Hospitals have changed from basic buildings offering limited and risky health care, which few entered by choice, to large complexes offering a wide range of usually effective services and treatments. The changing cost of establishing hospitals reflects this transformation – Auckland’s first public hospital (1847) cost less than £1,100 (about $100,000 in 2003 terms) to construct, compared to $447 million for the city’s new hospital in 2003.
The Gables building in New Plymouth’s Pukekura Park is the only one of the first four hospitals established by Governor George Grey still standing (the others were in Auckland, Wellington and Whanganui). Built in 1848, it was relocated to its present site in 1904. The hospital was made tapu in 1854 after Te Āti Awa chief Rāwiri Waiaua died there – it is still a sacred place for this reason.
The first public hospitals were set up shortly after New Zealand was settled by European immigrants – in Wellington and Auckland in 1847, New Plymouth in 1848 and Dunedin and Whanganui in 1851. Christchurch followed in 1862.
These hospitals were established to treat poor European people – most had to pay, but the very poor (and Māori) were treated for free. Other than those in Dunedin and Christchurch, the hospitals were all established by Governor George Grey, who believed that they would help introduce Māori to European culture and lifestyle. It was assumed that there would be little demand for hospitals by Europeans – most immigrants would be young and fit and sick people would be treated at home. The Destitute Persons Ordinance 1846 placed responsibility for the sick and destitute on the family. From 1885 public hospitals were run by charitable aid trusts.
Auckland’s hospital was on the tourist trail for 19th-century English visitor Annie Butler. In her book Glimpses of Maori land (1886) she wrote: ‘We had not been long at Auckland before we found our way up to the Hospital; and very much we enjoyed our visit. It is well worth seeing; is, like the Post Office, quite worthy of a place in London. And what would a London hospital committee give for the view which it commands?’1
Many hospitals were opened in the South Island during the gold rush of the 1860s. Fourteen, mostly small, hospitals were set up in the goldfields, mainly to accommodate accident cases. By the 1890s those hospitals still in existence were filled with elderly male patients with nowhere else to go. They provided these men with food, warmth and a clean bed. In 1889 the inspector-general of hospitals, Dr Duncan MacGregor, said that the West Coast hospitals were little more than refuges for ‘old broken-down miners’.2 Nevertheless, local communities had a sense of civic pride in their hospitals, which were seen as a symbol of civilisation.
By the turn of the 20th century the role and public image of the hospital was changing. A number of developments made hospitals less unpleasant for patients.
The discovery of anaesthesia in the 1840s made patients more willing to undergo operations and reduced the risk of dying of shock during surgery. However, anaesthesia did not dramatically improve the prognosis for the patient. Hospitals were still often unhygienic, which caused a high rate of post-operative infections.
From the 1860s antisepsis (use of antiseptic substances such as carbolic acid) and asepsis (exclusion of bacteria and viruses) were used during operations. Sterile hospital environments made operations safer for patients.
Laboratory and diagnostic facilities such as X-rays were not available in most New Zealand hospitals until well into the 20th century. Nevertheless, by the late 19th century scientific developments meant that more people were willing to enter hospitals.
The first medical school in New Zealand opened in Dunedin in 1875. Initially, the course was limited and students had to study overseas to qualify. The first student to complete a full course at Dunedin graduated in 1887. New Zealand’s second medical school (Auckland) did not open until 1968.
As in Britain, hospitals were integral to medical education. This altered their function – no longer solely places of refuge, they became the site of scientific training and research. Under the influence of the medical profession, hospitals increasingly admitted only cases which were deemed curable. Complaints about ‘incurables’ occupying beds around the turn of the century made it clear who was prioritised in hospital care.
Nursing has often been described in highly moral, almost religious terms. In 1910 Matron Thurston of Christchurch Hospital called it ‘the noblest profession … Self must be put aside; jealousy and disloyalty unknown. Instead of looking on each other as individuals setting forth on our task alone, let us remember we are members of the same family … and the training school our mother, ready to go forth, armed only with high ideals, banded together for the good and comfort of the sufferers; loyal to the traditions of nursing as shown us by the self-sacrificing life of Florence Nightingale.’1
The nursing reform movement led by Florence Nightingale, which originated in Britain in the 1860s, was significant in the transformation of hospitals. This produced a new style of nurse who was efficient, obedient, clean, hard-working and sober. Nursing leaders (matrons) were posted around the British Empire and took ideas about cleanliness and discipline within hospitals with them. Auckland Hospital appointed its first matron in 1865, but it was not until 1883 that the first Nightingale-trained matron, Annie Crisp, transformed the hospital environment.
Nursing was feminised – the trained male nurses who had previously dominated hospitals now mainly worked in mental hospitals. However, the orderlies who performed physical tasks such as moving patients around remained mostly male. To encourage respectable young women to become nurses, supervised nurses’ homes were set up on hospital premises.
The Nurses Registration Act 1901 was the first legislation covering nursing training and registration in the world. This act formalised the hospital-based nature of nurse training through a system of apprenticeship, involving three years of training and a state examination. From the 1970s nurses were trained in tertiary institutions rather than in hospitals.
Donating blood in the 1920s was not for the faint-hearted. A donor recalled his experience when he first gave blood in Auckland in 1925: ‘The needle used to draw blood seemed like a 2 ½ [inch] nail and about as blunt … Often the blood was taken in an operating theatre where a local anaesthetic was sometimes used and the patient [being operated on] lay beside you.’2
Medical science advanced significantly in the 20th century and hospitals were central to these developments. The discovery of blood types in 1901 made blood transfusion safer and helped prevent death from haemorrhage following surgery and childbirth. Techniques were devised between the world wars to store blood products. Blood banks were established, which increased the number of operations that could be performed.
New drugs to fight infections discovered in the 1920s reduced deaths in childbirth. Penicillin was developed during the Second World War and other antibiotics followed. Surgery expanded in the post-war period to include organ transplantation, such as kidney transplants and later heart transplants. These procedures were assisted by the discovery of immunosuppressant drugs (which prevent organ and tissue rejection) from the 1960s. Specialist units such as coronary care, intensive care and neonatal special care units were established in major hospitals.
Specialisation, whether in separate hospitals or separate departments within general hospitals, became a feature of New Zealand hospital care in the 20th century. An important exception was psychiatric hospitals, which were administered separately from the beginning.
In the 19th century spas were credited with curing all sorts of bodily ailments and problems. Men suffering from ‘sexual impotence’ took to the waters, as did people suffering from ‘congestions of various “viscera” [internal organs]’ and those hoping to ‘reduce plethora [excess of bodily fluids] and corpulency [obesity] without prostration’.1 Another reputed therapeutic benefit was reducing craving for alcohol.
Rotorua was famed for the general therapeutic value of its geothermal springs. A sanatorium accommodating 12 patients was established there in 1885. A second, larger, one opened in 1891. In 1901 the Department of Tourist and Health Resorts took responsibility for the institution and a government balneologist (specialist in the therapeutic use of baths) was appointed in 1902.
Spa treatment of arthritis was provided in the late 1930s, and the complex became a convalescent hospital for wounded servicemen during the Second World War. Non-servicemen were also treated from 1948 for arthritis, rheumatism and other locomotor (movement) disorders.
A new purpose-built hospital (the Queen Elizabeth Hospital) was founded in 1966. Administration of the hospital was transferred from the Health Department to the Waikato Hospital Board in 1968. In the 2010s it was privately owned by QE Health. It still catered for locomotor illnesses, though modern medicines now complemented the use of local springs.
Tuberculosis patients often remained in open-air sanatoriums for months. A brochure about a Central Otago sanatorium published in 1928 said: ‘It would be hard to find a happier, more healthy looking lot of men and women than those at Waipiata. The high percentage of sunshine and the cheerful surroundings appear to work wonders with the patients, and it is not easy to realise that they are [there] to have their health restored. With their sunburnt faces and well nourished bodies they look to be in perfect physical condition. A happy band of holiday-makers is the impression they create.’2 There was no mention of the dead and dying patients.
In the late 19th century tuberculosis was a major killer of Pākeha New Zealanders, accounting for 10% of all deaths. Māori were even more vulnerable; by the 1930s their tuberculosis death rates were probably 10 times those of non-Māori.
In 1903 the Department of Public Health established Te Waikato, a sanatorium near Cambridge for the treatment of tuberculosis. It was open until 1922. Te Waikato provided open-air treatment, which consisted of fresh air, sunlight, exercise and good food.
Other sanatoriums were set up by hospital boards. By 1910 Wellington, North Canterbury and Otago all had sanatoriums. From 1908 Auckland Hospital Board provided accommodation for tuberculosis patients at the Costley Home (later Green Lane Hospital). Other hospitals also set up annexes to accommodate tuberculosis patients, and in the 1920s two further open-air sanatoriums were established in Hawke’s Bay and Otago.
By the 1930s enthusiasm for this form of treatment waned in New Zealand (as elsewhere). It was replaced by surgery, albeit with little more success. Surgery was quickly abandoned once effective anti-tuberculosis drugs appeared (the first, streptomycin, was discovered in 1942). In the 1960s sanatoriums were closed or converted to other uses.
During the 20th century hospitals developed and specialised. For example, Costley Home grew from a home for the aged poor into Green Lane Hospital, where highly technical surgery was carried out. It opened in 1890 and an infirmary ward was added in 1907. The following year tuberculosis patients were admitted and from 1914 shelters for open-air treatment of tuberculosis patients were erected. The home was renamed the Auckland Infirmary in 1924. It catered for geriatric, chronically ill (including cancer patients) and tuberculosis cases. In the 1930s it became a centre for the surgical treatment of tuberculosis.
During the Second World War the infirmary was used for general medical and surgical cases, and it was renamed Green Lane Hospital in 1942. About the same time the hospital’s surgeons expanded their work from treating tuberculosis to heart disease.
Under the guidance of surgeons Douglas Robb and Brian Barratt-Boyes, Green Lane became an internationally recognised cardiothoracic surgical centre. The first open-heart surgery in New Zealand took place at Green Lane in 1958, and the first heart transplant in 1987 (20 years after the first ever transplant). In the early 21st century the hospital became the Greenlane Clinical Centre, focused on outpatients and day surgery.
Religious charities founded ‘rescue’ homes, where unmarried mothers could give birth in the late 19th century. Most married women gave birth at home. In 1904 the government set up seven public maternity hospitals (St Helens hospitals) around the country, which provided subsidised maternity care and trained midwives.
Dr Doris Gordon (1890–1956) was a prominent obstetrician and women’s health reformer. She exemplified the mid-20th century’s faith in medical science when she wrote in favour of founding National Women’s Hospital: ‘New Zealand thinks of women’s health solely in terms of a creditably low infantile and maternal death rate …. This Dominion does not yet realize that women have a right to POSITIVE good health, and that modern discoveries taught at a Post Graduate centre would soon cure 75% of the troubles hitherto passively accepted as "Women’s lot".'1
Until the 1960s these hospitals were run by midwives and controlled by the Health Department. Technological developments in maternity and neo-natal care were concentrated in the larger women’s hospitals. After the Second World War the St Helen’s hospitals were either closed or absorbed by these hospitals. St Helens Christchurch merged with Christchurch Women’s Hospital in 1968 and Wellington’s St Helens closed when a new high-tech maternity unit was completed at the city’s public hospital in 1978. In Auckland, the services of the local St Helens hospital were transferred to National Women’s Hospital in 1990.
National Women’s (at first called the Cornwall Hospital, Obstetrical and Gynaecological Unit) was established in 1946, after a major fundraising effort by women to provide more beds for women in childbirth, and to train doctors in obstetrics and gynaecology. The linking of childbirth and women’s diseases into one field followed an international trend. Gynaecological services at National Women’s were split from obstetrical services in 1990. In 2004 National Women’s Hospital closed and its services were merged with those of the general city hospital.
In 1931 the Observer newspaper commented that many fathers whose children were admitted to a Karitane hospital were ‘most attached to their delicate children, but simply don’t know what to do with them. An extremely worried and frightened father arrived at the Karitane Home, not long ago, carrying his tiny son and heir in a cardboard shoe-box.’2
Karitane hospitals, for newborn babies who failed to thrive, were established by the Plunket Society from 1907 to fill a gap in general hospital services and to train nurses in newborn childcare. Six hospitals were set up around the country. They also admitted new mothers to help them establish breastfeeding, and sometimes just to help them to cope with their newborn baby.
In the late 1970s the hospitals were closed, as they had become too expensive for Plunket, a voluntary organisation, to maintain. Their services were superseded by more high-tech public maternity and women’s hospitals, and in place of the hospitals the society opened Plunket Karitane Family Centres to provide daytime support for parents and babies in need.
Children’s hospitals were set up in Britain from the mid-19th century and in Australia from 1870, but New Zealand did not follow until well into the 20th century. The Princess Mary Hospital for Children was established on the Auckland Hospital site in 1918. Pressure came from paediatricians to extend the services, especially after the Paediatric Society of New Zealand was founded in 1947. Despite this, a purpose-built high-tech national children’s hospital (the Starship children’s hospital) was not established in Auckland until 1991.
By the late 20th century hospital services had become fragmented and expensive. Hospitals were managed regionally and central governments struggled to control costs. From the 1970s many maternity hospitals were closed. Their services were absorbed by large general hospitals.
In 1998 the Alliance Party planted 54 white crosses on the lawn of the Stratford Hospital in Taranaki, which closed the same year. The crosses represented hospitals that had closed between 1984 and 1998. Party member and Parliamentary candidate Kevin Campbell said, ‘[W]e’re talking about the slow death of our public health system and this is a way to really show people what’s happening.’1
In the 1990s major reforms to the health sector by the government led to the closure or downsizing of many general hospitals, particularly smaller ones in rural areas. Local communities fought against many closures, usually unsuccessfully.
By the 21st century hospitals were generally located in the larger towns and cities. Some smaller towns had district and community health centres with more limited services.
By the 1970s, when health technologies and medical knowledge had dramatically expanded, hospitals and medicine in general were widely criticised by members of the public and community health groups in New Zealand and elsewhere. This can be linked to the anti-authoritarian mood of the time, and campaigns around civil rights, consumer rights and women’s health.
Health advocates argued that the clinical nature of hospitals and the medical research conducted there made patients invisible and vulnerable. Others criticised the ever-increasing costs of hospitals, citing research which showed that modern therapeutic developments had played an insignificant role in the increase in life expectancy over the past 200 years. The effectiveness and the ethics of modern medicine, the ‘medical model’, were questioned.
In New Zealand criticism of medicine- and hospital-based healthcare came to a head with the Cartwright Inquiry (1987–1988). The inquiry, headed by Judge Silvia Cartwright, investigated allegations concerning the treatment of cervical cancer at National Women’s Hospital in Auckland. Cartwright concluded that treatment of some of these women was inadequate and that ‘for a minority of the women, their management resulted in persisting disease, the development of invasive cancer and, in some cases, death’.2
Controversy relating to the treatment of women for pre-cervical cancer at National Women's Hospital continued in the years following the inquiry. Whilst some commentators have continued to assert that Associate Professor Herbert Green’s management of cases of carcinoma in situ of the cervix caused harm, others have argued that a watch-and-wait approach was an appropriate response to positive cervical smears and that Green followed international best practice.
Women’s and health activists were particularly critical of the medical profession in the 1970s and 1980s. In its submission to the Cartwright Inquiry, the New Zealand Women’s Heath Network said it was their view, ‘that in general the New Zealand Medical Profession displays sexist attitudes and racist attitudes towards its patients.’3
The inquiry reflected its time and contributed to social change in medicine. In particular it signalled a lack of public trust in doctors and reflected a transformation of doctor–patient relationships, which was also occurring in other Western countries, as they moved from a paternalistic to more democratic relationship. As part of this process, consumers gained more power in the hospital setting and in medical decision making.
The Cartwright report recommended that an independent commission be established to uphold and promote the rights of health consumers. The first commissioner was appointed in 1994. The Code of Health and Disability Services Consumers' Rights, which sets out a number of specific rights and provider duties, became law in 1996.
The role of nurses changed in the late 20th century. From the 1970s nurses were trained in tertiary institutions, and considered themselves professionals in their own right, rather than simply doctors’ assistants. From the 1980s hospitals were administered by non-medical managers and doctors had less input into how they were run.
Early public hospitals did not provide free treatment unless patients could not pay. In 1885 charitable aid boards were established to manage hospitals. Hospitals were financed by patient fees, voluntary contributions, local rates and a government subsidy. By the late 19th century increasing staff and equipment costs meant that boards more actively sought to recover fees from patients.
Hospitals charged fees for social as well as economic reasons. In 1885 the inspector of hospitals, Dr G. W. Grabham, declared: ‘the provision of free hospital treatment by the Central Government is pauperising the population to an alarming extent, and taking away inducement for thrift.’1
The first four public hospitals, established by Governor George Grey, promised to provide free treatment for Māori. Later, authorities debated whether this was an obligation under the Treaty of Waitangi or whether only Māori who could not pay should receive free treatment. Hospitals in areas where Māori did not pay rates were reluctant to provide this service. These issues came to the fore in the 20th century as more Māori sought hospital care.
In the 19th century Maori were reluctant to go to hospital once deaths occurred there, as this made them tapu. Hospitals were culturally insensitive and made few allowances for extended family to stay. During the 20th century all sectors of society, including Māori, were more willing to use hospitals. This change was assisted by the Social Security Act 1938, which removed the distinction between charity cases and those who could pay.
The Labour Party’s founding manifesto promised free medical treatment for all. The party became the government in 1935 and passed the Social Security Act 1938, which promised security from the cradle to the grave. This included free treatment for all in public hospitals and 14 days free care in hospital for women following childbirth.
Increasing numbers of private hospitals were established from the early 20th century. In 1908 there were 56 public hospitals in New Zealand and 191 private hospitals. Private hospitals remained an option after public hospital care became free in 1938. Most were small operations owned by doctors or midwives, and often they were little more than nursing homes for the middle class. Most were unable to compete with the high-tech equipment and range of services offered at public hospitals.
Despite this, some private hospitals flourished in subsequent decades. The introduction of private medical insurance offered by companies such as Southern Cross (started in 1961) made them attractive for those willing to pay insurance premiums. Waiting lists in public hospitals were a further incentive. The introduction of accident compensation in 1974 boosted the private sector because patients could use compensation money to pay for care in these hospitals. Some private hospitals, such as the Mater Misericordiae Hospital in Auckland, grew to rival public hospitals in size and function.
The public sector, which offered free hospital care, continued to be the mainstay of New Zealand’s hospital services. From 1957 all funds came from central government, though it had little control over how this money was spent. By the late 20th century an ageing population, new health technologies and growing consumer expectations meant that the cost of running public hospitals soared. An attempt by the government to introduce overnight charges of $50 for patients in public hospitals in 1991 met with widespread disapproval and was abandoned as an election approached in 1993. This reaction demonstrated the public’s continuing commitment to paying for public hospitals through general taxes rather than user charges.
New high-tech medicine was expensive and contributed to budget blow-outs. In the 1970s there were only three public cardiac surgery units (at Green Lane, Wellington and Dunedin hospitals). About 40% of Wellington’s cardiac patients and half of the Green Lane cases came from outside their respective regions. Their costs were approximately $600 per patient per day, a figure which far exceeded the $260 per day flat rate paid to hospital boards for every outside patient in their care.
In 1983 Area Health Boards were established to replace Hospital Boards. Funding was based on population size. The National government separated health providers from funders in 1993, and the Area Health Boards were turned into Crown Health Enterprises (Hospital and Health Services from 1996). They operated like businesses and competed for contracts with four separate funding agencies called Regional Health Authorities. Many hospitals were closed during this period. A new Labour-led government (elected in 1999) replaced the Regional Health Authorities with 21 non-profit District Health Boards (20 after Otago and Southland merged in 2010).
The District Health Boards received government funding according to a population-based formula which took into account the socio-economic status, ethnicity and age of their populations. This funding formula is updated regularly using demographic information from the latest census. In 2015/16 this population-based funding formula was use to distribute $11.7 billion to health boards.
Armstrong, John. Under one roof: a history of Waikato Hospital. Hamilton: Half Court Press, 2009.
Belgrave, Michael. The mater: a history of Auckland’s Mercy Hospital 1900–2000. Palmerston North: Dunmore Press, 2000.
Bryder, Linda. A healthy country: essays on the social history of medicine in New Zealand. Wellington: Bridget Williams Books, 1991.
Bryder, Linda. A history of the ’unfortunate experiment’ at National Women’s Hospital. Auckland: Auckland University Press, 2009.
Bryder, Linda. The rise and fall of National Women's Hospital. Auckland: Auckland University Press, 2014.
Dow, Derek A. Auckland’s hospitals: a pictorial history 1847–2004, Auckland: Auckland District Health Board, 2005.
Hay, Iain. The caring commodity: the provision of health care in New Zealand. Auckland: Oxford University Press, 1989.
Tennant, Margaret. Paupers & providers: charitable aid in New Zealand. Wellington: Allen & Unwin/Historical Branch, Department of Internal Affairs, 1989.