Last week I outlined why the public health system, despite the best endeavours of the professionals who operate it, delivers to the public its services in an unfair and arbitrary fashion. The squeaky wheel syndrome, whereby those advantaged by having effective advocates on their side can get access before those whose cure would deliver the greatest benefit to New Zealand, is one inequity already out of control. Gaming the system by doctors and patients is another.
And as for expecting the system to satisfy all with the same need, forget it – the limited resources simply cannot accommodate that. This reality has been around for yonks now, yet it hasn’t even dawned on the public at large. Former Prime Minister Helen Clark’s way of dealing with this was to limit waiting times to six months. So as queues extended out that far the latecomers were just sent away. The concept of the queue for the queue was born. It’s a shame so many New Zealanders remain in la la land on this, naively believing still that all those with the same need get treated.
If we can bring ourselves to get real and accept all needs can’t be addressed, that not even all those with the same need can be treated, the question then becomes how might the system be better designed to more equitably select winners and losers – those who qualify for intervention and those who don’t?
One blessing is the nation’s politicians would love to be excused from having to make decisions on what the public health sector should or should not deliver. There are no votes to be won from the Minister of Health’s portfolio, the public expects everything to be delivered so there is only downside. If a Pharmac-style depoliticisation could be achieved (the disastrous Herceptin interception aside) then nobody would heave a bigger sigh of relief than the politician that draws the short straw of the health portfolio.
So how might this be done? Like Pharmac, allocation rules must have a strong evidence-based rationale, in other words be supported by what the data tells us in terms of the benefits that flow from the dollars spent. In some part the current failed prioritisation regime has arisen because talking dollars is such an anathema in the sheltered world of medicos. It is of course, incumbent upon doctors to be concerned first and foremost with the interests of the patient, but it doesn’t follow that the profession as a whole must dismiss with disdain any attempt to co-opt them into the big-picture decisions about where to spend money.
In fact the profession should, up there with nursing and health sector managers, be providing leadership for the public in making these difficult decisions on allocating the fixed resource. It’s the health sector professionals that have the knowledge of best technical practice, and combined with the data on costs, that should be sufficient to direct the big decisions on how the resource is allocated.
Empirical-based objective indicators such as QALYs (quality adjusted life years) which indicate what impact treatments have on the number of quality years of life that can be expected for the patient, and CPACs (clinical priority assessment criteria) which tell us the chance of success a certain procedure might have for a given patient as well as how material the improvement will be for that particular patient – are the tools of the rationing trade.
This type of evidence, with cost data, is vital for deriving an objective and rational basis for determining where and on whom the public health sector should spend its limited resources. Sure, the evidence will never be perfect, and the context will sometimes be critical. This is why we have expensively trained professionals to make decisions in the front line. Any guidelines have to have the room for exceptions based on clinical judgment, but for the rationing to be rational these exceptions must very much be the minority of cases and front line medicos must have firm limits on the discretion they can use.
Who then is the ideal leader of the public’s quest for rational rationing? A national health committee that’s apolitical and led by leaders of the professions involved – docs, nurses and managers – determining on a national basis, the prioritisation schema is the only credible way forward. The sector has to provide the leadership for the public. We don’t know how to make the call and it’s self-evident that politicians responding to lobbyists have demonstrated incapacity as well.
The result of the allocation should be that the patient’s geographical location is irrelevant, their advocacy irrelevant, and the political regime of the day should be irrelevant. What is relevant is only what the evidence-based rationale for spending a dollar on one procedure versus another, on one patient versus another, is. The secretariat of this board has to be equipped to provide the data for decisions to be informed. The minister should not be able to influence the decisions other than to the extent of setting the whole budget. Once determined, then the criteria need to be pasted to the walls of every town square in the land for every citizen to see. Just like the law, ignorance then becomes no excuse.
The list should incentivise self-management of health conditions, especially of those conditions where treatment is hard to get. Control of the public’s expectations of what the public health sector can do, and total transparency over what is beyond it, is an essential part of relieving the pressure. As well as serving to moderate the demands made on the public health system, such transparency and objectivity, in terms of what constitutes the public offer, would incentivise the system itself to strive harder for efficiencies.
There are significant benefits to be wrung from a health system that encourages its most expensive professionals to delegate certain work to technical specialists under their guidance, to utilise telemedicine to service patients in remote areas, and to stop fooling us all in the regions that the local hospital is any more than a primary care super centre. But without the financial pressures being applied in the right way to encourage these improvements, there is precious chance of such productivity gains being captured.
For example if the principle is that all New Zealanders with the same need and ability to benefit get treated and in the same way, no matter where they live, then the system simply has to work out ways to deliver that service as cheaply as possible to all corners of the catchment. But if deliver it they must, the need to capture the efficiencies becomes imperative. A national health system, rationing its limited resources in an equitable and transparent way, led by health sector professionals in the public interest, with politicians only having to set the overall budget, is overdue.
The biggest question in my mind is whether the medical profession is up to it. As individual practitioners they spend their days in their specialist silos thinking only of the patient in front of them – as they should. What’s required here is for the leaders of the medical profession to join the nursing and managerial leaders and think only in the public’s interest. A big step up. Similar ideas were also mooted by the Horn Report published last year. The Minister of Health has yet to indicate much will to step back from a hands-on allocation of healthcare spending, and so his Health Committee looks like it might be too under his thumb to make much progress.
That would be a shame as a timid, tentative toe in the water compared with what is urgently needed condemns the system to falling further from any sustainable future.
* Gareth Morgan and Geoff Simmons co-wrote the book Health Cheque, a study of the NZ health system