Once again Ian Powell has written a useful analysis in BusinessDesk of the proposed health reforms. In them he has written:
There are 12 national initial high-level indicators. Some are still in development – access to primary mental health and addiction services; participation in the National Bowel Screening Programme; percentage of people who say they can get primary care from a GP or nurse when they need it; and the percentage of people who say they felt involved in their own care and treatment with their GP or nurse.
He then went on to
Some are arguably noble in aspiration such as the percentage of children who have all their age-appropriate schedule vaccinations by two years; rate of hospital admissions for children and adults (45-64 years) for an illness that might have been prevented or better managed in the community; percentage of under-25-year-olds able to access specialist mental health services within three weeks of referral; acute hospital bed-day rate; and access to hospital planned care.
As heart-warming as these may appear, the most likely outcome is fudged nebulous results partly because of the generalised nature of the wording and partly because the abolition of DHBs are likely to lead to more aggregated results (possibly national only) thereby weakening their usefulness. Further, some are able to be manipulated by, for example, the way hospital admissions and bed-day rates are coded.
Distortionary financials Two further indicators help define the values and culture of Little’s health system – the annual surplus or deficit at financial year-end and the variance between planned budget and year-end actuals. But this excludes consideration of whether government funding is sufficient to meet the pressures on the health system. Because they are the most measurable, these indicators are the ones that the government can use to be judgemental about health system performance. The system can be held to account but not the funders of the system (ie, government). They tell you little about the financial performance of the health system when funding does not cover increasing acute admissions and chronic illnesses (both big cost drivers) driven by external social determinants of health such as overcrowded accommodation and low incomes.
Glaring omissions There are also glaring omissions from the indicators framework that speak volumes about the values and culture of the Labour government’s system. A huge omission is the exclusion of unmet patient need (denied access). We desperately need measures of what the health system doesn’t achieve, what doesn’t get done, and of those who did not receive the treatment they need. But the government’s indicators are about numerators (what got done) rather than denominators (estimated number of cases in the community). For example, as an anaesthetist recently advised me, if we do 1,000 hip replacements we might be doing well, but if we estimate there are 5,000 people out there who should be offered it, we are underperforming.
Another omission is the severe workforce shortages which are having a detrimental effect across the health system and fatiguing health professionals who are the prime driver of health system improvement. Workforce wellbeing through effective retention and recruitment should be an indicator. Further, there is nothing about the allied need to improve workforce engagement. Most of the expertise and experience necessary for health system improvement is possessed by its marginalised workforce. Strengthened engagement through distributed leadership with the most effective driver of innovation should be an indicator.
One of the biggest drivers of hospital operating costs – and a contributor to DHB deficits – is acute patient demand. This is because acute demand is increasing at a faster rate than population growth. Through its clinically led engagement between hospital and community, Canterbury was the most successful DHB in addressing this driver. There should be, but isn’t, an indicator on first slowing the rate of increase, and then reducing, acute demand for hospital treatment. The same can be said for rising chronic illnesses. Their omission smells of avoidance of political accountability.