Health practitioners are a significant occupational group in New Zealand – in 2015 there were almost 97,800 practitioners, not including workers in unregulated alternative practices. The range of people involved continues to expand as the boundaries of what is considered ‘health care’ expand, and as increased specialisation leads to one type of health care becoming two or more types of practice.
Historically, health practitioners included doctors, nurses and pharmacists. By the 21st century the practitioner list included midwives, radiographers, psychologists, dietitians, and speech and language therapists, as well as alternative practitioners like chiropractors, osteopaths and medical herbalists.
Most health practitioners’ work is regulated by the Health Practitioners Competence Assurance Act 2003. Unregulated health practices are not covered in this legislation. The act’s main purpose is to protect the public when there is a risk of harm from malpractice.
Unqualified people cannot claim to be practitioners of regulated health professions, and those who are qualified cannot work outside the scope of their regulated practice. Health practitioners need to maintain specific competencies, and may be required to have an annual practising certificate, which is issued by the profession’s responsible authority.
Complaints about health practitioners can be made to the Health and Disability Commissioner or the authority which registers the practitioner. The Health Practitioners Disciplinary Tribunal hears and makes determinations about any disciplinary action which may result from complaints.
The Health Practitioners Disciplinary Tribunal was established in 2004. By 2015 it had received 401 complaints about individual health practitioners. Of these, 252 were found guilty of professional misconduct, while 73 received criminal convictions.
Since the late 1980s patients have been seen as health ‘consumers’ who have rights. As well as handling complaints, the Health and Disability Commissioner upholds these rights. The Code of Health and Disability Services Consumers’ Rights sets out 10 specific rights which practitioners must honour.
Teams composed of different practitioners are a feature of health care in the 21st century. Multidisciplinary health services include primary health-care organisations (PHOs) and critical assessment and treatment teams (CAT teams) who work in mental health. A PHO team may comprise medical practitioners, practice nurses, physiotherapists, social workers or counsellors, podiatrists and pharmacists. A CAT team may include nurses, psychologists and psychiatrists. This team approach extends to all areas of health provision and has resulted in more collegial relationships between health practitioners.
Until the early 20th century most doctors were general practitioners (GPs), whether they worked in hospitals or private practice. Some doctors started to specialise in surgery from around 1900, and specialisation became more widespread and varied from the 1930s.
Until the first local medical school opened in 1875 doctors trained overseas, mainly in London or Edinburgh. Initially, the University of Otago Medical School’s programme in Dunedin was limited, and students had to qualify overseas. The first student qualified at Otago in 1887. The country’s second medical school, the University of Auckland School of Medicine and Health Sciences, was established in Auckland in 1968.
Trainee doctors spend six years at medical school. They work under supervision for a year before they can become registered by the Medical Council of New Zealand. Once qualified, doctors choose which branch of medicine to practise.
Recruitment into specialties is through vocational training controlled by professional organisations called colleges. The Royal New Zealand College of General Practitioners is a New Zealand college. Many of the other colleges are Australasian (New Zealand and Australian).
The first women to graduate from medical school in New Zealand were Emily Siedeberg in 1896 and Margaret Cruickshank in 1897. Women faced difficulties establishing themselves as medical professionals. There were few barriers to entering medical school, but once they graduated women were much less likely to earn the high salaries enjoyed by their male counterparts, or win honorary hospital appointments, which represented the peak of medical practice in the 19th and early 20th centuries. Even in the 21st century women were under-represented in surgical specialities.
In 2015 there were 14,678 registered doctors in New Zealand. They comprised 15% of the total health workforce. A third were GPs.
Women have increasingly participated in the medical workforce. They were 7% of registered doctors in the 1930s and only 8% in the early 1970s, but 42% in 2015. That year, 45% of female doctors were under the age of 40. compared to 28% of male doctors. This reflects the trend towards more female than male medical students that has been evident since the 1990s.
In 2014 women outnumbered men in vocational training for general practice (60%), obstetrics and gynaecology (84%), paediatrics (73%), pathology (61%) and public health medicine (82%). Areas where women were under-represented were general surgery (25%), accident and emergency practice (36%), and orthopaedic surgery (13%).
Doctors from overseas made up around 40% of the medical workforce in the early 21st century.
Doctors from North Africa and the Middle East have the highest retention rate – they are most likely to stay in New Zealand – followed by those from sub-Saharan Africa and Asia. Doctors from the Americas, the United Kingdom and Oceania have the lowest retention rates.
Doctors often have heavy workloads. Their average working week in 2014 was 44 hours. Workloads have declined in the 21st century, however – the average in 1999 was 49 hours.
The feminisation of medicine has implications for workforce planning as women doctors work fewer hours than men – six hours fewer per week in 2014. Women typically do fewer hours because they spend more time in unpaid work – having and caring for children, often while maintaining careers.
Some parts of New Zealand are better supplied with doctors than others. In 2014 the Auckland District Health Board (DHB) area had 105 GPs per 100,000 population and the Lakes District had 90 per 100,000, compared to 65 in Counties Manukau and 61 on the West Coast.
Rural practices and hospitals often struggle to attract doctors because of high workloads and difficulty accessing ongoing vocational training. Both the Otago and Auckland medical schools allocate places for rural students because they are more likely to practise in rural districts than their urban counterparts.
Early nurses were untrained and combined health work with domestic and childcare work. From the 1880s hospitals offered training programmes which formalised nursing as a profession. Supervised nurses’ homes were opened on hospital grounds to encourage young and respectable middle-class women to enter the profession. Male nurses were less common and tended to work in psychiatric hospitals.
The formalising process was completed by the Nurses Registration Act 1901, the first legislation of its kind in the world. Nurses were trained through a three-year apprenticeship scheme at hospitals, and sat an examination at the end. Successful candidates were registered.
Nursing became more specialised. Nurses could train as a general nurse, an obstetric nurse (or both), a psychiatric nurse or a psychopaedic nurse (who specialised in intellectual disabilities).
In 1971 the Carpenter Report recommended that nursing education take place in educational institutions rather than in hospitals. Student attrition rates were high and some nurses argued that the apprenticeship scheme in hospital was exploitative. The transition was completed in 1989 when the last hospital school of nursing closed. Initially, undergraduate training occurred at polytechnics, and postgraduate courses were available at universities. In the 21st century both were offered at polytechnics, institutes of technology and universities.
Until nurses were trained in educational institutes and developed more autonomy in learning and practice, they were seen as subordinate to doctors. This attitude was expressed by Nurse Sibylla Maude in 1908: ‘To hear a nurse answer “Yes, Sir” is surely more professional than “Yes, Doctor”, and to stand to receive orders … is equally important. Another point of etiquette too often violated is the questioning of doctor’s orders, after he has left the patient. Whatever a nurse may think, her duty is to obey without expression of opinion, as after all the patient is in the doctor’s charge, the nurse being required simply to carry out his instructions faithfully.’1
In the 21st century there are three categories of nurses: nurse practitioner, registered nurse and enrolled nurse.
The nurse practitioner role was introduced in 2001 and allows for autonomous practice for expert registered nurses with masters degrees. In 2015 there were 145 nurse practitioners in New Zealand.
Registered nurses have a nursing degree and are registered with the Nursing Council of New Zealand. They are qualified to work independently in all health-care settings.
Enrolled and assistant nurses have lesser qualifications and work alongside registered nurses in a support role.
The nursing workforce comprises over half of the total health workforce. In 2015 there were 52,729 nurses holding annual practising certificates.
Until 1904 most midwives received no formal training and learned on the job. Government concern about high maternal and infant mortality rates led to the Midwives Act 1904. Midwives were trained at seven St Helens hospitals throughout the country. After this, registered midwives managed most births.
A newspaper advertisement from 1860 shows the different tasks midwives undertook in the 19th century: ‘Mrs. M. Haughay, Midwife and Nurse. References as to the above can be given. Also WASHING and DRESSING Done in the Best Style at very Moderate Charges.’2
The Nurses and Midwives Registration Act 1925 created maternity nurses, who worked with a doctor. Midwives worked alone. However, from this time most graduates were maternity nurses so midwifery services were increasingly controlled by doctors. From 1957 midwives had to be registered nurses, and from 1971 could not deliver a baby without a doctor present.
The Nurses Amendment Act 1990 reintroduced autonomous midwifery practice. The act separated midwifery and nursing, which were established as separate and distinct professions. Educational institutes could offer direct-entry midwifery training – a nursing qualification was no longer necessary.
Since 1990 midwives have been increasingly responsible for managing normal births. About 75% of women choose a midwife as their lead maternity carer. Almost all GPs have ceased their involvement in normal birth, so women choose between a midwife or a medical specialist (an obstetrician).
In 2015 there were 3,068 midwives holding annual practising certificates in New Zealand. Over half worked at public hospitals, while almost one-third were self-employed independent midwives.
Allied health practitioners work in fields other than medicine or nursing.
Regulated allied practitioners are covered by the Health Practitioners Competence Assurance Act 2003. In addition to medicine and nursing, the act covers anaesthetic technology, chiropractic, dentistry and related professions, dietetics, medical laboratory science, medical radiation technology, midwifery, occupational therapy, optometry and optical dispensing, osteopathy, pharmacy, physiotherapy, podiatry, psychology and psychotherapy.
There is provision in the act for more occupations to be regulated. In 2016 traditional Chinese medicine was being considered for regulation.
Pharmacists are the allied health practitioners most regularly seen by New Zealanders. In 2015 there were 3,512 registered practising pharmacists. Pharmacists train at the National School of Pharmacy at the University of Otago, which was established in 1963.
In the 19th century pharmacists compounded medicines themselves. With the development of the international pharmaceutical industry in the early 20th century, the pharmacists’ main role became dispensing pre-prepared medicines. In the 21st century pharmacists supplement income from dispensing by selling a wide range of health and beauty products.
In November 2009 ACC reduced funding for physiotherapy by reducing the fee paid to physiotherapists for each treatment by one-third. ACC said that physiotherapy costs had increased from $39.7 million in 1999/2000 to $144 million in 2008/9. Critics said that physiotherapists were already underfunded and that limits on the amount of treatment in the short term would cause health costs to increase in the long term.
Physiotherapy developed from therapeutic massage, which emerged in the late 19th century. Official training courses started at hospitals in 1913. These courses evolved into four-year degree programmes available at the University of Otago and the Auckland University of Technology.
Physiotherapists have established themselves as experts in the treatment of sports injuries. They have many clients who receive funding for treatment through the Accident Compensation Corporation (ACC).
ACC provides no-fault personal injury cover for all New Zealanders and visitors to New Zealand. Many allied practitioners are ACC-registered so they can care for people who have received compensation.
Some alternative health practices have become part of the conventional health system despite facing challenges from other health practitioners and some members of the general public about their legitimacy. Acupuncture, chiropractic and osteopathy practitioners can register with the Accident Compensation Corporation (ACC). Chiropractic and osteopathy are regulated under the Health Practitioners Competence Assurance Act 2003, and in 2016 traditional Chinese medicine (including acupuncture) was in the process of being regulated.
Acupuncturists, chiropractors and osteopaths train at educational institutions approved by the New Zealand Qualifications Authority (NZQA). The New Zealand Chiropractic Board and the Osteopathic Council of New Zealand oversee the registration of practitioners, and fund continuing education courses. NZQA-approved courses are also available for a number of unregulated alternative practices, such as homeopathy and naturopathy.
The New Zealand Skeptics society has run an ongoing campaign against homeopathy. In 2010 they staged a protest during which members attempted to overdose on homeopathic remedies to prove they were ineffective. Homeopathy supporters argued that overdoses are not possible because of the way remedies are made, but that this did not mean they did not work.
Some conventional health practitioners such as doctors and physiotherapists incorporate alternative therapies such as acupuncture and homeopathy into their own practices. This is often referred to as complementary medicine. Registered midwives can train in midwifery acupuncture at the New Zealand School of Acupuncture and Traditional Chinese Medicine.
Because the boundaries between conventional and alternative practice are sometimes blurred, some people seek advice from several different practitioners at once, and also seek information on the internet. They may be reluctant to let their general practitioner know that they have sought advice from alternative practitioners because of fears doctors would not approve.
Māori and Pacific practitioners have always been significantly under-represented in the medical workforce compared to their proportion of the general population. This remains the case in the 21st century, though there have been increases since the 1990s. Māori and Pacific workers tend to be concentrated in support roles like caregiving, which require fewer qualifications.
Māori and Pacific people have long signalled a need for more Māori and Pacific health practitioners. It is considered that a more culturally appropriate service is likely to be available from someone who shares the same cultural values and beliefs. One response has been the establishment of Māori and Pacific health providers.
The first Māori medical doctor was Māui Pōmare, who graduated from the American Medical Missionary College at Chicago in 1899 and returned to New Zealand to practise. He was followed by Peter Buck in 1904, and Tūtere Wī Repa in 1908. Both Buck and Wī Repa had been inspired as Te Aute College students to enter medicine when Āpirana Ngata spoke about the need for Māori practitioners during a conference there in 1897.
The first Māori woman doctor was Rina Ropiha, who graduated in 1948. She specialised in psychiatry and established a private clinic at her home. During her medical training she got married and had four children.
In 2015, 2.7% of doctors identified themselves as Māori and 1.8% as Pasifika. This was a small increase from 2.5% and 0.8% respectively in 1997. Medical schools have set aside places for Māori and Pacific students to encourage their recruitment. The University of Auckland established the first Department of Māori and Pacific Health in 1996.
In response to the toll infectious diseases and poor living conditions took on Māori health, the first Māori nurses were registered in 1909. Māori nurses became an important element of district nursing schemes in rural areas.
Māori midwives assisted women in childbirth in traditional communities, and after European settlement. Māori district nurses began to attend deliveries in the 20th century.
Māori and Pacific nurses and midwives are under-represented in their profession compared to their proportion of the general population, though Māori are better represented than their Pacific counterparts, particularly in midwifery. In 2015, 6.5% of nurses and 9% of midwives identified themselves as Māori and 2.6% of nurses as Pasifika – in the 2013 census 14.9% of the population identified themselves as Māori and 7.4% as Pasifika.
Educational institutions have developed programmes to encourage Māori and Pacific people to work in these fields. Waikato Institute of Technology pioneered a nursing programme called Tihei Mauri Ora which supports Māori students to learn in culturally appropriate ways.
In 2009 the first undergraduate nursing programme for Māori was approved. It was devised by Te Whare Wānanga o Awanuiarangi in Wellington. Whitireia New Zealand in Porirua offers Māori and Pacific nursing degrees.
The Nursing Council of New Zealand’s definition of cultural safety is: ‘The effective nursing practice of a person or family/whānau from another culture, and is determined by that person or family. Culture includes, but is not restricted to, age or generation; gender; sexual orientation; occupation and socio-economic status; ethnic origin or migrant experience; religious or spiritual beliefs; and disability.’1
The term ‘cultural safety’ (kawa whakaruruhau) used within many health professions was first developed within nursing and midwifery to indicate practitioners’ responsibilities when working with Māori. It emerged from a nursing education leadership hui held in Christchurch in 1989. Irihapeti Ramsden led the development of its incorporation in nursing and midwifery training in 1992.
Since the inclusion of cultural safety in education programmes, there have been periods of controversy where some students or their parents have resisted course content. By the early 2000s this was rare. While some health practitioners might not use the term cultural safety, most have been exposed to it through education and professional organisations.
Bryder, Linda, ed. A healthy country: essays on the social history of medicine in New Zealand. Wellington: Bridget Williams Books, 1991.
Coney, Sandra, ed. Standing in the sunshine: a history of New Zealand women since they won the vote. Auckland: Penguin, 1993.
Donley, Joan. Save the midwife. Auckland: New Women’s Press, 1986.
Gage, Jeffrey D., and Andrew R. Hornblow. ‘Development of the New Zealand nursing workforce: historical themes and current challenges.’ Nursing inquiry, 14 no. 4 (2007): 330–334.
Ratima, Mihi M., and others. ‘Strengthening Māori participation in the New Zealand health and disability workforce.’ Australian medical journal 186 no.10 (2007): 541–543.