a) recognize diversity; (b) be proactive; (c) enablecaregivers; and (d) be inclusive. The principal objectives of the Carers Strategy are: (a) provide
information; (b) protect the wellbeing of caregivers; (c) provide ﬁnancial support for caregivers; and(d) provide training and pathways to employment for caregivers. Moreover, the Ministry of Social
Development has produced A Guide for Caregivers (2009), providing essential information onmatters such as ﬁnancial assistance; having a break; health and disability rights; and housing. It should
be noted, further, that the Accident Compensation Corporation (ACC) is also developing wellbeing andlearning programmes for informal caregivers.

MOUSOURAKIS: Health Care Services for the Elderly in New Zealand

91

plan.
Despite the progress that has been made in recent years, there is still much to
be done to improve care and satisfaction levels. In particular, there is a need for
improvement around so-called ‘transition points’between services, especially where
older people are moving between acute care or residential care and the community.
Services along each transition point in the continuum of care should improve healthoutcomes by ensuring that service recipients have their health and disability support
needs fully assessed; prevent or delay as far as possible the onset of high levels of
illness or disability and reduce the need for older people to be admitted to hospital orresidential facilities; restore and maintain physical and psychological health necessary
for functional independence; and support the further development of best-practiceservices for people with complex medical, psychiatric and social needs across alldelivery settings. Furthermore, the relevant services should be designed to improve
the fit between recipients and their environment, thereby enhancing their function.
One critically important reform for the future pertains to the need for up-skilling andimproving the working conditions of in-home caregivers. The move should be one
from domestic assistants to home health aides who possess adequate counseling andrehabilitative skills to not just maintain their clients, but to encourage and facilitate therestoration of function to the extent that this can be achieved. Moreover, in an age ofshrinking public budgets and growing public debt, cost savings must also be taken into
consideration. New Zealanders are currently financing public health services partly
through foreign debt, leaving the payments to future generations. This is a widespread
phenomenon driven by global economic forces. There is a moral imperative to address
this problem before more damage to intergenerational relations is done. In the context
of elderly health care, a better system of asset testing can conserve scarce publicresources for those who require services but who are truly unable to pay for these
services themselves.
In some ways, New Zealand is in an ideal position to implement the requiredchanges as it has several advantages over other countries in its policy context for
improving elderly health care. This is best reflected in, among other things, its strong
tradition of using health information technology in the primary and acute care sectors;
the trend towards a more coordinated approach to service delivery across settings;
and the comparatively more collaborative model of regulatory oversight that has
been adopted. It is critical that the country continues to build upon these significant
strengths to ensure that the longer-term implications of the changing demographics andageing population can successfully be met through the implementation of high quality,
sustainable and person-centred care models that better address patient needs and ensure
delivery of comprehensive and effective care.

92South Pacific Studies Vol.38, No.2, 2018

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