Medical Services in New Zealand and The Pacific
I: National Medical Committee
THE National Medical Committee came into being as a subcommittee of the Organisation for National Security. The New Zealand Committee of Imperial Defence, formed to ensure the co-ordination of all preparations for any future war, held its first conference in Wellington on 15 November 1933. Besides the armed services, most of the Government departments were represented, as the planning involved a wide range of the State's activities. The name of this committee was in August 1936 changed to the Organisation for National Security.
Among the committees set up by the Committee for Imperial Defence was the Manpower Committee to deal with the problem of manpower in war. Its first meeting was held on 13 June 1934. One of the problems to which this committee turned its attention was the standardisation of medical examinations so that men could be properly classified prior to their utilisation in the armed services. In 1936 the Medical Sub-committee was set up to consider this and other medical matters associated with a possible national emergency. The chairman was the Director-General of Health (Dr M. H. Watt). Other members of the Medical Committee were a representative of the British Medical Association (Sir Donald McGavin), the Director of Army Medical Services and Principal Medical Officer, Air Force (Colonel F. T. Bowerbank – later Major-General), and an inspecting officer of the Department of Health (Mr F. J. Fenton). The first secretary was Captain (later Brigadier) Clifton.1 With the exception of the secretary, who was succeeded by Major (later Major-General) Stevens2 and later by Mr Fenton, the personnel remained unchanged from the first meeting in 1936 until the last, held at the end of the war against Japan.
1 Brig G. H. Clifton, DSO and 2 bars, MC, m.i.d.; Porangahau; born Greenmeadows, 18 Sep 1898; Regular soldier; served North-west Frontier 1919–21 (MC, Waziristan); BM 5 Bde 1940; CRE NZ Div 1940–41; Chief Engineer, 30 Corps, 1941–42; comd 6 Bde Feb-Sep 1942; p.w. 4 Sep 1942; escaped Germany, Mar 1945; Commander, Northern Military District, Mar 1952–Sep 1953.
In 1935 the Manpower Committee had obtained Cabinet approval of a report by it on national service, in which was included a recommendation for the setting up throughout the country of civilian medical boards to deal with the medical grading of the male population as a necessary preliminary to national service. The Manpower Committee had also suggested that as this work was on a national scale, responsibility for administering the system should rest with the Department of Health. With the establishment of the Medical Sub-committee the Manpower Committee now drew up terms of reference, which it placed before the Medical Committee, asking it to work along the lines suggested and to prepare a report.
The terms of reference fell under three main headings. The Medical Committee was required, first, to draw up the detailed organisation and composition of the civilian medical boards, second, to draw up a 'Code of Instructions' for members of the boards and also the necessary examination form, and third, to consider the means by which sick and wounded of the fighting forces could be treated in New Zealand hospitals.
The proposal for the use of civilian medical boards at mobilisation was a departure from the old system (included in the 1935 Mobilisation Regulations) which required preliminary examination by a local doctor followed by a second examination after arrival in camp. This cumbersome dual system was promptly abandoned by the Medical Committee at its first meeting and a resolution was passed endorsing the principle of civilian boards for all national medical examinations in time of war, including the voluntary enlistment period, which it was assumed would come before the institution of compulsory national service.
The committee then considered the composition of the boards and decided that each should consist of three members – two general practitioners, an eye, ear, nose and throat specialist where practicable and, in his absence, a third general practitioner – with provision for consultation with specialists, including dentists, in exceptional cases. At a later meeting this was altered and every board included a dentist, who was to examine only those men graded I or II. All members of boards were to sign their full names on the examination record. (Note: The appointment of an EENT specialist was not practicable as there were so few in New Zealand, but later an page 311 optician was added to each board. The boards eventually comprised only two practitioners and the board papers for recruits were confirmed by the Regional Deputy.)
The question arose of disagreement among members of a board as to grading, and it was agreed that in each of the larger centres a suitable civilian doctor should be appointed to give a final opinion in doubtful cases. The chairman had already been authorised by the committee to choose in each area a senior practitioner to whom he would confide the proposed plan and whose advice he would ask in appointing members of the local boards, so now it was decided that the same senior doctors would naturally make good adjudicators. This was the beginning of the use of Regional Deputies, who held the key positions in the system of civilian medical boards in its final and working form. Several well-known doctors in the North Island were approached first and, after they had shown their willingness to co-operate, three or four doctors were contacted in the South Island. It was explained to them that officers on the reserve or retired list of the New Zealand Medical Corps should be chosen for boards wherever possible, and that in making their arrangements the needs of the civilian population must always be considered. They then chose personnel for their various boards, names were submitted to the committee and within a short time the lists were finalised.
In the same way dental board members were chosen after Colonel Saunders (Director of Dental Services, Health Department) had asked the advice of leading dentists in different parts of the country.
1 There were ultimately twelve Regional Deputies – at Auckland, Hamilton, Napier, New Plymouth, Wanganui, Palmerston North, Wellington, Nelson, Christchurch, Timaru, Dunedin and Invercargill. Whangarei also functioned in many ways as an independent area.
Code of Instructions for Medical Boards
While organising the executive side of the boarding system the committee had also been working at the technical side, drawing up a medical examination record form and a code of instructions to be issued to Regional Deputies and members of boards. At the first meeting it was decided to base both of those on the Hill Report, with modifications to suit New Zealand conditions. The Hill Report had been prepared in 1924 and revised in 1933 by a committee of doctors in Great Britain attached to the Committee of Imperial Defence. It was a comprehensive survey of all medical aspects of National Service, written in the light of the experience of 1914–18.
Among other points, it stressed the need for a thorough and well-recorded initial examination on enlistment, so as to save the State the tremendous cost in pensions that would be the result of an inefficient boarding system. The Medical Committee in New Zealand fully realised the vital importance of this and included in the examination record the warning that: 'The greatest care must be taken to enter any defects and/or ailments discovered by the Board whether affecting grading or not, on the Medical Examination Record. It is essential that an accurate description be recorded in order that if a man is enlisted in the fighting Services any difference on demobilisation may be noted.'
Grade I was at first accepted as laid down in the Hill Report, but was subdivided later to make provision for the temporarily unfit. The definition of Grade I was 'men who attain the full normal standard of health and strength and are capable of enduring physical exertion suitable to their age'; Grade IA was defined 'as for Grade I, but subject to such minor disabilities as can be remedied or adequately compensated by artificial means.'
To avoid any misunderstandings as to the object of boarding it was laid down in the Code of Instructions that this was 'to enable practitioners to classify a man on purely medical grounds, so that the Posting Board can determine the type of National Service for page 313 which he is most fitted.' In other words, the board when examining a man was not to take into account the branch of the service for which the man was destined, nor whether he was to be sent overseas or employed on home defence. The Code of Instructions and the examination form were sent in draft form to Regional Deputies for their comments before being finally considered and approved by the committee.
In June 1937 the committee submitted a report to the Manpower Committee on the steps taken to organise the civilian medical boarding system. Copies of the medical examination form and the Code of Instructions for Members of Medical Boards were attached, with a strong recommendation for the code to be printed, then circulated by the Department of Health. It was also suggested that in an emergency the existing Medical Sub-committee of the Organisation for National Security should be a National Medical Board, with executive control of the proposed organisation and working through the eleven Regional Deputies.
The report was approved by Cabinet in February 1938. Its acceptance meant that although the plan was still regarded as precautionary only and the Regional Deputies had been consulted confidentially, in essentials the boarding system was complete and ready to function at the shortest notice. The Code of Instructions was printed as a booklet by the Organisation for National Security in 1938.1
Hospitalisation of Sick and Wounded
The third of the main headings of the terms of reference – the question of the hospitalisation of sick and wounded – was dealt with separately. The committee had, in 1936, decided to recommend that, in principle, civil hospital facilities should be used and adapted where necessary for the treatment of the sick and wounded of the fighting forces in war. Details were to be arranged later. The recommendations under this heading were included in a report to Cabinet, which gave its approval on 7 February 1938, at the same time as it approved the civilian medical boarding scheme.
The Medical Committee's section of the report stated:
All medical examinations, whether under voluntary enlistment or under national service will, in general, be carried out under arrangements made by the Medical Committee, the executive control resting with the Health Dept.
Treatment of sick and wounded in New Zealand and sick and wounded returned from overseas.
To prevent overlapping the following principles will apply:
All treatment will be arranged by the Health Dept., which is most favourably situated to review the facilities for medical treatment
1 Further details are included in the section on medical boarding.
Where possible the man will be treated in the institution nearest his home.
Until classified by medical boards, and if classified as 'probably fit for further service', men will be retained under defence control. This may necessitate military wings being established in large hospitals, and will, in any case, necessitate some form of military discipline being maintained.
Men who are classified as 'unfit for further service' will be discharged from the Defence Forces, and again come under the control of the Department of National Service, which will be responsible for further medical treatment … [and for referring cases for consideration by the Pensions Department].
At a meeting of the Medical Committee on 15 June 1938 a Nursing Council was formed to advise the committee on all matters pertaining to army and civilian nursing in time of war, and to link up the activities of the Red Cross Society of New Zealand and the Order of St. John as far as the training of Voluntary Aid Detachments, both male and female, was concerned. The council was composed of the Director, Division of Nursing, Health Department (Miss M. I. Lambie), the Matron-in-Chief NZ Army Nursing Service (Miss I. G. Willis) and a representative of matrons of public hospitals (Miss L. M. Banks of Palmerston North).
The Nursing Council first met on 31 August 1938 and drafted a scheme covering the enrolment and organisation of the registered nurses of the Dominion in the event of a national emergency. This scheme was based on the assumption that the public hospital system of New Zealand would be the nucleus for all arrangements. The report was forwarded to the National Medical Committee, amended in some details and adopted and passed on to the Organisation for National Security. The latter body referred the draft scheme to the Army Department, which proceeded to revise the establishment of, and appointments to, the active list of the NZANS.
On the outbreak of war the Nursing Council submitted, on 5 September 1939, a report on the recruitment of nurses for the NZANS. This received ministerial approval a few days later, and this authority provided the basis for the reorganisation, recruitment and development of the NZANS during the war.1
Voluntary Aid Council
For the Voluntary Aid Detachments (male) a representative from the Red Cross Society and another from the Order of St. John, both doctors, were appointed co-opted members of the Medical Committee, and attended by invitation when the committee met to discuss matters concerning male Voluntary Aid Detachments. A joint report was submitted by these co-opted members (Dr A. Gillies of the Red Cross Society and Dr J. K. Elliott of the Order of St. John) and a general discussion was held by the committee on 17 July 1939 regarding the use of male voluntary aids in emergency. It was agreed that if the voluntary societies trained men as urine testers at medical examinations, as clerks to medical boards and in ambulance transport duties (other than Army), they would be rendering a valuable service.
Medical Appreciation for Mobilisation
The Director of Medical Services, Army Department, produced on 31 March 1939 a comprehensive appreciation of what would be required of the medical services on mobilisation, both for home defence forces and an overseas force. This appreciation was examined by the Medical Committee in April and May 1939 and a number of minor amendments were made. These were mainly concerned with adjusting the medical appreciation to the policy decided on in regard to the use of civilian medical boards and civilian hospitals.
Emergency Hospital Scheme
The emergency hospital organisation for the reception and treatment of sick and wounded to meet the demands of the Army and other forces on home defence was further considered on 17 July 1939. Previously the main consideration had been given to arrangements for the treatment of sick and wounded from overseas, where it was expected that numbers would not be such that their distribution to a number of hospitals would entail any great disorganisation in public hospitals, and therefore no extensive special measures had been considered necessary.
Based on 'Standing Orders for Mobilisation, 1939', a scheme was drawn up for emergency hospital organisation and this was approved page 316 by the Medical Committee on 17 July 1939. On its basis a report was made to the Organisation for National Security recommending that negotiations should be commenced with hospital boards so that detailed arrangements could be made in relation to the scheme.1
Completion of Original Duties
The Prime Minister asked in July 1939 that the committee should complete its work by 31 July, and at the last meeting before the war, on 17 July, action under the terms of reference originally submitted to the committee was completed. What the committee planned in peacetime was of immense value and was speedily put into effect upon the outbreak of war. War also made imperative the continuance of the functioning of the Medical Committee.
On 7 September 1939 the Ministers of Health and Defence gave their approval to control being assumed by the Medical Committee in the matters in which it had been acting in a planning capacity prior to the war, and the committee became in effect the adviser to the Government on all medical matters in connection with the war, apart from those directly under the control of the armed services. No members of the medical profession, other than those then under obligation to the Army, Navy or Air Force, whether in hospitals or private practice, could be accepted for the three services until their respective cases had been reviewed and approval given by the Medical Committee.
At its meeting on 26 September 1939 the Medical Committee expressed its opinion that, in addition to the functions already assumed, it should be given further powers to enable it to be the recommending authority direct to the Minister of Health for utilisation of all medical, nursing and semi-professional personnel, whether civil or institutional, connected with the health of the community. This included doctors, nurses, dentists, radiologists, pathologists, pharmacists and masseurs.
The matter had been raised when the Manpower Committee of the Organisation for National Security was preparing to assume control regarding the issue of permits to nurses desiring to leave New Zealand for service abroad. It was felt that a committee of laymen would be unable to decide an issue relating to professional matters, and in addition the Medical Committee could by making a recommendation direct to the Minister of Health achieve a more prompt decision. The point of these representations was conceded.page 317
In October 1939 a Dental Sub-committee and the Masseurs Advisory Committee were formed. No control was instituted in regard to the enlistment of chemists, but in March 1940 when the Director of Pharmacy pointed out the numbers of pharmacists who had enlisted and had been called up for military service, sometimes with combatant units, the Medical Committee recommended to the Director of National Service that no further pharmacists be called up unless required as dispensers in the Army Medical Corps.
The Medical Committee's activities came under the National Service Emergency Regulations 1940 (dated 15 June 1940), which provided for a Minister of National Service and a Director of National Service, with the right of delegation of their powers. Under the heading 'Medical Examination and Treatment', Regulation 34 stated:
In the exercise of his functions under these regulations the Minister of Health shall have regard to the recommendations of the National Medical Committee appointed to advise the Government in relation to medical matters arising out of the present war.
Regulations 35 to 41 covered medical examination and treatment. The method of appointment and functioning of the Medical Boards was also covered, provision being made for appointment of chairmen of the boards and for any disputed cases to be referred to the Regional Deputy.
The Medical Committee thus became in name the National Medical Committee with a continuance of its functions as previously.
Matters dealt with During War
The principal matters dealt with during the war by the committee were:
Measures for the orderly recruitment of doctors, dentists, masseurs, pharmacists, opticians, technicians, etc., so as to maintain a reasonable balance between the needs of the armed forces and the civilian community.
Arrangements for interchange of service between medical practitioners and medical officers serving with the forces.
Applications for return of medical officers to civilian practice.
Control of practising locations of medical practitioners.
Utilisation of services of medical students in connection with the war effort.
Organisation of medical boarding and revision of the Code of Instructions.page 318
Advice in connection with the provision of hospitals and convalescent hospitals for the reception of sick and wounded members of the armed forces.
Advice in connection with the remedial treatment of servicemen.
Advice to the Internal Affairs Department in connection with applications from doctors and nurses for permits to leave New Zealand.
Consideration of rehabilitation and post-graduate courses for medical officers on demobilisation.
Most of these matters are dealt with in detail in succeeding sections. The National Medical Committee held regular meetings throughout the war until 21 September 1945, when the final meeting (the 78th) was held. On that date the National Medical Committee, and its sub-committees, was dissolved. Any remaining functions in connection with continuing demobilisation were then administered by the Health Department.
When the committee disbanded the Prime Minister placed on record the Government's appreciation of the excellent service given by it. He stated that the Government realised that the task allotted to the National Medical Committee was not easy and that, as the war advanced and the country's commitments became greater, it became a task of no small magnitude to see that the medical needs of the civilian population, on the one hand, and those of the armed forces, on the other, were both adequately met. The committee's members were individually thanked for the able part they had played in its work.
The only statutory authority for the committee seems to have been in the National Service Emergency Regulations, whereby the Minister of Health was required under the section 'Medical Examination and Treatment' to 'have regard to the recommendations of the National Medical Committee appointed to advise the Government in relation to medical matters arising out of the present war'. The members of the committee themselves were not clear at first on their lack of power. On 12 December 1940 the Director-General of Medical Services wrote: 'The Director-General of Health, when replying to a letter from Sir Donald McGavin, stated that the National Medical Committee was wholly advisory and had no powers whatsoever: that all powers were vested in the Minister of Health and that as his representative and to prevent future misunderstanding he, the Director-General of Health, would sign all decisions or recommendations considered by the National Medical Committee, not as Chairman of that Committee but as Director-General of Health.' Continuing, the Director-General of Medical Services pointed out that the requirements of the armed forces in war had to take precedence over civilian needs, but that progressive difficulty was being experienced in obtaining suitable medical officers for whole-time service with the forces.
The Medical Committee had first operated under the manpower committee of the Organisation for National Security. The functions of the latter body were largely taken over by the National Service Department under the National Service Emergency Regulations 1940. The Regional Deputies who were in charge of medical examinations should logically have come under the National Service Department, and the National Medical Committee should have had some executive or advisory function to the National Service Department. The Medical Committee visualised such a position when it suggested in its report in 1937 that in a national emergency it would function as a National Medical Board having executive control of the organisation of medical boards, directed by the Department of National Service and working through the Regional Deputies. The committee considered questions that came within the provinces of the Minister of Defence, the Minister of Health and the Minister of National Service, but in the normal course the result of their deliberations was made known to the Minister of Health only. Cabinet approval seems to have been confined to the approval page 320 on 7 February 1938 of the constitution of the membership of the committee and the report under its terms of reference.
Sir Donald McGavin stated after the committee had concluded its valuable functions that questions on which members differed were referred to the Health or Army Departments (whichever the particular question involved) by the Director-General of Health or the Director-General of Medical Services respectively, and added: 'it is clear that when a debatable question is submitted to the Minister of a Department by an officer of that Department a less balanced view will be taken than when all sides of the question are represented to an impartial body by the whole committee. I suggest that it would have been much better if the whole committee had met the Ministers concerned (or the Cabinet if the question be of sufficient importance) and members put their individual views before them. I am sure that a few questions would have been more wisely decided had that been done.'1
The representation on the National Medical Committee was wide enough to ensure that all interests directly concerned were represented and that experienced advice was available to the Government. The Department of Health had the major representation and the committee functioned as an advisory body to the Minister of Health. Although the committee had little statutory backing it was consulted very freely by the Government and its recommendations were very seldom rejected or departed from. The Director-General of Health considered that the committee proved very flexible and dealt with a multiplicity of matters with a minimum of 'red tape' and delay. Its strength lay in its small size and the simplicity of its organisation.
1 It is interesting to note that under the Military Training Act 1949 a Medical Committee was appointed to advise the Minister of Defence in relation to medical examinations, the appointment of regional medical officers and appointment of medical boards. The committee consists of the Directors of Medical Services of the Navy, Army and Air Force, a representative of the British Medical Association, the Director-General of Health or a deputy recommended by the Minister of Health, and the Director of Employment.